Large Rectal Adenomas Research Articles

Retrospective Analysis of Rectal Endoscopic Submucosal Dissection at Ordensklinikum Linz and Kepler Universitätsklinikum Linz.

Background and study aim: Endoscopic submucosal dissection is a minimally invasive endoscopic procedure for the removal of neoplastic benign and early malignant lesions in the gastrointestinal tract. In this study, we analyse the success and safety of rectal ESD at Linz hospitals, focusing on a specific endoscopist. Additionally, we examine whether there is a learning curve regarding success parameters. Methods: This retrospective study included all 102 patients who underwent endoscopic submucosal dissection of the rectum by a defined endoscopist at Ordensklinikum Hospital and Kepler University Hospital between December 2010 and May 2021. With the collected data, a descriptive statistic was carried out and regression analyses were performed. Results: The en bloc resection rate was 78.4% and the rate of lesions removed in healthy tissue was 55.6%. The average procedure time was 179 min and the complication rate was 7.8%. In total, 26.4% of cases showed carcinoma; in 25.9% of these cases, an oncologically curative resection was achieved with ESD. Follow-up data were available for 61.1% of cases, with recurrence being diagnosed in 3.6% of cases. A learning curve was observed regarding the rate of lesions removed in healthy tissue and the procedure time, but not regarding the en bloc resection rate. Conclusions: Endoscopic submucosal dissection is a safe method for the removal of large rectal adenomas and early carcinomas. The en bloc resection rate of the analysed procedures is within the range of comparable European studies. The rate of lesions removed in healthy tissue is below the R0 resection rate of the comparative literature; however, a learning curve could be observed in this parameter.

Case Report of Multiple Rectosigmoid Adenomatous Polyps and Its Management i.e. Transanal Endoscopic Microsurgery

Adenomatous polyps in the colorectal region are prevalent. On account of its rarity and effective excision using Transanal Endoscopic Microsurgery (TEM) with assistance from a Covidien Small Incision Laparoscopic System (SILS) Port, we present this case of an adenomatous polyp wherein the patient complaints of per rectal bleed. Most frequently asymptomatic, adenomatous polyps are the most prevalent. In the present case, five to six polyps were found in the rectosigmoid area during colonoscopy. Rectal bleeding, stomach pain, and changes in bowel function that have a high malignant potential are the most typical symptoms associated with polyps. Large rectal adenomas should only be treated with TEM at this time, and traditional Trans Endoscopic (EMR/ESD) should be stopped. Despite the availability of newer procedures like endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), TEM is still the method of choice. TEM is not recorded in our country up till now. This is the first time it is performed in our country. Keywords: Adenomatous Polyp; Transanal Endoscopic Microsurgery; Small Incision Laparoscopic System; Endoscopic Mucosal Resection; Endoscopic Submucosal Dissection

Transanal endoscopic microsurgical submucosal dissection (TEM-ESD) for rectal adenomas: a retrospective cohort study of 145 consecutive cases.

Transanal endoscopic microsurgery (TEM) and endoscopic submucosal dissection (ESD) are currently the two most popular methods for resecting large rectal adenomas en bloc. However, damage to the mesorectum in the case of TEM, plus the technical challenges and long procedure times of flexible ESD, are major disadvantages of these procedures. Transanal endoscopic microsurgical submucosal dissection (TEM-ESD) is a new technique, combining the ergonomic features of TEM with the minimally invasive approach of ESD. The aim of our study was to assess the feasibility and safety of TEM-ESD for resection of large rectal adenomas. We retrospectively analyzed all TEM-ESD procedures performed in Karlsruhe Municipal Hospital between 2012 and 2019, isolated all cases of adenomas, and analyzed the perioperative and follow-up data of the patients. We identified 145 cases matching our criteria. The median size of the lesions was 4.2cm, and the median operating time was 45min. The en bloc resection rate was 100%, and the complete en bloc resection rate was 78.6%. The overall morbidity rate was 6.9%. In a median follow-up period of 24months, there was a local recurrence in 4.8% of the cases. TEM-ESD is a safe and feasible therapeutic option for resecting large rectal adenomas, offering high en bloc resection and low recurrence rates combined with short operating time and low morbidity. TRIAL REGISTRATION NUMBER (CLINICALTRIALS.GOV): NCT04870931.

McKittrick-Wheelock Syndrome: A Neoplastic Cause of Electrolyte Imbalance.

The authors present the case of a 79-year-old woman who presented with chronic secretory diarrhoea and severe electrolyte imbalance. A large rectal tubulovillous adenoma was discovered, leading to surgical resection of the tumour with complete resolution of the diarrhoea and electrolyte imbalance. The diagnosis of McKittrick-Wheelock syndrome was made.We hope this case report will contribute to a greater awareness among health professionals about this clinical condition. A multidisciplinary approach is essential for the best outcome.LEARNING POINTSMcKittrick-Wheelock syndrome is an important differential diagnosis in patients presenting with electrolyte abnormalities and secretory diarrhoea.A multidisciplinary approach from the beginning is important for a timely diagnosis and better outcome.Surgical removal of the hypersecretory villous adenoma is the definitive treatment for McKittrick–Wheelock syndrome and can be life-saving.

Analysis of the therapeutic effect of transanal endoscopic microsurgery on large rectal adenoma.

Rectal adenoma, a pre-cancerous lesion, is one of the indications for transanal endoscopic microsurgery (TEM). TEM has its unique advantages in the treatment of rectal adenomas. However, there are few reports on the therapeutic effects of large rectal adenoma (LRA). The objective of this study was to investigate the value of TEM in the treatment of LRA. We collected data from patients who underwent surgery at our center from 2007 to 2017. The postoperative pathology of all patients was rectal adenoma and the diameter of the adenoma was 3 cm or greater. Moreover, all patients underwent TEM. We followed up to observe the incidence of no wound healing, rectal stenosis and recurrence rate of rectal adenoma. The risk factors of adenoma recurrence and wound healing were analysed using single- and multiple-factor analysis. The clinicopathological data of 85 patients with LRA were collected through a pre-set table. During the follow-up period, eight patients were lost to follow-up, and three (3.90%) patients developed rectal stenosis. After 2 years of post-operative follow-up, 20 (25.97%) patients had recurrence and 57 (74.03%) patients had no recurrence. Multivariate analysis showed that positive margin was an independent risk factor for recurrence of adenoma. TEM is feasible in the treatment of large rectal tumours in Centers of Expertise with the technique.

Transanal endoscopic microsurgical submucosal dissection: Are there advantages over conventional ESD?

Introduction Transanal endoscopic microsurgical submucosal dissection (TEM-ESD) is a technique that has been recently described for the treatment of large rectal adenomas and early rectal cancer. The purpose of our study is to compare TEM-ESD with flexible endoscopic submucosal dissection (ESD) in an experimental, ex vivo porcine model. Material and methods We used TEM-ESD and flexible ESD to resect a total of 100 standardized 4 × 4cm lesions in an ex vivo porcine stomach model, performing 50 resections with each technique. Total procedure time, en bloc resection rate, injuries of the muscularis propria, perforation rate and learning curve were analysed. Results TEM-ESD was associated with a significantly shorter total procedure time in comparison to ESD (19 min vs. 33 min, p < .001). The rates of en bloc resection, injury of the muscularis propria layer, and perforation were the same in both groups. The learning curve of TEM-ESD was shallower than that of ESD. Conclusion TEM-ESD showed an advantage over ESD in terms of procedure time and learning curve, with similar en bloc resection rates and safety profile in our experimental model.

Successful TAMIS in an elderly patient with a large rectal adenoma.

Successful TAMIS in an elderly patient with a large rectal adenoma.

Transanal endoscopic microsurgery in very large and ultra large rectal neoplasia.

Transanal endoscopic microsurgery (TEM) has become the treatment of choice for benign rectal lesions and early rectal cancer (T1). The size classification of rectal polyps is controversial. Some articles define giant rectal lesions as those larger than 5cm, which present a significantly increased risk of complications. The aim of this study was to evaluate the feasibility of TEM in these lesions. An observational descriptive study with prospective data collection evaluating the feasibility of TEM in large rectal adenomas was performed between June 2004 and September 2018. Patients were assigned to one of the three groups according to size: < 5cm, very large (5-7.9cm) and ultra-large (≥ 8cm). Descriptive and comparative analyses between groups were performed. TEM was indicated in 761 patients. Five hundred and seven patients (66.6%) with adenoma in the preoperative biopsy were included in the study. Three hundred and nine out of 507 (60.9%) tumors < 5cm, 162/507 (32%) very large tumors (5-7.9cm) and 36/507 (7.1%) ultra-large tumors (≥ 8cm)were reviewed. Morbidity increased with tumor size: 17.5% in tumors < 5cm, 26.5% in those 5-7.9cm, and 36.1% in those > 8cm. Peritoneal perforation, fragmentation, free margins and stenosis were also more common in very large and ultra-large tumors (p < 0.001). There were no statistical differences between the groups in the definitive pathology (p = 0.38). TEM in these large tumors is associated with higher rates of morbidity, peritoneal perforation, free margins and stenosis. Although these tumors do not require total mesorectal excision and are eligible for TEM, the surgery must be carried out by experienced surgeons.

Transanal endoscopic microsurgery in benign rectal tumors treatment

The literature review concerning various minimally invasive surgical tmethods for benign rectal tumors treatment is given. Data from leading clinics suggests that currently the main methods of adenomas treatment, including large ones, are endoscopic electroexcision through a colonoscope (endoscopic mucosal resection and endoscopic submucosal dissection), local transanal excision of the tumor and transanal endoscopic microsurgery. In addition to these techniques, transrectal resection of the rectum and transabdominal surgical interventions is used for large rectal adenomas. Most authors assess the long‑term results of endoscopic techniques for the large rectal adenomas removal (endoscopic mucosal resection) as unsatisfactory due to a dramatically increased risk for relapse coused by single‑unit resection difficulty. The dissection technique in the submucosal layer requires a lot of time, technical tools and skills, and currently requires standardization for the rectal localisation. The authors attribute to the disadvantages of benign rectal neoplasms transanal excision the limitation of the method by application for adenomas in the lower and, in part, in the mid‑ampular rectal part, which makes it impossible to adequately remove the neoplasm when the proximal edge of the tumor is above 3 — 4 cm from the dentate line and, as a result, the occurrence of a large number of local recurrences. Comparative analysis of minimally invasive with open surgical methods of large rectal adenomas was not carried out due to the high invasiveness of the latter, dependence on anesthetic management, high probability of both surgical and anesthetic complications during surgery and in the postoperative period. The published studies’ results allow evaluating transanal endoscopic microsurgery as the most effective method for advanced benign rectal epithelial tumors treatment. Transanal endoscopic microsurgery has the optimal ratio between intervention radicalism and minimal invasiveness among the existing minimally invasive methods for rectal neoplasms, which is confirmed by significant international experience.

Randomised controlled trial of transanal endoscopic microsurgery versus endoscopic mucosal resection for large rectal adenomas (TREND Study)

目的 非随机研究表明内镜下黏膜切除术（endoscopic mucosal resection，EMR）在切除直肠较大腺瘤时与经肛门内镜显微手术（transanal endoscopic microsurgery，TEM）同样有效，但EMR可能更具成本效益且相对安全。本试验旨在对比摘除较大直肠腺瘤时EMR与TEM的临床结局与成本效益。 研究设计 研究人员将无恶性病变特征的、直肠腺瘤直径达到或超过3 cm的患者在EMR及TEM组中随机分配（1∶1），3个月内采用内镜切除残留腺瘤。对随机化分组后发现的意外恶性病变患者予以排除。该研究的主要结局为患者24个月内复发率（旨在证明EMR的非劣效性，上限为10%）及出院后无复发的存活天数。 结果 18所大学教学医院及社区医院收治的共204名患者被纳入研究。27例患者（13%）被诊断意外癌，该部分数据在进一步分析中被剔除。EMR治疗后的总复发率为15%，TEM中这一数据为11%，未达具统计学意义的非劣效性标准。2组间出院后无复发的存活天数基本相似[EMR为（609±209）天，TEM为（652±188）天，P=0.16]。并发症发生率分别为18%（EMR组）及26%（TEM组）（P=0.23），这一组数据对于严重并发症发生率分别为1%及8%（P=0.064）。基于质量调整后生命年限2组相当。相较TEM，EMR可节省费用约3 000欧元，因此更具成本效益。 结论 在该研究的统计假设下，无法证实EMR的非劣性效应。但基于更低的并发症发生率及更佳的成本效益，EMR有可能成为主要的选择方法。未来研究中应进一步关注意外癌症的高发生率。

Current Trends on the Status of Transanal Endoscopic Microsurgery

Transanal endoscopic surgery (TES) is the standard of care for the local excision of large rectal adenomas and selected rectal cancers: an “en bloc” full-thickness local excision is performed, with limited risk of specimen fragmentation and positive resection margins, and subsequent significantly lower risk of recurrence and better survival than after conventional transanal excision with retractors. We perform a literature review aiming at assessing the current trends on the status of TES. Patients undergoing TES report significantly lower rates of postoperative complications and better functional outcomes than patients who receive abdominal rectal resection with total mesorectal excision, with no adverse impact on long-term survival. To date, there are two different rigid platforms that are available to perform a TES procedure: the transanal endoscopic microsurgery (TEM) platform that was conceived by Buess in the early 1980s and the TEO (transanal endoscopic operation) platform. More recently, flexible platforms have been proposed as alternative to the rigid ones. Based on the current evidence, TEM and TEO represent the current standard of treatment for large rectal adenomas and selected rectal cancers. Large comparative studies are needed to assess the benefits of flexible platforms, considering that the wide adoption of flexible platforms might impair the quality of the local excision, mainly if performed in low-volume centers.

Transanal Endoscopic Microsurgery with or without Completion Total Mesorectal Excision for T2 and T3 Rectal Carcinoma

Aim: Transanal endoscopic microsurgery (TEM) is used for the resection of large rectal adenomas and well or moderately differentiated T1 carcinomas. Due to difficulty in preoperative staging, final pathology may reveal a carcinoma not suitable for TEM. Although completion total mesorectal excision is considered standard of care in T2 or more invasive carcinomas, this completion surgery is not always performed. The purpose of this article is to evaluate the outcome of patients after TEM-only, when completion surgery would be indicated. Methods: In this retrospective multicenter, observational cohort study, outcome after TEM-only (n = 41) and completion surgery (n = 40) following TEM for a pT2–3 rectal adenocarcinoma was compared. Results: Median follow-up was 29 months for the TEM-only group and 31 months for the completion surgery group. Local recurrence rate was 35 and 11% for the TEM-only and completion surgery groups respectively. Distant metastasis occurred in 16% of the patients in both groups. The 3-year overall survival was 63% in the TEM-only group and 91% in the completion surgery group respectively. Three-year disease-specific survival was 91 versus 93% respectively. Conclusions: Although local recurrence after TEM-only for pT2–3 rectal cancer is worse compared to the recurrence that occurs after completion surgery, disease-specific survival is comparable between both groups. The lower unadjusted overall survival in the TEM-only group indicates that TEM-only may be a valid alternative in older and frail patients, especially when high morbidity of completion surgery is taken into consideration. Nevertheless, completion surgery should always be advised when curation is intended.

STRAIN ELASTOGRAPHY AS DIAGNOSTIC TOOL FOR EVALUATION OF RECTAL NEOPLASMS

AIM. To establish cut-off point of strain ratio for rectal adenocarciomas. PATIENTS AND METHODS. Forty-five patients (29 female) at mean age ± SD of 61 ± 9.5 (range, 38-80) years with histologically confirmed rectal neoplasia were included into study. Endorectal Ultrasonography accomplished by strain elastography was performed by Hitachi Hi Vision Preirus (Japan). All patients were treated by Transanal Endoscopic Microsurgery. RESULTS. Pathologic examination of operative specimen revealed 31 adenomas (5 intraepithelial carcinomas) and 14 invasive carcinomas. Cut-off point of Strain Ratio was 5,7 with sensitivity of 0.94 (95 °%CI 0,68-0,99), specificity of 0.92 (95 %oCI 0,74-0,98), positive predictive value of 0,90 (95 % CI 0,84-0,96) and negative predictive value of 0,96 (95 %CI 0,85-0,99). CONCLUSION. Obtained results testified high diagnostic value of strain elastography and made one perspective method for detection of occult malignancy in large rectal adenomas.

The occurrence and characteristics of endoscopically unexpected malignant degeneration in large rectal adenomas

Large non-pedunculated rectal polyps are most commonly resected by endoscopic mucosal resection (EMR) or transanal endoscopic microsurgery (TEM). Despite pre-procedural diagnostics, unexpected rectal cancer is incidentally encountered within the resected specimen. This study aimed to compare the diagnostic assessment and procedural characteristics of lesions with and without unexpected submucosal invasion. A post-hoc analysis of a multicenter randomized trial (TREND study) was performed in which patients with a non-pedunculated rectal polyp of≥3 cm without endoscopic suspicion of invasive growth were randomized between EMR and TEM. Unexpected rectal cancer was detected in 13% (27/203) of patients; 15 after EMR and 12 after TEM. Most consisted of low-risk T1 cancers (78%, n= 18). There were no differences in the diagnostic assessment between lesions with and without unexpected submucosal invasion. Diagnostic biopsies revealed similar rates of high-grade dysplasia (28% [7/25] vs 18% [26/144]). When compared with EMR of adenomas, EMR procedures of unexpected cancers had a lower success rate of submucosal lifting (60% vs 93%, P< .001), were more often assessed as endoscopically incomplete (33% vs 10%, P= .01), and were more frequently terminated prematurely (60% vs 8%, P= .001). Diagnostic assessment of large non-pedunculated rectal polyps revealed similar characteristics between unexpected cancers and adenomas. Unexpected cancers during EMR were non-lifting in 40%, endoscopically assessed as incomplete in 33%, and terminated prematurely in 60%. In treatment-naive patients, these factors should raise suspicion of malignancy and need discussion in a multidisciplinary team meeting for decision on further treatment strategies.

Randomised controlled trial of transanal endoscopic microsurgery versus endoscopic mucosal resection for large rectal adenomas (TREND Study)

ObjectiveNon-randomised studies suggest that endoscopic mucosal resection (EMR) is equally effective in removing large rectal adenomas as transanal endoscopic microsurgery (TEM), but EMR might be more cost-effective and safer. This...

A Case Of Postileostomy Hypovolemia Presenting As Pseudohypoaldosteronism With Complete Resolution After Ostomy Reversal

ABSTRACT Objective: To report a rare case of postileostomy hypovolemia presenting as pseudohypoaldosteronism with complete resolution after ostomy reversal. Methods: Clinical and biochemical data and extensive relevant literature review are provided. Results: A 65-year-old female was found to have a large rectal tubular adenoma 10 cm from the anal verge on colonoscopy. She underwent open resection of the polyp and diverting loop ileostomy. Six weeks later, she presented with low appetite, a 17-pound weight loss, and hypotension. Biochemical work-up revealed hyponatremia, hyperkalemia, low bicarbonate level, hypercalcemia, and remarkably elevated aldosterone and renin levels. All of the above abnormal clinical and biochemical findings had normalized after the ileostomy reversal. Conclusion: We report a case of postileostomy hypovolemia presenting as pseudohypoaldosteronism with complete resolution after ostomy reversal. It is probably not uncommon for patients with ileostomy to develop similar acid-base an...

OC-045 Treatment Outcomes of Large Rectal Polyps at a Single Tertiary Health Centre in the UK

Introduction Large (>2 cm) rectal adenomas are currently treated by trans-anal endoscopic microsurgery (TEMS) or endoscopic mucosal resection (EMR). The aim of this study is to report on the effectiveness, safety and final outcome of both procedures in patients at a single tertiary health centre in the UK. Methods A cross-sectional study comparing patients and polyps specific variables in patients that underwent transanal endoscopic resection (TEMS) or endoscopic mucosal resection (EMR) for large rectal polyps, during 2011 to 2015. The data was obtained from colorectal multidisciplinary team (MDT) records, supplemented by information from the endoscopy reporting tool of the Hospital (Unisoft®). Variables analysed included polyp size, patient’s age and gender, procedure complication rate, success and failure rate. We also looked for the number for emergency admission needed. Chi-squared test was used to compare rates of examined variables between both techniques. Results Fifty four patients (mean age 74 ± 10.8) underwent EMR whilst fifty three patients (mean age 68 ± 11) had TEMS. Male: female ratio was 1:2 respectively (p value =0.16). Mean polyp sizes were 3 cm (range 2–10 cm) and 3.5 cm (range 2–10 cm) for EMR and TEMS, respectively (p value 0.4). The success rates of both procedures were comparable (92.6% and 88.7% for EMR and TEMS respectively). On the contrary, complication rate was slightly higher in those that had TEMS: 5.7% (1.9% post EMR, p value 0.29). We observed in our study that 9.4% of those who had TEMS required second, high risk surgery (3.7% had Anterior resection, 3.7% required Extralevator abdominoperineal excision ELAPE and 1.8% had Hartman’s surgery). 37% of patients underwent EMR polypectomy required second procedure (further EMR or TEMS) for complete excision. There was a significantly higher recurrence rate post EMR than post TEMS (34% and 7.4% respectively, p0.001) Conclusion In this single tertiary centre, both EMR and TEMS offered similar effectiveness in the treatment of large rectal polyps. The higher recurrence rate of polyps post EMR relative to TEMS engenders further investigation. Disclosure of Interest None Declared

Technical Feasibility of Endoscopic Submucosal Dissection for Lower Rectal Tumors

Introduction: Large (>2cm) rectal adenomas are usually treated by transanal endoscopic microsurgery or endoscopic piecemeal mucosal resection (EPMR). Recently, endoscopic submucosal dissection (ESD) has demonstrated to be effective for the en bloc resection of colorectal lesions. We aimed to investigate the feasibility and safety of ESD for lower rectal tumors. Methods: Between June 2009 and August 2014, 39 patients with lower rectal tumors (≥2 cm) were treated by ESD at our department. Data were examined and analyzed retrospectively according to database and histopathological reports, with respect to histopathological diagnosis, procedure time, en bloc resection rate and complications. Results: The mean adenoma size was 45.6 ± 24.4 mm and the mean distance from the anal verge was 33.5 ± 16.2mm. Among all the lesions, 26 (66.6%) were laterally spreading tumors (granular type), including 2 homogeneous type (5.1%) and 24 nodular mixed type (61.5%) lesions, and the most frequent histological type was tubulovillous adenoma (17/34, 50.0%) (Table 1). The mean procedure time was 100.1 ± 64.3 minutes. En bloc resection and en bloc R0 resection were achieved in 92.3% (36/39) and 87.1% (34/39) of patients, respectively. Perforation occurred in 2 patient (5.1%), which was treated by endoclip. Postoperative bleeding occurred in 2 patients (5.1%) and was managed conservatively (Figure 1, Table 2).Figure 1Table 1: Clinical features of lower rectal lesions (n=39)Table 2: Clinical outcomes and complicationsConclusion: ESD is safe and feasible for the treatment of non-invasive lower rectal tumors, with a low complication rate. To prove its long-term efficacy, a multicenter prospective study with large volume should be conducted in future.Figure 2

A new technique of totally laparoscopic resection with natural orifice specimen extraction (NOSE) for large rectal adenoma.

There is no consensus about the best technique to use for the surgical treatment for large rectal adenomas. The advent of laparoscopic surgery has led to the development of several new methods for the treatment of gastrointestinal tumors. This study was designed to introduce an innovative technique of totally laparoscopic resection with natural orifice specimen extraction (NOSE) for large rectal adenomas and to assess the feasibility and safety of the technique. Between February 2011 and January 2014, we performed totally laparoscopic resection with NOSE on 18 patients with a large rectal adenoma. This new technique was successful in all 18 patients. The average size of the adenoma was 4.2 cm. Mean operation time was 108.4 min, and mean intraoperative blood loss was 36.6 ml. The mean time to passing of the first flatus was 2.3 days, and the mean postoperative hospital stay was 7.2 days. Only one patient needed analgesics after the operation. All patients were able to walk within the first 2 days. There were no cases of morbidity and recurrence. Totally laparoscopic resection with NOSE appears to be suitable for selected patients with a large adenoma located in mid- or low rectum.

Endoscopic mucosal resection of large colorectal adenomas: Only for expert centers?

Endoscopic mucosal resection of large colorectal adenomas: Only for expert centers?