Top

Surgical Endoscopy

Published in:

01-09-2012

Recurrence after transanal endoscopic microsurgery for large rectal adenomas

Authors: Marco Ettore Allaix, Alberto Arezzo, Paola Cassoni, Federico Famiglietti, Mario Morino

Published in: Surgical Endoscopy | Issue 9/2012

Abstract

Background

Transanal endoscopic microsurgery (TEM) has revolutionized the technique and outcome of transanal surgery, becoming the standard of treatment for large sessile rectal adenomas. Nevertheless, only a few studies have evaluated the risk factors for local recurrence in order to recommend a “tailored” approach. The aim of this study was to identify predictor variables for recurrence after TEM to treat rectal adenoma.

Methods

This study is a retrospective analysis of a prospective database of patients treated for large sessile rectal adenomas by TEM at our institution, with a minimum follow-up of 12 months. Age, gender, tumor diameter, distance from the anal verge, degree of dysplasia, histology, and margin involvement were investigated.

Results

Between January 1993 and July 2010, 293 patients with a rectal adenoma ≥3 cm underwent TEM. Postoperative morbidity rate was 7.2 % (21/293) and there was no 30-day mortality. Over a median follow-up period of 110 (range = 12–216) months, 13 patients (5.6 %) were diagnosed with local recurrence. The median time to recurrence was 10 (range = 4–33) months, with 76.9 % of recurrences detected within 12 months after TEM. At univariate analysis, tumor diameter (p = 0.007), and positive margins (p < 0.001) were shown to be significant risk factors, while multivariate analysis indicated the presence of positive margins as the only independent predictor of recurrence (p = 0.003).

Conclusions

TEM provides excellent oncological outcomes in the treatment of large sessile benign rectal lesions, assuring a minimal risk of resection margin infiltration at pathology examination, which represents the only risk factor for recurrence.

Regula J, Rupinski M, Kraszewska E, Polkowski M, Pachlewski J, Orlowska J, Nowacki MP, Butruk E (2006) Colonoscopy in colorectal-cancer screening for detection of advanced neoplasia. N Engl J Med 355(18):1863–1872PubMedCrossRef

Jacobs ET, Martinez ME, Alberts DS, Jiang R, Lance P, Lowe KA, Thompson PA (2007) Association between body size and colorectal adenoma recurrence. Clin Gastroenterol Hepatol 5(8):982–990PubMedCrossRef

Muto T, Nagawa H, Watanabe T, Masaki T, Sawada T (1997) Colorectal carcinogenesis: historical review. Dis Colon Rectum 40(10 Suppl):S80–S85PubMedCrossRef

Rajendra S, Ho JJ, Arokiasamy J (2005) Risk of colorectal adenomas in a multiethnic Asian patient population: race does not matter. J Gastroenterol Hepatol 20(1):51–55PubMedCrossRef

Winawer SJ, Zauber AG, O’Brien MJ, Ho MN, Gottlieb LS, Sternberg SS, Waye JD, Schapiro M, Bond JH, Panish JF, Ackroyd F, Shike M, Kurtz RC, Hornsby-Lewis L, Gerdes H, Stewart ET, The National Polyp Study Workgroup (1993) Prevention of colorectal cancer by colonoscopic polypectomy. N Engl J Med 329(27):1977–1981PubMedCrossRef

Zheng S, Liu XY, Ding KF, Wang LB, Qiu PL, Ding XF, Shen YZ, Shen GF, Sun QR, Li WD, Dong Q, Zhang SZ (2002) Reduction of the incidence and mortality of rectal cancer by polypectomy: a prospective cohort study in Haining County. World J Gastroenterol 8(3):488–492PubMed

Barendse RM, van den Broek FJC, Dekker E, Bemelman WA, de Graaf EJR, Fockens P, Reitsma JB (2011) Systematic review of endoscopic mucosal resection versus transanal endoscopic microsurgery for large rectal adenomas. Endoscopy 43(11):941–955PubMedCrossRef

Rösch T, Sarbia M, Schumacher B, Deinert K, Frimberger E, Toermer T, Stolte M, Neuhaus H (2004) Attempted endoscopic en bloc resection of mucosal and submucosal tumors using insulated-tip knives: a pilot series. Endoscopy 36:788–801PubMedCrossRef

Neuhaus H, Costamagna G, Deviere J, Fockens P, Ponchon T, Rösch T, ARCADE Group (2006) Endoscopic submucosal dissection (ESD) of early neoplastic gastric lesions using a new double-channel endoscope (the “R-scope”). Endoscopy 38:1016–1023PubMedCrossRef

10.

Hurlstone DP, Atkinson R, Sanders DS, Thomson M, Cross SS, Brown S (2007) Achieving R0 resection in the colorectum using endoscopic submucosal dissection. Br J Surg 94:1536–1542PubMedCrossRef

11.

Probst A, Golger D, Arnholdt H, Messmann H (2009) Endoscopic submucosal dissection of early cancers, flat adenomas, and submucosal tumors in the gastrointestinal tract. Clin Gastroenterol Hepatol 7:149–155PubMedCrossRef

12.

Sakamoto GD, MacKeigan JM, Senagore AJ (1991) Transanal excision of large, rectal villous adenomas. Dis Colon Rectum 34:880–885PubMedCrossRef

13.

Mellgren A, Sirivongs P, Rothenberger DA, Madoff RD, Garcia-Aguilar J (2000) Is local excision adequate therapy for early rectal cancer? Dis Colon Rectum 43:1064–1074PubMedCrossRef

14.

Buess G, Hutterer F, Theiss R, Böbel M, Isselhard W, Pichlmaier H (1984) Das System für die transanale endoskopische Rektumoperation. Chirurgie 55:677–680

15.

Buess G (1993) Transanal endoscopic microsurgery (TEM). J R Coll Surg Edinb 38:239–245PubMed

16.

Allaix ME, Arezzo A, Caldart M, Festa F, Morino M (2009) Transanal endoscopic microsurgery for rectal neoplasms: experience of 300 consecutive cases. Dis Colon Rectum 52:1831–1836PubMedCrossRef

17.

Allaix ME, Rebecchi F, Giaccone C, Mistrangelo M, Morino M (2011) Long-term functional results and quality of life after transanal endoscopic microsurgery. Br J Surg 98(11):1635–1643PubMedCrossRef

18.

Iishi H, Tatsuta M, Iseki K, Narahara H, Uedo N, Sakai N, Ishikawa H, Otani T, Ishiguro S (2000) Endoscopic piecemeal resection with submucosal saline injection of large sessile colorectal polyps. Gastrointest Endosc 51:697–700PubMedCrossRef

19.

Miyamoto S, Muto M, Hamamoto Y, Boku N, Ohtsu A, Baba S, Yoshida M, Ohkuwa M, Hosokawa K, Tajiri H, Yoshida S (2002) A new technique for endoscopic mucosal resection with an insulated-tip electrosurgical knife improves the completeness of resection of intramucosal gastric neoplasms. Gastrointest Endosc 55:576–581PubMedCrossRef

20.

Yamamoto H, Kawata H, Sunada, Sasaki A, Nakazawa K, Miyata T, Sekine Y, Yano T, Satoh K, Ido K, Sugano K (2003) Successful en-bloc-resection of large superficial tumors in the stomach and colon using sodium hyaluronate and small-caliber-tip-transparent hood. Endoscopy 35:690–694PubMedCrossRef

21.

Onozato Y, Ishihara H, Iizuka H, Sohara N, Kakizaki S, Okamura S, Mori M (2006) Endoscopic submucosal dissection for early gastric cancers and large flat adenomas. Endoscopy 38:980–986PubMedCrossRef

22.

Fujishiro M, Yahagi N, Nakamura M, Kakushima N, Kodashima S, Ono S, Kobayashi K, Hashimoto T, Yamamichi N, Tateishi A, Shimizu Y, Oka M, Ogura K, Kawabe T, Ichinose M, Omata M (2006) Endoscopic submucosal dissection for rectal epithelial neoplasia. Endoscopy 38(5):493–497PubMedCrossRef

23.

Onozato Y, Kakizaki S, Ishihara H, Iizuka H, Sohara N, Okamura S, Mori M, Itoh H (2007) Endoscopic submucosal dissection for rectal tumors. Endoscopy 39(5):423–427PubMedCrossRef

24.

Kakushima N, Fujishiro M, Kodashima S, Muraki Y, Tateishi A, Omata M (2006) A learning curve for endoscopic submucosal dissection of gastric epithelial neoplasms. Endoscopy 38:991–995PubMedCrossRef

25.

Morino M, Allaix ME, Caldart M, Scozzari G, Arezzo A (2011) Risk factors for recurrence after transanal endoscopic microsurgery for rectal malignant neoplasm. Surg Endosc 25:3683–3690PubMedCrossRef

26.

Casadesus D (2009) Surgical resection of rectal adenoma: a rapid review. World J Gastroenterol 15(31):3851–3854PubMedCrossRef

27.

Zacharakis E, Freilich S, Rekhraj S, Athanasiou T, Paraskeva P, Ziprin P, Darzi A (2007) Transanal endoscopic microsurgery for rectal tumors: the St Mary’s experience. Am J Surg 194:694–698PubMedCrossRef

28.

Ganai S, Kanumuri P, Rao RS, Alexander AI (2006) Local recurrence after transanal endoscopic microsurgery for rectal polyps and early cancers. Ann Surg Oncol 13:547–556PubMedCrossRef

29.

Mörschel M, Heintz A, Bussmann M, Junginger T (1998) Follow-up after transanal endoscopic microsurgery or transanal excision of large benign rectal polyps. Langenbecks Arch Surg 383:320–324PubMedCrossRef

30.

Madhala O, Lelcuk S, Rabau M (1995) Transanal endoscopic microsurgery for local excision of rectal neoplasms. Harefuah 129(236–237):295

31.

McCloud JM, Waymont N, Pahwa N, Varghese P, Richards C, Jameson JS, Scott AN (2006) Factors predicting early recurrence after transanal endoscopic microsurgery excision for rectal adenoma. Colorectal Dis 8:581–585PubMedCrossRef

32.

O’Brien MJ, Winawer SJ, Zauber AG, Gottlieb LS, Sternberg SS, Diaz B, Dickersin GR, Ewing S, Geller S, Kasimian D et al (1990) The National Polyp Study: patient and polyp characteristics associated with high-grade dysplasia in colorectal adenomas. Gastroenterology 98:371–379PubMed

33.

de Jonge V, Sint Nicolaas J, van Leerdam ME, Kuipers EJ, Veldhuyzen van Zanten SJ (2011) Systematic literature review and pooled analyses of risk factors for finding adenomas at surveillance colonoscopy. Endoscopy 43(7):560–574PubMedCrossRef

34.

Katti G (2004) An evaluation of transanal endoscopic microsurgery for rectal adenoma and carcinoma. JSLS 8:123–126PubMed

35.

Vorobiev GI, Tsarkov PV, Sorokin EV (2006) Gasless transanal endoscopic surgery for rectal adenomas and early carcinomas. Tech Coloproctol 10:277–281PubMedCrossRef

36.

Guerrieri M, Baldarelli M, Morino M, Trompetto M, Da Rold A, Selmi I, Allaix ME, Lezoche G, Lezoche E (2006) Transanal endoscopic microsurgery in rectal adenomas: experience of six Italian centres. Dig Liver Dis 38:202–207PubMedCrossRef

37.

Platell C, Denholm E, Makin G (2004) Efficacy of transanal endoscopic microsurgery in the management of rectal polyps. J Gastroenterol Hepatol 19:767–772PubMedCrossRef

38.

Guerrieri M, Baldarelli M, de Sanctis A, Campagnacci R, Rimini M, Lezoche E (2010) Treatment of rectal adenomas by transanal endoscopic microsurgery: 15 years’ experience. Surg Endosc 24(2):445–449PubMedCrossRef

Title: Recurrence after transanal endoscopic microsurgery for large rectal adenomas
Authors: Marco Ettore Allaix
Alberto Arezzo
Paola Cassoni
Federico Famiglietti
Mario Morino
Publication date: 01-09-2012
Publisher: Springer-Verlag
Published in: Surgical Endoscopy / Issue 9/2012
Print ISSN: 0930-2794
Electronic ISSN: 1432-2218
DOI: https://doi.org/10.1007/s00464-012-2238-z

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Recurrence after transanal endoscopic microsurgery for large rectal adenomas

Abstract

Background

Methods

Results

Conclusions

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 9/2012

Argon plasma coagulator in a 2-month-old child with tracheoesophageal fistula

Totally laparoscopic strategies for the management of colorectal cancer with synchronous liver metastasis

Robot-assisted transvaginal peritoneoscopy using confocal endomicroscopy: a feasibility study in a porcine model

Reply to: a letter to the editors: Re: minimally invasive oesophagectomy: current status and future direction

SLEEVEPASS: A randomized prospective multicenter study comparing laparoscopic sleeve gastrectomy and gastric bypass in the treatment of morbid obesity: preliminary results

Robot-assisted total mesorectal excision: is there a learning curve?