Recurrence after transanal endoscopic microsurgery for benign and malignant rectal tumours: experience of a single New Zealand centre.

BACKGROUND: Transanal endoscopic microsurgery (TEM) is an established technique for the resection of rectal adenomas and selected malignant tumours. It avoids the morbidity of radical resection for tumours not amenable to endoscopic resection. An important marker of quality is the local recurrence rate. The primary objective was to determine local recurrence rates for benign and malignant rectal tumours. METHODS: We identified index TEM excisions of rectal adenomas and adenocarcinomas in patients age 18 and over at Dunedin Hospital, New Zealand, between 2000 and 2020, from a prospective database. Surveillance data were collected via chart review. The primary outcome was recurrence rate for adenomas and adenocarcinomas. Secondary outcomes included time to recurrence, association of recurrence with recognized risk factors, and adverse event rates. RESULTS: We identified 100 patients for analysis. Of 75 benign cases, 11 (14.7%) developed local recurrence, with 63.6% identified within 1 year. Of the 25 malignant cases (19 T1, 5 T2, 1 T3), 9 (36%) developed recurrence, with 77.8% identified within 2 years. Adverse events occurred in 26% of patients, with no reoperations or deaths. CONCLUSION: Our adenoma recurrence rate was at the higher end of the reported range of 2.4-16%. Minor complications were common, but not major morbidity. The propensity for rectal tumours to recur commonly and early reinforces the importance of regular standardized endoscopic surveillance.

Comparison between Endoscopic Submucosal Dissection and Transanal Endoscopic Microsurgery in Early Rectal Neuroendocrine Tumor Patients: A Meta-Analysis.

PURPOSE: To compare the effectiveness, safety and cost-effectiveness of endoscopic submucosal dissection (ESD) with transanal endoscopic microsurgery (TEM) in early rectal neuroendocrine tumor (RNET) patients. This article will provide reliable evidence for surgeons in regards to clinical decision-making. METHODS: Systematic literature retrieval was performed in Pubmed, Embase and Cochrane database from 2013/4/30 to 2023/4/30. Methodology validation was performed by using the Newcastle-Ottawa Scale (NOS). Data-analysis was conducted by using the Review manager version 5.3 software. RESULTS: A total of three retrospective studies were included in our meta-analysis. All eligible studies were considered to be high quality. By comparing baseline characteristics between TEM and ESD, patients in the TEM group seemed to be characterized by a larger tumor size and lower tumor level, even though no statistical significance was found. Clear statistical significance favoring TEM was identified in terms of R0 resection rate, procedure time and hospital stay. No statistical significance was found in terms of recurrence rate, adverse events rate and additional treatment rate. CONCLUSIONS: Compared with ESD, TEM was a more effective treatment modality for early RNET patients; it was associated with a relatively higher R0 resection rate and a similar degree of safety. However, the relatively higher cost and complicated manipulation restricted the promotion of TEM. Surgeons should opt for TEM as a primary treatment in patients with a larger tumor size and deeper degree of tumorous infiltration if the financial condition and hospital facility permit.

Transanal endoscopic microsurgery versus radical resection for early-stage rectal cancer: a systematic review and meta- analysis.

PURPOSE: In the treatment of early-stage rectal cancer, a growing number of studies have shown that transanal endoscopic microsurgery is one of the alternatives to radical surgery adhering to total mesorectal excision that can reduce the incidence of adverse events without compromising treatment outcomes. The purpose of this meta-analysis is to compare the safety and treatment effect of transanal endoscopic microsurgery and radical surgery adhering to total mesorectal excision to provide a basis for clinical treatment selections. METHOD: We searched the literatures of four major databases, PubMed, Embase, Web of science, and Cochrane Library, without limitation of time. The literatures included randomized controlled studies and cohort studies comparing two surgical procedures of transanal endoscopic microsurgery and radical surgery adhering to total mesorectal excision. Treatment effectiveness and safety results of transanal endoscopic microsurgery and radical surgery were extracted from the included literatures and statistically analyzed using RevMan5.4 and stata17. RESULT: Ultimately, 13 papers were included in the study including 5 randomized controlled studies and 8 cohort studies. The results of the meta-analysis showed that the treatment effect and safety of both transanal endoscopic microsurgery and radical surgery in distant metastasis (RR, 0.59 (0.34, 1.02), P > 0.05), overall recurrence (RR, 1.49 (0.96, 2.31), P > 0.05), disease-specific-survival (RR, 0.74 (0.09, 1.57), P > 0.05), dehiscence of the sutureline or anastomosis leakage (RR, 0.57 (0.30, 1.06), P > 0.05), postoperative bleeding (RR, 0.47 (0.22, 0.99), P > 0.05), and pneumonia (RR, 0.37, (0.10, 1.40), P > 0.05) were not significantly different. However, they differ significantly in perioperative mortality (RR, 0.26 (0.07, 0.93, P < 0.05)), local recurrence (RR, 2.51 (1.53, 4.21), P < 0.05),_overall survival_ (RR, 0.88 (0.74, 1.00), P < 0.05), disease-free-survival (RR, 1.08 (0.97, 1.19), P < 0.05), temporary stoma (RR, 0.05 (0.01, 0.20), P < 0.05), permanent stoma (RR, 0.16 (0.08, 0.33), P < 0.05), postoperative complications (RR, 0.35 (0.21, 0.59), P < 0.05), rectal pain (RR, 1.47 (1.11, 1.95), P < 0.05), operation time (RR, -97.14 (-115.81, -78.47), P < 0.05), blood loss (RR, -315.52 (-472.47, -158.57), P < 0.05), and time of hospitalization (RR, -8.82 (-10.38, -7.26), P < 0.05). CONCLUSION: Transanal endoscopic microsurgery seems to be one of the alternatives to radical surgery for early-stage rectal cancer, but more high-quality clinical studies are needed to provide a reliable basis.

Endoscopic Submucosal Dissection (ESD) Offers a Safer and More Cost-effective Alternative to Transanal Endoscopic Microsurgery (TEM): An International Collaborative Study.

BACKGROUND: Endoscopic submucosal dissection (ESD) and transanal endoscopic microsurgery (TEM) are minimally invasive procedures that treat early rectal cancer (ERC). Both are effective treatments, yet there are very few studies comparing them. The aim of our study was to identify ideal candidates for each procedure. MATERIALS AND METHODS: Between January 2016 and November 2019, 204 ERC patients were managed with either ESD (n=101) or TEM (n=103) at 7 international centers. Data analyzed included clinical success, tumor characteristics, procedure info, and recurrence rates. RESULTS: Median tumor size was 40 mm±23.9 in the ESD group and 56 mm±27.9 in the TEM group, significantly larger in the latter ( P <0.00001). Average procedure time was 131.5±67.9 minutes in ESD group and 104.9±28.4 minutes in TEM group ( P =0.000347). Average hospital stay was 3.3±2.6 days in the ESD group and 4.7±0.7 days in the TEM group ( P <0.00001). Adverse event rate was 6.8% in the ESD group and 24% in the TEM group. There were no significant difference in the rate of en bloc resection, technical success, tumor location, necessity of additional procedures, and tumor recurrence rates. CONCLUSION: Compared with TEM, ESD is a safer procedure with shorter hospital stay and should be offered for patients who have ERC.

Inflammatory cloacogenic polyp in an adolescent - case report and review of the literature.

Inflammatory cloacogenic polyp is a rare lesion arising in the anal transitional zone. It is usually benign, but rare cases of malignant transformation are known. It is most commonly seen in the adult population from the fourth to the sixth decade of life, but it can be found among children and adolescents as well. The most common clinical symptoms include rectal bleeding and altered bowel habits, although some patients may be asymptomatic. Treatment involves transanal endoscopic microsurgery followed by a bowel regimen with stool softeners. We present the case report of a 14-year-old boy presenting with intermittent rectal bleeding in whom a polypoid lesion was found during digital rectal examination. The patient underwent proctosigmoidoscopy during which the suspicious lesion was removed by transanal endoscopic microsurgery and the histological diagnosis of inflammatory cloacogenic polyp was established. In the postoperative period, the patient was without any further problems. In this case report, we want to raise awareness of this rare diagnosis and emphasize its place in the differential diagnosis of rectal bleeding across all age groups.

[Results of total mesorectal excision and transanal endoscopic microsurgery for rectal adenocarcinoma with submucosal invasion]. / Rezul'taty total'noi mezorektumektomii i transanal'noi endomikrokhirurgii pri adenokartsinomakh pryamoi kishki s invaziei v podslizistyi sloi.

OBJECTIVE: To analyze early and long-term outcomes after total mesorectal excision (TME) and transanal endoscopic microsurgery (TEM) in patients with T1 rectal cancer. MATERIAL AND METHODS: A retrospective non-randomized comparative study included 2 groups of patients: group 1 - total mesorectal excision, group 2 - transanal endoscopic microsurgery. In the second group, total mesorectal excision was proposed for patients with tumor invasion depth pT1sm3 and/or lymphovascular invasion and/or low differentiation. If total mesorectal excision was performed as a salvage surgery, the patient was excluded from further analysis. RESULTS: There were 156 patients with rectal adenocarcinoma pT1 between October 2011 and August 2019 (102 cases - TEM, 54 cases - TME). We excluded 10 patients from the TEM group due to salvage surgery. Duration of TEM was 40.0 (34; 50) min, TME - 139 (120; 180) min (p=0.00001). Postoperative hospital-stay was also significantly less in the TEM group (7 (6; 9) vs. 10 (7; 11) days, p=0.00001). Six (6.5%) patients in the TEM group and 1 (1.8%) patient in the TME group developed a local recurrence in pelvic cavity (p=0.1). There were no distant metastases. Disease-free 3-year survival was 92% after TEM and 96% after TME (p=0.058). CONCLUSION: Transanal endoscopic microsurgery is a relatively safe alternative to total mesorectal excision for early rectal cancer.

Short-term clinical and functional results of rectal wall suture defect after transanal endoscopic microsurgery-a prospective cohort study.

PURPOSE: Our goal was to assess the outcomes of rectal wall suture during the early and late periods after transanal endoscopic microsurgery (TEM) and long-term bowel function. METHODS: Patients who underwent TEM for rectal neoplasms from May 2017 to March 2021 were prospectively included. A total of 70 patients were enrolled. Seven to 10 days after TEM, clinical data were recorded, and digital rectal examination and rigid proctoscopy were performed. After at least 6 months, bowel function was evaluated using low anterior resection syndrome (LARS) and Wexner questionnaires. RESULTS: Forty-five men with an average age of 67 ± 10.1 (40-85) were included. TEM sutures were recorded as intact in 48/70 (68%) and as dehiscent in 22/70 (32%). It did not have any significant clinical manifestation and was not related with longer postoperative stay or incidence of postoperative complications. Eight of 22 (36.4%) patients with suture dehiscence had per rectal bleeding or febrile temperature without any need for intervention or treatment. The only risk factor for wound dehiscence was a posteriorly located defect. In late postoperative period, there was no difference between groups in LARS or Wexner questionnaire (p value 0.72 and 0.85, respectively). CONCLUSIONS: Our study suggests that 1/3 of the patients' rectal wall defect after TEM will undergo dehiscence in early postoperative period and will not transfer to clinically significant manifestation (without a need of hospitalization or prolonging it). In late postoperative period, there is no difference in bowel function.

Completion total mesorectal excision following transanal endoscopic microsurgery does not compromise outcomes in patients with rectal cancer.

BACKGROUND: Transanal endoscopic microsurgery (TEM) represents a choice of treatment in patients with neoplastic lesions in the rectum. When TEM fails, completion total mesorectal excision (cTME) is often required. However, a concern is whether cTME increases the rate of abdominoperineal resections (APR) and is associated with higher risk of incomplete mesorectal fascia (MRF) resection. The aim of this study was to compare outcomes of cTME with primary TME (pTME) in patients with rectal cancer. METHODS: This was a nationwide study on all patients with cTME from the Danish Colorectal Cancer Group database between 2005 and 2015. Patients with cTME were compared to patients with pTME after propensity score matching (matching ratio 1:2). Matching variables were age, gender, tumor distance from anal verge, American Society of Anesthesiologists (ASA) score and American Joint Committee on Cancer (AJCC) stage. RESULTS: A total of 60 patients with cTME were compared with 120 patients with pTME. Patients with cTME experienced more intraoperative complications as compared to pTME patients (18.3% vs. 6.7%, p = 0.021). However, there was no difference in the rate of perforations at or near the tumor/previous TEM site (6.7% vs. 2.5%, p = 0.224), conversion to open surgery (p = 0.733) or 30-day morbidity (p = 0.86). On multivariate analysis, cTME was not a risk factor for APR (OR 2.49; 95% CI 0.95-6.56; p = 0.064) or incomplete MRF (OR 1.32; 95% CI 0.48-3.63; p = 0.596). There was no difference in the rate of local recurrence between cTME and pTME (5.2% vs. 4.3%, p = 0.1), distant metastases (6.8% vs. 6.8%, p = 1), or survival (p = 0.081). The mean follow-up time was 6 years. CONCLUSION: In our study, the largest so far on the subject, we find no difference in postoperative short- or long-term outcomes between cTME and pTME.

Risk factors and treatment of rectal stenosis after transanal endoscopic microsurgery.

AIM: Rectal stenosis is a relatively rare complication after transanal endoscopic microsurgery (TEM). This study aims to identify the predictive parameters for stenosis and the application of TEM in the treatment. METHOD: The clinical data of patients who underwent TEM for rectal adenoma and early cancer from 2008 to 2019 were retrospectively reviewed. We compared the clinicopathological characteristics of patients with stenosis and those without stenosis and analysed the risk factors for stenosis. Treatment outcomes of stenosis with TEM were evaluated. RESULTS: A total of 230 patients were enrolled in this study. Overall, the postoperative complication rate was 11.7% (27/230), including eight (3.5%) patients with stenosis. Patients with stenosis exhibited a higher rate of tumour showing a laterally spreading morphology (P = 0.048), a wider circumferential extent of mucosal defect (P < 0.001), a shorter distance of the tumour from the anal verge (P = 0.001) and a wider longitudinal extent of mucosal defect (P = 0.027). A circumferential extent of mucosal defect >3/4 (OR 94.945, 95% CI 3.611-2496.41, P = 0.006) was identified as the only independent risk factor for stenosis. The four patients with both stenosis and clinical symptoms were treated by incising the stenosis ring using the TEM platform; the stenosis was cured, and symptoms disappeared after one to four courses of treatment. CONCLUSIONS: Circumferential extent of mucosal defect ≥3/4 was an independent risk factor for stenosis in treating rectal adenoma and early cancer with TEM. Incision of the stenosis ring using the TEM platform is an effective strategy for treating stenosis.

Long-term outcomes of transanal endoscopic microsurgery for clinical complete response after neoadjuvant treatment in T2-3 rectal cancer.

BACKGROUND: Organ sparing by the transanal endoscopic microsurgery (TEM) procedure is a treatment for patients with locally advanced rectal cancer after chemoradiotherapy (CRT) and complete clinical response (cCR). AIMS: To assess the surgical and long-term oncological outcomes of TEM for the treatment in T2-3 rectal cancer after CRT and cCR. METHODS: This study was a retrospective review of a prospective database of patients with rectal cancer who underwent TEM after CRT and cCR from April 2011 to March 2020. RESULTS: 52 patients underwent TEM during a period of 9 years. This group of patients included 27 females and 25 males. The median age was 62 (32-86) years, lesion size was 2.5 (1-4) cm, and lesion distance from the anal verge 7.3 (4-10) cm. Median operative time was 79.5 (25-120) min and hospital stay was 1 day (14 h-4 days). Morbidity rate was 13.5% and reoperation rate due to major complications was 3.8%. Final histological findings confirmed 34 (65.4%) patients with ypT0, 7 (13.5%), 6 (11.5%), and 5 (9.6%) patients with carcinoma ypT1, ypT2, and ypT3, respectively. After a median follow-up period of 86 (5-107) months, 1 (2.4%) patient had local recurrences and 3 (7.3%) distant metastases. The 5-year disease-free survival was 91.7% and 5-year overall survival 89.5%. CONCLUSION: Our experience has shown significant rates of ypT0 and ypT1 associated with excellent long-term results. Performing TEM to treat T2-3N0 rectal cancer after CRT and cCR appears to be an oncologically safe and effective procedure.

Long-term outcomes of open versus closed rectal defect after transanal endoscopic microscopic surgery.

AIM: Management of the rectal defect after transanal endoscopic microsurgery (TEM) is a matter of debate. Data are lacking on long term outcomes and continence of patients with open or closed rectal defect. We sought to analyse these in a retrospective cohort study. METHODS: Patients undergoing TEM via the Specialist Early Rectal Cancer (SERC) MDT between 2012 and 2019 were included from a prospectively maintained database. These were divided into two groups - open and closed, based on management of rectal defect. Patient demographics and outcomes, including pre- and postoperative oncological staging, morbidity, mortality, length of stay and faecal incontinence severity score (FISI) scores were assessed. RESULTS: A total of 170 matched patients were included (70-open, 100-closed rectal defects). Short-term complications (bleeding, infection, urinary retention and infection, length of stay and pain) were 18.8% with no significant difference between the two groups (22% vs. 16%). Most of the defects were well healed upon endoscopic follow-up; more unhealed/sinus formation was noticed in the open group (p = 0.01); more strictures were encountered in the closed group (p = 0.04). Comparing the open and closed defect groups, there was no difference in the functional outcome of patients in those who developed sinus (p = 0.87) or stricture (p = 0.79) but a significant difference in post-TEMS FISI scores in those with healed scar, with those in closed rectal defect group with worsening function (p = 0.02). CONCLUSION: There are pros and cons associated with both rectal defect management approaches. Long-term complications should be expected and actively followed up. Patients should be thoroughly counselled about these and possible deterioration in continence post-TEM.

Transanal Endoscopic Microsurgery (TEMS) for Rectal Cancer: Patient Decision-making, Postoperative Experience and Quality of Life.

BACKGROUND/AIM: Transanal endoscopic microsurgery (TEMS) is a form of minimally invasive surgery for selected rectal cancers. The aim of this study was to explore the factors affecting patients' decision-making concerning the choice of surgical treatment as well as to measure the Quality of Life (QoL) post-TEMS. PATIENTS AND METHODS: Thirty-four patients with rectal cancer stage T1/T2-N0-M0 that underwent TEMS were studied. The questionnaires used included the Short Form SF12v2, Wexner Score (CCF-FIS) and the Sexual Function Questionnaire (SFQ). The patients' views on experience and treatment decision were obtained with a custom-designed questionnaire. Questionnaires were completed at a mean of 6.9 years following treatment. RESULTS: The factors that influenced the patients' decisions were: experience satisfaction (p=0.003), postoperative bowel function (p<0.001), lower incontinence score (p=0.020) and agreement of TEMS experience with preoperative information (p=0.049). Treatment experience satisfaction was associated with family support (p=0.034) and agreement with preoperative information (p=0.047), better bowel function (p=0.026) and mental QoL (MCS) (p=0.003). CONCLUSION: factors important to patients when reflecting on treatment experience are adequate and reliable information, a good QoL and the presence of family support. Clinicians should incorporate those parameters in their practice when assisting patients in making a surgical treatment choice and provide informed consent on TEMS for rectal cancer.

Preoperative chemoradiotherapy affects postoperative outcomes and functional results in patients treated with transanal endoscopic microsurgery for rectal neoplasms.

BACKGROUND: The aim of this study was to quantify the incidence of short-term postoperative complications and functional disorders at 1 year from transanal endoscopic microsurgery (TEM) for rectal neoplasms, to compare patients treated with TEM alone and with TEM after preoperative chemoradiotherapy (CRT) and to analyse factors influencing postoperative morbidity and functional outcomes. METHODS: A retrospective study was conducted on all patients treated with TEM for rectal neoplasms at our institution in January 2000-December 2017. Data from a prospectively maintained database were retrospectively analysed. Patients were divided into two groups: adenoma or early rectal cancer (no CRT group) and locally advanced extraperitoneal rectal cancer with major or complete clinical response after preoperative CRT (CRT group). Short-term postoperative mortality and morbidity and the functional results at 1 year were recorded. The two groups were compared, and a statistical analysis of factors influencing postoperative morbidity and functional outcomes was performed. Functional outcome was also evaluated with the low anterior resection syndrome (LARS) score (0-20 no LARS, 21-29 minor LARS and 30-42 major LARS). RESULTS: One hundred and thirteen patients (71 males, 42 females, median age 64 years [range 41-80 years]) were included in the study (46 in the CRT group). The overall postoperative complication rate was 23.0%, lower in the noCRT group (p < 0.001), but only 2.7% were grade ≥ 3. The most frequent complication was suture dehiscence (17.6%), which occurred less frequently in the noCRT group (p < 0.001). At 1 year from TEM, the most frequent symptoms was urgency (11.9%, without significant differences between the CRT group and the noCRT group); the noCRT group experienced a lower rate of soiling than the CRT group (0% vs. 7.7%; p: 0.027). The incidence of LARS was evaluated in 47 patients from May 2012 on and was 21.3% occurring less frequently in the noCRT group (10% vs. 41.2%; p: 0.012). Only 6.4% of the patients evaluated experienced major LARS. In multivariate analysis, preoperative CRT significantly worsened postoperative morbidity and functional outcomes. CONCLUSIONS: TEM is a safe procedure associated with only low risk of severe postoperative complications and major LARS. Preoperative CRT seems to increase the rate of postoperative morbidity after TEM and led to worse functional outcomes at 1 year after surgery.

Feasibility and Safety of Endoscopic Submucosal Dissection for Recurrent Rectal Lesions that after Transanal Endoscopic Microsurgery: A Case Series.

OBJECTIVES: Recently, several studies have demonstrated the usefulness of endoscopic submucosal dissection (ESD) for residual or locally recurrent colorectal lesions after endoscopic treatment. However, the feasibility of ESD for recurrent rectal lesions after transanal endoscopic microsurgery (TEM) has not been fully investigated. In this study, we evaluated the feasibility and safety of ESD for recurrent rectal lesions after TEM. METHODS: The treatment outcomes of 10 lesions in 9 patients, who underwent ESD between January 2006 and March 2018 for recurrent rectal lesions after transanal endoscopic microsurgery, were evaluated. RESULTS: All lesions were successfully resected en bloc, and the R0 resection rate was 90%. The median size of the resected specimens and lesions (range) was 44 mm (21-70) and 27.5 mm (5-60), respectively. The pathological diagnoses included 4 adenomas and 6 cancerous lesions. The cancerous lesions included 5 cases of mucosal cancer and 1 case of superficial submucosal invasive cancer (depth of submucosal invasion <1,000 µm from the muscularis mucosae). No adverse events occurred. There was no recurrence during the follow-up period. CONCLUSIONS: ESD for recurrent rectal lesions after TEM by expert's hands appears to be safe and feasible.

Comparison among different techniques for en-bloc resection of rectal lesions: transanal endoscopic surgery vs. endoscopic submucosal dissection vs. full-thickness resection device with Over-The-Scope Clip® System.

BACKGROUND: The aim of our retrospective study is to compare the efficacy and indications of transanal endoscopic microsurgery (TEM), endoscopic submucosal dissection (ESD), and endoscopic full-thickness resection device (FTRD) with Over-The-Scope Clip (OTSC®) System for en-bloc resection of rectal lesions. METHODS: This study collected 76 cases of rectal neoplasms from a single hospital institution. Primary endpoints were complete en-bloc resection, intraprocedural adverse events, R0 en-bloc resection and an early discharge of the patient. Secondary endpoints included procedure-related adverse events. RESULTS: Mean tumor sizes were statistically significant smaller among patients treated with FTRD rather than TEM and ESD. TEO and FTRD treated patients experienced a higher en-bloc resection rate, with a shorter procedure time and hospital stay. No significant difference concerning the R0 resection was found. TEO and FTRD recorded lower perforation rates as compared to ESD, whereas no difference emerged concerning the bleeding rate and the post-polypectomy syndrome rate. CONCLUSIONS: Our study showed that each technique has specific features, so that each one offers advantages and disadvantages. Nevertheless, all of them ensure high en-bloc resection rates, whereas no difference exists for R0 resection rate. TEO provides the possibility to remove low rectal large lesions as compared to ESD and FTRD.

Endoscopic submucosal dissection (ESD) versus transanal endoscopic microsurgery (TEM) for treatment of rectal tumors: a comparative systematic review and meta-analysis.

BACKGROUND: While multiple studies have evaluated endoscopic submucosal dissection (ESD) and transanal endoscopic microsurgery (TEM) to remove large rectal tumors, there remains a paucity of data to evaluate their comparative efficacy and safety. The primary aim of this study was to perform a structured systematic review and meta-analysis to compare efficacy and safety of ESD versus TEM for the treatment of rectal tumors. METHODS: Individualized search strategies were developed from inception through November 2018 in accordance with PRISMA guidelines. Measured outcomes included pooled enbloc resection rates, margin-negative (R0) resection rates, procedure-associated adverse events, and rates of recurrence. This was a cumulative meta-analysis performed by calculating pooled proportions. Heterogeneity was assessed with Cochran Q test and I2 statistics, and publication bias by funnel plot using Egger and Begg tests. RESULTS: Three studies (n = 158 patients; 55.22% male) were included in this meta-analysis. Patients with ESD compared to TEM had similar age (P = 0.090), rectal tumor size (P = 0.108), and diagnosis rate of adenoma to cancer (P = 0.53). ESD lesions were more proximal as compared to TEM (8.41 ± 3.49 vs. 5.11 ± 1.43 cm from the anal verge; P < 0.001). Procedure time and hospital stay were shorter for ESD compared to TEM [(79.78 ± 24.45 vs. 116.61 ± 19.35 min; P < 0.001) and (3.99 ± 0.32 vs. 5.83 ± 0.94 days; P < 0.001), respectively]. No significant differences between enbloc resection rates [OR 0.98 (95% CI 0.22-4.33); P = 0.98; I2 = 0.00%] and R0 resection rates [OR 1.16 (95% CI 0.36-3.76); P = 0.80; I2 = 0.00%] were noted between ESD and TEM. ESD and TEM reported similar rates of adverse events [OR 1.15 (95% CI 0.47-2.77); P = 0.80; I2 = 0.00%] and rates of recurrence [OR 0.46 (95% CI 0.07-3.14); P = 0.43; I2 = 0.00%]. CONCLUSION: ESD and TEM possess similar rates of resection, adverse events, and recurrence for patients with large rectal tumors; however, ESD is associated with significantly shorter procedure times and duration of hospitalization. Future studies are needed to evaluate healthcare utilization for these two strategies.

Quality of Life and Bowel Dysfunction after Transanal Endoscopic Microsurgery for Rectal Cancer: One Third of Patients Experience Major Low Anterior Resection Syndrome.

BACKGROUND/AIMS: The low anterior resection syndrome (LARS) severely affects quality of life (QoL) after rectal cancer surgery. Studies investigating LARS and the effect on QoL after transanal endoscopic microsurgery (TEM) for rectal cancer are scarce. The aim of our study was to assess bowel dysfunction and QoL after TEM. METHODS: Seventy-three -patients who underwent TEM for stage I rectal cancer were included in this single-centre, cross-sectional study Bowel dysfunction was assessed by the LARS-Score, QoL by the -European Organization for the Research and Treatment of Cancer QLQ-C30 and -CR29 questionnaires. RESULTS: Fifty-five respondents (75.3%) could be included for the analyses. The median interval since treatment was 4.3 years, and the median age at the follow-up point was 72 years. "Major LARS" was observed in 29% of patients and "minor LARS" in 26%. Female gender (OR 4.00; 95% CI 1.20-13.36), neo-adjuvant chemoradiotherapy (OR 3.63; 95% CI 1.08-12.17) and specimen thickness in millimetres (OR 1.10 for each mm increase in thickness; 95% CI 1.01-1.20) were associated with the development of major LARS. Patients with major LARS fared worse in most QoL domains. CONCLUSION: This is the first study demonstrating major LARS after TEM treatment for rectal cancer, with a negative effect on QoL, even years after treatment. Our data provides an adequate counselling before TEM in terms of postoperative bowel dysfunction and its effect on QoL.

Simultaneous local excision of synchronous rectal polyps by transanal endoscopic microsurgery.

BACKGROUND: The approach to surgical resection of multiple rectal lesions when endoscopic polypectomy is unsuccessful has historically been radical rectal resection with total mesorectal excision. This approach is fraught with high morbidity and mortality. We explored the possibility of performing one transanal endoscopic microsurgery procedure to resect multiple synchronous rectal lesions. MATERIALS AND METHODS: A retrospective analysis of all adult patients undergoing transanal endoscopic microsurgery at a single institution between 2004 and 2015. Clinical, demographic, and pathologic data were analyzed for all patients with synchronous rectal lesions that were excised via one transanal endoscopic microsurgery procedure. RESULTS: Of the 158 patients who underwent transanal endoscopic microsurgery during the study period, 14 (8.8%) had two or more synchronous rectal lesions resected. The mean tumor size was 2.5 cm (range 0.5-3.5). The mean distance from the anal verge for the upper/proximal lesions: 10 ± 2.5 cm, and for the lower/distal lesions: 7 ± 2 cm. Mean operative time was 112 minutes (range 75-170). Median hospitalization time was 3 days (range 2-4). Two patients had urinary retention. No other complications were noted. All the transanal endoscopic microsurgery specimens were with clear margins. CONCLUSION: Transanal endoscopic microsurgery is a safe and feasible procedure for patients with multiple rectal lesions. We demonstrate no increase in surgical time, completeness of specimen resection, no increase in complications or hospital length or stay when compared to patients undergoing transanal endoscopic microsurgery for a single lesion.