Surgical Management of Large Sessile Villous and Tubulovillous Adenomas of the Lower Rectum

Abstract

Background: Large sessile adenomas of the rectum are premalignant lesions necessitating complete removal. Methods: We reviewed the data on 20 consecutive patients with large (≧2 cm) sessile villous and tubulovillous adenomas of the lower two thirds of the rectum (≤11 cm from the anal verge). Median (range) adenoma diameter and distance from the anal verge were 5 (2–8) and 7 (4–11) cm, respectively. All 11 patients with an adenomatous circumferential involvement of ≧50% or an endosonographic staging of ≧uT2 underwent a low anterior resection of the rectum. The remaining 9 patients underwent a posterior full-thickness local bowel wall resection (modified Mason procedure). The median (range) follow-up period was 3.8 (0.7–8.2) years. Results: Preoperative biopsy examination successfully excluded invasive carcinoma. Overstaging, however, occurred in 9 of 12 patients (75%) undergoing endosonography, resulting in surgical overtreatment of 4 patients. A curative resection (R0) was always achieved. Five patients had complications, but there was no in-hospital mortality and no cases of local recurrence. 4 out of 19 patients complained of minor stool incontinence, and 3 patients reported incomplete rectal emptying or constipation. Fourteen patients described the operative result as excellent (n = 7) or good (n = 7). Conclusions: Endosonography may lead to overstaging and overtreatment. An individualized approach based on the degree of adenomatous circumferential involvement and endosonographic staging showed no mortality, low morbidity, no local recurrence, and good functional medium-term results.

Treatment of rectal adenomas by transanal endoscopic microsurgery: 15 years’ experience

“…Removal of preneoplastic lesions such as adenomas is thought to be crucial in preventing colorectal cancer. In fact, adenomas of the colon and rectum have the potential to become malignant; this potential is related to size, histological type (villous adenoma), and grade of dysplasia [4][5][6].…”

Transanal Endoscopic Microsurgery (TEM) Facilitated by Video‐Assistance and Anal Insertion of a Single‐Incision Laparoscopic Surgery (SILS®)‐Port: Preliminary Experience

“…Transanal endoscopic microsurgery (TEM), which was described as an innovation in 1983 by Buess et al [1, 2], can be regarded as the first approach to pure natural orifice transluminal endoscopic surgery (NOTES) and single‐port surgery (SPS) [3, 4]. Despite the advantages of classical TEM and its superiority compared with conventional transanal excision [5, 6], including our own concept [7], some difficulties remain, detaining this technique from widespread adoption. The main reasons are the high costs of investment for the required specific TEM devices [8, 9], the long learning curve due to the demanding and inconvenient technique [10, 11], and the at least temporary fecal incontinence in some patients caused by anal dilatation and insertion of the large metal tube [11, 12].…”