Transanal endoscopic microsurgery after endoscopic resection of malignant rectal polyps: a useful technique for indication to radical treatment

Abstract

Background Management of malignant rectal polyps (MRPs) after endoscopic polypectomy (EP) is still debated. It is sometimes difficult to decide whether to simply follow-up (FU) or to treat such a removed lesion. Transanal endoscopic microsurgery (TEM) could have a role both in T staging and in treating MRPs after EP. Methods Patients who underwent a full-thickness TEM within 3 months after an EP between January 2008 and October 2012 were retrospectively analyzed. If post-TEM histology showed locally advanced rectal cancer, patients underwent a total mesorectal excision (TME) within 4-6 weeks. Patients without malignant disease or pT1sm1 cancers at post-TEM histology were followed up every 3 months for 2 years with clinical examination, flexible rectal endoscopy, and neoplastic markers monitoring. Results A total of 39 patients were included. Post-EP histology was adenocarcinoma in 27/39 cases (69.2 %) and adenoma in 12/39. Mean operative time was 64.2 min; no 30-day mortality occurred; 30-day morbidity was 2.7 % (rectal bleeding in 1/39 cases). Post-TEM histology showed a T2 cancer in 5/39 patients, four with and one without a previous cancer diagnosis, who were further treated by TME (four RARs and one APR) and are disease free with a mean FU of 24.2 months. Post-TEM histology showed adenoma in 10/39 cases and fibrosis in 24/39. These patients are disease free with a mean FU of 13 months. Conclusions A full-thickness TEM after EP of MRPs can establish the presence of residual malignant disease and its depth of invasion, precisely defining the indication to TME. In event of benign post-EP histology, TEM must be performed in presence of macroscopic residual disease, in order to obtain an RO resection and finally exclude cancer, while, in absence of macroscopic residual disease, only close FU is required. Keywords Rectal polyps Endoscopic mucosal resection Transanal endoscopic microsurgery Total mesorectal excision Colorectal cancer (CRC) represents the most frequently diagnosed neoplasm in Europe (436,000 new cases/year, i.e. 13.6 % of diagnosed tumors) [1] and accounts for 8 % of deaths for neoplasm in the world and 12.2 % in Europe [2]. With

Transanal endoscopic surgery is effective and safe after endoscopic polypectomy of potentially malignant rectal polyps with questionable margins

“…Arolfo et al . also reported the need to perform a TME in four patients (14.9%). It has been shown that prior TEM does not jeopardize a subsequent TME in terms of oncological outcome if it is performed within 4–6 weeks .…”

“… Morphology and the level of invasion of adenocarcinoma in the polyp . In pedunculate polyps at Haggitt level 4 the risk of lymph node metastasis is 12%–25%, but it is below 1% at Haggitt levels 0–3 , and in sessile polyps the risk of lymphatic involvement is proportional to the degree of submucosal invasion, with rates of 1%–3% in Kikuchi sm1 polyps, 8% in sm2 and 23% in sm3 . Poor differentiation is associated with a 36%–38% likelihood of recurrence or residual lesions . Lymphovascular invasion is associated with a risk of persistence or relapse of 17%–39% . Resection margin : when the resection margin is below 1 mm or affected, the recurrence rate is 21%–33% compared with 0%–2% if the margin is above 1 mm . Tumour budding is an indicator of the aggressiveness of malignant polyps that is associated with a high risk of lymph node metastases, with an odds ratio of 7.74 (95% confidence interval) .…”

“… and 38.5% by Arolfo et al . , the most recent series. In our study the percentage is higher since we included patients with NET histology.…”

Full-Thickness-Resection-Device (FTRD)

“…Die gesamte R0-Rate von Rektum und Kolon betrug 80 % bei einer erzielten Vollwandresektion in 60 % der Fälle. Die diagnostische Aussagekraft einer Vollwandresektion im Rektum mittels klassischer transanaler endoskopischer Mikrochirurgie (TEM) oder der "transanal minimal invasive surgery" (TA-MIS) ist einer endoskopischen Resektion (EMR, ESD) überlegen [8,9]. Darüber hinaus gelingt auch mit der ESD eine diagnostisch zu fordernde En-bloc-Resektion zu Rand und Tiefe nicht immer; die Ergebnisse schwanken zwischen 62-88 %, mit Perforations-und relevanten Blutungsraten von bis zu 14 bzw.…”

Endoscopic resection of colorectal lesions: The narrowing divide between East and West

“…The safety and efficacy of endoscopic resection means that TEMS is not appropriate for treatment of benign naive rectal polyps. It is likely that TEMS has a role for salvage treatment following failed endoscopic resection and it may have a role in select patients with T1 rectal cancer . Beyond the rectum, endoscopic full‐thickness resection (EFTR) is technically possible; however, major barriers exist in closure of a full thickness defect .…”