Transanal Endoscopic Microsurgery in Small, Large, and Giant Rectal Adenomas

Objective: To assess the outcomes of transanal endoscopic microsurgery in small (<3 cm), large (3-5 cm), and giant (>5 cm) lesions and compare these with reports of alternative techniques. Design: Data from January 1998 to February 2010 were prospectively collected. Lesions were divided into 3 groups according to the maximum diameter (group A, <3 cm; group B, 3-5 cm; and group C, >5 cm) and outcomes were analyzed separately. Setting: Colorectal unit in a single-district general hospital. Patients: Patients diagnosed as having benign rectal adenomas. Intervention: Transanal endoscopic microsurgery excision. Main Outcome Measures: Completion of excision (R0), en bloc and full-thickness excisions, complication and local recurrence rates, and disease-free survival. Results: A total of 320 lesions were analyzed. Overall en bloc and full-thickness excision rates were 99% and 80.7%, respectively. In the 279 benign lesions, the R0 rate was 90.3%. Outcomes for groups A, B, and C were, respectively: 9.3%, 12.8%, and 14.4% incidence of unexpected malignancy (P=.64); 95.9%, 92.2%, and 85.1% R0 resection for benign lesions (P=.19); and 7.4%, 14.9%, and 24.6% complication rates (P<.05). Overall operative mortality was 1 of 320 (0.3%). In group C, there was a higher estimated recurrence rate, therefore a lower disease-free survival than groups A and B; this difference was significant 40 months after surgery. Recurrences were associated with closeness to dentate line and advanced age (univariate analysis) and R1 resection (Cox regression). Conclusions: Outcomes of transanal endoscopic microsurgery on large rectal lesions compared favorably with literature reports of alternative techniques. Postoperative complications and recurrences increased significantly with lesions larger than 5 cm. Arch Surg. 2012; 147(12): 1093-1100. Published online August 20, 2012. doi:10.1001/archsurg.2012.1954