Endoscopic microsurgery effective for giant rectal adenomas

Transanal endoscopic microsurgery (TEMS) on large rectal adenomas provides results comparable to or better than those reported for alternative techniques, shows a UK study.

However, the authors found that patients with lesions larger than 5 cm in diameter had a significantly increased risk for postoperative complications and recurrence compared with those with smaller lesions.

The prospective study included data from lesions in 320 patients over a period of 12 years at a single hospital. Overall, the en bloc excision rate was 99%, and, of 301 lesions in which thickness was recorded, 80.7% were excised full thickness.

The authors divided lesions into those that had a maximum diameter of less than 3 cm, 3-5 cm, and greater than 5 cm. They found no statistical difference in rates of unexpected malignancy, or achievement of complete resection margins (R0) between the three groups. However, there was a trend toward higher rates of incomplete resection margins (R1) and unexpected malignancy for larger lesions than smaller lesions.

Univariate analysis showed that distance from the dentate line and age were significantly associated with recurrences, while Cox regression analysis showed that R1 margins had the greatest influence on recurrence.

The authors found that larger lesions were associated with a significantly greater rate of complications, with 24.6% of those with lesions bigger than 5 cm experiencing a complication, compared with 7.4% of those with lesions smaller than 3 cm.

Additionally, 40 months following surgery, disease-free survival was significantly lower in those with lesions greater than 5 cm, compared with the other two groups.

When compared with reports for peranal excision, TEMS resulted in lower R1 resection rates (10-19 vs 29-37%) and lower recurrence rates (5-9 vs 27%). TEMS also performed favorably compared to endoscopic techniques for lesions greater than 3 cm. For example, previous reports suggest that endoscopic submucosal dissection leads to intact en bloc resection rate of 79-93%, and R1 rates of up to 26%, in comparison with 98.9% and 10.9%, respectively, in the study.

Andrea Scala (St Richard's Hospital, Chichester, UK) and colleagues, writing in the Archives of Surgery, conclude: "TEMS on large rectal adenomas provides en bloc, full-thickness specimens, with R1 and recurrences comparable with or better than those reported in literature for peranal excision, EMR, or ESD."

However, they add: "In view of the limitations of this study, future prospective studies on larger series will be welcome to confirm our findings and better delineate the best way of managing giant lesions."

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