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Aim: Transanal endoscopic microsurgery (TEM) is the current treatment of choice for rectal adenomas and early rectal cancer. Postoperative admission to hospital is common but possibly unnecessary. Our objective was to analyse predictors and outcomes of TEM patients having same day discharge (TEM-D) compared with those who were admitted to hospital (TEM-A)., Method: At St Paul's Hospital (SPH), demographic, surgical, pathological and follow-up data have been collected prospectively since TEM was started in 2007. Trends in admission and readmission rates were analysed using the Cochran-Armitage trend test, and predictors of admission were analysed using univariate and multivariate logistic regressions., Results: Between 2007 and 2016, 500 patients were treated by TEM at SPH. The overall admission rate was 29% (145/500), but this decreased to 19% in the last 3 years of the study (P < 0.001). The readmission rate was 5.2% (n = 26/500) and did not change significantly over the study period (P = 0.30). Reasons for admission included the following: surgeon discretion/monitoring (35%), urinary retention (26%), haemorrhage (10%), breach of peritoneal cavity (7%), infection (7%) and other (15%). The most common reasons for readmission were haemorrhage (54%, n = 14), pain (19%, n = 5) and infection (12%, n = 3). Factors associated with admission were as follows: tumour height (OR 1.09, 1.02-1.17), prolonged operative time (OR 1.25, 1.14-1.37), unsutured surgical defect (OR 1.99, 1.22-3.25) and surgeon experience (OR 4.62, 2.75-7.77)., Conclusion: Outpatient TEM is safe and carries a low risk of readmission. In centres with an outpatient TEM strategy, predictors of hospital admission include proximal tumours, prolonged surgical time and open management of the surgical defect., (Colorectal Disease © 2018 The Association of Coloproctology of Great Britain and Ireland.)

Objective: Muscle injury is inevitable during surgical exposure of the spine. This study compared paraspinal muscle injury after 4 surgical techniques: microdiscectomy (MD), percutaneous endoscopic lumbar discectomy (PELD), percutaneous endoscopic interlaminar discectomy (PEID), unilateral biportal endoscopic discectomy (UBED)., Methods: Eighty patients who underwent MD, PELD, PEID, and UBED were prospectively observed. Creatine phosphokinase (CPK) and C-reactive protein levels were measured on admission and postoperative days 1, 3, 5, and 7. CPK ratio was calculated as CPK on postoperative day 1/CPK on admission. Cross-sectional area of the high-intensity lesion in the paraspinal muscle was measured on magnetic resonance imaging after surgery. Operative time and hospital stay duration were also examined. Clinical outcome was evaluated using the visual analog scale for back and leg pain., Results: MD group had the highest CPK levels on postoperative days 1 and 3 and CPK ratio (P < 0.01, P = 0.02, P = 0.04). Serial C-reactive protein levels were highest in MD group (P < 0.01). PELD and PEID groups had lower C-reactive protein level on postoperative day 1 than UBED group. MD group had largest cross-sectional area (P < 0.01). Cross-sectional area was larger in UBED group than in PELD and PEID groups (P < 0.01). Operative time and hospital stay duration were shortest in PELD group (P < 0.01, P < 0.01). MD group had significantly higher visual analog scale scores for back pain on postoperative days 1 and 3 than the other groups (P < 0.01, P = 0.02)., Conclusions: PELD is the least invasive spinal surgical technique., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Endoscopic resection of large colorectal lesions is well reported and is the first line of treatment for all noninvasive colorectal neoplasms in many centers, but little is known about the outcomes of endoscopic resection of truly massive colorectal lesions ≥8 cm., Objective: We report on the outcomes of endoscopic resection for massive (≥8 cm) colorectal adenomas and compare the outcomes with resection of large (2.0-7.9 cm) lesions., Design: This was a retrospective study., Settings: The study was conducted in a tertiary referral unit for interventional endoscopy., Patients: A total of 435 endoscopic resections of large colorectal polyps (≥2 cm) were included, of which 96 were ≥8 cm., Main Outcome Measures: Outcomes included initial successful resection, complications, recurrence, surgery, and hospital admission., Results: Endoscopic resection was successful for 91 of 96 massive lesions (≥8 cm). Mean size was 10.1 cm (range, 8-16 cm). A total of 75% had previous attempts at resection or heavy manipulation before referral. Thirty two were resected using endoscopic submucosal dissection or hybrid endoscopic submucosal dissection and the rest using piecemeal endoscopic mucosal resection. No patients required surgery for a perforation. Five patients had postprocedural bleeding. There were 25 recurrences: 2 were treated with transanal endoscopic microsurgery, 2 with right hemicolectomy, and the rest with endoscopic resection. Compared with patients with large lesions, more patients with massive adenomas had complications (19.8% versus 3.3%), required admission (39.6% versus 11.0%), developed recurrence (30.8% versus 9.9%), or required surgery for recurrence (5.0% versus 0.8%)., Limitations: This was a retrospective study., Conclusions: Endoscopic resection of massive colorectal adenomas ≥8 cm is achievable with few significant complications, and the majority of patients avoid surgery. Systematic assessment is required to appropriately select patients for endoscopic resection, which should be performed in specialist units. See Video Abstract at http://links.lww.com/DCR/A653.

Background: Patients' selection for transanal endoscopic microsurgery (TEM) depends on diagnostic modalities; however, there are still some limitations in the preoperative diagnosis of rectal lesions, and in some reports, up to third of the adenomas resected by TEM were found to be adenocarcinoma; therefore, salvage radical resection (RR) remains necessary for achieving oncological resection. Salvage RR may encounter some technical problems as the violation of the mesorectum and the scar formation. In this study, we aimed to report the outcome in patients undergoing salvage RR in terms of morbidity and oncological results., Materials and Methods: Demographic and clinical data pertaining to patients undergoing RR following TEM between 2004 and 2014 were retrospectively collected., Results: One hundred forty one TEM were performed in the study period, 53 (38%) for malignant rectal lesions. Indication for TEM: 15 (28%) benign adenoma, 25 (47%) early rectal cancer, and 13 (25%) had clinical complete response after neoadjuvant radiochemotherapy. Ten (19%) patients had no residual tumor in TEM specimen, 15 (28%) had T1, and 2 of them underwent salvage low anterior resection (LAR). Ten (19%) had T2, 4 had LAR, and 1 had abdominoperineal resection (APR). Five (9%) had a T3, 3 underwent LAR, and 2 had APR. Among the 13 (25%) after chemo-radiotherapy (CRT), 4 had salvage AR. The time from TEM to RR was 47 days (range32-70). Of 16 salvage surgeries, 8 (50%) were laparoscopic. The median operative time was 210 minutes (range165-360). Five patients had protective ileostomy. Rectal perforation occurred in 2 (12%) patients; both had a posterior location, one after CRT. Two (12%) postoperative small-bowl obstruction and three wound infections occurred. There was no perioperative mortality in any of the patients who underwent RR. The final pathology was no residual disease in 9, T3N1 in 1, T3N0 in 3, T2N1 in 1, and T2N0 in 2 patients. Eight (50%) had adjuvant chemotherapy., Conclusion: Laparoscopic total mesorectal excision following TEM seems to be safe, and with no negative impact of the completeness of the resection. The concern of intraoperative specimen perforation is real, and should be dealt with meticulous technique and careful dissection, particularly after CRT.

Background: Transanal endoscopic microsurgery (TEMS) is a proven alternative therapy to either radical surgery or endoscopic mucosal resection for rectal neoplasms. It has proven benefits with lower morbidity and mortality compared with total mesorectal excision, and a lower local recurrence rate when compared to endoscopic mucosal techniques., Methods: A retrospective data collection of TEMS procedures performed through Waikato District Health Board, New Zealand, from 2010 to 2015 was conducted. Supportive follow-up data were sourced from patient records and from local centres around New Zealand., Results: A total of 137 procedures were performed over the study period, with five being repeat procedures. Procedures were mostly performed for benign lesions (66.4%) with an overall complication rate of 15.3%, only five of which were Clavien-Dindo grade III (3.6%). Our local recurrence rate after resection of benign lesions was 5.1%., Conclusion: Our data set demonstrates the TEMS procedure to be safe compared to radical resection (total mesorectal excision) for sessile rectal lesions. Close endoscopic follow-up is recommended, especially for close or incomplete margins. Good therapeutic results can be obtained for appropriately selected early malignant lesions. TEMS provides better oncological results than endoscopic mucosal resection or transanal excision., (© 2017 Royal Australasian College of Surgeons.)

Background: Salvage surgery after transanal endoscopic microsurgery (TEM) has shown mixed results. Transanal total mesorectal excision (TaTME) might be advantageous in this population. The aim of this study was to assess the short-term oncologic and operative outcomes of salvage surgery after TEM, comparing TaTME to conventional salavge TME (sTME)., Methods: Consecutive patients treated with salvage surgery after TEM were identified. Patients who underwent TaTME were compared to those who had conventional sTME. The primary outcome was the ability to perform an appropriate oncologic procedure defined by a composite outcome (negative distal margins, negative radial margins and complete or near complete mesorectum specimen)., Results: During the study period, 41 patients had salvage surgery after TEM. Of those, 11 patients had TaTME while 30 patients had sTME. All patients in the TaTME group met the composite outcome of appropriate oncologic procedure compared to 76.7% for the conventional sTME group (p = 0.19). TaTME was associated with significantly higher rates of sphincter preservation (100 vs. 50%, p = 0.01), higher rates of laparoscopic surgery (100 vs. 23.3%, p < 0.001) and lower rates of conversion to open surgery (9.1 vs. 57%, p < 0.001). No difference was found in postoperative morbidity (36.3 vs. 36.7%, p = 0.77)., Conclusions: The present study demonstrates that for patients requiring salvage surgery after TEM, TaTME is associated with significantly higher rates of sphincter-sparing surgery when compared to conventional transabdominal TME while producing adequate short-term oncologic outcomes. Salvage surgery after TEM might be a clear indication for TaTME rather than conventional surgery.

Background: Transanal endoscopic microsurgery (TEM) has been accepted worldwide for the treatment of local rectal lesions. Rare rectal tumors consist of several different types of malignant or benign tumors. Surgical management is considered to be the only curative option. The aim of this study is to investigate the role of TEM in the treatment of rare rectal tumors., Materials and Methods: A total of 147 patients with rare rectal tumors underwent TEM in our center from April 2006 to May 2017. Clinical data were collected and a retrospective accurate database was constructed. Demographic characteristics, operative details, tumor details, complications, and follow-up data were analyzed., Results: Seventy-eight patients were male. Mean tumor diameter was 1.2 ± 0.7 cm and mean distance from the anal verge was 6.6 ± 2.3 cm. Full-thickness and complete resection with negative margins was achieved in all patients. Complications occurred in 3 patients during surgery and in 20 patients after surgery. Histopathologic results were neuroendocrine tumors in 104 patients; gastrointestinal stromal tumors in 35; melanoma, lymphoma, and leiomyoma each in 2; lipoma, and squamous carcinoma each in 1. One hundred thirty-five patients were followed up for 49.3 ± 33.2 months. Two patients died, 1 had local recurrence and 1 had a rectovaginal fistula 1 month after surgery. No local recurrence or metastasis, or fecal incontinence was observed in the remaining patients., Conclusion: TEM is an optimal treatment option for selected rare rectal tumors. The complication rate is low and the therapeutic effect is satisfactory.

Objective: Non-randomised studies suggest that endoscopic mucosal resection (EMR) is equally effective in removing large rectal adenomas as transanal endoscopic microsurgery (TEM), but EMR might be more cost-effective and safer. This trial compares the clinical outcome and cost-effectiveness of TEM and EMR for large rectal adenomas., Design: Patients with rectal adenomas ≥3 cm, without malignant features, were randomised (1:1) to EMR or TEM, allowing endoscopic removal of residual adenoma at 3 months. Unexpected malignancies were excluded postrandomisation. Primary outcomes were recurrence within 24 months (aiming to demonstrate non-inferiority of EMR, upper limit 10%) and the number of recurrence-free days alive and out of hospital., Results: Two hundred and four patients were treated in 18 university and community hospitals. Twenty-seven (13%) had unexpected cancer and were excluded from further analysis. Overall recurrence rates were 15% after EMR and 11% after TEM; statistical non-inferiority was not reached. The numbers of recurrence-free days alive and out of hospital were similar (EMR 609±209, TEM 652±188, p=0.16). Complications occurred in 18% (EMR) versus 26% (TEM) (p=0.23), with major complications occurring in 1% (EMR) versus 8% (TEM) (p=0.064). Quality-adjusted life years were equal in both groups. EMR was approximately €3000 cheaper and therefore more cost-effective., Conclusion: Under the statistical assumptions of this study, non-inferiority of EMR could not be demonstrated. However, EMR may have potential as the primary method of choice due to a tendency of lower complication rates and a better cost-effectiveness ratio. The high rate of unexpected cancers should be dealt with in further studies., Competing Interests: Competing interests: Dr. Dijkgraaf reports grants from The Netherlands Organisation for Health Research and Development, during the conduct of the study. Dr. Fockens reports personal fees from Covidien, personal fees from Fujifilm, personal fees from Olympus, outside the submitted work. Dr. Jansen reports personal fees from MSD, personal fees from Abbvie, personal fees from Takeda and personal fees from Hospira, outside the submitted work. Dr. Schoon reports personal fees from Boston-Scientific, personal fees from Medtronic, personal fees from Olympus, outside the submitted work. Furthermore, we declare no competing interests., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

In 2010 the first report of the application of the flexible transanal port ('operation platform') for the excision of rectal tumours was published. Due to the enhanced vision it provides, adenomas and small malignant rectal tumours can be radically resected with significantly fewer recurrences than with endoscopic mucosal resection or transanal excisions done without this platform. The application of this platform is cheaper and more intuitive than transanal endoscopic microsurgery, while the quality of the local resection, the risk of postoperative complications and the functional and oncological outcomes all appear to be comparable. This is the reason that this flexible platform is now in use in most Dutch hospitals. The flexible port has led to an increase in rectum-sparing treatment for low-risk T1 rectal carcinoma. Nowadays, this platform is also used for the transanal approach during radical rectal surgery for high-risk rectal carcinomas and for rectal operations in patients with benign conditions in the pelvis minor such as severe endometriosis or Crohn's disease.

Background and Aims: Large non-pedunculated rectal polyps are most commonly resected by endoscopic mucosal resection (EMR) or transanal endoscopic microsurgery (TEM). Despite pre-procedural diagnostics, unexpected rectal cancer is incidentally encountered within the resected specimen. This study aimed to compare the diagnostic assessment and procedural characteristics of lesions with and without unexpected submucosal invasion., Methods: A post-hoc analysis of a multicenter randomized trial (TREND study) was performed in which patients with a non-pedunculated rectal polyp of ≥3 cm without endoscopic suspicion of invasive growth were randomized between EMR and TEM., Results: Unexpected rectal cancer was detected in 13% (27/203) of patients; 15 after EMR and 12 after TEM. Most consisted of low-risk T1 cancers (78%, n = 18). There were no differences in the diagnostic assessment between lesions with and without unexpected submucosal invasion. Diagnostic biopsies revealed similar rates of high-grade dysplasia (28% [7/25] vs 18% [26/144]). When compared with EMR of adenomas, EMR procedures of unexpected cancers had a lower success rate of submucosal lifting (60% vs 93%, P < .001), were more often assessed as endoscopically incomplete (33% vs 10%, P = .01), and were more frequently terminated prematurely (60% vs 8%, P = .001)., Conclusions: Diagnostic assessment of large non-pedunculated rectal polyps revealed similar characteristics between unexpected cancers and adenomas. Unexpected cancers during EMR were non-lifting in 40%, endoscopically assessed as incomplete in 33%, and terminated prematurely in 60%. In treatment-naive patients, these factors should raise suspicion of malignancy and need discussion in a multidisciplinary team meeting for decision on further treatment strategies., (Copyright © 2018 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background/aim: To compare the treatment efficacy and safety between endoscopic submucosal dissection (ESD) and transanal endoscopic microsurgery (TEM) for the treatment of rectal epithelial tumors, including large adenoma, cancer, and subepithelial tumors (SET)., Patients and Methods: We conducted a retrospective analysis of the medical records of 71 patients with rectal tumors who were treated with ESD (48 patients) or TEM (23 patients) from January 2013 to December 2015. The patient group comprised 56 patients with epithelial tumors and 15 patients with SET. Treatment efficacy such as en bloc resection, procedure time, local recurrence, hospital stay, additional procedure rate, and safety between the treatment groups were evaluated and analyzed., Results: There were no significant differences in tumor size, location, macroscopic appearance, and histological depth between ESD and TEM groups. For ESD compared to TEM in rectal epithelial tumors, en bloc resection rates were 95% vs. 93.7% and R0 resection rates were 92.5% vs. 87.5% (P = 0.617); in rectal SET, en bloc resection rates were 100% vs. 100% and R0 resection rates were 87% vs. 85% (P = 0.91). The procedure time was 71.5 ± 51.3 min vs. 105.6 ± 28.2 min (P = 0.016) for epithelial tumors and 32.13 ± 13.4 min vs. 80.71 ± 18.35 min (P = 0.00) for SET, respectively. Hospital stay was 4.3 ± 1.2 days vs. 5.8 ± 1.8 days (P = 0.001) for epithelial tumors and 4.1 ± 4.1 days vs. 5.5 ± 2 days (P = 0.42) for rectal SET, respectively. There were no significant differences between recurrence rates, additional procedure rates, and complications in the two groups., Conclusions: ESD and TEM are both effective and safe for the treatment of rectal epithelial tumors and SET because of favorable R0 resection rates and recurrence rates. However, the ESD group showed shorter procedure times and hospital stays than the TEM group. Therefore, ESD should be considered more preferentially than TEM in the treatment of large rectal epithelial tumors and SET., Competing Interests: There are no conflicts of interest

Background: The management of the rectal wall defect after local excision of rectal neoplasms remains controversial, and the existing data are equivocal., Objective: This study aimed to determine the effect of open versus closed defects on postoperative outcomes after local excision of rectal neoplasms., Design: Data from 3 institutions were analyzed. Propensity score matching was performed in one-to-one fashion to create a balanced cohort comparing open and closed defects., Settings: This study was conducted at high-volume specialist referral hospitals., Patients: Adult patients undergoing local excision via transanal endoscopic surgery from 2004 to 2016 were included. Patients were assigned to open- and closed-defect groups, and further stratified by full- or partial-thickness excision., Intervention: Closure of the rectal wall defect was performed at the surgeon's discretion., Main Outcome Measures: The primary outcome measured was the incidence of 30-day complications., Results: A total of 991 patients were eligible (593 full-thickness excision with 114 open and 479 closed, and 398 partial-thickness excision with 263 open and 135 closed). After matching, balanced cohorts consisting of 220 patients with full-thickness excision and 210 patients with partial-thickness excision were created. Operative time was similar for open and closed defects for both full-and partial-thickness excision. The incidence of 30-day complications was similar for open and closed defects after full- (15% vs. 12%, p = 0.432) and partial-thickness excision (7% vs 5%, p = 0.552). The total number of complications was also similar after full- or partial-thickness excision. Patients undergoing full-thickness excision with open defects had a higher incidence of clinically significant bleeding complications (9% vs 3%, p = 0.045)., Limitations: Data were obtained from 3 institutions with different equipment and perioperative management over a long time period., Conclusions: There was no difference in overall complications between open and closed defects for patients undergoing local excision of rectal neoplasms, but there may be more bleeding complications in open defects after full-thickness excision. A selective approach to defect closure may be appropriate. See Video Abstract at http://links.lww.com/DCR/A470.

Background: Distal rectal cancer resection is an ongoing challenge for the colorectal surgeon. In recent years new technical approaches, especially with implementation of transanal platforms were developed to help in the visualization and resection of these tumors. Nevertheless, the use of these platforms is demanding with significant complications during the onset phase., Methods: Patients with very low rectal cancer were operated on in a single tertiary center with a combined abdominal and transanal endoscopic microsurgery (TEM) approach. Demographic, pathological, and surgical data were collected retrospectively with an emphasis on distal margin involvement., Results: Nineteen patients were operated on during the study period. All patients had negative distal resection margins with a low complication rate. The distant metastasis and local recurrence rates were low with a mean follow-up of 2 years., Conclusions: TEM provides an appealing and viable option for the resection of low rectal cancer in a combined transabdominal and transanal approach in patients with a good response after neoadjuvant treatment. This is one of the available platforms a colorectal surgeon might benefit from having in his armamentarium. It has a very low complication rate with maintenance of oncological principles, enabling a clear visualization of the distal rectum, and thus ensures free distal resection margins.

Introduction: McKittrick Wheelock Syndrome (MKWS) is a rare syndrome characterized by secretory diarrhea, dehydration, prerenal acute kidney injury, and severe electrolyte abnormalities caused by a large hypersecretory villous adenoma located in the rectum or rectosigmoid junction. Transabdominal (laparoscopic) procedures are the most described procedures in the treatment of MKWS. We report an alternative surgical approach, transanal minimally invasive surgery (TAMIS), to solve this syndrome., Materials and Methods: All patients who underwent transanal endoscopic microsurgery or TAMIS were included in a prospectively collected database in our center. Between 1996 and 2015, 3 patients were found to have MKWS and treated by TAMIS. Demographics, characteristics of the adenoma, surgery-related data, and outcome were analyzed., Results: The first patient had a villous adenoma 0-12 cm from the anal verge. After TAMIS, she complained of a stenosis that was successfully treated by dilatation. The second patient had an impressive bulky tumor in the rectum. An endoscopic mucosal resection was attempted twice, but incompletely. Pathology analysis showed villous adenoma with high-grade dysplasia and intramucosal carcinoma. One year after TAMIS, a recurrence was detected and treated by an abdominal-perineal resection. A TAMIS was performed in the third patient because of a giant villous circular adenoma, but because of high mucus and fluid production, no proper overview could be obtained. Together with opening of the peritoneum, this prompted us to convert to a laparoscopic Hartmann procedure. Besides this technical difficulty, the patient recovered uneventful., Conclusions: MKWS is a rare syndrome and missed diagnosis could result in life-threatening situations. Different endoscopic and surgical treatments are described to solve this syndrome. TAMIS should be considered as a rectum-preserving surgical treatment option for such extensive adenomas.

Aim: After endoluminal loco-regional resection (ELRR) by transanal endoscopic microsurgey (TEM) the N parameter may remain undefined. Nucleotide-guided mesorectal excision (NGME) improves the lymph node harvest. The aim of the present study is to evaluate the long-term oncological results after ELRR with NGME., Method: A total of 57 patients were enrolled over the period January 2001 to June 2015. All patients underwent ELRR by TEM. Prior to surgery, 99 m-technetium-marked nanocolloid was injected into the peritumoural submucosa. After removal of the specimen, the residual defect was probed to detect any residual radioactivity and 'hot' mesorectal fat was excised. All patients were included in a 5-year follow-up programme., Results: Significant radioactivity in the residual cavity was found in 28 out of 57 patients (49%). The mean number of lymph nodes harvest in irradiated and nonirradiated patients was 1.66 and 2.76, respectively. After 68.2 months' follow-up overall survival was 91.2%, disease-related mortality 3.5% and disease-free survival 89.5%. Two patients developed pulmonary metastases: one ypT3N0 patient underwent lung lobectomy after chemotherapy and one pT2N0 patient was managed with lung radiotherapy. Both patients are currently alive and disease-free at 48 months' follow-up. Two patients developed local recurrence 1 year after ELRR, both treated with neoadjuvant chemo-radiotherapy and total mesorectal excision. Comparing the present series with previous patients who did not undergo NGME, an increased number of harvested lymph nodes were observed, with a statistically significant difference (P = 0.0085)., Conclusion: NGME during ELRR improves the lymph node harvest and staging accuracy. The long-term results showed satisfactory local (3.5%) and distant (7%) recurrence rates., (Colorectal Disease © 2017 The Association of Coloproctology of Great Britain and Ireland.)

Background: To establish the incidence of unsuspected malignancy in lesions excised through transanal endoscopic microsurgery (TEM) and examine the justification for full-thickness excision of all lesions thought to be benign pre-operatively., Methods: Demographic, operative and pathology data of all patients undergoing TEM at a single institution were collected in a prospectively maintained database. Follow-up data were collected with a focus on polyp recurrence rates and outcome in patients found to harbour malignancy. For lesions thought to be benign pre-operatively, a submucosal excision was routinely performed., Results: TEM was attempted in 156 cases between June 1999 and April 2013. Mean (standard deviation) patient age was 66.8 (2.1) years, with 111 males. Mean tumour size was 4.1 (1.6) cm, and mean height from anal verge was 10.4 (2.1) cm. In nine cases, the procedure was unable to be completed and in eight cases a deliberate full-thickness excision was performed. In 139 patients with a presumed benign lesion, mean operating time was 53.4 min. A total of 17 (12.2%) were found to harbour an unsuspected malignancy. Recurrent polyp was seen in 14 (11.7%) of 122 cases of benign pathology (mean follow-up 24.5 months) and was managed by endoscopic means in 10 patients. Mean length of stay was 1.2 days and complications occurred in 7% of cases. No patient with an unsuspected malignancy has developed recurrent disease (mean follow-up 43 months)., Conclusion: Submucosal TEM can result in low complication rates, short duration of surgery, short hospital stay and satisfactory recurrence rates when performed for presumed benign rectal tumours., (© 2016 Royal Australasian College of Surgeons.)

Purpose: Patients affected by Cushing's disease often have important comorbidities directly linked to hypercortisolism that might enhance the operative risk. We report the safety of transsphenoidal surgery in patients affected by Cushing's disease as compared with patients with nonfunctioning pituitary adenoma., Methods: We have retrospectively analyzed 142 patients with Cushing's disease and 299 patients with nonfunctioning pituitary adenoma who underwent transsphenoidal surgery performed by a single experienced neurosurgeon between September 2007 and December 2014. For all of them, an intraoperative computerized anesthetic record for the automatic storage of data was available., Results: The intraoperative vital parameters and the frequency of drugs administered during anesthesia were comparable between Cushing's disease and nonfunctioning pituitary adenoma groups. The duration of surgery was similar between the two groups (41.2 ± 11.8 vs. 42.9 ± 15.6 min), while the duration of anesthesia was slightly shorter in Cushing's disease patients (97.6 ± 18.1 min) than in nonfunctioning pituitary adenoma patients (101.6 ± 20.6 min, p = 0.04). The total perioperative mortality rate was 0.2% (0% in Cushing's disease vs. 0.3% in nonfunctioning pituitary adenoma). Cushing's disease patients had surgical and medical complication rates of 3.5% each, not different from those occurring in nonfunctioning pituitary adenoma. The postoperative incidence of diabetes insipidus (10.6%) and isolated hyponatremia (10.6%) in Cushing's disease patients was significantly higher than in nonfunctioning pituitary adenoma patients (4.4 and 4.1%; p = 0.02 and p = 0.01, respectively)., Conclusions: In a large series of unselected and consecutive patients with Cushing's disease, transsphenoidal surgery performed by one dedicated experienced neurosurgeon had a reasonably low risk of complications. In particular, despite the higher burden of comorbidities typically associated with hypercortisolism, medical complications are rare and no more frequent than in patients with nonfunctioning pituitary adenoma.

Background: There are no data comparing the quality of local excision of rectal neoplasms using transanal endoscopic microsurgery and transanal minimally invasive surgery., Objective: The purpose of this study was to compare the incidence of tumor fragmentation and positive margins for patients undergoing local excision of benign and malignant rectal neoplasms using transanal endoscopic microsurgery versus transanal minimally invasive surgery., Design: This was a multi-institutional cohort study using coarsened exact matching., Settings: The study was conducted at high-volume tertiary institutions with specialist colorectal surgeons., Patients: Patients undergoing full-thickness local excision for benign and malignant rectal neoplasms were included., Interventions: Transanal endoscopic microsurgery and transanal minimally invasive surgery were the included interventions., Main Outcome Measures: The incidence of poor quality excision (composite measure including tumor fragmentation and/or positive resection margin) was measured., Results: The matched cohort consisted of 428 patients (247 with transanal endoscopic microsurgery and 181 with transanal minimally invasive surgery). Transanal minimally invasive surgery was associated with shorter operative time and length of stay. Poor quality excision was similar (8% vs 11%; p = 0.233). There were also no differences in peritoneal violation (3% vs 3%; p = 0.965) and postoperative complications (11% vs 9%; p = 0.477). Cumulative 5-year disease-free survival for patients undergoing transanal endoscopic microsurgery was 80% compared with 78% for patients undergoing transanal minimally invasive surgery (log rank p = 0.824). The incidence of local recurrence for patients with malignancy who did not undergo immediate salvage surgery was 7% (8/117) for transanal endoscopic microsurgery and 7% (7/94) for transanal minimally invasive surgery (p = 0.864)., Limitations: All of the procedures were also performed at high-volume referral centers by specialist colorectal surgeons with slightly differing perioperative practices and different time periods., Conclusions: High-quality local excision for benign and rectal neoplasms can be equally achieved using transanal endoscopic microsurgery or transanal minimally invasive surgery. The choice of operating platform for local excisions of rectal neoplasms should be based on surgeon preference, availability, and cost. See Video Abstract at http://links.lww.com/DCR/A382.

Objective: To determine the predictive factors for endocrinological remission of patients with growth hormone (GH)-secreting pituitary adenomas., Methods: In 47 patients with GH-secreting pituitary adenomas who underwent endoscopic endonasal transsphenoidal surgery with intraoperative GH measurements from 2002 to 2011, the relationship between the intraoperative GH levels and postoperative remission was analyzed, and 2 items that predicted remission (GH half-life obtained 30 minutes or less after removal and a minimum surgical GH level less than 2.5 ng/mL) were determined. In addition, 2 surgical observations (endoscopic confirmation of no tumor remnants and pathologic confirmation of the absence of tumor remnants in the bordering tissue) were also considered. Positive items resulted in one point, and scores ranged from 0 to 4. For 27 patients who underwent surgery from 2012 onwards, this scoring system was applied by 3 independent operators, and the remission rates and predictive values were estimated., Results: Twenty-six of the 47 (55.3%) patients achieved remission. The remission rates were significantly different for different scores. In the 27 patients treated from 2012 onward, repeat residual tumor examinations were performed if the GH score did not reach 2 at the end of the removal. Nine patients had final scores of 3 or 4. All of these patients achieved remission. In 16 patients with final scores of 2 or less, only 2 with Knosp grades of 0 and 1 achieved remission., Conclusions: Our scoring system, which incorporated GH measurements and surgical observations, predicted postoperative remission. Complete tumor removal was critical to achieve intraoperative scores over 3., (Copyright © 2017. Published by Elsevier Inc.)

Purpose: To analyze the feasibility and outcomes of robotic rectal cancer surgery in obese patients., Methods: From 2005 to 2012, 101 consecutive rectal cancers operated robotically were enrolled in a prospective database. Patients were stratified into obese (BMI ≥ 30 kg/m2) and non-obese (BMI &lt; 30 kg/m2) groups. Operative, perioperative parameters, and pathologic outcomes were compared. Data were analyzed using SPSS 22.0, while statistical significance was defined as a p value ≤ .05., Results: There were 33 obese patients (mean BMI 33.8 kg/m2). Patients were comparable regarding gender, T stage, and type of operation. Operative time and blood loss were higher in the obese group; only operative time was statistically significant. The conversion rate, length of stay, and anastomotic leak rates were similar. Circumferential margin positivity and lymph node yield were comparable. Disease free and overall survivals at 3 years were 75.8% versus 80.9% and 84.8% versus 92.6%, respectively for obese and non-obese subgroups., Conclusions: Robotic surgery for curative treatment of rectal cancer in the obese is safe and feasible. BMI does not influence conversion rates, length of stay, postoperative complications, and quality of the specimen or survival when the robotic platform is used.

Transanal endoscopic microsurgery (TEM) is currently the only one-port system in endoscopic surgery, which a direct endoluminal approach can lead to the target organ through a natural opening of human body. TEM has been applied in colorectal surgery for over 3 decades. Compared with radical surgery, TEM has the advantages, such as quicker recovery, shorter hospital stay and fewer complications. One perfect TEM surgical system, which mainly consists of three parts, namely peculiar rectoscope for surgery, special surgical instruments and imaging system, is the foundation of standardized development of TEM. Accurate preoperative evaluation and staging is the key for good outcomes in TEM technology. In addition to digital examination of rectum, rigid sigmoidoscopy(or rectoscopy) should be routinely performed to confirm the location of the lesion and record it in a "time-in-clock" form. For lesions with undetermined nature, biopsy should be performed. For patients with rectal tumor, pelvic MRI examination can be used on the basis of routine endorectal ultrasonography (ERUS). Endoluminal suture is the challenge for standardized development of TEM, especially for those with large intestinal wall defects. Professional training is required to master suture technique. In 2016, the consensus of experts on TEM technology was formulated by TEM Study Group of Colorectal Cancer Specialty Committee of Chinese Anticancer Association. The recommended surgical indications for TEM include (1)rectal adenoma; (2)early rectal cancer with good histopathological features; (3)extended resection of locally malignant polyps by colonoscopy; (4)other rectal tumors suitable for local resection; (5)benign stricture or anastomotic stricture of the rectum; (6)repair of anastomotic leakage after low anterior resection of rectum; (7)diagnosis of rectal hemorrhage; (8)biopsy of rectum and surrounding lesions; (9)repair of rectovaginal fistula or mucosal flap transposition of the internal mouth of anal fistula; (10)treatment of rectal foreign body. With the maturity of TEM technology, the indication of TEM continues to expand. Nowadays, TEM is applicable to rectal neuroendocrine tumor or gastrointestinal stromal tumor resection, as well as rectovaginal fistula repair. It can even serve as a "bottom-up" operation platform for transanal total mesorectal excision (taTME). This article introduces the standardization of TEM, its current indications, novel implications, and future perspectives, expecting that TEM will be further popularized and healthily developed in China.

Background: In patients who exhibit a complete clinical response after radio-chemotherapy for rectal cancer, the standard surgical approach might constitute overtreatment. The aim of this study is to analyse the outcomes of anorectal function and quality of life after transanal endoscopic microsurgery (TEM) in irradiated patients with complete clinical response., Patients and Methods: Between 2007 and 2014, 84 patients who were diagnosed with stage T2-T3-T4 N0 rectal cancer before chemoradiotherapy showed a complete clinical response to neoadjuvant therapy and underwent TEM. All patients were evaluated before and 1 year after TEM using the Cleveland Clinic Florida Fecal Incontinence Score (CCF-FIS) questionnaire to determine the impact of this surgical technique on the degree of faecal continence. To assess the quality of life of patients after surgery, we administered the Fecal Incontinence Quality of Life Scale., Results: Twenty-three patients exhibited a worse incontinence status after surgical intervention (27.4; 95% CI 18.2-38.2). These patients experienced a median positive absolute variation in the CCF-FIS of four points (95% CI 3.5-4.5; p < 0.001). Female sex and age showed a significant correlation with the worsening of continence status. Scores on the Fecal Incontinence Quality of Life Index Scale did not show a significant difference before and after TEM., Conclusions: TEM may be an alternative treatment for patients with rectal cancer who exhibit a complete clinical response to neoadjuvant chemoradiotherapy because it offers the possibility to achieve a full thickness excision of the rectal wall. TEM also allows the identification of any residual disease and provides optimal quality of life and functional results.

Aim: A Snapshot study design eliminates changes in treatment and outcome over time. This population based Snapshot study aimed to determine current practice and outcome of rectal cancer treatment with published landmark randomized controlled trials as a benchmark., Method: In this collaborative research project, the dataset of the Dutch Surgical Colorectal Audit was extended with additional treatment and long-term outcome data. All registered patients who underwent resection for rectal cancer in 2011 were eligible. Baseline characteristics and outcome were evaluated against the results of the Dutch TME trial and the COLOR II trial from which the original datasets were obtained., Results: A total of 71 hospitals participated, and data were completed for 2102 out of the potential 2633 patients (79.8%). Median follow-up was 41 (interquartile range 25-47) months. Overall circumferential resection margin (CRM) involvement was 9.3% in the Snapshot cohort and 18.5% in the Dutch TME trial. CRM positivity after laparoscopic resection was 7.8% in the Snapshot and 9.5% in the COLOR II trial. Three-year overall local recurrence rate in the Snapshot was 5.9%, with a disease-free survival of 67.1% and overall survival of 79.5%. Benchmarking with the randomized controlled trials revealed an overall favourable long-term outcome of the Snapshot cohort., Conclusion: This study showed that current rectal cancer care in a large unselected Dutch population is of high quality, with less positive CRM since the TME trial and oncologically safe implementation of minimally invasive surgery after the COLOR II trial., (Colorectal Disease © 2017 The Association of Coloproctology of Great Britain and Ireland.)

Background: A multimodal treatment has been applied for patients with rectal gastrointestinal stromal tumor (GIST) that represents 5% of the total localization. Meanwhile, transanal endoscopic microsurgery (TEM) offers a minimally invasive method for full-thickness tumor excision with negative margins and low morbidity. We report the single most extensive analysis of data from China to evaluate the feasibility and safety of the procedure combined with neoadjuvant imatinib therapy to treat patients with rectal GISTs., Materials and Methods: All the clinical data were obtained for patients who underwent the procedure in our hospital from February 2008 to May 2015, and the data were retrospectively analyzed., Results: Full-thickness excision by TEM was performed on 25 patients with rectal GIST by using primary surgical excision, 8 of whom had received perioperative chemotherapy after histopathological confirmation under the care of medical oncologists. No obvious postoperative complications were observed. The average tumor downsizing ratio was 14.5%, which apparently enabled oversized tumors to be resected by TEM. The comparative risk did not increase during or after the procedure. We did not observe recurrence or metastasis in any of the 25 patients during the median 3-year follow-up period after the procedures., Conclusions: The perioperative imatinib treatment effectively allowed oversized rectal GIST tumors to be resected by TEM, and the procedures did not exhibit an increased risk. Exclusively, the TEM procedure with alternative neoadjuvant imatinib therapy is a feasible and safe modality for treating patients with rectal GISTs.

Current guidelines recommend radical resection for stage I rectal cancer. However, since screening programs are being installed, an increasing number of cancers are being detected in early stages. Endoscopic resection is often performed at the time of diagnosis. This systematic review was undertaken to review the evidence on endoscopic approach vs. radical resection for stage I rectal cancer. Recommendations were issued based on the GRADE methodology and risk stratification used in clinical practice. A systematic search (until March 2015) identified 2 meta-analyses and 1 additional randomized trial. For the primary outcomes (overall survival, disease-free survival, local recurrence-free survival and metastasis-free survival) no evidence could be found on the superiority of local or radical resection. Secondary outcomes (blood loss, hospital stay, operative time, number of permanent stomas and perioperative deaths) were in favour of local resection. The authors strongly recommend radical resection for T2 rectal cancer, but consider 'en bloc' local resection sufficient for pT1 sm1 rectal cancers when confirmed pathologically. Discussion by a multidisciplinary team and adequate surveillance remain mandatory., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Aim: In patients with rectal cancer, surgery and chemoradiotherapy may affect anal sphincter function. Few studies have evaluated anorectal function after neoadjuvant chemoradiotherapy (n-CRT) and/or transanal endoscopic microsurgery (TEM). The aim of this study was to evaluate the effects of n-CRT and TEM on anorectal function., Method: Thirty-seven patients with rectal cancer underwent anorectal manometry and Wexner scoring for faecal incontinence at baseline, after n-CRT (cT2-T3N0 cancer) and at 4 and 12 months after surgery. Water-perfused manometry measured anal tone at rest and during squeezing, rectal sensitivity and compliance. Twenty-seven and 10 patients, respectively, underwent TEM without (Group A) or with n-CRT (Group B)., Results: In Group A, anal resting pressure decreased from 68 ± 23 to 54 ± 26 mmHg at 4 months (P = 0.04) and improved 12 months after surgery (60 ± 30 mmHg). The Wexner score showed a significant increase in gas incontinence (59%), soiling (44%) and urgency (37%) rates at 4 months, followed by clinical improvement at 1 year (41%, 26% and 18%, respectively). In group B, anal resting pressure decreased from 65 ± 23 to 50 ± 18 mmHg at 4 months but remained stable at 12 months (44 ± 11 mmHg, P = 0.02 vs preoperative values - no significant difference compared with evaluation at 4 months). Gas incontinence, soiling and urgency were observed in 50%, 50%, 25% and in 38%, 12% and 12% of cases, respectively, 4 and 12 months after treatment., Conclusion: TEM does not significantly affect anal function. Instead, n-CRT does affect anal function but without causing major anal incontinence., (Colorectal Disease © 2017 The Association of Coloproctology of Great Britain and Ireland.)

Aim: Full-thickness local excision after neoadjuvant chemoradiotherapy (CRT) for patients with rectal cancer and incomplete clinical response has been a treatment strategy for organ preservation. Follow-up of these patients is challenging since anatomic distortion and postoperative changes may be clinically indistinguishable from tumour recurrence. MRI may have a role in detecting recurrence. The aim of this study was to describe the MRI findings during follow-up in patients having local excision following CRT with and without local recurrence., Method: The data were collected retrospectively from a single centre. Fifty-three patients with rectal cancer who had full-thickness local excision after neoadjuvant CRT and near-complete response were eligible for the study. Patients with local recurrence were treated by radical salvage surgery. The main outcome was local MRI assessment findings during follow-up., Results: Fifteen patients (five who developed local recurrence and 10 with no evidence of local recurrence) had MR images available for review and were included in the study. High signal intensity and thickening of the rectal wall were present in all patients with recurrent disease within the rectal wall. Overall, 80% of the patients with recurrence showed diffusion restriction. MRI mesorectal fascia status and circumferential resection margin showed agreement in all cases. A low signal intensity scar was seen in all patients without recurrent disease., Conclusion: MRI shows high signal intensity and thickening of the rectal wall in recurrent disease in comparison to a low signal intensity fibrotic scar in non-recurrent disease. These findings may be useful in surveillance of these patients., (Colorectal Disease © 2017 The Association of Coloproctology of Great Britain and Ireland.)

Background: There is no consensus on the treatment and prognosis of malignant rectal polyps. The aim of the present study was to determine the role of transanal endoscopic microsurgery (TEM) after endoscopic complete polypectomy of malignant rectal adenomas with long-term follow-up., Methods: Of 105 patients with pT1 rectal carcinoma in 32 patients TEM followed complete endoscopic polypectomy while 73 had primary TEM. Local recurrence (LR), distant metastasis, overall and cancer-specific survival were determined by the Kaplan-Meier method., Results: Median follow-up was 9.1 years. In 32 patients with TEM following complete polypectomy no residual cancer was found. LR occurred in 3/28 (11%) patients with low-risk carcinoma (pT1 G1/2/X, L0/X, R0) and in 1/4 (25%) with high-risk carcinoma (pT1 G3/4 or L1). After primary TEM with complete resection (minimal distance >1 mm) LR occurred in 6/60 (10%) with low-risk carcinoma. After incomplete TEM resection (minimal distance ≤1 mm) LR occurred in 3/8 (38%) patients with low-risk and in 1/5 (20%) patients with high-risk carcinoma. Grading was the only significant risk factor for LR after endoscopic polypectomy followed by TEM (p = 0.002). At all outcomes did not differ between postpolypectomy TEM and primary TEM., Conclusions: Patients with malignant rectal polyps removed by endoscopic polypectomy have a substantial risk of LR even if TEM of polyp site is cancer free. Risk of LR depends on tumor characteristics. In low-risk carcinoma long-term follow-up is necessary. The high LR rate in patients with high-risk rectal carcinoma restricts the use of TEM alone.

Background: To determine whether closure of the defect created during full thickness excision of a rectal lesion with transanal endoscopic microsurgery (TEM) leads to fewer complications when compared to leaving the defect unsutured., Methods: This is a single-center cohort study using a prospectively maintained database. All patients ≥18 years old treated with full thickness TEM with no compromise of the peritoneal cavity were included. Two cohorts were established: patients with the defect sutured and patients with the defect left open. Demographic, operative, and pathologic data were compared. The main outcome analyzed was early (<30 day postoperative) complications, including bleeding that required investigation and readmission, infection, and reoperation., Results: Between 2007 and 2014, data for all patients treated with TEM have been maintained in the St. Paul's Hospital TEM database. Overall, 236 patients had the TEM defect sutured (TEM-S) and 105 patients had the defect left open (TEM-O). There were no differences between the groups in patient age, gender, tumor size or underlying tumor histology. There was no difference in OR time between the groups, but the most experienced TEM surgeon performed significantly more of the TEM-S procedures (61 vs. 39 %, p < 0.01). There were 40 postoperative complications, affecting 11.7 % of the cohort. The complication rate was higher in the TEM-O group (8.4 vs. 19.0 %, p = 0.03). There was no statistically significant difference in bleeding complications (4.7 vs. 7.6 %, p = 0.27) or infections (2.1 vs. 6.7 %, p = 0.05). Readmissions were less common in the TEM-S group (4.7 vs 12.4 %, p = 0.01)., Conclusion: The St. Paul's Hospital TEM experience suggests that while it is safe to leave rectal defects open when a robust mesorectal fat layer is present, there appears to be fewer postoperative complications when the defect is sutured closed.

Aim: The study aimed to establish the oncological outcome of patients who opted for close surveillance with or without adjuvant chemoradiotherapy rather than radical surgery after local excision (LE) of early rectal cancer., Method: The Royal Marsden Hospital Rectal Cancer database was used to identify rectal cancer patients treated by primary LE from 2006 to 2015. All patients were entered in an intensive surveillance programme., Results: Twenty-eight of 34 analysed patients had a high or very high risk of residual disease predicted by adverse histopathological features for which the recommendation had been radical surgery. Eighteen (52%) of the 34 had received radiotherapy following LE. Three-year disease-free survival for the 34 patients was 85% (95% CI 78.8%-91.2%) and overall survival was 100%. Twenty-two of 24 patients with a low tumour which would have required total rectal excision have so far avoided radical surgery and remain disease free at a median follow-up of 3.2 years., Conclusion: The findings suggest that with modern MRI and clinical surveillance radical surgery can be avoided in patients following initial LE of a histopathologically defined high risk early rectal cancer. These findings are comparable with those obtained after major radical resection and warrant further prospective investigation as a treatment arm in larger prospective trials., (Colorectal Disease © 2016 The Association of Coloproctology of Great Britain and Ireland.)

Background: There is debate regarding the appropriate use of transanal endoscopic microsurgery for rectal cancer., Objective: This study analyzed our single-center experience with transanal endoscopic microsurgery for early rectal cancer., Design: Medical charts of patients who underwent transanal endoscopic microsurgery were reviewed to determine lesion characteristics, as well as operative and treatment characteristics. Complications and recurrences were recorded., Settings: The study was conducted at a single academic medical center., Patients: Patients with early stage cancer (T1 or T2, N0, and M0) of the rectum were included., Main Outcome Measures: Local and overall recurrence and disease-specific survival were measured., Results: A total of 92 patients were analyzed. Median follow-up was 4.6 years. Negative margins were obtained in 98.9%. Length of stay was 1 day for 95.4% of patients. The complication rate was 10.9% (n = 10), including urinary retention at 4.3% (n = 4) and postoperative bleeding at 4.3% (n = 4). Preoperative staging included 54 at T1 (58.7%) and 38 at T2 (41.3%). Adjuvant therapy was recommended for all of the T2 and select T1 lesions with adverse features on histology. The final pathologic stages of tumors were ypT0 at 8.7% (n = 8), pT1 at 58.7% (n = 54), pT2 at 23.9% (n = 22), and ypT2 at 8.7% (n = 8). The 3-year local recurrence risk was 2.4% (SE = 1.7), and overall recurrence was 6.7% (SE = 2.9). There were no recurrences among patients with complete pathologic response to neoadjuvant therapy. Mean time to recurrence was 2.5 years (SD = 1.43). A total of 89.2% of patients with very low tumors underwent curative resection without a permanent stoma (33/37). The 3-year disease-specific survival rate was 98.6% (95% CI, 90.4%-99.8%), and overall survival rate was 89.4% (95% CI, 79.9%-94.6%)., Limitations: The study was limited by its single-center retrospective experience., Conclusions: Transanal endoscopic microsurgery provides comparable oncologic outcomes to radical resection in properly selected patients with early rectal cancer. Sphincter preservation rates approach 90% even in patients with very distal rectal cancer.

Surgical treatment for epidermoid cysts of the chiasmatic region is a challenge because of the tendency to a massive spread of epidermoid masses through the cerebrospinal fluid pathways and a significant lesion deviation from the midline., Purpose: To analyze capabilities of the extended endoscopic endonasal transsphenoidal approach in surgery for epidermoid cysts., Material and Methods: The study included 6 patients with epidermoid cysts of the chiasmatic region who were operated on using the extended anterior endoscopic endonasal transsphenoidal approach at the Burdenko Neurosurgical Institute in the past 5 years., Results: Epidermoid masses were completely removed in 5 patients; in none of the cases, complete removal of the epidermoid cyst capsule was achieved. There were no cases of vision deterioration and the development of new focal neurological symptoms. One female patient developed hypopituitary disorders in the postoperative period. There was no recurrence of epidermoid cysts during follow-up., Conclusion: Removal of epidermoid cysts of the chiasmatic region using the extended anterior endoscopic transsphenoidal approach may be an alternative to transcranial microsurgery.

The objective of this study was to evaluate the level of hormone variation between the peripheral blood and spermatic vein plexus in patients with varicoceles. A total of 23 patients diagnosed with varicoceles were enrolled in the study. All patients underwent a testicular artery-sparing microsurgical varicocelectomy. During the operation, a blood sample from the ipsilateral spermatic vein plexus and a peripheral blood sample were collected. A radioimmunoassay was performed to determine the total testosterone, free testosterone, dihydrotestosterone and oestradiol levels. An enzyme-linked immunosorbent assay was performed to determine the albumin level. The mean age of the patients was 32.3 ± 9.3 years. Compared with the hormone level in the peripheral blood, the total testosterone, free testosterone, dihydrotestosterone, and oestrogen levels were significantly increased in the left or right spermatic vein plexus (P < 0.05). There were no differences in the albumin levels in the peripheral blood and spermatic vein plexus (P > 0.05). The mean total testosterone, free testosterone, dihydrotestosterone, and oestradiol levels in the left spermatic vein plexus were 10.8-fold, 29.0-fold, 2.0-fold, and 26.6-fold those of the peripheral blood. The hormone concentration in the spermatic vein plexus was significantly higher than that in the peripheral blood in patients with varicoceles., (© 2016 Blackwell Verlag GmbH.)

Local surgery for rectal tumors has been traditionally limited due to technical issues for lower risk lesions. In the 1980s, Buess described the transanal endoscopic microsurgery (TEM) technique that enabled excision of lesions that were larger and in a higher location. TEM in a short time became the gold standard for the excision of large adenomas and early rectal carcinomas. Since the advent of TEM, and due to advances in minimal invasive technology, new devices and procedures have come to the surgical armamentarium, in many cases with only very slight differences between them. However, local surgery for rectal cancer still remains a challenge. An overview of the current status of minimal transanal invasive techniques is presented here and sheds some light on the controversies that the local management of rectal cancer still raises.

Background: Transanal endoscopic microsurgery (TEM) is a minimally invasive technique allowing to excise large rectal adenomas by local approach. This study shows the feasibility and results of a long term experience of TEM applied in this field., Methods: A retrospective investigation was performed in patients affected by rectal adenomas (5-11 cm in diameter) who had undergone transanal endoscopic microsurgery from 1992 to 2015. A series of 207 patients met the inclusion criteria and were analyzed for characteristics, intraoperative and postoperative results and long-term follow-up., Results: Median age was 71 years (52-83 years). Of the 207 total patients, 77 were women (37.2%) and 130 men (62.8%). Median distance from the anal verge was 8 cm (4-20 cm). Median size was 6 cm, with lesion ranging from 5 to 11 cm in diameter. Median operative time was 57 minutes (42-90 minutes). We observed 17 (8.2%) minor complications and 2 (0.9%) major complication according to the Clavien-Dindo classification. We did not observe any intraoperative or post-operative mortality. Histological examination showed preoperative undiagnosed cancer in 8 (3.8%) cases in which the pathologist revealed adenocarcinoma staged as T1 Sm1 according to the Kikuchi classification. The median follow-up was 115 months (12-288 months). Six recurrences (2.9%), we observed with a median time for recurrence of 14 months., Conclusions: TEM provides excellent oncological outcomes in the treatment of large benign rectal lesions, ensuring a minimal risk of resection margin infiltration at pathological examination, and is associated with low risk of complications.

Background: Transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS) have been shown to improve the quality of transanal resections, allowing for improved visibility and access to the proximal rectum. This study compares the short-term outcomes between TEM and TAMIS among experienced colorectal surgeons., Method: A retrospective review was conducted for TEM and TAMIS performed from 2012 to 2015 by local colorectal surgeons. Baseline patient demographics, operative variables, pathology results, and short-term outcomes were assessed., Results: Sixty-nine patients were identified (40 TEM and 29 TAMIS). Patient demographics, tumor characteristics, operative variables, margin status, and postoperative complications were similar for both. Volume of resection was higher for TAMIS (P < .001). Lymph node retrieval was achieved in 17.2% of TAMIS cases compared with 0% of TEM (P = .01)., Conclusions: TAMIS appears to have equivalent indications and outcomes compared with TEM. TAMIS is associated with larger specimens and more frequent presence of mesorectal lymph nodes., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: The last three decades have witnessed significant improvements in the diagnosis, staging and treatment of rectal cancer leading to a more tailored approach. One of the most clinically relevant advances in this field is represented by transanal endoscopic microsurgery (TEM). Several studies have investigated its role in the treatment of rectal cancer. However, evidence-based recommendations are limited. The aim of this report is to provide an evidence-based review of current indications, controversies and future perspectives of TEM in the management of rectal cancer., Methods: A review of the literature has been performed in PubMed/Medline electronic databases and the Cochrane Library. Quality of evidence was evaluated according to the GRADE system., Results: TEM allows to perform a more accurate en bloc full-thickness local excision of rectal tumors than transanal excision. TEM alone seems to provide similar oncologic results in selected T1sm1 N0 rectal cancers to those achieved by rectal resection and total mesorectal excision (TME), without impairing anorectal function. The oncologic outcomes of neoadjuvant therapy followed by TEM for selected T2 N0 rectal cancers are promising, but this approach is still under evaluation. A word of caution comes from the increased rate of suture dehiscence and rectal pain after TEM. TEM is a promising tool for the surgical treatment of locally advanced rectal cancer as a platform for transanal TME., Conclusions: Selected T1 rectal cancers with favorable features may be effectively treated with TEM without jeopardizing long-term oncologic outcomes. The lack of adequate lymphadenectomy represents the main concern of this approach for the treatment of rectal cancer. Several approaches are under evaluation to overcome this limitation.

Iatrogenic colonic perforations are relatively uncommon but serious complications of diagnostic and therapeutic colonoscopies. Transanal endoscopic microsurgery (TEM) is an useful approach to the rectum and may be used for repair of a rectal perforation during colonoscopy. A 56-year-old male had an iatrogenic perforation of the rectum during a routine follow-up colonoscopy repaired by TEM with an uneventful and rapid recovery.

Aim: Transanal endoscopic microsurgery (TEM) was originally invented by Buess et al. (Chirurg, 1984, 55, 677-80) for the treatment of infraperitoneal rectal adenomas. Its indications have progressively expanded to include larger and more advanced lesions. The aim of the study was to report the results of TEM used for the treatment of circumferential rectal lesions., Method: We retrospectively reviewed the medical records of 17 consecutive patients [median age 69 (32-89) years; nine men] who underwent TEM for a circumferential rectal lesion in our department between September 2010 and January 2015., Results: The median distance from the anal verge was 4 (3-11) cm, the median longitudinal extent was 7 (3-10) cm and the median surface area was 75 (40-255) cm(2) . An end-to-end anastomosis without proximal bowel mobilization was completed endoscopically in all cases. The median operating time was 120 (40-240) min. Persistent, endoscopically uncontrollable endoluminal bleeding in one patient was successfully treated with a second TEM procedure. One patient underwent preoperative radiotherapy for adenocarcinoma detected at the preoperative assessment. Surgical histology showed a pT3 cancer in one patient who refused further surgery, a pT2 cancer in two who subsequently underwent abdominoperineal resection, a pT1 cancer in four and a ypT0 in one patient. All are at present free of disease. No patients developed faecal incontinence or urinary or sexual dysfunction. Four patients required endoscopic balloon dilatation for stenosis., Conclusion: Transanal endoscopic microsurgery is a feasible and safe technique for large circumferential lesions with a satisfactory outcome. Preoperative staging may be inaccurate., (Colorectal Disease © 2016 The Association of Coloproctology of Great Britain and Ireland.)

Transanal endoscopic surgery is a safe, established technique to remove lesions in the rectum via the anus. This article reviews its evolution, approaches, indications and evidence for its role in treating benign rectal polyps. The future of transanal endoscopic surgery in rectal cancer and inflammatory bowel disease is also explored.

Objective: We describe the setup and use of different 3-dimensional (3-D) recording modalities (macroscopic, endoscopic, and microsurgical) in our laboratory and operating room and discuss their implications in neurosurgical research and didactics. We also highlight the utility of 3-D images in providing depth perception and discernment of structures compared with 2-dimensional (2-D) images., Methods: The technical details for equipment and laboratory setup for obtaining 3-D images were described. The stereoscopic pair of images was obtained using a modified "shoot-shift-shoot" method and later converged to a 3-D image. For microsurgical procedures, 3-D images were obtained using an integrated 3-D video camera coupled to the surgical microscope in both the laboratory and the operating room. Illustrative cases were used to compare 2-D and 3-D images., Results: Side-by-side comparisons of 2-D and 3-D images obtained using all modalities revealed that 3-D imaging was superior to 2-D imaging in providing depth perception and structure identification., Conclusions: This is the first report in the literature of the methodology for obtaining 3-D endoscopic endonasal images using the 2-D endoscope. The use of 3-D imaging is invaluable in neurosurgical research and education, as it provides immediate depth perception (third dimension), allowing efficient understanding of key spatial relationships. Integration of 3-D imaging in neurosurgical residency programs may increase learning efficiency and shorten learning curves. However, use of 3-D imaging should not replace direct hands-on practice., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Transanal endoscopic microsurgery is part of the colorectal surgeons' armamentarium for over 2 decades. Since its first implementation for the resection of benign and T1 malignant lesions in the rectum several new indications were developed and it carries additional promise for further extension in upcoming years. Herein we review the technique, its current indications, novel implications, and future perspectives.

Colorectal polyps are frequent in the general population. The diagnostic is made by endoscopy. Polyp's characteristics determine the technic to be used to remove them. Transanal endoscopic microsurgery offers an alternative to radical surgery for large rectal polyps or rectal tumors with low risk of node invasion. One peace resection is necessary to evaluate the resection margins. Lymphatic invasion, ≥ 1 mm submucosae invasion, tumor budding and poorly differentiated tumor are the four main risk factors for node invasion. In case of high risk of lymph node invasion a radical surgery is recommended. Surveillance must be adapted to the polyp type, their number, size, presence of a carcinomatous component as well as age and clinical status of the patient.