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Abstract: Although total mesorectal excision (TME) remains the standard of care for rectal cancer, including early-stage T1/T2 rectal adenocarcinoma, local excision may be warranted for these early-stage tumors in a select group of patients who may decline surgery or may be nonoptimal surgical candidates. Operative approaches for transanal local excision include transanal endoscopic microsurgery or transanal minimally invasive surgery for tumors <4 cm, occupying <40% of the rectal circumference and <10 cm from the dentate line. The use of preoperative chemoradiation therapy may help to downstage tumors and allow for more limited resections, and chemoradiation may also be employed postoperatively. Local excision approaches appear to result in improved quality of life compared with TME, but limited resections may also compromise survival rates compared with TME. Multidisciplinary management and shared decision-making can allow for the desired patient outcomes., Competing Interests: Conflicts of Interest and Source of Funding: S.K.J. receives National Institutes of Health funding. The other authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Transanal surgery facilitates organ preservation in select patients with benign and early malignant rectal lesions to avoid the functional consequences of radical surgery. The transanal endoscopic microsurgery (TEM) platform created a standard for local excision with lower margin positivity and recurrence rates than traditional transanal excision. The single-port robot (SP r) presents a promising alternative transanal platform. The goal of this study was to compare perioperative and pathologic outcomes of TEM and SP r for excision of rectal lesions., Methods: A review of consecutive patients who underwent local excision of rectal lesions at a tertiary referral center from 1/2001 to 5/2022 was performed. Cases were stratified into TEM or SP rTAMIS in a 1:1 propensity score-matched cohort, adjusting for all baseline characteristics. Clinical, tumor-specific, and perioperative outcomes were compared using χ 2 , and Mann-Whitney U-tests. The main outcomes were oncologic quality measures, complications, and operative time., Results: Matching resulted 50 patients in each cohort. Groups had similar age, gender, body mass index, comorbidity, diagnosis, lesion characteristics, and neoadjuvant chemoradiation rates. There were no intraoperative complications in either cohort. Three SP rTAMIS cases were converted intraoperatively; there were no conversions in TEM. SP rTAMIS had significantly shorter operative times than TEM (mean 104 vs. 245, p = 0.027). The rates of positive distal margins (2% TEM, 0% SP rTAMIS) and piecemeal resection (4% TEM, 0% SP rTAMIS) were similar. SP rTAMIS had significantly lower postoperative morbidity rates than TEM (9% vs. 20%, p = 0.031). There was no mortality in either cohort., Conclusions: SP robotics provided high-quality outcomes similar to TEM for local excision of rectal lesions. SP robotics had faster operative time with comparable clinical and oncologic outcomes to TEM. These early data are promising for expanding use of SP robotic platforms., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Despite its existence for more than 40 years, the TEM method has not become widespread. The main reasons are the high acquisition costs, the sophisticated technology and alternative procedures (especially radical resection procedures), which provide greater oncological safety. However, avoiding major abdominal surgery with the creation of a stoma and higher complication rates can outweigh the higher risk of recurrence for some patients. We examined the results using V-TEM with reduced acquisition costs in the resection of adenomas and carcinomas and discussed its importance by literature ., Method: From 2003 to 2019, 154 patients with 170 findings were operated by V-TEM technology. Data on the operation and follow-up were collected and analyzed retrospectively., Results: The median age was 67 years, 89 patients were male and 65 female. V-TEM was performed on 79 carcinomas, 77 adenomas and 14 other findings. The complication rate was 21.2 %. R0 resection was achieved in 78.8 %. The adenoma recurrence rate was 7.3 %, the overall recurrence rate for carcinomas 11.9 %, local recurrences were observed in 6.8 %. The disease-specific survival is 100 % at 5 years and 94.2 % at ten years., Discussion: The successful use of TEM in adenomas and early carcinomas is undisputed. When treating carcinomas from a T1 high risk stage using TEM, recurrence rates higher than 10 % must be expected. Better results can be achieved with radical procedures, this is why they are considered the therapy of choice in these cases. However, there are no differences in terms of survival rates and TEM offers proven better postoperative quality of life. In particular, the combination of neoadjuvant procedures with TEM delivered promising results in more advanced stages. Further studies on TEM and the possibility of lower acquisition costs through modification to V-TEM could make the method more popular in the future., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Background/aims:  Although endoscopic resection is an effective treatment of rectal neuroendocrine neoplasms (R-NENs) with low malignant potential, there is no consensus on the most recommended endoscopic method. This study aimed to assess the efficacy and acceptability of different endoscopic treatments for R-NENs with low malignant potential., Materials and Methods:  We searched databases for studies on treatments of R-NENs using endoscopic resection. These studies comprised techniques such as endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), modified endoscopic mucosal resection (EMRM), modified endoscopic submucosal dissection (ESDM), and transanal endoscopic microsurgery (TEM). The primary outcomes assessed were histological complete resection (HCR)., Results:  Overall, 38 retrospective studies (3040 R-NENs) were identified. Endoscopic mucosal resection with a cap (EMRC), endoscopic mucosal resection with ligation (EMRL), ESD, ESDM, and TEM demonstrated higher resectability than did EMR in achieving HCR. Endoscopic mucosal resection, EMRC, EMRL, EMRP, EMRD, and EMRU required shorter operation times than did ESD. Endoscopic mucosal resection, EMRC, ESDM, and TEM incurred lower risks than did ESD., Conclusion:  Regarding R-NENs <20 mm with low malignant potential, ESD could be used as the primary treatment. However, TEM may be more effective if supported by economic conditions and hospital facility. With respect to R-NENs <16 mm with low malignant potential, EMRL could be used as the primary treatment. In regard to R-NENs <10 mm with low malignant potential, EMRL, EMRC, and ESD could be used as the primary treatment. However, EMRL and EMRC might be better when operational difficulties and economic conditions were considered.

Background: Transanal endoscopic microsurgery (TEM) is an established technique for the resection of rectal adenomas and selected malignant tumours. It avoids the morbidity of radical resection for tumours not amenable to endoscopic resection. An important marker of quality is the local recurrence rate. The primary objective was to determine local recurrence rates for benign and malignant rectal tumours., Methods: We identified index TEM excisions of rectal adenomas and adenocarcinomas in patients age 18 and over at Dunedin Hospital, New Zealand, between 2000 and 2020, from a prospective database. Surveillance data were collected via chart review. The primary outcome was recurrence rate for adenomas and adenocarcinomas. Secondary outcomes included time to recurrence, association of recurrence with recognized risk factors, and adverse event rates., Results: We identified 100 patients for analysis. Of 75 benign cases, 11 (14.7%) developed local recurrence, with 63.6% identified within 1 year. Of the 25 malignant cases (19 T1, 5 T2, 1 T3), 9 (36%) developed recurrence, with 77.8% identified within 2 years. Adverse events occurred in 26% of patients, with no reoperations or deaths., Conclusion: Our adenoma recurrence rate was at the higher end of the reported range of 2.4-16%. Minor complications were common, but not major morbidity. The propensity for rectal tumours to recur commonly and early reinforces the importance of regular standardized endoscopic surveillance., (© 2023 The Authors. ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.)

Introduction: Retrorectal lesions (RRLs) are rare lesions that originate from the tissue present in the retrorectal space. The gold standard of care is complete resection regardless of pathology. The traditional approaches (anterior, posterior, and combined) are relatively well described. Transanal Endoscopic Microsurgery (TEM) is a minimally invasive technique offered as an alternative approach for RRLs., Aim: To evaluate the outcomes of patients diagnosed with RRL and treated by the TEM approach, especially postoperative complications, and the recurrence rate., Methods: Patients with RRLs treated with the TEM technique in one medical center between 2000 and 2020 were identified. Their postoperative outcomes were compared with historical controls., Results: Thirty-nine patients diagnosed with RRL were operated on using the TEM platform. Thirty-seven RRLs were benign, and two were malignant. Their median size (IQR) was 20 mm (15, 32.5). The median distance (IQR) from the anal verge was 50 mm (50, 72.5). The median operative time (IQR) was 48.5 min (41.75, 60). All, except one lesion, were completely resected. The median length of stay (IQR) was one day (1, 1 day). Postoperative complications were diagnosed in three patients, two of which resolved following a second operation., Conclusions: The implementation of TEM for the resection of RRLs demonstrated excellent overall results with acceptable complication and recurrence rate and represented a viable alternative surgical approach., (© 2023. Springer Nature Switzerland AG.)

Background: Endoscopic techniques allow resections of deep submucosal invasion rectal carcinoma, but mostly are facing issues such as costs, follow-up care or size limit. Our aim was to design a new endoscopic technique, which retains the advantages over surgical resections while eliminating the disadvantages mentioned above., Patients and Methods: We propose a technique for the resection of the superficial rectal tumours, with highly suspicious deep submucosal invasion. It combines steps of endoscopic submucosal dissection, muscular resection and edge-to-edge suture of the muscular layers, finally performing the equivalent of a "transanal endoscopic microsurgery" with a flexible colonoscope (F-TEM)., Results: A 60-year-old patient was referred to our unit, following the discovery of a 15 mm distal rectum adenocarcinoma. The computed tomography and the endoscopic ultrasound examination revealed a T1 tumour, without secondary lesions. Considering that the initial endoscopic evaluation highlighted a depressed central part of the lesion, with several avascular zones, an F-TEM was performed, without severe complication. The histopathological examination revealed negative resection margins, without risk factors for lymph node metastasis, no adjuvant therapy being proposed., Conclusion: F-TEM allows endoscopic resection of highly suspicious deep submucosal invasion T1 rectal carcinoma and it proves to be a feasible alternative to surgical resection or other endoscopic treatments as endoscopic submucosal dissection or intermuscular dissection., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Aim: The objective of this study was to evaluate the safety and effectiveness of transanal endoscopic microsurgery for rectal neuroendocrine tumours., Method: A retrospective cohort study of all pathology-confirmed rectal neuroendocrine tumours treated by transanal endoscopic microsurgery from April 2007 to December 2020 at a tertiary care centre was performed. Demographic, clinical, radiographic and pathological data were collected. Characteristics of patients with recurrence were examined. Descriptive statistics were performed., Results: There were 58 patients treated by transanal endoscopic microsurgery excision. Referrals were for primary excision (15, 25.9%), completion re-excision after incomplete endoscopic removal (38, 65.5%) or locally recurrent rectal neuroendocrine tumours (5, 8.6%). The mean age of patients was 56.4 ± 11.9 years and 26 patients were women (44.8%). Mean tumour size was 7.4 ± 3.8 mm (range 1.0-15.0 mm). Most (86.4%) were Grade 1 tumours. Mean operative time was 37.2 ± 17.2 min and 56 patients (96.6%) were discharged on the same day. All patients had negative margins on final pathology. Of the 38 patients who were referred for completion re-excision after incomplete endoscopic removal, eight (21.1%) had residual tumour on final pathology. Three recurrences were diagnosed at 2.1, 4.5 and 12.5 years after excision. All recurrences were from Grade 1 or 2 primary tumours, less than 2 cm, and diagnosed radiographically., Conclusion: To date, this is the largest North American study looking at transanal endoscopic microsurgery for rectal neuroendocrine tumours. This technique is effective in managing primary, incompletely excised and recurrent tumours with good clinical and oncological outcomes., (© 2023 Association of Coloproctology of Great Britain and Ireland.)

Background: The standard treatment of T2-T3ab,N0,M0 rectal cancers is total mesorectal excision (TME) due to the high recurrence rates recorded with local excision. Initial reports of the combination of pre-operative chemoradiotherapy (CRT) and transanal endoscopic microsurgery (TEM) have shown reductions in local recurrence. The TAU-TEM study aims to demonstrate the non-inferiority of local recurrence and the improvement in morbidity achieved with CRT-TEM compared with TME. Here we describe morbidity rates and pathological outcomes., Patients and Methods: This was a prospective, multicentre, randomised controlled non-inferiority trial including patients with rectal adenocarcinoma staged as T2-T3ab,N0,M0. Patients were randomised to the CRT-TEM or the TME group. Patients included, tolerance of CRT and its adverse effects, surgical complications (Clavien-Dindo and Comprehensive Complication Index classifications) and pathological results (complete response in the CRT-TEM group) were recorded in both groups. Patients attended follow-up controls for local and systemic relapse., Trial Registration: NCT01308190., Results: From July 2010 to October 2021, 173 patients from 17 Spanish hospitals were included (CRT-TEM: 86, TME: 87). Eleven were excluded after randomisation (CRT-TEM: 5, TME: 6). Modified intention-to-treat analysis thus included 81 patients in each group. There was no mortality after CRT. In the CRT-TEM group, one patient abandoned CRT, 1/81 (1.2%). The CRT-related morbidity rate was 29.6% (24/81). Post-operative morbidity was 17/82 (20.7%) in the CRT-TEM group and 41/81 (50.6%) in the TME group (P < 0.001, 95% confidence interval 42.9% to 16.7%). One patient died in each group (1.2%). Of the 81 patients in the CRT-TEM group who received the allocated treatment, 67 (82.7%) underwent organ preservation. Pathological complete response in the CRT-TEM group was 44.3% (35/79). In the TME group, pN1 were found in 17/81 (21%)., Conclusion: CRT-TEM treatment obtains high pathological complete response rates (44.3%) and a high CRT compliance rate (98.8%). Post-operative complications and hospitalisation rates were significantly lower than those in the TME group. We await the results of the follow-up regarding cancer outcomes and quality of life., Competing Interests: Disclosure The authors have declared no conflicts of interest., (Copyright © 2022 European Society for Medical Oncology. Published by Elsevier Ltd. All rights reserved.)

Purpose: Our goal was to assess the outcomes of rectal wall suture during the early and late periods after transanal endoscopic microsurgery (TEM) and long-term bowel function., Methods: Patients who underwent TEM for rectal neoplasms from May 2017 to March 2021 were prospectively included. A total of 70 patients were enrolled. Seven to 10 days after TEM, clinical data were recorded, and digital rectal examination and rigid proctoscopy were performed. After at least 6 months, bowel function was evaluated using low anterior resection syndrome (LARS) and Wexner questionnaires., Results: Forty-five men with an average age of 67 ± 10.1 (40-85) were included. TEM sutures were recorded as intact in 48/70 (68%) and as dehiscent in 22/70 (32%). It did not have any significant clinical manifestation and was not related with longer postoperative stay or incidence of postoperative complications. Eight of 22 (36.4%) patients with suture dehiscence had per rectal bleeding or febrile temperature without any need for intervention or treatment. The only risk factor for wound dehiscence was a posteriorly located defect. In late postoperative period, there was no difference between groups in LARS or Wexner questionnaire (p value 0.72 and 0.85, respectively)., Conclusions: Our study suggests that 1/3 of the patients' rectal wall defect after TEM will undergo dehiscence in early postoperative period and will not transfer to clinically significant manifestation (without a need of hospitalization or prolonging it). In late postoperative period, there is no difference in bowel function., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Transanal endoscopic microsurgery (TEM) and transanal endoscopic operation (TEO) have been initially described for local excision of rectal adenomas and selected cases of rectal carcinomas. In the past decade, however, several new indications raised, and others could raise in the future. The aim of this review was to evaluate, both in the literature and in our personal experience, the use of TEM and TEO for non-conventional applications, different from rectal tumors., Evidence Acquisition: We conducted a systematic review of published papers and we selected articles reporting patients who underwent endoscopic surgery for other medical reason than polyp cancer resection, with TEM or TEO. PubMed, MEDLINE, EMBASE and bibliographies of the selected studies were searched for articles in English published up to May 2020 to identify all relevant articles. We excluded articles reporting TEM and TEO used for classical indications. We finally report our experience of non-conventional use of TEO in 5 patients with different diseases., Evidence Synthesis: The research revealed 800 papers and among them we selected 52 articles for a total of 697 patients. Of all patients, only 52 had intraoperative or postoperative complications, with only 10 patients requiring major surgery., Conclusions: Our study suggests that TEM and TEO may be valid alternatives to traditional surgery in situations other than its classical indication. These findings can positively impact on the care of patients, who could benefit from less invasive surgical procedures associated with lower morbidity.

Surgical resection is the cornerstone of curative intent therapy for rectal cancer. The introduction of the concept of total mesorectal excision (TME) led to significant decreases in local recurrence. However, TME carries substantial morbidity. The advent of transanal endoscopic techniques, such as transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS), has allowed patients with early-stage disease to be managed with local excision and avoid the morbidity of TME. Advances in surgery such as laparoscopy, robotic surgery, and transanal approaches have also broadened the options for achieving TME. However, there is significant debate within the literature regarding the optimal approach and oncologic outcomes of these modalities., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Endoscopic submucosal dissection (ESD) is technically demanding and time-consuming. Moreover, it bears a high risk of adverse events compared to other endoscopic methods, due to the lack of tissue manipulation. Robotic technology can significantly reduce the time of the procedure and increase the rate of complete resection for ESD. In the case of an unclear deep margin it allows to proceed to the full-thickness excision of the bowel wall. While the gain over transanal endoscopic microsurgery (TEM) is limited today, the longer systems currently under development will allow these complex procedures to be performed at least in the left side of the colon. The Supplementary video shows the application of the Flex Robotic System to perform an ESD and a full-thickness excision.

Aim: Since its introduction, transanal endoscopic microsurgery (TEM) has become the treatment of choice for rectal benign lesions not amenable to flexible endoscopic excision and for early rectal cancer. Disposable soft devices as the Trans-anal Minimally Invasive Surgery (TAMIS) are a valid alternative to non-disposable rigid trans-anal endoscopic microsurgery (TEM) platforms. The aim of the present study is to compare TEM and TAMIS in terms of incidence of R1 resection and lesion fragmentation which were combined in a composite outcome called quality resection. Perioperative complication and operative time were also investigated., Methods: A total of 132 patients were eligible for this study of whom 63 (47.7%) underwent TAMIS and 69 (52.3%) underwent TEM. Patients were extracted for from a prospective maintained database and groups resulted homogenous after matching using propensity score in terms of size of the lesion, height from the anal verge, position within the rectal lumen, preoperative histology, neoadjuvant treatment. A multivariate logistic and linear regression analysis was carried out using those variables that have significant independent relationship with the quality of surgical resection and operative time., Results: The incidence of R0 resection and lesion fragmentation was similar between groups. No differences were found in terms of perioperative complication. TAMIS was associated with less setup time and less operative time compared with TEM. Variables influencing quality resection at the multivariate analysis were larger lesion (> 5 cm) and ≥ T2 stage. Variables influencing operative time were surgical procedure (TEM vs TAMIS), height from the anal verge and size of the lesion., Conclusion: The present study shows that TEM and TAMIS are equally effective in terms of quality of local excision and perioperative complication. TAMIS resulted less operative time consuming compared to TEM., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: To analyze early and long-term outcomes after total mesorectal excision (TME) and transanal endoscopic microsurgery (TEM) in patients with T1 rectal cancer., Material and Methods: A retrospective non-randomized comparative study included 2 groups of patients: group 1 - total mesorectal excision, group 2 - transanal endoscopic microsurgery. In the second group, total mesorectal excision was proposed for patients with tumor invasion depth pT1sm3 and/or lymphovascular invasion and/or low differentiation. If total mesorectal excision was performed as a salvage surgery, the patient was excluded from further analysis., Results: There were 156 patients with rectal adenocarcinoma pT1 between October 2011 and August 2019 (102 cases - TEM, 54 cases - TME). We excluded 10 patients from the TEM group due to salvage surgery. Duration of TEM was 40.0 (34; 50) min, TME - 139 (120; 180) min ( p =0.00001). Postoperative hospital-stay was also significantly less in the TEM group (7 (6; 9) vs. 10 (7; 11) days, p =0.00001). Six (6.5%) patients in the TEM group and 1 (1.8%) patient in the TME group developed a local recurrence in pelvic cavity ( p =0.1). There were no distant metastases. Disease-free 3-year survival was 92% after TEM and 96% after TME ( p =0.058)., Conclusion: Transanal endoscopic microsurgery is a relatively safe alternative to total mesorectal excision for early rectal cancer.

Background: Treatment of early rectal cancer is evolving towards organ-preserving therapy which includes endoscopic resection and transanal approaches. We aimed to explore the role of local treatments such as endoscopic polypectomy (Endoscopic Mucosal Resection (EMR) or Endoscopic submucosal dissection (ESD)) and transanal endoscopic microsurgery/ transanal minimal invasive surgery (TEM/TAMIS) in patients who had early rectal cancer. We considered these outcomes alongside conventional major surgery using total mesorectal excision (TME) for early stage disease., Methods: All patients identified at MDT with early stage rectal cancer at our institution between 2010 and 2019 were included. Long-term outcomes in terms of local recurrence, survival and procedure-specific morbidity were analysed., Results: In total, 536 patients with rectal cancer were identified, of which 112 were included based on their pre-operative identification at the MDT on the basis that they had node-negative early rectal cancer. Among these, 30 patients (27%) had the lesion excised by flexible endoscopic polypectomy techniques (EMR/ESD), 67 (60%) underwent TEM/TAMIS and 15 (13%) had major surgery. There were no differences in patient demographics between the three groups except for TEM/TAMIS patients being more likely to be referred from another hospital (p < 0.001) and they were less active (WHO performance status p = 0.04). There were no significant differences in overall survival rates and cancer-specific survival between the three treatment groups. The 5-year overall survival rate for endoscopic polypectomy, TEM/TAMIS or major resection was 96% versus 90% and 88%, respectively (p = 0.89). The 5- year cancer-specific survival rate was 96%, versus 96% and 100%, respectively (p = 0.74)., Conclusion: Endoscopic polypectomy by EMR/ESD is an appropriate local treatment for early stage rectal cancer in selected patients. It is possible to achieve good oncological outcomes with a polypectomy similar to TEM/TAMIS and major surgery; however, a multidisciplinary approach is necessary enabling close surveillance and the use of adjuvant radiotherapy., (© 2021. The Author(s).)

Background: Complete local resection is currently the treatment of choice for low-risk early rectal cancer; however, the ideal resection technique for such tumours is still debated. Transanal endoscopic microsurgical submucosal dissection (TEM-ESD) is a new technique which combines the ergonomic advantages of transanal endoscopic microsurgery (TEM) with the minimally invasive approach of endoscopic submucosal dissection (ESD). The aim of our study was to assess the feasibility, safety, and long-term outcomes of TEM-ESD in treating early rectal cancer., Materials and Methods: We retrospectively analysed all cases of rectal adenocarcinomas treated with TEM-ESD in Karlsruhe Municipal Hospital between 2012 and 2019, as well as the perioperative and follow-up data of the patients., Results: We identified 40 cases (19 low-risk and 21 high-risk carcinomas) matching our criteria. The median size of the lesions was 3.8 cm and the median operating time 48.5 min. En bloc resection was possible in all cases, while histologically complete resection was confirmed in 18 of 19 low-risk tumours and in 30 out of all lesions. The resection was curative in 19 cases. No scarring of the mesorectum was reported during the completion of total mesorectal excision for high-risk tumours. There was only 1 case of local recurrence among patients treated with curative intent, with an overall survival rate of 100% and a disease-free survival rate of 96% at both 2 and 5 years for these patients., Conclusion: TEM-ESD is a safe and feasible therapeutic option for resecting early rectal cancer, offering very good long-term outcomes., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background and Aim: Endoscopic submucosal dissection and transanal endoscopic microsurgery are good options for the treatment of rectal adenomas and early rectal carcinomas, but whether long-term outcomes of these procedures are comparable is not known. The aim of this study was to address this question., Methods: A retrospective single-center study evaluating 98 consecutive procedures between June 2008 and December 2017 was performed in a tertiary cancer center. Consecutive patients who had undergone either endoscopic submucosal resection or transanal endoscopic microsurgery for rectal adenomas and early rectal carcinomas were evaluated, and long-term recurrence and complication rates were compared., Results: Both groups were similar regarding sex, age, preoperative surgical risk, and en bloc resection rate (95.7% in the endoscopic and 100% in the surgical group, P = 0.81). Mean follow-up period was 37.6 months. Lesions resected endoscopically were significantly larger (68.5 mm) than those resected by transanal resection (44.5 mm), P = 0.003. Curative resections occurred in 97.2% of endoscopic resections and 85.2% of the surgical ones (P = 0.04). Comparing resections that fulfilled histologic curative criteria, there were no recurrences in the endoscopic group (out of 69 cases) and two recurrences in the transanal group (8.3% of 24 cases), P = 0.06. Late complications occurred in 12.7% of endoscopic procedures and 25.9% of surgical procedures (P = 0.13)., Conclusions: In our experience, endoscopic submucosal resection seems to have advantages over transanal endoscopic microsurgery, with similar en bloc resection rate and lower rate of late complications and recurrences. Multicenter randomized controlled trials are needed to support our findings., (© 2020 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

The application of 3D printing in planning endoscopic endonasal transsphenoidal surgery is illustrated based on the analysis of patients with intracranial skull base diseases who received treatment in our department. Cranial computed tomography/magnetic resonance imaging data are attained preoperatively, and three-dimensional reconstruction is performed using MIMICS (Materialise, Leuven, Belgium). Models of intracranial skull base diseases are printed using a 3D printer before surgery. The models clearly demonstrate the morphologies of the intracranial skull base diseases and the spatial relationship with adjacent large vessels and bones. The printing time of each model is 12.52-15.32 h, and the cost ranges from 900 to 1500 RMB. The operative approach was planned in vitro, and patients recovered postoperatively well without severe complications or death. In a questionnaire about the application of 3D printing, experienced neurosurgeons achieved scores of 7.8-8.8 out of 10, while unexperienced neurosurgeons achieved scores of 9.2-9.8. Resection of intracranial skull base lesions is demonstrated to be well assisted by 3D printing technique, which has great potential in disclosing adjacent anatomical relationships and providing the required help to clinical doctors in preoperative planning.

Fecal microbiota transplantation (FMT) is a highly effective treatment for recurrent Clostridioides difficile infection (rCDI). However, standardization of FMT products is essential for its broad implementation into clinical practice. We have developed an oral preparation of freeze-dried, encapsulated microbiota, which is ~ 80% clinically effective, but results in delayed engraftment of donor bacteria relative to administration via colonoscopy. Our objective was to measure the engraftment potential of freeze-dried microbiota without the complexity of variables associated with oral administration. We compared engraftment of identical preparations and doses of freeze-dried microbiota following colonoscopic (9 patients) versus oral administration (18 patients). Microbiota were characterized by sequencing of the 16S rRNA gene, and engraftment was determined using the SourceTracker algorithm. Oligotyping analysis was done to provide high-resolution patterns of microbiota engraftment. Colonoscopic FMT was associated with greater levels of donor engraftment within days following the procedure (ANOVA P = 0.035) and specific increases in the relative abundances of donor Lachnospiraceae, Bacteroidaceae, and Porphyromonadaceae (P ≤ 0.033). Lower relative abundances of Bacteroidaceae, Lachnospiraceae, and Ruminococcaceae families were associated with clinical failures. These results suggest that further optimization of oral capsule FMT may improve its engraftment efficiency and clinical efficacy.

Objectives: The aim of this study was to compare radiofrequency ablation (RFA), diode laser, and microdebrider-assisted inferior turbinoplasty (MAIT) in the treatment of chronic nasal obstruction in a one-year follow-up, and to pay special attention to the effect of the procedures on the contractility capacity of the inferior turbinates., Methods: The patients filled a Visual Analogue Scale (VAS) questionnaire regarding nasal symptoms pre- and postoperatively. Saccharin transit time (STT) evaluation and acoustic rhinometry were also performed. A total of 77 patients attended the one-year control visit and had technically reliable acoustic rhinometry results., Results: All the examined techniques decreased the VAS score for the severity of nasal obstruction statistically significantly. There was no deterioration found in the symptoms of crusting, nasal discharge, and sneezing, nor in mucociliary function in any of the groups. All the three techniques increased the non-decongested total V2-5 cm values and decreased the decongested total V2-5 cm values statistically significantly. The V2-5 cm change (%) values decreased statistically significantly in the RFA, diode laser, and the MAIT groups following the operations, the mean changes being -57 percentage points (pp), -53 pp, and -73 pp respectively., Conclusion: All three techniques decreased the severity of nasal obstruction significantly in the one-year follow-up. Although submucosal fibrosis seemed to increase, all the techniques increased the anterior nasal cavity volume significantly. Inferior turbinate contractility decreased to the normal level from the preoperative congested state following the surgery with every examined technique., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: Management of the rectal defect following transanal endoscopic microsurgery (TEMS) or minimally invasive surgery (TAMIS) carried out for excision of neoplasm in the lower rectum is controversial. We aimed to extract evidence by carrying out a meta-analysis to compare the peri- and postoperative outcomes following rectal neoplasm excision carried out by TEMS and/or TAMIS, whereby the defect is either sutured or left open., Methods: A literature search of Ovid MEDLINE and EMBASE was performed. Full-text comparative studies published until November 2019, in English and of adult patients, whereby TEMS or TAMIS was undertaken for rectal neoplasms were included. The main outcome measures were postoperative bleeding, infection, operative time and hospital stay., Findings: Three studies (one randomised controlled trial and two comparative case series) yielded 555 cases (283 in the sutured group and 272 in the open group). The incidence of postoperative bleeding was higher and statistically significant ( p = 0.006) where the rectal defect was left open following excision of the neoplasm (19/272, 6.99% vs 6/283, 2.12%). There was no statistical difference between the sutured and open groups regarding infection ( p = 0.27; (10/283, 3.53% vs 5/272, 1.84%, respectively), operative time ( p = 0.15) or length of stay ( p = 0.67)., Conclusion: Suturing the rectal defect following excision of rectal neoplasm by TEMS/TAMIS reduces the incidence of postoperative bleeding in comparison to leaving the defect open. However, suturing makes the procedure slightly longer but there was no statistical difference between both groups when postoperative infection and length of hospital stay were compared.

Background: Transanal total mesorectal excision (TaTME) is routinely performed to excise low rectal tumors. TaTME often relies on transanal endoscopic microsurgery (TEM) or transanal minimally invasive surgery (TAMIS) platform, all using rigid endoscopes. Our study reported a novel approach to TaTME which was completed using flexible endoscope, and we named it F-TaTME., Methods: The feasibility of rectum resection using F-TaTME was evaluated in five pigs. Firstly, the superior rectal artery and vein were managed under the assistance of laparoscopy. Secondly, the flexible endoscope was used to complete the full-thickness rectotomy and rectal mobilization. Finally, the specimen was removed and the manual colon-rectal anastomosis was performed under direct vision., Results: F-TaTME was accomplished in all 5 pigs. The mean procedure time was 136.6 min (97-162 min). The mean length from the lower edge of the lesion to circumferential dissection line was 1.4 cm (1.0-1.8 cm) and mean length of exteriorized rectum was 12.6 cm (11-14 cm). No injury to colorectal wall, adjacent pelvic or abdominal organs was found., Conclusions: Our preliminary data suggested that F-TaTME may be a feasible method for TaTME.

Objective: To investigate differences in postoperative outcomes between short-course radiotherapy and delayed surgery (SCRT-delay) and chemoradiation (CRT) in patients with locally advanced rectal cancer (LARC)., Background: Previous trials suggest that SCRT-delay could serve as an adequate neoadjuvant treatment for LARC. Therefore, in frail LARC patients SCRT-delay is recommended as an alternative to CRT. However, data on postoperative outcomes after SCRT-delay in comparison to CRT is scarce., Methods: This was an observational study with data from the Dutch ColoRectal Audit (DCRA). LARC patients who underwent surgery (2014-2017) after an interval of ≥6 weeks were included. Missing values were replaced by multiple imputation. Propensity score matching (PSM), using age, Charlson Comorbidity Index, cT-stage and surgical procedure, was applied to create comparable groups. Differences in postoperative outcomes were analyzed using Chi-square test for categorical variables, independent sample t-test for continuous variables and Mann-Whitney U test for non-parametric data., Results: 2926 patients were included. In total, 288 patients received SCRT-delay and 2638 patients underwent CRT. Patients in the SCRT-delay group were older and had more comorbidities. Also, ICU-admissions and permanent colostomies were more common, as well as pulmonic, cardiologic, infectious and neurologic complications. After PSM, both groups comprised 246 patients with equivalent age, comorbidities and tumor stage. There were no differences in postoperative complications., Conclusion: Postoperative complications were not increased in LARC patients undergoing SCRT-delay as neoadjuvant treatment. Regarding treatment-related complications, SCRT-delay is a safe alternative neoadjuvant treatment option for frail LARC patients., (Copyright © 2020 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

The principle of sphincter-preserving surgery is to preserve the anal sphincter function under the premise of radical resection. Due to low position of rectal tumor, conventional laparoscopic surgery has difficulties in operating in the deep and narrow pelvis, which may lead to inaccurate tissue dissociation, imprecise positioning of tumor edge, excessive stretch of the anal sphincter complex, and excessive removal of distal rectal mucosa. Moreover, pain from abdominal auxiliary incision has an unavoidable side effect for postoperative recovery. With the help of the Liu's transanal microsurgery system, precision functional sphincter-preserving surgery (PPS) can be successfully performed. PPS tries to preserve left colonic artery and pelvic autonomic nerve in the transabdominal operation. In the part of transanal surgery, measurement, localization and resection of the lower edge of the tumor are conducted under a clear and open visual field with the transparent screw anal dilator. After the rectum is cut off, the specimen is taken out through the anus to avoid abdominal incision. Inserting the intestinal supporter to support the bowel stump, full thickness of bowel stump is then sutured with anal canal by vertical mattress suture. Special transanal tube is placed afterwards without routine prophylactic stoma. PPS can achieve precise tumor resection and sphincter preservation simultaneously.

Background: Transanal endoscopic microsurgery (TEM) was introduced to combine the curativeness of full thickness excision with minimum morbidity, while traditional rectal surgery is burdened by high morbidity and mortality rates. However, while it is still a matter of considerable debate whether local excision is an adequate approach for curative resection of rectal cancer, new minimally invasive operative techniques have been introduced. The purpose of this paper was to show the indications, the tips and long term results of this technique through the review of the largest single-center database available to date. The showed results derived from the single center experience of the Clinica Chirurgica of Polytechnic University of Marche., Methods: We retrospectively reviewed a 25-year database from May 1992 to May 2017. We divided the patients into three different groups of patients according to the preoperative diagnosis: rectal cancers, adenomas and other rectal lesions. Rectal adenomas were divided into two groups according to their diameter (> or <5 cm). Rectal cancer patients were divided into two groups according to the preoperative staging: early rectal cancer and irradiated rectal cancer., Results: Among the 1324 patients who had rectal tumors excised with TEM at our institution, preoperative histology was rectal adenoma in 729 (55%) patients, adenocarcinoma in 536 (40.5%) patients and other lesions in the remaining 59 (4.4%) patients. 5 years overall survival (OS) and Recurrence free survival (RFS) were 93.3% and 98.6% for patients with rectal adenomas and 86.8% and 70.9% for patients with rectal cancer., Conclusions: TEM can be a valid alternative for the treatment of both benign and malignant rectal lesions, further studies are needed to define more specific indications to justify the survival of this technique in the future.

Introduction: This study evaluated the accuracy of endoscopic ultrasound (EUS) for preoperative staging of rectal cancer and guiding the treatment of transanal endoscopic microsurgery (TEM) in early rectal cancer. Material and methods: One-hundred-twenty-six patients with rectal cancer were staged preoperatively using EUS and the results were compared with postoperative histopathology results. Radical surgeries, including low anterior resection (LAR), abdominal-perineal resection (APR) and Hartmann surgeries, were performed on patients with advanced rectal cancers, and TEM was performed on patients with stage T1. The Kappa statistic was used to determine agreement between EUS-based staging and pathology staging. Results: The overall accuracies of EUS for T and N stage were 90.8% (Kappa = 0.709) and 76.7% (Kappa = 0.419), respectively. The accuracies of EUS for uT1, uT2, uT3, and uT4 stages were 96.8%, 92.1%, 84.1%, and 88.9%, respectively, and for uN0, uN1, and uN2 stages, they were 71.9%, 64.9%, and 93.0%, respectively. Twelve patients underwent TEM and received confirmed pathology results of early rectal cancer. After postoperative follow-up, there were no local recurrences or distant metastases. Conclusion: EUS is a good and comparable technique for postoperative staging of rectal cancer. Moreover, EUS is used as indicator for preoperative staging and tumor assessment strategy when considering TEM.

Background: While multiple studies have evaluated endoscopic submucosal dissection (ESD) and transanal endoscopic microsurgery (TEM) to remove large rectal tumors, there remains a paucity of data to evaluate their comparative efficacy and safety. The primary aim of this study was to perform a structured systematic review and meta-analysis to compare efficacy and safety of ESD versus TEM for the treatment of rectal tumors., Methods: Individualized search strategies were developed from inception through November 2018 in accordance with PRISMA guidelines. Measured outcomes included pooled enbloc resection rates, margin-negative (R 0 ) resection rates, procedure-associated adverse events, and rates of recurrence. This was a cumulative meta-analysis performed by calculating pooled proportions. Heterogeneity was assessed with Cochran Q test and I 2  statistics, and publication bias by funnel plot using Egger and Begg tests., Results: Three studies (n = 158 patients; 55.22% male) were included in this meta-analysis. Patients with ESD compared to TEM had similar age (P = 0.090), rectal tumor size (P = 0.108), and diagnosis rate of adenoma to cancer (P = 0.53). ESD lesions were more proximal as compared to TEM (8.41 ± 3.49 vs. 5.11 ± 1.43 cm from the anal verge; P < 0.001). Procedure time and hospital stay were shorter for ESD compared to TEM [(79.78 ± 24.45 vs. 116.61 ± 19.35 min; P < 0.001) and (3.99 ± 0.32 vs. 5.83 ± 0.94 days; P < 0.001), respectively]. No significant differences between enbloc resection rates [OR 0.98 (95% CI 0.22-4.33); P = 0.98; I 2  = 0.00%] and R 0 resection rates [OR 1.16 (95% CI 0.36-3.76); P = 0.80; I 2  = 0.00%] were noted between ESD and TEM. ESD and TEM reported similar rates of adverse events [OR 1.15 (95% CI 0.47-2.77); P = 0.80; I 2  = 0.00%] and rates of recurrence [OR 0.46 (95% CI 0.07-3.14); P = 0.43; I 2  = 0.00%]., Conclusion: ESD and TEM possess similar rates of resection, adverse events, and recurrence for patients with large rectal tumors; however, ESD is associated with significantly shorter procedure times and duration of hospitalization. Future studies are needed to evaluate healthcare utilization for these two strategies.

Materials and Methods: The records of patients treated with TLM with previously untreated early stage glottic squamous cell carcinoma were reviewed., Results: A total of 201 patients were enrolled: 191 men (95.0%) and 10 women (4.98%). The anterior commissure (AC) was involved in 94 (47.8%) patients. The 3- and 5-year overall survival rates of all patients were 94.5% and 90.9%. The local recurrence rates were 30.8% in the AC involvement (AC+) group and 16.0% in the group without AC involvement (AC-). The mortality rates were 18.1% and 3.7% in the AC+ and AC- groups. The 3- and 5-year disease-free survival rates were lower in the AC+ group (89.1%, 82.5%) than that in AC- group (99.0%, 96.5%). Local recurrence rates were 25%, 22.7%, 23.4%, and 22.1% for Tis, T1a, T1b, and T2 lesions. The mortality rates were 0.0%, 4.6%, 12.8%, and 15.3%. Three- and 5-year disease-free survival rates did not differ significantly between the tumor stage subgroups. The mortality for patients with local recurrence was 22.2%, which was higher than that for those without recurrence. The organ preservation rate was 98.5%., Purpose: This study was to assess the rates of oncological outcomes in patients with early stage glottic squamous cell carcinoma treated with transoral laser microsurgery (TLM)., Conclusion: AC involvement was a predictor of local recurrence, and its presence was associated with a reduced survival rate and increased mortality after TLM. TLM got high survival rate and low recurrence rate. The staging and oncological outcomes did not differ between tumor stage subgroups., Competing Interests: Declaration of competing interest None., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To explore the effectiveness of KeyPort access in transanal endoscopic mircrosurgery (TEM). Methods: A descriptive case series study was performed. Clinicopathological data of 20 patients undergoing KeyPort access TEM in Beijing Chaoyang Hospital of Capital Medical University from December 2016 to April 2018 were collected and analyzed retrospectively. Procedure of KeyPort access TEM: general anesthesia or combined spinal epidural anesthesia (CSEA); lithotomy or prone jack-knife position; anal dilation; placement of the KeyPortaccess; connection of TEM pneumoperitoneum device, light source and imaging equipment; placement of 5 mm dedicated endoscope; insufflation of CO2 with pressure of 1.6-2.0 kPa (12-15 mmHg); after rinsing the intestinal lumen, circular resection marginlabeled by the needle-shaped electrocautery;electric coagulation or ultrasonic knife used to perform a full-thickness resection with a 0.5 cm-1 cm margin along the marking line. Indications of KeyPort access TEM: (1) benign large sessile polyps which were difficult to resect under colonoscopy; (2) submucosal lesions with diameter <2 cm; (3) Tis and T1 stage rectal carcinoma without lymph node metastasis; (4) palliative resection of T2 stage rectal carcinoma without lymph node metastasis. Contraindications: (1) accompanying serious diseases without the tolerance of anesthesia and operation; (2) distance from lesion to anal verge >20 cm. Results: There were 10 males and 10 females with age of (63±15) years old and BMI of (24.5±3.3) kg/m(2). The diameter of the lesions was (2.0±1.3) cm, and the distance from lesion to anal verge was (6.2±2.2) cm. One patient had 3 lesions at different positions in rectum with diameters of 0.5 cm, 0.5 cm, and 1 cm, respectively. All operations were accomplished through the KeyPort access TEM and no case was transferred to other methods. The duration of surgery was 75 (30-220) minutes; intraoperative blood loss was 10 (0-30) ml. Two patients with rectal anterior wall lesions underwent full-thickness resection of the intestine wall reaching the peritoneal reflex with penetration into the peritonealcavity, and received suture closure immediately. For the patient with 3 rectal lesions, the 1.0 cm lesion received a full-thickness resection and the other 2 lesions received submucosal resection. No postoperative complication occurred. Postoperative pathology showed that there were 1 case of chronic inflammatory lesion, 4 cases of benign tumor, 3 cases of carcinoma in situ, 4 cases of neuroendocrine tumor, 6 cases of pT1 rectal cancer, 2 cases of pT2 rectal cancer (both invading the superficial muscle layer). The median hospital stay was 6 (3-7) days. The postoperative follow-up was (7.2±3.8) months. No postoperative complication or recurrence was observed. Conclusion: TEM with KeyPort access is safe, rapid and effective in the treatment of rectal tumors.

Background & Aims: Complex benign rectal polyps can be managed with transanal surgery or with endoscopic resection (ER). Though the complication rate after ER is lower than transanal surgery, recurrence is higher. Patients lost to follow up after ER might therefore be at increased risk for rectal cancer. We evaluated the costs, benefits, and cost effectiveness of ER compared to 2 surgical techniques for removing complex rectal polyps, using a 50-year time horizon-this allowed us to capture rates of cancer development among patients lost from follow-up surveillance., Methods: We created a Markov model to simulate the lifetime outcomes and costs of ER, transanal endoscopic microsurgery (TEM), and transanal minimally invasive surgery (TAMIS) for the management of a complex benign rectal polyp. We assessed the effect of surveillance by allowing a portion of the patients to be lost to follow up. We calculated the cost, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio or each intervention over a 50-year time horizon., Results: We found that TEM was slightly more effective than TAMIS and ER (TEM, 19.54 QALYs; TAMIS, 19.53 QALYs; and ER, 19.53 QALYs), but ER had a lower lifetime discounted cost (ER cost $7161, TEM cost $10,459, and TAMIS cost $11,253). TEM was not cost effective compared to ER, with an incremental cost-effectiveness ratio of $485,333/QALY. TAMIS was dominated by TEM. TEM became cost effective when the mortality from ER exceeded 0.63%, or if the loss to follow up rate exceeded 25.5%., Conclusions: Using a Markov model, we found that ER, TEM, and TAMIS have similar effectiveness, but ER is less expensive, in management of benign rectal polyps. As the rate of loss to follow up increases, transanal surgery becomes more effective relative to ER., (Copyright © 2019 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Objective: Rectal schwannomas are extremely rare tumors and their surgical treatment is widely variable in literature. Transanal endoscopic microsurgery (TEM) approach could be a reasonable option for such lesions, offering an organ-sparing strategy, but evidence is scarce., Methods: We report a 69-year-old man with a rectal submucosal lesion at 10 cm from the anal verge, treated by TEM. A systematic literature review on surgical approaches in rectal schwannoma was performed., Results: The patient was successfully treated by TEM, with adequate excision of the submucosal lesion. Histopathology revealed a rectal schwannoma. No recurrence was found at 1-year endoscopic follow-up. Previous studies reported 23 cases of rectal schwannoma and several treatment options, but only 2 cases were treated by TEM. Anterior rectal resection was generally adopted in cases of large, symptomatic masses with inconclusive preoperative biopsy, while lesions with features suggestive of stromal tumors were preferentially treated by endoscopy or, if located in distal rectum, by transanal approaches., Conclusions: An organ-sparing minimally invasive approach should be the standard of care for rectal schwannomas. TEM could extend the indication for their endoscopic treatment, providing adequate excision even for larger schwannomas of the middle-upper rectum.

Over the past several decades, technical advances in breast reconstruction have resulted in the development of flaps that are aimed at progressively decreasing abdominal wall morbidity. There is, however, ongoing controversy related to the superiority of deep inferior epigastric perforator (DIEP) flaps over muscle-sparing TRAM (MS-TRAM) flaps. Hence, the question remains unanswered as to which approach should be considered the standard of care, and more importantly, whether the rate of DIEP flap utilization should be considered a quality metric in breast reconstruction. In this review article, we examine the literature pertaining to abdominal free tissue transfer in breast reconstruction from both donor site and flap characteristics as well as the resultant complications and morbidity. The impact on the donor site remains a prevailing principle for autologous breast reconstruction; thus, must be adequately respected when classifying what is left behind following flap harvest. The most commonly used nomenclature is too simplistic. This, in turn, leads to inadequate incorporation of critical variables, such as degree of muscular preservation, fascial involvement, mesh implantation, and segmental nerve anatomy. Currently, there is insufficient evidence to support DIEP flap harvest as a quality indicator in breast reconstruction, as DIEP flap outcomes are not clearly superior when compared with MS-TRAM flaps., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Introduction: Small rectal neuroendocrine tumours are good candidates for endoscopic resection provided that complete pathological resection (R0) is obtained and their risk of metastatic progression is low. We conducted a large multicentre nationwide study to evaluate the outcomes of the management of non-metastatic rectal neuroendocrine tumours ≤2 cm diagnosed endoscopically., Patients and Methods: The medical records, the endoscopic and pathological findings of patients with non-metastatic rectal neuroendocrine tumours ≤2 cm managed from January 2000-June 2018 in 16 French hospitals, were retrospectively analysed. The primary objective was to describe the proportion of R0 endoscopic resections., Results: A total of 329 patients with 345 rectal neuroendocrine tumours were included, 330 (96%) tumours were managed by local treatments: 287 by endoscopy only and 43 by endoscopy followed by transanal endoscopic microsurgery. The final endoscopic R0 rate was 134/345 (39%), which improved from the first endoscopy (54/225, 24%), to the second (60/100, 60%) and the third endoscopy (20/26, 77%). R0 was associated with endoscopic technique (90% for advanced techniques, 40% for mucosectomy and 17% for polypectomy), but not with tumour or patient characteristics. Twenty patients had metastatic disease, which was associated with tumour size ≥10 mm (odds ratio: 9.1, 95% confidence interval (3.5-23.5)), tumour grade G2-G3 (odds ratio: 4.2, (1.5-11.7)), the presence of muscular (odds ratio: ∞, (11.9-∞)) and lymphovascular invasion (odds ratio: 57.2, (5.6-578.9))., Conclusions: The resection of small rectal neuroendocrine tumours often requires multiple procedures. Training of endoscopists is necessary in order to better recognise these tumours and to perform the appropriate resection technique., (© Author(s) 2019.)

Background: Transanal endoscopic microsurgery (TEM) is the treatment of choice for benign rectal tumors and select early rectal cancers. This surgical approach has become ubiquitous and surgeons are seeing recurrent lesions after TEM resection. This study aims to outline the safety and outcomes of repeat TEM when compared to primary TEM procedures., Methods: At St. Paul's Hospital, demographic, surgical, pathologic, and follow-up data for patients treated by TEM are maintained in a prospectively populated database. Two groups were established for comparison: patients undergoing first TEM procedure (TEM-P) and patients undergoing repeat TEM procedure (TEM-R)., Results: Between 2007 and 2017, 669 patients had their first TEM procedure. Over this time frame, 57 of these patients required repeat TEM procedures, including 15 of these patients treated by 3 or more TEMs. Indications for repeat TEM included recurrence (78%), positive margins (15%), and metachronous lesions (7%). There were no differences between the groups in patient age, gender, or tumor histology. Compared to TEM-P, TEM-R had shorter operative times (38 vs. 52 min, p < 0.001), more distal lesions (5 vs. 7 cm, p < 0.004), and smaller lesions (3 vs. 4 cm, p < 0.0003). The TEM-R group had similar length of hospital stay (0.45 vs. 0.56 days, p = 0.65), rates of clear margins on pathology (81% vs. 88%, p = 0.09), and 30-day readmission rates (7% vs. 4%, p = 0.27) when compared to TEM-P group. TEM-R was more likely to be managed without suturing the surgical defect (72% vs. 32%, p < 0.0001). Repeat TEM was associated with similar post-operative complications as primary TEM graded on the Clavien-Dindo classification scale (Grade 1: 5% vs. 5%, Grade 2: 5% vs. 4%, Grade 3: 5% vs. 1%, p = 0.53). No 30-day mortality occurred in either group., Conclusions: The St. Paul's Hospital TEM experience suggests repeat TEM is a safe and feasible procedure with similar outcomes as patients undergoing first TEM.

Aim: Early rectal cancer can be managed effectively with local excision, which is now the standard of care for many T1 lesions. However, the presence of unexpected adverse histopathological factors may indicate an increased risk of local recurrence, prompting consideration of completion radical surgery. Many patients are unfit or prefer to avoid radical surgery, relying instead on surveillance and early detection of recurrent disease. Recently, radiotherapy has shown promise as an adjuvant therapy in this group. This study assesses local recurrence rates after local excision with adjuvant radiotherapy at a single centre., Method: This was a retrospective review of a prospective database of all patients undergoing transanal endoscopic microsurgery (TEM) in a single institution. Data covering a 10-year period were analysed., Results: Of 197 patients undergoing TEM for rectal cancer, 33 (17%) had adjuvant radiotherapy because of adverse histopathological features. At 3.2 years' median follow-up, there were three instances of local recurrence (9.1%). Estimated local recurrence at 1 and 3 years was 0% and 6.9%, compared to 16.8% and 21.2% in a propensity-score-matched group who were followed by surveillance alone. Local recurrence was diagnosed at a median of 23 months post-TEM in the radiotherapy group, compared to 8 months in the matched group., Conclusion: Radiotherapy after TEM is associated with a trend towards a reduced rate of local recurrence, even for high-risk disease. Radiotherapy would appear to offer a viable alternative to radical completion surgery in the presence of unforeseen adverse histopathological features, as long as a meticulous surveillance programme is in place., (Colorectal Disease © 2018 The Association of Coloproctology of Great Britain and Ireland.)

Background: In patients treated by transanal endoscopic microsurgery (TEM), breach of the peritoneal cavity is a feared intraoperative challenge. Our aim is to analyze predictors and short-term outcomes of patients with peritoneal perforation (TEM-P) when compared to similar patients with no peritoneal compromise (TEM-N)., Methods: At St. Paul's Hospital, demographic, surgical, pathologic, and follow-up data for all patients treated by TEM is maintained in a prospectively populated database. A retrospective review was performed and two groups were established for comparison: TEM-P and TEM-N. Statistical analysis was performed using student's t or chi-squared test, where appropriate., Results: Of 619 patients treated by TEM between 2007 and 2016, 39 (6%) patients were in the TEM-P group and 580 (94%) in the TEM-N group. There were no differences between the groups in patient age, gender, histology, or tumor size. Patients who had peritoneal perforations had more proximal lesions (11 vs. 7 cm, p < 0.0001), anterior lesions (56 vs. 43%, p < 0.05), and longer operations (80 vs. 51 min, p < 0.005). While most defects were closed endoluminally, 2 patients with perforation were converted to transabdominal surgery. There was a difference in overall hospital stay with TEM-P patients staying on average 2 days in hospital with fewer patients managed as day surgery (31 vs. 73%, p < 0.0001). There were no mortalities or significant 30-day complications in the TEM-P group and only one patient required readmission., Conclusions: The St. Paul's Hospital TEM experience suggests patients with peritoneal breach during TEM can be safely managed with outcomes similar to patients without peritoneal entry. Proximal, anterior lesions are at highest risk of peritoneal perforation.

Background and Aims: To optimize therapeutic decision-making in early invasive colorectal cancer (T1 CRC) patients, it is important to elicit the patient's perspective next to considering medical outcome. Because empirical data on patient-reported impact of different treatment options are lacking, we evaluated patients' quality of life, perceived time to recovery, and fear of cancer recurrence after endoscopic or surgical treatment for T1 CRC., Methods: In this cross-sectional study, we selected patients with histologically confirmed T1 CRC who participated in the Dutch Bowel Cancer Screening Programme and received endoscopic or surgical treatment between January 2014 and July 2017. Quality of life was measured using the European Organization for Research and Treatment 30-item Core Quality of Life Questionnaire and the 5-level EuroQoL 5-dimension questionnaire. We used the Cancer Worry Scale (CWS) to evaluate patients' fear of cancer recurrence. A question on perceived time to recovery after treatment was also included in the set of questionnaires sent to patients., Results: Of all 119 eligible patients, 92.4% responded to the questionnaire (endoscopy group, 55/62; surgery group, 55/57). Compared with the surgery group, perceived time to recovery was on average 3 months shorter in endoscopically treated patients after adjustment for confounders (19.9 days vs 111.3 days; P = .001). The 2 treatment groups were comparable with regard to global quality of life, functioning domains, and symptom severity scores. Moreover, patients in the endoscopy group did not report more fear of cancer recurrence than those in the surgery group (CWS score, 0-40; endoscopy 7.6 vs surgery 9.7; P = .140)., Conclusions: From the patient's perspective, endoscopic treatment provides a quicker recovery than surgery, without provoking more fear of cancer recurrence or any deterioration in quality of life. These results contribute to the shared therapeutic decision-making process of clinicians and T1 CRC patients., (Copyright © 2019 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Surgical competence is a complex, multifactorial process, requiring ample time and training. Optimal training is based on acquiring knowledge and psychomotor and cognitive skills. Practicing surgical skills is one of the most crucial tasks for both the novice surgeon learning new procedures and surgeons already in practice learning new techniques. Focus is placed on teaching traditional technical skills, but the importance of cognitive skills cannot be underestimated. Cognitive skills allow recognizing environmental cues to improve technical performance including situational awareness, mental readiness, risk assessment, anticipating problems, decision-making, adaptation, and flexibility, and may also accelerate the trainee's understanding of a procedure, formalize the steps being practiced, and reduce the overall training time to become technically proficient. The introduction and implementation of the transanal total mesorectal excision (TaTME) into practice may be the best demonstration of this new model of teaching and training, including pre-training, course attendance, and post-course guidance on technical and cognitive skills. To date, the TaTME framework has been the ideal model for structured training to ensure safe implementation. Further development of metrics to grade successful learning and assessment of long term outcomes with the new pathway will confirm the success of this training model., (Copyright © 2018 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. All rights reserved.)

Background: The aim of this study was to compare the short-term outcome after Transanal Endoscopic Microsurgery (TEM) and Transanal Minimally Invasive Surgery (TAMIS) for intraluminal rectal lesions., Methods: Retrospective analysis of a prospectively maintained database of all TEM and TAMIS procedures performed at a single institution by one surgeon between March 2009 and September 2017 was conducted. Primary outcome was operating time. Secondary outcomes were blood loss, pathological outcome, length of hospital stay, 30-day readmission and mortality., Results: Fifty-three patients underwent TEM procedure and 68 patients underwent TAMIS. Operating time was significantly shorter for TAMIS compared with TEM (median 45 vs 65 min, p < 0.0001). Blood loss was negligible for both TEM and TAMIS. Resection margins, lesion grade and invasion depth were comparable for both approaches. A significantly higher postoperative readmission rate was observed in the TEM group (17% vs 4.4%, p = 0.031). Mortality was zero in both groups., Conclusions: TAMIS is a valuable alternative to TEM, leading to decreased operating times, because all resections can be done in lithotomy position.

Aim: Local excision is recommended for early rectal cancer (pT1). Complementary total mesorectal excision (cTME) is warranted when bad pathological features are present. The impact of a prior local resection on the outcome remains unclear. The aim of this study was to assess if prior local excision increases the morbidity of a subsequent cTME compared with primary TME., Methods: From 2001 to 2016 all patients who underwent TME after local excision for rectal adenocarcinoma were studied. All were matched (1:1) with patients who underwent primary TME, without neoadjuvant radiochemotherapy. The matching factors included age, sex, body mass index, American Society of Anesthesiologists score and type of surgery. Short-term morbidity and pathological examination of the resected specimen were compared., Results: Forty-one patients were included (14 women, 34%, mean age 65 ± 11 years), comprising classic transanal excision (66%) and transanal endoscopic microsurgery (34%), and were matched to 41 patients who had primary TME. cTME was significantly longer (315 min ± 87 vs 275 min ± 58, P = 0.03). The overall morbidity was 48.8% in the local excision group vs 31.7% in the control group (P = 0.18). Surgical morbidity was 31.7% vs 26.8% (P = 0.8). Anastomotic related morbidity was similar (local excision 17% vs TME 14.6%, P = 0.84) and the mean length of stay was similar (14 days) in both groups. There was a tendency to a worse quality of mesorectal excision in the cTME group (17% vs 5%, P = 0.15)., Conclusion: Local excision prior to TME for early rectal cancer tends to increase overall morbidity and may worsen the quality of the mesorectal plane but should be considered as a surgical approach in select cases., (Colorectal Disease © 2018 The Association of Coloproctology of Great Britain and Ireland.)

Background: Although the incidence of colorectal cancer increases with the patient's age, the elderly continue to be less likely to be scheduled for surgery. Transanal endoscopic micro-surgery (TEM) is a surgical alternative to total mesorectal excision (TME) in early stage rectal cancer and/or in selected patients that could decrease morbidity and mortality rates in this group of patients. Our main objective is to assess the safety and feasibility of TEM in elderly (75-84 years) and very elderly (≥ 85 years) patients., Methods: Observational study was conducted with prospective data collection of all consecutive patients who underwent TEM between April 2004 and January 2017. Patients were assigned to groups according to age. Descriptive and comparative analyses between groups were performed., Results: We analyzed 693 patients, 429 patients < 75 years (61.9%), 220 patients between the ages of 75 and 84 (31.7%), and 44 patients ≥ 85 years old (6.3%). The tendency in our series is to increase comorbidities with age. Palliative or consensus intent was more frequently performed in elderly (10.5%, 34/220), and very elderly (45.4%, 20/44), compared with the youngest (6.3%, 27/429), (p < 0.001). Global morbidity presented an increasing trend related to age from 20.3% in < 75 years, to 25.9% in elderly and 34.1% in very elderly. Surgical complications were recorded in 18.5% (128/693) of patients with no significant differences between groups. The most common one was rectal bleeding 16.1% (111/693). Significant differences were found in non-surgical complications, recorded in 7.3% (16/220) in the elderly, and 15.9% (7/44) in the group above 84 years (p = 0.013)., Conclusions: TEM presents acceptable morbidity rates mainly due to non-surgical-related adverse effects in elderly and very elderly patients and may be a feasible and safe alternative in this population in both curative and non-curative indications.

Importance: Treatment of rectal cancer is shifting toward organ preservation aiming to reduce surgery-related morbidity. Short-term outcomes of organ-preserving strategies are promising, but long-term outcomes are scarce in the literature., Objective: To explore long-term oncological outcomes and health-related quality of life (HRQL) in patients with cT1-3N0M0 rectal cancer who underwent neoadjuvant chemoradiotherapy (CRT) followed by transanal endoscopic microsurgery (TEM)., Design, Setting, and Participants: In this multicenter phase II feasibility study, patients with cT1-3N0M0 rectal cancer admitted to referral centers for rectal cancer throughout the Netherlands between February 2011 and September 2012 were prospectively included. These patients were to be treated with neoadjuvant CRT followed by TEM in case of good response. An intensive follow-up scheme was used to detect local recurrences and/or distant metastases. Data from validated HRQL questionnaires and low anterior resection syndrome questionnaires were collected. Data were analyzed from February 2011 to April 2017., Main Outcomes and Measures: The primary study outcome of the study was the number of ypT0-1 specimens by performing TEM. Secondary outcome parameters were locoregional recurrences and HRQL., Results: Of the 55 included patients, 30 (55%) were male, and the mean (SD) age was 64 (39-82) years. Patients were followed up for a median (interquartile range) period of 53 (39-57) months. Two patients (4%) died during CRT, 1 (2%) stopped CRT, and 1 (2%) was lost to follow-up. Following CRT, 47 patients (85%) underwent TEM, of whom 35 (74%) were successfully treated with local excision alone. Total mesorectal excision was performed in 16 patients (4 with inadequate responses, 8 with completion after TEM, and 4 with salvage for local recurrence). The actuarial 5-year local recurrence rate was 7.7%, with 5-year disease-free and overall survival rates of 81.6% and 82.8%, respectively. Health-related quality of life during follow-up was equal to baseline, with improved emotional well-being in patients treated with local excision (mean score at baseline, 72.0; 95% CI, 67.1-80.1; mean score at follow-up, 86.9; 95% CI, 79.2-94.7; P = .001). Major, minor, and no low anterior resection syndrome was experienced in 50%, 28%, and 22%, respectively, of patients with successful organ preservation., Conclusions and Relevance: In early-stage rectal cancer (cT1-3N0M0), CRT enables organ preservation with additional TEM surgery in approximately two-thirds of patients with good long-term oncological outcome and HRQL. This multimodality treatment triggers a certain degree of bowel dysfunction, and one-third of patients still undergo radical surgery and are overtreated by CRT.

Transanal excision (TAE) with conventional retractors and transanal endoscopic microsurgery (TEM) are two well established minimally invasive surgical options for the treatment of selected rectal cancers. TEM is nowadays considered the standard of care for the transanal excision of rectal tumors, since it is associated with significantly better quality of excision and lower rates of recurrence than TAE. When compared with rectal resection and total mesorectal excision, TEM has lower postoperative morbidity and better functional outcomes, with similar long-term survival rates in selected early rectal cancers. More recently, transanal minimally invasive surgery (TAMIS) has been developed as an alternative to TEM. Possible benefits of TAMIS are under evaluation.

Background: Endoscopic endonasal transsphenoidal surgery (EETS) is a common treatment for patients with pituitary adenomas (PAs). A disadvantage of endoscopic surgery has been the lack of stereoscopic vision and depth perception. Recent developments offer high-definition 3-dimensional (3D-HD) visualization with a higher resolution and better image quality compared with 3D standard endoscopy (3D-SD). In this study, we compared treatment results of surgically treated patients with PAs using 3 different visualization systems: 2-dimensional (2D)-HD, 3D-SD, and 3D-HD., Methods: Data from patients with primary PAs that were surgically treated between December 2008 and December 2017 were analyzed. Preoperative and postoperative tumor size and location, perioperative complications, and ophthalmologic, endocrine, and clinical outcomes were compared., Results: A total of 170 patients underwent endoscopic resection of a primary PA (54 patients with 2D-HD, 75 with 3D-SD, and 41 with 3D-HD). Preoperatively, no statistical differences were found for tumor size, extension, and endocrine and ophthalmologic status. Tumor resection was not statistically different among the 3 groups. Complete resection was performed in 33 patients (80%) in the 3D-HD group, 54 patients (72%) in the 3D-SD group, and 39 patients (72%) in the 2D-HD group. The number of complications was not different across the groups (P = 0.436). Ophthalmologic outcomes did not differ based on EETS technique. The rate of new pituitary insufficiency was slightly lower in the 3D-HD group compared with 2D-HD and 3D-SD groups (4.8%, 16.6%, and 12%, respectively; P = 0.290)., Conclusions: Although the resection rate was higher in the 3D-HD group, and subjective advantages of the 3D-HD endoscopes were noted, there were no significant differences in terms of gross total resection or new hormonal deficits among the 3 groups., (Copyright © 2018 Elsevier Inc. All rights reserved.)