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Transanal endoscopic microsurgery: the preferred technique in a small but important group of rectal neoplasms

It has been suggested that up to 40% of the population in the developed world will harbour a large bowel adenoma at some stage in their life [1]. A significant number of these will be in the rectum or rectosigmoid. The majority will not progress to invasive carcinoma but some do. It has been estimated that the cumulative risk of an adenoma of undergoing malignant transformation over 5, 10 and 20 years is 2.5%, 8% and 24%, respectively [2]. It has thus become conventional practice to remove rectal adenomas whenever possible to eradicate or at least significantly lower the incidence of carcinoma. Most adenomas can be removed endoscopically particularly if they are small or pedunculated. Larger adenomas especially when sessile may require surgical excision either by an open approach with its associated morbidity and mortality or they can be removed by local excision through endoanal, transsphincteric or transcoccygeal approaches [3]. Transanal endoscopic microsurgery (TEMS) is a relatively new technique, which was developed by Professor Gerhard Buess in the 1980s and has become generally accepted for the following reasons: While TEMS is a challenging skill to acquire, surgeons have welcomed it as it provides an excellent view of the entire rectum and any lesion within. Furthermore, the results have been good in treating lesions unsuitable for conventional endoscopic removal. Patients benefit from less radical surgery and recurrence rates have been low. The functional outcome has, however, received less attention. In a recent prospective study, Cataldo et al. [3] assessed the function after TEMS. Their study included 27 patients with benign conditions including 24 with adenoma (16 first time removal and eight recurrent). All patients completed a questionnaire before and after TEMS. This included an attempt to assess the quality of life, number of bowel movements per 24 h and the ability to defer defecation. TEMS had no detrimental effect on faecal continence despite the introduction of a proctoscope of 40-mm diameter through the anus for a mean of 69 min (range: 19–197). There were no significant changes in the other parameters assessed. It is interesting to note that in this study a case of anastomotic stenosis was also treated. The pathologist also benefits by receiving a wellprepared specimen with a recognizable clear resection margin facilitating the complete assessment. In a study from our group, we compared the results of the initial biopsy with examination of the entire resected lesion in a cohort of 433 neoplastic polypoidal lesions. In 18.5% of cases showing no carcinoma on biopsy, definite evidence of malignant invasion was seen when the entire polyp was examined. There was thus a false-negative result in 18.5% of cases. It was concluded that, unless the entire specimen is submitted for histopathological examination, it is impossible to exclude carcinoma [4]. TEMS provides such a complete specimen. The procedure offers cost savings, since it reduces hospital stay. In a systematic review by Middelton et al. [5], the average TEMS base case cost of treating an adenoma was about two thirds of that of radical or other local excision techniques [5]. It is unfortunate that this technique has not received its full share of randomizedcontrolled trials as there are only a few published in the literature [5]. It also likely that this is a technique, which will stay with us for a long time, as it is applicable to a reasonable number of patients. As with many specialized techniques, there is a strong need for centralizing such services as already pertains in the UK. In this issue, the paper from Whitehouse et al. (Transanal endoscopic microsurgery: risk factors for local recurrence of benign rectal adenomas) has detailed their considerable experience of this technique for the treatment of rectal adenomas. It is a very large series, which contains a great deal of useful information particularly regarding the risk factors for recurrence. It would have been interesting to see whether the increasing experience over the time of the study of the single surgeon carrying out the operation resulted in a diminishing local recurrence rate, as has been reported for other surgical techniques [6].