Interesting case

OD 224562963

62 yo man with irretrievable rectal TVA on screening colonoscopy, prior transanal excision

8 cm from anal verge

Pmhx: hypothyroidism, arthritis

Pshx: appendectomy, bilateral inguinal hernia repair

Meds: ASA, MVI

• Decision made to proceed with transanal minimally invasive surgery

• Lesion located between lowest and middle rectal valves

• Positioning: prone with leg splitter

• Applied Medical gelport, 90 degree scope, laparoscopic instruments

Rectal adenoma

Villous adenoma is a premalignant lesion

2/3 occur in the rectum

Equal sex distribution, peak incidence 6th and 7th decades

Difficult to detect

Harbor malignancy in 40% of cases

Biopsy often misses 40% of cancers

Patients older than 80 undergoing APR have 15% risk of perioperative death

ASA grade I patients have perioperative mortality of 0.5%

ASA grade IV patients have risk approaching 25%

Consider impact of radical surgery on QOL

Surgical options

Local excision with transanal technique

Kraske sacral operation

Radical excision (LAR or APR)

Transanal Endoscopic MicroSurgery

Transanal Minimally Invasive Surgery

What is TAMIS?

Named by Atallah et als

Described its use in 6 patients, 2 with early rectal cancers

Crossover technique using SILS equipment

Single surgeon experience using TAE vs transbdominal resections

Main outcomes were complications, recurrence and malignancy rates

• Retrospective review

• T1 and T2 rectal cancers

• Local excisions from 1997-2006

• 42 TEMS, 129 TAE patients

• Median followup 60 months for TEMS, 45 for TAE

• Only 34 patients had local recurrence

• 145 of 164 patients were disease free at last followup

• Authors conclude that TEMS resection is superior to TAE

• Indications for both may overlap

• Variables such as tumor distance from AV, T stage and adjuvant therapy may be more important predictors of outcome

Conclusions

Local excision safe for villous adenomas and early rectal cancers by multiple means (TAE, TEMS, TAMIS)

Careful patient selection

Diligent followup

Discussion with patient about radical surgery