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S. I. ALLISON, O. A. ADEDEJI and J. S. VARMA
Coloproctology Unit, Department of Surgery, Royal Victoria Infirmary, Newcastle upon
Tyne,UK
Large rectal adenomas can be approached per-anally by open excision or by transanal endoscopic microsurgery (TEMS). We describe the adaptation of an endoscopic linear stapler-cutter for per anal excision of rectal polyps. It can be used for difficult polyps with minimal risk of complications and is easier and more accessible than TEMS.
Keywords: endoscopic linear stapler, excision, rectal adenoma
J.R.Coll.Surg.Edinb., 46, October 2001, 290-291
Resection of small rectal polyps can be dealt with adequately through the endoscope but larger ones are more demanding. Current treatment options include transanal endoscopic microscopic surgery (TEMS) which is technically demanding and is limited to a few institutions in the UK.1 Per anal excision of these tumours still offers the best first line management providing complete pathological assessment, less complications than abdominal or posterior approaches and fewer recurrences than endoscopic procedures.2 We describe a technique using an endoscopic stapler-cutter for difficult adenomas.
Three patients aged 63, 67 and 78 years with large ( > 5cm) rectal adenomas were treated. The adenomas were in the upper rectum in all patients, and two had had previous multiple endoscopic snarings. One of these two patients declined anterior resection and the other was incapacitated by severe chronic obstructive airways disease (COAD). The third patient was listed for an anterior resection, but at operation, per anal resection of the polyp was possible.
Pre-operatively, all patients had colonoscopy and multiple biopsies, and one had endorectal ultrasound carried out. The distal rectum was prepared with phosphate enemas and under general anaesthesia, the patient was placed in the lithotomy position. An Eisenhammer or illuminated Hill-Ferguson anal retractor was introduced and the tumour was pulled into the lower rectum using Babcock or Ellis forceps. An EndoGIA 30 (Autosuture Co. UK•• was positioned via the anal retractor across the artificial pedicle formed and the lesions were excised with three firings (Figure 1). Haemostasis was achieved satisfactorily. All patients were discharged on the third post-operative day without any complications.
Histology did not show any malignant change nor any muscular wall in the specimens. Residual polyps in two patients were treated with endosocopic fulguration in a single session each; both were free of recurrence 30 and 60 months, respectively, after their initial treatment. The third patient did not return for follow-up because of severe COAD, which caused her death 14 months later.
Figure 1: Diagramatic representation of stapler-cutter excision of rectal polyp
The false pedicle created when upper rectal polyps are pulled into the rectal ampulla can be clamped, the tumour excised and the defect closed with absorbable suture. Alternatively, the pedicle is divided with suture ligation.2 We have modified these techniques by using an endoscopic stapler-cutter. We have shown that stapling can be applied to the upper rectum without incorporating the full thickness of the rectal wall in the procedure. Any residual tumour can be treated adequately with endoscopic fulguration. Other advantages are the rapidity of the procedure, thus reducing the risk of sphincter damage and, as it is a closed mucosectomy, bleeding and infective complications are less likely. Recurrence rate after closed mucosectomy is comparable to that of open mucosectomy using open endoanal excision or TEMS. 1,2 Since we began using this procedure, similar techniques have been described but with limited patient data. 3,4 Stapling rectal polyps is easier and more accessible than using TEMS. However, data from larger groups and longer follow-up will provide further useful evaluation.
1. Steele RJC, Hershman MJ, Scholfield JH, et al. Transanal endoscopic
microsurgery - initial experience from three centres in the United Kingdom. Br J Surg 1996;
83: 207-10
2. Whitlow CB, Beck DE, Gathright JB. Surgical excisions of large rectal villous adenoma. Surg
Oncol Clin N Am 1996; 5: 723-34
3. Qureshi MA, Monson JRT, Lee PWR. Transanal Multifire Endo GIA technique for rectal
polypectomy. Dis Colon Rectum 1997; 40: 116
Copyright date: 28th June 2001
Correspondence: J.S. Varma, Coloproctology Unit, Department of Surgery, Royal Victoria
Infirmary, Newcastle upon Tyne NE1 4LP, UK