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1.  Endoscopic mucosal resection of large rectal adenomas in the era of centralization: Results of a multicenter collaboration 
Background and objective
Endoscopic mucosal resection (EMR) of large rectal adenomas is largely being centralized. We assessed the safety and effectiveness of EMR in the rectum in a collaboration of 15 Dutch hospitals.
Methods
Prospective, observational study of patients with rectal adenomas >3 cm, resected by piecemeal EMR. Endoscopic treatment of adenoma remnants at 3 months was considered part of the intervention strategy. Outcomes included recurrence after 6, 12 and 24 months and morbidity.
Results
Sixty-four patients (50% male, age 69 ± 11, 96% ASA 1/2) presented with 65 adenomas (diameter 46 ± 17 mm, distance ab ano 4.5 cm (IQR 1–8), 6% recurrent lesion). Sixty-two procedures (97%) were technically successful. Histopathology revealed invasive carcinoma in three patients (5%), who were excluded from effectiveness analyses. At 3 months’ follow-up, 10 patients showed adenoma remnants. Recurrence was diagnosed in 16 patients during follow-up (recurrence rate 25%). Fifteen of 64 patients (23%) experienced 17 postprocedural complications.
Conclusion
In a multicenter collaboration, EMR was feasible in 97% of patients. Recurrence and postprocedural morbidity rates were 25% and 23%. Our results demonstrate the outcomes of EMR in the absence of tertiary referral centers.
doi:10.1177/2050640614554218
PMCID: PMC4245307  PMID: 25452845
Rectum; adenoma; endoscopic mucosal resection; recurrence; morbidity
2.  Efficacy and Safety of Endoscopic Resection Therapies for Rectal Carcinoid Tumors: A Meta-Analysis 
Yonsei Medical Journal  2014;56(1):72-81.
Purpose
Several endoscopic resection therapies have been applied for the treatment of rectal carcinoid tumors. However, there is currently no consensus regarding the optimal strategy. We performed a meta-analysis to compare the efficacy and safety of endoscopic mucosal resection (EMR) or modified EMR (m-EMR) versus endoscopic submucosal dissection (ESD) for the treatment of rectal carcinoid tumors.
Materials and Methods
PubMed, Web of Science, Medline, Embase and CNKI were searched up to the end of January 2014 in order to identify all studies on the effects of EMR (or m-EMR) and ESD on rectal carcinoid tumors.
Results
A total of fourteen studies involving 782 patients were included. The pooled data suggested a significantly higher rate of pathological complete resection among patients treated with ESD or m-EMR than those treated with EMR [odds ratio (OR)=0.42, 95% confidence interval (CI): 0.25-0.71; OR=0.10, 95% CI: 0.03-0.33, respectively], while there was no significant difference between the m-EMR group and ESD group (OR=1.19, 95% CI: 0.49-2.86); The procedure time of ESD was longer than EMR or m-EMR groups [mean differences (MD)=-11.29, 95% CI: -14.19 - -8.38, MD= -10.90, 95% CI: -18.69 - -3.11, respectively], but it was insignificance between the EMR and m-EMR groups. No significant differences were detected among the treatment groups with regard to complications or recurrence.
Conclusion
The results of this meta-analysis suggest that treatment of rectal carcinoid tumors with ESD or m-EMR is superior to EMR, and the efficacy of m-EMR is equivalence to ESD treatment. However, more well-designed studies are needed to confirm these findings.
doi:10.3349/ymj.2015.56.1.72
PMCID: PMC4276780  PMID: 25510749
Endoscopic submucosal dissection; endoscopic mucosal resection; rectal carcinoid tumor; meta-analysis
3.  Transanal Endoscopic Microsurgery for the Treatment of Well-Differentiated Rectal Neuroendocrine Tumors 
Purpose
Recently, an increase in well-differentiated rectal neuroendocrine tumors (WRNETs) has been noted. We aimed to evaluate transanal endoscopic microsurgery (TEM) for the treatment of WRNETs.
Methods
Between December 1995 and August 2009, 109 patients with WRNETs underwent TEM. TEM was performed for patients with tumors sizes of up to 20 mm and without a lymphadenopathy. These patients had been referred from other clinics after having been diagnosed with WRNETs by using a colonoscopic biopsy; they had undergone a failed endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR) and exhibited an involved resection margin and remaining tumor after ESD or EMR, regardless of the distance from the anal verge. This study included 38 patients that had more than three years of follow-up.
Results
The mean age of the patients was 51.3 ± 11.9 years, the mean tumor size was 8.0 ± 3.9 mm, and no morbidity occurred. Thirty-five patients were asymptomatic. TEM was performed after a colonoscopic resection in 13 cases because of a positive resection margin, a residual tumor or a non-lifting lesion. Complete resections were performed in 37 patients; one patient with a positive margin was considered surgically complete. In one patient, liver metastasis and a recurrent mesorectal node occurred after five and 10 years, respectively.
Conclusion
TEM might provide an accessible and effective treatment either as an initial or as an adjunct after a colonoscopic resection for a WRNET.
doi:10.3393/jksc.2012.28.4.201
PMCID: PMC3440489  PMID: 22993706
Well-differentiated rectal neuroendocrine tumors; Transanal endoscopic microsurgery; Colonoscopic resection; Treatment
4.  Transanal endoscopic microsurgery: a review 
Canadian Journal of Surgery  2014;57(2):127-138.
Rectal adenomas and cancers occur frequently. Small adenomas can be removed colonoscopically, whereas larger polyps are removed via conventional transanal excision. Owing to technical difficulties, adenomas of the mid- and upper rectum require radical resection. Transanal endoscopic microsurgery (TEM) was first designed as an alternative treatment for these lesions. However, since its development TEM has been also used for a variety of rectal lesions, including carcinoids, rectal prolapse and diverticula, early stage carcinomas and palliative resection of rectal cancers. The objective of this review is to describe the current status of TEM in the treatment of rectal lesions. Since the 1980s, TEM has advanced substantially. With low recurrence rates, it is the method of choice for resection of endoscopically unresectable adenomas. Some studies have shown benefits to its use in treating early T1 rectal cancers compared with radical surgery in select patients. However, for more advanced rectal cancers TEM should be considered palliative or experimental. This technique has also been shown to be safe for the treatment of other uncommon rectal tumours, such as carcinoids. Transanal endoscopic microsurgery may allow for new strategies in the treatment of rectal pathology where technical limitations of transanal techniques have limited endoluminal surgical innovations.
doi:10.1503/cjs.022412
PMCID: PMC3968206  PMID: 24666451
5.  Is Transanal Endoscopic Microsurgery Adequate in the Removal of Rectal Lesions? 
Introduction
Transanal endoscopic microsurgery (TEM) was developed by G. Buess in 1983 as a minimally invasive surgery for the removal of anorectal lesions that cannot be excised by conventional transanal instruments. TEM uses specialized equipment including an operating proctoscope and insufflator to form an airtight system. We reviewed the experience of a single surgeon using this technique at our institution.
Methods
A retrospective and prospective review of all patients who underwent TEM between November 2002 and April 2007 by a single surgeon at our institution was performed. One hundred thirteen patients were identified. All 113 patients had a preoperative enema. Those with rectal lesions also underwent rectal endoscopic ultrasonography (REUS). A single dose of preoperative cefazolin and metronidazole was given before the start of all procedures. All patients were followed with flexible sigmoidoscopy at 1, 6, and 12 months.
Results
A total of 113 patients underwent TEM excision between November 2002 and April 2007. Diagnoses included benign adenomas (64.6%), carcinoid tumors (14.6%), T1 cancers (18.8%), and a small number of T2 cancers (2.1%). The mean distance from the anal verge was 16 cm. Mean operative time was 79 minutes (range, 48–170 minutes). The average blood loss was 100 cc. The average length of hospital stay was less than 24 hours; 92 patients went home the same day. The longest length of stay was 7 days for a patient who had a long segment of carpet adenomas between 14–6 cm and the peritoneum was entered and subsequently closed. However, postoperatively, there was a question of peritoneal signs and the patient was explored. No spillage was found but the presence of clots was found. In one case, the procedure could not be completed due to a tortuous rectum and the patient underwent a low anterior resection instead. Two patients experienced postoperative bleeding that stopped without intervention and did not require transfusion. One patient developed a hematoma that drained on its own. In all cases, postoperative pain was controlled with oral narcotics. Eight patients had a recurrence of their lesion.
Discussion
Endoscopic removal of adenomatous colorectal polyps during diagnostic procedures is the first-line treatment of such lesions. It is efficient, safe, relatively inexpensive, and associated with the lowest complication rate. However, this is not always possible due to size and/or location limitations. Additionally, adenomas in the middle or upper rectum are difficult to remove using standard transanal excision instruments. In our series, only 5 of 113 patients (4%) experienced any type of complication. These consisted of bleeding and hematoma. This finding is consistent with other evidence in the literature. TEM is an effective treatment for lesions between 6–18 cm. We believe that it is less invasive than abdominal surgery or the Kraske procedure. The need for conversion and the complication rates are low. It is a useful tool for surgeons to excise lesions that cannot be reached by traditional transanal instruments. Of the 8 patients who had recurrences, 6 were benign while 2 were malignant. The 2 patients with malignant recurrences were not candidates for abdominal surgery due to their comorbidities. TEM is adequate for the removal of rectal lesions, providing the patients are appropriate candidates for the procedure.
PMCID: PMC2645510
6.  Transanal endoscopic micro-surgery (TEMS) for the management of large or sessile rectal adenomas: a review of the technique and indications 
In this review article the surgical technique of Transanal Endoscopic Microsurgery (TEMS) is examined. A number of techniques have been used to treat adenomas of the rectum. The treatment of large adenomas which occupy a large surface of the rectal lumen or adenomas which are flat and grow in a "carpet-like" fashion is particularly challenging. Major rectal surgery carries a risk of morbidity and mortality, particularly in elderly and unfit patients. Although local excision with transanal resection (TAR) and the Kraske sacral operation have been used in the past, during the last twenty years TEMS has become the method of choice for those lesions. TEMS is efficient and minimally invasive. The technique allows the patient to recover rapidly and the incidence of complications is much lower than that of major surgery. In case of recurrence the option of repeat TEMS or major surgery remain available. TEMS has been slow to gain popularity mainly for reasons of cost and steep learning curve but it is now an established procedure and a valuable therapeutic option which is particularly useful for elderly and unfit patients. Gastroenterologists should be aware of the nature and indications of TEMS in order to advise and refer selected patients with rectal adenomas accordingly.
doi:10.1186/1477-7800-3-13
PMCID: PMC1468413  PMID: 16674824
7.  Endoscopic mucosal resection with circumferential incision for treatment of rectal carcinoid tumours 
Background
Endoscopic mucosal resection (EMR) is simple and quick and has low complication rates. However, the disadvantage of local recurrence or remnant rate limits the use of this technique. We aimed to analyse the outcomes of conventional EMR and EMR with circumferential incision (CIEMR), a simplified modification of EMR, in the endoscopic treatment of rectal carcinoid tumours.
Methods
A total of 59 consecutive patients with rectal carcinoid tumours without regional lymph node enlargement confirmed by endoscopic ultrasonography were included in the study. These patients underwent endoscopic treatment from January 2009 to September 2011 and were randomly designated into CIEMR (n = 31) or EMR group (n = 28). En bloc resection rate, pathological complete resection rate, procedure time, complications and follow-up outcomes were analysed.
Results
The en bloc resection rate was not significantly different between the CIEMR and EMR groups (100% versus 96.55%, P > 0.05). The pathological complete resection rate was higher in the CIEMR group than in the EMR group (96.7% versus 82.14%, P < 0.05). The overall complication rate, delayed bleeding and procedure time were not significantly different between the two groups. No recurrence was observed in either the EMR or CIEMR group.
Conclusions
CIEMR optimises the procedure of EMR and simplifies the technique of endoscopic submucosal dissection; thus, it has a better histologically complete resection rate and more acceptable complication rate than EMR. Thus, CIEMR may be preferable to conventional EMR for resection of rectal carcinoid tumours less than 15 mm.
doi:10.1186/1477-7819-12-23
PMCID: PMC3912495  PMID: 24472342
CIEMR; Endoscopic mucosal resection (EMR); Rectal carcinoid tumours
8.  Efficacy and Long-Term Outcome of Endoscopic Treatment of Sporadic Nonampullary Duodenal Adenoma 
Gut and Liver  2010;4(3):373-377.
Background/Aims
Endoscopic resection has proven to be a safe and effective alternative to surgery for duodenal adenomas. However, few data are available on the adequacy of resection and long-term outcomes. This study evaluated the efficacy and longterm endoscopic findings in a cohort of Korean patients who underwent endoscopic mucosal resection (EMR) of sporadic duodenal adenomas.
Methods
Seventeen patients with nonampullary duodenal adenomas without familial polyposis syndrome and who were treated by EMR between January 2001 and December 2007 were evaluated retrospectively. Their management, follow-up, and outcomes were reviewed.
Results
In total, seventeen lesions were removed from EMR in 17 patients (mean age, 59.3 years; 6 women, 11 men). The mean size of the tumors was 15.1 mm (median, 13 mm, range, 8-27 mm). Of these 17 adenomas, 16 adenomas were tubulous and 1 was tubulovillous. The EMR was performed successfully in all 17 patients in a single session. After a median follow-up period of 29 months (range, 13-72 months), all patients remained in remission. One patient had bleeding at the site of the EMR. There were no perforations after the EMR.
Conclusions
EMR for sporadic duodenal adenomas seemed to be a safe and effective treatment modality.
doi:10.5009/gnl.2010.4.3.373
PMCID: PMC2956351  PMID: 20981216
Duodenal neoplasm; Adenoma; Endoscopic mucosal resection; Treatment efficacy
9.  Developing an endoscopic mucosal resection service in a district general hospital 
Frontline Gastroenterology  2012;3(4):272-277.
Objective
To describe the implementation of a formal single-operator led endoscopic mucosal resection (EMR) service in a district general hospital, and the effect on patient outcome of this service development.
Design
Prospective audit during initiation and subsequent development of EMR service.
Setting
District general hospital.
Patients
All patients referred to EMR service between 1 January 2008 and 31 December 2011.
Interventions
Nil in addition to clinical care.
Main outcomes measured
The number of EMRs per year including polyp size and histology, recurrence of polyp tissue at 3 months following EMR, and complications including early/delayed bleeding and perforation.
Results
Following service implementation, the number of EMRs rose from 11 in 2008 to 35 in 2011, with the number of large polyps (>30 mm) rising from four in 2008 to 24 in 2011. Recurrent or residual adenomatous tissue fell from 75% in 2008 to 4.76% in 2011. Only one perforation occurred over the 4 years (0.8% perforation rate: 1 in 120 polypectomies). A reduction in surgical intervention for adenomatous polyp removal was observed during the audit period.
Conclusions
Professional engagement and support by medical, surgical and nursing members of the endoscopy team promoted development of skill and confidence in EMR. Exposure to higher volumes of EMR procedures allowed successful removal of larger lesions, while maintained patient safety and reduced the need for surgical removal of benign polyps.
doi:10.1136/flgastro-2012-100212
PMCID: PMC3724199  PMID: 23904969
ENDOSCOPY; POLYP; CANCER; ADENOMA; ENDOSCOPIC POLYPECTOMY
10.  Large endoscopic mucosal resection for colorectal tumors exceeding 4 cm 
AIM: To evaluate the feasibility and the outcome of endoscopic mucosal resection (EMR) for large colorectal tumors exceeding 4 cm (LCRT) undergoing piecemeal resection.
METHODS: From January 2005 to April 2008, 146 digestive tumors larger than 2 cm were removed with the EMR technique in our department. Of these, 34 tumors were larger than 4 cm and piecemeal resection was carried out on 26 colorectal tumors. The mean age of the patients was 71 years. The mean follow-up duration was 12 mo.
RESULTS: LCRTs were located in the rectum, left colon, transverse colon and right colon in 58%, 15%, 4% and 23% of cases, respectively. All were sessile tumors larger than 4 cm with a mean size of 4.9 cm (4-10 cm). According to the Paris classification, 34% of the tumors were type Is, 58% type IIa, 4% type IIb and 4% type IIc. Pathological examination showed tubulous adenoma in 31%, tubulo-villous adenoma in 27%, villous adenoma in 42%, high-grade dysplasia in 38%, in situ carcinoma in 19% of the cases and mucosal carcinoma (m2) in 8% of the cases. The two cases (7.7%) of procedural bleeding that occurred were managed endoscopically and one small perforation was treated with clips. During follow-up, recurrence of the tumor occurred in three patients (12%), three of whom received endoscopic treatment.
CONCLUSION: EMR for tumors larger than 4 cm is a safe and effective procedure that could compete with endoscopic submucosal dissection, despite providing incomplete histological assessment.
doi:10.3748/wjg.v16.i5.588
PMCID: PMC2816271  PMID: 20128027
Endoscopic mucosal resection; Perforation; Colorectal carcinoma; Large polyps
11.  Endoscopic mucosal resection of colorectal polyps in typical UK hospitals 
AIM: To evaluate the outcomes of endoscopic mucosal resection (EMR) for colorectal polyps, with particular regard to procedural complications and recurrence rate, in typical United Kingdom (UK) hospitals that perform an average of about 25 colonic EMRs per year.
METHODS: A total of 239 colorectal polyps (≥ 10 mm) resected from 199 patients referred to Rochdale Infirmary, Salford Royal Hospital and Royal Oldham Hospital for EMR between January 2003 and January 2009 were studied.
RESULTS: The mean size of polyps resected was 19.6 ± 12.4 mm (range 10-80 mm). The overall major complication rate was 2.1%. Complications were less frequent with non-adenomas compared with the other groups (Pearson’s χ2 test, P < 0.0001). Resections of larger-sized polyps were more likely to result in complications (unpaired t-test, P = 0.021). Recurrence was associated with histology, with carcinoma-in-situ more likely to recur compared with low-grade dysplasia [hazard ratio (HR) 186.7, 95% confidence interval (95% CI): 8.81-3953.02, P = 0.001]. Distal lesions were also more likely to recur compared with right-sided and transverse colon lesions (HR 5.93, 95% CI: 1.35-26.18, P = 0.019).
CONCLUSION: EMR for colorectal polyps can be performed safely and effectively in typical UK hospitals. Stricter follow-up is required for histologically advanced lesions due to increased recurrence risk.
doi:10.3748/wjg.v16.i42.5324
PMCID: PMC2980681  PMID: 21072895
Endoscopic mucosal resection; Polyps; Endoscopic; Resection
12.  Endoscopic Mucosal Resection with Circumferential Incision for the Treatment of Large Sessile Polyps and Laterally Spreading Tumors of the Colorectum 
Clinical Endoscopy  2015;48(1):52-58.
Background/Aims
Endoscopic mucosal resection (EMR) is the standard treatment for colorectal polyps such as adenomas and early cancers with no risk of lymph node metastasis. However, endoscopic resection of large colorectal polyps (≥20 mm diameter) is difficult to perform. We evaluated the clinical outcomes of EMR with circumferential incision (EMR-CI) for the resection of large sessile polyps (Is) and laterally spreading tumors (LSTs) in the colorectum.
Methods
Between February 2009 and March 2011, we resected 80 large colorectal polyps by EMR-CI. We retrospectively investigated the en bloc resection rate, histologic complete resection rate, recurrence rate, and complications.
Results
The median polyp size was approximately 25 mm (range, 20 to 50), and the morphologic types included Is (13 cases), LST-granular (37 cases), and LST-nongranular (30 cases). The en bloc and complete histologic resection rates were 66.3% and 45.0%, respectively. The recurrence rate was 0% (median follow-up duration, 23 months), and perforation occurred in five cases (6.3%).
Conclusions
EMR-CI is an effective treatment modality for 20 to 30 mm-sized colorectal polyps, and may be considered as a second line therapeutic option if ESD is difficult.
doi:10.5946/ce.2015.48.1.52
PMCID: PMC4323433
Colorectal polyps; Endoscopic mucosal resection; Circumferential incision
13.  Safety of Endoscopic Mucosal Resection for Barrett’s Esophagus 
The American journal of gastroenterology  2013;108(9):10.1038/ajg.2013.187.
OBJECTIVES
Endoscopic mucosal resection (EMR) is an established technique for the management of Barrett’s esophagus (BE). Although EMR is generally perceived to be a relatively safe procedure, the published data regarding EMR-related complications are variable and the expertise of those performing EMR is often not disclosed. Our aim was to determine the complication rates in a large cohort of patients who underwent EMR at a specialized BE unit.
METHODS
A prospectively maintained database was reviewed for patients with BE who underwent EMR from January 1995 to August 2008. EMR was performed in patients with neoplastic appearing lesions. Bleeding, stricture, and perforation related to EMR were reviewed as the main outcome measurements.
RESULTS
In all, 681 patients (83% male; mean age 70 years old) underwent a total of 1,388 endoscopic procedures and 2,513 EMRs. Median length of BE was 3.0 cm (interquartile range (IQR) 1–7). A single experienced endoscopist performed 99% of the EMR procedures. EMR was performed using commercially available EMR kits in 95% (77% cap–snare and 18% band–snare) and a variceal band ligation device in 5% of cases. No EMR-related perforations occurred during the study period. The rate of post-EMR bleeding was 1.2% (8 patients). Seven patients were successfully treated endoscopically and one needed surgery. The rate for symptomatic strictures after EMR was 1.0% (7 cases), and all of the cases did not involve intervening ablation therapies. All strictures were successfully treated with endoscopic dilation.
CONCLUSIONS
This is the largest series reported to date on EMR in BE. In this large retrospective study, EMR for BE was associated with a low rate of complications for selected patients when performed by experienced hands.
doi:10.1038/ajg.2013.187
PMCID: PMC3815637  PMID: 23857478
14.  Endoscopic mucosal resection for flat neoplasia in chronic ulcerative colitis: can we change the endoscopic management paradigm? 
Gut  2006;56(6):838-846.
Background
The potential of endoscopic mucosal resection (EMR) for treating flat dysplastic lesions in chronic ulcerative colitis (CUC) has not been addressed so far. Historically, such lesions were referred for colectomy. Furthermore, there are only limited data to support endoscopic resection of exophytic adenoma‐like mass (ALM) lesions in colitis.
Aims
To evaluate the safety and clinical outcomes of patients with colitis undergoing EMR for Paris class 0–II and class I ALM compared with sporadic controls. Secondary aims were to re‐evaluate the prevalence, anatomical “mapping” and histopathological characteristics of both Paris class 0–II and class I lesions in the context of CUC.
Methods
Prospective clinical, pathological and outcome data of patients with colitis‐associated Paris class 0–II and Paris class I ALM treated with EMR (primary end points being colorectal cancer development, resection efficacy, metachronous lesion rates and post‐resection recurrence rates) were compared with those of sporadic controls.
Results
204 lesions were diagnosed in 169 patients during the study period: 167 (82%) diagnosed at “entry” colonoscopy, and 36 (18%) diagnosed at follow‐up. 170 ALMs, 18 dysplasia‐associated lesion masses (DALMs) and 16 cancers were diagnosed. A total of 4316 colonoscopies were performed throughout the study period (median per patient: 6; range: 1–8). The median follow‐up period for the complete cohort was 4.1 years (range: 3.6–5.21). 1675 controls were included from our prospective database of patients without CUC who had undergone EMR for sporadic Paris class 0–II and snare polypectomy of Paris type I lesions from 1998 onwards, and were considered to be at moderate to high lifetime risk of colorectal cancer. 3792 colonoscopies were performed throughout the study period in this group (median per patient: 4; range: 1–7). The median follow‐up period was 4.8 years (range: 2.9–5.2). No statistically significant differences were observed between the CUC study group and controls with respect to age, sex, median number of colonoscopies per patient, median follow‐up duration, post‐resection complications, median lesional diameter or interval cancer rates. However, there was a significant between‐group difference regarding the prevalence of Paris class 0–II lesions in the CUC group (82/155 (61%)) compared with controls (285/801 (35%); χ2 = 31.13; p<0.001). Furthermore, recurrence rates of lateral spreading tumours were higher in the colitis cohort (1/7 (14%)) than among controls (0/10 (0%); p = 0.048 (95% CI 11.64% to 40.21%)).
Conclusions
Flat DALM, similarly to Paris class I ALM, can be managed safely by EMR in CUC. A change in management paradigm to include EMR for the resection of flat dysplastic lesions in selected cases is proposed.
doi:10.1136/gut.2006.106294
PMCID: PMC1954845  PMID: 17135310
15.  Endoscopic mucosal resection for rectal carcinoids under micro-probe ultrasound guidance 
AIM: To assess the therapeutic value of endoscopic mucosal resection (EMR) under micro-probe ultrasound guidance for rectal carcinoids less than 1 cm in diameter.
METHODS: Twenty-one patients pathologically diagnosed with rectal carcinoids following colonoscopy in our hospital from January 2007 to November 2012 were included in this study. The patients consisted of 14 men and 7 women, with a mean age of 52.3 ± 12.2 years (range: 36-72 years). The patients with submucosal tumors less than 1 cm in diameter arising from the rectal and muscularis mucosa detected by micro-probe ultrasound were treated with EMR and followed up with conventional endoscopy and micro-probe ultrasound.
RESULTS: All of the 21 tumors were confirmed by micro-probe ultrasound as uniform hypoechoic masses originating from the rectal and muscularis mucosa, without invasion of muscularis propria and vessels, and less than 1 cm in diameter. EMR was successfully completed without bleeding, perforation or other complications. The resected specimens were immunohistochemically confirmed to be carcinoids. Patients were followed up for one to two years, and no tumor recurrence was reported.
CONCLUSION: EMR is a safe and effective treatment for rectal carcinoids less than 1 cm in diameter.
doi:10.3748/wjg.v19.i16.2555
PMCID: PMC3646148  PMID: 23674859
Micro-probe ultrasound; Endoscopic mucosal resection; Rectal carcinoid; Endoscopic submucosal dissection; Submucosal tumors
16.  Transanal endoscopic microsurgery in treatment of rectal adenomas and T1 low-risk carcinomas 
Background
Transanal endoscopic microsurgery as a local therapy option for rectal neoplasms is a tissue-sparing technique that protects the anal sphincter. The present retrospective analysis reports the course of observation after local excision of adenomas and T1 low-risk carcinomas using transanal endoscopic microsurgery.
Methods
In a retrospective analysis we examined data on 279 patients for local recurrence. A total of 144 patients had a rectal adenoma (n = 103) or a R0 resection of low-risk T1 carcinomas (n = 41). In this collective, we also examined parameters concerning perioperative management, complications, intraoperative blood loss and duration of hospital stay.
Results
Patients with adenoma were on average 64.9 (range 37 to 90) years old; 83.5% of the adenomas were located 3 to 11 cm from the anocutaneous line. In adenoma patients the recurrence rate was 2.9% for an observation period of 21.8 months. The postoperative course was without any complications in 98.1% of patients.
Patients with T1 low-risk carcinoma were 64.6 (range 30 to 89) years old. In all cases, an R0 resection could be performed. The recurrence rate was 9.8% for an observation period of 34.4 months. In this group the postoperative course was free of complications in 97.6% of patients.
Conclusions
The high efficacy of transanal endoscopic microsurgery ensures minimally invasive treatment of adenomas and low-risk T1 carcinomas with low complication rates and a low rate of therapeutic failure.
doi:10.1186/1477-7819-10-255
PMCID: PMC3556112  PMID: 23181563
Transanal endoscopic microsurgery; Rectal adenoma; Rectal carcinoma; Local excision; Endoscopic surgery
17.  Transanal endoscopic microsurgery--impact on the practice of a colorectal surgeon in a district general hospital. 
INTRODUCTION: The objective was to assess the impact on the management of colorectal patients treated in a district general hospital within the first year after the introduction of transanal endoscopic microsurgery (TEM). PATIENTS AND METHODS: Data were collected for consecutive unselected patients who underwent TEM. Comparative data were derived from a matched group of patients who underwent anterior resection, peranal procedures (PAR) or transanal resection (TAR) in this unit. RESULTS: Twenty-two patients underwent TEM (11 men and 11 women; aged, 29-87 years; median, 75 years). Eighteen patients had a pre-operative diagnosis of benign rectal neoplasms; three were found to have invasive carcinoma, which might have been missed during TAR. Four patients had a pre-operative diagnosis of rectal cancer and TEM provided local tumour control in three cases. The operating time ranged between 20-150 min (mean, 65 min; median, 57 min). Hospital stay ranged between 0-10 days (mean, 3.7 days; median, 3 days), with a total of 97 in-patient days for the entire group of patients. Twenty-four operations were performed (22 TEM and two salvage anterior resections), with an estimated cost of 1544 pounds sterling for consumables used. Alternative treatments in the absence of TEM were considered to involve 10 anterior resections, 5 closures of ileostomy, 30 TAR procedures and one PAR procedure, with an estimated 306 days of in-patient admission, 46 operations and 6245 pounds sterling spent on consumables. CONCLUSIONS: Availability of TEM allows more efficient treatment for a significant number of patients with rectal tumours. The cost of the equipment is offset by a significant decrease in the length of in-patient admissions.
doi:10.1308/003588405X51083
PMCID: PMC1964132  PMID: 16263010
18.  An Evaluation of Transanal Endoscopic Microsurgery for Rectal Adenoma and Carcinoma 
Background:
Transanal endoscopic microsurgery was introduced in the early 1980s. Since then, increasing numbers of rectal adenomas are being excised by this technique. The aim of this study was to evaluate our institution's experience with transanal endoscopic microsurgery for rectal adenoma and carcinoma.
Methods:
Seventy-five patients (adenomas, n=58) underwent more than 90 TEM resections over a period of 5 years.
Results:
Postoperative complications were minimal with 3% (n=2) in the adenoma group requiring transfusion and 0% 30-day mortality. One patient in each group developed transient fecal incontinence. During the follow-up period, 6 patients (10%) in the adenoma group underwent further local resections for their recurrences. Two patients in the carcinoma group (1 each of pathological T1 and T2 stage) developed recurrence at 24 months. A female with a T2 tumor was found to have an inoperable lesion and underwent sigmoid colostomy. Five of 17 patients had postoperative radiotherapy, and 2 patients developed radiation enteritis. Four patients died during follow-up due to unrelated reasons.
Conclusion:
The transanal endoscopic microsurgery technique appears to be safe and associated with minimal morbidity. Careful selection of patients with thorough preoperative assessment is necessary for carcinoma patients. Patients with T1 lesions and favorable histology should only be considered for curative resection by this technique.
PMCID: PMC3015527  PMID: 15119655
Transanal endoscopic microsurgery; Rectal adenoma; Rectal carcinoma; Local resection
19.  Cost-Effectiveness of Treatment and Endoscopic Surveillance of Precancerous Lesions to Prevent Gastric Cancer 
Cancer  2010;116(12):2941-2953.
Background
While surveillance for Barrett’s esophagus and other gastrointestinal precancerous conditions is recommended, no analogous guidelines exist for gastric lesions. We sought to estimate the clinical benefits and cost-effectiveness of treatment and endoscopic surveillance to prevent gastric cancer.
Methods
We developed a state-transition decision model for a cohort of U.S. men with a recent incidental diagnosis of gastric precancerous lesions (dysplasia, intestinal metaplasia, or atrophy). Strategies included (1) no treatment or surveillance, and (2) referral for treatment and surveillance, and varied by treatment for dysplastic and cancerous lesions (surgery or endoscopic mucosal resection (EMR)) and surveillance frequency (none, every 10, 5, or 1 years). We restrict the term ‘post-treatment surveillance’ to surveillance in individuals after treatment. Data were based on published literature and databases. Outcomes included lifetime gastric cancer risk, quality-adjusted-life-expectancy, lifetime costs, and incremental cost-effectiveness ratios.
Results
For a 50-year-old cohort of men with dysplasia, lifetime gastric cancer risk was 5.9%. EMR with annual surveillance reduced lifetime cancer risk by 90% and cost $39,800 per quality-adjusted-life-year (QALY). Addition of post-treatment surveillance every 10 years provided little incremental benefit (~5%), but cost >$1 million per QALY. Results were most sensitive to surgical risks and proportion of lesions completely removed with EMR.
Conclusions
EMR with surveillance every 1 to 5 years for gastric dysplasia is promising for secondary cancer prevention, and has a cost-effectiveness ratio that would be considered attractive in the U.S. Endoscopic surveillance of less advanced lesions does not appear to be cost-effective, except possibly for immigrants from high-risk countries.
doi:10.1002/cncr.25030
PMCID: PMC2946062  PMID: 20564399
gastric cancer; surveillance; secondary prevention; cost-effectiveness; outcomes research
20.  Selection of appropriate endoscopic therapies for duodenal tumors: An open-label study, single-center experience 
AIM: To determine an appropriate compartmentalization of endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR) for duodenal tumors.
METHODS: Forty-six duodenal lesions (excluding papillary lesions) from 44 patients with duodenal tumors treated endoscopically between 2005 and 2013 were divided into the ESD and EMR groups for retrospective comparison and analysis.
RESULTS: The mean age was 65 ± 9 years (35-79 years). There were 24 lesions from men and 22 from women. The lesions consisted of 6 early cancers, 31 adenomas and 9 neuroendocrine tumors. Lesion location was the duodenal bulb in 15 cases and the descending part of the duodenum in 31 cases. The most common macroscopic morphology was elevated type in 21 cases (45.6%). Mean tumor diameter was 11.9 ± 9.7 mm (3-60 mm). Treatment procedure was ESD (15 cases) vs EMR (31 cases). The examined parameters in the ESD vs EMR groups were as follows: mean tumor diameter, 12.9 ± 14.3 mm (3-60 mm) vs 11.4 ± 6.7 mm (4-25 mm); en bloc resection rate, 86.7% vs 83.9%; complete resection rate, 86.7% vs 74.2%; procedure time, 86.5 ± 63.1 min (15-217 min) vs 13.2 ± 17.0 min (2-89 min) (P < 0.0001); intraprocedural perforation, 3 cases vs none (P = 0.0300); delayed perforation, none in either group; postprocedural bleeding, 1 case vs none; mean postoperative length of hospitalization, 8.2 ± 2.9 d (5-16 d) vs 6.1 ± 2.0 d (2-12 d) (P = 0.0067); recurrence, none vs 1 case (occurring at 7 mo postoperatively).
CONCLUSION: ESD was associated with a longer procedure time and a higher incidence of intraprocedural perforation; EMR was associated with a lower rate of complete resection.
doi:10.3748/wjg.v20.i26.8624
PMCID: PMC4093713  PMID: 25024618
Duodenal tumor; Endoscopic submucosal dissection; Endoscopic mucosal resection; Cancer; Adenoma; Neuroendocrine tumor
21.  Which endoscopic treatment is the best for small rectal carcinoid tumors? 
The incidence of rectal carcinoids is rising because of the widespread use of screening colonoscopy. Rectal carcinoids detected incidentally are usually in earlier stages at diagnosis. Rectal carcinoids estimated endoscopically as < 10 mm in diameter without atypical features and confined to the submucosal layer can be removed endoscopically. Here, we review the efficacy and safety of various endoscopic treatments for small rectal carcinoid tumors, including conventional polypectomy, endoscopic mucosal resection (EMR), cap-assisted EMR (or aspiration lumpectomy), endoscopic submucosal resection with ligating device, endoscopic submucosal dissection, and transanal endoscopic microsurgery. It is necessary to carefully choose an effective and safe primary resection method for complete histological resection.
doi:10.4253/wjge.v5.i10.487
PMCID: PMC3797901  PMID: 24147192
Carcinoid tumor; Rectum; Polypectomy; Endoscopic mucosal resection; Endoscopic submucosal dissection
22.  Focal endoscopic mucosal resection before radiofrequency ablation is equally effective and safe compared with radiofrequency ablation alone for the eradication of Barrett’s esophagus with advanced neoplasia 
Gastrointestinal endoscopy  2012;76(4):733-739.
Background
Endoscopic mucosal resection (EMR) is commonly performed before radiofrequency ablation (RFA) for nodular dysplastic Barrett’s esophagus (BE).
Objective
To determine the efficacy and safety of EMR before RFA for nodular BE with advanced neoplasia (high-grade dysplasia (HGD) or intramucosal carcinoma (IMC)).
Design
Retrospective study.
Setting
University of North Carolina Hospitals, from 2006 to 2011.
Patients
169 patients with BE with advanced neoplasia – 65 patients treated with EMR and RFA for nodular disease and 104 patients treated with RFA alone for non-nodular disease.
Interventions
Endoscopic mucosal resection, radiofrequency ablation.
Main Outcome Measurements
Efficacy (complete eradication of dysplasia, complete eradication of intestinal metaplasia, total treatment sessions, RFA treatment sessions), safety (stricture formation, bleeding, and hospitalization).
Results
EMR followed by RFA achieved complete eradication of dysplasia and complete eradication of intestinal metaplasia in 94.0% and 88.0%, respectively, compared with 82.7% and 77.6%, respectively in the RFA only group (p=0.06 and p=0.13, respectively). The complication rates between the two groups were similar (7.7% vs. 9.6%, p=0.79). Strictures occurred in 4.6% of patients in the EMR before RFA group compared with 7.7% of patients in the RFA only group (p=0.53).
Limitations
Retrospective study at a tertiary-care referral center.
Conclusion
In patients treated with EMR before RFA for nodular BE with HGD or IMC, no differences in efficacy and safety outcomes were observed compared with RFA alone for non-nodular BE with HGD or IMC. EMR followed by RFA is safe and effective for patients with nodular BE and advanced neoplasia.
doi:10.1016/j.gie.2012.04.459
PMCID: PMC3909515  PMID: 22732872
Endoscopic mucosal resection; radiofrequency ablation; Barrett’s esophagus; efficacy; safety
23.  Transanal endoscopic microsurgery for early rectal cancer: single center experience 
Introduction
The use of transanal endoscopic microsurgery (TEM) is increasing due to the ability to perform minimally invasive local treatment with large full-thickness local excision under improved vision.
Aim
To evaluate the initial experience with TEM for early rectal cancer in a single center.
Material and methods
From February 2010 to November 2013 a total of 20 patients underwent TEM for early rectal cancer. Nine were women and 11 men, age range 39 to 88 years (median: 71 years). The postoperative surveillance protocol, which includes rigid proctoscopy, carcinoembryonic antigen (CEA) and endorectal ultrasound every 3 months during the first 2 years, was applied to all patients after TEM.
Results
Final histology revealed 14 (70%) lesions to be T1 and 6 (30%) T2 cancers. There were no postoperative complications. All 6 patients in the pT2 group and those in the pT1 group with unfavorable histology were offered adjuvant chemoradiotherapy or immediate radical surgery. Patients were followed up from 2 to 35 months (median: 21 months). There was one local recurrence (5%) in a patient who refused to undergo abdominoperineal excision for T1 low rectal cancer, had unfavorable histology after TEM, and for which reason underwent postoperative chemoradiation. The patient had abdominoperineal resection 7 months after TEM (rpT2N0M0). One patient was lost to follow-up. The rest of the patients are alive and disease-free.
Conclusions
In our hands, TEM was an alternative to total mesorectal excision in patients with low-risk early rectal cancer. Further follow-up is necessary to evaluate recurrence and survival rates after TEM for patients with invasive rectal cancer.
doi:10.5114/wiitm.2014.44138
PMCID: PMC4280406  PMID: 25561999
transanal endoscopic microsurgery; early rectal cancer; recurrence; survival
24.  Rectal laterally spreading tumors successfully treated in two steps by endoscopic submucosal dissection and endoscopic mucosal resection 
BMC Gastroenterology  2010;10:135.
Background
Endoscopic submucosal dissection (ESD) is an advanced technique of therapeutic endoscopy alternative to endoscopic mucosal resection (EMR) for superficial gastrointestinal neoplasms >2 cm. ESD allows for the direct dissection of the submucosa and large lesions can be resected en bloc. ESD is not limited by resection size, increases histologically complete resection rates and may reduce the local recurrence.
Nevertheless, the technique is time-consuming, technically demanding and associated with a high complication rate. To reduce the risk of complications, different devices and technical advances have been proposed with conflicting results and, still, ESD en bloc resections of huge lesions are associated with increased complications.
Case Presentation
We successfully used a combined ESD/EMR technique for huge rectal laterally spreading tumors (LSTs). ESD was used for circumferential resection of 2/3 of the lesion followed by piecemeal resection (2-3 pieces) of the central part of the tumour.
In all three patients we obtained the complete dissection of the polyp and the complete histological evaluation in absence of complications and recurrence at 6 months' follow up.
Conclusions
In the treatment of rectal LSTs, the combined treatment - ESD/EMR resection may be considered a suitable therapeutic option, indicated in selected cases as an alternative to surgery, in which the two techniques are neither reliable nor safe separately. However, to confirm our results, larger trials with longer follow up are required together with improvement of the technique and of the technical devices.
doi:10.1186/1471-230X-10-135
PMCID: PMC2994792  PMID: 21083919
25.  Endoscopic mucosal resection of large hyperplastic polyps in 3 patients with Barrett’s esophagus 
AIM: To report the endoscopic treatment of large hyperplastic polyps of the esophagus and esophago-gastric junction (EGJ) associated with Barrett’s esophagus (BE) with low-grade dysplasia (LGD), by endoscopic mucosal resection (EMR).
METHODS: Cap fitted EMR (EMR-C) was performed in 3 patients with hyperplastic-inflammatory polyps (HIPs) and BE.
RESULTS: The polyps were successfully removed in the 3 patients. In two patients, with short segment BE (SSBE) (≤ 3 cm), the metaplastic tissue was completely excised. A 2 cm circumferential EMR was performed in one patient with a polyp involving the whole EGJ. A simultaneous EMR-C of a BE-associated polypoid dysplastic lesion measuring 1 cm x 10 cm, was also carried out. In the two patients, histologic assessment detected LGD in BE. No complications occurred. Complete neosquamous re-epithelialization occurred in the two patients with SSBE. An esophageal recurrence occurred in the remaining one and was successfully retreated by EMR.
CONCLUSION: EMR-C appears to be a safe and effective method for treating benign esophageal mucosal lesions, allowing also the complete removal of SSBE.
doi:10.3748/wjg.v12.i35.5699
PMCID: PMC4088173  PMID: 17007025
Hyperplastic polyps; Endoscopic mucosal resection; Barrett’s esophagus

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