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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.  Endoscopic mucosal resection (EMR) versus endoscopic submucosal dissection (ESD) for resection of large distal non-pedunculated colorectal adenomas (MATILDA-trial): rationale and design of a multicenter randomized clinical trial 
BMC Gastroenterology  2016;16:56.
Background
Endoscopic mucosal resection (EMR) is currently the most used technique for resection of large distal colorectal polyps. However, in large lesions EMR can often only be performed in a piecemeal fashion resulting in relatively low radical (R0)-resection rates and high recurrence rates. Endoscopic submucosal dissection (ESD) is a newer procedure that is more difficult resulting in a longer procedural time, but is promising due to the high en-bloc resection rates and the very low recurrence rates. We aim to evaluate the (cost-)effectiveness of ESD against EMR on both short (i.e. 6 months) and long-term (i.e. 36 months). We hypothesize that in the short-run ESD is more time consuming resulting in higher healthcare costs, but is (cost-) effective on the long-term due to lower patients burden, a higher number of R0-resections and lower recurrence rates with less need for repeated procedures.
Methods
This is a multicenter randomized clinical trial in patients with a non-pedunculated polyp larger than 20 mm in the rectum, sigmoid, or descending colon suspected to be an adenoma by means of endoscopic assessment. Primary endpoint is recurrence rate at follow-up colonoscopy at 6 months. Secondary endpoints are R0-resection rate, perceived burden and quality of life, healthcare resources utilization and costs, surgical referral rate, complication rate and recurrence rate at 36 months. Quality-adjusted-life-year (QALY) will be estimated taking an area under the curve approach and using EQ-5D-indexes. Healthcare costs will be calculated by multiplying used healthcare services with unit prices. The cost-effectiveness of ESD against EMR will be expressed as incremental cost-effectiveness ratios (ICER) showing additional costs per recurrence free patient and as ICER showing additional costs per QALY.
Discussion
If this trial confirms ESD to be favorable on the long-term, the burden of extra colonoscopies and repeated procedures can be prevented for future patients.
Trial registration
NCT02657044 (Clinicaltrials.gov), registered January 8, 2016.
doi:10.1186/s12876-016-0468-6
PMCID: PMC4882830  PMID: 27229709
Colorectal adenoma; Endoscopic mucosal resection; Endoscopic submucosal dissection; Randomized clinical trial; Colonoscopy
3.  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
4.  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
5.  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
6.  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
7.  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
8.  Comparison of Transanal Endoscopic Microsurgery and Total Mesorectal Excision in the Treatment of T1 Rectal Cancer: A Meta-Analysis 
PLoS ONE  2015;10(10):e0141427.
Background
Transanal endoscopic microsurgery (TEM) for the treatment of early-stage rectal cancer has attracted attention due to its advantages of reduced surgical trauma, fewer complications, low operative mortality, rapid postoperative recovery and short hospital stay. However, there are still significant controversies regarding TEM for the treatment of rectal cancer, mainly related to the prognosis associated with this method.
Objective
This study sought to compare the efficacy of transanal endoscopic microsurgery (TEM) and total mesorectal excision (TME) for the treatment of T1 rectal cancer.
Methods
We searched the Cochrane Library, PubMed, Embase and CNKI databases. Based on the Cochrane Handbook for Systematic Reviews, we screened the trials, evaluated the quality and extracted the data.
Results
One randomized controlled trial (RCT) and six non-randomized controlled clinical trials (CCTs) were included in the meta-analysis (a total of 860 rectal cancer patients were included; 303 patients were treated with TEM, and 557 patients were treated with TME). Analysis revealed that all seven studies reported local recurrence rates, and there was a significant difference between the TEM and TME groups [odds ratio (OR) = 4.62, 95% confidence interval (CI) (2.03, 10.53), P = 0.0003]. A total of five studies reported distant metastasis rates, and there was no significant difference between the TEM and TME groups [OR = 0.74, 95%CI (0.32, 1.72), P = 0.49]. A total of six studies reported postoperative overall survival of the patients, and there was no significant difference between the TEM and TME groups [OR = 0.87, 95%CI(0.55, 1.38), P = 0.55]. In addition, two studies reported the postoperative disease-free survival rates of patients, and there was no significant difference between the TEM and TME groups [OR = 1.12, 95%CI (0.31, 4.12), P = 0.86].
Conclusions
For patients with T1 rectal cancer, the distant metastasis, overall survival and disease-free survival rates did not differ between the TEM and TME groups, although the local recurrence rate after TEM was higher than that after TME.
doi:10.1371/journal.pone.0141427
PMCID: PMC4624726  PMID: 26505895
9.  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
10.  Endoscopic Mucosal Resection versus Endoscopic Submucosal Dissection for Large Polyps: A Western Colonoscopist’s View 
Clinical Endoscopy  2016;49(5):454-456.
To discuss the rationale for the widespread application of endoscopic mucosal resection (EMR) rather than endoscopic submucosal dissection (ESD) in Western centers. In Western centers, EMR is the treatment of choice for most non-pedunculated colorectal adenomas >2 cm in size. EMR is sufficiently effective and safe to be performed without post-procedure hospitalization. Advances in EMR have led to reduced recurrence rates, and recent studies have demonstrated excellent outcomes with endoscopic treatment of recurrent adenomas. While studies from Asia have demonstrated lower recurrence rates with ESD, concern about the higher perforation risk and lengthy procedure time of ESD are two of the barriers preventing widespread adoption of ESD in the West. EMR is likely to continue as the dominant method for the treatment of large colorectal adenomas in Western centers until the limitations of ESD are overcome.
doi:10.5946/ce.2016.077
PMCID: PMC5066401  PMID: 27561263
Colonic polyps; Colonoscopy; Colorectal neoplasms
11.  Effects of preceding endoscopic mucosal resection on the efficacy and safety of radiofrequency ablation for treatment of Barrett’s esophagus: results from the United States Radiofrequency Ablation Registry 
Summary
The effects of preceding endoscopic mucosal resection (EMR) on the efficacy and safety of radiofrequency ablation (RFA) for treatment of nodular Barrett’s esophagus (BE) is poorly understood. Prior studies have been limited to case series from individual tertiary care centers. We report the results of a large, multicenter registry. We assessed the effects of preceding EMR on the efficacy and safety of RFA for nodular BE with advanced neoplasia (high-grade dysplasia or intramucosal carcinoma) using the US RFA Registry, a nationwide study of BE patients treated with RFA at 148 institutions. Safety outcomes included stricture, gastrointestinal bleeding, and hospitalization. Efficacy outcomes included complete eradication of intestinal metaplasia (CEIM), complete eradication of dysplasia (CED), and number of RFA treatments needed to achieve CEIM. Analyses comparing patients with EMR before RFA to patients undergoing RFA alone were performed with Student’s t-test, Chi-square test, logistic regression, and Kaplan–Meier analysis. Four hundred six patients were treated with EMR before RFA for nodular BE, and 857 patients were treated with RFA only for non-nodular BE. The total complication rates were 8.4% in the EMR-before-RFA group and 7.2% in the RFA-only group (P = 0.48). Rates of stricture, bleeding, and hospitalization were not significantly different between patients treated with EMR before RFA and patients treated with RFA alone. CEIM was achieved in 84% of patients treated with EMR before RFA, and 84% of patients treated with RFA only (P = 0.96). CED was achieved in 94% and 92% of patients in EMR-before-RFA and RFA-only group, respectively (P = 0.17). Durability of eradication did not differ between the groups. EMR-before-RFA for nodular BE with advanced neoplasia is effective and safe. The preceding EMR neither diminished the efficacy nor increased complication rate of RFA treatment compared to patients with advanced neoplasia who had RFA with no preceding EMR. Preceding EMR is not associated with poorer outcomes in RFA.
doi:10.1111/dote.12386
PMCID: PMC4977202  PMID: 26121935
ablation technique; Barrett’s esophagus; safety; treatment efficacy
12.  Systematic review and meta-analysis of endoscopic submucosal dissection vs endoscopic mucosal resection for colorectal lesions 
Background and aims
This systematic review and meta-analysis compares the safety and effectiveness of endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) in the treatment of flat and sessile colorectal lesions >20 mm preoperatively assessed as noninvasive.
Methods
We reviewed the literature published between January 2000 and March 2014. Pooled estimates of the proportion of patients with en bloc, R0 resection, complications, recurrence, and need for further treatment were compared in a meta-analysis using fixed and random effects.
Results
A total of 11 studies and 4678 patients were included. The en bloc resection rate was 89.9% for ESD vs 34.9% for EMR patients (RR 1.93 p < 0.001). The R0 resection rate was 79.6% for ESD vs 36.2% for EMR patients (RR 2.01 p < 0.001). The rate of perforation was 4.9% for the ESD group and 0.9% for EMR (RR 3.19, p < 0.001), while the rate of bleeding was 1.9% for ESD and 2.9% for EMR (RR 0.68, p = 0.070). Therefore, the overall need for further surgery, including surgery for oncologic reasons and surgery for complications, was 7.8% for ESD and 3.0% for EMR (RR 2.40, p < 0.001).
Conclusions
ESD achieves a higher rate of en bloc and R0 resection compared to EMR, at the cost of a higher risk of complications. This, added to an increased need for surgery for oncologic reasons for a plausible tendency to extend indication for endoscopic excision, increases the risk of further surgery after ESD.
doi:10.1177/2050640615585470
PMCID: PMC4766548  PMID: 26966519
Colorectal adenoma; endoscopic mucosal resection; endoscopic submucosal dissection; systematic review; meta-analysis
13.  Advantage of endoscopic mucosal resection with a cap for rectal neuroendocrine tumors 
AIM: To compare the outcomes of endoscopic mucosal resection with a cap (EMR-C) with those of endoscopic submucosal dissection (ESD) for the resection of rectal neuroendocrine tumors.
METHODS: One hundred and sixteen lesions in 114 patients with rectal neuroendocrine tumor (NET) resected with EMR-C or ESD were included in the study. This study was performed at Pusan National University Yangsan Hospital between July 2009 and August 2014. We analyzed endoscopic complete resection rate, pathologic complete resection rate, procedure time, and adverse events in the EMR-C (n = 65) and ESD (n = 51) groups. We also performed a subgroup analysis by tumor size.
RESULTS: Mean tumor size was 4.62 ± 1.66 mm in the EMR-C group and 7.73 ± 3.14 mm in the ESD group (P < 0.001). Endoscopic complete resection rate was 100% in both groups. Histologic complete resection rate was significantly greater in the EMR-C group (92.3%) than in the ESD group (78.4%) (P = 0.042). Mean procedure time was significantly longer in the ESD group (14.43 ± 7.26 min) than in the EMR-C group (3.83 ± 1.17 min) (P < 0.001). Rates of histologic complete resection without complication were similar for tumor diameter ≤ 5 mm (EMR-C, 96%; ESD, 100%, P = 0.472) as well as in cases of 5 mm < tumor diameter ≤ 10 mm (EMR-C, 80%; ESD, 71.0%, P = 0.524).
CONCLUSION: EMR-C may be simple, faster, and more effective than ESD in removing rectal NETs and may be preferable for resection of small rectal NETs.
doi:10.3748/wjg.v21.i31.9387
PMCID: PMC4541391  PMID: 26309365
Neuroendocrine tumor; Endoscopic mucosal resection with cap; Endoscopic submucosal dissection; Complete resection; Complication
14.  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
15.  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
16.  Transanal Minimally Invasive Surgery for Rectal Lesions 
Background and Objectives:
Transanal minimally invasive surgery (TAMIS) has emerged as an alternative to transanal endoscopic microsurgery (TEM). The authors report their experience with TAMIS for the treatment of mid and high rectal tumors.
Methods:
From November 2011 through May 2016, 31 patients (21 females, 68%), with a median age of 65 years who underwent single-port TAMIS were prospectively enrolled. Mean distance from the anal verge of the rectal tumors was 9.5 cm. Seventeen patients presented with T1 cancer, 10 with large adenoma, 2 with gastrointestinal stromal tumor (GIST) and 2 with carcinoid tumor. Data concerning demographics, operative procedure and pathologic results were analyzed.
Results:
TAMIS was successfully completed in all cases. In 4 (13%) TAMIS was converted to standard Park's transanal technique. Median postoperative stay was 3 days. The overall complication rate was 9.6%, including 1 urinary tract infection, 1 subcutaneous emphysema, and 1 hemorrhoidal thrombosis. TAMIS allowed an R0 resection in 96.8% of cases (30/31 cases) and a single case of local recurrence after a large adenoma resection was encountered.
Conclusion:
TAMIS is a safe technique, with a short learning curve for laparoscopic surgeons already proficient in single-port procedures, and provides effective oncological outcomes compared to other techniques.
doi:10.4293/JSLS.2016.00032
PMCID: PMC4978546  PMID: 27547025
Colorectal surgery; Natural orifice transluminal endoscopic surgery (NOTES) Single-site laparoscopic surgery (SILS); Surgical oncology; Transanal minimally invasive Surgery (TAMIS)
17.  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
18.  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
19.  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
20.  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
21.  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
22.  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
23.  Transanal endoscopic microsurgery as optimal option in treatment of rare rectal lesions: A single centre experience 
AIM
To analyze the outcomes of transanal endoscopic microsurgery (TEM) in the treatment of rare rectal condition like mesenchymal tumors, condylomas, endometriosis and melanoma.
METHODS
We retrospectively reviewed a twenty-three years database. Fifty-two patients were enrolled in this study. The lesions were considered suitable for TEM if they were within 20 cm from the anus. All of them underwent an accurate preoperative workup consisting in clinical examination, total colonoscopy with biopsies, endoscopic ultrasonography, and pelvic computerized tomography or pelvic magnetic resonance imaging. Operative time, intraoperative complications, rate of conversion, tumor size, postoperative morbidity, mortality, the length of hospital stay, local and distant recurrence were analyzed.
RESULTS
Among the 1328 patients treated by TEM in our department, the 52 patients with rectal abnormalities other than adenoma or adenocarcinoma represented 4.4%. There were 30 males (57.7%) and 22 females (42.3%). Mean age was 55 years (median = 60, range = 24-78). This series included 14 (26.9%) gastrointestinal stromal tumors, 21 neuroendocrine tumors (40.4%), 1 ganglioneuroma (1.9%), 2 solitary ulcers in the rectum (3.8%), 6 cases of rectal endometriosis (11.5%), 6 cases of rectal condylomatosis (11.5%) and 2 rectal melanomas (3.8%). Mean lesion diameter was 2.7 cm (median: 4, range: 0.4-8). Mean distance from the anal verge was 9.5 cm (median: 10, range: 4-15). One patient operated for rectal melanoma developed distant metastases and died two years after the operation. We experienced 2 local recurrences (3.8%) with an overall survival equal to 97.6% (95%CI: 95%-99%) at the end of follow-up and a disease free survival of 98% (95%CI: 96%-99%).
CONCLUSION
We could conclude that TEM is an important therapeutical option for rectal rare conditions.
doi:10.4253/wjge.v8.i17.623
PMCID: PMC5027033  PMID: 27668073
Transanal endoscopic microsurgery; Rare rectal conditions; Full-thickness excision; Minimally invasive surgery; Retrospective study
24.  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  PMID: 25674527
Colorectal polyps; Endoscopic mucosal resection; Circumferential incision
25.  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

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