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The ASCRS Textbook of Colon and Rectal Surgery pp 495–505Cite as

Local Excision of Rectal Neoplasia

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Abstract

Although proctectomy is the most oncologically effective treatment of rectal neoplasms, the procedure is associated with substantial morbidity and chance of temporary or permanent stoma. Transanal local excision offers a viable option for effective treatment of benign rectal neoplasms and early stage rectal cancers. Outcomes following local excision are dependent of thoughtful selection of patients for the procedure and optimal surgical technique. It is critical to achieve negative circumferential margins of resection and to remove the tumor without fragmentation. Unfortunately, if pelvic recurrence of cancer occurs following local excision, probability of cure with salvage treatment is low. It is possible that adjuvant or neoadjuvant chemoradiotherapy may improve oncologic outcomes.

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References

  1. Corman ML. Jacques Lisfranc 1790–1847. Dis Colon Rectum. 1983;26(10):694–5.

    Google Scholar 

  2. Parks AG. A technique for excising extensive villous papillomatous change in the lower rectum. Proc R Soc Med. 1968;61(5):441–2.

    CAS  PubMed  PubMed Central  Google Scholar 

  3. Buess G, Hutterer F, Theiss J, Böbel M, Isselhard W, Pichlmaier H. A system for a transanal endoscopic rectum operation. Chirurg. 1984;55(10):677–80.

    CAS  PubMed  Google Scholar 

  4. Atallah S, Albert M, Larach S. Transanal minimally invasive surgery: a giant leap forward. Surg Endosc. 2010;24(9):2200–5.

    PubMed  Google Scholar 

  5. Albert MR, Atallah SB, deBeche-Adams TC, Izfar S, Larach SW. Transanal minimally invasive surgery (TAMIS) for local excision of benign neoplasms and early-stage rectal cancer: efficacy and outcomes in the first 50 patients. Dis Colon Rectum. 2013;56(3):301–7.

    PubMed  Google Scholar 

  6. Salehomoum NM, Nogueras JJ. Conventional transanal excision: current status and role in the era of transanal endoscopic surgery. Sem Colon Rectal Surg. 2015;26(1):9–14.

    Google Scholar 

  7. Buess G, Whiteford MH, Swantsrom LL. Transanal endoscopic microsurgery procedure for low rectal tumors. In: Asbun HJ, Young-Fadok TM, editors. American College of Surgeons Multimedia Atlas of Surgery. Woodbury: Ciné-Med Inc.; 2008.

    Google Scholar 

  8. Lezoche E, Guerrieri M, Paganini AM, D’Ambrosio G, Baldarelli M, Lezoche G, Feliciotti F, De Sanctis A. Transanal endoscopic versus total mesorectal laparoscopic resections of T2-N0 low rectal cancers after neoadjuvant treatment: a prospective randomized trial with a 3-years minimum follow-up period. Surg Endosc. 2005;19(6):751–6.

    CAS  PubMed  Google Scholar 

  9. Gavagan JA, Whiteford MH, Swanstrom LL. Full-thickness intraperitoneal excision by transanal endoscopic microsurgery does not increase short-term complications. Am J Surg. 2004;187(5):630–4.

    PubMed  Google Scholar 

  10. Morino M, Allaix ME, Famiglietti F, Caldart M, Arezzo A. Does peritoneal perforation affect short- and long-term outcomes after transanal endoscopic microsurgery? Surg Endosc. 2013;27(1):181–8.

    PubMed  Google Scholar 

  11. Hahnloser D, Cantero R, Salgado G, Dindo D, Rega D, Delrio P. Transanal minimal invasive surgery for rectal lesions: should the defect be closed? Colorectal Dis. 2015;17(5):397–402.

    Google Scholar 

  12. Cataldo PA. Local excison of rectal cancer. In: Beck DE et al., editors. The ASCRS textbook of colon and rectal surgery. 2nd ed. New York: Springer; 2011.

    Google Scholar 

  13. Middleton PF, Sutherland LM, Maddern GJ. Transanal endoscopic microsurgery: a systematic review. Dis Colon Rectum. 2005;48(2):270–84.

    PubMed  Google Scholar 

  14. Moore JS, Cataldo PA, Osler T, Hyman NH. Transanal endoscopic microsurgery is more effective than traditional transanal excision for resection of rectal masses. Dis Colon Rectum. 2008;51(7):1026–30. discussion 1030-1.

    PubMed  Google Scholar 

  15. de Graaf EJ, Burger JW, van Ijsseldijk AL, Tetteroo GW, Dawson I, Hop WC. Transanal endoscopic microsurgery is superior to transanal excision of rectal adenomas. Colorectal Dis. 2011;13(7):762–7.

    PubMed  Google Scholar 

  16. Clancy C, Burke JP, Albert MR, O’Connell PR, Winter DC. Transanal endoscopic microsurgery versus standard transanal excision for the removal of rectal neoplasms: a systematic review and meta-analysis. Dis Colon Rectum. 2015;58(2):254–61.

    Google Scholar 

  17. Barendse RM, van den Broek FJ, Dekker E, Bemelman WA, de Graaf EJ, Fockens P, Reitsma JB. Systematic review of endoscopic mucosal resection versus transanal endoscopic microsurgery for large rectal adenomas. Endoscopy. 2011;43(11):941–9.

    CAS  PubMed  Google Scholar 

  18. Arezzo A, Passera R, Saito Y, Sakamoto T, Kobayashi N, Sakamoto N, Yoshida N, Naito Y, Fujishiro M, Niimi K, Ohya T, Ohata K, Okamura S, Iizuka S, Takeuchi Y, Uedo N, Fusaroli P, Bonino MA, Verra M, Morino M. Systematic review and meta-analysis of endoscopic submucosal dissection versus transanal endoscopic microsurgery for large noninvasive rectal lesions. Surg Endosc. 2014;28(2):427–38.

    PubMed  Google Scholar 

  19. Swellengrebel HA, Marijnen CA, Verwaal VJ, Vincent A, Heuff G, Gerhards MF, van Geloven AA, van Tets WF, Verheij M, Cats A. Toxicity and complications of preoperative chemoradiotherapy for locally advanced rectal cancer. Br J Surg. 2011;98(3):418–26.

    CAS  PubMed  Google Scholar 

  20. van der Pas MH, Haglind E, Cuesta MA, Fürst A, Lacy AM, Hop WC, Bonjer HJ, COlorectal cancer Laparoscopic or Open Resection II (COLOR II) Study Group. Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol. 2013;14(3):210–8.

    PubMed  Google Scholar 

  21. Paun BC, Cassie S, MacLean AR, Dixon E, Buie WD. Postoperative complications following surgery for rectal cancer. Ann Surg. 2010;251(5):807–18.

    PubMed  Google Scholar 

  22. Chang HC, Huang SC, Chen JS, Tang R, Changchien CR, Chiang JM, Yeh CY, Hsieh PS, Tsai WS, Hung HY, You JF. Risk factors for lymph node metastasis in pT1 and pT2 rectal cancer: a single-institute experience in 943 patients and literature review. Ann Surg Oncol. 2012;19(8):2477–84.

    PubMed  Google Scholar 

  23. Rasheed S, Bowley DM, Aziz O, Tekkis PP, Sadat AE, Guenther T, Boello ML, McDonald PJ, Talbot IC, Northover JM. Can depth of tumour invasion predict lymph node positivity in patients undergoing resection for early rectal cancer? A comparative study between T1 and T2 cancers. Colorectal Dis. 2008;10(3):231–8.

    CAS  PubMed  Google Scholar 

  24. Kobayashi H, Mochizuki H, Kato T, Mori T, Kameoka S, Shirouzu K, Saito Y, Watanabe M, Morita T, Hida J, Ueno M, Ono M, Yasuno M, Sugihara K. Is total mesorectal excision always necessary for T1-T2 lower rectal cancer? Ann Surg Oncol. 2010;17(4):973–80.

    PubMed  Google Scholar 

  25. Salinas HM, Dursun A, Klos CL, Shellito P, Sylla P, Berger D, Bordeianou L. Determining the need for radical surgery in patients with T1 rectal cancer. Arch Surg. 2011;146(5):540–4.

    PubMed  Google Scholar 

  26. Kikuchi R, Takano M, Takagi K, Fujimoto N, Nozaki R, Fujiyoshi T, Uchida Y. Management of early invasive colorectal cancer. Risk of recurrence and clinical guidelines. Dis Colon Rectum. 1995;38(12):1286–95.

    CAS  PubMed  Google Scholar 

  27. Okuyama T, Oya M, Ishikawa H. Budding as a risk factor for lymph node metastasis in pT1 or pT2 well-differentiated colorectal adenocarcinoma. Dis Colon Rectum. 2002;45(5):628–34.

    PubMed  Google Scholar 

  28. Bach SP, Hill J, Monson JR, Simson JN, Lane L, Merrie A, Warren B, Mortensen NJ, Association of Coloproctology of Great Britain and Ireland Transanal Endoscopic Microsurgery (TEM) Collaboration. A predictive model for local recurrence after transanal endoscopic microsurgery for rectal cancer. Br J Surg. 2009;96(3):280–90.

    CAS  PubMed  Google Scholar 

  29. Nascimbeni R, Burgart LJ, Nivatvongs S, Larson DR. Risk of lymph node metastasis in T1 carcinoma of the colon and rectum. Dis Colon Rectum. 2002;45(2):200–6.

    PubMed  Google Scholar 

  30. Masaki T, Sugiyama M, Atomi Y, Matsuoka H, Abe N, Watanabe T, Nagawa H, Muto T. The indication of local excision for T2 rectal carcinomas. Am J Surg. 2001;181(2):133–7.

    CAS  PubMed  Google Scholar 

  31. Bosch SL, Teerenstra S, de Wilt JH, Cunningham C, Nagtegaal ID. Predicting lymph node metastasis in pT1 colorectal cancer: a systematic review of risk factors providing rationale for therapy decisions. Endoscopy. 2013;45(10):827–34.

    PubMed  Google Scholar 

  32. Glasgow SC, Bleier JI, Burgart LJ, Finne CO, Lowry AC. Meta-analysis of histopathological features of primary colorectal cancers that predict lymph node metastases. J Gastrointest Surg. 2012;16(5):1019–28.

    PubMed  Google Scholar 

  33. Wang HS, Liang WY, Lin TC, Chen WS, Jiang JK, Yang SH, Chang SC, Lin JK. Curative resection of T1 colorectal carcinoma: risk of lymph node metastasis and long-term prognosis. Dis Colon Rectum. 2005;48(6):1182–92.

    PubMed  Google Scholar 

  34. Benson III AB, Venook AP, Bekaii-Saab T, Chan E, Chen YJ, Cooper HS, Engstrom PF, Enzinger PC, Fenton MJ, Fuchs CS, Grem JL, Grothey A, Hochster HS, Hunt S, Kamel A, Kirilcuk N, Leong LA, Lin E, Messersmith WA, Mulcahy MF, Murphy JD, Nurkin S, Rohren E, Ryan DP, Saltz L, Sharma S, Shibata D, Skibber JM, Sofocleous CT, Stoffel EM, Stotsky-Himelfarb E, Willett CG, Gregory KM, Freedman-Cass D. Rectal cancer, version 2.2015. J Natl Compr Canc Netw. 2015;13(6):719–28.

    Google Scholar 

  35. Beets-Tan RG, Lambregts DM, Maas M, Bipat S, Barbaro B, Caseiro-Alves F, Curvo-Semedo L, Fenlon HM, Gollub MJ, Gourtsoyianni S, Halligan S, Hoeffel C, Kim SH, Laghi A, Maier A, Rafaelsen SR, Stoker J, Taylor SA, Torkzad MR, Blomqvist L. Magnetic resonance imaging for the clinical management of rectal cancer patients: recommendations from the 2012 European Society of Gastrointestinal and Abdominal Radiology (ESGAR) consensus meeting. Eur Radiol. 2013;23(9):2522–31.

    PubMed  Google Scholar 

  36. van de Velde CJ, Boelens PG, Tanis PJ, Espin E, Mroczkowski P, Naredi P, Pahlman L, Ortiz H, Rutten HJ, Breugom AJ, Smith JJ, Wibe A, Wiggers T, Valentini V. Experts reviews of the multidisciplinary consensus conference colon and rectal cancer 2012: science, opinions and experiences from the experts of surgery. Eur J Surg Oncol. 2014;40(4):454–68.

    PubMed  Google Scholar 

  37. Lambregts DM, Beets GL, Maas M, Kessels AG, Bakers FC, Cappendijk VC, Engelen SM, Lahaye MJ, de Bruïne AP, Lammering G, Leiner T, Verwoerd JL, Wildberger JE, Beets-Tan RG. Accuracy of gadofosveset-enhanced MRI for nodal staging and restaging in rectal cancer. Ann Surg. 2011;253(3):539–45.

    PubMed  Google Scholar 

  38. Steele Jr GD, Herndon JE, Bleday R, Russell A, Benson III A, Hussain M, Burgess A, Tepper JE, Mayer RJ. Sphincter-sparing treatment for distal rectal adenocarcinoma. Ann Surg Oncol. 1999;6(5):433–41.

    PubMed  Google Scholar 

  39. Mellgren A, Sirivongs P, Rothenberger DA, Madoff RD, García-Aguilar J. Is local excision adequate therapy for early rectal cancer? Dis Colon Rectum. 2000;43:1064–71. discussion 1071–4.

    CAS  PubMed  Google Scholar 

  40. Paty PB, Nash GM, Baron P, Zakowski M, Minsky BD, Blumberg D, Nathanson DR, Guillem JG, Enker WE, Cohen AM, Wong WD. Long-term results of local excision for rectal cancer. Ann Surg. 2002;236(4):522–9. discussion 529-30.

    PubMed  PubMed Central  Google Scholar 

  41. Nascimbeni R, Nivatvongs S, Larson DR, Burgart LJ. Long-term survival after local excision for T1 carcinoma of the rectum. Dis Colon Rectum. 2004;47:1773–9.

    PubMed  Google Scholar 

  42. Madbouly KM, Remzi FH, Erkek BA, Senagore AJ, Baeslach CM, Khandwala F, Fazio VW, Lavery IC. Recurrence after transanal excision of T1 rectal cancer: should we be concerned? Dis Colon Rectum. 2005;48(4):711–9. discussion 719-21.

    PubMed  Google Scholar 

  43. You YN, Baxter NN, Stewart A, Nelson H. Is the increasing rate of local excision for stage I rectal cancer in the United States justified? A nationwide cohort study from the National Cancer Database. Ann Surg. 2007;245(5):726–33.

    PubMed  PubMed Central  Google Scholar 

  44. Kidane B, Chadi SA, Kanters S, Colquhoun PH, Ott MC. Local resection compared with radical resection in the treatment of T1N0M0 rectal adenocarcinoma: a systematic review and meta-analysis. Dis Colon Rectum. 2015;58(1):122–40.

    Google Scholar 

  45. Hahnloser D, Wolff BG, Larson DW, Ping J, Nivatvongs S. Immediate radical resection after local excision of rectal cancer: an oncologic compromise? Dis Colon Rectum. 2005;48(3):429–37.

    PubMed  Google Scholar 

  46. Read TE, Andujar JE, Caushaj PF, Johnston DR, Dietz DW, Myerson RJ, Fleshman JW, Birnbaum EH, Mutch MG, Kodner IJ. Neoadjuvant therapy for rectal cancer: histologic response of the primary tumor predicts nodal status. Dis Colon Rectum. 2004;47(6):825–31.

    PubMed  Google Scholar 

  47. Rullier E, Denost Q. Transanal surgery for cT2T3 rectal cancer: patient selection, adjuvant therapy, and outcomes. Sem Colon Rectal Surg. 2015;26(1):26–31.

    Google Scholar 

  48. Rullier E, Vendrely V. Can mesorectal lymph node excision be avoided in rectal cancer surgery? Colorectal Dis. 2011;13 Suppl 7:37–42.

    PubMed  Google Scholar 

  49. Garcia-Aguilar J, Shi Q, Thomas Jr CR, Chan E, Cataldo P, Marcet J, Medich D, Pigazzi A, Oommen S, Posner MC. A phase II trial of neoadjuvant chemoradiation and local excision for T2N0 rectal cancer: preliminary results of the ACOSOG Z6041 trial. Ann Surg Oncol. 2012;19(2):384–91.

    PubMed  Google Scholar 

  50. Garcia-Aguilar J, Renfro LA, Chow OS, Shi Q, Carrero XW, Lynn PB, Thomas CR Jr, Chan E, Cataldo PA, Marcet JE, Medich DS, Johnson CS, Oommen SC, Wolff BG, Pigazzi A, McNevin SM, Pons RK, Bleday R. Organ preservation for clinical T2N0 distal rectal cancer using neoadjuvant chemoradiotherapy and local excision (ACOSOG Z6041): results of an open-label, single-arm, multi-institutional, phase 2 trial. Lancet Oncol. 2015;16(15):1537–46.

    Google Scholar 

  51. Lezoche G, Baldarelli M, Guerrieri M, Paganini AM, De Sanctis A, Bartolacci S, Lezoche E. A prospective randomized study with a 5-year minimum follow-up evaluation of transanal endoscopic microsurgery versus laparoscopic total mesorectal excision after neoadjuvant therapy. Surg Endosc. 2008;22(2):352–8.

    CAS  PubMed  Google Scholar 

  52. Chakravarti A, Compton CC, Shellito PC, Wood WC, Landry J, Machuta SR, Kaufman D, Ancukiewicz M, Willett CG. Long-term follow-up of patients with rectal cancer managed by local excision with and without adjuvant irradiation. Ann Surg. 1999;230(1):49–54.

    CAS  PubMed  PubMed Central  Google Scholar 

  53. Friel CM, Cromwell JW, Marra C, Madoff RD, Rothenberger DA, Garcia-Aguílar J. Salvage radical surgery after failed local excision for early rectal cancer. Dis Colon Rectum. 2002;45:875–9.

    PubMed  Google Scholar 

  54. Weiser MR, Landmann RG, Wong WD, Shia J, Guillem JG, Temple LK, Minsky BD, Cohen AM, Paty PB. Surgical salvage of recurrent rectal cancer after transanal excision. Dis Colon Rectum. 2005;48(6):1169–75.

    PubMed  Google Scholar 

  55. Greenberg JA, Shibata D, Herndon II JE, Steele Jr GD, Mayer R, Bleday R. Local excision of distal rectal cancer: an update of cancer and leukemia group B 8984. Dis Colon Rectum. 2008;51(8):1185–91.

    PubMed  Google Scholar 

  56. Doornebosch PG, Ferenschild FT, de Wilt JH, Dawson I, Tetteroo GW, de Graaf EJ. Treatment of recurrence after transanal endoscopic microsurgery (TEM) for T1 rectal cancer. Dis Colon Rectum. 2010;53(9):1234–9.

    PubMed  Google Scholar 

  57. de Graaf EJ, Doornebosch PG, Tetteroo GW, Geldof H, Hop WC. Transanal endoscopic microsurgery is feasible for adenomas throughout the entire rectum: a prospective study. Dis Colon Rectum. 2009;52(6):1107–13.

    PubMed  Google Scholar 

  58. Kumar AS, Coralic J, Kelleher DC, Sidani S, Kolli K, Smith LE. Complications of transanal endoscopic microsurgery are rare and minor: a single institution’s analysis and comparison to existing data. Dis Colon Rectum. 2013;56(3):295–300.

    PubMed  Google Scholar 

  59. Ramwell A, Evans J, Bignell M, Mathias J, Simson J. The creation of a peritoneal defect in transanal endoscopic microsurgery does not increase complications. Colorectal Dis. 2009;11(9):964–6.

    CAS  PubMed  Google Scholar 

  60. Cataldo PA, O’Brien S, Osler T. Transanal endoscopic microsurgery: a prospective evaluation of functional results. Dis Colon Rectum. 2005;48(7):1366–71.

    PubMed  Google Scholar 

  61. Fenech DS, Takahashi T, Liu M, Spencer L, Swallow CJ, Cohen Z, Macrae HM, McLeod RS. Function and quality of life after transanal excision of rectal polyps and cancers. Dis Colon Rectum. 2007;50(5):598–603.

    PubMed  Google Scholar 

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Authors and Affiliations

  1. Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, Portland, OR, USA

    Mark H. Whiteford M.D., F.A.C.S., F.A.S.C.R.S.

  2. Providence Cancer Center, Providence Portland Medical Center, Portland, OR, USA

    Mark H. Whiteford M.D., F.A.C.S., F.A.S.C.R.S.

  3. Professor of Surgery, Oregon Health and Science University, The Oregon Clinic, 4805 NE Glisan, Suite 6 N60, Portland, OR, 97213, USA

    Mark H. Whiteford M.D., F.A.C.S., F.A.S.C.R.S.

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  1. Mark H. Whiteford M.D., F.A.C.S., F.A.S.C.R.S.
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Correspondence to Mark H. Whiteford M.D., F.A.C.S., F.A.S.C.R.S. .

Editor information

Editors and Affiliations

  1. Division of Colorectal Surgery, University Hospitals Case Medical Center Case Western Reserve University, Cleveland, OH, USA

    Scott R. Steele

  2. Cleveland Clinic, Cleveland, OH, USA

    Tracy L. Hull

  3. Tufts University School of Medicine, Lahey Hospital & Medical Center, Burlington, MA, USA

    Thomas E. Read

  4. Ambrose and Gladys Bowyer, Loyola University, Chicago, IL, USA

    Theodore J. Saclarides

  5. University of Texas Medical Branch at Galveston, Galveston, TX, USA

    Anthony J. Senagore

  6. Ochsner Medical Center, New Orleans, LA, USA

    Charles B. Whitlow

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Whiteford, M.H. (2016). Local Excision of Rectal Neoplasia. In: Steele, S.R., Hull, T.L., Read, T.E., Saclarides, T.J., Senagore, A.J., Whitlow, C.B. (eds) The ASCRS Textbook of Colon and Rectal Surgery. Springer, Cham. https://doi.org/10.1007/978-3-319-25970-3_29

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  • DOI: https://doi.org/10.1007/978-3-319-25970-3_29

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