Published online Nov 27, 2023. doi: 10.4240/wjgs.v15.i11.2406
Peer-review started: July 18, 2023
First decision: September 19, 2023
Revised: September 29, 2023
Accepted: October 29, 2023
Article in press: October 29, 2023
Published online: November 27, 2023
Trans-anal endoscopic microsurgery (TEM) is a surgical method which is capable of resecting lesions up to 20 cm. It enables for excellent access, visualization of the surgical field and for precise full-thickness excision of rectal lesions.
The rectum, as well as the retro-rectal space, can be the origin of a heterogeneous group of uncommon neoplasms that range from aggressive malignancies to benign lesions that are almost always symptomatic. The treatment of this rare and heterogeneous group of lesions varies depending on the location and nature of the lesions; accordingly, certain lesions require radical trans-abdominal surgery, while others can be treated by a less aggressive approach.
Several studies suggest that TEM can also be an effective method for excision of uncommon lesion of the rectum and retro-rectal space.
The objective of this study is to report outcomes in patients undergoing TEM for rare and non-adenomatous rectal and retro-rectal lesions over a period of 11 years.
Retrospective analysis was completed for all patients who underwent TEM procedure for non-adenomatous rectal lesion or retro-rectal mass from January 2008 to December 2019. The original Richard Wolf equipment was used to perform the procedure, and the procedure was performed according to the standard technique described specimens were pinned and marked for orientation by the surgeon. Patients resumed oral intake of liquid and soft diet on post-operative day one; with full diet being subsequently advanced, once tolerated. Patients were discharged once diet was well tolerated and no complications were identified.
Patients were evaluated at 3 wk post operatively. Follow ups were completed at 3 mo intervals for the first 2 years and then every 6 mo depending on the nature of the final pathology. Clinical examination and rectoscopy were performed during each of the followup visits.
Out of 198 patients who underwent TEM during the study period, 18 (9%) had non-adenomatous (non-carcinomas or adenomas) rectal or retro-rectal lesions. Mean age was 47 years (27–81). The mean size of the lesions described was 2.9 mm (1-6 mm), with a mean distance from the anal margin of 7.9 cm (5-13 cm). Regarding the locations of the lesions in the rectal wall; 10 lesions were in the posterior wall, 4 were in the anterior wall, 3 in lateral position, and 1 patient had circular stenosis of rectum. Mean surgical time was 97.8 min (50-200). There were no intra-operative complications. Mean length of stay was 2.5 d (1-4). No late postoperative complications were observed. The final pathologies (detailed in Table 1) of the specimens confirmed the diagnosis. Mean patient follow-up duration was 42 mo (14-80): All patients were disease free, except for the patient with the leiomyosarcoma who died due to lung metastasis at 37 mo following intervention.
It can be argued that TEM allows for reduced morbidity given its minimally invasive nature. Surgeons should be familiar with the technique but careful patient selection should be considered. TEM can be used safely for uncommon rectal and selected retro-rectal lesions without compromising outcomes. We believe that TEM should be reasonably considered as one of the surgical methods when treating rare lesions.
Additional research is necessary, with more extensive and diverse sample size, to expand upon the findings of this study.