interesting case. od 224562963 62 yo man with irretrievable rectal tva on screening colonoscopy,...
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![Page 1: Interesting case. OD 224562963 62 yo man with irretrievable rectal TVA on screening colonoscopy, prior transanal excision 8 cm from anal verge Pmhx: hypothyroidism,](https://reader035.vdocument.in/reader035/viewer/2022062217/5697c0201a28abf838cd221e/html5/thumbnails/1.jpg)
Interesting case
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OD 224562963
62 yo man with irretrievable rectal TVA on screening colonoscopy, prior transanal excision
8 cm from anal verge
Pmhx: hypothyroidism, arthritis
Pshx: appendectomy, bilateral inguinal hernia repair
Meds: ASA, MVI
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• Decision made to proceed with transanal minimally invasive surgery
• Lesion located between lowest and middle rectal valves
• Positioning: prone with leg splitter
• Applied Medical gelport, 90 degree scope, laparoscopic instruments
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Rectal adenoma
Villous adenoma is a premalignant lesion
2/3 occur in the rectum
Equal sex distribution, peak incidence 6th and 7th decades
Difficult to detect
Harbor malignancy in 40% of cases
Biopsy often misses 40% of cancers
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Patients older than 80 undergoing APR have 15% risk of perioperative death
ASA grade I patients have perioperative mortality of 0.5%
ASA grade IV patients have risk approaching 25%
Consider impact of radical surgery on QOL
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Surgical options
Local excision with transanal technique
Kraske sacral operation
Radical excision (LAR or APR)
Transanal Endoscopic MicroSurgery
Transanal Minimally Invasive Surgery
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What is TAMIS?
Named by Atallah et als
Described its use in 6 patients, 2 with early rectal cancers
Crossover technique using SILS equipment
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Single surgeon experience using TAE vs transbdominal resections
Main outcomes were complications, recurrence and malignancy rates
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• Retrospective review
• T1 and T2 rectal cancers
• Local excisions from 1997-2006
• 42 TEMS, 129 TAE patients
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• Median followup 60 months for TEMS, 45 for TAE
• Only 34 patients had local recurrence
• 145 of 164 patients were disease free at last followup
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• Authors conclude that TEMS resection is superior to TAE
• Indications for both may overlap
• Variables such as tumor distance from AV, T stage and adjuvant therapy may be more important predictors of outcome
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Conclusions
Local excision safe for villous adenomas and early rectal cancers by multiple means (TAE, TEMS, TAMIS)
Careful patient selection
Diligent followup
Discussion with patient about radical surgery