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Management of large rectal adenoma

Management of large rectal adenoma. Dr. Hester YS Cheung. Department of surgery Pamela Youde Nethersole Eastern Hospital. Adenoma. Neoplastic polyps Precursor of colorectal cancer. Anatomical distribution. National polyp study Colonoscopy study 8% in rectum. O’Brien et al. 1990.

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Management of large rectal adenoma

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  1. Management of large rectal adenoma Dr. Hester YS Cheung Department of surgery Pamela Youde Nethersole Eastern Hospital

  2. Adenoma • Neoplastic polyps • Precursor of colorectal cancer

  3. Anatomical distribution • National polyp study • Colonoscopy study • 8% in rectum O’Brien et al. 1990

  4. Large rectal adenoma • Large polyps More than 30mm in size The larger the size, the greater is the risk of malignancy Williams 1999

  5. Malignancy risk Shinya and Wolff 1979

  6. Management • Diagnosis • Work-up • Surgical treatment • Follow-up

  7. Diagnosis • Rectal examination • Rigid sigmoidoscopy • Flexible sigmoidoscopy

  8. Diagnosis • Rigid sigmoidoscopy • Villous adenoma • 97% within 30cm from anal verge • Problems • View obscured by blood or mucus • Sub-optimal insufflation

  9. Diagnosis • Flexible sigmoidoscopy • Advantages • Possible to negotiate the rectosigmoid junction and pass up to splenic flexure • Relatively comfortable • Polypectomy

  10. Diagnosis • Flexible sigmoidoscopy Yield is three times as high as with the rigid instrument Marks et al. 1979 McCallum et al. 1984

  11. Work-up • Biopsy • Colonoscopy • Synchronous polyps(20-26%) / cancer(3%) • Endoluminal ultrasound • Mid and low rectal polyps : below 12cm

  12. Work-up • Endoluminal ultrasound • Depth of rectal wall invasion • T- and N-stages, if malignant • Guides further management

  13. Surgical treatment • Endoscopic polypectomy • Peranal excision • Perineal surgical manoeuvre • Abdominal procedures • Others

  14. Endoscopic polypectomy • Ideal for • Small polyps • Larger polyp with a stalk • Sessile polyps • Piecemeal removal

  15. Endoscopic mucosal resection (EMR) • Colonoscopy using electrocautery • Reported by Deyhle et al. 1973 • Early gastric cancer by Tada et al. • Indications • Flat-type or depressed lesions

  16. Positioning Injection EMR Wiring Excision Extraction Koji Matsuda Gastrointestinal endoscopy 2001

  17. Peranal excision • Large polyp with a long pedicle in lower rectum • Digitally palpable • Polyp hooked down through the anal orifice • Pedicle transfixed and excised • 10-15mm margin

  18. Perineal surgical manoeuvre • Not amenable to endoscopic polypectomy • Too large and sessile • Behind a fold • Too low

  19. Perineal surgical manoeuvre • Conventional transanal excision (Park’s approach) • Transanal endoscopic microsurgery (TEM) • Trans-sphincteric excision

  20. Conventional approach (Park’s) • Low rectal adenoma (digitally palpable) • Lithotomy / Jack-knife position • Submucosal plane infiltration with saline and adrenaline • 1cm margin • Submucosal excision

  21. Transanal excision

  22. Transanal endoscopic microsurgery (TEM) • First clinical application in 1983 • Complex • Costly • Needs substantial training • Conglomeration of endoscopic and laparoscopic technique Buess et al. 1984 Buess, 1994

  23. TEM • Indications • Upper and middle rectal lesions • Primarily for benign adenoma • Local excision for cancer palliation

  24. TEM • Depth of excision

  25. TEM • Benefits • For removal of villous adenomas that cannot be removed by conventional technique • Up to 24cm from anal verge Buess 1992

  26. Complications Hemorrhage Perforation Incontinence Rectal stricture Suture dehiscence Urinary tract infection Urinary retention TEM

  27. Results • Transanal endoscopic microsurgery

  28. Trans-sphincteric excision • Originally described by Bevan • Revived by York Mason • Indications • For anterior or anterolateral lesions 8-12cm from the anal verge • Poor risk patients who cannot withstand major laparotomy Bevan 1917 Mason 1970

  29. Trans-sphincteric excision • Anal sphincters and rectal wall divided in the longitudinal axis • Sphincter function retained if the cut layers are sutured accurately

  30. Trans-sphincteric excision • Advantages Too high for transanal excision Under direct vision Lower risks of perforation Tumor upper limit can be reached more easily

  31. Trans-sphincteric excision • Disadvantages Inferior function results Higher morbidity Replaced by TEM or laparoscopic approach

  32. Abdominal procedures • Radical surgery • Indications • Upper and mid-rectal lesions (TEM not available) • Lesions behind a mucosal fold • Approach • Anterior / low anterior resection • Laparoscopic approach

  33. Other techniques • Diathermy fulguration • Endoscopic transanal resection of tumor • Laser photocoagulation • Photodynamic therapy

  34. Other techniques • Disadvantages • No intact specimen for accurate histological examination and staging For palliation in poor risk patients

  35. Follow-on treatment after final histology is available

  36. Recommendation

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