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

2. Department of surgery Pamela Youde Nethersole Eastern Hospital Adenoma Neoplastic polyps Precursor of colorectal cancer

3. Department of surgery Pamela Youde Nethersole Eastern Hospital Anatomical distribution National polyp study –Colonoscopy study –8% in rectum O’Brien et al. 1990

4. Department of surgery Pamela Youde Nethersole Eastern Hospital Large rectal adenoma Large polyps More than 30mm in size The larger the size, the greater is the risk of malignancy Williams 1999

5. Department of surgery Pamela Youde Nethersole Eastern Hospital Malignancy risk Shinya and Wolff 1979

6. Department of surgery Pamela Youde Nethersole Eastern Hospital Management Diagnosis Work-up Surgical treatment Follow-up

7. Department of surgery Pamela Youde Nethersole Eastern Hospital Diagnosis Rectal examination Rigid sigmoidoscopy Flexible sigmoidoscopy

8. Department of surgery Pamela Youde Nethersole Eastern Hospital Diagnosis Rigid sigmoidoscopy –Villous adenoma 97% within 30cm from anal verge –Problems View obscured by blood or mucus Sub-optimal insufflation

9. Department of surgery Pamela Youde Nethersole Eastern Hospital Diagnosis Flexible sigmoidoscopy –Advantages Possible to negotiate the rectosigmoid junction and pass up to splenic flexure Relatively comfortable Polypectomy

10. Department of surgery Pamela Youde Nethersole Eastern Hospital Diagnosis Flexible sigmoidoscopy Yield is three times as high as with the rigid instrument Marks et al. 1979 McCallum et al. 1984

11. Department of surgery Pamela Youde Nethersole Eastern Hospital Work-up Biopsy Colonoscopy –Synchronous polyps(20-26%) / cancer(3%) Endoluminal ultrasound –Mid and low rectal polyps : below 12cm

12. Department of surgery Pamela Youde Nethersole Eastern Hospital Work-up Endoluminal ultrasound –Depth of rectal wall invasion –T- and N-stages, if malignant –Guides further management

13. Department of surgery Pamela Youde Nethersole Eastern Hospital Surgical treatment Endoscopic polypectomy Peranal excision Perineal surgical manoeuvre Abdominal procedures Others

14. Department of surgery Pamela Youde Nethersole Eastern Hospital Endoscopic polypectomy Ideal for –Small polyps –Larger polyp with a stalk –Sessile polyps Piecemeal removal

15. Department of surgery Pamela Youde Nethersole Eastern Hospital 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. Department of surgery Pamela Youde Nethersole Eastern Hospital Koji Matsuda Gastrointestinal endoscopy 2001 Positioning Injection Wiring Excision Extraction EMR

17. Department of surgery Pamela Youde Nethersole Eastern Hospital 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. Department of surgery Pamela Youde Nethersole Eastern Hospital Perineal surgical manoeuvre Not amenable to endoscopic polypectomy –Too large and sessile –Behind a fold –Too low

19. Department of surgery Pamela Youde Nethersole Eastern Hospital Perineal surgical manoeuvre Conventional transanal excision (Park’s approach) Transanal endoscopic microsurgery (TEM) Trans-sphincteric excision

20. Department of surgery Pamela Youde Nethersole Eastern Hospital 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. Department of surgery Pamela Youde Nethersole Eastern Hospital Transanal excision

22. Department of surgery Pamela Youde Nethersole Eastern Hospital 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. Department of surgery Pamela Youde Nethersole Eastern Hospital TEM Indications –Upper and middle rectal lesions Primarily for benign adenoma Local excision for cancer palliation

24. Department of surgery Pamela Youde Nethersole Eastern Hospital TEM Depth of excision

25. Department of surgery Pamela Youde Nethersole Eastern Hospital TEM Benefits –For removal of villous adenomas that cannot be removed by conventional technique –Up to 24cm from anal verge Buess 1992

26. Department of surgery Pamela Youde Nethersole Eastern Hospital TEM Complications –Hemorrhage –Perforation –Incontinence –Rectal stricture – Suture dehiscence – Urinary tract infection – Urinary retention

27. Department of surgery Pamela Youde Nethersole Eastern Hospital Results Transanal endoscopic microsurgery

28. Department of surgery Pamela Youde Nethersole Eastern Hospital 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. Department of surgery Pamela Youde Nethersole Eastern Hospital Trans-sphincteric excision –Anal sphincters and rectal wall divided in the longitudinal axis –Sphincter function retained if the cut layers are sutured accurately

30. Department of surgery Pamela Youde Nethersole Eastern Hospital 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. Department of surgery Pamela Youde Nethersole Eastern Hospital Trans-sphincteric excision Disadvantages Inferior function results Higher morbidity Replaced by TEM or laparoscopic approach

32. Department of surgery Pamela Youde Nethersole Eastern Hospital 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. Department of surgery Pamela Youde Nethersole Eastern Hospital Other techniques Diathermy fulguration Endoscopic transanal resection of tumor Laser photocoagulation Photodynamic therapy

34. Department of surgery Pamela Youde Nethersole Eastern Hospital Other techniques Disadvantages –No intact specimen for accurate histological examination and staging For palliation in poor risk patients

35. Department of surgery Pamela Youde Nethersole Eastern Hospital Follow-on treatment after final histology is available

36. Department of surgery Pamela Youde Nethersole Eastern Hospital Recommendation