Allaix ME, Arezzo A, Caldart M, Festa F, Morino M. Transanal endoscopic microsurgery for rectal neoplasms: experience of 300 consecutive cases
Abdominal resection for rectal neoplasms is associated with significant morbidity. Local excision with retractors can be proposed only for distal rectal lesions. With this retrospective review of our prospective series of transanal endoscopic microsurgery procedures, we wanted to verify the advantages of local treatment in terms of disease recurrence and complication rates. Indications for transanal endoscopic microsurgery were adenoma, early carcinoma, rectal ulcers, carcinoid tumors, gastrointestinal stromal tumors, and leiomyosarcoma apparently located in the extraperitoneal rectum. We analyzed operating time, morbidity and mortality rates, length of hospital stay, staging discrepancy, recurrence rate, and oncological outcome. From January 1993 to January 2007, 300 patients underwent transanal endoscopic microsurgery at our institution. The mean operating time was 66 minutes. The peritoneum was inadvertently opened in 13 cases. The overall morbidity rate was 7.7%. The mean hospital stay was five days. Histology demonstrated cancer in 90 patients. At a mean follow-up of 60 months, the recurrence rate was zero in pT1, 24% in pT2, and 50% in pT3. The overall estimated five-year survival rate was 87%, and the disease-free survival rate was 82%. Transanal endoscopic microsurgery is safe and effective in the treatment of adenoma and pT1 carcinoma; it carries a lower morbidity than conventional surgery and a recurrence rate comparable to that of conventional surgery.
Transanal Endoscopic Microsurgery for Rectal
Neoplasms: Experience of 300 Consecutive Cases
Marco Ettore Allaix, M.D. • Alberto Arezzo, M.D. • Mario Caldart, M.D.
Federico Festa, M.D. • Mario Morino, M.D.
Center for Minimally Invasive Surgery, Dipartimento di Discipline Medico Chirurgiche, Universita` di Torino, Torino, Italy
PURPOSE: Abdominal resection for rectal neoplasms is
associated with significant morbidity. Local excision with
retractors can be proposed only for distal rectal lesions.
With this retrospective review of our prospective series of
transanal endoscopic microsurgery procedures, we
wanted to verify the advantages of local treatment in
terms of disease recurrence and complication rates.
METHODS: Indications for transanal endoscopic
microsurgery were adenoma, early carcinoma, rectal
ulcers, carcinoid tumors, gastrointestinal stromal tumors,
and leiomyosarcoma apparently located in the
extraperitoneal rectum. We analyzed operating time,
morbidity and mortality rates, length of hospital stay,
staging discrepancy, recurrence rate, and oncological
RESULTS: From January 1993 to January 2007, 300
patients underwent transanal endoscopic microsurgery at
our institution. The mean operating time was 66
minutes. The peritoneum was inadvertently opened in 13
cases. The overall morbidity rate was 7.7%. The mean
hospital stay was five days. Histology demonstrated
cancer in 90 patients. At a mean follow-up of 60 months,
the recurrence rate was zero in pT1, 24% in pT2, and
50% in pT3. The overall estimated five-year survival rate
was 87%, and the disease-free survival rate was 82%.
CONCLUSIONS: Transanal endoscopic microsurgery is
safe and effective in the treatment of adenoma and pT1
carcinoma; it carries a lower morbidity than conventional
surgery and a recurrence rate comparable to that of
KEY WORDS: Transanal endoscopic microsurgery; Rectal
adenoma; Rectal adenocarcinoma.
he rectum is a challenging district for surgeons due
to limited access and maneuverability. Although ad-
vances in conventional surgery have led to a broader
choice of sphincter-saving procedures, definitive colos-
tomy is still necessary in 10% to 30%
of cases. Also, post
operative morbidity and mortality rates remain high,
cluding urogenital dysfunction.
Transanal excision has
been proposed for local resection of wide-based benign
neoplasms unresectable by colonoscopy and of early stage
malignant neoplasms with favorable prognostic factors.
Nevertheless, transanal resection allows comfortable ac-
cess only to the distal rectum, which explains in part the
high rates of local recurrence.
Transanal endoscopic mi
crosurgery (TEM), proposed 25 years ago by Buess,
be considered a viable alternative in select cases because it
combines the advantages of minimally-invasive local treat-
ment with large full-thickness local resection and im-
proved visualization. This study presents the results of a
retrospective analysis of a large clinical series with up to 15
years of follow-up.
MATERIALS AND METHODS
This study is a retrospective analysis of a prospective data-
base created in January 1993. Indications for TEM were
benign rectal lesions judged unsuitable for endoscopic re-
moval, early rectal cancer, and invasive or metastatic rectal
carcinoma treated with palliative intent. Inclusion criteria
were depending on anatomic restrictions assessed by rigid
rectoscopy to locate the lesion along the circumference and
to measure its distance from the anal verge. Lesions were
considered suitable for TEM treatment only when located
within 12 cm of the anal verge on the anterior wall, 15 cm
on the lateral walls, and 20 cm on the posterior wall, these
being the limits of insertion of the peritoneum on the rectal
Address of correspondence: Prof. Mario Morino, Center for Minimally
Invasive Surgery, Dipartimento di Discipline Medico Chirurgiche, Uni-
versita` di Torino, Corso Dogliotti 14, 10126 Torino, Italy. Email:
Dis Colon Rectum 2009; 52: 1831–1836
©The ASCRS 2009
DISEASES OF THE COLON &RECTUM VOLUME 52: 11 (2009) 1831
The procedure was performed with original Richard
Wolf (Knittlingen, Germany) TEM equipment, according
to the standard technique described by Buess.
cases, a full-thickness excision was made on the rectal wall
to the perirectal fatty tissue, and the wound was closed with
one or more running sutures secured with silver clips. All
patients had a urinary catheter in place at the time of sur-
gery, which was removed 72 hours after surgery in cases of
anterior wall dissection, or 24 hours after surgery in all
other cases. In cases of benign lesions, follow-up consisted
of digital examination and rectoscopy every three months
for the first year, then every six months. In cases of malig-
nant lesions, tumor marker assays were performed every
3 months for the first year and every 12 months there-
after; additionally, full colonoscopy was performed at 12
months, and endoscopic ultrasound (EUS) and computed
tomography (CT) were performed at 6, 12, and 24 months.
Local recurrence was defined as any recurrence diagnosed
more than six months after the TEM procedure and con-
firmed by biopsy.
We entered into the database information about pa-
tient characteristics, preoperative assessment, lesion loca-
tion and histology, perioperative complications, and fol-
low-up. Quantitative data are given as the mean, median,
and range. Overall and disease-free survival rates were cal-
culated using the Kaplan–Meier method. Patients with a
minimum follow-up of 12 months were included in the
Between January 1993 and January 2007, 300 patients (185
males; mean age, 65.3 ⫾ 11.6 (range, 25–94; median, 66)
years) with rectal disease underwent TEM. The preopera-
tive indications were 222 adenomas, 47 carcinomas, 4 rec-
tal ulcers, 2 carcinoid tumors, 1 gastrointestinal stromal
tumor (GIST), and 1 leiomyosarcoma. In addition, 5 ade-
nomas and 18 carcinomas had previous attempts at endo-
scopic removal that resulted in unclear margins; these were
referred for TEM for safe completion of the previous pro-
cedures. The distance between the lower edge of the neo-
plasm and the anal verge ranged between 2 and 20 (mean,
7.5 ⫾ 2.5; median, 7) cm. Twenty-six uT2 and six uT3
lesions were treated by TEM for different reasons: 8 pa-
tients had benign histologies of biopsy samples on two oc-
casions preoperatively, 13 were judged ineligible for ab-
dominal resection due to their general condition, 5 refused
the risk of temporary or definitive stomas, 3 received neo-
adjuvant radiotherapy and chemotherapy with apparent
downstaging, and 3 had synchronous liver metastases and
were treated with palliative intent.
The mean operating time was 66.4 ⫾ 42.8 (range, 15–240;
median, 60) minutes. The intraoperative complication was
inadvertent opening of the peritoneum in 13 (4.3%) cases.
Ten patients were treated with direct suturing, and three
required conversion to laparoscopic (two cases) or lapa-
rotomic (one case) anterior resection. The conversion rate
was 1.0% (3/300). Intraoperative bleeding was always neg-
ligible; no intraoperative blood transfusion was required.
There was no 30-day mortality. The 30-day morbidity rate
was 7.7% (23/300) (Table 1). None of the patients required
a loop ileostomy. No urinary retention was observed. The
mean length of hospital stay was 5.0 (range, 2–14) days.
Pathology Results and Staging
The mean surface area removed was 12.9 ⫾ 9.5 (range,
2–56; median, 10) cm
. Histological examination of the
surgical specimens demonstrated an adenoma in 184 cases,
a carcinoma in 90, carcinoid tumors in 2, leiomyosarcoma
in 1, and GIST in 1. Four rectal ulcers were completely
excised with no evidence of dysplasia. Of the 23 patients
who underwent TEM with radical intent following incom-
plete endoscopic polypectomy without histologically-
proven clear resection margins, 18 showed no residual dis-
ease and the remaining 5 had a diagnosis of adenoma. In
the 43 patients with a preoperative diagnosis of adenoma,
the definitive diagnosis was adenocarcinoma, with a dis-
crepancy rate of 19.4% (43/222).
Postoperative staging of resected adenocarcinomas
was as follows: 38 pT1, 37 pT2, and 15 pT3. Positive resec-
tion margins were detected in 9.8%, 2.6%, 16.2%, and
46.7% of patients with adenoma, pT1, pT2, and pT3
carcinoma, respectively. No specimen fragmentation
In all, 178 patients underwent preoperative EUS for
staging (Table 2). EUS understaged 22 (12.3%) and over-
TABLE 1. Postoperative morbidity and treatment in 23 of 300
consecutive patients who underwent transanal endoscopic
11 rectal bleeding 3 endoscopic hemostasis
3 transrectal packing
5 blood transfusion
5 suture dehiscence 3 medical therapy
1 abdominal surgery
4 rectovaginal ﬁstula 2 transvaginal surgical suture
2 total parenteral nutrition
1 parietal abscess antibiotic therapy
1 major incontinence biofeedback therapy
1 rectovesical ﬁstula abdominal surgery
1832 ALLAIX ET AL:LONG-TERM RESULTS OF A LARGE SERIES
staged 18 (10.1%) lesions. Of the 47 preoperatively diag-
nosed rectal cancers resected by TEM in the patients who
had undergone EUS, 13 (27.6%) were understaged and 6
(12.7%) were overstaged. Specifically, in the 15 patients
who had been referred to TEM for a suspected pT2 or pT3
carcinoma, an adenoma or a pT1 tumor was detected; in
the 16 patients referred for TEM for a suspected adenoma
or pT1 carcinoma, a pT2 or pT3 tumor was detected.
Over a mean follow-up period of 82 ⫾ 39 (range, 12–189;
median, 100) months, 11 patients (6%) operated on for a
rectal adenoma relapsed. Recurrence was observed in 6 of
18 patients with an adenoma, 1 of 6 with pT2, and 4 of 6
with pT3 tumors with positive resection margins. A second
TEM procedure was performed in eight patients, laparo-
scopic anterior resection with coloanal anastomosis was
performed in one patient, and abdominoperineal resection
was performed in one patient. All were disease-free in fur-
ther follow-up. One patient refused a second TEM proce-
dure and was lost at follow-up.
Three patients underwent palliative TEM because of
synchronous unresectable liver metastasis and were ex-
cluded from the follow-up analysis. No dropouts were ob-
served among the cancer patients.
No recurrent disease was detected among the 38 pa-
tients with pT1 cancer at a mean follow-up of 60 ⫾ 33
(range, 14 –162; median, 51) months. Of the 49 patients
with histologically-assessed pT2 and pT3 cancers, 8 (4 pT2
and 4 pT3) underwent immediate abdominal surgery, 22
(17 pT2 and 5 pT3) underwent chemoradiotherapy, and
19 (16 pT2 and 3 pT3) only received follow-up because
they had either declined further surgery or adjuvant ther-
apy or were deemed ineligible on account of age or co-
morbidity. Local and/or distant recurrence was observed
in 15 cases: 9 of 37 (24.3%) with pT2 cancer and 6 of 12
(50%) with pT3 cancer. Three of the eight patients who
underwent salvage surgery, one with pT2 cancer and two
with pT3 cancer, developed a local recurrence. Recurrence
was diagnosed for these patients at 15, 6, and 29 months.
All died of the disease (Table 3).
The overall 5-year survival rate of the cancer patients
was 87.6%, and the disease-free rate was 82.2%. Stratified
by tumor stage, the overall (Fig. 1) and disease-free (Fig. 2)
survival rates were both 100% for pT1; 87.7% and 76.7%,
respectively, for pT2; and 44.4% and 38.9%, respectively,
for pT3 (P ⬍ 0.001). All of these estimated survival rates
take into consideration not just the results of TEM, but also
data from patients with additional treatments such as che-
moradiotherapy and salvage surgery.
None of the patients with malignant neoplasms other
than carcinoma showed recurrence at follow-up.
Abdominal surgery has long been considered the appro-
priate surgical treatment for rectal neoplasms. Neverthe-
less, anterior rectal resection and total mesorectal excision
are burdened by high morbidity and mortality rates,
cluding urogenital dysfunctions.
Transanal surgery with
retractors, although less invasive, is associated with a con-
sistent incidence of recurrence, especially for tumors of the
upper and medium rectum.
Twenty-five years ago, the introduction of transanal
endoscopic microsurgery (TEM) afforded the advantage of
combining a less invasive transanal approach with low re-
currence rates thanks to enhanced visualization of the sur-
gical field which allowed more precise dissection. Initially
proposed as a technique for excision of benign rectal neo-
plasms, TEM indications were extended to include “low
TABLE 2. Staging discrepancy between preoperative
endoscopic ultrasound and histology
adenoma/pT1 pT2 pT3 Total
u-T0/u-T1 130 13 3 146
u-T2 13 (1 post RT) 7 (2 post RT) 6 26
u-T3 2 3 1 6
Total 145 23 10 178
RT ⫽ radiotherapy.
TABLE 3. Oncological outcomes
Postoperative treatment n (months) Treatment Follow-up
pT1 Postoperative RT-CT 3 0 all disease-free
Salvage surgery 0 0
No treatment 35 0
pT2 Preoperative RT 5 0 all disease-free
Postoperative RT-CT 16 4 (12, 12, 10, 70) 1 AR, 3 none 1 disease-free, 3 dead
Salvage surgery 4 1 (15) APR ⫹ CT dead
No treatment 12 4 (12, 12, 10, 13) 2 RT, 1 APR, 1 AR 3 disease-free, 1 dead
pT3 Postoperative RT-CT 5 2 (14,13) 1 RT, 1 APR 1 dead, 1 disease-free
Salvage surgery 4 2 (6, 29) 2 CT 2 dead
No treatment 3 2 (12, 4) none 2 dead
RT ⫽ radiotherapy; CT ⫽ chemotherapy; AR ⫽ anterior resection; APR ⫽ abdominoperineal resection.
DISEASES OF THE COLON &RECTUM VOLUME 52: 11 (2009) 1833
risk” pT1 rectal adenocarcinomas
with curative intent
and more invasive rectal adenocarcinomas with palliative
intent. To date, only one randomized study
pared the outcome after anterior resection (26 patients)
with TEM (24 patients) for T1 rectal tumors. At a mean
follow-up of 46 months, local recurrence (4%) and 5-year
survival (96%) rates were similar in the two groups. These
data suggest that TEM may offer some advantages over
anterior resection for T1 tumors and achieve similar onco-
Patients who have T1 tumors with favorable patho-
logic features may undergo local excision alone with ac-
ceptable oncological outcomes,
whereas those with un
favorable criteria will require radical surgery or adjuvant
More recently, several authors
posed that patients with pT2 tumors receive a combination
of preoperative chemoradiotherapy and local resection by
TEM with radical intent.
This retrospective analysis of a prospective consecu-
tive series reports what may be the largest experience with
TEM for excision of benign and malignant rectal tumors.
Our analysis confirms that the procedure is safe and carries
low postoperative mortality and morbidity rates. In line
with previous studies that reported complication rates be-
tween 2% and 30%,
only 23 of 300 patients (7.7%)
experienced complications in our series, and no deaths oc-
curred. The most common local complications, bleeding
and dehiscence, were managed conservatively in the ma-
jority of cases. Also noteworthy was the occurrence in four
patients of rectovaginal fistulas; therefore, special care
should be taken when performing an anterior full-thick-
ness resection in female patients. When a diagnosis of ma-
lignancy is not suspected at preoperative workup, a muco-
sectomy could be considered in case of anterior lesions.
The standard indication for TEM with curative intent
is the treatment of adenomas and pT1 neoplasms of the
rectum. With these indications, our recurrence rate was 11
of 222 (4.9%), which is comparable to that reported in
smaller series. Other authors have compared TEM with
transanal local excision according to Parks. Local excision
was associated with a higher recurrence rate, ranging be-
tween 10% and 27%.
The higher recurrence risk of
conventional transanal surgery is most likely due to the
lower rate of complete excision with tumor-free mar-
in conventionally-treated patients. These re
sults derive from small retrospective studies and have not
yet been confirmed by multicenter cohort studies.
Appropriate patient selection is key to obtaining satis-
factory results with TEM. It is crucial to accurately evaluate
the depth of tumor invasion and lymph node metastasis.
So far, no recurrence has been observed among the 38 pT1
cancers confirmed at histology. EUS, with an overstaging
risk of approximately 10%, appears to be the most accurate
preoperative diagnostic tool for investigating tumor inva-
sion of the wall.
This was also confirmed in our series, in
which we noted a 12% risk of understaging and a 10% risk
of overstaging among all lesions; the risks were 27% and
12%, respectively, when restricted only to detected can-
cers. Furthermore, 43 of 222 (19.3%) suspected adenomas,
detected by tissue sampling and EUS, were found to be
adenocarcinomas in the pathology examinations.
An important factor to consider in staging discrepancy
in our series is the long period of recruitment: over the
years, we have observed consistent improvement in EUS
results. The limited reliability of preoperative diagnosis
and staging resulted in a high number of pT2 and pT3
discovered in pathology examination. In those cases in
which abdominal surgery was not contraindicated, pa-
FIGURE 1. Overall survival rate of cancer patients stratiﬁed by
tumor stage, including data of patients with additional treatments
such as chemoradiotherapy and salvage surgery.
FIGURE 2. Disease-free survival rate of cancer patients stratiﬁed by
tumor stage, including data of patients with additional treatments
such as chemoradiotherapy and salvage surgery.
1834 ALLAIX ET AL:LONG-TERM RESULTS OF A LARGE SERIES
tients were promptly referred for more radical treatments
including anterior resection, total mesorectal excision, or
even abdominoperineal resection. Of the eight patients
who underwent immediate salvage surgery, three died of
disease-related causes; this mortality rate is in line with that
reported elsewhere. In all other cases unsuitable for ab-
dominal surgery, the patients were either referred to adju-
vant therapy (radiotherapy and chemotherapy) if not con-
traindicated, or just followed-up.
The role of TEM in the treatment of invasive carci-
noma remains more controversial. Traditionally, local sur-
gery has been used for palliation.
More recently, TEM in
combination with neoadjuvant treatment has yielded
In our series, only three patients un
derwent neoadjuvant treatment for downstaging and
downsizing uT2 cancers in order to become eligible for
TEM with curative intent. Histology demonstrated that
only one lesion was downstaged to pT1 cancer. Neverthe-
less, all three patients are presently free of disease. Further
data will be needed to confirm this preliminary clinical
In conclusion, TEM allows excision of benign rectal
neoplasms with a low morbidity rate and has results com-
parable to those of conventional abdominal surgery. TEM
also permits the curative treatment of malignant neo-
plasms that are histologically confirmed as pT1 carcino-
mas. In line with these observations, histologic diagnosis
and preoperative staging are essential for an accurate selec-
tion of patients. We hold that such patients should be re-
ferred to specialized medical centers in which surgeons,
endoscopists, gastroenterologists, and pathologists are ex-
perienced with TEM. When indicated, this innovative sur-
gical technique can provide the potential benefit of a min-
imally invasive procedure, but without the risks associated
with abdominal rectal surgery. Moreover, the analysis of
this consecutive series of patients undergoing TEM sug-
gests that the technique is safe and effective in the treat-
ment of adenomas and pT1 carcinomas, with a recurrence
rate comparable to that of conventional surgery.
1. Morris E, Quirke P, Thomas JD, Fairley L, Cottier B, Forman D.
Unacceptable variation in abdominoperineal excision rates for
rectal cancer: time to intervene? Gut 2008;57:1690 –7.
2. Morino M, Parini U, Giraudo G, et al. Laparoscopic total meso-
rectal excision: a consecutive series of 100 patients. Ann Surg
3. Morino M, Parini U, Allaix ME, Monasterolo G, Brachet Contul
R, Garrone C. Male sexual and urinary function after laparo-
scopic total mesorectal excision. Surg Endosc 2008 Oct 15.
[Epub ahead of print].
4. Sakamoto GD, MacKeigan JM, Senagore AJ. Transanal excision
of large, rectal villous adenomas. Dis Colon Rectum 1991;34:
5. Mellgren A, Sirivongs P, Rothenberger DA, Madoff RD, Garcia-
Aguilar J. Is local excision adequate therapy for early rectal can-
cer? Dis Colon Rectum 2000;43:1064–74.
6. Buess G, Hutterer F, Theiss R, Bobel M, Isselhard W, Pichlmaier
H. Das System fu¨r die transanale endoskopische Rektumopera-
tion. Chirurgie 1984;55:677– 80.
7. Buess G. Transanal Endoscopic Microsurgery (TEM). J R Coll
Surg Edinb 1993;38:239 – 45.
8. Parks AG, Stuart AE. The management of villous tumours of the
large bowel. Br J Surg 1973;60:688–95.
9. Nivatvongs S, Balcos EG, Schottler JL, Goldberg SM. Surgical
management of large villous tumors of the rectum. Dis Colon
10. Hermanek P, Gall FP. Early (microinvasive) colorectal carci-
noma. Pathology, diagnosis, surgical treatment. Int J Colorectal
Dis 1986;1:79– 84.
11. Mentges B, Buess G, Raestrup H, Manncke K, Becker HD. TEM
results of the Tuebingen group. Endosc Surg Allied Technol
12. Winde G, Nottberg H, Keller R, Schmid KW, Bunte H. Surgical
cure for early rectal carcinomas (T1). Transanal endoscopic mi-
crosurgery vs. anterior resection. Dis Colon Rectum 1996;39:
13. Floyd ND, Saclarides TJ. Transanal endoscopic microsurgical
resection of pT1 rectal tumors. Dis Colon Rectum 2006;49:
14. Bentrem DJ, Okabe S, Wong WD, et al. T1 adenocarcinoma of
the rectum: transanal excision or radical surgery? Ann Surg
15. Lezoche E, Guerrieri M, Paganini AM, Feliciotti F. Long-term
results of patients with pT2 rectal cancer treated with radiother-
apy and transanal endoscopic microsurgical excision. World
J Surg 2002;26:1170 – 4.
16. Borschitz T, Heintz A, Junginger T. Transanal endoscopic mi-
crosurgical excision of pT2 rectal cancer: results and possible
indications. Dis Colon Rectum 2007;50:292–301.
17. Duek SD, Issa N, Hershko DD, Krausz MM. Outcome of
transanal endoscopic microsurgery and adjuvant radiotherapy
in patients with T2 rectal cancer. Dis Colon Rectum 2008;51:
379 – 84.
18. Tjandra T. Long-term results in patients with T2–3 N0 distal
rectal cancer undergoing radiotherapy before transanal endo-
scopic microsurgery. Tech Coloproctol 2006;10:158.
19. Stipa F, Lucandri G, Ferri M, Casula G, Ziparo V. Local excision
of rectal cancer with transanal endoscopic microsurgery (TEM).
Anticancer Res 2004;24:1167–72.
20. Lezoche E, Guerrieri M, Paganini AM, Feliciotti F, Pietrantoni F.
Is transanal endoscopic microsurgery (TEM) a valid treatment
for rectal tumors? Surg Endosc 1996;10:736– 41.
21. Heintz A, Morshel M, Junginger T. Comparison of results after
transanal endoscopic microsurgery and radical resection for T1
carcinoma of the rectum. Surg Endosc 1998;12:1145– 8.
22. Middleton PF, Sutherland LM, Maddern GJ. Transanal endo-
scopic microsurgery: a systematic review. Dis Colon Rectum
2005;48:270 – 84.
23. Lee W, Lee D, Choi S, Chun H. Transanal endoscopic microsur-
gery and radical surgery for T1 and T2 rectal cancer. Surg Endosc
24. Langer C, Liersch T, Su¨ss M, et al. Surgical cure for early rectal
DISEASES OF THE COLON &RECTUM VOLUME 52: 11 (2009) 1835
carcinoma and large adenoma: Transanal endoscopic microsur-
gery (using ultrasound or electrosurgery) compared to conven-
tional local and radical resection. Int J Colorectal Dis 2003;18:
25. Sengupta S, Tjandra JJ. Local excision of rectal cancer: What is
the evidence? Dis Colon Rectum 2001;44:1345–61.
26. Gavagan JA, Whiteford MH, Swanstrom LL. Full-thickness in-
traperitoneal excision by transanal endoscopic microsurgery
does not increase short-term complications. Am J Surg 2004;
187:630 – 4.
27. Steele RJ, Hershman MJ, Mortensen NJ, Armitage NC, Schole-
field JH. Transanal endoscopic microsurgery: initial experience
from three centres in the United Kingdom. Br J Surg 1996;83:
28. Smith N, Brown G. Preoperative staging of rectal cancer. Acta
29. Bretagnol F, Merrie A, George B, Warren BF, Mortensen NJ.
Local excision of rectal tumours by transanal endoscopic micro-
surgery. Br J Surg 2007;94:627–33.
30. Lezoche G, Baldarelli M, Guerrieri M, et al. A prospective ran-
domized study with a 5-year minimum follow-up evaluation of
transanal endoscopic microsurgery versus laparoscopic total
mesorectal excision after neoadjuvant therapy. Surg Endosc
1836 ALLAIX ET AL:LONG-TERM RESULTS OF A LARGE SERIES