low - lying rectal lesions can very easily be dealt with by parks ' excision . mid and upper rectal tumors pose a special problem due to inaccessibility and poor vision . these lesions were traditionally excised by low anterior resection for lesions above the peritoneal reflection and perineal approach for lesions below the peritoneal reflection . parks et al suggested that such radical procedures for low - grade rectal villous adenomas would be unnecessary in 60% to 80% of patients . buess et al developed a stereoscopic microscope with channels for irrigation , suction , and diathermy for use in transanal endoscopic microsurgery ( tem ) and resected more than 250 rectal lesions between 1983 to 1991 . since then , an increasing number of rectal adenomas and selected carcinomas have been excised using this technique . we wanted to evaluate our institution 's results of the tem technique for rectal adenoma and carcinoma . patients were identified from the surgical records , operation lists , and the hospital pms system . case notes were studied thoroughly and data collected regarding duration of operation , operation technique , complications , duration of follow - up , etc . briefly , tem was performed using the equipment developed by buess and manufactured by wolf ( knittlingten , germany ) . this is based on an operating sigmoidoscope 12 cm or 20 cm in length and 4 cm in outer diameter , which incorporates a high quality binocular optical system providing up to 6x magnification . rectal distension to a pressure of 10 mm hg with simultaneous , continuous low - pressure suction is achieved with a combined endosurgical unit incorporating pressure sensitive insufflation of carbon dioxide and a roller suction unit . absorbable sutures were used to close the defect , and the sutures were secured by silver clips . the position of the patient varied with the site of the lesion , and the lloyd - davies position was used for posterior lesions . over a period of 5 years ( 1993 to 1998 ) , 75 patients ( adenomas , n=58 ) underwent 90 tem resections . in the adenoma group , 31 were male and the median age was 71 years ( range , 31 to 94 ) . in the carcinoma group , 7 patients were male and the median age was 76 years ( range , 52 to 89 ) . of the 17 patients with carcinoma lesions , 6 were diagnosed preoperatively with benign lesions and hence underwent mucosectomy . the majority of patients were primarily referred by general practitioners ( adenoma , n=40 ; carcinoma , n=13 ) . two patients in the adenoma group and 1 in the carcinoma group were fecal occult blood test ( fobt ) screen detected . rectal bleeding was the predominant presenting symptom in 30 ( 51% ) adenoma and 9 ( 52% ) carcinoma patients , respectively . altered bowel habits ( adenoma , n=5 ; carcinoma , n=3 ) , diarrhea ( adenoma , n=8 ; carcinoma , n=3 ) was noted ( table 1 ) . a family history of bowel cancer was recorded in 8 ( 13% ) adenoma and 2 ( 11% ) carcinoma patients . the median distance from the anal verge of adenoma lesions was 10 cm ( range , 5 to 15 ) and approximately half of the lesions ( n=24 ) were located in the posterior quadrant . an equal number of lesions ( n=17 ) were located in the anterior and lateral quadrants . polypoid lesions were the commonest ( n=27 ) , with sessile lesions accounting for 10 lesions . these lesions were difficult to dissect , and some areas of partial thickness excision had to be done . the median duration of surgery was 112.7 minutes ( range , 40 to 180 ) , with 55% ( n=32 ) of patients undergoing mucosectomy . histopathological examination revealed tubulovillous ( n=20 ) , villous ( n=28 ) , tubular adenoma in 10 patients . eleven patients in the carcinoma group underwent full - thickness excision with a median operating time of 131.2 minutes ( range , 60 to 180 ) . an equal number of lesions were located in the posterior and lateral quadrants ( n=7 ) . histology revealed t1 ( n=9 ) , t2 ( n=4 ) , t3 ( n=3 ) , and t0 in 1 patient . no perforations occurred , and no conversions to open surgery due to technical difficulties were required . major rectal bleeding requiring transfusion was noted in 2 of the adenoma and none of carcinoma patients . transient fecal incontinence was noted in 1 each of the adenoma and carcinoma patients , which settled before the next follow - up . minor complications like postoperative pyrexia were noted in 6 of the adenoma and 2 of the carcinoma patients . four of the adenoma and 2 of the carcinoma patients were catheterized , and half of these had to be catheterized for their previous history of urinary symptoms ( table 2 ) . all the patients were followed up for at least 24 months , and the median follow - up for adenomas and carcinomas was 34 ( range , 24 to 78 ) and 36 ( range , 25 to 76 ) months , respectively ( table 3 ) . during this period , 6 patients in the adenoma group had local recurrence and underwent further tem and endoscopic resections with good local control . all these patients underwent further tem within 3 months of the initial treatment with no further recurrences to date . amongst the 6 patients with true recurrence , tubulo - villous with severe dysplasia ( n=2 ) and moderate dysplasia ( n=1 ) , villous adenoma with moderate dysplasia ( n=2 ) and tubular adenoma with severe dysplasia ( n=1 ) were found . one patient in the adenoma group developed rectal stricture , which was successfully treated by dilatation . two patients in the t3 group were discharged after 2 and 4 years of follow - up due to their age . five patients underwent adjuvant radiotherapy , and 2 patients developed radiation enteritis , which settled with conservative management ( table 4 ) . the median distance from the anal verge of adenoma lesions was 10 cm ( range , 5 to 15 ) and approximately half of the lesions ( n=24 ) were located in the posterior quadrant . an equal number of lesions ( n=17 ) were located in the anterior and lateral quadrants . polypoid lesions were the commonest ( n=27 ) , with sessile lesions accounting for 10 lesions . these lesions were difficult to dissect , and some areas of partial thickness excision had to be done . the median duration of surgery was 112.7 minutes ( range , 40 to 180 ) , with 55% ( n=32 ) of patients undergoing mucosectomy . histopathological examination revealed tubulovillous ( n=20 ) , villous ( n=28 ) , tubular adenoma in 10 patients . eleven patients in the carcinoma group underwent full - thickness excision with a median operating time of 131.2 minutes ( range , 60 to 180 ) . an equal number of lesions were located in the posterior and lateral quadrants ( n=7 ) . histology revealed t1 ( n=9 ) , t2 ( n=4 ) , t3 ( n=3 ) , and t0 in 1 patient . no perforations occurred , and no conversions to open surgery due to technical difficulties were required . major rectal bleeding requiring transfusion was noted in 2 of the adenoma and none of carcinoma patients . transient fecal incontinence was noted in 1 each of the adenoma and carcinoma patients , which settled before the next follow - up . minor complications like postoperative pyrexia were noted in 6 of the adenoma and 2 of the carcinoma patients . four of the adenoma and 2 of the carcinoma patients were catheterized , and half of these had to be catheterized for their previous history of urinary symptoms ( table 2 ) . all the patients were followed up for at least 24 months , and the median follow - up for adenomas and carcinomas was 34 ( range , 24 to 78 ) and 36 ( range , 25 to 76 ) months , respectively ( table 3 ) . during this period , 6 patients in the adenoma group had local recurrence and underwent further tem and endoscopic resections with good local control . all these patients underwent further tem within 3 months of the initial treatment with no further recurrences to date . amongst the 6 patients with true recurrence , tubulo - villous with severe dysplasia ( n=2 ) and moderate dysplasia ( n=1 ) , villous adenoma with moderate dysplasia ( n=2 ) and tubular adenoma with severe dysplasia ( n=1 ) one patient in the adenoma group developed rectal stricture , which was successfully treated by dilatation . two patients in the t3 group were discharged after 2 and 4 years of follow - up due to their age . five patients underwent adjuvant radiotherapy , and 2 patients developed radiation enteritis , which settled with conservative management ( table 4 ) . our series of 75 patients who underwent tem shows that this procedure can be done safely with minimum morbidity and no postoperative mortality . steele et al reported the series of the first 100 cases in 1996 from the uk with 5% overall recurrence rates . chiavellati et al reported a series of 24 patients with no recurrences albeit with short follow - up . in our series of 58 adenomas and 17 carcinomas , the recurrence rates have been 10% and 11% , respectively , with a minimum of 24 months of follow - up . the importance of careful selection of carcinoma patients for tem excision can not be overemphasized . mentges et al laid out the criteria for local therapy of rectal carcinomas based on hermeneck 's data : 1 ) stage cs1 , ut1 , g1 , or g2 well to moderately differentiated carcinomas . 2 ) stage cs1 , ut1 , g3 , or g4 carcinomas ( suspected at operation to be p t1 high - risk carcinoma ) . 3 ) major advanced stage carcinomas in patients with risk factors and in those who refuse major surgery or stoma ( palliation ) . in our series , the majority of our patients were old with associated co - morbid conditions in whom major surgery would have been inappropriate . it appears as though tem for rectal adenomas and carefully selected cases of carcinomas is safe and achieves the objectives of cure with minimal morbidity and mortality .
background : transanal endoscopic microsurgery was introduced in the early 1980s . since then , increasing numbers of rectal adenomas are being excised by this technique . the aim of this study was to evaluate our institution 's experience with transanal endoscopic microsurgery for rectal adenoma and carcinoma.methods:seventy-five patients ( adenomas , n=58 ) underwent more than 90 tem resections over a period of 5 years.results:postoperative complications were minimal with 3% ( n=2 ) in the adenoma group requiring transfusion and 0% 30-day mortality . 
 one patient in each group developed transient fecal incontinence . during the follow - up period , 6 patients ( 10% ) in the adenoma group underwent further local resections for their recurrences . 
 two patients in the carcinoma group ( 1 each of pathological t1 and t2 stage ) developed recurrence at 24 months . 
 a female with a t2 tumor was found to have an inoperable lesion and underwent sigmoid colostomy . 
 five of 17 patients had postoperative radiotherapy , and 2 patients developed radiation enteritis . 
 four patients died during follow - up due to unrelated reasons.conclusion:the transanal endoscopic microsurgery technique appears to be safe and associated with minimal morbidity . 
 careful selection of patients with thorough preoperative assessment is necessary for carcinoma patients . 
 patients with t1 lesions and favorable histology should only be considered for curative resection by this technique .