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B M Stephenson et al.

11 Buess G, Theiss R, Hutterer F, Pichimaier H. Endoscopic surgery in the rectum. Endoscopy 1985;17:31-5. 12 Buess G, Kipfmuller K, Naruhn M, Braunstein S, Junginger Th. Endoscopic microsurgery of rectal tumours. Endoscopy 1987;19: S38-42. 13 Magos AL, Baumann R, Turnball AC. Transcervical resection of the endometrium in women with menorrhagia. Br MedJ 1989;298:1209-12. 14 Boto TCA, Fowler CG, Djahanbakhch 0. Transcervical resection of the endometrium in women with menorrhagia. Br Med J 1989;298:1518.

15 Goligher J. Surgery of the Anus Rectum and Colon. London: Bailliere Tindall, 1985:5. 16 Gale DW, Notley RG. TURP without TURP syndrome. Br J Urol 1985;57:708-10. 17 Anonymous. Reducing deaths from large bowel cancer. Lancet 1990;335:1583. 18 Anonymous. Cancer of the colon and rectum. Br J Surg 1990;77: 1063-5. Received 15 May 1991

Assessor's comment This thoughtful paper describes the use of a technique which proctologists may well need to add to their armamentarium if others' experience of it is as favourable as that of Mr Stephenson and his colleagues. The symptoms of untreated villous adenoma can be very disabling, while abdominal surgery may carry unacceptable risks in the frail elderly patient; this paper highlights the present position, that few patients need to be left to choose between these two unsatisfactory therapeutic extremes. Having said this, the technique has its shortcomings. As the authors point out, the method does not allow easy appraisal by the pathologist of the unexpected cancer. A well-orientated disc excision of a favourable cancer may not need further treatment if the pathologist finds it to be completely excised, confined to the bowel wall and at

least moderately differentiated. A mass of 'chips' from an ETAR-resected adenoma among which slivers of cancer are found leaves pathologist, surgeon and patient in a fix as to what should be done next, if anything. But in the majority of cases of villous adenoma, in which this problem does not arise, the elderly patient with a lesion difficult to remove en bloc transanally should certainly be offered ETAR. It is unlikely that the Buess technique, which allows disc excision by 'remote control', will ever be available outside a few specialist units, if any, in the UK. J M NORTHOVER FRCS

Consultant Surgeon St Mark's Hospital London

Dilemmas in providing a vascular surgical service.

58 B M Stephenson et al. 11 Buess G, Theiss R, Hutterer F, Pichimaier H. Endoscopic surgery in the rectum. Endoscopy 1985;17:31-5. 12 Buess G, Kipfm...
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