Transanal Excision of Large, Rectal Villous Adenomas Glenn D. Sakamoto, M.D., John M. MacKeigan, M.D., Anthony J. Senagore, M.D., M.S. From Ferguson Hospital, Grand Rapids, Michigan The purpose of this study is to demonstrate that a transanal excisional approach can be successfully used in most cases of large, benign, rectal villous adenomas with acceptable rates of recurrence and complications in comparison with historic controls. A retrospective review of all cases of benign, large, rectal villous adenomas at this institution from 1975 to 1985 was performed. A total of 122 patients had large, benign, rectal villous adenomas excised. MI except five were treated by transanal excision. Thirty-eight percent of lesions were more proximal than 8 cm from the anal verge. The average follow-up was 55 months. Twenty-seven percent of patients were treated for residual disease after a known incomplete initial treatment or an adenoma at the same location within 6 months of the original treatment. Thirty percent of patients were treated for recurrent adenoma 6 months after complete initial treatment. Two patients (1.7 percent) with recurrences were found to have invasive carcinoma. Both patients had excisional therapy, and one had additional radiation therapy for these carcinomas. Ten postoperative hemorrhages and two perforations occurred as symptomatic or serious complications. This renders a 10 percent complication rate for the study group, which is lower than reported by others using the Kraske or transsphincteric approach to the rectum. Because of the expected higher recurrence rate, regular follow-up is necessary for this type of therapy. In conclusion, this study demonstrated that transanal excision of large, benign, rectal villous adenomas can be a safe and effective method of treatment. [Key words: Transanal excisions; Large, rectal villous adenomas; Benign, rectal villous adenomas; Villous adenomas]
o f l e s i o n s in t h e m i d d l e a n d u p p e r r e c t u m , s u c h as low anterior resection, the Kraske procedure, and several transsphincteric operations. These procedures allow complete resection of the neoplasm a n d b o a s t l o w r e c u r r e n c e rates; h o w e v e r , this is a c c o m p l i s h e d w i t h s i g n i f i c a n t m o r b i d i t y . 1'2 A n alt e r n a t i v e a p p r o a c h is t r a n s a n a l e x c i s i o n , w h i c h all o w s r e m o v a l o f e v e n l a r g e l e s i o n s as p r o x i m a l as 1 2 - 1 5 cm; h o w e v e r , c o n c e r n s e x i s t b e c a u s e o f higher recurrence rates and the perceived technical d i f f i c u l t y o f r e s e c t i n g l e s i o n s in t h e m i d d l e a n d upper rectum transanally. 3 Despite these potential problems, transanal excision does carry a conside r a b l y l o w e r risk o f c o m p l i c a t i o n s for t h e t r e a t m e n t of large rectal villous adenomas and a low potential for loss o f a n a l s p h i n c t e r f u n c t i o n . T h e p u r p o s e o f this r e p o r t is to e x a m i n e o u r p a s t experience with transanal excision of large, ben i g n , r e c t a l v i l l o u s a d e n o m a s f r o m 1975 to 1985. S p e c i f i c a l l y , w e s o u g h t to a s s e s s t h e e f f i c a c y a n d c o m p l i c a t i o n r a t e s a s s o c i a t e d w i t h this a p p r o a c h .
MATERIALS AND M E T H O D S A review of all cases of rectal villous adenomas treated during a 10-year period from 1975 to 1985 at Ferguson Hospital was performed. Included in this study were all benign villous adenomas larger than 2 cm located within 15 cm of the anal verge. Data collected included patient age, symptoms, sex, operative technique, and complications. Data were obtained by hospital and office chart review. All operations were performed or supervised by one group of attending surgeons. The specific transanal excisional technique varied depending on the location of the lesion within the rectum and the individual preference of the attending surgeon. Exposure of lesions within the anal canal and lower rectum was generally accomplished using the Hill-Ferguson anal retractor. For lesions in the mid-to-high rectum (6-15 cm), excision was accomplished with the aid of either the
Sakamoto GD, MacKeigan JM, Senagore AJ. Transanal excision of large, rectal villous adenomas. Dis Colon Rectum 1 9 9 1 ; 3 4 : 8 8 0 - 8 8 5 .
he treatment of large, rectal villous adenomas can present a challenging clinical problem. Because villous adenomas possess considerable malignant potential, complete removal is optimal; however, this should be accomplished without the sacrifice of anal sphincter function. The technical difficulty of excision increases proportionally to the size of the neoplasm and the distance from the anal verge. As a result, a number of operative techniques have been developed to allow resection
T
Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, April 29 to May 4, 1990. Address reprint requests to Dr. Senagore: Ferguson Clinic, 75 Sheldon Boulevard, S.E., Grand Rapids, Michigan 49503. 880
Vol. 34, No. 10
TRANSANAL EXCISION OF RECTAL VILLOUS ADENOMAS
plastic operating anoscope or the rigid sigmoidoscope. In some cases, the two-scope technique described by Muldoon and Capehart 4 was utilized. Adenomas were preferentially excised in one or two pieces with a small margin of normal-appearing mucosa. A piecemeal excision of large lesions was performed if necessary owing to the location or size of the lesion. All patients received followup examinations every 3 months for 2 years, or until clearance of their rectal villous adenomas, and annually thereafter. Residual disease was defined as known incomplete primary excision or identification of villous adenoma at the same location within 6 months of the original surgery. A recurrence was defined as a villous adenoma occurring later than 6 months after complete excision with interval clearing of neoplasm. Statistical analyses consisted of Student's t-test for adenoma size and location, and chi-squared for the remainder of the data. Significance was set at P < 0.05. RESULTS There were 122 patients with villous adenomas larger than 2 cm eligible for study during this 10year period at our institution. Five patients were excluded from analysis because they received major resectional therapy. Two patients underwent abdominoperineal resection for circumferential rectal villous adenomas, while three patients had low anterior resections for similar neoplasms. Therefore, 117 patients received treatment by transanal excision alone and form the study population. Eight (7 percent) patients were lost to follow-up and, therefore, were not included in the long-term evaluation of treatment but were included in the data for initial surgery. The mean age of patients in this study was 60 years (range, 32-92 years), with an approximately 2:1 female/male ratio. The mean follow-up of these patients was 55 months, with a range of 1-176 months. The most commonly reported symptoms at presentation were rectal bleeding (60 percent), anal protrusion (30 percent), and mucoid anal discharge (22 percent). Only 18 percent of patients were completely asymptomatic at the time of initial presentation (Fig. 1). On physical examination, 60 percent of the adenomas were palpable by digital examination and six adenomas had firm areas sus-
881
picious for malignancy. However, none of these adenomas proved to be malignant. The average size of the villous adenomas was 3.7 cm (range, 2.0-10.0 cm), and the average height from the anal verge was 6 cm (range, 2-12 cm) (Table 1). However, 38 percent of lesions were more proximal than 8 cm from the anal verge. Pathologic examination of all the removed specimens revealed that 50 percent had typical villous histology, 46 percent contained areas of epithelial atypia, and 4 percent were mixed tubulovillous adenomas. Thirty-two patients (27 percent) were treated at least once for residual disease. There was no significant difference in histologic makeup between index adenomas complicated by residual disease and those complicated by recurrent disease (50 percent and 51 percent, respectively). Of note is the fact that patients with residual disease had significantly larger primary adenomas than did patients without residual disease (4.9 cm v s . 3.6 cm; P < 0.05, Student's t-test). Thirty-five patients (30 percent) had recurrent rectal villous adenomas occurring later than 6 months after the primary surgery. Patients with recurrent disease also had significantly larger index adenomas than did patients without recurrence (5.8 cm v s . 3.6 cm; P < 0.05, Student's t-test). There
SYMPTOMS AT PRESENTATION [] [] [] [] [] 9 []
37.2%
18.9%
~ ~"
13.8%
~"\'
BLEEDING PROTRUSION DISCHARGE DIARRHEA CONSTIPATION PAIN NONE
11.2% ~
\ 4.1% 12.2%
Figure 1. Data demonstrating the distribution of presenting symptoms for patients with large, rectal villous lesions.
Table 1. A Comparison of the Size of Rectal Villous Adenomas Treated by Transanal Excision and Their Distance from the Anal Verge Distance from Anal Verge
Size 2-4 cm > 5 - 7 cm
2 cm), rectal villous adenomas containing atypical epithelial changes. While smaller adenomas in the anal canal and lower rectum are easily and completely excised per anum, larger adenomas of the middle and upper rectum pose technical challenges. 6-11 Difficulty in exposing the neoplasm may lead to incomplete resections and the possibility of missing a malignant focus. In addition, it is felt that piecemeal resection may lead to high recurrence rates. 3 Wheat and Ackerman 3 also raised the concern of increased mortality associated with inadequate, piecemeal excision of villous lesions owing to malignant degeneration; however, they note that adequate local excision is the best means of treatment of totally benign villous adenomas. In order to gain better access to the middle and upper rectum, posterior proctotomy (the Kraske procedure) has been applied to excision of rectal villous adenomas. Klingensmith e t al. 9 reported a series of eight patients who underwent posterior proctotomy with excision of the lesion. One case recurred, one patient developed a fecal fistula, and one bled postoperatively. Arnaud e t al. 12 performed posterior proctotomy on 11 patients, and three fecal fistulas developed postoperatively. A third study by Wilson and Gordon: reported the results of 20 cases treated by the Kraske procedure with one recurrence, eight fecal fistulas, two wound infections, and three postoperative hemorrhages. All three studies showed low recurrence rates but together resulted in a 21 percent incidence of fecal fistula and an overall morbidity rate of 34 percent (Table 2). The transsphincteric approach has also been advocated as a means of gaining full access to the middle rectum and has been used for excision of rectal villous adenomas. Thompson and Tucker 1~ reported 20 cases treated in this manner resulting in no recurrences, but seven patients developed fecal fistulas and 11 had temporary incontinence. Of concern is the report of permanent incontinence occurring in one patient. ~ Heij e t al. ~~ performed transsphincteric procedures on six patients, with two recurrences and one benign rectal stricture. Mason, 2 reporting his experience with 26
Vol. 34, No. 10
TRANSANAL EXCISION OF RECTAL VILLOUS ADENOMAS
patients using the transsphincteric approach, found significant morbidity. Five of these patients had protecting colostomies, and two recurrences occurred. One patient each developed a fecal fistula, wound infection, and rectal necrosis. In reviewing the literature on the transsphincteric approach to rectal villous adenomas, there were a total of 68 cases reported with a recurrence rate of 6 percent (Table 3). 2'I~ However, 15 percent of patients developed a fecal fistula, and at least 18 percent had temporary incontinence. The concurrent use of a protecting colostomy has been supported by some authors, while others consider it too extreme for benign disease. 2 With the use of the plastic operating anoscope and the two-scope technique as described by Muldoon and Capehart, ~ full access to lesions in the middle and upper rectum is made. Excision can be done in one or many pieces while maintaining control of the operative field. Another technique to remove adenomas of the middle and upper rectum involves cautery snare loop excision v i a the rigid sigmoidoscope. This piecemeal excisional technique, deemed inadequate by Wheat and Ackerman, is supported by others, v' 15.16 Several studies have examined the effectiveness of the transanal excisional approach for benign, rectal villous adenomas. Nivatvongs et al. 6 reported on 60 patients who underwent transanal excision
883
of rectal villous adenomas, with seven recurrences and two complications. Jahadi and Baldwin 17 reported on 48 patients who underwent transanal excision of rectal villous adenomas, with 14 (29 percent) recurrences, 14 percent of which were malignant. Thomson 1~ reported 100 cases of transanal excision and found a 19 percent recurrence rate, without any malignancies among recurrences, and an 8 percent complication rate. Our experience is similar, with a 27 percent residual rate, 30 percent recurrence rate, 1.7 percent incidence of malignancy among recurrences, and 10 percent complication rate (Table 4). All the residual neoplasms were eventually cleared with repeat excision except in one patient, who continues to undergo transanal excision for benign disease. Although transanal excision of large, rectal villous adenomas results in higher recurrence rates, the advantage of avoiding the high complication rates of posterior proctotomy and transsphincteric approaches is significant. It can also be an alternative to radical resection of very large, rectal villous adenomas in medically compromised patients. Nivatvongs e t a1.15 reported that, if transanal piecemeal excision had been done for their large rectal lesions, 14 percent of patients would not have undergone low anterior or abdominoperineal resection. On the other hand, this higher recurrence rate may be a disadvantage if the patient is unreli-
Table 2. A Review of the Literature on the Kraske Procedure for Excision of Rectal Villous Adenomas Demonstrating a Significant Risk of Morbidity Authors
Recurrence
Fistula
Wound Infection
Hemorrhage
Klingensmith et al. 4 (n = 8) Arnaud et al. ~2 (n = 11) Wilson and Gordon 1 (n = 20)
1 0 0
1 3 4
0 0 2
1 0 2
Total (n = 39)
1 (3%)
8 (21%)
2 (5%)
3 (8%)
Table 3. A Review of the Literature on Transsphincteric Resection of Villous Adenomas Demonstrating a Low Recurrence Rate but Considerable Morbidity Authors
Recurrence
Mason 2 (n = 26) Criado and Wilson la (n = 9) Heij et al. 1~ (n = 6) Thompson and Tucker" (n = 20) Oh and Kark TM (n = 7)
2 0 2 0
Total (n = 68)
4 (6%)
PE = pulmonary embolus.
Colostomy 5 0 2
7 (10%)
Incontinence
Fistula
Infection
0
1 1
1 0
12
7
0
7
1
19 (28%)
10 (15%)
1 (1%)
Other Necrosis Stenosis PE
3 (4%)
884
SAKAMOTO E T AL
Dis Colon Rectum, October 1991
Table 4. A Review of the Data Available on Transanal Excision of Rectal Villous Adenomas Including Our Data Authors Thomson TM (n = 100) Nivatvongs et al. 6 (n = 60) Jahadi and Baldwin lr (n = 48) Sakamoto et al. (present study) (n = 117)
Recurrence 19 7 14 35
(19%) (12%) (29%) (30%)
Cancer
Atypia
Complications
0 0 14% 1.7%
N/A 26% N/A 46%
8 (8%) 2 (3%) N/A 10%
Although the recurrence rates are higher than those associated with other approaches, morbidity is considerably less. able or will be unable to s e e k medical attention for e x t e n d e d periods of time. Therefore, patients selected for transanal excision should b e aware that continuous careful surveillance is essential for successful treatment b e c a u s e of the lifelong potential for recurrence. T h o m s o n ~s believes that the high r e c u r r e n c e rate is not due to i n c o m p l e t e resection but to a " . . . particular instability of the m u c o s a . . . " Galandiuk e t al. 5 d e t e r m i n e d the risk of r e c u r r e n c e by examining data from 1,049 patients with rectal villous a d e n o m a s , including 176 that u n d e r w e n t transanal excision. T h e y found, a m o n g other factors, that larger, m o r e dysplastic a d e n o m a s and those excised rather than r e s e c t e d w e r e m o r e likely to recur. Likewise, Nivatvongs e t al. 15 f o u n d that those villous a d e n o m a s with superficial c a r c i n o m a had twice the r e c u r r e n c e rate as those that w e r e totally benign. Although i n c o m p l e t e excision is a potential explanation for recurrence, mucosal instability w o u l d better account for r e c u r r e n c e s years after the initial excision. This is the reason for the distinction b e t w e e n r e s i d u u m ( n e o p l a s m < 6 m o n t h s after resection) and r e c u r r e n c e ( n e o p l a s m > 6 m o n t h s ) in our study. D e v e l o p m e n t of invasive c a r c i n o m a o c c u r r e d in 1.7 p e r c e n t of r e c u r r e n c e s in this study. Both of these patients had villous a d e n o m a s with atypical epithelial changes. Likewise, Nivatvongs e t al. ~5 r e p o r t e d a 4 p e r c e n t incidence of c a r c i n o m a a m o n g recurrences. T h e y also f o u n d that c a r c i n o m a occurred only a m o n g villous a d e n o m a s with superficial carcinoma. F r e q u e n t surveillance is m a n d a t e d in this patient p o p u l a t i o n as the risk is lifelong. In conclusion, transanal excision of large, rectal villous a d e n o m a s can be easily a c c o m p l i s h e d with a low c o m p l i c a t i o n rate (10 p e r c e n t ) and an acceptable recurrence rate (30 p e r c e n t ) while preserving anal sphincter function. Therefore, the transanal excisional a p p r o a c h s h o u l d be conside r e d the initial a p p r o a c h of choice for large, rectal villous adenomas.
ACKNOWLEDGMENT The authors wish to thank Mrs. Pamela Brown for her administrative s u p p o r t t h r o u g h o u t this study. REFERENCES 1. Wilson SE, Gordon HE. Excision of rectal lesions by the Kraske approach. Am J Surg 1969;118:213-7. 2. Mason AY. Trans-sphincteric surgery of the rectum. Prog Surg 1974;13:66-97. 3. Wheat MWJr, Ackerman LV. Villous adenomas of the large intestine. Ann Surg 1958;147:476-87. 4. Muldoon JP, Capehart RJ. Two scope technique for the transrectal removal of lesions high in the rectum and sigmoid colon. Surg Gynecol Obstet 1973;137:1019-22. 5. Galandiuk S, Fazio VW, Jagelman DG, e t al. Villous and tubulovillous adenomas of the colon and rectum: a retrospective review, 1964-1985. Am J Surg 1987;153:41-7. 6. Nivatvongs S, Balcos EG, SchottlerJL, Goldberg SM. Surgical management of large villous tumors of the rectum. Dis Colon Rectum 1973;16:508-14. 7. Hanley PH, Hines MO, Ray JE. Villous tumors: experience with 217 patients. Am Surg 1971;37:190 7. 8. Hagood MF, O'Brien PH. Villous tumors of the rectum: excision by the posterior approach. South Med J 1975;68:184-8. 9. Klingensmith W, Dickinson WE, Hays RS. Posterior resection of selected rectal tumors. Arch Surg 1975;110:647-51. 10. Heij HA, Tan KG, van Houten H. The transsphincteric approach to rectal villous adenomas. Neth J Surg 1982;34:4-7. 11. Thompson BW, Tucker WE. Transsphincteric approach to lesions of the rectum. South Med J 1987;80:41-3. 12. Arnaud JP, Eloy MR, Clendinnen G, Adloff M. The posterior approach for villous tumors of the rectum: report of eleven cases. Am J Surg 1978;136:273-5. 13. Criado FJ, Wilson TH Jr. Posterior transsphincteric approach for surgery of the rectum: the Bevan operation. Dis Colon Rectum 1981;24:145-50. 14. Oh C, Kark AE. The transsphincteric approach to
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TRANSANAL EXCISION OF RECTAL VILLOUS ADENOMAS
mid and low rectal villous adenoma: anatomic basis of surgical treatment. Ann Surg 1972;176:605-12. 15. Nivatvongs S, Nicholson JD, Rothenberger DA, et aL Villous adenomas of the rectum: the accuracy of clinical assessment. Surgery 1980;87:549-51. 16. Hanley PH. Treatment of large villous tumors of the lower rectum by multiple-stage fulguration. Tex Med
885
1976;72:98-101. 17. Jahadi MR, Baldwin A Jr. Villous adenomas of the colon and rectum. Am J Surg 1975;130:729-32. 18. Thomson Jp. Treatment of sessile villous and tubulovillous adenomas of the rectum: experience of St. Mark's Hospital, 1963 1972. Dis Colon Rectum 1977;20:467-72.
o f l e s i o n s in t h e m i d d l e a n d u p p e r r e c t u m , s u c h as low anterior resection, the Kraske procedure, and several transsphincteric operations. These procedures allow complete resection of the neoplasm a n d b o a s t l o w r e c u r r e n c e rates; h o w e v e r , this is a c c o m p l i s h e d w i t h s i g n i f i c a n t m o r b i d i t y . 1'2 A n alt e r n a t i v e a p p r o a c h is t r a n s a n a l e x c i s i o n , w h i c h all o w s r e m o v a l o f e v e n l a r g e l e s i o n s as p r o x i m a l as 1 2 - 1 5 cm; h o w e v e r , c o n c e r n s e x i s t b e c a u s e o f higher recurrence rates and the perceived technical d i f f i c u l t y o f r e s e c t i n g l e s i o n s in t h e m i d d l e a n d upper rectum transanally. 3 Despite these potential problems, transanal excision does carry a conside r a b l y l o w e r risk o f c o m p l i c a t i o n s for t h e t r e a t m e n t of large rectal villous adenomas and a low potential for loss o f a n a l s p h i n c t e r f u n c t i o n . T h e p u r p o s e o f this r e p o r t is to e x a m i n e o u r p a s t experience with transanal excision of large, ben i g n , r e c t a l v i l l o u s a d e n o m a s f r o m 1975 to 1985. S p e c i f i c a l l y , w e s o u g h t to a s s e s s t h e e f f i c a c y a n d c o m p l i c a t i o n r a t e s a s s o c i a t e d w i t h this a p p r o a c h .
MATERIALS AND M E T H O D S A review of all cases of rectal villous adenomas treated during a 10-year period from 1975 to 1985 at Ferguson Hospital was performed. Included in this study were all benign villous adenomas larger than 2 cm located within 15 cm of the anal verge. Data collected included patient age, symptoms, sex, operative technique, and complications. Data were obtained by hospital and office chart review. All operations were performed or supervised by one group of attending surgeons. The specific transanal excisional technique varied depending on the location of the lesion within the rectum and the individual preference of the attending surgeon. Exposure of lesions within the anal canal and lower rectum was generally accomplished using the Hill-Ferguson anal retractor. For lesions in the mid-to-high rectum (6-15 cm), excision was accomplished with the aid of either the
Sakamoto GD, MacKeigan JM, Senagore AJ. Transanal excision of large, rectal villous adenomas. Dis Colon Rectum 1 9 9 1 ; 3 4 : 8 8 0 - 8 8 5 .
he treatment of large, rectal villous adenomas can present a challenging clinical problem. Because villous adenomas possess considerable malignant potential, complete removal is optimal; however, this should be accomplished without the sacrifice of anal sphincter function. The technical difficulty of excision increases proportionally to the size of the neoplasm and the distance from the anal verge. As a result, a number of operative techniques have been developed to allow resection
T
Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, April 29 to May 4, 1990. Address reprint requests to Dr. Senagore: Ferguson Clinic, 75 Sheldon Boulevard, S.E., Grand Rapids, Michigan 49503. 880
Vol. 34, No. 10
TRANSANAL EXCISION OF RECTAL VILLOUS ADENOMAS
plastic operating anoscope or the rigid sigmoidoscope. In some cases, the two-scope technique described by Muldoon and Capehart 4 was utilized. Adenomas were preferentially excised in one or two pieces with a small margin of normal-appearing mucosa. A piecemeal excision of large lesions was performed if necessary owing to the location or size of the lesion. All patients received followup examinations every 3 months for 2 years, or until clearance of their rectal villous adenomas, and annually thereafter. Residual disease was defined as known incomplete primary excision or identification of villous adenoma at the same location within 6 months of the original surgery. A recurrence was defined as a villous adenoma occurring later than 6 months after complete excision with interval clearing of neoplasm. Statistical analyses consisted of Student's t-test for adenoma size and location, and chi-squared for the remainder of the data. Significance was set at P < 0.05. RESULTS There were 122 patients with villous adenomas larger than 2 cm eligible for study during this 10year period at our institution. Five patients were excluded from analysis because they received major resectional therapy. Two patients underwent abdominoperineal resection for circumferential rectal villous adenomas, while three patients had low anterior resections for similar neoplasms. Therefore, 117 patients received treatment by transanal excision alone and form the study population. Eight (7 percent) patients were lost to follow-up and, therefore, were not included in the long-term evaluation of treatment but were included in the data for initial surgery. The mean age of patients in this study was 60 years (range, 32-92 years), with an approximately 2:1 female/male ratio. The mean follow-up of these patients was 55 months, with a range of 1-176 months. The most commonly reported symptoms at presentation were rectal bleeding (60 percent), anal protrusion (30 percent), and mucoid anal discharge (22 percent). Only 18 percent of patients were completely asymptomatic at the time of initial presentation (Fig. 1). On physical examination, 60 percent of the adenomas were palpable by digital examination and six adenomas had firm areas sus-
881
picious for malignancy. However, none of these adenomas proved to be malignant. The average size of the villous adenomas was 3.7 cm (range, 2.0-10.0 cm), and the average height from the anal verge was 6 cm (range, 2-12 cm) (Table 1). However, 38 percent of lesions were more proximal than 8 cm from the anal verge. Pathologic examination of all the removed specimens revealed that 50 percent had typical villous histology, 46 percent contained areas of epithelial atypia, and 4 percent were mixed tubulovillous adenomas. Thirty-two patients (27 percent) were treated at least once for residual disease. There was no significant difference in histologic makeup between index adenomas complicated by residual disease and those complicated by recurrent disease (50 percent and 51 percent, respectively). Of note is the fact that patients with residual disease had significantly larger primary adenomas than did patients without residual disease (4.9 cm v s . 3.6 cm; P < 0.05, Student's t-test). Thirty-five patients (30 percent) had recurrent rectal villous adenomas occurring later than 6 months after the primary surgery. Patients with recurrent disease also had significantly larger index adenomas than did patients without recurrence (5.8 cm v s . 3.6 cm; P < 0.05, Student's t-test). There
SYMPTOMS AT PRESENTATION [] [] [] [] [] 9 []
37.2%
18.9%
~ ~"
13.8%
~"\'
BLEEDING PROTRUSION DISCHARGE DIARRHEA CONSTIPATION PAIN NONE
11.2% ~
\ 4.1% 12.2%
Figure 1. Data demonstrating the distribution of presenting symptoms for patients with large, rectal villous lesions.
Table 1. A Comparison of the Size of Rectal Villous Adenomas Treated by Transanal Excision and Their Distance from the Anal Verge Distance from Anal Verge
Size 2-4 cm > 5 - 7 cm
2 cm), rectal villous adenomas containing atypical epithelial changes. While smaller adenomas in the anal canal and lower rectum are easily and completely excised per anum, larger adenomas of the middle and upper rectum pose technical challenges. 6-11 Difficulty in exposing the neoplasm may lead to incomplete resections and the possibility of missing a malignant focus. In addition, it is felt that piecemeal resection may lead to high recurrence rates. 3 Wheat and Ackerman 3 also raised the concern of increased mortality associated with inadequate, piecemeal excision of villous lesions owing to malignant degeneration; however, they note that adequate local excision is the best means of treatment of totally benign villous adenomas. In order to gain better access to the middle and upper rectum, posterior proctotomy (the Kraske procedure) has been applied to excision of rectal villous adenomas. Klingensmith e t al. 9 reported a series of eight patients who underwent posterior proctotomy with excision of the lesion. One case recurred, one patient developed a fecal fistula, and one bled postoperatively. Arnaud e t al. 12 performed posterior proctotomy on 11 patients, and three fecal fistulas developed postoperatively. A third study by Wilson and Gordon: reported the results of 20 cases treated by the Kraske procedure with one recurrence, eight fecal fistulas, two wound infections, and three postoperative hemorrhages. All three studies showed low recurrence rates but together resulted in a 21 percent incidence of fecal fistula and an overall morbidity rate of 34 percent (Table 2). The transsphincteric approach has also been advocated as a means of gaining full access to the middle rectum and has been used for excision of rectal villous adenomas. Thompson and Tucker 1~ reported 20 cases treated in this manner resulting in no recurrences, but seven patients developed fecal fistulas and 11 had temporary incontinence. Of concern is the report of permanent incontinence occurring in one patient. ~ Heij e t al. ~~ performed transsphincteric procedures on six patients, with two recurrences and one benign rectal stricture. Mason, 2 reporting his experience with 26
Vol. 34, No. 10
TRANSANAL EXCISION OF RECTAL VILLOUS ADENOMAS
patients using the transsphincteric approach, found significant morbidity. Five of these patients had protecting colostomies, and two recurrences occurred. One patient each developed a fecal fistula, wound infection, and rectal necrosis. In reviewing the literature on the transsphincteric approach to rectal villous adenomas, there were a total of 68 cases reported with a recurrence rate of 6 percent (Table 3). 2'I~ However, 15 percent of patients developed a fecal fistula, and at least 18 percent had temporary incontinence. The concurrent use of a protecting colostomy has been supported by some authors, while others consider it too extreme for benign disease. 2 With the use of the plastic operating anoscope and the two-scope technique as described by Muldoon and Capehart, ~ full access to lesions in the middle and upper rectum is made. Excision can be done in one or many pieces while maintaining control of the operative field. Another technique to remove adenomas of the middle and upper rectum involves cautery snare loop excision v i a the rigid sigmoidoscope. This piecemeal excisional technique, deemed inadequate by Wheat and Ackerman, is supported by others, v' 15.16 Several studies have examined the effectiveness of the transanal excisional approach for benign, rectal villous adenomas. Nivatvongs et al. 6 reported on 60 patients who underwent transanal excision
883
of rectal villous adenomas, with seven recurrences and two complications. Jahadi and Baldwin 17 reported on 48 patients who underwent transanal excision of rectal villous adenomas, with 14 (29 percent) recurrences, 14 percent of which were malignant. Thomson 1~ reported 100 cases of transanal excision and found a 19 percent recurrence rate, without any malignancies among recurrences, and an 8 percent complication rate. Our experience is similar, with a 27 percent residual rate, 30 percent recurrence rate, 1.7 percent incidence of malignancy among recurrences, and 10 percent complication rate (Table 4). All the residual neoplasms were eventually cleared with repeat excision except in one patient, who continues to undergo transanal excision for benign disease. Although transanal excision of large, rectal villous adenomas results in higher recurrence rates, the advantage of avoiding the high complication rates of posterior proctotomy and transsphincteric approaches is significant. It can also be an alternative to radical resection of very large, rectal villous adenomas in medically compromised patients. Nivatvongs e t a1.15 reported that, if transanal piecemeal excision had been done for their large rectal lesions, 14 percent of patients would not have undergone low anterior or abdominoperineal resection. On the other hand, this higher recurrence rate may be a disadvantage if the patient is unreli-
Table 2. A Review of the Literature on the Kraske Procedure for Excision of Rectal Villous Adenomas Demonstrating a Significant Risk of Morbidity Authors
Recurrence
Fistula
Wound Infection
Hemorrhage
Klingensmith et al. 4 (n = 8) Arnaud et al. ~2 (n = 11) Wilson and Gordon 1 (n = 20)
1 0 0
1 3 4
0 0 2
1 0 2
Total (n = 39)
1 (3%)
8 (21%)
2 (5%)
3 (8%)
Table 3. A Review of the Literature on Transsphincteric Resection of Villous Adenomas Demonstrating a Low Recurrence Rate but Considerable Morbidity Authors
Recurrence
Mason 2 (n = 26) Criado and Wilson la (n = 9) Heij et al. 1~ (n = 6) Thompson and Tucker" (n = 20) Oh and Kark TM (n = 7)
2 0 2 0
Total (n = 68)
4 (6%)
PE = pulmonary embolus.
Colostomy 5 0 2
7 (10%)
Incontinence
Fistula
Infection
0
1 1
1 0
12
7
0
7
1
19 (28%)
10 (15%)
1 (1%)
Other Necrosis Stenosis PE
3 (4%)
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SAKAMOTO E T AL
Dis Colon Rectum, October 1991
Table 4. A Review of the Data Available on Transanal Excision of Rectal Villous Adenomas Including Our Data Authors Thomson TM (n = 100) Nivatvongs et al. 6 (n = 60) Jahadi and Baldwin lr (n = 48) Sakamoto et al. (present study) (n = 117)
Recurrence 19 7 14 35
(19%) (12%) (29%) (30%)
Cancer
Atypia
Complications
0 0 14% 1.7%
N/A 26% N/A 46%
8 (8%) 2 (3%) N/A 10%
Although the recurrence rates are higher than those associated with other approaches, morbidity is considerably less. able or will be unable to s e e k medical attention for e x t e n d e d periods of time. Therefore, patients selected for transanal excision should b e aware that continuous careful surveillance is essential for successful treatment b e c a u s e of the lifelong potential for recurrence. T h o m s o n ~s believes that the high r e c u r r e n c e rate is not due to i n c o m p l e t e resection but to a " . . . particular instability of the m u c o s a . . . " Galandiuk e t al. 5 d e t e r m i n e d the risk of r e c u r r e n c e by examining data from 1,049 patients with rectal villous a d e n o m a s , including 176 that u n d e r w e n t transanal excision. T h e y found, a m o n g other factors, that larger, m o r e dysplastic a d e n o m a s and those excised rather than r e s e c t e d w e r e m o r e likely to recur. Likewise, Nivatvongs e t al. 15 f o u n d that those villous a d e n o m a s with superficial c a r c i n o m a had twice the r e c u r r e n c e rate as those that w e r e totally benign. Although i n c o m p l e t e excision is a potential explanation for recurrence, mucosal instability w o u l d better account for r e c u r r e n c e s years after the initial excision. This is the reason for the distinction b e t w e e n r e s i d u u m ( n e o p l a s m < 6 m o n t h s after resection) and r e c u r r e n c e ( n e o p l a s m > 6 m o n t h s ) in our study. D e v e l o p m e n t of invasive c a r c i n o m a o c c u r r e d in 1.7 p e r c e n t of r e c u r r e n c e s in this study. Both of these patients had villous a d e n o m a s with atypical epithelial changes. Likewise, Nivatvongs e t al. ~5 r e p o r t e d a 4 p e r c e n t incidence of c a r c i n o m a a m o n g recurrences. T h e y also f o u n d that c a r c i n o m a occurred only a m o n g villous a d e n o m a s with superficial carcinoma. F r e q u e n t surveillance is m a n d a t e d in this patient p o p u l a t i o n as the risk is lifelong. In conclusion, transanal excision of large, rectal villous a d e n o m a s can be easily a c c o m p l i s h e d with a low c o m p l i c a t i o n rate (10 p e r c e n t ) and an acceptable recurrence rate (30 p e r c e n t ) while preserving anal sphincter function. Therefore, the transanal excisional a p p r o a c h s h o u l d be conside r e d the initial a p p r o a c h of choice for large, rectal villous adenomas.
ACKNOWLEDGMENT The authors wish to thank Mrs. Pamela Brown for her administrative s u p p o r t t h r o u g h o u t this study. REFERENCES 1. Wilson SE, Gordon HE. Excision of rectal lesions by the Kraske approach. Am J Surg 1969;118:213-7. 2. Mason AY. Trans-sphincteric surgery of the rectum. Prog Surg 1974;13:66-97. 3. Wheat MWJr, Ackerman LV. Villous adenomas of the large intestine. Ann Surg 1958;147:476-87. 4. Muldoon JP, Capehart RJ. Two scope technique for the transrectal removal of lesions high in the rectum and sigmoid colon. Surg Gynecol Obstet 1973;137:1019-22. 5. Galandiuk S, Fazio VW, Jagelman DG, e t al. Villous and tubulovillous adenomas of the colon and rectum: a retrospective review, 1964-1985. Am J Surg 1987;153:41-7. 6. Nivatvongs S, Balcos EG, SchottlerJL, Goldberg SM. Surgical management of large villous tumors of the rectum. Dis Colon Rectum 1973;16:508-14. 7. Hanley PH, Hines MO, Ray JE. Villous tumors: experience with 217 patients. Am Surg 1971;37:190 7. 8. Hagood MF, O'Brien PH. Villous tumors of the rectum: excision by the posterior approach. South Med J 1975;68:184-8. 9. Klingensmith W, Dickinson WE, Hays RS. Posterior resection of selected rectal tumors. Arch Surg 1975;110:647-51. 10. Heij HA, Tan KG, van Houten H. The transsphincteric approach to rectal villous adenomas. Neth J Surg 1982;34:4-7. 11. Thompson BW, Tucker WE. Transsphincteric approach to lesions of the rectum. South Med J 1987;80:41-3. 12. Arnaud JP, Eloy MR, Clendinnen G, Adloff M. The posterior approach for villous tumors of the rectum: report of eleven cases. Am J Surg 1978;136:273-5. 13. Criado FJ, Wilson TH Jr. Posterior transsphincteric approach for surgery of the rectum: the Bevan operation. Dis Colon Rectum 1981;24:145-50. 14. Oh C, Kark AE. The transsphincteric approach to
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