S. Maslekar

Cost analysis of transanal endoscopic microsurgery for rectal tumours

Objective  Transanal endoscopic microsurgery (TEM) is considered to be a safe and effective treatment for selected rectal neoplasms. We demonstrate that in addition to the recognized clinical benefits of the less invasive TEM approach, there are substantial economic benefits.

Transanal endoscopic microsurgery for carcinoma of the rectum

BackgroundThe authors present their experience with rectal cancers managed by transanal endoscopic microsurgery (TEM).MethodsThis prospective study investigated patients undergoing primary TEM excision for definitive treatment of rectal cancer between January 1996 and December 2003 by a single surgeon in a tertiary referral colorectal surgical unit.ResultsFor this study, 52 patients (30 men and 22 women) underwent TEM excision of a rectal cancer. Their mean age was 74.3 years (range, 48–93 years). The median diameter of the lesions was 3.44 cm (range, 1.6–8.5 cm). The median distance of the lesions from the anal verge was 8.8 cm (range, 3–15 cm), with the tumor more than 10 cm from the anal verge in 36 patients. The median operating time was 90 min (range, 20–150 min), and the median postoperative stay was 2 days. All patients underwent full-thickness excisions. There were 11 minor complications, 2 major complications, and no deaths. The mean follow-up period was 40 months (range, 22–82 months). None of the pT1 rectal cancers received adjuvant therapy. Eight patients with pT2 rectal cancer and two patients with pT3 rectal cancer received postoperative adjuvant therapy. The overall local rate of recurrence was 14%, and involved cases of T2 and T3 lesions, with no recurrence after excision of T1 cancers. Three patients died during the follow-up period, but no cancer-specific deaths occurred.ConclusionsThe findings warrant the conclusion that TEM is a safe, effective treatment for selected cases of rectal cancer, with low morbidity and no mortality. The TEM procedure broadens the range of lesions suitable for local resection to include early cancers (pTis and pT1) and more advanced cancers only in frail people.

Transanal endoscopic microsurgery in early rectal cancer: time for a trial?

Objective  The optimal aim of oncological surgery is to balance cancer outcomes with preservation of function and quality of life. Radical resection (RR) offers the best curative procedure in colorectal cancer but at significant morbidity. Transanal endoscopic microsurgery (TEM) offers an alternative with less morbidity and better function. Its role remains unclear and needs to be established in the light of new emerging trends in rectal cancer. This review aims to evaluate the use of TEM and its limitations.

Transanal Endoscopic Microsurgery: Where Are We Now?

Aims: This review of literature aimed to assess the role and establish the current status of transanal endoscopic microsurgery (TEM) in the management of benign and malignant rectal lesions. Methods: Areview of the literature was undertaken through the Medline database and by cross-referencing previous publications, thus identifying 54 relevant publications on TEM in the management of rectal lesions. Aggregated results of various parameters were calculated but statistical comparisons deemed unsuitable due to heterogeneity of data. Results: The TEM procedure is associated with good functional results, morbidity of 4% and zero procedure-related mortality. The local recurrence rates after TEM excision is 4.5% (range 0–14) for benign rectal lesions, 6% (0–13) for T1 cancers, 14% (range 0–50) for T2 cancers and 20% (range 14–67%) for T3 cancers. Local recurrences after TEM can be surgically salvaged with good disease free survival rates. Conclusions: The TEM procedure clearly offers the benefits of good exposure of the operative field allowing extremely precise dissection and access to high rectal lesions unresectable by other methods. For pTis and low risk pT1 lesions, the oncological results are comparable to the more traditional formal resection. The routine use of TEM for high-risk pT1 and higher stage lesions is not an oncologically sound choice at the present moment.

Randomized clinical trial of Entonox®versus midazolam–fentanyl sedation for colonoscopy†

Intravenous sedation for colonoscopy is associated with cardiorespiratory complications and delayed recovery. The aim of this randomized clinical trial was to compare the efficacy of Entonox® (50 per cent nitrous oxide and 50 per cent oxygen) and intravenous sedation using midazolam–fentanyl for colonoscopy.

Patient satisfaction with lower gastrointestinal endoscopy: doctors, nurse and nonmedical endoscopists

Aim  Assessment of patient satisfaction with lower gastrointestinal endoscopy (LGE) comprising colonoscopy and flexible sigmoidoscopy is gaining increasing importance. We have now trained non healthcare professionals such as nonmedical endoscopists (NMEs) to perform LGE to overcome shortage of trained endoscopists. The aim of this study was to prospectively determine patient satisfaction, factors affecting satisfaction with LGE and to compare with nurses, NME and medical endoscopists, in terms of patient satisfaction.

Randomized controlled trial of patient-controlled sedation for colonoscopy: Entonox vs modified patient-maintained target-controlled propofol

Aim  Propofol sedation is often associated with deep sedation and decreased manoeuvrability. Patient‐maintained sedation has been used in such patients with minimal side‐effects. We aimed to compare novel modified patient‐maintained target‐controlled infusion (TCI) of propofol with patient‐controlled Entonox inhalation for colonoscopy in terms of analgesic efficacy (primary outcome), depth of sedation, manoeuvrability and patient and endoscopist satisfaction (secondary outcomes).

Artificial neural networks to predict presence of significant pathology in patients presenting to routine colorectal clinics.

Aim  Artificial neural networks (ANNs) are computer programs used to identify complex relations within data. Routine predictions of presence of colorectal pathology based on population statistics have little meaning for individual patient. This results in large number of unnecessary lower gastrointestinal endoscopies (LGEs – colonoscopies and flexible sigmoidoscopies). We aimed to develop a neural network algorithm that can accurately predict presence of significant pathology in patients attending routine outpatient clinics for gastrointestinal symptoms.

Quality assurance in colonoscopy: role of endomucosal clips

Objective  Quality assurance in colonoscopy is important, and subjective assessment of completion based on endoscopic signs can be inaccurate leading to missed lesions. We aimed to determine the technique of endomucosal clips with follow‐up X‐rays in objectively documenting completion and correlation with pathology miss rates.