title: Anorectal functional outcome after repeated transanal endoscopic microsurgery.
abstract: OBJECTIVE
  To evaluate the status of anorectal function after repeated transanal endoscopic microsurgery (TEM).
  
  
  METHODS
  Twenty-one patients undergoing subtotal colectomy with ileorectal anastomosis were included. There were more than 5 large (> 1 cm) polyps in the remaining rectum (range: 6-20 cm from the anal edge). All patients, 19 with villous adenomas and 2 with low-grade adenocarcinomas, underwent TEM with submucosal endoscopic excision at least twice between 2005 and 2011. Anorectal manometry and a questionnaire about incontinence were carried out at week 1 before operation, and at weeks 2 and 3 and 6 mo after the last operation. Anal resting pressure, maximum squeeze pressure, maximum tolerable volume (MTV) and rectoanal inhibitory reflexes (RAIR) were recorded. The integrity and thickness of the internal anal sphincter (IAS) and external anal sphincter (EAS) were also evaluated by endoanal ultrasonography. We determined the physical and mental health status with SF-36 score to assess the effect of multiple TEM on patient quality of life (QoL).
  
  
  RESULTS
  All patients answered the questionnaire. Apart from negative RAIR in 4 patients, all of the anorectal manometric values in the 21 patients were normal before operation. Mean anal resting pressure decreased from 38 ± 5 mmHg to 19 ± 3 mmHg (38 ± 5 mmHg vs 19 ± 3 mmHg, P = 0.000) and MTV from 165 ± 19 mL to 60 ± 11 mL (165 ± 19 mL vs 60 ± 11 mL, P = 0.000) at month 3 after surgery. Anal resting pressure and MTV were 37 ± 5 mmHg (38 ± 5 mmHg vs 37 ± 5 mmHg, P = 0.057) and 159 ± 19 mL (165 ± 19 mL vs 159 ± 19 mL, P = 0.071), respectively, at month 6 after TEM. Maximal squeeze pressure decreased from 171 ± 19 mmHg to 62 ± 12 mmHg (171 ± 19 mmHg vs 62 ± 12 mmHg, P = 0.000) at week 2 after operation, and returned to normal values by postoperative month 3 (171 ± 19 vs 166 ± 18, P = 0.051). RAIR were absent in 4 patients preoperatively and in 12 (χ(2) = 4.947, P = 0.026) patients at month 3 after surgery. RAIR was absent only in 5 patients at postoperative month 6 (χ(2) = 0.141, P = 0.707). Endosonography demonstrated that IAS disruption occurred in 8 patients, and 6 patients had temporary incontinence to flatus that was normalized by postoperative month 3. IAS thickness decreased from 1.9 ± 0.6 mm preoperatively to 1.3 ± 0.4 mm (1.9 ± 0.6 mm vs 1.3 ± 0.4 mm, P = 0.000) at postoperative month 3 and increased to 1.8 ± 0.5 mm (1.9 ± 0.6 mm vs 1.8 ± 0.5 mm, P = 0.239) at postoperative month 6. EAS thickness decreased from 3.7 ± 0.6 mm preoperatively to 3.5 ± 0.3 mm (3.7 ± 0.6 mm vs 3.5 ± 0.3 mm, P = 0.510) at month 3 and then increased to 3.6 ± 0.4 mm (3.7 ± 0.6 mm vs 3.6 ± 0.4 mm, P = 0.123) at month 6 after operation. Most patients had frequent stools per day and relatively high Wexner scores in a short time period. While actual fecal incontinence was exceptional, episodes of soiling were reported by 3 patients. With regard to the QoL, the physical and mental health status scores (SF-36) were 56.1 and 46.2 (50 in the general population), respectively.
  
  
  CONCLUSIONS
  The anorectal function after repeated TEM is preserved. Multiple TEM procedures are useful for resection of multi-polyps in the remaining rectum.
authors.affiliation: Department of General Surgery, the Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai 200233, China.
authors.forename: Hong-Wei
authors.initials: HW
authors.lastname: Zhang
authors.forename: Xiao-Dong
authors.initials: XD
authors.lastname: Han
authors.forename: Yu
authors.initials: Y
authors.lastname: Wang
authors.forename: Pin
authors.initials: P
authors.lastname: Zhang
authors.forename: Zhi-Ming
authors.initials: ZM
authors.lastname: Jin
mesh_terms: D000230:Adenocarcinoma / Q000473:pathology / Q000601:surgery*; D018253:Adenoma, Villous / Q000473:pathology / Q000601:surgery*; D000368:Aged; D000369:Aged, 80 and over; D001003:Anal Canal / Q000503:physiopathology / Q000601:surgery*; D000714:Anastomosis, Surgical; D001005:Anus Neoplasms / Q000473:pathology / Q000601:surgery*; D016009:Chi-Square Distribution; D003082:Colectomy; D016099:Endoscopy, Gastrointestinal / Q000009:adverse effects / Q000379:methods*; D005242:Fecal Incontinence / Q000209:etiology / Q000503:physiopathology; D005260:Female; D005414:Flatulence / Q000209:etiology / Q000503:physiopathology; D006801:Humans; D007417:Intestinal Polyps / Q000473:pathology / Q000601:surgery*; D008297:Male; D008365:Manometry; D008866:Microsurgery / Q000009:adverse effects / Q000379:methods*; D008875:Middle Aged; D011312:Pressure; D011788:Quality of Life; D020127:Recovery of Function; D012004:Rectal Neoplasms / Q000473:pathology / Q000601:surgery*; D012086:Reoperation; D011795:Surveys and Questionnaires; D013997:Time Factors; D016896:Treatment Outcome