title: Pushing the limits of local excision for rectal cancer: transanal minimally invasive surgery for an upper rectal/rectosigmoid lesion.
abstract: BACKGROUND
  Transanal minimally invasive surgery (TAMIS) is an evolving technique for the local excision of early rectal cancers,1 particularly for mid-rectal lesions. The approach to upper rectal lesions is significantly more challenging and prone to complications. We demonstrate TAMIS for an upper rectal/rectosigmoid lesion, with transanal repair of an intraoperative rectal/rectosigmoid perforation.
  
  
  METHODS
  The patient is an elderly male in whom colonoscopy demonstrated a large polypoid lesion of the upper rectum/rectosigmoid colon. On rigid proctoscopy, the lesion was 4 cm in size and occupied 40 % of the rectal circumference, with distal extent at 14 cm from the anal verge. Endoscopic ultrasound was consistent with TisN0 disease. Multiple attempts at endoscopic mucosal resection were unsuccessful and the patient refused radical resection. The patient underwent TAMIS with a disposable transanal access port, using our previously published stepwise technique.2 RESULTS: The patient successfully underwent TAMIS. Intraoperatively, a small full-thickness perforation was created proximal to the excision site and was primarily repaired. A stepwise approach to excision and repair is described. Postoperatively, the patient had low-grade fevers for which he was treated empirically with antibiotics. The fevers resolved without further intervention. Pathologic examination revealed a 3.5 cm villous adenoma with focal high-grade dysplasia, negative margins, and two negative lymph nodes. On outpatient follow-up, the patient was symptom-free and had no fevers, pain, bleeding, fecal incontinence, or genitourinary functional deficits. He is disease-free 10 months from his procedure.
  
  
  CONCLUSIONS
  TAMIS of upper rectal lesions is technically challenging, but can be accomplished safely in well-selected patients.
authors.affiliation: Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.
authors.forename: Qaali
authors.initials: Q
authors.lastname: Hussein
authors.forename: Avo
authors.initials: A
authors.lastname: Artinyan
mesh_terms: D000368:Aged; D001003:Anal Canal / Q000473:pathology / Q000601:surgery*; D003113:Colonoscopy; D006801:Humans; D008297:Male; D019060:Minimally Invasive Surgical Procedures; D011183:Postoperative Complications; D011351:Proctoscopy; D011379:Prognosis; D012004:Rectal Neoplasms / Q000473:pathology / Q000601:surgery*