title: Transanal endoscopic microsurgery with entrance into the peritoneal cavity: is it safe?
abstract: BACKGROUND
  Relative contraindications for transanal endoscopic microsurgery include high, anterior-based lesions for full-thickness excisions because of worries about entering the peritoneal cavity. Concerns exist regarding safety and oncological outcome.
  
  
  OBJECTIVE
  We examined the outcomes of transanal endoscopic microsurgery excisions with entry into the peritoneal cavity and compared them with those that did not to address our hypothesis that entry is safe with no ill infectious or oncological consequences.
  
  
  METHODS
  This single-institution retrospective review uses a prospectively maintained database.
  
  
  METHODS
  This study was conducted at a tertiary colorectal surgery referral center.
  
  
  METHODS
  From 1997 to 2012, we identified 303 patients who underwent transanal endoscopic microsurgery resections, with 26 patients having entrance into the peritoneal cavity.
  
  
  METHODS
  Perioperative data, postoperative morbidities, delayed morbidities, and oncological outcomes were the primary outcomes measured.
  
  
  RESULTS
  Of 26 patients, there were 8 women with a mean age of 67.5 years. Mean BMI was 31 kg/m, and ASA class was III or IV in 69%. Mean superior border of the lesion was 10.4 cm (4.5-16). Forty-eight percent had anterior-based lesions. Anterior location, level from anorectal ring, and diagnosis of cancer were significantly higher in the peritoneal entry group (p = 0.003, p = 0.007, and p = 0.007). Preoperative diagnoses included 16 adenocarcinomas, 8 polyps, and 2 carcinoid tumors. Thirteen patients had preoperative chemoradiation. Median estimated blood loss was 15 mL (5-400), and 3 patients underwent diversions. Median time to discharge was 3 days (2-10). There were no perioperative mortalities. Median follow-up time was 21.0 months. There was 1 local recurrence (3.8%), and there was no development of carcinomatosis.
  
  
  CONCLUSIONS
  This review was limited by its retrospective nature.
  
  
  CONCLUSIONS
  High anterior location rectal lesions should be considered candidates for transanal endoscopic microsurgery excision in experienced hands. After obtaining considerable transanal endoscopic microsurgery experience, our use of transanal endoscopic microsurgery in a high-risk patient population allowed us to definitively treat 88% of patients without an abdominal operation and the need for a temporary or permanent colostomy. Theoretic concerns of abscess or carcinomatosis were not experienced (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A154).
authors.affiliation: Lankenau Medical Center, Wynnewood, Pennsylvania.
authors.forename: John H
authors.initials: JH
authors.lastname: Marks
authors.forename: Joseph L
authors.initials: JL
authors.lastname: Frenkel
authors.forename: Christopher E
authors.initials: CE
authors.lastname: Greenleaf
authors.forename: Anthony P
authors.initials: AP
authors.lastname: D'Andrea
mesh_terms: D000230:Adenocarcinoma / Q000601:surgery* / Q000628:therapy; D000368:Aged; D000369:Aged, 80 and over; D001003:Anal Canal; D000964:Antimetabolites, Antineoplastic / Q000627:therapeutic use; D016063:Blood Loss, Surgical; D002276:Carcinoid Tumor / Q000601:surgery* / Q000628:therapy; D059186:Chemoradiotherapy, Adjuvant; D016099:Endoscopy, Gastrointestinal / Q000009:adverse effects / Q000379:methods*; D005260:Female; D005472:Fluorouracil / Q000627:therapeutic use; D006801:Humans; D007417:Intestinal Polyps / Q000601:surgery; D007902:Length of Stay; D008297:Male; D008866:Microsurgery / Q000009:adverse effects / Q000379:methods*; D008875:Middle Aged; D057605:Natural Orifice Endoscopic Surgery / Q000009:adverse effects; D061646:Operative Time; D010529:Peritoneal Cavity / Q000601:surgery*; D012004:Rectal Neoplasms / Q000601:surgery* / Q000628:therapy; D012189:Retrospective Studies
chemical_list: D000964:Antimetabolites, Antineoplastic; D005472:Fluorouracil