title: Is there a limit to transanal endoscopic surgery? A comparative study between standard and technically challenging indications among 168 consecutive patients.
abstract: OBJECTIVE
  To assess the surgical outcome of transanal endoscopic surgery (TES) for rectal neoplasms in technically challenging indications.
  
  
  METHODS
  All patients who underwent TES for a rectal neoplasm from 2007 to 2014 were included. Technically challenging indications included a tumour with (i) diameter ≥ 5 cm, (ii) involving ≥ 50% of the rectal circumference and (iii) located ≥ 10 cm from the anal verge. Patients were divided into three groups according to how many of these features they had, as follows: Group 1, none; Group 2, one; Group 3, two or more.
  
  
  RESULTS
  Of the 168 patients (80 benign and 88 malignant tumours) included in the study, 73 (44%) were in Group 1, 46 (27%) in Group 2 and 49 (29%) in Group 3. There was no difference between Group 1 and Group 2 with regard to peritoneal perforation (P = 0.210), severe postoperative morbidity (P = 0.804), length of hospital stay (P = 0.444), incomplete resection (P = 0.441), piecemeal resection (P = 0.740), locoregional recurrence (P = 0.307) and long-term symptomatic rectal stenosis (P = 0.076). Conversely Group 3 showed significantly impaired results compared with Group 1 with regard to peritoneal perforation (P = 0.003), piecemeal resection (P = 0.005), incomplete resection (P = 0.025), locoregional recurrence (P = 0.035) and long-term symptomatic rectal stenosis (P < 0.001), but no difference in severe postoperative morbidity (P = 0.328).
  
  
  CONCLUSIONS
  Transanal endoscopic surgery for rectal neoplasms appears to be safe and effective, even in patients presenting with a technically challenging tumours. Although the short- and long-term outcomes after TES are worse in patients with highly challenging tumours, nevertheless the technique should still be considered in patients at high risk of requiring a proctectomy.
authors.affiliation: Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif, Beaujon Hospital, University Denis Diderot (Paris VII), Clichy, France.
authors.forename: A
authors.initials: A
authors.lastname: Saget
authors.affiliation: Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif, Beaujon Hospital, University Denis Diderot (Paris VII), Clichy, France.
authors.forename: L
authors.initials: L
authors.lastname: Maggiori
authors.forename: N
authors.initials: N
authors.lastname: Petrucciani
authors.affiliation: Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif, Beaujon Hospital, University Denis Diderot (Paris VII), Clichy, France.
authors.forename: N
authors.initials: N
authors.lastname: Petruciani
authors.affiliation: Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif, Beaujon Hospital, University Denis Diderot (Paris VII), Clichy, France.
authors.forename: M
authors.initials: M
authors.lastname: Ferron
authors.affiliation: Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif, Beaujon Hospital, University Denis Diderot (Paris VII), Clichy, France.
authors.forename: Y
authors.initials: Y
authors.lastname: Panis
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003251:Constriction, Pathologic; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local; D010537:Peritoneum / Q000293:injuries; D012004:Rectal Neoplasms / Q000473:pathology / Q000601:surgery*; D012007:Rectum / Q000473:pathology / Q000601:surgery; D012189:Retrospective Studies; D000067368:Transanal Endoscopic Surgery / Q000009:adverse effects / Q000379:methods*; D016896:Treatment Outcome; D047368:Tumor Burden
keywords: Transanal endoscopic surgery; local recurrence; oncological results; peritoneal perforation; piecemeal; rectal tumour