title: Transanal Endoscopic Microsurgery Combined with Laparoscopic Colectomy for Synchronous Colorectal Tumors: A Word of Caution.
abstract: BACKGROUND
  The incidence of malignant synchronous colorectal tumors (SCRT) is between 2% and 5%, and the association of synchronous adenomatous polyps in colon cancer has been reported to be 15%-50%. Surgical resection is the primary treatment option for SCRT not amendable to endoscopic resection. Lesions in adjacent segments are usually treated with more extensive resection; however, there is still some controversy on how to best treat synchronous lesions in separate segments, especially when the rectum is involved. In this study, we aimed to report the outcome of patients with SCRT treated by laparoscopic colectomy combined with Transanal Endoscopic Microsurgery.
  
  
  METHODS
  Data pertaining patients undergoing combined colectomy and Transanal Endoscopic Microsurgery (TEM) between 2004 and 2014 were retrospectively collected.
  
  
  RESULTS
  141 TEM performed in the study period, 9 (6.5%) with combined laparoscopic colectomy were included. Mean age was 69.1 ± 10.6 years. There were 6 (66%) right, 2 (22%) left, and one (11%) sigmoid colectomy. All rectal lesions were benign adenomas, with mean tumor size 2.5 cm, and distance from the verge 9 ± 2.5 cm. Lesions were located in lateral rectal wall in 4, posterior in 4, and anterior in one case. Seven patients had the colectomy before TEM, and 2 had the TEM first. Mean operative time was 245 minutes (range 185-313) for the combined procedures. Median time of hospitalization was 6 days (range 4-11). Six patients (66%) had prolonged postoperative diarrhea. The final rectal pathology reports were adenoma with high-grade dysplasia (HGD) in 5 patients and adenoma with low-grade dysplasia in four cases. The colon pathology was T1 N0 in 3, T2 N0 in one, T3 N1 in one, adenoma with HGD in 2, and no residual tumor in 2 patients. Two patients underwent re-TEM for recurrent adenoma of rectum at 14 and 18 months postoperatively.
  
  
  CONCLUSIONS
  The combination of TEM with laparoscopic colectomy is feasible and should be kept in mind as an alternative procedure in case of SCRT. However, more strict selection criteria should be considered and the disadvantages should be discussed with the patient.
authors.affiliation: 1 Department of Surgery, Hasharon Hospital, Rabin Medical Center , Petach Tikva, Israel .|2 The Sackler School of Medicine, Tel-Aviv University , Tel Aviv, Israel .
authors.forename: Nida
authors.initials: N
authors.lastname: Issa
authors.affiliation: 3 Department of Surgery, Monmouth Medical Center , Long Branch, New Jersey.
authors.forename: Yaniv
authors.initials: Y
authors.lastname: Fenig
authors.affiliation: 1 Department of Surgery, Hasharon Hospital, Rabin Medical Center , Petach Tikva, Israel .|2 The Sackler School of Medicine, Tel-Aviv University , Tel Aviv, Israel .
authors.forename: Muhammad
authors.initials: M
authors.lastname: Khatib
authors.affiliation: 1 Department of Surgery, Hasharon Hospital, Rabin Medical Center , Petach Tikva, Israel .|2 The Sackler School of Medicine, Tel-Aviv University , Tel Aviv, Israel .
authors.forename: Mustafa
authors.initials: M
authors.lastname: Yasin
authors.affiliation: 1 Department of Surgery, Hasharon Hospital, Rabin Medical Center , Petach Tikva, Israel .|2 The Sackler School of Medicine, Tel-Aviv University , Tel Aviv, Israel .
authors.forename: Eldad
authors.initials: E
authors.lastname: Powsner
authors.affiliation: 4 Department of Surgery, Rambam Health Care Campus , Haifa, Israel .
authors.forename: Wisam
authors.initials: W
authors.lastname: Khoury
mesh_terms: D000236:Adenoma / Q000473:pathology / Q000601:surgery*; D000368:Aged; D003082:Colectomy / Q000009:adverse effects*; D015179:Colorectal Neoplasms / Q000473:pathology / Q000601:surgery*; D003967:Diarrhea / Q000209:etiology; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects*; D008297:Male; D009378:Neoplasms, Multiple Primary / Q000473:pathology / Q000601:surgery*; D061646:Operative Time; D011183:Postoperative Complications / Q000209:etiology; D012189:Retrospective Studies; D000067369:Transanal Endoscopic Microsurgery / Q000009:adverse effects*; D016896:Treatment Outcome
keywords: laparoscopic colectomy; synchronous colorectal tumors; transanal endoscopic microsurgery