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Background and Objectives: To analyze the Kraske procedure as an approach to mid-rectal disease., Methods: Twenty-two patients underwent a Kraske procedure at either Duke University Medical Center, the Durham Veterans Administration Medical Center, or the Durham Regional Hospital between 1992 and 1997. The clinical and pathologic characteristics of these patients were retrospectively analyzed and compared with previous published series., Results: Of the 22 patients, 13 underwent resection of an adenocarcinoma and 9 underwent resection of a villous adenoma. Post-operative complications included four fecal fistulas (two of which required a temporary diverting colostomy), two wound infections, two cases of urinary retention, and one case of transient fecal incontinence., Conclusions: The Kraske procedure minimizes exposure of mid-rectal lesions without the morbidity of a major laparotomy. However, it does carry a moderate complication rate and thus should be utilized selectively in managing patients with mid-rectal tumors not amenable to other treatment options., (2006 Wiley-Liss, Inc.)

We present a case of a rare small bowel tumor. A 73-year-old female patient presented at our department with vague abdominal pain. Ultrasound examination discovered an inhomogeneous vascularised mass originating from a small bowel loop, mesenteric enlarged lymph nodes and a nodule in the liver. Multislice Computed Tomography of the abdomen confirmed the ultrasonographic findings and found omental implants together with a left-sided ovarian mass. Surgery was performed. Pathology revealed a rare ileal collision tumor consisting of an adenocarcinoma and a small cell neuroendocrine tumor with peritoneal metastasis of neuroendocrine origin and coincidental benign lesions on both ovaries.

Aims: Pseudomyxoma peritonei may have as its primary site a mucinous gastrointestinal adenoma or carcinoma that gains access to the peritoneal cavity. This manuscript describes this disease arising from a benign or malignant colonic polyp., Methods: From a database of over 1000 pseudomyxoma peritonei patients and colorectal carcinomatosis patients, three cases were identified in which the primary tumor site was a colonic polyp. The clinical history and course of these patients were studied., Results: In a review of the clinical management of these patients, all three had an event whereby neoplastic cells from the surface of the colonic polyp could have gained access to the free peritoneal cavity. The patients developed the characteristic pseudomyxoma peritonei syndrome. All three patients were treated with cytoreductive surgery plus perioperative hyperthermic intraperitoneal chemotherapy., Conclusions: Colonic polyps can serve as a source of dysplastic cells whereby pseudomyxoma peritonei can result. Caution to prevent seeding to the free peritoneal cavity during surgery for colonic polyps should be observed. If pseudomyxoma peritonei develops, cytoreductive surgery and perioperative intraperitoneal chemotherapy should be considered for treatment.

A case of tubulovillous adenoma arising in an augmented bladder is described. Ureteroileal substitution and ileocystoplasty was performed when the patient was 18 years old. She noticed gross hematuria 44 years after the surgery. Cystoscopy revealed a non-papillary multiple tumor at the site of ileovesical anastomosis and transurethral resection biopsy was performed. Histopathological examination revealed a tubulovillous adenoma. A tubulovillous adenoma developing at the augmented bladder is rare. To our knowledge, this is the second case in which a tubulovillous adenoma developed in an augmented bladder.

Introduction: transanal endoscopic microsurgery (TEM) was developed in 1983 by Büess as a minimally invasive technique to manage rectal villous adenomas and early rectal adenocarcinomas. Many studies have been published worldwide about its excellent results in morbidity and recidive rate, but there are few studies addressing functional results. The objective of this study is to analyze the effect of this technique in the anal anatomy and compare with the manometric results., Material and Methods: we devised a prospective study of 40 patients. 39% female, 61% male. All of them filled an incontinence questionnaire (Pescatori scale) and endoanal ultrasonography and manometry was carried out preoperatively, third month postoperative and at sixth month only if incontinence appeared., Results: 32 patients (80%) had villous adenomas and 8 patients (20%) had adenocarcinomas (uT1). Three patients complained of flatus incontinence at 3rd postoperative month that disappeared with normal continence at 6th month. Anorectal manometric values: mean anal resting pressure (ARP) decreased at 3rd month (from 87.2 mmHg to 70.1 mmHg), as it was for maximal squeeze pressure (MSP) from 152.5 mmHg preoperatively to 142.2 mmHg at 3rd month. Ultrasonography demonstrated internal anal sphincter (IAS) rupture in 3 patients, with a full integrity of the external anal sphincter in all patients., Conclusions: during TEM, a significant anal dilatation occurs, because of rectoscopy (40 mm wide), what can produce a rupture of IAS, with the consequent decreasing in ARP, and a dilatation without rupture of external sphincter what produces a decreasing of MSP. The fall of anal pressures had minima clinical repercussion when sphincter is intact, but when IAS is broken a temporal incontinence develops.

Purpose: Intersphincteric resection of low rectal tumors is a surgical technique extending rectal resection into the intersphincteric space. This procedure is performed by a synchronous abdominoperineal approach with mesorectal excision and excision of the entire or part of the internal sphincter. This study was designed to evaluate the long-term results of this method focused on continence function and oncologic results., Methods: From 1984 to 2000, a total of 121 patients were operated on. The patients were evaluated prospectively according to a detailed preoperative and postoperative program., Results: One hundred seventeen patients had rectal cancers, two had dysplastic villous adenomas, and two had carcinoid tumors. Cancers were staged according to the Dukes classification (Stage A in 41 percent, Stage B in 28 percent, and Stage C in 31 percent; median distance from the anal margin, 3 (range, 1-5) cm). Postoperative complications were: one death because of pulmonary embolism, 5.1 percent developed an anastomotic fistula, one patient had a fistula to the bladder requiring reoperation, one patient with ileus needed relaparotomy as well as one for intra-abdominal hemorrhage and a small-bowel fistula. One patient developed a fistula after closing the protective colostomy. Five patients developed late strictures of the coloanal anastomosis. After a median follow-up of 72.86 months, 5.3 percent of patients developed local recurrence. The continence status was satisfactory with 16 patients (13.7 percent) showing continence for solid stool only, and 1 patient (0.8 percent) showing episodes of incontinence. A transient problem was a high stool frequency after closure of the protective stoma., Conclusions: Intersphincteric resection is a valuable procedure for sphincter-saving rectal surgery. We showed that this technique has satisfactory long-term results in functional and oncologic respects. An important prerequisite is a careful preoperative evaluation of local tumor spread with rectal magnetic resonance imaging excluding infiltration of the external sphincter.

Background: Epithelial tumors of the papilla of Vater are rare neoplasms of the gastrointestinal tract. The carcinogenesis of these tumors seems to be fairly analogous to the genetic mechanisms which have been described for colorectal carcinoma. Patients with familial adenomatous polyposis bear a particularly increased risk for periampullary tumors. Data on whether the prevalence of colorectal tumors is increased in patients with sporadic ampullary neoplasms are scarce., Methods: 26 consecutive patients (16 women, 10 men; median age 59 years) with sporadic adenomas (n = 19) or adenocarcinomas (n = 7) of the ampulla of Vater were retrospectively evaluated. The study patients were compared with 104 age-matched asymptomatic controls. All patients had undergone total colonoscopy., Results: Neoplastic colorectal polyps were present in a similar proportion (23%) of patients of the study group compared with 26% in the control group (p > 0.05). Overall, 16 polyps were found among patients with ampullary tumors and 40 in asymptomatic controls (p > 0.05). Colonoscopy detected rectal carcinoma in 2 patients (8%) of the study group. Patients with and without colorectal polyps differed neither significantly by age nor by ampullary histological findings. 50% of the colonic polyps in patients with ampullary neoplasms were located in the ascending colon., Conclusions: The frequency of colorectal polyps in patients with ampullary tumors did not exceed the risk in the control group. However, the finding of 2 rectal carcinomas among patients with ampullary neoplasms supports the place of screening colonoscopy for the diagnostic work-up of ampullary tumors. Prospective multicenter studies should address this issue to provide a broad basis for future recommendations.

Villous adenomas of the duodenum (VAD) are infrequent lesions of the gastrointestinal tract but have a high risk of recurrence and malignancy. For these reasons and its specific topographic location, the surgical treatment of VAD is still controversial. Herein we present a case of large VAD located in the second duodenal portion that was successfully treated with a head of the pancreas, pylorus-preserving total duodenectomy (PPTD). PPTD should be an excellent option in patients with large adenomas because it allows preservation of the pancreas, gastrointestinal function is maintained, the possibility of a recurrence and of an invasive carcinoma of the ampulla is eliminated, and finally because it permits an adequate endoscopic follow-up. PPTD should not be used in the presence of malignancy and/or high-grade dysplasia.

Most colonic polyps are asymptomatic and the incidence rises during sixth and seventh decades. Symptoms and signs may vary with histological types and location. Clinical features include fresh rectal bleeding, mucoid diarrhea and prolapsus of stalked rectal polyps located near distal segment. Here we discuss a case with a rare clinical presentation, who had sessile malign villous adenoma located in the descending colon, which caused colocolic intussusception and prolapsed through the anus.

Introduction: Endoscopic mucosal resection is a safe resection tool for selected flat, sessile and lateral spreading tumours of the colon. Transanal microsurgical resection of select rectal neoplastic lesions is another accepted modality. Recent data suggests transanal microsurgery may have high complication rates. We conducted a prospective clinicopathological evaluation of an extended endoscopic mucosal resection technique for highly selected lesions of the rectum and assessed outcome data over a maximal 24-month period., Patients and Methods: Eighty-three patients with known rectal neoplastic lesions underwent chromoscopic colonoscopy and on-table staging using a high-frequency (12.5 MHz) mini-probe EUS by a single endoscopist. Patients with T2 or node positive disease were referred for surgery. Following extended endoscopic mucosal resection patients were followed-up at 3, 6, 12 and 24 months post 'index' resection with chromoscopic endoscopy and EUS. Procedural complications, recurrence rates and outcome data were collected., Results: Sixty-two patients fulfilled inclusion criteria. Median procedure time was 48 mins (range 32-126). Lateral spreading tumours (median diameter 30 mm; range 18-42 mm) and sessile lesions (median diameter 38 mm; range 25-86 mm) accounted for 19% and 81% of lesions, respectively. Ninety-seven percent of patients undergoing EMR were discharged within 6-h of procedure. Thirty-day re-admission and death rate was 0%. Bleeding complications occurred in 5/62 (8%) of patients with all achieving complete haemostasis using endo clips. None required transfusion. There were no procedural related complications or perforations. Overall 'cure' rate at a median follow-up of 16 months was 98%., Conclusions: Extended endoscopic mucosal resection for rectal neoplastic lesions can achieve superior results to those of per-anal excision and trans-anal microsurgery with regard to complications and recurrence rates. Extended endoscopic mucosal resection may be an alternative therapeutic modality in selected patients.

We describe a successful simultaneous laparoscopic treatment of a gallstone and gastric and colonic neoplasms. The patient was a 72-year-old man with epigastric discomfort. Abdominal ultrasound revealed a gallstone 2 cm in diameter. Gastroscopy revealed a 3-cm protruding submucosal tumor in the gastric fundus and colonoscopy revealed a 2-cm sessile lesion in the sigmoid colon. He underwent simultaneous laparoscopic treatment of the 3 organs because of the high risk of perforation or bleeding after gastric or colonic resection. This required the use of 5 ports, and a 3.5-cm incision was made in the left lower quadrant to access the 3 organs. The laparoscopic procedures consisted of cholecystectomy, partial stapled resection of the gastric fundus, and partial resection of the sigmoid colon. The histopathologic diagnoses were chronic cholecystitis, leiomyoma of the stomach, and tubulovillous adenoma with severe dysplasia of the colon. The operation took 183 minutes and blood loss was minimal. The patient started oral intake from the second postoperative day and was discharged uneventfully. He had from no postoperative complications or abdominal symptoms during a 15-month follow-up period. To our knowledge, this is a first successful clinical report of simultaneous laparoscopic treatment of 3 organ disorders.

Patient and Methods: A 68-year-old woman presenting with bloody stools and anemia was referred to our hospital. Colonoscopy showed a Is-type tumor of 45 mm in diameter in the cecum and three Is-type tumors in the ascending colon. Ileocecal resection with regional lymph node dissection was performed. Microscopically, the large tumor consisted of a well-differentiated adenocarcinoma with a tubulovillous adenoma (TVA) component (carcinoma in adenoma). Some carcinoma (CA) cells had invaded the submucosal layer, but the lymph nodes were negative for malignancy. The other three polyps were diagnosed as TVAs. Because her family history fulfilled the Amsterdam criteria II for hereditary non-polyposis colorectal cancer (HNPCC), genetic analysis was performed. All of the four tumor tissues were classified as microsatellite stable (MSS) according to the National Cancer Institute guideline for analysis of microsatellite instability (MSI). K-ras mutation was detected in both CA and TVA lesions of the carcinoma in adenoma. To clarify relevant alterations of gene expression associated with adenoma-carcinoma progression, the gene expression profiles of these tumor tissues were analyzed by a cDNA array., Results: Although the gene expression profiles were similar, insulin-like growth factor-II (IGF-II) was expressed most differentially in CA and TVA tissues. The results were further substantiated by comparison of the gene expression profiles of CA and TVA lesions of the carcinoma in adenoma., Conclusion: The results suggest that overexpression of IGF-II played an important role in the progression of adenoma to carcinoma in this patient.

Background: Functional outcome after sphincter-saving operations can be improved by colonic pouch compared to the straight procedure. However, it is not clear whether the colonic pouch has a different behavior in patients treated by low anterior resection with colorectal (LAR) or coloanal anastomosis (CAA)., Methods: We evaluated the 1-year results of 75 patients who underwent a sphincter-saving operation for rectal carcinoma or villous tumor of the middle or lower third of the rectum: 18 patients underwent coloanal anastomosis (CAA), in 13 patients we performed a coloanal anastomosis with a colonic pouch (PCAA), 20 patients had low anterior resection (LAR) and 24 had LAR with pouch construction (PLAR). The two groups of patients were similar in terms of age and gender. Anorectal function was assessed 12 months after the initial operation by an interview and anorectal manometry., Results: One year after surgery, the daily mean number of defecations was significantly higher in the LAR group than in the other groups (2.0+/-1.5 in CAA group, 2.2+/-1.0 in PCAA, 2.3+/-1.8 in PLAR, 4.1+/-0.7 in LAR; p<0.05). Frequent soiling was observed in all the groups except PLAR. A lower degree of incontinence and a lower frequency of urgency were found in PCAA than in CAA. There were no differences in anal resting pressure and squeeze pressure among the various groups. Greater distensibility and compliance of the neorectum were observed in CAA, PCAA and PLAR compared to LAR, respectively 8.5+/-7.0 ml air/mmHg for CAA, 8.7+/-5.0 ml air/mmHg for PCAA, 6.3+/-4.0 ml air/mmHg for PLAR and 3.1+/-2.7 ml air/mmHg for LAR. A significant inverse linear correlation was present between the mean daily number of defecations and compliance. No difference in sense of incomplete evacuation was observed among the groups of patients., Conclusions: Colonic J-pouch provides an advantage over straight anastomosis in sphincter-saving operations by reducing the daily number of defecations, and the frequencies of fecal soiling and urgency. The role of the pouch seems to be different in LAR compared to CAA. In fact, in LAR the pouch increases compliance and consequently decreases the daily number of defecations. In CAA, the pouch does not reduce the number of defecations or the compliance, but reduces the frequency of fecal soiling and urgency.

Large villous adenomas of the rectum are not uncommon and will be encountered often by general and colorectal surgeons in their practices. The approach to large adenomas can be via the colonoscope either transabdominally or transanally. A simple transanal method was instituted by the author in 1992 and has been used up to the time of writing. This involves using a 4-cm diameter transanal operating rectoscope with laparoscopic instruments and the laparoscope itself. The results for 13 patients from January 1992 to April 2001 are reviewed. The method is simple and allows access to lesions up to 15 cm from the anal verge with a low incidence of complications, residual disease, and recurrence.

Background: Although there are many advantages of a posterior approach to rectal disease, these procedures are not widely accepted because many surgeons fear the postoperative complications., Methods: The medical records were reviewed of 57 patients who underwent a posterior approach to the rectum between January 1980 and December 2002., Results: Twenty-eight men and 29 women with a mean age of 70.5 (range 47-83) years underwent either a posterior transsacral (n = 52) or a transsphincteric (n = 5) procedure. Indications for surgery were benign lesions (n = 33), e.g. villous adenoma, rectal prolapse and endometriosis as well as invasive adenocarcinoma (n = 24). All patients with an invasive adenocarcinoma were classified as ASA grade III or IV. Postoperative morbidity occurred in 12 patients (21%), consisting of temporary incontinence, anastomotic leakage, wound infection, and hemorrhage. There was no mortality. During a mean follow-up of 29 (range 2-86) months, 3 patients with a villous adenoma and 2 patients who were treated for a malignant lesion had a locally recurrent lesion., Conclusion: We believe that a posterior approach to the rectum should be considered for various benign and selected malignant diseases, especially in case of elderly patients or patients with a compromised general condition, and has to be a part of the surgeon's armamentarium.

Introduction: Transanal resection of rectal villous adenomas or adenocarcinomas can be carried out using various modalities such as operative excision, fulguration, laser coagulation or cryotherapy. Transanal endoscopic microsurgery is currently not widely available. Transanal resection can provide effective palliation for locally advanced rectal tumours in patients unfit for abdomino-perineal excision of rectum. A urological resectoscope can be safely and repeatedly used to resect advanced primary or locally recurrent rectal tumours by colorectal surgeons with urological expertise. This study reports our experience of treating rectal lesions with endoscopic transanal resection (ETAR) using the urological resectoscope., Methods: Patients were identified from one surgeons' prospectively collected operating data. Charts were retrieved and reviewed., Results: Over a 13-year period a total of 43 ETAR procedures were carried out in 20 patients (11 males; mean age 74 years; range 54-92 years) using the urological resectoscope. Twelve (60%) patients had a single resection; 8 (40%) patients required more than one resection; the mean number of procedures per patient was 2.2 (range 1-8). The median interval between resections for recurrent disease (excluding planned repeat resections) was 340 days (range 168-2337 days). Histopathology revealed rectal adenoma (with varying degrees of dysplasia) in 11 (55%) patients and adenocarcinoma in 9 (45%). The majority (30; 70%) of resections were carried out in patients with benign disease, with 13 (30%) in patients with rectal adenocarcinoma. Mean operating time per resection was 25 min. Thirteen (30%) resections were carried out under spinal anaesthetic. There was no procedure related mortality. There were no cases of haemorrhage, rectal perforation, 'TUR syndrome' or pelvic sepsis. No patients with benign disease subsequently developed an invasive carcinoma., Conclusions: Accepting that this technique provides limited histopathological information regarding extent of resection and tumour clearance, our experience demonstrates that ETAR of rectal tumours using the urological resectoscope can provide a minimally invasive, effective and safe means of treating and palliating patients with benign and malignant rectal disease. There remains a place for this technique in selected patients.

Objective: The aim of this study was to assess one and a half years experience gained in Lithuania while treating rectal tumors with transanal endoscopic microsurgery in the Centre of Abdominal Surgery of Vilnius University Hospital "Santariskiu klinikos"., Materials and Methods: The patients who had rectal adenomas and low-risk T1 carcinomas of good or moderate differentiation, with no lymphatic and vascular invasion were selected for surgery. Tumor stage was determined by transanal endosonoscopy and rectoscopy with multiple macrobiopsies before surgery., Results: A total of 47 patients were operated on. The average tumor size was 3.4+/-1.4 cm (ranged from 1 to 7 cm). Overall 25 (52.1%) carcinomas and 23 (47.9%) adenomas were removed. Pre-operative diagnoses did not correspond to the final clinical diagnoses in 14 (29.8%) cases. Forty-three (89.6%) radical operations (R0) and 5 (10.6%) doubtful complete operations (RX) were performed. One (2.1%) intra-operative complication and one (2.1%) post-operative complication were observed. After the removal of Ca T2 three patients underwent adjuvant radiotherapy. Twenty-six patients were followed up for 3-17 months after operation: 17 after removal of cancer and 9 after removal of adenoma. One (2.1%) recurrence of a tubulovillous adenoma was diagnosed. No other complications were reported., Conclusions: Initial results of transanal endoscopic microsurgery obtained while treating rectal adenomas and low-risk T1 cancers are promising. The low rate of complications and recurrences in this group offers many hopes. The experience of the treatment of T2 cancers with transanal endoscopic microsurgery and adjuvant radiotherapy is limited but the results are encouraging. It is obvious that the results of randomized and controlled trials need to be awaited before definite conclusions can be drawn.

Cystitis glandularis is a benign proliferative disease of the bladder mucosa with a characteristic histopathologic appearance. If a mass lesion is identified, it is resected transurethrally. More extensive surgical management for severe or recurrent cases is poorly characterized in published studies. We present a patient with multiple rapid recurrences of polypoid masses on the trigone causing irritative voiding symptoms. He developed a low-compliance small-capacity bladder and bilateral ureteral obstruction. The patient underwent total cystoprostatectomy with cavernosal nerve sparing and ileal neobladder construction. We advocate such aggressive surgical management in select cases of this disease.

Background: Patients with inoperable advanced rectal carcinoma require palliation for local symptoms. Endoscopic Nd-Yag laser ablation is a valid palliative treatment option in patients with advanced rectal carcinoma who are poor operative risks due to coexistent multiple comorbidities., Methods: All patients who cannot undergo radical surgery due to various factors such as tumour size, poor risk patients, distant metastasis and refusal to undergo surgery were offered palliation with endoscopic Nd-YAG laser ablation. Indications included troublesome bleeding, local recurrence, mucous discharge and impending obstruction. Patients were admitted on the day of treatment, phosphate enema given for bowel preparation and endoscopic ablation done through a flexible sigmoidoscope under intravenous sedation with midazolam. All patients were discharged the next day after overnight observation. Patients were reviewed every 3 months and laser ablation repeated if deemed necessary., Results: Eleven patients (7 males, 4 females; mean age 83.6 years, range 77-90 years) underwent endoscopic laser ablation in a District General Hospital --8 for rectal carcinoma, 2 for rectosigmoid tumour and 1 for recurrent tubulovillous adenoma. The number of treatment episodes varied from 1 to 12 with symptom free interval from 2 to 18 months between treatment episodes. There were 3 failures, one patient required defunctioning colostomy, one patient was referred for radiotherapy due to persistent symptoms and in one patient laser treatment had to be abandoned due to local extent. There were no immediate post-treatment complications, but one patient developed incontinence after 5 episodes which might be attributable to tumour infiltration., Discussion: Endoscopic laser ablation is a practical and feasible alternative to other palliative treatment modalities in the management of this unfortunate category of patients due to low morbidity and mortality, short hospitalization and low complication rates.

An 85-year-old woman was admitted to our hospital due to pain and swelling in her right inguinal region. She had a right inguinal hernia. Abdominal computerized tomography revealed an 8 x 8 cm cecal mass and also a 13.5 cm segmental asymmetric nodular thickening of the cecum. Colonoscopic examination revealed a sessile polypoid mucus-secreting mass mimicking carcinoma that narrowed the cecal lumen. Histopathological examinations of sections from colonoscopic biopsy materials on light microscopy revealed villous adenoma morphology. The patient underwent operation, and an 18 x 6 x 4 cm mass, which partially obstructed the cecum, was seen. A right hemicolectomy was performed for complete excision. Histopathological examination revealed a pure villous adenoma, and there was no sign of malignant degeneration. On the 6th postoperative day, the patient was discharged from the hospital. During follow-ups at three-month intervals throughout one year, no abnormal colonoscopic or laboratory findings were assessed. We believe that, in older patients with inguinal hernia, presence of intraabdominal mass should be considered. Furthermore, we showed in this report that villous adenomas can reach significant dimensions without causing any obstructing signs or electrolyte imbalance and can mimic colon carcinoma.

Introduction: Adenomas are the most frequent tumors of the Vater s ampulla. Their capacity for malignant transformation following the adenoma-carcinoma sequence is well known. It is because of this that resection after diagnosis is required. The identification of the appropriate technique according to tumor features would require that patients not be undertreated or overtreated, which would give rise to serious consequences derived from their location., Patients and Methods: Villous adenomas and adenocarcinomas of the Vater s ampulla candidates for local resection were revised from January 1st, 1998 through June 30th, 2003. We describe the methods of diagnosis and ampulectomy techniques we performed., Results: We performed an ampulectomy by first intention in all 8 patients included in this study. However, pancreatoduodenectomy was necessary in two patients because of the closeness of resection margins. We had no mortality in this series, and morbidity was limited to two episodes of digestive bleeding that were controlled by electrocoagulation and embolization. The mean follow-up was 28.5 months (range, 6-72 months)., Conclusions: The difficulty of precise preoperatory diagnosis in adenomas of the Vater s ampulla demands resection after identification. Ampulectomy is the treatment of choice for villous adenomas and T1 adenocarcinomas, with 1 cm of resection margin to avoid local recurrence.

The local excision of a rectal polyp is often wrongly considered to be a minor surgical procedure. In reality, the malignant potential of adenomas and the not-infrequent presence of cancer in larger polyps, require, for their removal, an oncologically correct operation with strict indication and accurate execution. Despite an increasing inclination to extend the indications of endoscopic polypectomies to polyps of larger size and villous configuration, the local surgical approach remains the preferred treatment in most cases. Here the indications and the results of different surgical techniques proposed for the local excision of a rectal polyp are reported. Among these procedures, transanal endoscopic microsurgery is gaining a primary role in many circumstances.

Background and Aims: This study reviewed the outcome of endoscopic transanal resection (ETAR) for the treatment of patients with villous rectal adenomas (VRA)., Patients and Methods: This study included 28 consecutive patients who underwent ETAR for VRA between October 1992 and December 2000. All tumors were believed to be benign (clinical examination, endorectal ultrasonography, multiples biopsies) A retrospective evaluation of the outcome of ETAR was performed., Results: Thirteen patients (46.4%) had a large VRA with a tumor length of more than 5 cm. The tumor involved the anterior rectal wall in ten cases. Ten patients (35.7%) required more than one procedure. Median operating time was 35 min (range 20-50). Morbidity was 5% ( n=2); no patient died. Median postoperative stay was 3 days (range 1-5). Three patients (9.3%) were confirmed on histology as having adenocarcinoma of the rectum and underwent a conventional surgical procedure. At a median follow-up of 5 years (2.5-10.5), two recurrences were noted., Conclusion: Our data suggest that the technique of transanal resection has a limited but valuable place in rectal surgery. ETAR is a simple, minimally invasive, and economical method for treatment of patient with VRA. ETAR should be performed in collaboration with an experienced urological endoscopist. ETAR is a useful addition to the surgeon's armamentarium together with laser destruction and transanal endoscopic microsurgery.

A 47-year-old woman underwent endoscopic polypectomy of a villous adenoma in the lesser curvature of the gastric antrum. Shortly after the procedure, she complained of severe abdominal pain. An abdominal x-ray showed air under the diaphragm, suggestive of gastric perforation. On re-endoscopy, the cavity at the site of polypectomy was closed using endoscopically applied metallic clips. She was treated with intravenous hyperalimentation, omeprazole, and antibiotics for 10 days. Ingestion of food was started 10 days after admission, and she was discharged without any complaints. She is free of symptoms on follow-up after 8 months, and endoscopy showed complete healing of the perforation. The procedure is the third described for the stomach in the English literature and emphasizes the use of endoclipping in selected cases of small and well-defined perforations.

Aims: A review of the literature indicated that only one case of serrated adenoma of the appendix has been recorded. The aim was to explore the possible occurrence of serrated adenomas of the appendix at the department of pathology, Karolinska Institute and University Hospital, Stockholm, Sweden., Methods: Between January 1993 and December 2003, 38 non-carcinoid, non-neoplastic, or neoplastic polyps or tumours of the appendix were surgically removed at this hospital. All filed histological sections (haematoxylin and eosin stained) were reviewed., Results: Of the 38 lesions, four were hyperplastic polyps, 10 serrated adenomas, six villous adenomas, and the remaining eight mucinous adenocarcinomas without a remnant adenoma. Serrated adenomas accounted for six of the 11 adenomas without invasion, and four of the 15 adenomas with invasive carcinoma. At the time of surgical resection, four of the 10 serrated adenomas had evolved into invasive carcinomas, in addition to 11 of the 16 villous adenomas., Conclusions: Serrated and villous adenomas of the appendix appear to be highly aggressive lesions, more aggressive than similar adenomas in the colon and rectum. Of the seven cases with a hyperplastic polyp, one concurred with a serrated adenoma, two with a serrated adenoma having an invasive carcinoma, and one with invasive carcinoma without a remnant adenomatous structure. At present, there is an increased awareness that some hyperplastic polyps of the colon and rectum may evolve into serrated adenomas. Whether this pathway is also valid for the appendix vermiformis should be investigated in a larger number of cases.

Background: Duodenal adenomas are extremely common in patients with familial adenomatous polyposis. However, it is uncertain whether patients with duodenal adenomas without familial adenomatous polyposis are at greater risk for colorectal neoplasia and, therefore, should routinely undergo surveillance colonoscopy. The aim of this study was to determine whether there is a correlation between non-papillary duodenal adenoma without familial adenomatous polyposis and colorectal adenoma., Methods: Twenty-five patients with non-papillary duodenal adenomas without familial adenomatous polyposis, seen from January 1990 to April 2003, were retrospectively evaluated., Results: Non-papillary duodenal polyps were diagnosed by endoscopy in the 25 patients. Of these, 21 underwent colonoscopy and one underwent proctoscopy. The mean age of these 22 patients (12 women, 10 men) was 69 years (range 50-83 years). Sixteen of the 22 patients (72.7%) with duodenal adenomas had associated colorectal adenomas. A total of 38 adenomas and one colorectal cancer were detected. The mean size of the polyps was 6.2 mm (range 3-15 mm). The adenomas were removed by snare excision or with a biopsy forceps., Conclusions: Based on the results of this uncontrolled, retrospective study, the frequency of colorectal adenomas in patients with duodenal polyps without familial adenomatous polyposis appears to be increased compared with the general population. All patients with duodenal polyps should undergo surveillance colonoscopy for colorectal adenomas. A prospective study to definitively establish the frequency of colorectal adenomas in these patients is warranted.

Objective: To summarise the results of transanal endoscopic microsurgery for the treatment of rectal villous adenoma and early rectal tumours., Design: Prospective study., Setting: Regional hospital, Hong Kong., Patients: Consecutive patients between November 1995 and January 2003., Intervention: Transanal endoscopic microsurgery., Main Outcome Measures: Intra-operative morbidity and mortality, complication rate, operating time, postoperative morbidity and mortality, recurrence rate and correlation between preoperative ultrasonography staging and postoperative pathological staging., Results: Thirty-two patients with rectal villous adenoma and early rectal carcinoma were registered, 31 of whom (14 men and 17 women) were included in the study. The median tumour size was 2.5 (range, 1-8) cm and the median operating time was 95 (45-220) minutes. The median follow-up period was 23 (2-92) months, and there was no local recurrence. There was no operation-related mortality and the resection margins were all clear. Complications included temporary flatus incontinence (n=2), acute retention of urine (n=1), exacerbation of chronic obstructive airway disease (n=1), and secondary haemorrhage in a patient on aspirin., Conclusions: Transanal endoscopic microsurgery is a safe procedure and can achieve good local tumour control. It is ideal in the management of rectal villous adenomas at stages pT0 and pTis. Its application is now extended to the treatment of early rectal carcinoma at stage pT1 with curative intent. For tumours at stage pT2 or later, it can also serve as a good option for local palliation.

Adenomas of the rectum are frequently found during endoscopic examination. We report on our 30 years of experience with the treatment of tubulo-villous adenomas based on histotype. Between 1971 and 2001, 104 villous tumours of the rectum were treated surgically. The patients' average age was 65 years. These were sessile tumours in 69% of cases, pedunculated in 17.5% and flowing tumours in 13.5%. The mean tumour size was 3 cm. They were associated with colon cancer in 15% of cases and with polyadenoma in 10%. They were located in the rectum within 0 to 6 cm of the anal margin in half the cases. These tumours were treated by local excision in 74 cases and by wide excision in 30 cases. The malignant potential of the tumours was 30%, including 10% invasive malignancy. There were no surgical fatalities, but a 6% medical fatality rate was registered. There was a 20% complication rate related to the surgical technique. Twenty patients were lost to follow-up. Out of 84 villous tumours, monitored over a mean survival period of 6.5 years, there were 24 recurrences: 18 underwent endoscopic excision and in 6 cases a wide resection. The various tumour resection techniques and the operative indications of variable difficulty are presented. It would seem, at present, that total resection of the rectum with a colo-anal anastomosis is the best treatment for large flowing villous tumours occupying almost the entire rectum. Thorough preoperative examination and the mastering of various surgical procedures should allow the most suitable choice of treatment for each individual case.

Background: Bleeding following transanal rectal surgery can be difficult to manage., Case: We report a case where a Minnesota tube was used to achieve haemostasis in a patient with severe bleeding after transanal excision of a large dysplastic polyp.

Background: Nonhepatic abdominal surgery, and especially colorectal surgery, is associated with high rates of morbidity and mortality among cirrhotic patients. With proper patient selection and preoperative optimization of the patient's condition, laparoscopic-assisted colectomy could become effective and safe for patients with compensated liver cirrhosis. The aim of this study was to evaluate the safety and feasibility of minimal-access surgery in these patients., Methods: Between September 1993 and March 2003, 820 patients underwent laparoscopic-assisted colectomy at our hospital. We studied all patients with liver cirrhosis who underwent this operation., Results: Seventeen patients with cirrhosis were included in the study. Twelve were Child's A and five were Child's B. The mean operative time was 150 min (ranges 75-280), mean estimated blood loss was 245 ml (ranges 100-250). The conversion rate to open surgery was 29% (five patients). Median length of hospital stay was 5 days. The morbidity rate was 29% (five patients). There were no anastomotic leaks or operative-related deaths. The median follow-up was 21 months., Conclusions: Laparoscopic-assisted colorectal surgery can be performed in compensated cirrhotic patients with low morbidity and mortality. Adequate patient selection and expertise in advanced minimal-access surgery are essential to obtain such good results.

Background: In Germany screening colonoscopy was introduced into the national program on colorectal cancer prevention in October 2002 for asymptomatic subjects older than 55 years. It is the aim of this program to reduce the rate of mortality of colorectal cancer (CRC) during the next decade. Up to now no data are available concerning the outcome and patient tolerance of screening colonoscopy., Methods: Patients were enrolled in the prospective study between October 2002 and June 2003. The diagnoses from colonoscopy and complications were recorded. A short interview provided information on individual family risks of CRC. During June 2003 all subjects were handed a questionnaire to evaluate their satisfaction and tolerance concerning screening colonoscopy. All subjects were offered sedation (Disoprivan: Propofol)., Results: A total of 1117 subjects (776 [69.5 %] female, 341 [30.5 %] male) underwent screening colonoscopy; age: 64.3 +/- 6.9 years. 1104 (98.8 %) requested sedation. In 1090 cases (97.6 %) colonoscopy was completed to the cecum (photographic documentation of cecal landmarks). A total of 11 patients had invasive cancer (1 %), 4 of these had adenomas containing invasive carcinoma. The stage was T1/N0 or T2/N0. A total of 138 (12.4 %) patients had 168 polypoid lesions, which were treated by complete polypectomy. 402 small polypoid lesions (< 0.5 cm) were only detected by biopsy. In this group 233 adenomas (20.9 %) were found. Complications were: 1 perforation and 4 haemorrhages after polypectomy. Patient tolerance was very high. 99.4 % of all subjects agreed to a control colonoscopy or recommended screening colonoscopy to their relatives and friends., Conclusion: Screening colonoscopy is an effective and well-accepted method in our unit for gastroenterology. The high prevalence of adenoma and invasive carcinoma suggests that screening colonoscopy should be provided for all persons at the age of 55, especially for men.

Objectives: Villous adenoma is a benign neoplasia, the appearance of which in the urinary tract is extraordinarily unfrequent. We report a new case recently experienced in our department., Methods: We report the case with its past urologic history, clinical picture, diagnostic tests, and treatment., Results: Pathologic report confirmed the diagnosis of bladder villous adenoma, being transurethral resection the only treatment applied to leave the patient disease-free., Conclusions: Prognosis of this kind of neoplasia, which is unfrequent, is excellent; being endoscopic resection curative, with no local or distant progression, except in cases associated with adenocarcinoma foci, in which local recurrence or distant metastasis are possible, and a more aggressive treatment might be indicated.

Introduction: Laparoscopic surgery of the colon is becoming more and more popular. However, regarding sigmoid resection, controversy remains concerning the extent of mobilisation, particularly regarding the splenic flexure. We developed a technique for anterior resection that meets all surgical standards: the anterior approach., Materials and Methods: From October 1999 to March 2001, 50 patients with benign diseases of the colon underwent laparoscopically assisted sigmoid resection. A completely anterior approach for mobilisation of the left hemicolon was used in all cases. Positioning the patients in Trendelenburg position on the extreme right side enabled primary ligation of the inferior mesenteric vein and artery as well as complete mobilisation of the splenic flexure from the middle. A transanal circular stapling device was used to reanastomose the colon 10-12 cm from the anus., Results: There were conversion and complication rates of 10% each, and three patients needed to be reoperated. The median operating time was 180 min. Patients could be dismissed on the 14th postoperative day., Conclusion: To establish an operative standard, this technique has so far been used only for benign colon diseases. According to our experience, we think that it meets all oncological standards. Use of this technique in the treatment of malignant diseases seems therefore justified.

Background: The misdiagnosis of a rectal adenoma by biopsy and subsequent finding of invasive cancer after transanal excision is associated with a number of pitfalls. Problems include suboptimal therapy for a potentially curable cancerous lesion, potential tumor transgression of the local site with increased chance for local recurrence, and increased potential for more radical surgery or adjuvant chemoradiation. The utility of endorectal ultrasound (ERUS) in guiding treatment decisions of rectal villous adenomas has been reported, but series are small and are from single institutions. To determine the utility of ERUS in the diagnosis of rectal adenomas, we compared diagnosis made by biopsy alone to diagnosis made by a combination of biopsy and ERUS., Methods: A systematic literature review was performed by way of a PubMed search to find articles with the following terms: "biopsy-negative rectal adenomas," "preoperative ERUS diagnosis," and "surgical histopathology." Five studies met the criteria, thus providing data for 258 adenomas. A quantitative meta-analysis was performed on the data., Results: Among the 258 biopsy-negative rectal adenomas, 24% had focal carcinoma on histopathology. ERUS correctly established a cancer diagnosis in 81% (95% confidence interval 69 to 90) of these misdiagnosed lesions. Thus, ERUS diagnosis of biopsy-negative rectal adenomas could be expected to decrease the need for additional surgery and other associated problems caused by misdiagnosis from 24% to 5%., Conclusions: ERUS is a useful adjunct to biopsy in the preoperative workup of rectal villous adenomas, and we recommend its routine use. Accurate preoperative assessment allows the surgeon to counsel the patient appropriately regarding the best operation, the perioperative risks, and the chances of local recurrence.

Hyperplastic polyps are not thought to carry a malignant potential. They are, therefore, not regularly screened by the majority of clinicians. We present two case reports of serrated adenomas that add to a small but expanding body of clinical and histological evidence that suggests a hyperplastic to neoplastic pathway. Regular colonoscopic surveillance may be indicated in at least some cases of hyperplastic polyposis

Tumors of the papillary region are an unusual and heterogeneous group of neoplasms that arise from the major papilla, the ampulla of Vater, and the peripapillary duodenum. Benign adenomas of the papilla of Vater are an increasingly recognized condition in those with familial adenomatous polyposis syndromes as well as sporadic cases. Papillary adenoma is a recognized but rare cause of acute pancreatitis. We describe a patient who presented with acute recurrent pancreatitis that was attributed to an intrapapillary pedunculated villous adenoma. Following diagnosis by endoscopic needle knife sphincterotomy and endoscopic retrograde cholangiopancreatography, endoscopic snare resection of the adenoma resulted in symptomatic improvement.

Purpose: Considering the malignant potential of villous adenoma of the rectum, complete resection at the first intervention is desirable and yet many series suggest that a high recurrence rate must be expected. The experience of one colorectal surgeon in the management of this condition is described., Methods: Between 1993 and 2000, 50 patients underwent per-anal resection of villous adenoma. The procedure was conducted in the prone jackknife position unless contraindicated, with dissection performed using a diathermy blade, with particular attention to circumferential and deep margins of excision., Results: The mean distance of the proximal margin of the tumor from the dentate line was 5.6 (range, 0.5-11) cm. The mean length of the tumor was 5.2 (range, 0.5-9) cm. Mean anesthetic time was 27 (range, 10-110) minutes, and median hospital stay was two (range, 1-14) days. There was no significant perioperative morbidity and no mortality. On histology of ten patients, there were foci of adenocarcinoma. Excision was complete histologically in 49 patients. The median follow-up was 30 (range, 6-91) months. The patient with incomplete excision developed a probable recurrence after six months, which was ablated with diathermy (residual tumor rate, 2.1 percent). Two patients have subsequently developed villous adenoma at different sites within the rectum (metachronous tumor rate, 4.3 percent)., Conclusions: Many series of this procedure report recurrence in up to 36 percent and significant complication in up to 19 percent of patients. Transanal endoscopic microsurgery has achieved recurrence rates of 2.8 percent and low complication rates but for economic reasons has failed to find a widespread role. This article demonstrates that large, villous tumors of the low and mid rectum can be simply and effectively treated by per-anal resection with recurrence rates equivalent to transanal endoscopic microsurgery.

Background: Large sessile adenomas of the rectum are premalignant lesions necessitating complete removal., Methods: We reviewed the data on 20 consecutive patients with large (>or=2 cm) sessile villous and tubulovillous adenomas of the lower two thirds of the rectum (or=50% or an endosonographic staging of >or=uT2 underwent a low anterior resection of the rectum. The remaining 9 patients underwent a posterior full-thickness local bowel wall resection (modified Mason procedure). The median (range) follow-up period was 3.8 (0.7-8.2) years., Results: Preoperative biopsy examination successfully excluded invasive carcinoma. Overstaging, however, occurred in 9 of 12 patients (75%) undergoing endosonography, resulting in surgical overtreatment of 4 patients. A curative resection (R0) was always achieved. Five patients had complications, but there was no in-hospital mortality and no cases of local recurrence. 4 out of 19 patients complained of minor stool incontinence, and 3 patients reported incomplete rectal emptying or constipation. Fourteen patients described the operative result as excellent (n = 7) or good (n = 7)., Conclusions: Endosonography may lead to overstaging and overtreatment. An individualized approach based on the degree of adenomatous circumferential involvement and endosonographic staging showed no mortality, low morbidity, no local recurrence, and good functional medium-term results., (Copyright 2004 S. Karger AG, Basel.)

A laterally spreading tumor (LST) is considered to be a specific subtype of superficial colorectal tumors, in view of its characteristic clinicopathological features. We attempted to compare genetic alterations found in LST (>10 mm) with those found in IIa-type adenomas (10 mm or less (small superficial elevated lesion)) and conventional polypoid adenomas (>10 mm). In addition, multiple sampling by microdissection was performed for 14 LST to examine genetic heterogeneity in the Ki-ras and p53 gene mutation patterns. Polymerase chain reaction, single-strand conformation polymorphism and direct sequencing were used to analyze Ki-ras and p53 gene mutations in 73 sporadic colorectal adenomas: 28 LST; 22 IIa-type adenomas; and 23 polypoid adenomas. Ki-ras gene mutations were found more frequently in LST (6/28 tumors) and polypoid adenomas (6/23 tumors) than in IIa-type adenomas (2/22 tumors), although this difference was not statistically significant. The frequency of p53 gene mutations in the 28 LST was 25% (7/28), which was significantly higher than that found in IIa-type adenomas (P < 0.05). However, although p53 gene mutations were found more frequently in LST than in polypoid adenomas, this difference was not statistically significant. Seven LST exhibited a combination of wild-type and mutant-type tumor cells having the p53 gene mutation pattern, whereas a pattern of different Ki-ras gene mutations was found in two of three LST that exhibited Ki-ras gene mutation heterogeneity. We suggest that the LST exhibited a characteristic pattern in terms of the Ki-ras as well as the p53 gene mutation pattern, thereby supporting the hypothesis that LST is a specific subtype of colorectal tumors.

The management of patients suffering from abdominal aortic aneurysms with concomitant intestinal disease is demanding. Surgical procedures have to be evaluated meticulously with regard to morbidity and priority. We retrospectively investigated early and late results of nine patients (eight males, one female) with coincidental aortic and intestinal surgery during the last 9.5 years. The average age was 77 years (range 67-85). One-stage procedures were undertaken twice with implantation of aortic grafts to replace abdominal aortic aneurysms (AAA). During these emergency procedures, an aortoduodenal fistula was repaired in one case and resection of an ischemic segment of the sigmoid colon was resected in another. Seven two-stage procedures were performed as elective surgery. Five AAA were excluded before the intestinal repair. In two cases of urgent visceral pathologies, colon resection was done first, followed by elimination of the AAA. In case of elective surgery, two-stage procedures seem to be safe and effective. However, in certain emergent cases, one-stage procedures with implantation of vascular grafts in combination with colon or bowel surgery might also be justified.

Transanal local excision of posterior benign rectal tumors is usually safe. Here, we report a case of transanal excision of a posterior anastomotic recurrence of a rectal adenoma after a stapled anterior resection that resulted in perforation into the peritoneal cavity.

Aims: To clarify the cellular differentiation of colorectal villous tumours in malignant transformation, compared with that of tubular tumours (tubular adenoma and adenocarcinoma arising in tubular adenoma)., Methods and Results: Forty-nine cases of colorectal villous tumours [six cases of low-grade villous adenoma, 21 of high-grade villous adenoma (VA), nine of invasive carcinoma in villous adenoma (CIVA), and 13 of pure villous carcinoma (PVC)] and 46 cases of tubular tumours [14 cases of low-grade and 17 of high-grade tubular adenoma (TA), and 15 cases of carcinoma in tubular adenoma (CITA)] were selected for this study based on their expression patterns of CD10 (small intestinal brush border), MUC2 (intestinal goblet cell), and HGM (gastric foveolar epithelium). HGM was more frequently expressed in the adenomatous components of villous tumours (63%) than in those of tubular tumours (14%) (P < 0.05). CD10 expression of high-grade TAs (47%) and carcinomas arising in TA (60%) was significantly higher than that of villous tumours (0%) (P < 0.05)., Conclusions: There were significant differences in the phenotypic expression of adenoma and adenocarcinoma between villous and tubular tumours, respectively. Villous tumours have a pathway of malignant transformation different from that of tubular tumours. Because of biological differences, colorectal villous tumours should be distinguished from tubular neoplasia. The analysis of the phenotype of colorectal neoplasms is useful for the evaluation of tumour progression.