Safe Transanal Tumor Resection Using a Harmonic Scalpel

We performed a safe and simple transanal tumor resection involving total layer resection using a harmonic scalpel as a resecting device. Here we report the results of our experience with this technique between 2005 and 2011. This study involved 32 patients who underwent transanal tumor resection using a harmonic scalpel. The subjects comprised 18 men and 14 women ranging in age from 34 to 87 years (mean: 64.5 years). The tumors measured 8 to 70 mm (mean: 31 mm) in diameter. The operation took 7 to 86 minutes (mean: 29 minutes), and the amount of bleeding was 0 to 165 mL (mean: 16.2 mL). There was no intraoperative blood loss that necessitated hemostatic procedures. Histopathologically, the lesions included hyperplastic polyp in 1 case, adenoma in 9, carcinoma in situ in 7, submucosal invasive cancer in 6, muscularis propria cancer in 4, carcinoid in 1, malignant lymphoma in 1, gastrointestinal stromal tumor in 1, mucosal prolapsed syndrome in 1, and mucosa-associated lymphoid tissue lymphoma in 1. With our technique, en bloc resection was achieved in all patients, and the use of a harmonic scalpel enabled us to complete the operation within 30 minutes, on average, without intraoperative bleeding.Key words: Rectal tumor, Transanal tumor resection, Harmonic scalpelWith technical developments and advances in colonoscopic diagnosis, such as magnifying endoscopy^1–3 and the narrow band imaging system,^4,5 and ablative surgery, such as endoscopic mucosal resection (EMR)^1,6 and endoscopic submucosal dissection (ESD),⁷ cures have become achievable with endoscopic resection (ER) alone in many cases of early colorectal carcinoma. ER is the treatment of choice for early colorectal carcinoma. However, with large lesions, conventional EMR cannot be performed as an en bloc resection; and even with lesions smaller than 20 mm in diameter, incomplete resection or piecemeal resection often occurs. After endoscopic piecemeal mucosal resection, histopathological assessment of complete resection is difficult and the risk of local recurrence is high.⁸ ESD has also been used to treat large colorectal adenomas, with recurrence rates of 0 to 9% and complication rates of only 0 to 9%.^9–11 However, compared with conventional EMR, the ESD technique is technically challenging and time consuming and requires a steep learning curve.^9,12 In addition, there are some issues involved in ER of lower rectal neoplastic lesions. Specifically, ER of these lesions is associated with higher risk of postoperative bleeding than that of lesions at other sites, because the rectum has abundant blood flow, and resection of some lower rectal lesions causes pain because of the sensory nerve distribution in this area.On the other hand, spread of laparoscopic surgery for colorectal cancer has led to a marked improvement of the quality of life (QOL) of these patients after resection,^13,14 and the incidence of lymph node metastasis in cases of submucosal invasive (SM) cancer is as low as about 10%.^15–18 Taking these into account, radical surgical resection, including abdominoperitoneal resection that requires a permanent stoma, seems to be excessively invasive in cases of early colorectal cancer. Recent years have seen great benefits of surgical treatment for lower rectal cancer, because intersphincteric resection (ISR)¹⁹ has become more common, allowing sphincter-preserving surgery even in patients in whom creation of a permanent stoma would have otherwise been required. The feasibility of ISR under laparoscopy has also improved the postoperative QOL.²⁰ However, even at present, the QOL is not necessarily satisfactory in terms of bowel function. In this regard, transanal tumor resection is a useful procedure for tumor removal in some cases, yielding a postoperative QOL comparable with that after EMR.We perform safe transanal tumor resection involving total layer resection using a harmonic scalpel as a resecting device. Here we report the results of our experience with this technique.