Importance of Resection Margins in the Treatment of Rectal Adenomas by Transanal Endoscopic Surgery



Polypectomy is the gold standard for treating colorectal adenomas up to 2 cm in size. For larger lesions, various procedures ranging from endoscopy to transanal surgery can be performed and achieve varying results for en bloc resection and recurrence. There are no clear guidelines for dealing with involved resection margins. We assess the recurrence of rectal adenomas operated using TEM with full-thickness wall excision with or without free resection margins and define optimal endoscopic follow-up.


Observational study with prospective data collection, including patients undergoing TEM between 6/2004 and 11/2017, with definitive diagnosis of rectal adenoma. Data on epidemiological, preoperative, surgical, postoperative, pathological, and follow-up variables were recorded. Univariate analysis, follow-up risk function, and multivariate logistic regression analysis were performed to detect risk factors for recurrence.


TEM was indicated in 736 patients; 481 adenomas were identified in the preoperative biopsy, of which 95 were infiltrating adenocarcinomas (19.8%) in the definitive pathology study. With a minimum follow-up of 1 year, 372 patients were included. Pathology study showed free margins in 324 (87%). Recurrences were recorded in 15 patients (4%), up to 18 months in the free margins group and up to 24 months in the involved margins group. Thirteen patients with recurrence (86.6%) were treated with TEM. No predictors of recurrence were found in the multivariate analysis.


TEM is the technique of choice for treating rectal adenomas and recurrences, achieving a low relapse rate. Follow-up must be adapted to resection margins and should be extended to 24 months.

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  1. 1.

    Buess G, Hutterer F, Theiss J, Böbel M, Isselhard W, Pichlmaier H. [A system for a transanal endoscopic rectum operation]. Chirurg 1984;55:677–-80.

    CAS  PubMed  Google Scholar 

  2. 2.

    Lezoche E, Guerrieri M, Paganini A, Feliciotti F, Di Pietrantonj F. Is transanal endoscopic microsurgery (TEM) a valid treatment for rectal tumors?. Surg Endosc 1996;10:736–-41.

    Article  CAS  PubMed  Google Scholar 

  3. 3.

    Bories E, Pesenti C, Monges G, Lelong B, Moutardier V, Delpero JR, et al. Endoscopic Mucosal Resection for Advanced Sessile Adenoma and Early-Stage Colorectal Carcinoma. Endoscopy 2006;38:231–-5.

    Article  CAS  PubMed  Google Scholar 

  4. 4.

    Saunders BP, Tsiamoulos ZP. Endoscopic mucosal resection and endoscopic submucosal dissection of large colonic polyps. Nat Rev Gastroenterol Hepatol 2016;13:486–-96.

    Article  PubMed  Google Scholar 

  5. 5.

    Vitali F, Naegel A, Siebler J, Neurath MF, Rath T. Endoscopic full-thickness resection with an over-the-scope clip device (FTRD) in the colorectum: results from a university tertiary referral center. Endosc Int open 2018;6:E98–-103.

    Article  PubMed  PubMed Central  Google Scholar 

  6. 6.

    Fucini C, Segre D, Trompetto M. Local excision of rectal polyp: indications and techniques. Tech Coloproctol 2004;8 Suppl 2:s300–-4.

    Article  PubMed  Google Scholar 

  7. 7.

    Serra-Aracil X, Caro-Tarrago A, Mora-López L, Casalots A, Rebasa P, Navarro-Soto S. Transanal Endoscopic Surgery With Total Wall Excision Is Required With Rectal Adenomas due to the High Frequency of Adenocarcinoma. Dis Colon Rectum 2014;57:823–-9.

    Article  PubMed  Google Scholar 

  8. 8.

    Serra-Aracil X, Mora-Lopez L, Alcantara-Moral M, Caro-Tarrago A, Gomez-Diaz CJ, Navarro-Soto S. Transanal endoscopic surgery in rectal cancer. World J Gastroenterol 2014;20:11538–-45.

    Article  PubMed  PubMed Central  Google Scholar 

  9. 9.

    Serra-Aracil X, Mora-Lopez L, Alcantara-Moral M, Corredera-Cantarin C, Gomez-Diaz C, Navarro-Soto S. Atypical indications for transanal endoscopic microsurgery to avoid major surgery. Tech Coloproctol 2014;18:157–-64.

    Article  CAS  PubMed  Google Scholar 

  10. 10.

    Levin B, Lieberman DA, McFarland B, Andrews KS, Brooks D, Bond J, et al. Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous Polyps, 2008: A Joint Guideline From the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Gastroenterology 2008;134:1570–-95.

    Article  CAS  PubMed  Google Scholar 

  11. 11.

    Rocha JJR da, Féres O. Transanal endoscopic operation: a new proposal. Acta Cir Bras 2008;23 Suppl 1:93–-104; discussion 104.

  12. 12.

    Scala A, Gravante G, Dastur N, Sorge R, Simson JNL. Transanal Endoscopic Microsurgery in Small, Large, and Giant Rectal Adenomas. Arch Surg 2012;147:1093.

    Article  PubMed  Google Scholar 

  13. 13.

    Barendse RM, Dijkgraaf MG, Rolf UR, Bijnen AB, Consten ECJ, Hoff C, et al. Colorectal surgeons’ learning curve of transanal endoscopic microsurgery. Surg Endosc 2013;27:3591–-602.

    Article  PubMed  Google Scholar 

  14. 14.

    Dindo D, Demartines N, Clavien P-A. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205–-13.

    Article  PubMed  PubMed Central  Google Scholar 

  15. 15.

    Higaki S, Hashimoto S, Harada K, Nohara H, Saito Y, Gondo T, et al. Long-Term Follow-Up of Large Flat Colorectal Tumors Resected Endoscopically. Endoscopy 2003;35:845–-9.

    Article  CAS  PubMed  Google Scholar 

  16. 16.

    Serra-Aracil X, Gálvez A, Mora-López L, Rebasa P, Serra-Pla S, Pallisera-Lloveras A, et al. Endorectal ultrasound in the identification of rectal tumors for transanal endoscopic surgery: factors influencing its accuracy. Surg Endosc 2017 Dec 21. doi:

  17. 17.

    Binmoeller KF, Bohnacker S, Seifert H, Thonke F, Valdeyar H, Soehendra N. Endoscopic snare excision of "giant" colorectal polyps. Gastrointest Endosc 1996;43:183–-8.

    Article  CAS  PubMed  Google Scholar 

  18. 18.

    Hall JF. Management of Malignant Adenomas. Clin Colon Rectal Surg 2015;28:215–-9.

    Article  PubMed  PubMed Central  Google Scholar 

  19. 19.

    Laliberte A-S, Lebrun A, Drolet S, Bouchard P, Bouchard A. Transanal endoscopic microsurgery as an outpatient procedure is feasible and safe. Surg Endosc 2015;29:3454–-9.

    Article  PubMed  Google Scholar 

  20. 20.

    Schmidt A, Beyna T, Schumacher B, Meining A, Richter-Schrag H-J, Messmann. H, et al. Colonoscopic full-thickness resection using an over-the-scope device: a prospective multicentre study in various indications. Gut 2017;gutjnl-2016-313677.

  21. 21.

    Lee L, Burke JP, deBeche-Adams T, Nassif G, Martin-Perez B, Monson JRT, et al. Transanal Minimally Invasive Surgery for Local Excision of Benign and Malignant Rectal Neoplasia. Ann Surg 2018 May;267(5):910–-916.

    Article  PubMed  Google Scholar 

  22. 22.

    Ferlitsch M, Moss A, Hassan C, Bhandari P, Dumonceau J-M, Paspatis G, et al. Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2017;49:270–-97.

    Article  PubMed  Google Scholar 

  23. 23.

    Meier B. Endoscopic management of colorectal adenomas. Ann Gastroenterol 2017;30:592–-7.

    PubMed  PubMed Central  Google Scholar 

  24. 24.

    Kim B, Choi AR, Park SJ, Cheon JH, Kim TIl, Kim WH, et al. Long-Term Outcome and Surveillance Colonoscopy after Successful Endoscopic Treatment of Large Sessile Colorectal Polyps. Yonsei Med J 2016;57:1106.

    Article  PubMed  PubMed Central  Google Scholar 

  25. 25.

    Sakamoto GD, MacKeigan JM, Senagore AJ. Transanal excision of large, rectal villous adenomas. Dis Colon Rectum 1991;34:880–-5.

    Article  CAS  PubMed  Google Scholar 

  26. 26.

    Guerrieri M, Ortenzi M, Lezoche G, Mancini S, Ghiselli R. Transanal endoscopic microsurgery in the treatment of large rectal adenomas. Minerva Chir 2016;71:360–-4.

    PubMed  Google Scholar 

  27. 27.

    Barendse RM, Musters GD, de Graaf EJR, van den Broek FJC, Consten ECJ, Doornebosch PG, et al. Randomised controlled trial of transanal endoscopic microsurgery versus endoscopic mucosal resection for large rectal adenomas (TREND Study). Gut 2017;gutjnl-2016-313101.

  28. 28.

    McCloud JM, Waymont N, Pahwa N, Varghese P, Richards C, Jameson JS, et al. Factors predicting early recurrence after transanal endoscopic microsurgery excision for rectal adenoma. Colorectal Dis 2006;8:581–-5.

    Article  CAS  PubMed  Google Scholar 

  29. 29.

    Endreseth BH, Wibe A, Svinsas M, Marvik R, Myrvold HE. Postoperative morbidity and recurrence after local excision of rectal adenomas and rectal cancer by transanal endoscopic microsurgery. Color Dis 2005;7:133–7.

    Article  CAS  Google Scholar 

  30. 30.

    Zlatanic J, Waye JD, Kim PS, Baiocco PJ, Gleim GW. Large sessile colonic adenomas: use of argon plasma coagulator to supplement piecemeal snare polypectomy. Gastrointest Endosc 1999;49:731–5.

    Article  CAS  PubMed  Google Scholar 

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The study has not been presented previously in any form. All the authors contributed to the design and writing of the paper.

We thank the rest of the members of the Coloproctology Unit in the General Surgery Department and all the members of the Multidisciplinary Team in Colorectal Cancer for their help in applying the study protocol. We thank Cristina Gomez Vigo for correcting the manuscript and Michael Maudsley for his help with the English.

Author information




-Study conception and design: Serra-Aracil, Mora-Lopez, Ruiz-Edo.

-Acquisition of data: Serra-Aracil, Ruiz-Edo, Casalots-Casado, Mora-Lopez, Pallisera-Llobera, Serra-Pla, Puig-Diví, Navarro-Soto.

-Analysis and interpretation of data: Serra-Aracil, Ruiz-Edo, Casalots-Casado, Mora-Lopez, Pallisera-Llobera, Serra-Pla, Puig-Diví, Navarro-Soto.

-Drafting of manuscript: Serra-Aracil, Ruiz-Edo, Casalots-Casado, Mora-Lopez, Pallisera-Llobera, Serra-Pla, Puig-Diví, Navarro-Soto.

-Critical revision: Serra-Aracil, Ruiz-Edo, Casalots-Casado, Mora-Lopez, Pallisera-Llobera, Serra-Pla, Puig-Diví, Navarro-Soto.

Corresponding author

Correspondence to Neus Ruiz-Edo.

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Serra-Aracil, X., Ruiz-Edo, N., Casalots-Casado, A. et al. Importance of Resection Margins in the Treatment of Rectal Adenomas by Transanal Endoscopic Surgery. J Gastrointest Surg 23, 1874–1883 (2019).

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  • TEM
  • Rectal adenomas
  • Recurrence rectal adenomas
  • Follow-up rectal adenomas