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Transanal Excision of Tumor

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  • Stage T1 tumors:
    • Mobile and < 4 cm in diameter.
    • Involving < 40% of the rectal wall circumference.
    • Located within 6 cm of the anal verge.
  • Well or moderately differentiated histology only.
  • Absence of vascular and lymphatic invasion.
  • No evidence of nodal involvement on preoperative rectal ultrasound or MRI.

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Low Anterior Resection (LAR) with Total Mesorectal Excision

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  • Malignant lesion of the rectum diagnosed by evaluation of a tissue biopsy specimen obtained within 2 cm of the anal sphincter in moderately or well-differentiated tumors or within 5 cm for poorly differentiated tumors.

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Abdominoperineal Resection (APR) with Total Mesorectal Excision

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  • Malignant lesion of the rectum diagnosed by evaluation of a tissue biopsy specimen obtained < 2 cm from the anal sphincter for moderately or well-differentiated tumors or < 5 cm for poorly differentiated tumors.

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Transanal Excision of Tumor

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  • Tumors stage greater than T1N0M0.
  • Fixed tumors.
  • Tumors > 4 cm in diameter or involving > 40% of the circumference of the rectal wall.
  • Tumors located > 6 cm from the anal verge.
  • Tumors with poorly differentiated histology or angiolymphatic invasion, or those that show evidence of nodal involvement on preoperative rectal ultrasound or MRI.

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LAR with Total Mesorectal Excision

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  • Malignant lesion of the rectum diagnosed by evaluation of a tissue biopsy specimen obtained < 2 cm from the anal sphincter for moderately or well-differentiated tumors or < 5 cm for poorly differentiated tumors.

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APR with Total Mesorectal Excision

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  • Malignant lesion of the lower rectum diagnosed by evaluation of a tissue biopsy specimen showing local invasion into the pelvic sidewall or pelvis that could benefit from neoadjuvant treatment to facilitate possible curative resection.

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Transanal Excision of Tumor

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Expected Benefits

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  • Removal of tumor with preservation of anus.
  • Avoidance of radical surgery.

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Potential Risks

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  • Bleeding requiring reoperation.
  • Rectal stricture.
  • Need for further resection based on pathologic findings.
  • Fistula to prostate or vagina.
  • Injury to the urethra for distal anterior tumors in men.

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LAR or APR with Total Mesorectal Excision

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Expected Benefits

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  • Treatment of rectal cancer.
  • Potential prevention of colonic obstruction, tenesmus, and invasion of adjacent pelvic structures.

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Potential Risks

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  • Bleeding requiring reoperation from presacral or splenic injuries (LAR or APR) or from the anastomosis (LAR).
  • Infection, including intra-abdominal or pelvic abscesses resulting from anastomotic leaks (LAR) or infected intra-abdominal or pelvic fluid collections (LAR or APR).
  • Fistula formation from anastomotic leak (LAR).
  • Postoperative ileus (LAR or APR).
  • Ureteral injury (LAR or APR).
  • Need for a permanent or temporary stoma (LAR).
  • Bladder or sexual dysfunction (LAR or APR).
  • Fecal incontinence (LAR).
  • Clustering of bowel movements (LAR).

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Transanal Excision of Tumor

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  • Self-retaining (Ferguson) anoscope.
  • Lone Star retractor (for more proximal lesions).

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LAR or APR with Total Mesorectal Excision

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  • Self-retaining retractors.
  • Bookwalter abdominal retractor with a lighted St. Mark's retractor.
  • Lone Star retractor (for perineum).
  • Handheld lighted St. ...

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