Radiol Oncol 1997; 31: 109-8.
Local excision of flat adenomas of the rectum in the period
from 1987 to 1991
Janko Novak
University Medical Centre Surgical Services, Dept. for Abdominal Surgery, Hospital P. Drzaj,
Ljubljana, Slovenia
In a period of 5 years, 35 patients underwent operations on for flat adenomas of the rectum located at a depth of 10 cm from the anocutaneous line. All the tumours were removed by transanal submucous excision. The average period of follow-up was 22 months. Three recurrences were detected and treated with reoperation. No major complications occurred. We consider our method suitable for clinical use if combined, with careful follow-up.
Key words: rectal adenomas; surgery
Introduction
This report presents the results of surgical treatment of flat adenoma of the rectum at the Proctology Unit of the Department of Gastroenterologie Surgery in Ljubljana. Thirty-five patients underwent operations during a period of 5 years. The safety and success of the surgical procedure were evaluated with regard to peri- and postoperative complications and the frequency of recurrence. Our series is too small to reveal a possible association between the histologic type of the tumour and likelyhood of recurrence.'
Patients and methods
In the years from 1987 to 1991, 35 patients with flat adenoma of the rectum attended our outpatient clinic. The lesions were located within 10 cm from anocutaneous line. Prior to surgery, the patients underwent colonoscopy, a routine preoperative investigation and, in case of associated conditions, also appropriate preoperative preparations. The operation was performed under epidural or caudal anaesthesia. The patients received a preoperative ene-
Correspondence to: Dr. Janko Novak, Bolnišnica Petra Držaja, Oddelek za abdominalno kirurgijo, Vodnikova 62, 1000 Ljubljana, Slovenia
UDC: 616.351-006.6-089
ma and intraoperative antibiotic prophylaxis consisting of metronidazol 500 mg and gentamicin 80 mg in a single dose. Local excision was performed with the use of Park's retractor. The submucous layer was infiltrated with physiological solution to facilitate exposure. In 11 cases, the defect was closed with a running suture. In the rest, hemosta-sis was achieved with individual sutures.23 The removed adenomas were histologically classified according to Morson's system. The patients attended for follow-up proctoscopy a month after the procedure to rule out residual tumour. Further follow-up proctoscopies were performed at monthly intervals during the first year and annually later on.4
Results
In 5-year period, 341 patients with polyps involving different parts of the large intestine were treated at our department. Among them were 35 patients with flat adenomas located at a depth of up to 10 cm from anocutaneous line. This group included 19 women and 16 men, aged between 39 and 85 years (Table 1). The distribution of operations over the 5-year period is shown in Table 2.
The base of the resected adenomas ranged in size from 1.5 to 5.5 cm (Table 3). One patient required a reoperation on for control of haemorrhage. No other major complications were encountered. The op-
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erated site healed completely in all the patients. Histologic classification of the resected adenomas according to Morson's method is presented in Table 4. Three recurrences were detected at follow-up. One of them, in a male patient, showed malignant alteration. All three patients with recurrent adenomas received appropriate surgical treatment.
Table 1. Age of patients.
Age of patients by				
Decade 4 5		6	7	8
Number 2 5		9	11	8
Table 2. Beginning of treatment.				
Beginning of treatment				
Year 87 88		89	90	91
Number 8 6		5	9	7
Table 3. Base diameter.				
Base diameter				
In cm 1,5 2 2,5	3	3,5	4 4,5	5 5,5
Number 1 0 4	7	9	8 3	1 2
Tabic 4. Grade of dysplasia.				
Grade of dysplasia				
Histologic type 1		2	3	Total
Villous 1		3	4	8
Tubular 0		2	8	10
Tubulovillous 0		6	11	17
Total 1		11	23	35
Discussion and conclusion
We consider our method to be favourable for the patient as hospitalization is relatively short. With careful follow up, recurrences can be detected and reoperated on before the tumours undergo malignant alteration requiring more extensive resection that may lead to permanent disability or premature death. To our judgement and by our experience and data from literature, these patients may be followed-up after the first year in the same manner as any patients with adenoma involving other parts of the colon. Likelyhood of recurrence for individual histologic types of resected adenomas could not be estimated because of inadequate size of the series and advanced age of our patients, many of whom died of other conditions in the course of follow-up.1'4
References
1.	Morson BC. Gastrointestinal pathology. London: Harvey Miller Press, 1988: 222-51.
2.	Goligher JC. Surgery of the anus, rectum and colon. London: Baillere Tyndall Press, 1975: 442-58.
3.	Kuegler S. Praktische Proctologic. Stutgartt: Thieme Verlag, 1976: 70-7.
4.	Verne J. Mass screening for colorectal cancer and adenomas, might it saves lives: modern coloproctology. St. Marks Hospital. London: Edward Arnold Press, 1993.