1. Interesting case

2. OD 224562963 62 yo man with irretrievable rectal TVA on screening colonoscopy, prior transanal excision 8 cm from anal verge Pmhx: hypothyroidism, arthritis Pshx: appendectomy, bilateral inguinal hernia repair Meds: ASA, MVI

3. Decision made to proceed with transanal minimally invasive surgery Lesion located between lowest and middle rectal valves Positioning: prone with leg splitter Applied Medical gelport, 90 degree scope, laparoscopic instruments

5. Rectal adenoma Villous adenoma is a premalignant lesion 2/3 occur in the rectum Equal sex distribution, peak incidence 6 th and 7 th decades Difficult to detect Harbor malignancy in 40% of cases Biopsy often misses 40% of cancers

6. Patients older than 80 undergoing APR have 15% risk of perioperative death ASA grade I patients have perioperative mortality of 0.5% ASA grade IV patients have risk approaching 25% Consider impact of radical surgery on QOL

7. Surgical options Local excision with transanal technique Kraske sacral operation Radical excision (LAR or APR) Transanal Endoscopic MicroSurgery Transanal Minimally Invasive Surgery

9. What is TAMIS? Named by Atallah et als Described its use in 6 patients, 2 with early rectal cancers Crossover technique using SILS equipment

11. Single surgeon experience using TAE vs transbdominal resections Main outcomes were complications, recurrence and malignancy rates

13. Retrospective review T1 and T2 rectal cancers Local excisions from 1997-2006 42 TEMS, 129 TAE patients

16. Median followup 60 months for TEMS, 45 for TAE Only 34 patients had local recurrence 145 of 164 patients were disease free at last followup

17. Authors conclude that TEMS resection is superior to TAE Indications for both may overlap Variables such as tumor distance from AV, T stage and adjuvant therapy may be more important predictors of outcome

18. Conclusions Local excision safe for villous adenomas and early rectal cancers by multiple means (TAE, TEMS, TAMIS) Careful patient selection Diligent followup Discussion with patient about radical surgery