Endoscopic Transanal Resection Provides Palliation Equivalent to Transabdominal Resection in Patients With Metastatic Rectal Cancer zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIH Herbert Chen, M.D., Bruce D. George, ER.C.S., Howard S. Kaufian, M.D., EA.C.S., Mohammad B. Malaki, NeilJ. McC. Mortemen, ER.C.S., Michael G. W KettLewell, ER.C.S. Patients with metastatic rectal cancer precluding curative low anterior resection (LAR) or ab- dominoperineal resection (APR) can require palliation for impending obstruction. LAR or APR is fre- quently not optimal because of the associated operative morbidity. Lesser procedures such as diverting colostomy require patients to live with a permanent stoma. Endoscopic transanal resection (ETAR) has been used for excision of rectal lesions. To determine whether ETAR provides palliation equivalent to LAR or APR, we reviewed the outcomes of 49 patients with rectal adenocarcinoma and unresectable liver metastases who required palliative intervention between January 1989 and July 1996. Of these 49 pa- tients, 24 underwent ETAR; the intraluminal tumor was resected using the urologic resectoscope to achieve a hemostatic, patent lumen. The outcomes of these patients were compared to those of the other 25 patients who had palliative LAR, APR, or a Hartmann procedure during the same period. The median distance of the tumors from the anal verge was similar (5 cm; range 1 to 15 cm). ETAR patients had a higher percentage of poorly differentiated tumors (35% vs. 6%, P = 0.034) and higher preoperative al- kaline phosphatase values (478 -C 75 mg/dl vs. 23 zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFED 1 k 24 mg/dl; P <0.015), suggesting more aggressive disease and greater hepatic tumor burden, respectively. Despite these differences, overall survival and time spent outside the hospital were similar in the two groups. The median number of debulking proce- dures required in the 24 ETAR patients was two (range 1 to 17). Resections in the 2 5 LAR/APR patients included LAR in 20, APR in two, and Hartmann procedures in three. There was a trend toward more stomas in the LAR/APR group (28% vs. 17%). More important, morbidity was significantly higher in the LAIUApR patients (24% vs. 4%; P = 0.049). In conclusion, ETAR is a safe alternative for the palliation of incurable rectal tumors. Compared to transabdominal resection, ETAR provides equivalent palliation as measured by survival and proportion of the patient’s life spent outside the hospital, with a lower stoma rate and significantly less morbidity. Therefore, in select patients with metastatic rectal cancer, ETAR is an important palliative option. (J GA STROINTEST SURG 2001;5:282-286.) KEY WORDS: Rectal cancer, endoscopy, palliation, colon resection Operative resection by low anterior resection (LAR) or abdominoperineal resection (APR) remains the standard for curative treatment of rectal adeno- carcinoma. Unfortunately, some patients present with widely metastatic disease precluding curative resec- tion. Such patients with stage IV disease often have symptoms such as rectal bleeding or impending ob- struction that necessitate palliation. Palliative LAR or APR is frequently not optimal because of the associ- ated operative morbidity, especially in elderly pa- tients.’ Other surgical options include diverting colostomy, which requires patients to live with a per- manent stoma for their limited life expectancy, and U-ansanal resection for smaller primary lesions. Endoscopic transanal resection (ETAR) using the urologic resectoscope has been described for the man- agement of select benign and malignant lesions of the rectum.*m9 During this minimally invasive procedure, From the Departments of Surgery, University of Wisconsin Medical School (H.C.), Madison, Wk.; The John Radcliffe Hospital (B.D.G., M.B.M., N.J.M.M., and M.G.W.K.), Oxford, England; and The Johns Hopkins Medical Institutions (H.S.K.), Baltimore, Md. Presented at the Forty-First Annual Meeting of The Society for Surgery of the Alimentary Tract, San Diego, Calif., May 2 l-24,2000. Reprint requests: Herbert Chen, M.D., Department of Surgery, University of Wisconsin Medical School, H4/ 750 Clinical Science Cen- ter, 600 Highland Ave., Madison, Wl 53792. 282