Scala et al1 present one of the largest series of patients who underwent transanal endoscopic microsurgery (TEMS) for rectal adenomas. In this series, the authors analyzed an important question in the management of polyps of the rectum. Their results offered new insights into the management of large benign adenomas of the colon.
Historically, large lesions of the rectum have been referred for resection using an abdominal approach, often leaving some patients with long-term defecatory dysfunction. As technology has advanced, newer procedures are available to remove these polyps in less-invasive ways. As the authors pointed out, the outcomes of these different methods should be carefully examined so that the care of patients with cancer is not compromised. It is comforting to know that the malignancy rate in large rectal adenomas is low and that perhaps in some cases, the TEMS procedure can serve as an additional safe excisional biopsy technique, allowing for additional therapy to be given prior to a larger, more definitive resection. Finally, what is lacking in the management of these patients is more definitive preoperative staging methods, which would take the guess work out of the equation.