Local excision of rectal neoplasia: a real-world survey of current practices and perspectives

Background: Advancements in transanal management of rectal tumours have improved outcomes in appropriately selected patients. However, variation exists regarding optimal perioperative investigational and surgical strategy. This survey captures current opinions and practices of surgeons managing rectal neoplasia transanally. Methods: Electronic survey regarding theranostic approaches for the transanal management of rectal neoplasia distributed via European surgical associations’ mailing lists. Results: One hundred and thirty-four surgeons from 29 countries responded, 49%, 80% and 4.5% of whom respectively perform ≤5, ≤10, and >20 excisions/year. Transanal Minimally Invasive Surgery (TAMIS) was the most popular access method (75.4%), with rigid platforms (Transanal Endoscopic Microsurgery/Transanal Endoscopic Operation) and flexible methods being used similarly (42.5% vs. 43.3%). MRI was considered the most reliable preoperative investigation overall. Surgeons performing >10 cases/year were more likely to use submucosal (53.8% vs. 31.1%, p = 0.03) and intermuscular (38.5% vs. 14.2%, p = 0.005) planes of excision and narrow band imaging as an assessment requirement (p = 0.009) but less likely to insist on MRI (p < 0.001). Surgeons performing >5 cases/year were more likely to use multiple access methods (67.6% vs. 40.9%, p = 0.003). TAMIS users were more likely to perform full thickness and intermuscular excisions (p < 0.001) with surgeons who use flexible endoscopy more likely to use the submucosal plan (p < 0.001). Conclusions: Various surgical and perioperative practices exist for significant rectal neoplasia with significant variance by caseload, access method, and geographical location.