The findings showed that low- and high-risk criteria are too robust for identifying tumors at risk for LR. Tumor size alone or in combination with submucosal invasion depth or tumor budding appeared to be a significant predictive factor for locoregional failure after TEM for T1 rectal cancer.

Background Previous research indicates that application of 5-mm harmonic shears rather than diathermia significantly reduces operation time in transanal endoscopic microsurgery (TEM). Frequently, however, additional instruments were required to complete resection. We investigated whether the new 5-mm harmonic long shears (H-LS) are better equipped for TEM compared with regular harmonic shears (HS). Methods Between 2001 and 2006, 162 tumors (117 adenomas, 42 carcinomas, and 3 other tumors; mean distance 6.6 cm, mean area 40 cm 2 ) were excised in 161 patients (82 men, 79 women; mean age 66 years). Results Eighty-eight resections were performed with HS and 74 with H-LS. Tumor and patient characteristics were similar except for specimen area. Tumors resected by H-LS were on average smaller than those resected by HS (34.4 versus 44.1 cm 2 ; Mann-Whitney U-test: p = 0.027). Mean operation time was 48 min and proportional to area in both groups (univariate analysis of variance p \ 0.001). Mean operation time was 54 min using HS and 41 min using H-LS (t-test: p \ 0.001). After correction for area, operation time for H-LS was reduced by 14% compared with HS (t-test: p \ 0.001). H-LS is singly capable of completing resection in 88% compared with 26% for HS (MannWhitney U-test: p \ 0.001). Mean blood loss was 16 cc for HS and 3 cc for H-LS (p \ 0.001). Morbidity (11%) and mortality (0.6%) were not different between the two groups (Fisher's exact test). Conclusion Performing transanal endoscopic microsurgery with 5-mm harmonic long shears reduces operation time compared with regular shears, and completing resection seldom requires other instruments.Transanal endoscopic microsurgery (TEM) is a minimal invasive technique for local resection of rectal tumors. Because of the excellent results in safety and radicality and because of low rates of recurrence, TEM is the method of choice for resecting adenomas in the rectosigmoid [1][2][3][4][5][6][7][8].Despite the attribution of negative properties to monopolar diathermia, such as capacitive coupling, burns, and thermal damage, it remains the preferred method for dissection in both open and endoscopic surgery [9][10][11]. The original TEM set applied a high-frequency knife for monopolar cutting and coagulation. Evolution of TEM technology resulted in a purpose-designed multifunctional tool with bipolar cutting and monopolar coagulation: the TEM 400 instrument (T400) [12,13]. Other studies suggest use of regular endoscopic instruments in TEM, applying

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