Thématique :
- Endoscopie/Imagerie
Originalité :
Solidité :
Très solide
Doit faire évoluer notre pratique :
Dans certains cas
Nom du veilleur :
Docteur Yann LE BALEUR
Coup de coeur :
  2018 May;67(5):837-846.  
  doi: 10.1136/gutjnl-2016-313101.  
  Randomised controlled trial of transanal endoscopic microsurgery versus endoscopicmucosal resection for large rectal adenomas (TREND Study).  
  Barendse RM, Musters GD, de Graaf EJR, van den Broek FJC, Consten ECJ, Doornebosch PG, Hardwick JC, de Hingh IHJT, Hoff C, Jansen JM, van Milligen de Wit AWM, van der Schelling GP, Schoon EJ, Schwartz MP, Weusten BLAM, Dijkgraaf MG, Fockens P, Bemelman WA, Dekker E; TREND Study group.  



Non-randomised studies suggest that endoscopic mucosal resection (EMR) is equally effective in removing large rectal adenomas as transanal endoscopic microsurgery (TEM), but EMR might be more cost-effective and safer. This trial compares the clinical outcome and cost-effectiveness of TEM and EMR for large rectal adenomas.


Patients with rectal adenomas ≥3 cm, without malignant features, were randomised (1:1) to EMR or TEM, allowing endoscopic removal of residual adenoma at 3 months. Unexpected malignancies were excluded postrandomisation. Primary outcomes were recurrence within 24 months (aiming to demonstrate non-inferiority of EMR, upper limit 10%) and the number of recurrence-free days alive and out of hospital.


Two hundred and four patients were treated in 18 university and community hospitals. Twenty-seven (13%) had unexpected cancer and were excluded from further analysis. Overall recurrence rates were 15% after EMR and 11% after TEM; statistical non-inferiority was not reached. The numbers of recurrence-free days alive and out of hospital were similar (EMR 609±209, TEM 652±188, p=0.16). Complications occurred in 18% (EMR) versus 26% (TEM) (p=0.23), with major complications occurring in 1% (EMR) versus 8% (TEM) (p=0.064). Quality-adjusted life years were equal in both groups. EMR was approximately €3000 cheaper and therefore more cost-effective.


Under the statistical assumptions of this study, non-inferiority of EMR could not be demonstrated. However, EMR may have potential as the primary method of choice due to a tendency of lower complication rates and a better cost-effectiveness ratio. The high rate of unexpected cancers should be dealt with in further studies.


Question posée
La mucosectomie piecemeal est-elle équivalente à la TEM en terme de risque de récidive dans les LST rectales non dégénérées > 3 cm ?
Question posée

Cette étude randomisée multicentrique Européenne n’a pas pu etablir la non inferiorité statistique en terme de risque de récidive de la mucosectomie piece meal versus la TEM . Néanmoins la différence statistique de complications majeures (8% dans le groupe TEM versus 1 % dans le groupe mucosectomie) plaide pour l'indication d’une résection muqueuse endoscopique en première intention qui pour beaucoup d’auteurs devrait être dans le rectum une dissection sous muqueuse, qui est la vraie alternative à la TEM (on attend avec impatience l’étude randomisée TEM versus dissection dans les LST rectales).