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Gascon MA, Aguilella V, Martinez T, Antinolfi L, Valencia J, Ramírez JM. Local full-thickness excision for sessile adenoma and cT1-2 rectal cancer: long-term oncological outcome. Langenbecks Arch Surg 2022; 407:2431-2439. [PMID: 35732844 PMCID: PMC9467953 DOI: 10.1007/s00423-022-02593-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 06/15/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE We analyzed all patients who underwent local transanal surgery at our institution to determine oncological outcomes and perioperative risk. METHODS In 1997, we developed a prospective protocol for rectal tumors: transanal local full-thickness excision was considered curative in patients with benign adenoma and early cancers. In this analysis, 404 patients were included. To analyze survival, only those patients exposed to the risk of dying for at least 5 years were considered for the study. RESULTS The final pathological analysis revealed that 262 (64.8%) patients had benign lesions, whereas 142 had malignant lesions. Postoperative complications were recorded in 12.6%. At the median time of 21 months, 14% of the adenomas and 12% of cancers had recurred, half of which were surgically resected. The overall 5-year survival rate was 94%. CONCLUSION With similar outcomes and significantly lower morbidity, we found local surgery to be an adequate alternative to radical surgery in selected cases of early rectal cancer.
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Affiliation(s)
- Maria A Gascon
- Department of Surgery, "Lozano Blesa" University Hospital, San Juan Bosco 15, 50009, Saragossa, Spain
| | - Vicente Aguilella
- Department of Surgery, "Lozano Blesa" University Hospital, San Juan Bosco 15, 50009, Saragossa, Spain
| | - Tomas Martinez
- Department of Microbiology, Preventive Medicine and Public Health, University of Zaragoza, Domingo Miral s/n 50009-Saragossa, Spain
| | - Luigi Antinolfi
- Department of Surgery, "Lozano Blesa" University Hospital, San Juan Bosco 15, 50009, Saragossa, Spain
| | - Javier Valencia
- Department of Radiotherapy, "Lozano Blesa" University Hospital, San Juan Bosco 15, 50009, Saragossa, Spain
| | - Jose M Ramírez
- Department of Surgery, "Lozano Blesa" University Hospital, San Juan Bosco 15, 50009, Saragossa, Spain.
- Aragon Health Research Institute, San Juan Bosco 13, 50009, Saragossa, Spain.
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Ondhia M, Tamvakeras P, O'Toole P, Montazerri A, Andrews T, Farrell C, Ahmed S, Slawik S, Ahmed S. Transanal endoscopic microsurgery for rectal lesions in a specialist regional early rectal cancer centre: the Mersey experience. Colorectal Dis 2019; 21:1164-1174. [PMID: 31207005 PMCID: PMC6900238 DOI: 10.1111/codi.14730] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 06/14/2019] [Indexed: 12/13/2022]
Abstract
AIM Organ-preserving local excision by transanal endoscopic microsurgery (TEM) for early rectal cancer offers significantly lower morbidity as compared to formal rectal cancer resection with acceptable outcomes. This study presents our 6-year experience of TEM for rectal lesions referred to a specialist early rectal cancer centre in the UK. METHOD Data were collected for all patients referred for TEM of suspected early rectal cancer to a regional specialist early rectal cancer multidisciplinary team (MDT) over a 6-year period. RESULTS One hundred and forty-one patients who underwent full-thickness TEM for suspected or confirmed early rectal cancer were included. Thirty patients were referred for TEM following incomplete endoscopic polypectomy. Final pathology was benign in 77 (54.6%) cases and malignant in 64 (45.4%). Of the 61 confirmed adenocarcinomas, TEM resections were pT0 in 17 (27.9%), pT1 in 32 (51.7%), pT2 in 11 (18.0%) and pT3 in 1 (1.6%). Thirty-eight of 61 patients (62.3%) had one or more poor histological prognostic features and these patients were offered further treatment. Twenty-three of 61 (37.7%) patients with rectal adenocarcinoma required no further treatment following TEM. Forty-three cases of rectal adenocarcinoma were available for establishing recurrence rates. Two of 43 patients (4.7%) developed a recurrence at a median follow-up of 28.7 months (12.1-66.5 months). The overall estimated 5-year overall survival rate was 87.9% and the disease-free survival rate was 82.9%. CONCLUSION Acceptable outcomes are possible for TEM surgery with appropriate patient selection, effective technique, expert histopathology, appropriate referral for adjuvant treatment and meticulous follow-up. This can be achieved through an early rectal cancer MDT in a dedicated specialist regional centre.
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Affiliation(s)
- M. Ondhia
- Royal Liverpool and Broadgreen University Hospital NHS TrustLiverpoolUK
| | - P. Tamvakeras
- Aintree University Hospital NHS Foundation TrustLiverpoolUK
| | - P. O'Toole
- Royal Liverpool and Broadgreen University Hospital NHS TrustLiverpoolUK
| | - A. Montazerri
- Clatterbridge Cancer Centre NHS Foundation TrustWirralUK
| | - T. Andrews
- Royal Liverpool and Broadgreen University Hospital NHS TrustLiverpoolUK
| | - C. Farrell
- Royal Liverpool and Broadgreen University Hospital NHS TrustLiverpoolUK
| | - S. Ahmed
- Aintree University Hospital NHS Foundation TrustLiverpoolUK
| | - S. Slawik
- Aintree University Hospital NHS Foundation TrustLiverpoolUK
| | - S. Ahmed
- Royal Liverpool and Broadgreen University Hospital NHS TrustLiverpoolUK
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Spinelli P, Calarco G, Gallo C, Rigante A, Schicchi AA. Endoscopic Treatment of Carpet-Like Adenomas of the Rectum. TUMORI JOURNAL 2018; 85:265-8. [PMID: 10587029 DOI: 10.1177/030089169908500410] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background Transanal microsurgery, endoscopic laser photocoagulation and snare resection have all been used to treat large sessile adenomas of the rectum alternatively to a surgical approach. However, such modalities are often defective due to the carpet-like shape and the frequently large extension of the lesions. Methods Ten patients with carpet-like adenoma were submitted to transanal endoscopic resection by urological resectoscope. Results Complete eradication was obtained in all lesions. The mean number of treatment sessions was 3 (range, 1-5). The mean time between the first treatment and the complete eradication was 6 months (range, 1-18). The only complications were an intraoperative and an early postoperative bleeding. There was no early or late mortality related to the procedure. Conclusions Transanal endoscopic resection by urological resectoscope appears to be a suitable therapeutic approach for sessile and carpet-like adenomas of the rectum or for pTI cancer in patients who refuse major surgery.
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Affiliation(s)
- P Spinelli
- Divisione di Diagnostica e Chirurgia Endoscopica, Istituto Nazionale per lo Studio e la Cura dei Tumori, Milan, Italy.
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4
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Abstract
Transanal endoscopic surgery (TES) techniques encompass a variety of approaches, including transanal endoscopic microsurgery and transanal minimally invasive surgery. These allow a surgeon to perform local excision of rectal lesions with minimal morbidity and the potential to spare the need for proctectomy. As understanding of the long-term outcomes from these procedures has evolved, so have the indications for TES. In this study, we review the development of TES, its early results, and the evolution of new surgical techniques. In addition, we evaluate the most recent research on indications and outcomes in rectal cancer.
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Affiliation(s)
- Earl V Thompson
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Joshua I S Bleier
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
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5
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Devaraj B, Kaiser AM. Impact of technology on indications and limitations for transanal surgical removal of rectal neoplasms. World J Surg Proced 2015; 5:1. [DOI: 10.5412/wjsp.v5.i1.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Revised: 12/21/2014] [Accepted: 01/19/2015] [Indexed: 02/06/2023] Open
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McLemore EC, Weston LA, Coker AM, Jacobsen GR, Talamini MA, Horgan S, Ramamoorthy SL. Transanal minimally invasive surgery for benign and malignant rectal neoplasia. Am J Surg 2014; 208:372-81. [PMID: 24832238 DOI: 10.1016/j.amjsurg.2014.01.006] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 12/27/2013] [Accepted: 01/05/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND Transanal minimally invasive surgery (TAMIS), an alternative technique to transanal endoscopic microsurgery, was developed in 2009. Herein, we describe our initial experience using TAMIS for benign and malignant rectal neoplasia. METHODS This is an institutional review board approved, retrospective case series report. RESULTS TAMIS was performed in 32 patients for rectal adenoma (13), adenocarcinoma (16), and carcinoid (3). There were 14 women, with mean age 62 ± 15 years and body mass index 28 ± 5 kg/m(2). Lesion size ranged from .5 to 8.5 cm, distance from the dentate line 1 to 11 cm, and circumference of the lesion 10% to 100%. The mean operative time was 123 ± 62 minutes. Mean hospital length of stay was 2.5 ± 2 days. Complications included urinary tract infection (1), Clostridium difficile diarrhea (1), atrial fibrillation (1), rectal stenosis (1), and rectal bleeding (1). CONCLUSION TAMIS using a disposable transanal access platform is a safe and effective method to remove rectal lesions in this case series.
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Affiliation(s)
| | - Lynn A Weston
- Department of Surgery, Scripps Health Systems, San Diego, CA, USA
| | - Alisa M Coker
- Department of Surgery, University of California, San Diego, CA, USA
| | - Garth R Jacobsen
- Department of Surgery, University of California, San Diego, CA, USA
| | - Mark A Talamini
- Department of Surgery, University of California, San Diego, CA, USA
| | - Santiago Horgan
- Department of Surgery, University of California, San Diego, CA, USA
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Heidary B, Phang TP, Raval MJ, Brown CJ. Transanal endoscopic microsurgery: a review. Can J Surg 2014; 57:127-38. [PMID: 24666451 PMCID: PMC3968206 DOI: 10.1503/cjs.022412] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2013] [Indexed: 12/18/2022] Open
Abstract
Rectal adenomas and cancers occur frequently. Small adenomas can be removed colonoscopically, whereas larger polyps are removed via conventional transanal excision. Owing to technical difficulties, adenomas of the mid- and upper rectum require radical resection. Transanal endoscopic microsurgery (TEM) was first designed as an alternative treatment for these lesions. However, since its development TEM has been also used for a variety of rectal lesions, including carcinoids, rectal prolapse and diverticula, early stage carcinomas and palliative resection of rectal cancers. The objective of this review is to describe the current status of TEM in the treatment of rectal lesions. Since the 1980s, TEM has advanced substantially. With low recurrence rates, it is the method of choice for resection of endoscopically unresectable adenomas. Some studies have shown benefits to its use in treating early T1 rectal cancers compared with radical surgery in select patients. However, for more advanced rectal cancers TEM should be considered palliative or experimental. This technique has also been shown to be safe for the treatment of other uncommon rectal tumours, such as carcinoids. Transanal endoscopic microsurgery may allow for new strategies in the treatment of rectal pathology where technical limitations of transanal techniques have limited endoluminal surgical innovations.
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Affiliation(s)
- Behrouz Heidary
- From the Department of Surgery, St. Paul’s Hospital, University of British Columbia, Vancouver, BC
| | - Terry P. Phang
- From the Department of Surgery, St. Paul’s Hospital, University of British Columbia, Vancouver, BC
| | - Manoj J. Raval
- From the Department of Surgery, St. Paul’s Hospital, University of British Columbia, Vancouver, BC
| | - Carl J. Brown
- From the Department of Surgery, St. Paul’s Hospital, University of British Columbia, Vancouver, BC
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Khoury W, Igov I, Issa N, Gimelfarb Y, Duek SD. Transanal endoscopic microsurgery for upper rectal tumors. Surg Endosc 2014; 28:2066-71. [DOI: 10.1007/s00464-014-3428-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Accepted: 01/02/2014] [Indexed: 11/30/2022]
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Levic K, Bulut O, Hesselfeldt P. Transanal endoscopic microsurgery for giant polyps of the rectum. Tech Coloproctol 2013; 18:521-7. [PMID: 24057356 DOI: 10.1007/s10151-013-1069-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Accepted: 09/06/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND The potential for malignancy in rectal polyps increases with the size of the polyp, and unexpected malignancy is reported in up to 39 % of large rectal adenomas. Transanal endoscopic microsurgery (TEM) offers the possibility of an en bloc full-thickness excision for lesions in the rectum. We present our results with TEM in the removal of giant polyps equal or greater than 4 cm in diameter. METHODS In the period between 1998 and 2012, TEM was performed in 39 patients with rectal polyps measuring at least 4 cm in diameter. Transrectal ultrasound and/or magnetic resonance imaging of the rectum was used when cancer was suspected. RESULTS The polyp was removed with en bloc full-thickness excision in 77 % (n = 30). The preoperative diagnosis was benign rectal adenoma in 89.7 % (n = 35). The median size of the polyps was 30 cm(2) (range 16-100 cm(2)). Postoperative complications included bleeding in 4 patients (10.3 %). Histological examination showed unexpected cancer in 4 patients (10.3 %). TEM was curative in 2 of these patients, and the other 2 underwent further surgery. Recurrences occurred in 10 patients (25.6 %) and consisted of 5 adenomas and 5 adenocarcinomas. In 5 patients, these recurrences were treated with endoscopic removal or re-TEM. The remaining 5 underwent total mesorectal excision and/or chemotherapy. CONCLUSIONS Full-thickness TEM provides a safe and efficient treatment for excision of giant polyps. In case of unexpected cancer, TEM can be curative. Local recurrence can be often treated with a second TEM procedure.
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Affiliation(s)
- K Levic
- Department of Surgical Gastroenterology, Copenhagen University Hospital Hvidovre, Kettegaards Allé 30, 2650, Hvidovre, Copenhagen, Denmark
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10
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Complications of transanal endoscopic microsurgery are rare and minor: a single institution's analysis and comparison to existing data. Dis Colon Rectum 2013; 56:295-300. [PMID: 23392142 DOI: 10.1097/dcr.0b013e31827163f7] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Transanal endoscopic microsurgery, a minimally invasive procedure for treatment of early-stage rectal cancer, carcinoid tumors, and adenomas, is shown to be a safe procedure with very low perioperative morbidity. OBJECTIVE We aimed to compare the outcomes of transanal endoscopic microsurgery at a large volume tertiary care center with the existing literature. DESIGN We retrospectively reviewed a prospectively collected database of 325 transanal endoscopic microsurgery procedures and looked for risk factors associated with complications. Indications for transanal endoscopic microsurgery included rectal adenocarcinomas, adenomas, and carcinoids. SETTING Procedures were performed by a single surgeon at a large-volume tertiary care center. PATIENTS Patients were enrolled over a 20-year period, and data were collected on demographics, perioperative details, tumor characteristics, and complications. INTERVENTIONS Transanal endoscopic microsurgery was performed on all 325 patients. MAIN OUTCOME MEASURES Main outcome measures were urinary retention, late bleeding requiring intervention, dehiscence, peritoneal cavity entry, conversion to abdominal approach, fecal soiling, and rectovaginal fistula. RESULTS Intraoperative bleeding was associated with larger tumor size, whereas postoperative bleeding requiring intervention was not associated with any factors studied. Peritoneal cavity entry and urinary retention were more likely if the tumor was in either the anterior or lateral position in the rectum. The peritoneal cavity was entered in 9 patients, and conversion to abdominal approach occurred in 1 patient. Intraoperative bleeding, by surgeon's choice, and urinary retention, by patient's choice, were associated with a greater likelihood of admission to the inpatient ward. Fecal soiling was not reported by patients and not recorded. LIMITATIONS This study was limited because it was a retrospective analysis CONCLUSIONS Transanal endoscopic microsurgery is an extremely safe procedure, offering very low perioperative morbidity. The overall morbidity found in our study was 10.5%, on par with published data for large series of 21%, 7.7%, and 14.9%. In contrast, complications from radical resection are reported at 18% to 55%.
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Transanal minimally invasive surgery (TAMIS) for local excision of benign neoplasms and early-stage rectal cancer: efficacy and outcomes in the first 50 patients. Dis Colon Rectum 2013; 56:301-7. [PMID: 23392143 DOI: 10.1097/dcr.0b013e31827ca313] [Citation(s) in RCA: 160] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Since its inception in 2009, transanal minimally invasive surgery has been used increasingly in the United States and internationally as an alternative to local excision and transanal endoscopic microsurgery for local excision of neoplasms in the distal and mid rectum. Despite its increasing acceptance, the clinical benefits of transanal minimally invasive surgery have not yet been validated. OBJECTIVE The aim of this study is to assess the adequacy of transanal minimally invasive surgery for the local excision of benign and malignant lesions of the rectum. DESIGN This is a retrospective analysis of consecutive patients who underwent transanal minimally invasive surgery for local excision of neoplasms at a single institution. SETTINGS The study was conducted by a single group of colorectal surgeons at a tertiary referral center. PATIENTS Eligible patients with early-stage rectal cancer and benign neoplasms were offered transanal minimally invasive surgery as a means for local excision. Data from these patients were collected prospectively in a registry. MAIN OUTCOME MEASURES The primary outcome measures included the feasibility of transanal minimally invasive surgery for local excision, resection quality, and short-term clinical results. RESULTS : Fifty patients underwent transanal minimally invasive surgery between July 2009 and December 2011. Twenty-five benign neoplasms, 23 malignant lesions, and 2 neuroendocrine tumors were excised. All lesions were excised using transanal minimally invasive surgery without conversion to an alternate transanal platform. The average length of stay was 0.6 days (range, 0-6), and 68% of patients were discharged on the day of surgery. The average distance from the anal verge was 8.1 cm (range, 3-14 cm). All lesions were excised completely with only 2 fragmented specimens (4%). All specimens were removed with grossly negative margins, although 3 (6%) were found to have microscopically positive margins on final pathology. There were 2 recurrences (4%) at 6- and 18-month follow-up. Early complications occurred in 3 patients (6%). No long-term complications were observed at a median follow-up of 20 months. LIMITATIONS The study was limited by its retrospective nature and midterm follow-up. CONCLUSIONS Transanal minimally invasive surgery is an advanced transanal platform that provides a safe and effective method for resecting benign neoplasms, as well as carefully selected, early-stage malignancies of the mid and distal rectum.
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McLemore EC, Coker A, Jacobsen G, Talamini MA, Horgan S. eTAMIS: endoscopic visualization for transanal minimally invasive surgery. Surg Endosc 2012. [PMID: 23179071 DOI: 10.1007/s00464-012-2652-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Transanal endoscopic microsurgical (TEM) resection is associated with improved outcomes compared to transanal excision of rectal lesions. However, TEM equipment requires additional operative setup time, and tumor location dictates patient positioning. In 2010, Drs. Attallah, Albert, and Larach developed an alternative technique, transanal minimally invasive surgery (TAMIS). Herein, we describe our novel experience using endoscopic visualization to perform TAMIS (eTAMIS) to remove a large rectal polyp. METHODS This is a technical note describing a new surgical technique, eTAMIS. The technique is performed with the Gelpoint Path TAMIS platform (Applied Medical, Rancho Santa Margarita, CA) and a standard single-channel endoscope for visualization. Patient demographics, operative data, and pathologic data were recorded. RESULTS eTAMIS was initially performed in a 50-year-old woman with an endoscopically defiant rectal mass discovered on routine screening colonoscopy. The lesion was a tubulovillous adenoma, 10 cm from the anal verge, anterior, and occupied 15-20 % of the circumference. The rectal mass was removed by eTAMIS. The operative time was 101 minutes, and the patient was discharged within 24 h without event. Final pathology revealed a focus of well-differentiated rectal adenocarcinoma with focal invasion into the muscularis mucosa (Haggit level 0, pTis) arising in the head of a pedunculated tubulovillous adenoma. At 1-year follow-up endoscopy, the patient had no evidence of recurrent mass or polyp. CONCLUSIONS This is the first technical report describing endoscopic visualization for TAMIS. Endoscopic visualization facilitates intraluminal articulation and lens cleaning while minimizing extraluminal instrument collisions. eTAMIS is a practical and logical evolution of the visual approach to natural orifice transluminal endoscopic surgery and laparoendoscopic surgery.
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Affiliation(s)
- Elisabeth C McLemore
- UC San Diego Medical Center, Moores Cancer Center, Department of Surgery, University of California, 3855 Health Sciences Dr., #0987, La Jolla, San Diego, CA 92093-0987, USA.
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Kunitake H, Abbas MA. Transanal endoscopic microsurgery for rectal tumors: a review. Perm J 2012; 16:45-50. [PMID: 22745615 DOI: 10.7812/tpp/11-120] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Since its introduction in 1983, transanal endoscopic microsurgery (TEM) has emerged as a safe and effective method to treat rectal lesions including benign tumors, early rectal cancer, and rectal fistulas and strictures. This minimally invasive technique offers the advantages of superior visualization of the lesion and greater access to proximal lesions with lower margin positivity and specimen fragmentation and lower long-term recurrence rates over traditional transanal excision. In addition, over two decades of scientific data support the use of TEM as a viable alternative to radical excision of the rectum with less morbidity, faster recovery, and greater potential cost savings when performed at specialized centers.
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Affiliation(s)
- Hiroko Kunitake
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.
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de Graaf EJR, Burger JWA, van Ijsseldijk ALA, Tetteroo GWM, Dawson I, Hop WCJ. Transanal endoscopic microsurgery is superior to transanal excision of rectal adenomas. Colorectal Dis 2011; 13:762-7. [PMID: 20345967 DOI: 10.1111/j.1463-1318.2010.02269.x] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Comparison of transanal excision (TE) and transanal endoscopic microsurgery (TEM) of rectal adenomas (RA) has rarely been performed. METHOD From 1990 to 2007, the results of TE (43 RA) and TEM (216 RA) were compared. Rectal adenomas were matched for diameter and distance from the anal verge. RESULTS Operation time was 47.5 min for TE and 35 min for TEM (P < 0.001). Morbidity was 10% after TE and 5.3% after TEM (P < 0.001). Negative resection margins were observed in 50% after TE and 88% after TEM (P < 0.001). Fragmentation of the excised specimen was observed in 23.8% after TE and 1.4% after TEM (P < 0.001). In cases of fragmentation, positive resection margins were observed more frequently. Recurrence was 28.7% after TE and 6.1% after TEM (P < 0.001). After TE, RA with a negative resection margin had a local recurrence rate of 0%, compared with 59.6% with a positive margin (P < 0.001), and after TEM these rates were 3.2 and 7.7% (P = 0.3), respectively. CONCLUSION Transanal endoscopic microsurgery is superior to transanal excision of RA.
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Affiliation(s)
- E J R de Graaf
- Department of General Surgery, IJsselland Hospital, Capelle aan den IJssel, The Netherlands.
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15
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Modarai B, Forshaw MJ, Sankararajah D, Murali K, Stewart M. Endoscopic transanal resection of rectal adenomas using the urological resectoscope. Colorectal Dis 2009; 11:859-65. [PMID: 18727717 DOI: 10.1111/j.1463-1318.2008.01677.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Large sessile rectal adenomas are often difficult to excise and several different techniques have been described. This study evaluates the results of adenoma excision by endoscopic transanal resection using the urological resectoscope by a single surgeon in a UK district general hospital. METHOD Between January 1989 and November 2004, data on all patients treated by endoscopic transanal resection of benign rectal tumours using a urological resectoscope (ETAR) were prospectively collected and analysed. RESULTS Forty patients (50% male, median age 72 years) underwent a total of 81 endoscopic transanal resections. The tumour characteristics were: size > 2 cm (83%), location in lower 2/3 of rectum (83%) and extensive circumferential carpet-like appearances (13%). Fifty percent of the patients required only one procedure to achieve clearance. Mean operative time was 26 min (range 10-65 min). Seventy-eight percent of the patients were discharged home within 24 h. Postoperative morbidity was 8% and in-hospital mortality was zero. Histology revealed severe dysplasia in 48% of the tumours and five patients were incidentally found to have foci of rectal adenocarcinoma. With a median follow-up of 47 months (range 2-162 months), local recurrences occurred in 13% (n = 5) of patients. All, except one, were treated successfully with further endoscopic transanal resections. CONCLUSION ETAR is simple and safe for managing rectal adenomas.
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Affiliation(s)
- B Modarai
- Department of Surgery, Darent Valley Hospital, Dartford, Kent, UK
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16
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Abstract
Transanal excision (TE), endoscopic transanal resection (ETAR) and transanal endoscopic microsurgery (TEM) can be used to remove adenomatous polyps. However, their use is limited by the size or location of the tumor. TE is limited to the lower rectum, TEM offers better access to lesions in the middle and upper rectum, and ETAR is used less frequently than it deserves for resection of rectal lesions.
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17
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Development of a new operating rectal tube with a side window for transanal endoscopic surgery. MINIM INVASIV THER 2009; 10:243-7. [PMID: 16754023 DOI: 10.1080/136457001753334422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
The authors describe a new rectal tube for use in transanal endoscopic surgery. The tube is a transparent plastic sheath with its forward end closed, measuring 40 mm in diameter and 150 mm in insert length. It has a window, measuring 40 mm in diameter, on its side. The target lesion, captured within the side window, prolapses into the rectal tube and is excellently visualised without positive pressure gas insufflation. This paper gives details of the tube and reports on a sessile rectal tumour successfully treated using the new system.
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Transanal endoscopic microsurgery is feasible for adenomas throughout the entire rectum: a prospective study. Dis Colon Rectum 2009; 52:1107-13. [PMID: 19581854 DOI: 10.1007/dcr.0b013e3181a0d06d] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Transanal endoscopic microsurgery for rectal adenomas is safe and has low recurrence rates. However, the feasibility of the procedure for all rectal adenomas is unclear. This issue was investigated prospectively. METHODS From 1996 to 2007, 353 consecutive rectal adenomas were evaluated according to a standard protocol. Transanal endoscopic microsurgery was intended in all rectal adenomas. RESULTS The median diameter was 3 cm and median distance was 8 cm. The peritoneum was opened peroperatively without any adverse effects in 8.7 percent. The conversion rate was 9.6 percent, with an alternative local procedure performed in 4.2 percent and a transabdominal procedure performed in 5.4 percent. Conversion rate correlated with the distance of the tumor (P = 0.007) and the operating surgeon's level of experience (P = 0.004). The median operation time was 45 minutes. Operation time correlated with specimen area, experience, and operating surgeon (all P < 0.001). All rectal adenomas were excised in one piece. Complete margins were observed in 85 percent. Rectal adenomas with incomplete margins were larger (P < 0.001) and were located more proximally (P < 0.001). Morbidity was 7.8 percent and mortality 0.6 percent. The median hospital stay was four days. The median follow-up was 27 months. The recurrence rate at three years was 9.1 percent. The median time from operation to recurrence was 12 (range, 4-54) months. Resection margin status was a predictor of recurrence, with 6.1 percent recurrence in cases of complete margins and 25.2 percent in cases of incomplete margins (P < 0.001). CONCLUSIONS For nearly all rectal adenomas, transanal endoscopic microsurgery is safe, feasible, and has excellent results.
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van den Broek FJC, de Graaf EJR, Dijkgraaf MGW, Reitsma JB, Haringsma J, Timmer R, Weusten BLAM, Gerhards MF, Consten ECJ, Schwartz MP, Boom MJ, Derksen EJ, Bijnen AB, Davids PHP, Hoff C, van Dullemen HM, Heine GDN, van der Linde K, Jansen JM, Mallant-Hent RCH, Breumelhof R, Geldof H, Hardwick JCH, Doornebosch PG, Depla ACTM, Ernst MF, van Munster IP, de Hingh IHJT, Schoon EJ, Bemelman WA, Fockens P, Dekker E. Transanal endoscopic microsurgery versus endoscopic mucosal resection for large rectal adenomas (TREND-study). BMC Surg 2009; 9:4. [PMID: 19284647 PMCID: PMC2664790 DOI: 10.1186/1471-2482-9-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2009] [Accepted: 03/13/2009] [Indexed: 02/07/2023] Open
Abstract
Background Recent non-randomized studies suggest that extended endoscopic mucosal resection (EMR) is equally effective in removing large rectal adenomas as transanal endoscopic microsurgery (TEM). If equally effective, EMR might be a more cost-effective approach as this strategy does not require expensive equipment, general anesthesia and hospital admission. Furthermore, EMR appears to be associated with fewer complications. The aim of this study is to compare the cost-effectiveness and cost-utility of TEM and EMR for the resection of large rectal adenomas. Methods/design Multicenter randomized trial among 15 hospitals in the Netherlands. Patients with a rectal adenoma ≥ 3 cm, located between 1–15 cm ab ano, will be randomized to a TEM- or EMR-treatment strategy. For TEM, patients will be treated under general anesthesia, adenomas will be dissected en-bloc by a full-thickness excision, and patients will be admitted to the hospital. For EMR, no or conscious sedation is used, lesions will be resected through the submucosal plane in a piecemeal fashion, and patients will be discharged from the hospital. Residual adenoma that is visible during the first surveillance endoscopy at 3 months will be removed endoscopically in both treatment strategies and is considered as part of the primary treatment. Primary outcome measure is the proportion of patients with recurrence after 3 months. Secondary outcome measures are: 2) number of days not spent in hospital from initial treatment until 2 years afterwards; 3) major and minor morbidity; 4) disease specific and general quality of life; 5) anorectal function; 6) health care utilization and costs. A cost-effectiveness and cost-utility analysis of EMR against TEM for large rectal adenomas will be performed from a societal perspective with respectively the costs per recurrence free patient and the cost per quality adjusted life year as outcome measures. Based on comparable recurrence rates for TEM and EMR of 3.3% and considering an upper-limit of 10% for EMR to be non-inferior (beta-error 0.2 and one-sided alpha-error 0.05), 89 patients are needed per group. Discussion The TREND study is the first randomized trial evaluating whether TEM or EMR is more cost-effective for the treatment of large rectal adenomas. Trial registration number (trialregister.nl) NTR1422
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Whitehouse PA, Tilney HS, Armitage JN, Simson JNL. Transanal endoscopic microsurgery: risk factors for local recurrence of benign rectal adenomas. Colorectal Dis 2006; 8:795-9. [PMID: 17032328 DOI: 10.1111/j.1463-1318.2006.01098.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Transanal endoscopic microsurgery (TEM) is a minimally invasive technique for excision of selected benign and malignant rectal neoplasms. It is considered a safe and effective treatment but recurrence rates of 1-13% are reported for benign lesions. The aim of this study was to assess risk factors for local recurrence of benign rectal lesions and to evaluate mortality and morbidity following TEM. METHOD Data were prospectively collected from all patients undergoing TEM for benign adenomas from January 1998 to March 2005. The procedure was performed by a single surgeon and patients were regularly followed up. RESULTS One hundred and forty-six procedures were included, with a median patient age of 74 years (range 22-92 years). The mean lesion area was 16 cm(2) (range 0.3-150 cm(2)) and the median distance from the dentate line was 9 cm (range 0-17 cm). Immediate complications included bleeding (six) and acute urinary retention (six). There has been one (0.68%) procedure-related death. After a median follow up of 39 months (range 4-89 months) there have been seven recurrences (4.8%), recurring at a mean time of 23.3 months (range 5-48 months). Only microscopic involvement of the circumferential resection margin was found to be significantly associated with recurrence (P = 0.0059). Recurrence was not associated with age, size of lesion, previous treatment, severity of dysplasia or use of the harmonic scalpel. CONCLUSION TEM is a safe and effective treatment for benign rectal adenomas. Circumferential resection margin involvement is associated with recurrence, which tends to occur late. Therefore extended follow up is recommended.
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Affiliation(s)
- P A Whitehouse
- Department of Surgery, St Richard's Hospital, Chichester, UK.
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Schäfer H, Baldus SE, Hölscher AH. Giant adenomas of the rectum: complete resection by transanal endoscopic microsurgery (TEM). Int J Colorectal Dis 2006; 21:533-7. [PMID: 16133003 DOI: 10.1007/s00384-005-0025-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/12/2005] [Indexed: 02/04/2023]
Abstract
BACKGROUND Large sessile adenomas of the rectum, with a diameter greater than 5 cm, have a high risk to undergo malignant transformation. Transanal endoscopic microsurgery (TEM) offers an alternative operation method to low-anterior rectum resection in this potentially benign tumor situation. PATIENTS We retrospectively investigated patients with giant adenomas of the rectum (>5 cm) who were treated by TEM over the last 10 years. A total of 33 patients met the criteria and were analyzed for postoperative complications, histology, and incidence of occult adenocarcinoma; residual tumor status; and tumor recurrence. RESULTS Partial suture-line insufficiency (n=5, 15%) was the major postoperative complication, but could be managed conservatively in four cases. The residual adenoma status was 18% (n=6), especially in patients with tumors sizes more than 30 cm2. In case of adenoma recurrence (n=4, 12%), a conventional transanal excision (Parks) was applicable, as these tumors were mostly located within the suture-line region of the lower rectum. Incidentally, five carcinomas were found in the specimens. In case of advanced tumors (1xpT2, 1xpT3), anterior rectum resection was carried out, whereas for the early tumors (2xpT1 low risk, 1x1 pTis), no further therapy was added. All patients (adenomas and carcinomas, n=33) were without recurrence during follow-up. CONCLUSION TEM is an alternative method for the resection of large benign rectal tumors located in the mid- and upper third of the rectum. The main postoperative complication is suture-line insufficiency, which generally heals by conservative treatment.
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Affiliation(s)
- Hartmut Schäfer
- Department of Visceral and Vascular Surgery, University of Cologne, Joseph-Stelzmann Str. 9, 50924 Cologne, Germany.
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Papagrigoriadis S. Transanal endoscopic micro-surgery (TEMS) for the management of large or sessile rectal adenomas: a review of the technique and indications. INTERNATIONAL SEMINARS IN SURGICAL ONCOLOGY 2006; 3:13. [PMID: 16674824 PMCID: PMC1468413 DOI: 10.1186/1477-7800-3-13] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/27/2005] [Accepted: 05/04/2006] [Indexed: 11/10/2022]
Abstract
In this review article the surgical technique of Transanal Endoscopic Microsurgery (TEMS) is examined. A number of techniques have been used to treat adenomas of the rectum. The treatment of large adenomas which occupy a large surface of the rectal lumen or adenomas which are flat and grow in a "carpet-like" fashion is particularly challenging. Major rectal surgery carries a risk of morbidity and mortality, particularly in elderly and unfit patients. Although local excision with transanal resection (TAR) and the Kraske sacral operation have been used in the past, during the last twenty years TEMS has become the method of choice for those lesions. TEMS is efficient and minimally invasive. The technique allows the patient to recover rapidly and the incidence of complications is much lower than that of major surgery. In case of recurrence the option of repeat TEMS or major surgery remain available. TEMS has been slow to gain popularity mainly for reasons of cost and steep learning curve but it is now an established procedure and a valuable therapeutic option which is particularly useful for elderly and unfit patients. Gastroenterologists should be aware of the nature and indications of TEMS in order to advise and refer selected patients with rectal adenomas accordingly.
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Ganai S, Kanumuri P, Rao RS, Alexander AI. Local recurrence after transanal endoscopic microsurgery for rectal polyps and early cancers. Ann Surg Oncol 2006; 13:547-56. [PMID: 16514476 DOI: 10.1245/aso.2006.04.010] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2005] [Accepted: 10/12/2005] [Indexed: 12/16/2022]
Abstract
BACKGROUND Transanal endoscopic microsurgery (TEM) allows for local excision of rectal neoplasms with greater exposure than transanal excision and less morbidity than transabdominal approaches. This study examines the implications of the procedure with respect to predictors of recurrence. METHODS We performed a retrospective analysis of 144 consecutive TEMs from 1993 to 2004. RESULTS The study comprises 107 patients presenting for TEM with benign disease and 32 patients with cancer. Patients had a mean age of 64+/-14 (SD) years. TEM was performed for recurrent lesions in 17% of cases. Pathologic classification of the lesions after TEM was benign adenoma in 45%, adenoma with high-grade dysplasia (HGD) in 17%, cancer in 33%, and other in 4%. Complications occurred in 10%, and local recurrence occurred in 15% of patients. Median follow-up was 44 months, with a median time to recurrence of 14 months. Positive margins did not influence lesion recurrence. Recurrence of cancers correlated with the depth of tumor invasion (P<.05). On multivariate analysis, independent predictors of recurrence were lesion size and the presence of HGD within adenomas (P<.05). Five-year neoplastic recurrence probabilities were 11% for benign adenomas, 35% for adenomas with HGD, and 20% for cancers (P=.31); invasive recurrence probabilities were 0% for benign adenomas, 15% for adenomas with HGD, and 13% for cancers (P<.05). CONCLUSIONS Close endoscopic follow-up is warranted after TEM for both benign and malignant disease, with special attention to lesions with HGD. TEM can be performed safely for early rectal cancer with careful patient selection.
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Affiliation(s)
- Sabha Ganai
- Department of Surgery, Baystate Medical Center/Tufts University School of Medicine, 759 Chestnut Street, Springfield, Massachusetts 01199, USA.
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Hurlstone DP, Sanders DS, Cross SS, George R, Shorthouse AJ, Brown S. A prospective analysis of extended endoscopic mucosal resection for large rectal villous adenomas: an alternative technique to transanal endoscopic microsurgery. Colorectal Dis 2005; 7:339-44. [PMID: 15932555 DOI: 10.1111/j.1463-1318.2005.00813.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Endoscopic mucosal resection is a safe resection tool for selected flat, sessile and lateral spreading tumours of the colon. Transanal microsurgical resection of select rectal neoplastic lesions is another accepted modality. Recent data suggests transanal microsurgery may have high complication rates. We conducted a prospective clinicopathological evaluation of an extended endoscopic mucosal resection technique for highly selected lesions of the rectum and assessed outcome data over a maximal 24-month period. PATIENTS AND METHODS Eighty-three patients with known rectal neoplastic lesions underwent chromoscopic colonoscopy and on-table staging using a high-frequency (12.5 MHz) mini-probe EUS by a single endoscopist. Patients with T2 or node positive disease were referred for surgery. Following extended endoscopic mucosal resection patients were followed-up at 3, 6, 12 and 24 months post 'index' resection with chromoscopic endoscopy and EUS. Procedural complications, recurrence rates and outcome data were collected. RESULTS Sixty-two patients fulfilled inclusion criteria. Median procedure time was 48 mins (range 32-126). Lateral spreading tumours (median diameter 30 mm; range 18-42 mm) and sessile lesions (median diameter 38 mm; range 25-86 mm) accounted for 19% and 81% of lesions, respectively. Ninety-seven percent of patients undergoing EMR were discharged within 6-h of procedure. Thirty-day re-admission and death rate was 0%. Bleeding complications occurred in 5/62 (8%) of patients with all achieving complete haemostasis using endo clips. None required transfusion. There were no procedural related complications or perforations. Overall 'cure' rate at a median follow-up of 16 months was 98%. CONCLUSIONS Extended endoscopic mucosal resection for rectal neoplastic lesions can achieve superior results to those of per-anal excision and trans-anal microsurgery with regard to complications and recurrence rates. Extended endoscopic mucosal resection may be an alternative therapeutic modality in selected patients.
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Affiliation(s)
- D P Hurlstone
- Gastroenterology and Liver Unit at the Royal Hallamshire Hospital Sheffield, Sheffield, UK.
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Norberto L, Polese L, Angriman I, Erroi F, Cecchetto A, D'Amico DF. Laser photoablation of colorectal adenomas: a 12-year experience. Surg Endosc 2005; 19:1045-8. [PMID: 15942811 DOI: 10.1007/s00464-004-2179-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2004] [Accepted: 01/17/2005] [Indexed: 12/24/2022]
Abstract
BACKGROUND We analyze laser photoablation as an alternative treatment of large sessile polyps in inoperable patients. METHODS Ninety-four colorectal polyps (mean diameter 3.09 +/- 2.7 cm, range 1-15 cm) were treated using high-energy lasers (Nd:YAG and diode). Grade of dysplasia was low in 51, high in 35, with focally invasive cancer in eight. RESULTS After 405 laser sessions (4.3 per polyp) five procedure-related complications were observed: two strictures, two bleedings, and one perforation. The last needed a surgical resection; the others were successfully treated by endoscopic therapy. Fifty-seven polyps (61%) were completely eradicated and the growth was controlled in all but two (98%). No degeneration was found after 28-month follow-up of treated adenomas with low- or high-grade dysplasia. Outcome of treatment was dependent on the dimension and grade of the dysplasia (p < 0.05), but not on the polyps' position (rectum or colon). Relief of rectal bleeding was obtained in 90%, of mucus discharge in 77%, and of tenesmus in 100% of cases. CONCLUSIONS Laser photoablation of colonic adenomas can be considered a valid procedure not only to relieve symptoms, but also to control the risk of degeneration in patients unfit for surgery or when surgical treatment is considered excessively invalidating.
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Affiliation(s)
- L Norberto
- Dipartimento di Scienze Chirurgiche e Gastroenterologiche, Clinica Chirurgica Generale I, Università di Padova, 35128 Padova, Italy.
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Abstract
Local excision of rectal cancer is advocated for cure only in selected patients. It should be done according to specific standards and needs close follow up. The transanal technique is well defined and indicated for posterior rectal wall tumours. Otherwise, technical modifications or microsurgery can be performed. The transacral approach should be abandoned.
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Affiliation(s)
- C Gouillat
- Département de chirurgie, hôpital de l'Hôtel-Dieu, 1, place de l'Hôpital, 69288 Lyon cedex 2, France
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Endreseth BH, Wibe A, Svinsås M, Mårvik R, Myrvold HE. Postoperative morbidity and recurrence after local excision of rectal adenomas and rectal cancer by transanal endoscopic microsurgery. Colorectal Dis 2005; 7:133-7. [PMID: 15720349 DOI: 10.1111/j.1463-1318.2004.00724.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Tumours in the middle and upper part of the rectum are not easy accessible to local excision. Transanal endoscopic microsurgery (TEM) has been recommended for excision of sessile adenomas in the middle and upper part of the rectum, and for small cancers in patients not fit for major surgery. The purpose of this study was to evaluate postoperative morbidity and local recurrence after TEM. MATERIAL AND METHODS Seventy-nine patients were treated by TEM in the period 1994-2001. The median age was 74 years. The indications for TEM were rectal adenoma in 72 patients and rectal cancer in 7 patients. The tumours were located within 18 cm from the dentate line, median 10 cm. There were performed 69 transmural and 10 mucosal excisions. Mean follow up was 24 months (range 1-95 months). Twenty (25%) patients died during the follow up period, two because of metastases and 18 of other causes. RESULTS Seven patients had complications. Two (2.5%) patients had peroperative perforation in the intra-abdominal part of the rectum treated by laparotomy. Five (6%) patients had postoperative cardiopulmonal or surgical complications. Eight patients with benign pre-operative histopathological examination had cancer. The local recurrence rate (13%) was similar for adenomas and for carcinomas. CONCLUSION TEM is a safe technique well tolerated also by high-risk patients, and should be the preferred method in patients with benign tumours in the middle and upper part of the rectum, and in selected cases of early rectal cancer. Benign pre-operative histology does not preclude malignancy and some patients may need further treatment for unexpected malignancy.
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Affiliation(s)
- B H Endreseth
- Department of Surgery, St. Olavs Hospital, University of Trondheim, Norway.
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Abstract
PURPOSE The aim of this study was to systematically review the evidence relating to the safety and efficacy of transanal endoscopic microsurgery, a relatively new technique used to locally excise rectal tumors, compared with existing techniques such as anterior resections and abdominoperineal resections or local excisions. METHODS We conducted a systematic review of comparative studies and case series of transanal endoscopic microsurgery from 1980 to August 2002. RESULTS Three comparative studies (including one randomized, controlled trial) and 55 case series were included. The first area of study was the safety and efficacy of adenomas. In the randomized, controlled trial, no difference could be detected in the rate of early complications between transanal endoscopic microsurgery (10.3 percent) and direct local excision (17 percent) (relative risk, 0.61; 95 percent confidence interval, 0.29-1.29). Transanal endoscopic microsurgery resulted in less local recurrence (6/98; 6 percent) than direct local excision (20/90; 22 percent) (relative risk, 0.28; 95 percent confidence interval, 0.12-0.66). The 6 percent rate of local recurrence for transanal endoscopic microsurgery in this trial is consistent with the rates found in case series of transanal endoscopic microsurgery (median, 5 percent). The second area of study was the safety and efficacy of carcinomas. In the randomized, controlled trial, no difference could be detected in the rate of complications between transanal endoscopic microsurgery and direct local excision (relative risk for overall early complication rates, 0.56; 95 percent confidence interval, 0.22-1.42). No differences in survival or local recurrence rate between transanal endoscopic microsurgery and anterior resection could be detected in either the randomized, controlled trial (hazard ratio,1.02 for survival) or the nonrandomized, comparative study. There were 2 of 25 (8 percent) transanal endoscopic microsurgery recurrences in the randomized, controlled trial, but no figures were given for recurrence after anterior resection. In the case series, the median local recurrence rate for transanal endoscopic microsurgery was 8.4 percent, ranging from 0 percent to 50 percent. The third comparison was cost of the procedures. Transanal endoscopic microsurgery had both a lower recurrence rate and a lower cost than local excision or anterior resection for adenomas. Although the effectiveness of transanal endoscopic microsurgery could not be established for carcinomas, costs were lower than those for either anterior resection or abdominoperineal resection. CONCLUSIONS The evidence regarding transanal endoscopic microsurgery is very limited, being largely based on a single relatively small randomized, controlled trial. However, transanal endoscopic microsurgery does appear to result in fewer recurrences than those with direct local excision in adenomas and thus may be a useful procedure for several small niches of patient types--e.g., for large benign lesions of the middle to upper third of the rectum, for T1 low-risk rectal cancers, and for palliative, not curative, use in more advanced tumors.
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Abstract
OBJECTIVE Transanal endoscopic microsurgery (TEM), a minimally invasive technique has been employed in the excision of benign and well-selected malignant rectal tumours since June 1998. We present a prospective descriptive study and analyse the currently accepted indications. PATIENTS AND METHODS Over a 4-year period 100 patients underwent TEM for treatment of rectal tumours located between 4 and 18 cm from the anal verge. RESULTS TEM was performed in 71 cases for adenomas, 20 potentially curative excisions for pre-operative staged low-grade carcinoma, 3 palliative procedures for advance carcinoma, 5 carcinoids and 1 solitary ulcer. The local complication rate included wound breakdown in 7 patients, three of them requiring ileostomy. Conversion to laparotomy was performed in two patients. Five adenomas recurred and were successfully treated by TEM. Of the cancers, four patients required immediate salvage therapy by means of total mesorectal excision. Three patients underwent palliative TEM procedures combined with radiotherapy. A single cancer recurrence was treated by means of abdomino-perineal resection after radiotherapy. CONCLUSIONS TEM appears to be an effective method of excising benign tumours and selected T1 carcinomas of the rectum. The superior exposure of tumours higher in the rectum combined with the greater precision of excision make this minimally invasive technique an attractive surgical approach.
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Affiliation(s)
- P Palma
- Department of Surgery, University Clinic, Mannheim, Germany.
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Platell C, Denholm E, Makin G. Efficacy of transanal endoscopic microsurgery in the management of rectal polyps. J Gastroenterol Hepatol 2004; 19:767-72. [PMID: 15209623 DOI: 10.1111/j.1440-1746.2004.03364.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Transanal endoscopic microsurgery (TEM) was a technique developed to allow the excision of adenomas and early-stage cancers from the rectum and distal sigmoid colon. The aim of this project was to prospectively study surgical morbidity, mortality and the local recurrence rate of all patients treated with this technique. METHODS All patients undergoing TEM were prospectively evaluated. Endpoints to assess the surgical morbidity and mortality were defined before the study commenced. All patients underwent regular follow up to determine treatment efficacy in terms of the local recurrence rate and survival. RESULTS The study involved 113 patients, with a mean age of 69 years (standard deviation 14 years, range 30-94 years), and a male to female ratio of 1.4:1. The mean polyp area was 20.5 cm(2) (range 1-169 cm(2)) and the mean height above the anal verge was 9.5 cm (range 4-25 cm). Histology of the tumors found 62 adenomas, 20 carcinomas in situ, and 31 adenocarcinomas. There were no unplanned returns to theater or postoperative deaths. Four patients required readmission within 30 days because of bleeding, and nine patients underwent more radical surgical procedures following histological evaluation of the resected specimens. During a mean follow up of 1.5 +/- 0.8 years (maximum 3.2 years), there have been two recurrences of villous adenomas. The actuarial local recurrence rate at 2 years is 2.4% (95% confidence interval 0.8-4.0%). CONCLUSION TEM was demonstrated to be a safe surgical procedure, and early follow up has shown it to be an efficacious treatment for benign rectal adenomas and early rectal cancers.
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Affiliation(s)
- Cameron Platell
- Colorectal Unit, Fremantle Hospital, Fremantle, Western Australia, Australia.
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Gavagan JA, Whiteford MH, Swanstrom LL. Full-thickness intraperitoneal excision by transanal endoscopic microsurgery does not increase short-term complications. Am J Surg 2004; 187:630-4. [PMID: 15135680 DOI: 10.1016/j.amjsurg.2004.01.004] [Citation(s) in RCA: 128] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2003] [Revised: 01/19/2004] [Indexed: 02/07/2023]
Abstract
PURPOSE Transanal endoscopic microsurgery (TEM) is a minimally invasive technique for full-thickness excision of benign and malignant rectal neoplasms located 4 to 24 cm above the anal verge. Entrance into the peritoneal cavity during TEM has been regarded as a complication that mandates conversion to open laparotomy for adequate repair of the defect. This study compares the rate of complications arising from TEM with and without intraperitoneal entry. METHODS Patients undergoing peritoneal entry were compared to those who did not. RESULTS No perioperative deaths occurred. There was no significant difference in the incidence of postoperative complications. No major complications occurred with peritoneal entry, and all peritoneal entries were closed transanally via endoscope. CONCLUSIONS Entry into the peritoneum during TEM is not associated with an increased incidence of complication. Entry into the peritoneum during TEM excision does not mandate conversion to open laparotomy but may be safely repaired endoscopically. Lesions likely to be above the peritoneal reflection and within reach of the endoscope (4 to 24 cm) should be considered for TEM excision.
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Affiliation(s)
- Justine A Gavagan
- Department of Minimally Invasive Surgery, Legacy Health System, 1040 NW 22nd Ave., Suite 560, Portland, OR 97210, USA
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Cocilovo C, Smith LE, Stahl T, Douglas J. Transanal endoscopic excision of rectal adenomas. Surg Endosc 2003; 17:1461-3. [PMID: 12739115 DOI: 10.1007/s00464-002-8929-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2002] [Accepted: 01/09/2003] [Indexed: 12/29/2022]
Abstract
Transanal endoscopic microsurgery (TEM) is a minimally invasive surgical technique for performing local excision of rectal lesions in the mid and upper rectum that would otherwise be inaccessible for local excision by the direct transanal approach. In the absence of this approach, low anterior resection would be required, which is major abdominal surgery. The justification for excising adenomas of the colon and rectum is their malignant potential, which correlates with the size of the lesion. This retrospective review examines our experience using TEM for excision of adenomas of the rectum from February 1991 to the present. The decision for using TEM is based on a precise localization of the lesion with particular attention to the upper margin of the lesion and its diameter. A total of 56 adenomas were removed. The average diameter was 4.9 cm (range, 3-8 cm). The average distance from the anal verge was 7.92 cm (range, 5-12 cm). Carcinoma in situ was seen in 7 lesions, and the remaining lesions were benign. Morbidity was minimal, with one conversion to an open procedure for an intraperitoneal perforation that required a low anterior resection. No patient required transfusion and there was no mortality. The hospital stay was short, with half of the patients being discharged the same day. The average cost from July 1996 to December 1999 was 7775 dollars for TEM versus 34,018 dollars for LAR. Subsequent follow-up average was 38.8 months (range, 1-100 months), during which time two patients had recurrence of their adenomas. This was successfully treated with reexcision. In conclusion, TEM is an accurate, safe, and relatively inexpensive technique when compared to low anterior resection. This technique significantly reduces the proportion of adenomas requiring abdominal surgery.
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Affiliation(s)
- C Cocilovo
- Section of Colon and Rectal Surgery, Washington Hospital Center, 106 Irving Street, NW, Suite 2100, Washington, DC 20010, USA
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Lirici MM, Di Paola M, Ponzano C, Hüscher CGS. Combining ultrasonic dissection and the Storz operation rectoscope. Surg Endosc 2003; 17:1292-7. [PMID: 12739122 DOI: 10.1007/s00464-002-8727-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2002] [Accepted: 12/05/2002] [Indexed: 11/24/2022]
Abstract
BACKGROUND Transanal endoscopic microsurgery (TEM) allows a precise, full-thickness resection of rectal tumors anywhere within the rectum. Unfortunately, the standard TEM technique needs complex and rather expensive equipment, demands high skill, and is attended by bleeding and oozing that may be challenging. A modified TEM procedure combining the new Storz operation rectoscope and ultrasonic dissection has been developed to overcome the limitations of the original technique. METHODS The Storz operation rectoscope features a 5-mm telescope combined with a single-monitor display. Standard laparoscopic instruments and the LCSC5 Ultracision Maniple are used for dissection and coagulation. Full-thickness resection is performed most often. Closure of the defect is accomplished by interrupted 3-0 polydoxanone sutures secured by extracorporeal slipknots. RESULTS Altogether, 18 TEMs have been performed according to the modified technique: 9 for malignant and 9 for benign lesions. The median operating time was 92.5 min for resection of malignant lesions and 40 min for resection of benign lesions. Two postoperative complications occurred: a bleeding and a partial dehiscence. The median follow-up periods were 35 months for malignant disease and 19.5 months for benign disease. No recurrence was observed. CONCLUSION For tumors located up to 15 cm from the anal verge, TEM with the Storz rectoscope and ultrasonic dissection is indicated. Despite the complication described, coagulation is optimal and ultrasonic scissors allow working in a fairly bloodless field. The overall costs of the equipment are significantly lower.
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Affiliation(s)
- M M Lirici
- Department of Surgery, Ospedale S. Giovanni, Via Amba Aradam 8, 00184 Rome, Italy.
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Nakagoe T, Ishikawa H, Sawai T, Tsuji T, Jibiki M, Nanashima A, Yamaguchi H, Yasutake T. Gasless, video endoscopic transanal excision for carcinoid and laterally spreading tumors of the rectum. Surg Endosc 2003; 17:1298-304. [PMID: 12739126 DOI: 10.1007/s00464-002-8580-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2002] [Accepted: 12/07/2002] [Indexed: 01/17/2023]
Abstract
BACKGROUND The aim of this study is to determine whether gasless, video endoscopic transanal-rectal tumor excision (gasless VTEM) is a valid treatment for rectal carcinoid and laterally spreading tumors (LST). METHODS Eighty-four patients with an adenoma, adenocarcinoma (Tis/T1), or carcinoid tumor of the rectum were divided into three groups: (i) LST ( n = 17 patients), (ii) carcinoid ( n = 11), and (iii) control with other types of tumors ( n = 56). RESULTS The LST group had a longer median operating time than in the control group, whereas the carcinoid group had a shorter operating time. Two patients (11.7%) in LST group developed peritoneal entry during the operation, while 2 patients (3.6%) in the control group experienced postoperative complications. During a median follow-up length of 55.2 months, one patient in the LST group developed a recurrence. CONCLUSIONS Gasless VTEM is a simple, minimally invasive procedure used to treat LST and carcinoid tumors of the rectum. However, resection for the LST group had a high risk of peritoneal entry during operation.
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Affiliation(s)
- T Nakagoe
- First Department of Surgery, Nagasaki University School of Medicine, Nagasaki, Japan.
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Nakagoe T, Ishikawa H, Sawai T, Tsuji T, Tanaka K, Ayabe H. Surgical technique and outcome of gasless video endoscopic transanal rectal tumour excision. Br J Surg 2002; 89:769-74. [PMID: 12027989 DOI: 10.1046/j.1365-2168.2002.02097.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Transanal endoscopic microsurgery (TEM) is unpopular because of its high cost and most surgeons' unfamiliarity with microscopic surgery. This report describes an experience with a modification of TEM, gasless video endoscopic transanal rectal tumour excision (gasless VTEM), which incorporates a standard laparoscopic video camera and requires no carbon dioxide insufflation system. METHODS One hundred and one patients with 105 rectal tumours underwent gasless VTEM between 1993 and 2000. RESULTS Histological examination revealed 18 adenomas, 75 carcinomas (Tis, 47; T1, 23; T2, five), 11 carcinoid tumours and one lymphoma. The median height above the dentate line and maximum tumour diameter was 5.0 (range 2-14) cm and 2.0 (range 0.4-8.0) cm respectively. The peritoneal cavity was opened intraoperatively in two patients. The median operating time was 53 (range 15-202) min. Bleeding, suture dehiscence and transient incontinence developed after operation in four patients. There was no operative death. Median hospital stay was 5 (range 1-21) days. Eleven patients with T1/T2 staging underwent subsequent radical resection. The median duration of follow-up was 52.3 months. One patient with a carcinoma developed a recurrence. CONCLUSION Gasless VTEM is a feasible, safe and minimally invasive procedure for the treatment of selected rectal adenomas and early carcinomas. The suggested modifications may make the procedure more widely available.
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Affiliation(s)
- T Nakagoe
- First Department of Surgery, Nagasaki University School of Medicine and Department of Surgery, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
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Abstract
PURPOSE Although local excision of rectal cancers is a less morbid alternative to radical resection, its role as a curative procedure is unclear. The role of adjuvant therapy after local excision is also controversial. This review aims to examine current evidence on local excision of rectal cancers and how it fits into the management algorithm for rectal cancer. METHODS A literature review was undertaken through the MEDLINE database and by cross-referencing previous publications, thus identifying 41 studies on curative local excision of rectal cancer published in English. Details of preoperative staging, surgical procedures, adjuvant therapy, follow-up, and outcome measures, including complications, survival data, recurrences, and salvage were examined. RESULTS Preoperative staging of rectal cancers is variable. Digital rectal examination and computerized tomography are used in most studies. Endorectal ultrasound is used in some patients in 9 of 41 studies. Local excision preserves anorectal function, and seems to have limited morbidity (0-22 percent). Local excision alone is associated with local recurrences in 9.7 (range, 0-24) percent of T1, 25 (range, 0-67) percent of T2 and 38 (range, 0-100) percent of T3 cancers. The addition of adjuvant chemoradiotherapy after local excision yields local recurrence rates of 9.5 (range, 0-50) percent for T1, 13.6 (range, 0-24) percent for T2, and 13.8 (range, 0-50) percent for T3 cancers. Data on local excision after preoperative chemoradiotherapy for tumor down staging are limited. Factors other than T-stage that lead to higher local recurrence rates after local excision include poor histologic grade, the presence of lymphovascular invasion, and positive margins. Local recurrences after local excision can be surgically salvaged (84 of 114 patients in 15 studies), with a disease-free survival rates between 40 and 100 percent at a follow-up of 0.1 to 13.5 years. CONCLUSIONS Local excision for rectal cancers is associated with a low morbidity and provides satisfactory local control and disease-free survival rates for T1 rectal cancers. There is, however, a need for a randomized, controlled trial for T2 cancers, comparing local excision with adjuvant chemoradiotherapy to radical resection.
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Affiliation(s)
- S Sengupta
- Department of Surgery, Colorectal Unit, Royal Melbourne Hospital, University of Melbourne, Australia
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Demartines N, von Flüe MO, Harder FH. Transanal endoscopic microsurgical excision of rectal tumors: indications and results. World J Surg 2001; 25:870-5. [PMID: 11572026 DOI: 10.1007/s00268-001-0043-2] [Citation(s) in RCA: 94] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Transanal endoscopic microsurgery (TEM) allows local excision of rectal tumors located 4 to 18 cm above the anal verge. The technique is not yet generally established because of the necessary special instrumentation and tools, the unusual technical aspects of the approach, and the stringent patient selection criteria. The aim of this prospective, descriptive study was to analyze the currently accepted indications for TEM and to evaluate the use of this procedure for treating rectal cancer. Over a 4-year period 50 patients aged 31 to 86 years (mean 64 years) underwent TEM for treatment of rectal tumors located 12 cm above the anal verge (range 4-18 cm). The local complication rate was 4%. Altogether, 76% of lesions were benign, and 24% were T1 and T2 tumors. Of 12 cancer cases, 4 required reoperation by total mesorectal resection; the other 8 are currently under follow-up management. Over the follow-up period of 30.6 months (range 11-54 months) the recurrence rate of T1 tumors was 8.3%. TEM is a minimally invasive surgical technique that may benefit a small, specific population of patients with rectal tumors. Compared with conventional transanal resection, TEM provides superior exposure of tumors higher up in the rectum (i.e., up to 18 cm from the anal verge). The greater precision of resection combined with low morbidity (10%, relative to that of anterior resection) and short duration of hospitalization (5.5 days) make this technique a reliable and in some cases more effective surgical approach than laparotomy and low anterior resection.
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Affiliation(s)
- N Demartines
- Department of Surgery, University Hospital of Basel, Spitalstrasse 21, CH-4031 Basel, Switzerland.
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Chung JJ, Kim MJ, Lee JT, Yoo HS. Large villous adenoma in rectum mimicking cerebral hemispheres. AJR Am J Roentgenol 2000; 175:1465-6. [PMID: 11044067 DOI: 10.2214/ajr.175.5.1751465] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- J J Chung
- Research Institute of Radiological Science Yonsei University College of Medicine Seoul, 120-752, Korea
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Abstract
BACKGROUND Transanal resection of benign and selected malignant rectal tumors is a well accepted surgical technique. The use of a stereoscopic microsurgical technique, as originally described by Buess et al in 1984, has been shown to improve the results of standard transanal resection by allowing precise, full thickness resections up to 24 cm from the anal verge. Transanal endoscopic microsurgery (TEM) has failed to gain widespread popularity for two reasons: The proprietary instrument set is expensive and complex ($68,000 and 30 components), and the procedure is difficult to master technically. We present our results with a modification of the TEM instrument that incorporates a standard laparoscope and video camera as well as standard laparoscopic instruments. METHODS Four surgeons have been trained to date. Details of the training curriculum are presented. The technique of videoendoscopic transanal tumor resection (VTEM) is described. A prospective data base was maintained of all VTEM cases. This was reviewed for this study to determine indications, operative times, complications and outcomes. RESULTS Four surgeons performed 27 VTEM cases between August 1994 and June 1996. The average age was 69 years and the majority (16) of patients were ASA III. Pre-op diagnosis was benign polyp in 25 patients and adenocarcinoma in 2. Average operating time was 127 minutes (49 to 280 minutes), and was longer during a surgeon's first 5 cases and for lesions more than 16 cm from the anal verge. Operative problems were rare (4%) and post-op complications (incontinence 2, late bleeding 1, adenoma recurrence 1) were seen in 15%. CONCLUSIONS VTEM can be taught successfully to GI and colorectal surgeons using a format similar to that used for advanced laparoscopic courses. The use of already available laparoscopes and instruments decreases the initial costs of the set-up. Results are good, with low rates of complications and recurrence and a very short hospital stay. The patient benefits from an effective, minimally invasive alternative to open surgery.
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Affiliation(s)
- L L Swanstrom
- Department of Minimally Invasive Surgery, Legacy Portland Hospital, Oregon 97227, USA
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Smith LE, Ko ST, Saclarides T, Caushaj P, Orkin BA, Khanduja KS. Transanal endoscopic microsurgery. Initial registry results. Dis Colon Rectum 1996; 39:S79-84. [PMID: 8831552 DOI: 10.1007/bf02053811] [Citation(s) in RCA: 85] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
UNLABELLED Transanal endoscopic microsurgery (TEM) was first used on a regular basis in the United States in 1990. Because there is a sole source of instrumentation, the surgeons who use this equipment are known to us. Thus, this earliest registry is a compilation of data based on most patients who underwent TEM in the United States from 1990 to 1994. METHOD One hundred fifty-three cases were voluntarily registered by six surgeons. Pathology included 54 carcinomas, 82 adenomas, and 17 other entities. Most resections were full thickness. Fifty percent of cases were out of reach of standard instruments. Complication rate, hospital stay, and blood loss were recorded. Technical difficulties at time of surgery (9 percent), early complications (15 percent), and late complications (5 percent) have been tabulated. RESULTS Recurrence rates for carcinoma were 10 percent for T1, 40 percent for T2, and 66 percent for T3 stages. Failures were treated by abdominoperineal resection or low anterior resection. Adenomas recurred in 11 percent, but these recurrences were small and easily treatable. CONCLUSION TEM has a low complication rate. By carefully selecting small, superficial cancers and adenomas, TEM results in superior outcome over other approaches to the mid and upper rectum.
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Affiliation(s)
- L E Smith
- George Washington University, Washington, D.C., USA
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Basso L, Pescatori M. Transanal endoscopic microsurgery for management of early invasive cancer. Dis Colon Rectum 1996; 39:827-8. [PMID: 8674381 DOI: 10.1007/bf02054454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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