Impact of technology on indications and limitations for transanal surgical removal of rectal neoplasms

Table 1 Single center comparison of transanal excision and standard resection for T1 rectal cancer

Ref.	Year	Follow-up (yr)	n		5 yr local recurrence		5 yr overall survival
			TAE	SR	TAE	SR	TAE	SR
Mellgren et al[31]	2000	4.4-4.8	69	30	18%1	01	72%	80%1
Nascimbeni et al[32]	2004	9.2	70	74	6.6%	2.8%	72%1	90%1
Bentrem et al[30]	2005	4.3	151	168	15%1	3%1	89%	93%
Nash et al[33]	2009	5.6	137	145	13.2%1	2.7%1	87%1	96%1

¹Statistically significant. TAE: Transanal excision; SR: Standard resection.

Table 2 National cancer registries comparison of transanal excision and standard resection for T1 rectal cancer

Ref.	Year	Follow-up (yr)	n		5 yr local recurrence		5 yr overall survival
			TAE	SR	TAE	SR	TAE	SR
Endreseth et al[37]	2005	2-8.1	35	256	12%	6%1	70%1	80%1
You et al[42]	2007	6.3	601	493	12.5%	6.9%1	77%	82%
Ptok et al[40]	2007	3.5	85	359	5.1%1	1.4%1	84%	92%
2Folkesson et al[38]	2007	NA	256	1141	7%	2%1	87%	93%
Hazard et al[39]	2009	3.9	573	3040	NA	NA	71%	84%
2Saraste et al[41]	2013	NA	448	3246	11.2%	2.9%	81%	92%

¹Statistically significant;

²Mix of T1 and T2 tumors. SR: Standard resection; TAE: Transanal excision; NA: Not available.

Table 3 Recurrence after transanal endoscopic microsurgery resection of benign rectal adenoma

Ref.	Year	Follow-up (yr)	n	Recurrence
Said et al[67]	1995	3.2	260	6.5%
Platell et al[65]	2004	1.5	62	2.4%
Endreseth et al[60]	2005	2	64	13%
Whitehouse et al[71]	2006	3.3	143	4.8%
McCloud et al[63]	2006	2.6	75	16%
Guerrieri et al[86]	2008	3.7	588	4.3%
Speake et al[68]	2008	1	80	12.5%
Moore et al[64]	2008	1.7	40	3%
de Graaf et al[59]	2009	2.3	309	6.6%
Ramirez et al[66]	2009	3.6	149	5.4%
van den Broek et al[70]	2009	1.1	248	9.3%
Guerrieri et al[61]	2010	7	402	4%
Tsai et al[69]	2010	2	156	5%
de Graaf et al[58]	2011	2.7	208	6.1%

Table 4 Single center comparison of transanal endoscopic microsurgery and standard resection for T1 rectal cancer

Ref.	Year	Follow-up (yr)	n		5 yr local recurrence		5 yr overall survival
			TEMS	SR	TEMS (%)	SR (%)	TEMS (%)	SR (%)
Winde et al[81]	1996	3.8[TEMS]/3.4[SR]	24	26	4.2	0	96	96
Heintz et al[78]	1998	4.3	46	34	4.3	2.9	79	81
Lee et al[79]	2003	2.6[TEMS]/2.9[SR]	52	22	4.1	0	100	92.9
Palma et al[80]	2009	7.2[TEMS]/7.8[SR]	34	17	5.9	0	88.23	82.35
De Graaf et al[77]	2009	3.5[TEMS]/7[SR]	80	75	241	01	75	77

Table 5 Appropriate indications for the use of transanal excision/transanal endoscopic microsurgery/transanal minimally invasive surgery or endoscopic mucosal resection

Category	Primary approach	Secondary or individualized approach
Benign pathology	Low rectum: TAE or TEMS Middle to high rectum: TEMS/TAMIS/EMR or LAR Proximal to rectum: EMR or L/O CR	Very large lesion: LAR
Borderline pathology	Carcinoid < 1 cm with favorable features: TEMS/TAMIS Scar after colonoscopic removal of cancerous polyp: TEMS/TAMIS Uncertain dignity: TEMS/TAMIS mucosal resection as excisional biopsy	Excisional biopsy with TEMS/TAMIS/TAE → LAR if malignant?
Malignant (Rectum)	u/pT1: LAR u/pT2: LAR u/pT3: CRT + LAR Recurrence: CRT + LAR Carcinoid > 1 cm: LAR	u/pT1 + morbidity: TAE/TEMS/TAMIS u/pT2: TAE/TEMS/TAMIS + CRT
Malignant (Colon)	pTis: EMR/polypectomy pT1: L/O CR (unless free stalk > 2 mm) > T1: L/O CR	pTis (large): L/O CR pT1 + morbidity: EMR + observation

LAR: Low anterior resection (laparoscopic, robotic, open); L/O CR: Laparoscopic vs open colon resection; TAE: Transanal excision; TAMIS: Transanal minimally invasive surgery; TEMS: Transanal endoscopic microsurgery; TME: Total mesorectal excision; EMR: Endoscopic mucosal resection.