Benefit in therapy of superficial rectal neoplasms objectivized: Transanal endoscopic microsurgery (TEM) compared to surgical standards

Abstract

SummaryA prospective randomized study was launched to compare local resection using transanal endoscopic microsurgery (TEM) with anterior resection for early rectal carcinomas (uT1 Negative low risk) and with peranal submucosal excision for sessile adenomas. Randomized distribution to the operative techniques was used after endoluminal ultrasound staging. The procedures followed were transanal endoscopic microsurgery, deep anterior resection (AR) and peranal submucosal excision (PSE). Patients in the study were: with T1 -carcinoma, n = 25 (TEM-CA) vs n = 28 (AR) and with adenomas, n = 98 (TEM-AD) vs n = 90 (PSE). There was no significant difference in age and sex and intraluminal distribution of rectal cancer between the groups. Blood loss, operation time, hospitalization, analgetic demand, early and late morbidity, mortality, recurrence, 5-year survival rate (for carcinomas) were evaluated. Surgery was performed under general anaesthesia. Significant differences of TEM-CA to AR were found for blood loss, operation time, hospitalization time and analgetic demand (ANOVA, Student-Newman-Keuls test P < 0.001). Peri-operative mortality was 0; early and late complications of TEM-CA were 20% and 8%, respectively, compared to 35% and 25%, respectively for AR. There was no difference in 5-year survival probability rates between TEM-CA and AR. Mean follow-up was 41 months for TEM-CA and 45 months for AR. Local relapse of cancer after TEM-CA was found in 4% of the patients. Comparing TEM-AD with PSE for adenomas, insignificant differences were found concerning blood loss, operation time, hospitalization and analgetic demand. Obvious differences were noted for early (10%) and late (4%) complications of TEM-AD compared to PSE (17% vs 6.6%). Local recurrence of adenomas after TEM-AD (6.6%) and PSE (22%) differed obviously. In comparison to other procedures, the most precise transanal procedure (TEM) has distinct advantages in surgery for sessile adenomas concerning morbidity and local recurrence. TEM-excision of rectal carcinomas showed similar survival rates compared to anterior resection, provided that endoluminal ultrasound is used for staging and strictly low risk tumours are selected. These advantages, combined with a superior intrarectal overview, justify the increased difficulty of the TEM technique.