Role Of Transanal Endoscopic Microsurgery Research Articles

Extending the role of Transanal Endoscopic Microsurgery (TEM) in rectal cancer

Increasingly it is becoming clear that there is a role for local excision of early rectal cancer by Transanal Endoscopic Microsurgery (TEM) as part of an organ-preservation strategy. This role is based on careful preoperative assessment, thorough postoperative histopathological examination and standardized follow up, with recourse to completion or salvage radical surgery in the face of poor prognostic factors, or early concerns over recurrent disease. Additionally, TEM is also proposed in selected circumstances after neoadjuvant treatment for rectal cancer. This latter topic is even more controversial with clinical evidence still evolving, but specialist centres report impressive results that cannot be ignored in the modern management of rectal cancer.

Transanal Endoscopic Microsurgery: Where it Stands as of Today?

Objective: To review the present role of transanal endoscopic microsurgery (TEM) in the treatment of rectal neoplasms. Methods: Literature search was conducted with restriction to english language and only published material was considered. Search was performed at Medline, Google, Cochrane library and SpringerLink. Search terms were: transanal endoscopic microsurgery, TEM, rectal cancer, rectal adenoma and carcinoid tumor. Results and conclusion: The review of the present literature is confirming the increasing acceptance of TEM, as a primary modality, over conventional surgery in the management of early rectal cancers, especially pT1 lesions. As far as pT2 is considered, it has to be combined with either adjuvant chemoradiation or salvage surgery. For locally advanced pT3, lesions, it is not preferred unless neoadjuvant therapy is successful in downstaging the tumor or in patients who refuse or are unfit for major surgery. However, the cost of equipment and steep learning curve are restricting this therapy to few specialized centers around the world.

Laparoscopic surgery for rectal cancer: The state of the art

At present time, there is evidence from randomized controlled studies of the success of laparoscopic resection for the treatment of colon cancer with reported smaller incisions, lower morbidity rate and earlier recovery compared to open surgery. Technical limitations and a steep learning curve have limited the wide application of mini-invasive surgery for rectal cancer. The present article discusses the current status of laparoscopic resection for rectal cancer. A review of the more recent retrospective, prospective and randomized controlled trial (RCT) data on laparoscopic resection of rectal cancer including the role of trans-anal endoscopic microsurgery and robotics was performed. A particular emphasis was dedicated to mid and low rectal cancers. Few prospective and RCT trials specifically addressing laparoscopic rectal cancer resection are currently available in the literature. Improved short-term outcomes in term of lesser intraoperative blood loss, reduced analgesic requirements and a shorter hospital stay have been demonstrated. Concerns have recently been raised in the largest RCT trial of the oncological adequacy of laparoscopy in terms of increased rate of circumferential margin. This data however was not confirmed by other prospective comparative studies. Moreover, a similar local recurrence rate has been reported in RCT and comparative series. Similar findings of overall and disease free survival have been reported but the follow-up time period is too short in all these studies and the few RCT trials currently available do not draw any definitive conclusions. On the basis of available data in the literature, the mini-invasive approach to rectal cancer surgery has some short-term advantages and does not seem to confer any disadvantage in term of local recurrence. With respect to long-term survival, a definitive answer cannot be given at present time as the results of RCT trials focused on long-term survival currently ongoing are still to fully clarify this issue.

The Role of Transanal Endoscopic Microsurgery for Rectal Tumors

The management of rectal tumors is complex, because of the balance between preserving rectoanal function and curing the patient. Transanal endoscopic microsurgery (TEM) is both an effective treatment for benign rectal tumors and early cancers, and a diagnostic tool for determining tumor depth, or for residual tumors of post endoscopic mucosal resection. In the present study, we evaluated the role of TEM in the management of rectal tumors. Twenty-six patients with rectal tumors underwent TEM from December 2000 through March 2005 in our department. The operations were performed by a single surgeon, and the indications were mainly limited to a) benign tumors for which endoscopic resection was difficult, b) early cancers that had invaded the submucosa within 500 microm of the muscularis mucosae, c) submucosal tumors, i.e., gastrointestinal stromal tumor, carcinoid tumors, d) local excision for diagnosis, and e) palliative resection for high-risk cases. Anesthesia, operation time, sizes of the tumor and of resected specimens, postoperative complications, length of hospitalization, pathological results, and postoperative recurrence rate were reviewed. The mean age of patients was 61.9 years, and the cases included 14 rectal cancers, 7 adenomas, 1 gastrointestinal stromal tumor, and 3 rectal carcinoid tumors. The mean operation time was 96 min (range, 40 approximately 235 min.). The average postoperative hospital stay was 4.8 days. All tumors were resected with horizontal and vertical safety margin. The mean size of the resected specimens was 9.0 cm(2). In one case, the tumor had infiltrated the proper muscle layer, as shown by intraoperative frozen sectioning, which necessitated abdominoperineal resection. In 3 cases, pathological examination revealed massive infiltration into the submucosal layer. 2 patients underwent low anterior resection, and the remaining patient refused additional surgery despite our recommendation. No deaths occurred. No major postoperative complications were noted. The mean follow-up period was 27.2 months. Only one case of lymph node metastasis was observed, in the left iliac lymph node 3 years after TEM. TEM is a minimally invasive surgical procedure for rectal tumors, which allows the whole depth of the rectal wall to be resected with a safety surgical margin. Although TEM requires technical skill and accurate preoperative diagnosis, the procedure is safe, facilitates accurate diagnosis of tumor depth, and limits the need for additional surgery.

Transanal endoscopic microsurgery--lessons from a single UK centre series.

Transanal endoscopic microsurgery (TEM), a minimally invasive technique has been employed in the excision of benign and selected malignant rectal tumours since 1983. We present a single surgeon's series of 102 procedures. A retrospective case note review of 102 procedures performed over a 6-year period between 1996 and 2001. One hundred and two TEM procedures were performed on 100 patients. 68 for adenomas, 19 potentially curative excisions for carcinoma, 13 palliative procedures for advanced carcinoma and 2 for solitary rectal ulcer syndrome (SRUS). Four adenomas recurred and were successfully treated by various procedures. None went on to develop malignancy, or a further recurrence. Of the cancers, six T1 and 10 T2 were excised with curative intent. Three T3 cancers were excised before endorectal ultrasound was available in the unit and went on to have definitive procedures. One T1 and two T2 carcinomas were not completely histologically excised. These patients were offered definitive procedure and there have been no recurrences. 11 patients underwent palliative TEM procedures, 2 went on to have a recurrence of symptoms. Both underwent a successful second TEM procedure. Although longer term follow up is still required, TEM appears to be an effective method of excising benign tumours and T1 carcinomas of the rectum. The role of TEM in the treatment of T2 carcinomas is, as yet, unclear and needs further evaluation although the results of our series and others are encouraging.

Colorectal 10

Aims: The role of local resection for benign rectal disease is well established, however, controversy still exists regarding its use in the treatment of malignant tumours. The aim of this study is to evaluate the role of Transanal Endoscopic Microsurgery (TEM) in the management of rectal tumours, in particular cancers. Methods: A total of 56 successive patients, mean age of 68 (range 37–91) years, underwent TEM by a single surgeon for rectal tumours over a 5-year period. Data were collected prospectively and reviewed with regards to diagnosis, TNM stage, length of operation and hospital stay, resection margins and recurrence rates. Results: Mean follow up was 21 months (range 3–60). 37 patients had benign rectal tumours and 19 had cancers of which 7 were T1, 9 T2, and 3 were T3. Mean length of surgery was 83 min (range 43–180) and mean hospital stay was 3.6 days (range 1–10). Margins were clear in 54 patients (96 per cent). Involved margins were observed in one patient with benign disease and one patient with rectal carcinoma, who had a palliative resection and died of metastatic disease. Hospital mortality was zero and only minor morbidity was observed in 23 per cent, which included bleeding, transient faecal incontinence and urinary retention. Recurrence rates for T1 and T2 tumours were 0 and 43 per cent, respectively. Conclusions: TEM for both benign and malignant disease is safe with zero mortality and low morbidity. However, its use in the surgical management of rectal cancer should be limited to those with early disease (T1) or for palliation.

Role of Transanal Endoscopic Microsurgery in the Palliative Treatment of Rectal Cancer

Background: Palliative, minimal invasive treatment of rectal cancer is advocated in patients with advanced and incurable disease or poor clinical condition and in those who refuse radical surgery. Several methods have been used during recent years. We report our experience with palliative transanal endoscopic microsurgery. Materials: Between 1983 and 1995, 29 patients underwent transanal endoscopic microsurgery for palliation. Eleven patients had advanced malignant disease, nine were in poor clinical condition, and nine repeatetly refused radical surgery. Results: Intraoperatively one severe complication, an intra-abdominal perforation, occurred. The morbidity rate was 14%. Postoperatively, clinical signs were abolished or improved in all cases. Only three patients required further palliative resections after initial symptom relief. Conclusions: Transanal endoscopic microsurgery is a successful approach in the palliative treatment of rectal cancer. The technique enables complete resection of rectal tumors. Although anesthesia is needed, the morbidity is low, even in patients with poor clinical condition.

Training or derailment?

As in 1995 (Lancet 1995; 346: s23), minimal-access surgery continues to interest general surgeons, with emphasis on controlled trials. Mini-cholecystectomy stood up well in comparison with laparoscopic cholecystectomy (Lancet 1996; 347: 989) whilst the technique and limitations of laparoscopic common bile duct exploration have been beautifully described by a highly experienced unit (Br J Surg 1996; 83: 341). The role of transanal endoscopic microsurgery has been clarified by a threecentre study (Br J Surg 1996; 83: 207) and carefully assembled evidence has changed the approach to management of necrotising pancreatitis by recommending early deployment of prophylactic antibiotics (Lancet 1995; 346: 663, BrJ Surg 1996; 83: 883). In the UK, the surgical year has been dominated by training issues. Our heads are spinning with Calmanisation, SACs, HSTs and BSTs but to what benefit (Collins)? Training in this country has been overlylong the frequent result being over-trained and disillusioned senior registrars failing to achieve consultancy until their late thirties or early forties. As we move into Europe (Greenhalgh) surgery, as one of the vanguard specialties, is already feeling the effects of change (Parker). The old-style FRCS dies at the end of this year to be replaced by the MRCS, qualifying the candidate to enter specialist training (RCS regulations). Selection to a training cont inuum virtually assures progression to consultant level, barring major transgressions. This process will take 5 to 6 years including 1 year of research that is unlikely to lead to a higher degree (Dawson). Completion of specialist training is marked by an exit exam and the award of a certificate. Are these changes for better or for worse? Appointment to consultancy, once highly competitive, is now much less so. In some subspecialties, there is such a shortage of trainees that those with accredited training can pick and choose their employment. Nevertheless, it is the perception of the current cohort of trainees that their career structure has been simplified and many feel that consultancy is now a highly achievable goal. This will surely mean that junior doctors will be attracted back to a specialty that they have deserted over fears of poor career progression and, together with a shorter training period should provide the much needed numbers of consultants for the next century. What are the implications for patient care? Old style senior registrars were highly qualified and highly experienced doctors, conversant with many areas of general surgery as well as their own subspecialty. Furthermore, their role as consultant-in-waiting was clear and was accorded suitable duties and respect. The new breed of consultant will have a CV devoid of higher qualifications or publications and will be less fully trained