Use Of Transanal Endoscopic Microsurgery Research Articles

Transanal Endoscopic Microsurgery for Early Rectal Cancer: A Single-Center Experience.

There is debate regarding the appropriate use of transanal endoscopic microsurgery for rectal cancer. This study analyzed our single-center experience with transanal endoscopic microsurgery for early rectal cancer. Medical charts of patients who underwent transanal endoscopic microsurgery were reviewed to determine lesion characteristics, as well as operative and treatment characteristics. Complications and recurrences were recorded. The study was conducted at a single academic medical center. Patients with early stage cancer (T1 or T2, N0, and M0) of the rectum were included. Local and overall recurrence and disease-specific survival were measured. A total of 92 patients were analyzed. Median follow-up was 4.6 years. Negative margins were obtained in 98.9%. Length of stay was 1 day for 95.4% of patients. The complication rate was 10.9% (n = 10), including urinary retention at 4.3% (n = 4) and postoperative bleeding at 4.3% (n = 4). Preoperative staging included 54 at T1 (58.7%) and 38 at T2 (41.3%). Adjuvant therapy was recommended for all of the T2 and select T1 lesions with adverse features on histology. The final pathologic stages of tumors were ypT0 at 8.7% (n = 8), pT1 at 58.7% (n = 54), pT2 at 23.9% (n = 22), and ypT2 at 8.7% (n = 8). The 3-year local recurrence risk was 2.4% (SE = 1.7), and overall recurrence was 6.7% (SE = 2.9). There were no recurrences among patients with complete pathologic response to neoadjuvant therapy. Mean time to recurrence was 2.5 years (SD = 1.43). A total of 89.2% of patients with very low tumors underwent curative resection without a permanent stoma (33/37). The 3-year disease-specific survival rate was 98.6% (95% CI, 90.4%-99.8%), and overall survival rate was 89.4% (95% CI, 79.9%-94.6%). The study was limited by its single-center retrospective experience. Transanal endoscopic microsurgery provides comparable oncologic outcomes to radical resection in properly selected patients with early rectal cancer. Sphincter preservation rates approach 90% even in patients with very distal rectal cancer.

Long-term Oncologic Outcome After Transanal Endoscopic Microsurgery for Rectal Carcinoma.

Transanal endoscopic microsurgery is superior to other methods of local excision of rectal cancer, but few studies report long-term follow-up data. This study investigated the use of transanal endoscopic microsurgery alone as curative and compromise therapy based on long-term disease recurrence and mortality. This was a retrospective review of prospectively collected data. The study was conducted at a tertiary care university medical center. The study included 133 patients treated between 1985 and 2007. There were 3 groups, including transanal endoscopic microsurgery in curative intent (low-risk rectal carcinoma, including pT1, G1/2, L0, and LX with clear margins and a minimal distance between tumor and resection margin of >1 mm (N = 64) or clear margins only (N = 18 ))) and as compromise therapy (high-risk or incompletely resected rectal carcinoma; N = 51). Log-rank tests were used to compare overall and cancer-specific survival. The median follow-up time was 8.6 years (range, 0.2-25.1 years), and a total of 131 of 133 patients (98.5%) were followed >5 years or until death. The preoperative diagnosis of carcinoma was not associated with belonging into 1 of the 3 categories. In patients with low-risk completely (>1 mm) resected carcinoma, the 5- and 10-year local recurrence rates were 6.6% and 11.6%. In patients with high-risk or incompletely resected carcinoma, the rates were 32.5% and 35.0% (p = 0.006). The 5- and 10-year cancer-specific survival rates for low-risk patients were 98.0% and 91.0% and 84.3% and 74.3% for high-risk patients (p = 0.05). The study was limited by its retrospective design and small subgroups. The high cancer-specific survival justifies transanal endoscopic microsurgery alone as curative treatment in low-risk rectal carcinoma. Complete resection is essential to lower the risk of local recurrence. The high local recurrence rate in patients with high-risk rectal carcinoma restricts the use of TEM alone as compromise therapy.

Transanal Endoscopic Proctectomy: a new approach to the total excision of the mesorectum

IntroductionColorectal cancer is a serious public health problem. In 1982, Heald managed to reduce mortality by standardizing the total excision of mesorectum. The use of transanal endoscopic microsurgery has emerged to allow resection of rectal tumors as a minimally invasive method. With the association of Transanal Endoscopic Operation with total excision of mesorectum, it was possible to develop a new approach for total excision of mesorectum. Surgical techniqueThe procedure is started by the perineal time with Transanal Endoscopic Operation device; introduction of Transanal Endoscopic Operation system follows, with exposure of the lesion with a circumferential incision at a distance between 2 and 4cm from distal tumor margin after making a purse string suture to close the rectal stump. Then, dissection is carried out by the posterior portion until reaching the presacral avascular fascia, completing the mesorectal circumferential dissection until the peritoneal reflection. After this step, a laparoscopic procedure is performed with the use of three trocars, with mobilization of splenic flexure and ligation of the inferior mesenteric artery, as well as confection of a protective ileostomy. Then, transanal removal of the surgical specimen is performed, and the procedure goes on with a coloanal anastomosis.

Transanal endoscopic microsurgery with entrance into the peritoneal cavity: is it safe?

Relative contraindications for transanal endoscopic microsurgery include high, anterior-based lesions for full-thickness excisions because of worries about entering the peritoneal cavity. Concerns exist regarding safety and oncological outcome. We examined the outcomes of transanal endoscopic microsurgery excisions with entry into the peritoneal cavity and compared them with those that did not to address our hypothesis that entry is safe with no ill infectious or oncological consequences. This single-institution retrospective review uses a prospectively maintained database. This study was conducted at a tertiary colorectal surgery referral center. From 1997 to 2012, we identified 303 patients who underwent transanal endoscopic microsurgery resections, with 26 patients having entrance into the peritoneal cavity. Perioperative data, postoperative morbidities, delayed morbidities, and oncological outcomes were the primary outcomes measured. Of 26 patients, there were 8 women with a mean age of 67.5 years. Mean BMI was 31 kg/m, and ASA class was III or IV in 69%. Mean superior border of the lesion was 10.4 cm (4.5-16). Forty-eight percent had anterior-based lesions. Anterior location, level from anorectal ring, and diagnosis of cancer were significantly higher in the peritoneal entry group (p = 0.003, p = 0.007, and p = 0.007). Preoperative diagnoses included 16 adenocarcinomas, 8 polyps, and 2 carcinoid tumors. Thirteen patients had preoperative chemoradiation. Median estimated blood loss was 15 mL (5-400), and 3 patients underwent diversions. Median time to discharge was 3 days (2-10). There were no perioperative mortalities. Median follow-up time was 21.0 months. There was 1 local recurrence (3.8%), and there was no development of carcinomatosis. This review was limited by its retrospective nature. High anterior location rectal lesions should be considered candidates for transanal endoscopic microsurgery excision in experienced hands. After obtaining considerable transanal endoscopic microsurgery experience, our use of transanal endoscopic microsurgery in a high-risk patient population allowed us to definitively treat 88% of patients without an abdominal operation and the need for a temporary or permanent colostomy. Theoretic concerns of abscess or carcinomatosis were not experienced (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A154).

Transanal endoscopic microsurgery for early rectal cancer: single center experience.

IntroductionThe use of transanal endoscopic microsurgery (TEM) is increasing due to the ability to perform minimally invasive local treatment with large full-thickness local excision under improved vision.AimTo evaluate the initial experience with TEM for early rectal cancer in a single center.Material and methodsFrom February 2010 to November 2013 a total of 20 patients underwent TEM for early rectal cancer. Nine were women and 11 men, age range 39 to 88 years (median: 71 years). The postoperative surveillance protocol, which includes rigid proctoscopy, carcinoembryonic antigen (CEA) and endorectal ultrasound every 3 months during the first 2 years, was applied to all patients after TEM.ResultsFinal histology revealed 14 (70%) lesions to be T1 and 6 (30%) T2 cancers. There were no postoperative complications. All 6 patients in the pT2 group and those in the pT1 group with unfavorable histology were offered adjuvant chemoradiotherapy or immediate radical surgery. Patients were followed up from 2 to 35 months (median: 21 months). There was one local recurrence (5%) in a patient who refused to undergo abdominoperineal excision for T1 low rectal cancer, had unfavorable histology after TEM, and for which reason underwent postoperative chemoradiation. The patient had abdominoperineal resection 7 months after TEM (rpT2N0M0). One patient was lost to follow-up. The rest of the patients are alive and disease-free.ConclusionsIn our hands, TEM was an alternative to total mesorectal excision in patients with low-risk early rectal cancer. Further follow-up is necessary to evaluate recurrence and survival rates after TEM for patients with invasive rectal cancer.

Transanal NOTES Applications

In recent years, experimental studies have evolved to clinical series on natural orifice surgery, with increasing numbers published. Transanal (transrectal) NOTES using a single-port access and other platforms applied for colorectal diseases is a recent improvement, and its applications for rectal cancer and other indications are discussed. Analysis of the published reports on NOTES applied to colorectal surgery is discussed and examined with critical examination of the limitations, complications and need for new technology. New methods such as NOTES down-to-up total mesorectal resection, advanced use of transanal endoscopic microsurgery (TEM and TEO) and transanal minimally invasive surgery are described with preliminary good results and a low conversion rate. Successful reports on human transanal NOTES surgery represent a new step in minimally invasive surgery and can be applied for similar indications as laparoscopic and open surgery to improve patient care. Oncologic results have to be evaluated in further long-term studies.

PTH-012 The Impact of a Dedicated Mdt on the Management of early Rectal Cancer

IntroductionThe management of significant rectal neoplasms and early rectal cancers (ERCa) is vitally dependent on accurate pre-treatment assessment and consideration of all therapeutic options. This study analyses the impact of...

Minimally Invasive Anorectal Surgery: From Parks Local Excision to Transanal Endoscopic Microsurgery to Transanal Minimally Invasive Surgery

Total mesorectal excision remains the preferred oncological treatment of tumors of the rectum, providing excellent cure rates and minimal local recurrence. Surgical advances have led to more sphincter-sparing procedures using coloanal anastomosis. However, abdominoperineal resection with permanent colostomy remains the most common procedure performed today for tumors of the distal rectum. In addition, even precise total mesorectal excision results in frequent incidence of sexual, urologic, and bowel dysfunction. Local excision has slowly gained popularity, but is still considered a substandard operation owing to higher recurrence rates. However, the innovation of potentially superior platforms (transanal endoscopic microsurgery/transanal minimally invasive surgery) designed to enable improved access and visualization to the rectum has allowed surgeons to excise lesions more proximally in the rectum and with improved precision, yielding diminished recurrence rates. More recent data demonstrate the use of transanal endoscopic microsurgery and transanal minimally invasive surgery in combination with multimodality therapy and careful patient selection results in outcomes approaching standard oncological treatment. The evolution of procedures, newer instrumentation, and increasing knowledge of the tumor biology is quickly closing the gap between classical resection and various modalities of local excision.

Transanal endoscopic microsurgery approach for rectal stump resection as an alternative to transperitoneal stump resection

Transperitoneal rectal stump resection is a complicated procedure with risk of inadvertent bowel, vascular and nerve injury. This study analysed the feasibility and safety of the use of transanal endoscopic microsurgery (TEM) to excise rectal stumps that would otherwise require a combined transabdominal and perineal approach. Rectal stump resection was performed by a transanal approach using TEM. Stumps were removed by complete rectal wall resection and intersphincteric resection of the anus, leaving the mesorectum in place. The study included nine patients with a rectal stump ranging in length from 8 to 20 cm after previous surgery for inflammatory bowel disease (6), Lynch syndrome (1), collagenous colitis (1) or anastomotic leakage (1). The median duration of operation was 161 (range 107-239) min. The median postoperative length of hospital stay was 5 (range 2-71) days. One patient required an additional small-incision laparotomy to remove a stump extending up to the promontory and another developed a postoperative abscess. There were no perioperative complications. TEM appeared to be a useful and safe approach for close rectal dissection and removal of a rectal stump while avoiding an abdominal approach for pelvic dissection.

Transanal endoscopic microsurgery for rectal carcinoids: the largest reported United States experience

Rectal carcinoids are often inadequately resected by snare excision during colonoscopy. Transanal endoscopic microsurgery is a minimally invasive procedure with low morbidity that offers full-thickness excision with a low rate of negative margins. It presents an excellent alternative to radical surgery for mid and proximally located lesions. We report the largest United States (US) experience in the use of transanal endoscopic microsurgery for rectal carcinoids. Data of patients who had undergone transanal endoscopic microsurgery for rectal carcinoids were prospectively collected and retrospectively analyzed. Patient and tumour characteristics, operative and perioperative details, as well as oncological outcomes were reviewed. Over a 12-year period, 24 patients underwent transanal endoscopic microsurgery for rectal carcinoids. Of these, six (25%) were primary surgical resections and 18 (75%) were performed after incomplete snare excisions during colonoscopy. Three (17%) patients who underwent full-thickness resection after snare excision had residual tumour on histopathological examination. Negative margins were obtained in all cases. No recurrences were noted. Transanal endoscopic microsurgery is effective and safe for the surgical resection of rectal carcinoids<2 cm in diameter, with typical features and located more than 5 cm from the anal verge. Transanal endoscopic microsurgery can be used for primary resection or for resection after incomplete colonoscopic snare excision.

Glove Port Technique for Transanal Endoscopic Microsurgery

Introduction. Despite initial enthusiasm, the use of transanal endoscopic microsurgery (TEM) is still quite limited at present because of the expense of highly specialized equipment and the complexity of the learning curve. Furthermore, some authors report a relevant, although temporary, effect on anorectal function because of the considerable anal dilatation which can even produce a rupture of the internal anal sphincter. The “glove TEM” proposes itself as an alternative to traditional TEM that could settle these problems. Materials and Methods. The technique is accurately described together with the necessary equipment to perform it. Between 2011 and 2012, we operated eight patients with this technique for rectal adenomas or early carcinomas achieving R0 resection in all cases and reporting no early or late complications during the first five months of followup. Discussion. This technique offers multiple advantages compared to the original TEM. (i) It allows the use of all available laparoscopic instruments. (ii) It gives a great manoeuvrability of the instruments in contrast to rigid rectoscope systems. (iii) Given the limited length of the device, it permits to operate on tumors closer to the dentate line. (iv) It is less traumatic to the anal sphincter. It is definitively much cheaper. Conclusions. We believe that this new technique is easy to perform, cost-effective, and less traumatic to the anal sphincter compared to traditional TEM.

Surgical excision of retrorectal tumour using transanal endoscopic microsurgery

Abstract Surgical excision is the best therapeutic option for tumours in the retrorectal space. Classically, surgery in this area required an abdominal or posterior approach, or a combination of the two methods. We report the use of transanal endoscopic microsurgery for the treatment of retrorectal tumours as an alternative to classical procedures.

PTH-002 Transanal endoscopic microsurgery: our experience with early rectal cancer

<h3>Introduction</h3> The use of transanal endoscopic microsurgery (TEMS) for the resection of benign rectal lesions is well established; its role in the management of carcinoma is less well defined. With the advent of the Bowel Cancer Screening Programme the incidence of early rectal cancer is increasing. Here we describe our experience of 25 cases undergoing TEMS resection for cancer. <h3>Methods</h3> An electronic database was used to identify the outcomes of patients undergoing TEMS procedures; operation and anaesthetic notes and original pathology reports were reviewed. Patients underwent TEMS if preoperative staging was limited to early uT1 disease or in more advanced disease where patients were not deemed fit for an anterior resection. <h3>Results</h3> 25 patients were included, (16 male 9 female), mean age was 69. ASA grade I,2; II,11 and III,12. Patients underwent preoperative staging with endoanal ultrasound and/or MRI. 20 patients were staged as uT1, four patients as uT2 and one patient as uT2/3 N1. In seven cases the lesion was located in the lower rectum and in 18 in the mid or upper third. Full thickness resections were performed in 22 patients with resection in the submucosal plane in three. Full thickness defects were closed in all cases. The mean size of specimen was 9 cm² (95% CI 3.5 to 14.5 cm². Histopathology revealed that two patients had been understaged; both had pT2 N0 disease; one underwent anterior resection and one declined further surgery. All but two patients had R0 resections and one patient with a pT1 R0 resection developed recurrent disease. Mean operating time was 110 min (95% CI 92 to 128) and median length of stay was 3 days (range 2–15 days). Four patients had complications; two patients bled post-operatively, one requiring re-operation, one patient developed post-operative emphysema and one a recto-vaginal fistula. <h3>Conclusion</h3> Our series demonstrates that TEMS is a useful technique for the resection of uT1 disease though is not without complication. Where pT1 SM3 or more advanced disease is present anterior resection is advised.

Outcome of Transanal Endoscopic Microsurgery and Adjuvant Radiotherapy in Patients with T2 Rectal Cancer

The use of transanal endoscopic microsurgery for local excision of rectal cancer has recently gained wide acceptance as a valid and safe alternative for the surgical treatment of T1 tumors. The adequacy of such treatment for T2 tumors, however, is still controversial. This study was designed to evaluate our results with local excision of T2 cancers. Patients with T2 cancer admitted to our hospital between 1995 and 2005 were offered surgery by transanal endoscopic microsurgery if found medically unfit or were unwilling to undergo radical surgery. Patients who were preoperatively staged as T1 tumor but were found to be pathologically T2 also were included. Overall, we performed 59 transanal endoscopic microsurgery operations for rectal cancers, of which 21 were for T2 cancers. In 16 (76 percent) of the T2 patients, the tumors were completely removed with clear margins by transanal endoscopic microsurgery and no additional surgery was performed, except for 2 patients who developed radiation-induced complications. Radical surgery was performed in a second operation in five patients because of involved margins and residual disease was found in two. At a median follow-up of three years, all 12 patients who received local excision and radiotherapy remained disease free, whereas a 50 percent recurrence rate was observed in patients who refused adjuvant radiotherapy. The results of this study support the feasibility of transanal endoscopic microsurgery for the treatment of selected patients with T2 rectal cancer. The addition of radiotherapy may decrease the rates of early local recurrence. However, at present, this treatment strategy should not be routinely considered for patients who may undergo radical procedures.

Transanal endoscopic microsurgery for rectal tumors: the St. Mary’s experience

Background The aim of this study is to describe a single institution’s experience in the use of transanal endoscopic microsurgery for rectal tumors. Methods Between 1996 and 2005, transanal endoscopic microsurgery was performed in 76 patients. The histologic diagnosis was adenoma in 48 and adenocarcinoma in 28 patients. Results Clear resection margins were achieved in 71 of 74 patients (95.9%). Overall morbidity was 18.9% because 14 patients developed minor (10 patients) or major complications (4 patients). During the follow-up, benign tumor recurrence was detected in 3 patients (6.3%). The recurrence rates among patients with T1, T2, and T3 malignant tumors were 7.1%, 42.8%, and 66.6%, respectively. Comments Transanal endoscopic microsurgery is a safe and feasible technique with low incomplete excision rates and may be the preferred method in patients with benign rectal tumors. Its role in the management of malignant tumors should be limited to selected patients with T1 lesions.

Transanal endoscopic microsurgery in the treatment of select rectal cancers or tumors suspicious for cancer.

This study describes a personal experience with the use of transanal endoscopic microsurgery to facilitate surgical access, and to determine the ability of this technique to reduce the need for major abdominal procedure and prevent the need for a temporary or permanent colostomy in select patients with known or suspected rectal cancer. The subjects of this study were 43 patients with rectal cancer or tumors who had a high likelihood of malignancy. The 24 men and 19 women comprised two groups: patients with known cancer ( n = 16) and patients with tumors suspicious for cancer ( n = 27), six of whom proved to have invasive malignancy. The tumors ranged in size from 1 to 7 cm (average, 3.5 cm). The tumor's inferior level in the rectum ranged from -1 to 21 cm (average, 6.5 cm). Eleven patients known to have rectal cancer were treated with preoperative radiation or chemoradiation. By ordinary standards, 22 patients would have received an abdominal perineal resection; 14 patients would have qualified for abdominal sphincter-preserving operations; and 7 patients were indeterminate. Full-thickness local excisions were disk excisions ( n = 23), hemicircumferential excisions ( n = 19), and sleeve resection ( n = 1). The ages of the patients ranged from 30 to 91 years (average, 66.7 years). In this study, 90% avoided a major abdominal operation (39/43), and 90% avoided an abdominal perineal resection of the patients (20/22). The complications were as follows: mortality ( n = 10), morbidity ( n = 9), minor wound separation ( n = 6), and major wound separation ( n = 3). Two of these complications were rectovaginal fistulas: the one in a 91-year-old patient who presented with a fistula and the other in a 77-year-old patient who presented with a previously irradiated and incompletely excised cancer. A single instance of locally recurrent cancer required an abdominal perineal resection. There were no other recurrences. Overall, three patients required a stoma (7%). Transanal endoscopic microsurgery promises to offer a safe and effective option for the selective treatment of patients with rectal cancer after preoperative chemoirradiation, and for the management of tumors suspicious for rectal cancer. Transanal endoscopic microsurgery used selectively can reduce the need for major abdominal surgery and colostomy.