Novel combined approach in the management of non-healing solitary rectal ulcer syndrome - laparoscopic resection rectopexy and transanal endoscopic microsurgery

Solitary rectal ulcer syndrome (SRUS) is an uncommon chronic disorder with a wide range of endoscopic findings, clinical presentations and characteristic histopathological features. There is no clear consensus regarding SRUS management, because of its poorly understood pathogenesis and frequent association with various pelvic floor disorders. Laparoscopic resection rectopexy and transanal endoscopic microsurgery (TEM) were used for the treatment of non-healing SRUS. The present paper reports a case of non-healing SRUS due to obstructive defecation syndrome based on combined pelvic floor disorders (rectocele, enterocele, internal rectal prolapse and dolichosigma) successfully managed by a novel combined mini-invasive approach which has never been previously reported in the literature (laparoscopic resection rectopexy and TEM). The new minimally invasive concept seems to be safe and feasible – laparoscopic resection rectopexy results in effective correction of the obstructive defecation syndrome, while TEM allows comfortable access for radical resection of a rectal ulcer.

Transanal minimal invasive surgery for rectal lesions: should the defect be closed?

AIM

Transanal minimal invasive surgery (TAMIS) of rectal lesions is increasingly being used, but the technique is not yet standardized. The aims of this study were to evaluate peri-operative complications and long-term functional outcome of the technique and to analyse whether or not the rectal defect needs to be closed.

METHOD

Consecutive patients undergoing TAMIS using the SILS port (Covidien) and standard laparoscopic instruments were studied.

RESULTS

Seventy-five patients (68% male) of mean age 67 (± 15) years underwent single-port transanal surgery at three different centres for 37 benign lesions and 38 low-risk cancers located at a mean of 6.4 ± 2.3 cm from the anal verge. The median operating time was 77 (25-245) min including a median time for resection of 36 (15-75) min and for closure of the rectal defect of 38 (9-105) min. The defect was closed in 53% using interrupted (75%) or a running suture (25%). Intra-operative complications occurred in six (8%) patients and postoperative morbidity was 19% with only one patient requiring reoperation for Grade IIIb local infection. There was no difference in the incidence of complications whether the rectal defect was closed or left open. Patients were discharged after 3.4 (1-21) days. At a median follow-up of 12.8 (2-29) months, the continence was normal (Vaizey score of 1.5; 0-16).

CONCLUSION

Transanal rectal resection can be safely and efficiently performed by means of a SILS port and standard laparoscopic instruments. The rectal defect may be left open and at 1 year continence is not compromised.

Replacing Transanal Excision with Transanal Endoscopic Microsurgery and/or Transanal Minimally Invasive Surgery for Early Rectal Cancer

The use of local resection of rectal polyps and early rectal cancer has progressed to become the standard of care in most institutions with a colorectal surgery specialist. The use of transanal excision (TAE) with anorectal retractors and standard instrumentation has been supplanted by the application of endoscopic techniques which allow direct video augmented visualization. The transanal endoscopic microsurgery method provides a 3D view and works under a constant flow of air to keep the rectal vault open. Instruments capable of accomplishing a surgical excision and suture closure work through a long 4 cm tube set at the anal canal. The newest version of TAE is transanal minimally invasive surgery which is similar to a single-site laparoscopic technique using a hand access port at the anal canal to maintain a seal for insufflation of the rectum, regular 2D video camera for visualization, and laparoscopic instrumentation through the port in the anus. Each of these techniques is described in detail and the outcomes compared, which show the progress being made in this area of colorectal surgery.

[Is it radical enough? Transanal endoscopic microsurgery for the treatment of rectal neoplasia -- clinicopathological viewpoint]

The transanal endoscopic microsurgery (TEM) provides lower relapse and complication rate for the the surgical treatment of the neoplasms of the middle and lower third of the rectum in selected cases. Hence, it can be an alternative method of the conventional approaches, if it does not compromise oncological radicality. The TEM procedure has been started at the 1st Department of Surgery, Semmelweis University in the fall of 2013. In this short study we have evaluated the clinicopathological characteristics of patients undergoing TEM between September 2013 and September 2014. Fourty-four patients were included in our retrospective analysis. 12 patients had low grade adenoma, 14 patients had high grade adenoma, 17 patients had invasive adenocarcinoma, while one was operated for a neuroendocrine tumor. There was no difference in the size of neoplasms between the low and high grade adenomas or adenocarcinomas (p = 0.210), tumors below the size of 30 mm or over 30 mm displayed no significant difference either (p = 0.424). The surgical margins were free of tumor in 41 cases (95.3%). In 13 out of 44 cases the preoperative histology proposed a lower grade neoplasm than the final report (p < 0.001). These results demonstrate that the surgical treatment of large adenomas with TEM technique, which involves excision of the whole bowel wall, is more appropriate than the fractionated removal or polypectomy supplemented by mucosectomy. The pT2 stage tumours might be subjected to the TEM method in selected cases (e.g. following neoadjuvant treatment or palliative care), but this has to be confirmed with prospecively evaluated large series clinical studies which are currently ongoing.

Transanal endoscopic microsurgery for early rectal cancer: single center experience

INTRODUCTION

The 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.

AIM

To evaluate the initial experience with TEM for early rectal cancer in a single center.

MATERIAL AND METHODS

From 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.

RESULTS

Final 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.

CONCLUSIONS

In 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 ileoproctostomy is feasible in human cadavers

AIM

An ileorectal bypass performed entirely through a transanal route has recently been described in an animal model. The present study aimed to demonstrate its technical feasibility in four human cadavers.

METHOD

A transanal endoscopic microsurgery (TEM) device and endoscopic instruments were used. The principal steps of the procedure included insertion of the TEM device, rectostomy above the peritoneal reflection, peritoneoscopy using a standard gastroscope and delivery of the small bowel through the proctostomy to perform an anastomosis.

RESULTS

The procedure was successfully completed using transanal access in all cases. The mean procedure time was 90 min. The bypass was patent, and the anastomosis between the intraperitoneal rectum and the terminal ileum was leakproof.

CONCLUSION

Transanal ileoproctostomy is technically feasible in human cadavers. The procedure may become an alternative to stoma formation in selected patients with colonic obstruction.

Local excision of T1 and T2 rectal cancer: proceed with caution

AIM

This study aimed to compare the clinical outcome between local excision (LE) and total mesorectal excision (TME) for early rectal cancer.

METHOD

After Institutional Review Board approval, charts of patients with T1 or T2 N0M0 rectal adenocarcinoma treated by curative LE or TME without preoperative radiotherapy from 2004 to 2012 were reviewed. Categorical and continuous variables were compared using chi-square analysis and the ANOVA test. Kaplan-Meier analysis compared survival rates.

RESULTS

The study included 153 patients: 79 underwent TME and 74 LE. Postoperative infection was more common after TME (P = 0.009). There was tumour involvement of the margins in 13.5% after LE compared with 0% after TME (P = 0.001). Of the patients treated initially by LE, 13.5% had additional surgery for unfavourable histological findings and 4.1% had residual tumour. Median follow up was 35 (17-96) months. No deaths were recorded in 56 patients with a pT1 lesion. There was no significant difference in local recurrence (P = 0.332) or 3-year disease-free survival (DFS; P = 0.232) between patients having LE or TME. The 68 patients with a T2 lesion had higher local recurrence (P = 0.025) and lower DFS following LE compared with TME (P = 0.044). There was no difference in overall survival (P = 0.351).

CONCLUSION

LE of early rectal cancer is associated with higher local recurrence and decreased DFS. These disadvantages are significant for T2 lesions.

Endoscopic resection yields reliable outcomes for small rectal neuroendocrine tumors

BACKGROUND AND AIM

We analyzed the characteristics of gastrointestinal neuroendocrine tumors and examined the outcomes and safety of modalities in rectal neuroendocrine tumors.

METHODS

Between 2007 and 2011, a total of 91 patients with gastrointestinal neuroendocrine tumors were retrospectively reviewed in terms of the characteristics of tumors.

RESULTS

Sixty-six patients had rectal neuroendocrine tumors and underwent endoscopic mucosal resection (EMR, n = 29), endoscopic submucosal dissection (ESD, n = 23), or transanal endoscopic microsurgery (TEM, n = 14). The complete resection rate was higher in the ESD group (82.7%) and in the TEM group (100%) compared to the EMR group (65.5%) (P < 0.046). The complication rate was higher in the ESD group (47.8%) than in the EMR group (18.5%) (P = 0.003). No local tumor recurrence was observed in all patients, regardless of the procedure, during the median follow-up period of 21.5 ± 13.5 months.

CONCLUSIONS

ESD achieved a higher complete resection rate than EMR and comparable to TEM. Tumor recurrence was not observed in the endoscopic resection and TEM groups, regardless of the completeness of resection. Small neuroendocrine tumors of the gastrointestinal tract can be managed reliably with both endoscopic resection and TEM.

Transanal endoscopic microsurgery combined with endoscopic posterior mesorectum resection in the treatment of patients with T1 rectal cancer - 3-year results

Introduction

Rectum-sparing transanal endoscopic microsurgery (TEM) is a well-established treatment for T1 rectal cancer (RC). However, it is associated with an increased rate of local recurrence in comparison with extended resection. In most cases this failure is linked to inappropriate case selection and the presence of clinically non-detectable metastases in the regional lymph nodes. Endoscopic posterior mesorectal resection (EPMR) makes it possible to remove the relevant lymphatic drainage of the lower third of the rectum in a minimally invasive way, which in turn can help in adequate tumor staging.

Aim

To evaluate the long-term clinical results and influence of combined TEM and EPMR treatment on the anorectal functions.

Material and methods

Ten consecutive patients with T1 RC were operated on using TEM and EPMR as a two-stage procedure between 2007 and 2009.

Results

After a median follow-up of 42.6 (range: 36–80) months, none of our patients complained of symptoms of incontinence apart from one female patient with gas incontinence diagnosed preoperatively. There was no statistically significant difference in basal anal pressure, squeeze anal pressure, high pressure zone length or fecal continence assessed using the Fecal Incontinence Severity Index before and in follow-up months after the procedure. Postoperative morbidity consisted of one hematoma formation and one male patient complaining about sexual dysfunction until 6 months postoperatively. There was no evidence of locoregional recurrence.

Conclusions

Endoscopic posterior mesorectal resection in combination with TEM appears to be safe, feasible and with no impact on the basic anorectal functions in the 3-year follow-up.

Perivascular epithelioid cell tumor of the rectum: report of a case and review of the literature

We report a case of perivascular epithelioid cell tumor arising in the rectum of a 55-year-old woman. The tumor was treated by transanal endoscopic microsurgery. After 1 year follow-up, the patient is alive with no radiologic or endoscopic evidence of recurrence. Perivascular epithelioid cell tumor is a rare mesenchymal tumor characterized by co-expression of melanocytic and smooth muscle markers. This rare tumor can arise in various organs, including the falciform ligament, uterus, uterine cervix, liver, kidney, lung, breast, cardiac septum, pancreas, prostate, thigh, and gastrointestinal tract. Perivascular epithelioid cell tumor of the gastrointestinal tract is very rare, with only 23 previously reported cases. We review the literature on perivascular epithelioid cell tumors arising in the gastrointestinal tract.

Systematic review and meta-analysis of published trials comparing the effectiveness of transanal endoscopic microsurgery and radical resection in the management of early rectal cancer

AIM

A systematic analysis was conducted of trials comparing the effectiveness of transanal endoscopic microsurgery (TEMS) with radical resection (RR) for T1 and T2 rectal cancer.

METHOD

An electronic search was carried out of trials reporting the effectiveness of TEMS and RR in the treatment of T1 and T2 rectal cancers.

RESULTS

Ten trials including 942 patients were retrieved. There was a trend toward a higher risk of local recurrence (odds ratio 2.78; 95% confidence interval 1.42, 5.44; z = 2.97; P < 0.003) and overall recurrence (P < 0.01) following TEMS compared with RR. The risk of distant recurrence, overall survival (odds ratio 0.90; 95% confidence interval 0.49, 1.66; z = 0.33; P = 0.74) and mortality was similar. TEMS was associated with a shorter operation time and hospital stay and a reduced risk of postoperative complications (P < 0.0001). The included studies, however, were significantly diverse in stage and grade of rectal cancer and the use of neoadjuvant chemoradiotherapy.

CONCLUSION

Transanal endoscopic microsurgery appears to have clinically measurable advantages in patients with early rectal cancer. The studies included in this review do not allow firm conclusions as to whether TEMS is superior to RR in the management of early rectal cancer. Larger, better designed and executed prospective studies are needed to answer this question.

The effect of endoscopic mucosal resection and transanal endoscopic microsurgery on anorectal function

AIM

The study assessed the impact on anorectal function of endoscopic mucosal resection (EMR) and transanal endoscopic microsurgery (TEM) of large rectal adenomas.

METHOD

Patients with a large (≥ 3 cm) rectal adenoma undergoing EMR or TEM were included. Self-reported faecal incontinence was assessed using the Colorectal Functional Outcome (COREFO) questionnaire and the Wexner Incontinence Grading Scale. Anorectal manometry was performed before and at 6 months after treatment to measure anal resting (ARP) and squeeze pressure (SP), squeeze endurance (SE), the rectoanal inhibitory reflex (RAIR), rectal volumetry of first sensation (FS), first urge (FU), maximum tolerable volume (MTV) and rectal compliance (RC).

RESULTS

Twenty-four patients were included in the study, of whom 11 underwent EMR and 13 underwent TEM. The mean adenoma size was 51 ± 19 mm and the median distance from the anal verge was 3 cm (interquartile range 1-10 cm). Follow-up data were available from 20 patients; one patient had died and three had undergone total mesorectal excision. Incontinence for liquid stool and Wexner score decreased significantly after treatment. In contrast, none of the measured parameters of anorectal motility (ARP, SP, SE, RAIR, RC) and perception (FS, FU, MTV) was affected by adenoma resection. No differences were found in baseline and follow-up incontinence and functional parameters between intervention groups, except for postprocedural ARP, which was lower after TEM than after EMR.

CONCLUSION

Continence in patients with a large rectal adenoma improved after EMR or TEM, probably due to decreased rectal mucus production. Anal sphincter pressure, rectoanal reflexes, rectal sensation and compliance were not affected by adenoma resection.

Treatment of preoperatively diagnosed colorectal adenomas by transanal endoscopic microsurgery: the experience in China

INTRODUCTION

Colorectal adenoma is a recognized precancerous lesion that has the potential for malignant transformation. Surgical resection of colorectal adenomas is required for exact diagnosis and treatment. The aim of this study is to assess the safety and therapeutic effect of transanal endoscopic microsurgery for preoperatively diagnosed colorectal adenomas.

METHODS

From September 2006 to February 2011, 45 patients with preoperatively diagnosed colon and rectal adenomas underwent transanal endoscopic microsurgery. The clinical data of these patients were reviewed.

RESULTS

The mean tumor diameter was 2.2 cm, mean operative time was 65 min, and the mean estimated blood loss was less than 10 mL. There was no conversion to transabdominal procedure. The mean tumor distance from the anal verge was 8.2 cm. Four patients had perforation into the peritoneal cavity during full-thickness resection; these were repaired by continuous suturing, and there was no postoperative leakage after 1 week of fasting. The surgical margins of specimens were negative in 44 patients. Complications included rectal bleeding in one patient, acute urinary retention in one patient and pulmonary infection in one patient. The mean postoperative hospital stay was 4.5 days. Only one patient experienced incontinence of hard stool 6 months after surgery. The patients were followed up for a median period of 42 months, with four cases of tumor recurrence observed.

CONCLUSION

Transanal endoscopic microsurgery is a safe and effective technique for excising large adenomas in the mid and upper rectum and in the lower sigmoid colon. It is also an oncologically preferred method for T1 focal carcinomas that develop from villous adenomas.

Transanal endoscopic microsurgery: what indications in 2013?

Thanks to major advances in the field of surgical techniques and neoadjuvant chemoradiation therapy, along with more accurate pre-operative staging tools and the widespread introduction of population-based screening programs, treatment of rectal cancer has been evolving over the past few decades, moving towards a more tailored approach. This has brought a shift in the treatment algorithm of benign rectal lesions and selected early rectal cancers, for which today transanal endoscopic microsurgery (TEM) is accepted as an effective alternative to abdominal surgery.

In 2013, topics of controversy are the role of TEM in the treatment of more advanced rectal cancers, in cases of complete pathological response after chemoradiation therapy and the role of TEM as a platform for single-port surgery and NOTES. This article reviews the current indications for TEM and the future perspectives of this approach in the treatment of rectal tumors.

Local treatment for rectal cancer

The treatment of rectal cancer includes both radical resection and local therapy. Radical resection remains the standard treatment, but is associated with increased morbidity and mortality, as well as the potential need for a temporary and occasionally, a permanent ostomy. The benefits of local treatment include a less invasive procedure with maintenance of bowel function and avoidance of a stoma. However, the efficacy of local treatment is now being challenged as the rates of recurrence after local excision alone appear to be much higher than previously thought. Although the primary goal of an oncologic resection is disease eradication, each case must be individualized to determine an optimal care plan.

An evaluation of transanal endoscopic microsurgery for rectal adenoma and carcinoma

BACKGROUND

Transanal endoscopic microsurgery was introduced in the early 1980s. Since then, increasing numbers of rectal adenomas are being excised by this technique. The aim of this study was to evaluate our institution's experience with transanal endoscopic microsurgery for rectal adenoma and carcinoma.

METHODS

Seventy-five patients (adenomas, n = 58) underwent more than 90 TEM resections over a period of 5 years.

RESULTS

Postoperative complications were minimal with 3% (n = 2) in the adenoma group requiring transfusion and 0% 30-day mortality. One patient in each group developed transient fecal incontinence. During the follow-up period, 6 patients (10%) in the adenoma group underwent further local resections for their recurrences. Two patients in the carcinoma group (1 each of pathological T1 and T2 stage) developed recurrence at 24 months. A female with a T2 tumor was found to have an inoperable lesion and underwent sigmoid colostomy. Five of 17 patients had postoperative radiotherapy, and 2 patients developed radiation enteritis. Four patients died during follow-up due to unrelated reasons.

CONCLUSION

The transanal endoscopic microsurgery technique appears to be safe and associated with minimal morbidity. Careful selection of patients with thorough preoperative assessment is necessary for carcinoma patients. Patients with T1 lesions and favorable histology should only be considered for curative resection by this technique.