Is transanal endoscopic microsurgery (TEM) a valid treatment for rectal tumors?

Importance of Resection Margins in the Treatment of Rectal Adenomas by Transanal Endoscopic Surgery

BACKGROUND

Polypectomy is the gold standard for treating colorectal adenomas up to 2 cm in size. For larger lesions, various procedures ranging from endoscopy to transanal surgery can be performed and achieve varying results for en bloc resection and recurrence. There are no clear guidelines for dealing with involved resection margins. We assess the recurrence of rectal adenomas operated using TEM with full-thickness wall excision with or without free resection margins and define optimal endoscopic follow-up.

METHOD

Observational study with prospective data collection, including patients undergoing TEM between 6/2004 and 11/2017, with definitive diagnosis of rectal adenoma. Data on epidemiological, preoperative, surgical, postoperative, pathological, and follow-up variables were recorded. Univariate analysis, follow-up risk function, and multivariate logistic regression analysis were performed to detect risk factors for recurrence.

RESULTS

TEM was indicated in 736 patients; 481 adenomas were identified in the preoperative biopsy, of which 95 were infiltrating adenocarcinomas (19.8%) in the definitive pathology study. With a minimum follow-up of 1 year, 372 patients were included. Pathology study showed free margins in 324 (87%). Recurrences were recorded in 15 patients (4%), up to 18 months in the free margins group and up to 24 months in the involved margins group. Thirteen patients with recurrence (86.6%) were treated with TEM. No predictors of recurrence were found in the multivariate analysis.

CONCLUSION

TEM is the technique of choice for treating rectal adenomas and recurrences, achieving a low relapse rate. Follow-up must be adapted to resection margins and should be extended to 24 months.

Assessing the safety and outcomes of repeat transanal endoscopic microsurgery

BACKGROUND

Transanal endoscopic microsurgery (TEM) is the treatment of choice for benign rectal tumors and select early rectal cancers. This surgical approach has become ubiquitous and surgeons are seeing recurrent lesions after TEM resection. This study aims to outline the safety and outcomes of repeat TEM when compared to primary TEM procedures.

METHODS

At St. Paul's Hospital, demographic, surgical, pathologic, and follow-up data for patients treated by TEM are maintained in a prospectively populated database. Two groups were established for comparison: patients undergoing first TEM procedure (TEM-P) and patients undergoing repeat TEM procedure (TEM-R).

RESULTS

Between 2007 and 2017, 669 patients had their first TEM procedure. Over this time frame, 57 of these patients required repeat TEM procedures, including 15 of these patients treated by 3 or more TEMs. Indications for repeat TEM included recurrence (78%), positive margins (15%), and metachronous lesions (7%). There were no differences between the groups in patient age, gender, or tumor histology. Compared to TEM-P, TEM-R had shorter operative times (38 vs. 52 min, p < 0.001), more distal lesions (5 vs. 7 cm, p < 0.004), and smaller lesions (3 vs. 4 cm, p < 0.0003). The TEM-R group had similar length of hospital stay (0.45 vs. 0.56 days, p = 0.65), rates of clear margins on pathology (81% vs. 88%, p = 0.09), and 30-day readmission rates (7% vs. 4%, p = 0.27) when compared to TEM-P group. TEM-R was more likely to be managed without suturing the surgical defect (72% vs. 32%, p < 0.0001). Repeat TEM was associated with similar post-operative complications as primary TEM graded on the Clavien-Dindo classification scale (Grade 1: 5% vs. 5%, Grade 2: 5% vs. 4%, Grade 3: 5% vs. 1%, p = 0.53). No 30-day mortality occurred in either group.

CONCLUSIONS

The St. Paul's Hospital TEM experience suggests repeat TEM is a safe and feasible procedure with similar outcomes as patients undergoing first TEM.

Peritoneal perforation during transanal endoscopic microsurgery is not associated with significant short-term complications

BACKGROUND

In patients treated by transanal endoscopic microsurgery (TEM), breach of the peritoneal cavity is a feared intraoperative challenge. Our aim is to analyze predictors and short-term outcomes of patients with peritoneal perforation (TEM-P) when compared to similar patients with no peritoneal compromise (TEM-N).

METHODS

At St. Paul's Hospital, demographic, surgical, pathologic, and follow-up data for all patients treated by TEM is maintained in a prospectively populated database. A retrospective review was performed and two groups were established for comparison: TEM-P and TEM-N. Statistical analysis was performed using student's t or chi-squared test, where appropriate.

RESULTS

Of 619 patients treated by TEM between 2007 and 2016, 39 (6%) patients were in the TEM-P group and 580 (94%) in the TEM-N group. There were no differences between the groups in patient age, gender, histology, or tumor size. Patients who had peritoneal perforations had more proximal lesions (11 vs. 7 cm, p < 0.0001), anterior lesions (56 vs. 43%, p < 0.05), and longer operations (80 vs. 51 min, p < 0.005). While most defects were closed endoluminally, 2 patients with perforation were converted to transabdominal surgery. There was a difference in overall hospital stay with TEM-P patients staying on average 2 days in hospital with fewer patients managed as day surgery (31 vs. 73%, p < 0.0001). There were no mortalities or significant 30-day complications in the TEM-P group and only one patient required readmission.

CONCLUSIONS

The St. Paul's Hospital TEM experience suggests patients with peritoneal breach during TEM can be safely managed with outcomes similar to patients without peritoneal entry. Proximal, anterior lesions are at highest risk of peritoneal perforation.

Endoscopic Treatment of Carpet-Like Adenomas of the Rectum

Background

Transanal microsurgery, endoscopic laser photocoagulation and snare resection have all been used to treat large sessile adenomas of the rectum alternatively to a surgical approach. However, such modalities are often defective due to the carpet-like shape and the frequently large extension of the lesions.

Methods

Ten patients with carpet-like adenoma were submitted to transanal endoscopic resection by urological resectoscope.

Results

Complete eradication was obtained in all lesions. The mean number of treatment sessions was 3 (range, 1-5). The mean time between the first treatment and the complete eradication was 6 months (range, 1-18). The only complications were an intraoperative and an early postoperative bleeding. There was no early or late mortality related to the procedure.

Conclusions

Transanal endoscopic resection by urological resectoscope appears to be a suitable therapeutic approach for sessile and carpet-like adenomas of the rectum or for pTI cancer in patients who refuse major surgery.

Transanal endoscopic microsurgery

The aim of oncologic surgery is radical cancer treatment with preservation of function and quality of life. Almost 30 years ago, transanal endoscopic microsurgery (TEM) revolutionised the technique and outcomes of transanal surgery, first becoming the standard of treatment for large rectal adenomas, then offering a possibly curative treatment for early rectal cancer, and finally generating discussion on its potential role in combination with neoadjuvant therapies for the treatment of more invasive cancer. TEM afforded the advantage of combining a less invasive transanal approach with low recurrence rates thanks to enhanced visualization of the surgical field, which allows more precise dissection. We describe the current indications, the preoperative work-up, the surgical technique (with the aid of a video), postoperative management and results obtained in an over 20-year-long experience. Designed as an accurate means to allow excision of benign rectal neoplasms with a very low morbidity rate, TEM today is indicated as a curative treatment of malignant neoplasms that are histologically confirmed as pT1 sm1 carcinomas. T1 sm2-3 and T2 lesions should at present be included in prospective trials. Accurate preoperative staging is essential for optimal selection of patients. Patients with clear indication for TEM should be referred to specialized medical centres experienced with the technique.

Application of endoscopic sonography in preoperative staging of rectal cancer: six-year experience

OBJECTIVES

The aim of this study was to evaluate our experience with the application of endoscopic sonography in preoperative staging of rectal cancer.

METHODS

Between April 2004 and May 2010, 192 patients with rectal cancer first underwent endoscopic sonography and then underwent surgery at our hospital. None of the patients in this study received neoadjuvant therapy. The endoscopic sonographic staging results were compared with those of postoperative pathologic staging.

RESULTS

The accuracy of overall T staging was 86.5%, and for T1, T2, T3, and T4, the accuracy rates were 86.7%, 94.0%, 86.2%, and 65.5%, respectively. The accuracy of T staging for ulcerated lesions was significantly lower than that for nonulcerated lesions (P = .013). The accuracy of T staging between nontraversable stenotic lesions and traversable lesions was also significantly different (P = .002). The accuracy of N staging was 77.8%, and the specificity and sensitivity were 85.6% and 74.2%, respectively.

CONCLUSIONS

Endoscopic sonography is safe and effective for preoperative staging of rectal cancer and should be a routine examination before surgery. As for ulcerated and nontraversable stenotic lesions, however, the results of endoscopic sonographic staging could be doubtful. Moreover, the accuracy of endoscopic sonographic N staging still needs modification by further research.

Treatment of recurrence after transanal endoscopic microsurgery (TEM) for T1 rectal cancer

PURPOSE

The aim of this study was to evaluate the management and outcome of local recurrences after transanal endoscopic microsurgery for T1 rectal cancer.

METHODS

Consecutive patients who underwent transanal endoscopic microsurgery for pT1 rectal cancer at a Dutch referral center (IJsselland Hospital) were registered in a prospective database. Follow-up was according to Dutch guidelines on rectal cancer, with additional rigid rectoscopy and endorectal ultrasound examinations every 3 months for the first 2 years, and every 6 months thereafter. Annual MRI of the lesser pelvis was added during the last 2 years of the study. Patients with local recurrence during follow-up were selected for individual analysis of outcome.

RESULTS

Of a total of 88 patients who underwent transanal endoscopic microsurgery for pT1 rectal cancer, 18 patients (20.5%) had a local recurrence. Median time to local recurrence was 10 (range, 4-50) months. Median age at diagnosis of recurrence was 74 (range, 56-84) years. Of the 18 patients, 2 did not undergo further surgery because of concomitant metastatic disease, and 16 underwent salvage surgery, without need for multivisceral resections. No postoperative mortality was observed. In 15 patients (94%), a microscopically negative excision margin was obtained; in 1 patient, the excision margin was microscopically positive. Median follow-up after salvage surgery was 20 (range, 2-112) months. One patient had a local renewal of recurrence, and 7 patients (39%) had distant metastases. At 3 years, overall survival was 31%; cancer-related survival was 58%.

CONCLUSIONS

Recurrent disease after transanal endoscopic microsurgery for T1 rectal cancer is a major problem. Although salvage surgery for achieving local control is feasible in most patients, survival is limited, mainly because of distant metastases. Tailoring selection of T1 rectal cancers and exploring possible adjuvant treatment strategies following salvage procedures should be the next steps toward improving survival.

Transanal endoscopic microsurgery for rectal neoplasms: experience of 300 consecutive cases

PURPOSE

Abdominal resection for rectal neoplasms is associated with significant morbidity. Local excision with retractors can be proposed only for distal rectal lesions. With this retrospective review of our prospective series of transanal endoscopic microsurgery procedures, we wanted to verify the advantages of local treatment in terms of disease recurrence and complication rates.

METHODS

Indications for transanal endoscopic microsurgery were adenoma, early carcinoma, rectal ulcers, carcinoid tumors, gastrointestinal stromal tumors, and leiomyosarcoma apparently located in the extraperitoneal rectum. We analyzed operating time, morbidity and mortality rates, length of hospital stay, staging discrepancy, recurrence rate, and oncological outcome.

RESULTS

From January 1993 to January 2007, 300 patients underwent transanal endoscopic microsurgery at our institution. The mean operating time was 66 minutes. The peritoneum was inadvertently opened in 13 cases. The overall morbidity rate was 7.7%. The mean hospital stay was five days. Histology demonstrated cancer in 90 patients. At a mean follow-up of 60 months, the recurrence rate was zero in pT1, 24% in pT2, and 50% in pT3. The overall estimated five-year survival rate was 87%, and the disease-free survival rate was 82%.

CONCLUSIONS

Transanal endoscopic microsurgery is safe and effective in the treatment of adenoma and pT1 carcinoma; it carries a lower morbidity than conventional surgery and a recurrence rate comparable to that of conventional surgery.

Development of a new operating rectal tube with a side window for transanal endoscopic surgery

The authors describe a new rectal tube for use in transanal endoscopic surgery. The tube is a transparent plastic sheath with its forward end closed, measuring 40 mm in diameter and 150 mm in insert length. It has a window, measuring 40 mm in diameter, on its side. The target lesion, captured within the side window, prolapses into the rectal tube and is excellently visualised without positive pressure gas insufflation. This paper gives details of the tube and reports on a sessile rectal tumour successfully treated using the new system.

Treatment of rectal adenomas by transanal endoscopic microsurgery: 15 years' experience

BACKGROUND

The authors present their experience with rectal adenomas managed by transanal endoscopic microsurgery (TEM). The goals of this study were to examine our institution's experience by evaluating surgical morbidity, mortality, and local recurrence rate.

METHODS

This retrospective study investigated 402 patients who underwent TEM a for preoperative diagnosis of adenoma from January 1993 to October 2008. The mean age was 65 years (range = 22-92 years). All patients were regularly followed up to determine treatment efficacy in terms of local recurrence rate.

RESULTS

No 30-day perioperative mortality occurred. No conversion to laparoscopic or open procedures was reported. Minor complications occurred in 28 (7%) patients, whereas major complications were found only in 2 (0.5%) patients. Definitive histology confirmed adenomas in 366 cases (91%). At a mean follow-up of 84 months (range = 1-190 months), 16 (4%) adenomas recurred and were successfully retreated by TEM [14 cases (87.5%)] and by conventional surgery [2 patients (12.5%)]. No further recurrences were observed at subsequent follow-up.

CONCLUSION

The findings warrant the conclusion that TEM is a safe, effective treatment for rectal adenomas where endoscopic removal is not applicable and has low morbidity and no mortality.

Transanal endoscopic microsurgery for the treatment of rectal cancer: comparison of wound complication rates with and without neoadjuvant radiation therapy

BACKGROUND

Neoadjuvant therapy for rectal cancer has led to improved tumor downstaging and higher complete pathologic response rates. At the same time, the introduction of transanal endoscopic microsurgery (TEM) technique has renewed interest in local excision of rectal cancer. There has been concern that radiation may make the more radical local excision with TEM unsuitable. Our study compared morbidity rates and wound complication rates for patients undergoing TEM and local excision with and without neoadjuvant radiation to determine whether this could be accomplished safely.

METHODS

Data for all patients undergoing TEM are prospectively entered into a database. This database was queried for patients with rectal cancer undergoing TEM from November 1997 to June 2007. Of 64 patients identified, 2 were excluded because of previous radiation to the pelvis.

RESULTS

The study enrolled 62 patients with a final pathologic diagnosis of rectal cancer: 43 treated using neoadjuvant therapy with radiation (XRT) and 19 patients treated with TEM alone. The patients in the XRT group were 67 years of age (range, 29-86 years) and included 13 women. The patients in the non-XRT group were 66 years of age (range, 40-89 years) and included 8 women. Neither group had any mortalities. The overall morbidity rate was 33% for the XRT group and 5.3% for the non-XRT group, and this difference was statistically significant (p < 0.05). The wound complication rates were 25.6% for the XRT group (11 patients) and 0% for the non-XRT group (p = 0.015). Nine patients in the XRT group (82%) had minor wound separations, and two patients (18%) had major wound separation. Ten patients with wound separations were treated as outpatients and administered long-term oral antibiotics. One patient required additional surgery (diverting stoma).

CONCLUSIONS

Not unexpectedly, the wound complication rate was higher in the XRT group. However, 82% of those wounds were minor, and 91% were treated without any additional surgery or intervention. Although a significant concern, wound complications do not prohibit TEM treatment after neoadjuvant treatment.

Harmonic long shears further reduce operation time in transanal endoscopic microsurgery

BACKGROUND

Previous research indicates that application of 5-mm harmonic shears rather than diathermia significantly reduces operation time in transanal endoscopic microsurgery (TEM). Frequently, however, additional instruments were required to complete resection. We investigated whether the new 5-mm harmonic long shears (H-LS) are better equipped for TEM compared with regular harmonic shears (HS).

METHODS

Between 2001 and 2006, 162 tumors (117 adenomas, 42 carcinomas, and 3 other tumors; mean distance 6.6 cm, mean area 40 cm(2)) were excised in 161 patients (82 men, 79 women; mean age 66 years).

RESULTS

Eighty-eight resections were performed with HS and 74 with H-LS. Tumor and patient characteristics were similar except for specimen area. Tumors resected by H-LS were on average smaller than those resected by HS (34.4 versus 44.1 cm(2); Mann-Whitney U-test: p = 0.027). Mean operation time was 48 min and proportional to area in both groups (univariate analysis of variance p < 0.001). Mean operation time was 54 min using HS and 41 min using H-LS (t-test: p < 0.001). After correction for area, operation time for H-LS was reduced by 14% compared with HS (t-test: p < 0.001). H-LS is singly capable of completing resection in 88% compared with 26% for HS (Mann-Whitney U-test: p < 0.001). Mean blood loss was 16 cc for HS and 3 cc for H-LS (p < 0.001). Morbidity (11%) and mortality (0.6%) were not different between the two groups (Fisher's exact test).

CONCLUSION

Performing transanal endoscopic microsurgery with 5-mm harmonic long shears reduces operation time compared with regular shears, and completing resection seldom requires other instruments.

Long-term results of transanal excision after neoadjuvant chemoradiation for T2 and T3 adenocarcinomas of the rectum

INTRODUCTION

Traditionally, selected early distal rectal cancers have been considered for treatment by transanal excision (TAE) with acceptable oncologic results. With the frequent use of neoadjuvant chemoradiation (NCR) for the treatment of locally advanced rectal cancer, there is growing interest in the application of TAE for such lesions. We report our experience of TAE for T2 and T3 rectal cancers following NCR.

MATERIAL AND METHODS

Between July 1994 and August 2006, 44 patients were identified as having undergone full-thickness TAE of pretreatment ultrasound-staged T2 and T3 rectal cancers that were treated with NCR. Fifteen patients were deemed medically unfit for radical resection, and 29 would have required abdominoperineal resection but were opposed to colostomy.

RESULTS

Our patient population consisted of 26 men and 18 women, with a median age of 69 (range, 43-89) and a median follow up of 64 months (6-153). Thirty-one patients had a clinical complete response (cCR) to NCR of which 19 (61%) had a pathologic CR (pCR). Seven (16%) of 44 patients sustained disease recurrence of which two were local only, two local and systemic, and three systemic only. Only four (9%) patients had died of disease at current follow up. Overall 5-year survival rates for T2/T3N0 and T2/T3N1 patients were 84% and 81%, respectively. Five patients underwent radical resection immediately following TAE for either positive margins or residual cancer. There was minimal morbidity with no perioperative mortality associated with TAE.

CONCLUSIONS

TAE of T2 and T3 rectal cancers following NCR is a safe alternative to radical resection in a highly select group of patients for which recurrence and survival rates comparable to radical resection can be achieved. This study supports ongoing efforts to assess this approach in prospective, multi-center trials.

A new proctoscope for transanal endoscopic operations

Transanal access is one of many currently used procedures for rectal cancer treatment. The techniques used for local excision include conventional transanal excision, posterior access, therapeutic colonoscopy and transanal endoscopic approaches. The aim of the present study was to present a new surgical proctoscope for the endoscopic transanal excision of rectal lesions. A cylindrical proctoscope with a diameter of 4 cm was devised and built. The end inserted into the anus has a bevelled aspect and rounded borders, allowing correct exposure of the anal lesion. The rectoscope is fixed to the anal border with surgical thread through perforations in the external end. A base screw holds a fibre-light which illuminates the operative field. Part of the equipment is a guide which is positioned inside the rectoscope on insertion into the anus. In operations utilizing this proctoscope, 17 adenomas, 25 adenocarcinomas, 1 carcinoid and 1 endometrioma were excised. The diameter of the lesions varied from 1 to 6 cm. The range of procedures that are possible with this new proctoscope are similar to those achieved with conventional techniques which, however, require more expensive equipment. Hence, the present study demonstrates that this newly devised low-cost proctoscope is an efficient tool for the transanal endoscopic excision of rectal lesions.

Transanal local excision for preoperative concurrent chemoradiation therapy for distal rectal cancer in selected patients

PURPOSE

To evaluate the clinical course and outcomes of patients with T2 or T3 rectal cancer treated by transanal local excision after preoperative chemoradiation therapy (CRT).

METHODS

Between June 2000 and August 2004, seven patients underwent local excision of T2 or T3 rectal cancer after preoperative CRT. Preoperative clinical staging was on the basis of the findings of endorectal ultrasound. Computed tomography (CT) and digital rectal examination consisted of radiation therapy with 4 500 cGy/25 fractions, given over 5 weeks with 5-FU-based chemosensitization. Local excision was performed 4-7 weeks later.

RESULTS

The mean age of the patients was 54.9 (35-70) years and the median follow-up period was 23 (5-57) months. The lesions were located 2-6 cm above the anal verge (median 3.0 cm). Pretreatment T staging was estimated as T3 in one patient, and T2 in six patients. Post-treatment T staging was estimated as complete remission (CR) in two patients, T1 in three patients, and T2 in two patients. Pathologic evaluation revealed tumor downstaging in six patients, including three (42.9%) with CR. No tumor cells were seen in the resection margin and there was no sign of recurrence in any of the patients.

CONCLUSION

These findings support local excision after preoperative CRT as an effective alternative to radical resection in carefully selected patients with T2 and T3 distal rectal cancer.

Local excision of rectal tumours by transanal endoscopic microsurgery

BACKGROUND

Transanal endoscopic microsurgery (TEM) allows locally complete excision of rectal tumours and provides an alternative to conventional surgery for benign tumours. However, its role in the curative treatment of invasive carcinoma is controversial. The aim of this study was to determine the morbidity and long-term results for rectal tumours excised by TEM.

METHODS

Between February 1993 and January 2005, 200 patients underwent TEM for excision of adenomas (148) or carcinomas (52). The median tumour distance from the anal verge was 8 (range 1-16) cm.

RESULTS

Mortality and morbidity rates were 0.5 and 14.0 per cent respectively. At a median follow-up of 33 (range 2-133) months, local recurrence had developed in 11 patients (7.6 per cent) with an adenoma. Histological examination of carcinomas revealed pathological tumour (pT) stage 1 in 31 patients, pT2 in 17 and pT3 in four. Immediate salvage surgery was performed in seven patients (13 per cent). At a median follow-up of 34 (range 1-102) months, eight patients (15 per cent) with carcinomas had developed local recurrence. The overall and disease-free 5-year survival rates for patients with carcinomas were 76 and 65 per cent respectively.

CONCLUSION

TEM is an appropriate surgical treatment option for benign rectal tumours. For carcinomas, it is oncologically safe provided that resection margins are clear, but strict patient selection is required.

Decision for salvage treatment after transanal endoscopic microsurgery

BACKGROUND

Transanal endoscopic microsurgery (TEM) has emerged as an alternative to classic radical operation for early rectal cancer. Early rectal cancer can be treated by adequate local excision such as TEM. If there are adverse risk factors, especially poor cellular differentiation, close resection margin, or positive lymphovascular invasion or incomplete excision, a radical resection is indicated. This study aimed to clarify the factors related to recurrence for patients required to undergo a salvage operation after TEM.

METHODS

This retrospective study analyzed 167 patients who underwent TEM for rectal cancer between 1994 and 2004. Of these patients, 36 with poor differentiation, mucinous carcinoma, proper muscle invasion, lymphovascular invasion, and positive resection margin were included in the analysis.

RESULTS

Of the 36 patients, 12 underwent a salvage operation, and the remaining 24 did not because of poor physical condition or refusal of radical surgery. There were a total of 6 (16.7%) recurrences. One (8.3%) of the 12 patients who underwent salvage surgery had systemic recurrence. Five (20.8%) of the 24 patients who did not receive surgery had recurrence (3 local recurrences, 2 distant recurrences). Analysis of the subgroups showed that 2 (28.6%) of 7 patients with lymphovascular invasion had recurrence, and that 1 patient (100%) had a T3 lesion. Three (17.6%) of 17 patients had T2 lesions.

CONCLUSIONS

For high-risk patients, TEM followed by radical surgery is the most beneficial in preventing local recurrence. Radical salvage surgery is strongly recommended if pathologic results after TEM show T3 lesion or lymphovascular invasion.

Transanal endoscopic microsurgery for carcinoma of the rectum

BACKGROUND

The authors present their experience with rectal cancers managed by transanal endoscopic microsurgery (TEM).

METHODS

This prospective study investigated patients undergoing primary TEM excision for definitive treatment of rectal cancer between January 1996 and December 2003 by a single surgeon in a tertiary referral colorectal surgical unit.

RESULTS

For this study, 52 patients (30 men and 22 women) underwent TEM excision of a rectal cancer. Their mean age was 74.3 years (range, 48-93 years). The median diameter of the lesions was 3.44 cm (range, 1.6-8.5 cm). The median distance of the lesions from the anal verge was 8.8 cm (range, 3-15 cm), with the tumor more than 10 cm from the anal verge in 36 patients. The median operating time was 90 min (range, 20-150 min), and the median postoperative stay was 2 days. All patients underwent full-thickness excisions. There were 11 minor complications, 2 major complications, and no deaths. The mean follow-up period was 40 months (range, 22-82 months). None of the pT1 rectal cancers received adjuvant therapy. Eight patients with pT2 rectal cancer and two patients with pT3 rectal cancer received postoperative adjuvant therapy. The overall local rate of recurrence was 14%, and involved cases of T2 and T3 lesions, with no recurrence after excision of T1 cancers. Three patients died during the follow-up period, but no cancer-specific deaths occurred.

CONCLUSIONS

The findings warrant the conclusion that TEM is a safe, effective treatment for selected cases of rectal cancer, with low morbidity and no mortality. The TEM procedure broadens the range of lesions suitable for local resection to include early cancers (pTis and pT1) and more advanced cancers only in frail people.

Long-term results in patients with T2-3 N0 distal rectal cancer undergoing radiotherapy before transanal endoscopic microsurgery

BACKGROUND

Local excision after radiotherapy for node-negative low rectal cancer may be an alternative to radical excision. This study evaluated the results of local excision in patients with small (less than 3 cm in diameter) T2 and T3 distal rectal tumours following neoadjuvant therapy.

METHODS

One hundred patients with rectal cancer (54 uT2 and 46 uT3 uN0 tumours) were enrolled. All patients underwent preoperative radiotherapy followed by local excision by means of transanal endoscopic microsurgery.

RESULTS

Definitive histological examination revealed nine pT1, 54 pT2 and 19 pT3 tumours. A complete response (R0) or microscopic residual tumour (R1mic) was found in three and 15 patients respectively. Minor complications occurred in 11 patients and major complications in two. At a median follow-up of 55 (range 7-120) months, the local failure rate was 5 per cent and metastatic disease was found in two patients. The cancer-specific survival rate at 90 months' follow-up was 89 per cent, and the overall survival rate 72 per cent. Salvage abdominoperineal resection was performed in three patients, two of whom were disease free at 15 and 19 months.

CONCLUSION

Treatment of small uT2 and uT3 uN0 rectal cancers with preoperative high-dose radiotherapy followed by transanal endoscopic microsurgery is an acceptable alternative to conventional radical resection.

Minimally invasive surgery for early lower GI cancer

Two technical developments in colorectal surgery-i.e. transanal endoscopic microsurgery (TEM) and laparoscopic surgery for colorectal disease-are now available for the treatment of early lower GI cancer. Benign lesions and early-stage tumours of the rectosigmoid are amenable for a transanal approach. Transanal endoscopic microsurgery is performed using a rectoscope 4 cm in diameter with a four-port insert. After installation of a pneumorectum, lesions up to 25 cm from the anal verge, including circumferential lesions, can be removed with a recurrence rate of 0-5% for adenomas, 3% for low-risk T1 carcinomas, and 8% for all carcinomas. Laparoscopic-assisted colonoscopic polypectomy, laparoscopic wedge resection or laparoscopic-assisted colostomy have a 67-100% success rate for avoiding a formal bowel resection for benign tumours that cannot be treated by colonoscopy alone. Early colonic cancer requires laparoscopic colectomy guided by preoperative colonoscopy or preoperative endoscopic tattooing for localisation of the affected segment.

Outcome of transvaginal excision of large rectal adenomas

PURPOSE

The purpose is to recommend a new approach-transvaginal excision-for large rectal adenomas and audit its results after being performed by dedicated surgeons at a specialized colorectal unit.

METHODS

The surgical outcome of 11 patients undergoing transvaginal excision between July 1995 and March 2000 was reviewed. Data were collected retrospectively and no patients were lost to follow-up.

RESULTS

Eleven patients underwent the procedure during the study period. Follow-up ranged from 7 to 75 months. There were complications in two patients. One had urinary retention, the other developed a rectal stenosis, which was resolved with multiple balloon dilatations. There was only one recurrence detected. None of the patients died.

CONCLUSIONS

Transvaginal local excision is an alternative and feasible technique for the treatment of selected large sessile rectal adenomas that carries low mortality and complication rates.

Laser photoablation of colorectal adenomas: a 12-year experience

BACKGROUND

We analyze laser photoablation as an alternative treatment of large sessile polyps in inoperable patients.

METHODS

Ninety-four colorectal polyps (mean diameter 3.09 +/- 2.7 cm, range 1-15 cm) were treated using high-energy lasers (Nd:YAG and diode). Grade of dysplasia was low in 51, high in 35, with focally invasive cancer in eight.

RESULTS

After 405 laser sessions (4.3 per polyp) five procedure-related complications were observed: two strictures, two bleedings, and one perforation. The last needed a surgical resection; the others were successfully treated by endoscopic therapy. Fifty-seven polyps (61%) were completely eradicated and the growth was controlled in all but two (98%). No degeneration was found after 28-month follow-up of treated adenomas with low- or high-grade dysplasia. Outcome of treatment was dependent on the dimension and grade of the dysplasia (p < 0.05), but not on the polyps' position (rectum or colon). Relief of rectal bleeding was obtained in 90%, of mucus discharge in 77%, and of tenesmus in 100% of cases.

CONCLUSIONS

Laser photoablation of colonic adenomas can be considered a valid procedure not only to relieve symptoms, but also to control the risk of degeneration in patients unfit for surgery or when surgical treatment is considered excessively invalidating.

Transanal endoscopic microsurgery: a systematic review

PURPOSE

The aim of this study was to systematically review the evidence relating to the safety and efficacy of transanal endoscopic microsurgery, a relatively new technique used to locally excise rectal tumors, compared with existing techniques such as anterior resections and abdominoperineal resections or local excisions.

METHODS

We conducted a systematic review of comparative studies and case series of transanal endoscopic microsurgery from 1980 to August 2002.

RESULTS

Three comparative studies (including one randomized, controlled trial) and 55 case series were included. The first area of study was the safety and efficacy of adenomas. In the randomized, controlled trial, no difference could be detected in the rate of early complications between transanal endoscopic microsurgery (10.3 percent) and direct local excision (17 percent) (relative risk, 0.61; 95 percent confidence interval, 0.29-1.29). Transanal endoscopic microsurgery resulted in less local recurrence (6/98; 6 percent) than direct local excision (20/90; 22 percent) (relative risk, 0.28; 95 percent confidence interval, 0.12-0.66). The 6 percent rate of local recurrence for transanal endoscopic microsurgery in this trial is consistent with the rates found in case series of transanal endoscopic microsurgery (median, 5 percent). The second area of study was the safety and efficacy of carcinomas. In the randomized, controlled trial, no difference could be detected in the rate of complications between transanal endoscopic microsurgery and direct local excision (relative risk for overall early complication rates, 0.56; 95 percent confidence interval, 0.22-1.42). No differences in survival or local recurrence rate between transanal endoscopic microsurgery and anterior resection could be detected in either the randomized, controlled trial (hazard ratio,1.02 for survival) or the nonrandomized, comparative study. There were 2 of 25 (8 percent) transanal endoscopic microsurgery recurrences in the randomized, controlled trial, but no figures were given for recurrence after anterior resection. In the case series, the median local recurrence rate for transanal endoscopic microsurgery was 8.4 percent, ranging from 0 percent to 50 percent. The third comparison was cost of the procedures. Transanal endoscopic microsurgery had both a lower recurrence rate and a lower cost than local excision or anterior resection for adenomas. Although the effectiveness of transanal endoscopic microsurgery could not be established for carcinomas, costs were lower than those for either anterior resection or abdominoperineal resection.

CONCLUSIONS

The evidence regarding transanal endoscopic microsurgery is very limited, being largely based on a single relatively small randomized, controlled trial. However, transanal endoscopic microsurgery does appear to result in fewer recurrences than those with direct local excision in adenomas and thus may be a useful procedure for several small niches of patient types--e.g., for large benign lesions of the middle to upper third of the rectum, for T1 low-risk rectal cancers, and for palliative, not curative, use in more advanced tumors.

Ultracision Harmonic Scalpel and multifunctional tem400 instrument complement in transanal endoscopic microsurgery: a prospective study

BACKGROUND

For transanal endoscopic microsurgery, the ultracision Harmonic Scalpel (UC) and the multifunctional TEM400 instrument (T400) seem advantageous. This study investigated their clinical use.

METHODS

Prospective analysis of tumor, patient, and operation characteristics was performed for 196 tumor resections per instrument intended for application.

RESULTS

The T400 instrument was applied in 162 operations, and the UC in 34 operations. Tumor and patient characteristics were similar except for tumor area (respectively, 7.5 and 17 cm(2); p = 0.003). Operative time was proportionate to the tumor area (p < 0.001) and inversely proportionate to its distance from the dentate line to the lower margin of the tumor of the UC (p = 0.002). Application reduced operative time by 26% (p = 0.02, corrected for area). Whereas, T400 was always singly sufficient for excision, the UC required T400 application in 50% of operations, especially for larger tumors (p = 0.026), with the result that more rectal wall circumference was captured (p = 0.043). Both groups had similar safety parameters.

CONCLUSIONS

The UC substantially reduced operative time compared with the T400, but frequently required the T400 for procedure completion. The T400 is always singly sufficient.

Full-thickness intraperitoneal excision by transanal endoscopic microsurgery does not increase short-term complications

PURPOSE

Transanal endoscopic microsurgery (TEM) is a minimally invasive technique for full-thickness excision of benign and malignant rectal neoplasms located 4 to 24 cm above the anal verge. Entrance into the peritoneal cavity during TEM has been regarded as a complication that mandates conversion to open laparotomy for adequate repair of the defect. This study compares the rate of complications arising from TEM with and without intraperitoneal entry.

METHODS

Patients undergoing peritoneal entry were compared to those who did not.

RESULTS

No perioperative deaths occurred. There was no significant difference in the incidence of postoperative complications. No major complications occurred with peritoneal entry, and all peritoneal entries were closed transanally via endoscope.

CONCLUSIONS

Entry into the peritoneum during TEM is not associated with an increased incidence of complication. Entry into the peritoneum during TEM excision does not mandate conversion to open laparotomy but may be safely repaired endoscopically. Lesions likely to be above the peritoneal reflection and within reach of the endoscope (4 to 24 cm) should be considered for TEM excision.

Transvaginal local excision of rectal carcinoma

PURPOSE

To recommend a new approach-transvaginal local excision of early rectal cancers-and report the results of the approach applied by dedicated surgeons at a specialized colorectal unit during a 10-year period.

METHODS

The surgical outcome of 18 patients undergoing transvaginal local resection between January 1991 and August 2001 was reviewed. Patients were identified according to the consultants' personal records and cross-referenced with the operating room logs. Data were collected retrospectively, and follow-up was performed on all patients.

RESULTS

A total of 18 patients underwent 18 procedures during the study period. Follow-up ranged from 2 months to 104 months. There were no treatment-related complications. Two patients suffered from recurrences at a median follow-up time of 35.7 months, but they underwent subsequent surgical treatment: APR (one) and LAR (one). No evidence of disease was found during a median follow-up of 20 months (12 and 28 months). No one died.

CONCLUSIONS

Transvaginal local excision is an alternative and feasible technique with low rates of death and complications for the treatment of rectal cancer in strictly selected cases.

Transanal endoscopic microsurgery and radical surgery for T1 and T2 rectal cancer

BACKGROUND

Transanal endoscopic microsurgery (TEM) has gained increasing acceptance as a local treatment of early rectal cancer. The purpose of this study was to compare the results of TEM and radical surgery in patients with T1 and T2 rectal cancer.

METHODS

From October 1994 to December 2000, 74 patients with T1 and T2 rectal adenocarcinoma treated with TEM were compared with 100 patients with T1N0M0 and T2N0M0 rectal adenocarcinoma treated with radical surgery. Retrospective analysis was performed regarding to recurrence and survival rate. Neither group received adjuvant chemoradiation. There was no significant difference in age, gender, tumor location, or follow-up period between the two groups. The only difference was in tumor size.

RESULTS

Of the 74 patients in TEM group, 52 were T1 (70.3%) and 22 were T2 (29.7%). Of the 100 patients in radical surgery group, 17 were T1 (17%) and 83 patients were T2 (83%). The 5-year local recurrence rates were 4.1% for T1, 19.5% for T2 after TEM, 0% for T1, and 9.4% for T2 after radical surgery. There was no statistical difference between the TEM and radical surgery groups for T1 rectal cancer ( p = 0.95), but for T2 rectal cancer, the 5-year local recurrence rate was higher after TEM than after radical surgery ( p = 0.04). There were no significant statistical difference between the two groups in terms of the 5-year disease-free survival rate and the survival rate.

CONCLUSIONS

For T1 rectal cancer, there was no difference in recurrence or 5-year survival rate between the TEM and the radical surgery groups. For T2 rectal cancer, there was no statistical difference in the 5-year survival rate between the two groups, but TEM carried higher risk of local recurrence. Therefore, careful selection of the patients is required for TEM, and when proper muscle invasion is proven, the TEM procedure should be supplemented by further treatment, or radical surgery should be performed.

Transanal endoscopic microsurgery for rectal cancer

If curation is intended for rectal cancer, total mesorectal excision with autonomic nerve preservation (TME) is the gold standard. Transanal resection is tempting because of low mortality and morbidity rates. However, inferior tumour control, provoked by the limitations of the technique, resulted in its cautious application and use mainly for palliation. Transanal endoscopic microsurgery (TEM) is a minimal invasive technique for the local resection of rectal tumours. It is a one-port system, introduced transanally. An optical system with a 3D-view, 6-fold magnification and resolution as the human eye, together with the creation of a stabile pneumorectum, and specially designed instruments allow full-thickness excision under excellent view and a proper histological examination. The technique can also be applied for larger and more proximal tumours. Mortality, morbidity as well as incomplete excision rates are minimal. Local recurrence and survival rates seem comparable to TME in early rectal cancer. TEM is the method of choice when local resection of rectal cancer is indicated. Results justify a re-evaluation of the indications for the local excision of rectal cancer with a curative intent.

Ten-year experience of endoscopic transanal resection

OBJECTIVE

To audit the results of endoscopic transanal resection of tumor (ETAR) performed by a single surgeon at a specialized colorectal unit during a 10- year period.

SUMMARY BACKGROUND DATA

A minimally invasive surgical technique, ETAR has enabled much progress to be made in the development of local treatment strategies for rectal neoplasia. It can be used in both the curative and palliative management of rectal lesions and is a treatment option for patients who would be unable to tolerate major surgery.

METHODS

The surgical outcome of 104 patients (43 women, 61 men) undergoing ETAR under the care of a single surgeon between 1989 and 1999 was reviewed. Patients were identified from the consultant's personal records and cross-referenced with operating room logs. Data were collected retrospectively and no patients were lost to follow-up.

RESULTS

One hundred four patients underwent 163 procedures during the study period. Follow-up ranged from 6 months to 10 years. Seventy-five patients with a pre-ETAR diagnosis of benign rectal adenoma underwent resection. In 60 patients, the diagnosis was confirmed to be benign; 30 of these were treated with a single resection and 28 with multiple resections. There were two technical failures, both a result of high mobility of the lesion. In no patients did carcinoma subsequently develop. In the remaining 15 patients the final histology demonstrated a malignancy; 9 patients underwent an open surgical rectal resection and 5 had complete endoscopic resection of their lesion. No carcinomas that were fully resected endoscopically have recurred (follow-up 13 months to 8years). The final patient had an extensive rectal cancer and was palliated for 2 months by ETAR. Twelve patients (8 men, 4 women) underwent ETAR for anastomotic strictures; successful treatment was achieved in 11. The one failure was in a Park's pouch that was subsequently refashioned. Seventeen patients underwent 30 ETARs for palliation of nonresectable rectal adenocarcinoma. Successful palliation of symptoms was achieved in 13 patients and the remainder underwent colostomy formation. One patient died of a myocardial infarction. There were two further complications (blood transfusion for postoperative bleeding, postoperative cerebrovascular accident).

CONCLUSIONS

Endoscopic transanal resection of tumor is safe and effective and offers successful palliation or definitive treatment of rectal lesions with low rates of death and complications when performed by a dedicated surgeon.

Local excision of rectal cancer: what is the evidence?

PURPOSE

Although local excision of rectal cancers is a less morbid alternative to radical resection, its role as a curative procedure is unclear. The role of adjuvant therapy after local excision is also controversial. This review aims to examine current evidence on local excision of rectal cancers and how it fits into the management algorithm for rectal cancer.

METHODS

A literature review was undertaken through the MEDLINE database and by cross-referencing previous publications, thus identifying 41 studies on curative local excision of rectal cancer published in English. Details of preoperative staging, surgical procedures, adjuvant therapy, follow-up, and outcome measures, including complications, survival data, recurrences, and salvage were examined.

RESULTS

Preoperative staging of rectal cancers is variable. Digital rectal examination and computerized tomography are used in most studies. Endorectal ultrasound is used in some patients in 9 of 41 studies. Local excision preserves anorectal function, and seems to have limited morbidity (0-22 percent). Local excision alone is associated with local recurrences in 9.7 (range, 0-24) percent of T1, 25 (range, 0-67) percent of T2 and 38 (range, 0-100) percent of T3 cancers. The addition of adjuvant chemoradiotherapy after local excision yields local recurrence rates of 9.5 (range, 0-50) percent for T1, 13.6 (range, 0-24) percent for T2, and 13.8 (range, 0-50) percent for T3 cancers. Data on local excision after preoperative chemoradiotherapy for tumor down staging are limited. Factors other than T-stage that lead to higher local recurrence rates after local excision include poor histologic grade, the presence of lymphovascular invasion, and positive margins. Local recurrences after local excision can be surgically salvaged (84 of 114 patients in 15 studies), with a disease-free survival rates between 40 and 100 percent at a follow-up of 0.1 to 13.5 years.

CONCLUSIONS

Local excision for rectal cancers is associated with a low morbidity and provides satisfactory local control and disease-free survival rates for T1 rectal cancers. There is, however, a need for a randomized, controlled trial for T2 cancers, comparing local excision with adjuvant chemoradiotherapy to radical resection.

Transanal endoscopic microsurgical excision of rectal tumors: indications and results

Transanal endoscopic microsurgery (TEM) allows local excision of rectal tumors located 4 to 18 cm above the anal verge. The technique is not yet generally established because of the necessary special instrumentation and tools, the unusual technical aspects of the approach, and the stringent patient selection criteria. The aim of this prospective, descriptive study was to analyze the currently accepted indications for TEM and to evaluate the use of this procedure for treating rectal cancer. Over a 4-year period 50 patients aged 31 to 86 years (mean 64 years) underwent TEM for treatment of rectal tumors located 12 cm above the anal verge (range 4-18 cm). The local complication rate was 4%. Altogether, 76% of lesions were benign, and 24% were T1 and T2 tumors. Of 12 cancer cases, 4 required reoperation by total mesorectal resection; the other 8 are currently under follow-up management. Over the follow-up period of 30.6 months (range 11-54 months) the recurrence rate of T1 tumors was 8.3%. TEM is a minimally invasive surgical technique that may benefit a small, specific population of patients with rectal tumors. Compared with conventional transanal resection, TEM provides superior exposure of tumors higher up in the rectum (i.e., up to 18 cm from the anal verge). The greater precision of resection combined with low morbidity (10%, relative to that of anterior resection) and short duration of hospitalization (5.5 days) make this technique a reliable and in some cases more effective surgical approach than laparotomy and low anterior resection.

UltraCision or high-frequency knife in transanal endoscopic microsurgery (TEM)? Advantages of a new procedure

The potential advantages of ultrasound dissection using UltraCision (UC) an ultrasonically activated scalpel, rather than conventional electrosurgery (ES) were investigated retrospectively in 63 patients following transanal endoscopic microsurgery (TEM) in 22 cases of rectal carcinoma (16 pT1, four pT2, two pT3), 40 cases of rectal adenoma >2 cm, and one neurinoma. In all, 21 patients (13 adenomas, seven carcinomas, and one neurinoma) were operated with UltraCision (Ethicon, Norderstedt, Germany), whereas 42 patients (27 adenomas, 15 carcinomas) were treated with conventional electrocautery. All tumors were completely excised (R0) in both groups. We encountered a total of nine complications, seven after ES and two after UC use. Surgical reintervention was necessary in three cases (4.7%), exclusively following resection by ES. There were five cases of tumor recurrence (7.9%), once again only in the ES group. The advantages of ultrasound dissection are magnified under the particular conditions of minimally invasive endoscopic rectum surgery by means of TEM. In principle, all the known risks associated with the application of electric current can be avoided by using ultrasound technology.

Local excision of rectal cancer through windowed specula: long-term results

Transanal local excision of rectal cancer has been advocated as a curative option in patients with early rectal cancer and for patients unsuitable for radical surgery. We report our long-term experience with an easy-to-use and inexpensive technique based on windowed specula. From 1982 to 1994, 137 patients with rectal cancer were treated by local excision with curative intention. An R0 resection was possible in 74% of all patients and in 80% of the patients with a tumor surface of less than 9 cm2. Ninety patients with a follow-up of more than 3 years (T1: n = 50, T2: n = 30, T3: n = 14) were evaluated for survival. Seventy-four of these 90 patients are currently alive. The cause of death is known for all 16 deceased patients. In 4, death was tumor-related; 3 of these patients had a component of local failure. In 6 of 8 patients with local recurrence, a radical reresection was possible. The rate of recurrence increased with T category and with tumor grade. There has been one recurrence in a patient with a T1G1 cancer. The instrumentation enables adequate local excision of rectal cancers of less than 9 cm2 surface area. In this group of patients including a considerable number with T2 and T3 cancers, only 3 died of tumor-related causes with a component of local failure, which compares well with mortality rates above 4% for abdominoperineal excision. Comparison with international data on radical surgery shows that the overall survival is not reduced by local transanal excision for early rectal cancer.

Video endoscopic transanal-rectal tumor excision

BACKGROUND

Transanal resection of benign and selected malignant rectal tumors is a well accepted surgical technique. The use of a stereoscopic microsurgical technique, as originally described by Buess et al in 1984, has been shown to improve the results of standard transanal resection by allowing precise, full thickness resections up to 24 cm from the anal verge. Transanal endoscopic microsurgery (TEM) has failed to gain widespread popularity for two reasons: The proprietary instrument set is expensive and complex ($68,000 and 30 components), and the procedure is difficult to master technically. We present our results with a modification of the TEM instrument that incorporates a standard laparoscope and video camera as well as standard laparoscopic instruments.

METHODS

Four surgeons have been trained to date. Details of the training curriculum are presented. The technique of videoendoscopic transanal tumor resection (VTEM) is described. A prospective data base was maintained of all VTEM cases. This was reviewed for this study to determine indications, operative times, complications and outcomes.

RESULTS

Four surgeons performed 27 VTEM cases between August 1994 and June 1996. The average age was 69 years and the majority (16) of patients were ASA III. Pre-op diagnosis was benign polyp in 25 patients and adenocarcinoma in 2. Average operating time was 127 minutes (49 to 280 minutes), and was longer during a surgeon's first 5 cases and for lesions more than 16 cm from the anal verge. Operative problems were rare (4%) and post-op complications (incontinence 2, late bleeding 1, adenoma recurrence 1) were seen in 15%.

CONCLUSIONS

VTEM can be taught successfully to GI and colorectal surgeons using a format similar to that used for advanced laparoscopic courses. The use of already available laparoscopes and instruments decreases the initial costs of the set-up. Results are good, with low rates of complications and recurrence and a very short hospital stay. The patient benefits from an effective, minimally invasive alternative to open surgery.