Transanal endoscopic microsurgical submucosa dissection in the treatment of rectal adenomas and T1 rectal cancer

Transanal Minimally Invasive Surgery Versus Endoscopic Submucosal Dissection for Rectal Lesions: A Community Hospital Experience

Background: To compare tumor margins and surgical outcomes between transanal minimally invasive surgery (TAMIS) and endoscopic submucosal dissection (ESD) for large or malignant rectal adenomatous polyps. Methods: Single institution retrospective analysis of patients who underwent TAMIS or ESD surgery. Results: In total, 30 consecutive patients with similar demographics who underwent either TAMIS (n = 19) or ESD (n = 11) were included. The median (interquartile range, IQR) tumor distances from the anal verge for TAMIS and ESD were 5 cm (3.5-8) and 3 cm (2-4.25) (P = 0.016). Four in TAMIS and two in ESD occupied more than half of the circumference of the bowel lumen. Five (four in situ and one stage 1) in TAMIS and two (one in situ and one stage 1) in ESD were malignant. The median specimen length, width, and height were 3.2 cm, 2.6 cm, and 1.0 cm and 3.5 cm, 2.0 cm, and 0.3 cm for TAMIS and ESD, respectively. There were no statistically significant differences in tumor circumference, malignant ratios, or specimen sizes. Resection margins were involved in two of the ESD, while none of the TAMIS were involved (P = 0.041). The median (IQR) operative time was 72 (62-89) minutes and 120 (90-180) minutes for TAMIS and ESD (P = 0.005). The median (IQR) follow-up time was 3.3 (0.3-11.7) and 0.9 (0.3-15.4) months for TAMIS and ESD. There were no morbidities, no mortalities, or local recurrences among the two groups. Conclusions: Both TAMIS and ESD were found to be feasible and safe in community hospital practice. Operative time was shorter, and there were no involved margins in TAMIS (versus ESD).

[Transanal Tumor Resection: Indication, Surgical Technique and Management of Complications]

Transanal resection procedures are special operations for the minimally invasive treatment of rectal tumours. Apart from benign tumours, this procedure is suitable for the excision of low-risk T1 rectal carcinomas, if these can be completely removed (R0 resection). With stringent patient selection, very good oncological results are achieved. Various international trials are currently evaluating whether local resection procedures are oncologically sufficient if there is a complete or near complete response after neoadjuvant radio-/chemotherapy. Numerous studies have shown that the functional results and the postoperative quality of life after local resection are excellent, especially considering the well-known functional deficits of alternative operations, such as low anterior or abdominoperineal resection.Severe complications are very rare. Most complications, such as urinary retention or subfebrile temperatures, are minor in nature. Suture line dehiscences are usually clinically unremarkable. Major complications comprise significant haemorrhage and the opening of the peritoneal cavity. The latter must be recognized intraoperatively and can usually be managed by primary suture. Infection, abscess formation, rectovaginal fistula, injury of the prostate or even urethra are extremely rare complications.

Risk of recurrence after local resection of T1 rectal cancer: a meta-analysis with meta-regression

BACKGROUND

T1 rectal cancer (RC) patients are increasingly being treated by local resection alone but uniform surveillance strategies thereafter are lacking. To determine whether different local resection techniques influence the risk of recurrence and cancer-related mortality, a meta-analysis was performed.

METHODS

A systematic search was conducted for T1RC patients treated with local surgical resection. The primary outcome was the risk of RC recurrence and RC-related mortality. Pooled estimates were calculated using mixed-effect logistic regression. We also systematically searched and evaluated endoscopically treated T1RC patients in a similar manner.

RESULTS

In 2585 unique T1RC patients (86 studies) undergoing local surgical resection, the overall pooled cumulative incidence of recurrence was 9.1% (302 events, 95% CI 7.3-11.4%; I2 = 68.3%). In meta-regression, the recurrence risk was associated with histological risk status (p < 0.005; low-risk 6.6%, 95% CI 4.4-9.7% vs. high-risk 28.2%, 95% CI 19-39.7%) and local surgical resection technique (p < 0.005; TEM/TAMIS 7.7%, 95% CI 5.3-11.0% vs. other local surgical excisions 10.8%, 95% CI 6.7-16.8%). In 641 unique T1RC patients treated with flexible endoscopic excision (16 studies), the risk of recurrence (7.7%, 95% CI 5.2-11.2%), cancer-related mortality (2.3%, 95% CI 1.1-4.9), and cancer-related mortality among patients with recurrence (30.0%, 95% CI 14.7-49.4%) were comparable to outcomes after TEM/TAMIS (risk of recurrence 7.7%, 95% CI 5.3-11.0%, cancer-related mortality 2.8%, 95% CI 1.2-6.2% and among patients with recurrence 35.6%, 95% CI 21.9-51.2%).

CONCLUSIONS

Patients with T1 rectal cancer may have a significantly lower recurrence risk after TEM/TAMIS compared to other local surgical resection techniques. After TEM/TAMIS and endoscopic resection the recurrence risk, cancer-related mortality and cancer-related mortality among patients with recurrence were comparable. Recurrence was mainly dependent on histological risk status.

Transanal Endoscopic Microsurgical Submucosal Dissection: An Efficient Treatment Option for Giant Superficial Neoplastic Lesions of the Rectum

Introduction

The resection of giant superficial neoplastic lesions of the rectum (>5 cm) is challenging even for experienced specialists. Endoscopic mucosal resection, endoscopic submucosal dissection (ESD), and transanal endoscopic microsurgery (TEM) have all been used for the treatment of such tumors. However, because of their individual disadvantages, the ideal technique for the treatment of these lesions has yet to be determined. Transanal endoscopic microsurgical submucosal dissection (TEM-ESD) is a recently developed hybrid technique that combines the advantages of conventional TEM and flexible ESD. The aim of our study was to assess the feasibility and outcomes of TEM-ESD for the resection of giant superficial rectal neoplasms.

Methods

We retrospectively analyzed all cases of TEM-ESD performed in the Department of Surgery of the Municipal Hospital of Karlsruhe between 2010 and 2020 and isolated 43 patients with superficial rectal lesions >5 cm according to the postoperative histology report. The diagnostic, perioperative, histological, and follow-up data of the patients were analyzed in the form of a retrospective, observational cohort study.

Results

We identified 43 cases matching our criteria, including 35 adenomas and 8 occult adenocarcinomas. The median size of the lesions was 75 mm and the median operating time was 81.5 min. En bloc resection was possible in all cases, and histologically complete en bloc resection was confirmed in 29 cases. Five patients presented with postoperative bleeding, 2 of which were treated conservatively, 2 were treated endoscopically, and 1 required revision surgery. The median follow-up period was 15 months. There was no recurrence among patients with adenomas, 1 recurrence of a low-risk carcinoma, and 1 recurrence after the resection of a high-risk carcinoma in a patient that refused further treatment. During the follow-up period, 3 patients developed a stenosis, which was treated endoscopically.

Conclusions

TEM-ESD is a feasible and safe therapeutic option for the treatment of giant superficial rectal neoplasms.

Transanal endoscopic microsurgical submucosal dissection (TEM-ESD) for rectal adenomas: a retrospective cohort study of 145 consecutive cases

PURPOSE

Transanal endoscopic microsurgery (TEM) and endoscopic submucosal dissection (ESD) are currently the two most popular methods for resecting large rectal adenomas en bloc. However, damage to the mesorectum in the case of TEM, plus the technical challenges and long procedure times of flexible ESD, are major disadvantages of these procedures. Transanal endoscopic microsurgical submucosal dissection (TEM-ESD) is a new technique, combining the ergonomic features of TEM with the minimally invasive approach of ESD. The aim of our study was to assess the feasibility and safety of TEM-ESD for resection of large rectal adenomas.

METHODS

We retrospectively analyzed all TEM-ESD procedures performed in Karlsruhe Municipal Hospital between 2012 and 2019, isolated all cases of adenomas, and analyzed the perioperative and follow-up data of the patients.

RESULTS

We identified 145 cases matching our criteria. The median size of the lesions was 4.2 cm, and the median operating time was 45 min. The en bloc resection rate was 100%, and the complete en bloc resection rate was 78.6%. The overall morbidity rate was 6.9%. In a median follow-up period of 24 months, there was a local recurrence in 4.8% of the cases.

CONCLUSIONS

TEM-ESD is a safe and feasible therapeutic option for resecting large rectal adenomas, offering high en bloc resection and low recurrence rates combined with short operating time and low morbidity. TRIAL REGISTRATION NUMBER (CLINICALTRIALS.GOV): NCT04870931.

Transanal Endoscopic Microsurgical Submucosal Dissection for Recurrent Rectal Adenomas

BACKGROUND

The local resection of recurrent rectal adenomas is a technically challenging task associated with increased local recurrence rate. Transanal endoscopic microsurgical submucosal dissection (TEM-ESD) uses traction to better expose the fibrotic submucosal layer, and therefore, is a valuable alternative for the treatment of such lesions. The aim of our study was to assess the feasibility and outcomes of TEM-ESD for the resection of recurrent rectal adenomas.

METHODS

We retrospectively analysed all TEM-ESD procedures performed in the Karlsruhe Municipal Hospital between 2012 and 2021 and isolated all cases of recurrent adenomas. Subsequently, we matched these cases 1:1 to TEM-ESD cases for primary rectal adenomas according to the size, localization, and histological type of the lesions and compared the outcomes between the two groups.

RESULTS

We identified 19 cases matching our criteria. The median diameter of the lesions was 25 mm and the median operating time 39 min. Macroscopic en bloc resection was achieved in 100% of the cases and histological complete en bloc resection in 78.9%. There was 1 case of conservatively treated postoperative bleeding. After a median follow-up period of 36 months, there was one local recurrence. After comparing those findings to the outcomes of TEM-ESD for primary rectal lesions, we found no significant differences on total operating time, complete en bloc resection rates, adverse events, and local recurrence.

CONCLUSION

TEM-ESD is a feasible therapeutic option for the resection of recurrent rectal adenomas, offering short operating times as well as high en bloc resection and low recurrence rates.

Completion surgery vs. primary TME for early rectal cancer: a national study

PURPOSE

While local excision by transanal endoscopic microsurgery (TEM) or transanal minimally invasive surgery (TAMIS) is an option for low-risk early rectal cancers, inaccuracies in preoperative staging may be revealed only upon histopathological evaluation of the resected specimen, demanding completion surgery (CS) by formal resection. The aim of this study was to evaluate the results of CS in a national cohort.

METHOD

This was a retrospective analysis of national registry data, identifying and comparing all Norwegian patients who, without prior radiochemotherapy, underwent local excision by TEM or TAMIS and subsequent CS, or a primary total mesorectal excision (pTME), for early rectal cancer during 2000-2017. Primary endpoints were 5-year overall and disease-free survival, 5-year local and distant recurrence, and the rate of R0 resection at completion surgery. The secondary endpoint was the rate of permanent stoma.

RESULTS

Forty-nine patients received CS, and 1098 underwent pTME. There was no difference in overall survival (OR 0.73, 95% CI 0.27-2.01), disease-free survival (OR 0.72, 95% CI 0.32-1.63), local recurrence (OR 1.08, 95% CI 0.14-8.27) or distant recurrence (OR 0.67, 95% CI 0.21-2.18). In the CS group, 53% had a permanent stoma vs. 32% in the pTME group (P = 0.002); however, the difference was not significant when adjusted for age, sex, and tumor level (OR 2.17, 0.95-5.02).

CONCLUSIONS

Oncological results were similar in the two groups. However, there may be an increased risk for a permanent stoma in the CS group.

Transanal endoscopic microsurgical submucosal dissection (TEM-ESD): A novel approach to the local treatment of early rectal cancer

BACKGROUND

Complete local resection is currently the treatment of choice for low-risk early rectal cancer; however, the ideal resection technique for such tumours is still debated. Transanal endoscopic microsurgical submucosal dissection (TEM-ESD) is a new technique which combines the ergonomic advantages of transanal endoscopic microsurgery (TEM) with the minimally invasive approach of endoscopic submucosal dissection (ESD). The aim of our study was to assess the feasibility, safety, and long-term outcomes of TEM-ESD in treating early rectal cancer.

MATERIALS AND METHODS

We retrospectively analysed all cases of rectal adenocarcinomas treated with TEM-ESD in Karlsruhe Municipal Hospital between 2012 and 2019, as well as the perioperative and follow-up data of the patients.

RESULTS

We identified 40 cases (19 low-risk and 21 high-risk carcinomas) matching our criteria. The median size of the lesions was 3.8 cm and the median operating time 48.5 min. En bloc resection was possible in all cases, while histologically complete resection was confirmed in 18 of 19 low-risk tumours and in 30 out of all lesions. The resection was curative in 19 cases. No scarring of the mesorectum was reported during the completion of total mesorectal excision for high-risk tumours. There was only 1 case of local recurrence among patients treated with curative intent, with an overall survival rate of 100% and a disease-free survival rate of 96% at both 2 and 5 years for these patients.

CONCLUSION

TEM-ESD is a safe and feasible therapeutic option for resecting early rectal cancer, offering very good long-term outcomes.

Transanal endoscopic microsurgical submucosal dissection: Are there advantages over conventional ESD?

INTRODUCTION

Transanal endoscopic microsurgical submucosal dissection (TEM-ESD) is a technique that has been recently described for the treatment of large rectal adenomas and early rectal cancer. The purpose of our study is to compare TEM-ESD with flexible endoscopic submucosal dissection (ESD) in an experimental, ex vivo porcine model.

MATERIAL AND METHODS

We used TEM-ESD and flexible ESD to resect a total of 100 standardized 4 × 4cm lesions in an ex vivo porcine stomach model, performing 50 resections with each technique. Total procedure time, en bloc resection rate, injuries of the muscularis propria, perforation rate and learning curve were analysed.

RESULTS

TEM-ESD was associated with a significantly shorter total procedure time in comparison to ESD (19 min vs. 33 min, p < .001). The rates of en bloc resection, injury of the muscularis propria layer, and perforation were the same in both groups. The learning curve of TEM-ESD was shallower than that of ESD.

CONCLUSION

TEM-ESD showed an advantage over ESD in terms of procedure time and learning curve, with similar en bloc resection rates and safety profile in our experimental model.

Preoperative chemoradiotherapy affects postoperative outcomes and functional results in patients treated with transanal endoscopic microsurgery for rectal neoplasms

BACKGROUND

The aim of this study was to quantify the incidence of short-term postoperative complications and functional disorders at 1 year from transanal endoscopic microsurgery (TEM) for rectal neoplasms, to compare patients treated with TEM alone and with TEM after preoperative chemoradiotherapy (CRT) and to analyse factors influencing postoperative morbidity and functional outcomes.

METHODS

A retrospective study was conducted on all patients treated with TEM for rectal neoplasms at our institution in January 2000-December 2017. Data from a prospectively maintained database were retrospectively analysed. Patients were divided into two groups: adenoma or early rectal cancer (no CRT group) and locally advanced extraperitoneal rectal cancer with major or complete clinical response after preoperative CRT (CRT group). Short-term postoperative mortality and morbidity and the functional results at 1 year were recorded. The two groups were compared, and a statistical analysis of factors influencing postoperative morbidity and functional outcomes was performed. Functional outcome was also evaluated with the low anterior resection syndrome (LARS) score (0-20 no LARS, 21-29 minor LARS and 30-42 major LARS).

RESULTS

One hundred and thirteen patients (71 males, 42 females, median age 64 years [range 41-80 years]) were included in the study (46 in the CRT group). The overall postoperative complication rate was 23.0%, lower in the noCRT group (p < 0.001), but only 2.7% were grade ≥ 3. The most frequent complication was suture dehiscence (17.6%), which occurred less frequently in the noCRT group (p < 0.001). At 1 year from TEM, the most frequent symptoms was urgency (11.9%, without significant differences between the CRT group and the noCRT group); the noCRT group experienced a lower rate of soiling than the CRT group (0% vs. 7.7%; p: 0.027). The incidence of LARS was evaluated in 47 patients from May 2012 on and was 21.3% occurring less frequently in the noCRT group (10% vs. 41.2%; p: 0.012). Only 6.4% of the patients evaluated experienced major LARS. In multivariate analysis, preoperative CRT significantly worsened postoperative morbidity and functional outcomes.

CONCLUSIONS

TEM is a safe procedure associated with only low risk of severe postoperative complications and major LARS. Preoperative CRT seems to increase the rate of postoperative morbidity after TEM and led to worse functional outcomes at 1 year after surgery.

Transanal endoscopic operation for rectal lesion: a rapid initial experience

BACKGROUND

In recent decades, transanal surgery for rectal lesions has become a valid alternative treatment for the treatment of small lesions of the rectum. Significant benefits in terms of morbidity and mortality are confirmed. There are multiple platforms for transanal surgery but the TEO system® is one of the best known.

METHODS

Between November 2017 and July 2019, 25 patients with rectal lesions suitable to transanal treatment came to our observation. In all reported cases, full-thickness rectum resections were performed. Demographic, histopathological, surgical morbidity/mortality and clinical outcome in all patients who underwent TEO were retrospectively evaluated from a prospectively collected database.

RESULTS

For a period of less than 2 years, 25 rectal lesions were excised by TEO. Sixteen lesions (64%) were low (<4 cm), 7 (28%) were mid-rectal (4-8 cm) and 2 (8%) were in the proximal rectum (>8 cm). Postoperative complications included: 3 (12%) bleedings, and 8 (32%) post-polipectomy syndrome.

CONCLUSIONS

Our initial experience suggests TEO is safe and feasible. Full-thickness resection guarantees adequate deep margins. Moreover, the limited number of cases requires the development of adequate reference centers.