Transanal endoscopic micro-surgery in elderly and very elderly patients: a safe option? Observational study with prospective data collection

Excision of malignant and pre-malignant rectal lesions by transanal endoscopic microsurgery in patients under 50 years of age

BACKGROUND

The most common technique for treating benign and early malignant rectal lesions is transanal endoscopic microsurgery (TEM). Local excision is an acceptable technique for high-risk and elderly patients, but there are hardly any data regarding young patients.

AIM

To describe TEM outcomes in patients under 50 years of age.

METHODS

We collected demographic, clinical, and pathological data from all patients under the age of 50 years who underwent the TEM procedure at Hasharon Rabin Medical Center from January 2005 to December 2018.

RESULTS

During the study period, a total of 26 patients under the age of 50 years underwent TEM procedures. Their mean age was 43.3 years. Eleven (42.0%) were male. The mean operative time was 67 min, and the mean tumor size was 2.39 cm, with a mean anal verge distance of 8.50 cm. No major intraoperative or postoperative complications were recorded. The median length of stay was 2 d. Seven (26.9%) lesions were adenomas with low-grade dysplasia, four (15.4%) were high-grade dysplasia adenomas, two were T1 carcinomas (7.8%), and three were T2 carcinomas (11.5%). No residual disease was found following endoscopic polypectomy in two patients (7.8%), but four (15.4%) had other pathologies. Surgical margins were negative in all cases. Local recurrence was detected in one patient 33 mo following surgery.

CONCLUSION

Among young adult patients, TEM for benign rectal lesions has excellent outcomes. It may also offer a balance between the efficacy of complete oncologic resection and postoperative quality of life in the treatment of rectal cancer. In some cases, it may be considered an alternative to radical surgery.

Current Surgical Methods in Local Rectal Excision

Background

The treatment of rectal cancer has evolved with the advancement of surgical techniques. Less invasive approaches are becoming more accepted as the primary treatment method.

Summary

Such methods as transanal excision, transanal endoscopic microsurgery, and transanal minimally invasive surgery can reduce morbidity and mortality rates. However, not all patients are suitable candidates for these procedures, and proper diagnostics are necessary to establish indications. Compared to total mesorectal excision, transanal excision techniques have been shown to have fewer complications and comorbidities while still being able to remove cancerous tissue entirely. Transanal excision is the simplest method, where the operator removes visible rectal lesions. The basic principle of transanal endoscopic microsurgery is to dilate the rectum mechanically and by air insufflation and then use special surgical instruments to remove suspicious lesions under the vision of a telescope. Transanal minimally invasive surgery combines transanal endoscopic microsurgery and single-incision laparoscopic surgery, making the hard-to-reach proximal rectum accessible to classic laparoscopic instruments.

Key Message

Local excision techniques, when used as a monotherapy for treating patients with rectal cancer, have established themselves as a curative and less radical treatment for strictly selected patients with early rectal carcinoma, leading to improved quality of life. When combined with other modalities such as neoadjuvant chemoradiotherapy, total neoadjuvant therapy, and immunotherapy, transanal surgery can be offered to patients with locally advanced rectal cancer as part of the organ preservation strategy. This review will discuss the patient selection and technical aspects of transanal surgery, showcasing its current role in treating rectal carcinoma.

Prognosis of Patients Over 60 Years Old With Early Rectal Cancer Undergoing Transanal Endoscopic Microsurgery – A Single-Center Experience

Aim

Transanal endoscopic microsurgery (TEM) is widely performed in early rectal cancer. This technique offers greater organ preservation and decreases the risk of subsequent surgery. However, postoperative local recurrence and distant metastasis remain challenges for patients with high-risk pathological factors. This single-center study reports the prognosis of early rectal cancer patients over 60 years old after TEM.

Methods

The data of the patients over 60 years old who underwent local anal resection were collected retrospectively. Moreover, the 5-year follow-up data were analyzed to determine the 5-year DFS and OS.

Results

47 early rectal cancer patients over 60 years old underwent TEM. There were 27 patients with high-risk factors and 20 patients without high-risk factors. Two patients underwent radical surgery after TEM and ten patients received adjuvant treatment. Local recurrence occurred in 7 patients, of which 4 underwent salvage surgery. The 5-year progression-free survival rate was 75.6%, which was lower in the high-risk patients group (69.6%) than in the non-high-risk patients group (83.3%) (P>0.05). The 5-year OS was 90.2%, but there was no statistically significant difference between the two groups (high-risk patients 87.0%, non-high-risk patients 94.4%). Furthermore, there was no significant difference in DFS and OS between people over and under 70 years old.

Conclusion

Some high-risk factor patients over 60 years old do not have inferior 5-year DFS and OS to the non-high-risk patients. TEM is an option for old patients with high surgical risks. Even if postoperative pathology revealed high-risk factors, timely surgical treatment after local recurrence would be beneficial to improve the 5-year DFS and OS.

Theoretical Thermal-Mechanical Modelling and Experimental Validation of a Three-Dimensional (3D) Electrothermal Microgripper with Three Fingers

This paper presents the theoretical thermal-mechanical modeling and parameter analyses of a novel three-dimensional (3D) electrothermal microgripper with three fingers. Each finger of the microgripper is composed of a bi-directional Z-shaped electrothermal actuator and a 3D U-shaped electrothermal actuator. The bi-directional Z-shaped electrothermal actuator provides the rectilinear motion in two directions. The novel 3D U-shaped electrothermal actuator offers motion with two degrees of freedom (DOFs) in the plane perpendicular to the movement of the Z-shaped actuator. As a result, each finger possesses 3D mobilities with three DOFs. Each beam of the actuators is heated externally with polyimide films. In this work, the static theoretical thermal-mechanical model of the 3D U-shaped electrothermal actuator is established. Finite-element analyses and experimental tests are conducted to verify and validate the model. With this model, parameter analyses are carried out to provide insight and guidance on further improving the 3D U-shaped actuator. Furthermore, a group of micro-manipulation experiments are conducted to demonstrate the flexibility and versality of the 3D microgripper on manipulate different types of small/micro-objects.

Transanal Endoscopic Microsurgery: An Alternative Perineal Approach to Treat Rectal Prolapse: A Video Vignette

PURPOSE

Laparoscopic ventral rectopexy is the most favored surgical treatment for rectal prolapse. Perineal approaches are recommended for frail patients and those with major comorbidities, and in young men to avoid genitourinary disorders. There are very few descriptions in the literature of transanal endoscopic surgery to treat complete rectal prolapse. The aim of this article is to describe our experience with this technique.

PATIENTS AND METHODS

Patients undergoing transanal endoscopic surgery for rectal prolapse repair between 2010 and 2019 were recruited for the study. Preoperative, surgical, and postoperative variables were recorded. Surgical technique, 30-day morbidity and follow-up are described.

RESULTS

Five patients have been included. The postoperative period was uneventful and all patients were discharged in 48 hours without complications. All showed improved symptoms at 1-year control, and none presented recurrence in a mean follow-up period of 6 years.

CONCLUSIONS

The transanal endoscopic procedure allows improved endoscopic vision, and the reconstruction is performed transpelvically by fixing the anastomosis suture to the pelvic wall to prevent recurrence. Therefore, we think it is a valid alternative to other perineal procedures in patients in whom abdominal surgery is contraindicated.

How can we utilize local excision to help, not harm, geriatric patients with rectal cancer?

A majority of the morbidity and mortality burden of rectal cancer is distributed within the geriatric age group. Current surgical and medical treatment modalities pose significant challenges in treating complications specifically in the already pre-disposed senior population with baseline dysfunction. This chapter reviews the work-up, management, current data and oncologic outcomes of treating rectal cancer in the senior adult.