Transanal endoscopic microsurgery

Completion Surgery after Non-Curative Local Resection of Early Rectal Cancer

Background

The expanding indications of local - endoscopic and transanal surgical - resection of early rectal cancer has led to their increased popularity and inclusion in the treatment guidelines. The accuracy of the current diagnostic tools in identifying the low-risk T1 tumors that can be curatively treated with a local resection is low, and thus several patients require additional oncologic surgery with total mesorectal excision (TME). An efficient clinical strategy which avoids overtreatment and obstacle surgical procedures is under debate between different disciplines.

Summary

Completion surgery has comparable outcomes to primary surgery regarding perioperative morbidity and mortality but also recurrence rates and overall survival. However, local scarring in the mesorectum can make mesorectal excision technically challenging, especially after full-thickness resections, and has been associated with increased rates of permanent ostomy and worse quality of the TME specimen. This risk seems to be lower after muscle-sparing procedures like endoscopic submucosal dissection, which seem to show a benefit in comparison to full-thickness resections.

Key Messages

Completion surgery after non-curative local resection of gastrointestinal malignancies is safe and feasible. Full-thickness resection techniques can cause scarring of the mesorectum; therefore, muscle-sparing procedures should be preferred.

Total Mesorectal Excision vs. Transanal Endoscopic Microsurgery Followed by Radiotherapy for T2N0M0 Distal Rectal Cancer: A Multicenter Randomized Trial

Introduction

Transanal endoscopic microsurgery (TEM) is an organ-preserving treatment alternative for patients with early rectal cancer. However, TEM alone is associated with greater risk of local recurrence and inferior survival in comparison with total meso-rectal excision (TME). As an important adjuvant therapy, radiotherapy can effectively reduce the local recurrence rate of rectal cancer. This study aimed to investigate whether TEM followed by radiotherapy can be a valid alternative to TME in T2N0M0 distal rectal cancer treatment.

Methods

We plan to recruit 168 participants meeting established inclusion criteria. Following informed consent, participants will randomly receive treatment protocols of TEM followed by radiotherapy (a total dose of 45–50.4 Gy given in 25–28 factions) or TME. Depending on post-operative pathology, the participants will receive either long-term follow-up or further treatment. The primary endpoint of this trial is 3-year local recurrence rate. The secondary end points include 3-year disease-free survival rate, 3-year overall survival rate, 3-year mortality rate, post-operative quality of life, post-operative safety index, intraoperative evaluation index and post-operative short-term evaluation index.

Discussion

This trial is the first prospective randomized trial to investigate the rectum preserving treatment by using transanal local excision followed by radiotherapy.

Clinical trial registration

The trial was prospectively registered at ClinicalTrials.gov NCT04098471 on September 20, 2019.

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.

Preservation of the rectum is possible in early rectal cancer with neoadjuvant radiotherapy, delay and local excision-a 12-year single-centre experience of the evolution of early rectal cancer treatment

AIM

Treatment of early rectal cancer (ERC) is undergoing a revolution towards rectum preservation. Adjuvant and neoadjuvant therapy alongside local excision (LE) means that organ preservation is a real possibility for most patients and a viable alternative for frailer patients. This study presents our 12-year experience as a specialist regional ERC unit, evolving towards organ preservation.

METHOD

Data were collected prospectively between 2006 and 2018 for all patients referred to the regional ERC multidisciplinary team with suspected or confirmed ERC. Patients considered suitable for LE, or those declining radical surgery, were offered LE or neoadjuvant short-course radiotherapy (SCRT), delay and LE with subsequent rescue surgery or contact brachytherapy for unfavourable histopathology.

RESULTS

In all, 102 patients underwent LE. Ten patients were excluded (N = 92). 45 patients underwent LE directly and 47 patients received SCRT and LE. After SCRT and LE, a pathological complete response was achieved in 44.7%. This approach also resulted in a lower rate of lymphovascular invasion (22.2% vs. 6.4%), fewer distant recurrences (4.4% vs. 0%) and a better disease-specific mortality (11.1% vs. 0%) (P < 0.05). Although statistically insignificant, fewer patients required rescue surgery after SCRT (15.6% vs. 4.3%).

CONCLUSION

Organ preservation with a good oncological outcome is better achieved by neoadjuvant radiotherapy, delay and LE. To achieve this, careful patient selection, thorough preoperative investigation, experienced surgical technique and a deep appreciation of tumour biology managed via a dedicated ERC network is paramount.

Factors Associated With Margin Positivity and Incidental Carcinoma in Patients Undergoing Transanal Endoscopic Microsurgery (TEMS) for the Management of Adenomatous and Dysplastic Rectal Lesions

PURPOSE

Colorectal cancer screening has resulted in an increased detection of early premalignant rectal lesions. Transanal endoscopic microsurgery (TEMS) is a minimally invasive procedure for the resection of dysplastic and selected early malignant lesions with organ and functional preservation. The aim of this study was to assess factors associated with positive resection margin and the underlying invasive component.

METHODS

This was an analysis of a prospective consecutive series of all TEMS procedures performed over the last 10-year period. Data was collated from hospital databases and operative theater registers. Statistical analysis was performed using Minitab-V18 with a P<0.05 regarded as significant.

RESULTS

In total, 328 procedures were performed on 292 patients. The cohort included 165 male patients and 127 female patients with a mean age of 66.3 years (19 to 95 years). A total of 274 procedures performed were en bloc excisions and 54 procedures were piecemeal debulking excisions for larger lesions follow by formal TEMs at an interval. The mean tumor size was 41.9 mm (10 to 150 mm), and the mean distance from anal verge was 9.3 cm (2 to 20 cm). Clear margins were achieved in 85% of cases. An overall 10.6% of patients had pathologic upgrading to invasive disease after TEMS. Lesion volume was found to influence the completeness of excision, and the widest diameter of the lesions was related to the presence of an invasive component on histology (P=0.002, 0.008, respectively).

CONCLUSIONS

TEMS is a minimally invasive technique for the resection of rectal lesions that are not amenable to endoscopic removal. Lesion size and endoscopic diameter were associated with invasive component and margin positivity, respectively. These factors should be taken into consideration when considering TEMS.

Management of complex polyps of the colon and rectum

PUPRPOSE

Benign polyps that are technically challenging and unsafe to remove via polypectomy are known as complex polyps. Concerns regarding safety and completeness of resection dictate they undergo advanced endoscopic techniques, such as endoscopic mucosal resection or surgery. We provide a comprehensive overview of complex polyps and current treatment options.

METHODS

A review of the English literature was conducted to identifyarticles describing the management of complex polyps of the colon and rectum.

RESULTS

Endoscopic mucosal resection is the standard of care for the majority of complex polyps. Only polyps that fail endoscopic mucosal resection or are highly suspicious of invasive cancer but which cannot be removed endoscopically warrant surgery.

CONCLUSION

Several factors influence the treatment of a complex polyp; therefore, there cannot be a "one-size-fitsall" approach. Treatment should be tailored to the lesion's characteristics, the risk of adverse events, and the resources available to the treating physician.

Indications and Outcomes From 32 Consecutive Patients for the Treatment of Rectal Lesions by Transanal Minimally Invasive Surgery

BACKGROUND

The aim of this study was to evaluate the feasibility, safety, perioperative morbidity, and short-term outcomes of the transanal minimally invasive surgery (TAMIS) technique.

METHODS

This is a descriptive review of prospectively collected data from 32 consecutive patients who underwent TAMIS procedures in our colorectal unit over a 40-month period. GelPOINT Path port was used in all cases. Demographic data, indications, tumor characteristics, morbidity, and follow-up data were collected. Primary endpoints included feasibility, safety, perioperative morbidity, and resection quality.

RESULTS

Fifteen adenomas, 12 carcinomas, 1 gastrointestinal stromal tumor, and 1 neuroendocrine tumor were locally excised. Additionally, 3 pelvic abscesses were drained transanally using the TAMIS port. Mean distance from the anal verge was 5.6 ± 1.5 cm. Early postoperative complications occurred in 22%, with only one case of major complication (3.1%) requiring reoperation, and no postoperative mortality. Four carcinomas were understaged (33.3%) and 1 adenoma overstaged (6.7%) preoperatively. Three carcinomas were not suspected preoperatively (25%). Microscopic positive lateral margin was found in one case, and no affected deep margin was found. Fragmentation rate was 6.9%, 2 cases, both lesions over 20 cm². In cases of fit patients with high-risk carcinomas, 2 underwent immediate salvage surgery and another 2 refused and were treated with adjuvant radiotherapy. With a median follow-up of 26 months, the overall recurrence rate was 10.3%, 1 adenoma and 2 carcinomas.

CONCLUSION

TAMIS seems to be a safe and reproducible procedure for local excision of well-selected rectal lesions with low morbidity and good functional outcomes.

Transanal Endoscopic Operation for Benign Rectal Lesions and T1 Carcinoma

Background and Objectives:

Transanal endoscopic operation (TEO) is a minimally invasive technique used for local excision of benign and selected malignant rectal lesions. The purpose of this study was to investigate the feasibility, safety, and oncological outcomes of the procedure and to report the experience in 3 centers.

Methods:

Retrospective review of a prospectively collected database was performed of all patients with benign lesions or ≤cT1N0 rectal cancer who underwent TEO with curative intent at 3 Belgian centers (2012 through 2014).

Results:

Eighty-three patients underwent 84 TEOs for 89 rectal lesions (37 adenomas, 43 adenocarcinomas, 1 gastrointestinal stromal tumor, 1 lipoma, 2 neuroendocrine tumors, and 5 scar tissues). Operative time was associated with lesion size (P < .001). Postoperative complications occurred in 13 patients: 7 hemorrhages, 1 urinary tract infection, 1 urinary retention, 2 abscesses, 1 anastomotic stenosis, and 1 entrance into the peritoneal cavity. Median hospital stay was 3 days (range, 1–8). During a median follow-up of 13 months (range, 2–27), there was 1 recurrence.

Conclusion:

Although longer follow-up is still necessary, TEO appears to be an effective method of excising benign tumors and low-risk T1 carcinomas of the rectum. However, TEO should be considered as part of the diagnostic work-up. Furthermore, the resected specimen of a TEO procedure allows adequate local staging in contrast to an endoscopic piecemeal excision. Nevertheless, definitive histology must be appreciated, and in case of unfavorable histology, radical salvage resection still has to be performed.

Submucosal dissection has advantages over full-thickness transanal endoscopic microsurgery in selected rectal lesions

BACKGROUND

To establish the incidence of unsuspected malignancy in lesions excised through transanal endoscopic microsurgery (TEM) and examine the justification for full-thickness excision of all lesions thought to be benign pre-operatively.

METHODS

Demographic, operative and pathology data of all patients undergoing TEM at a single institution were collected in a prospectively maintained database. Follow-up data were collected with a focus on polyp recurrence rates and outcome in patients found to harbour malignancy. For lesions thought to be benign pre-operatively, a submucosal excision was routinely performed.

RESULTS

TEM was attempted in 156 cases between June 1999 and April 2013. Mean (standard deviation) patient age was 66.8 (2.1) years, with 111 males. Mean tumour size was 4.1 (1.6) cm, and mean height from anal verge was 10.4 (2.1) cm. In nine cases, the procedure was unable to be completed and in eight cases a deliberate full-thickness excision was performed. In 139 patients with a presumed benign lesion, mean operating time was 53.4 min. A total of 17 (12.2%) were found to harbour an unsuspected malignancy. Recurrent polyp was seen in 14 (11.7%) of 122 cases of benign pathology (mean follow-up 24.5 months) and was managed by endoscopic means in 10 patients. Mean length of stay was 1.2 days and complications occurred in 7% of cases. No patient with an unsuspected malignancy has developed recurrent disease (mean follow-up 43 months).

CONCLUSION

Submucosal TEM can result in low complication rates, short duration of surgery, short hospital stay and satisfactory recurrence rates when performed for presumed benign rectal tumours.

Local excision by transanal endoscopic surgery

Transanal endoscopic surgery (TES) consists of a series of anorectal surgical procedures using different devices that are introduced into the anal canal. TES has been developed significantly since it was first used in the 1980s. The key point for the success of these techniques is how accurately patients are selected. The main indication was the resection of endoscopically unresectable adenomas. In recent years, these techniques have become more widespread which has allowed them to be applied in conservative rectal procedures for both benign diseases and selected cases of rectal cancer. For more advanced rectal cancers it should be considered palliative or, in some controlled trials, experimental. The role of newer endoscopic techniques available has not yet been defined. TES may allow for new strategies in the treatment of rectal pathology, like transanal natural orifice transluminal endoscopic surgery or total mesorectal excision.

Impact of technology on indications and limitations for transanal surgical removal of rectal neoplasms

Transanal surgery has and continues to be well accepted for local excision of benign rectal disease not amenable to endoscopic resection. More recently, there has been increasing interest in applying transanal surgery to local resection of early malignant disease. In addition, some groups have started utilizing a transanal route in order to accomplish total mesorectal excision (TME) for more advanced rectal malignancies. We aim to review the role of various transanal and endoscopic techniques in the local resection of benign and malignant rectal disease based on published trial data. Preliminary data on the use of transanal platforms to accomplish TME will also be highlighted. For endoscopically unresectable rectal adenomas, transanal surgery remains a widely accepted method with minimal morbidity that avoids the downsides of a major abdomino-pelvic operation. Transanal endoscopic microsurgery and transanal minimally invasive surgery offer improved visualization and magnification, allowing for finer and more precise dissection of more proximal and larger rectal lesions without compromising patient outcome. Some studies have demonstrated efficacy in utilizing transanal platforms in the surgical management of early rectal malignancies in selected patients. There is an overall higher recurrence rate with transanal surgery with the concern that neither chemoradiation nor salvage surgery may compensate for previous approach and correct the inferior outcome. Application of transanal platforms to accomplish transanal TME in a natural orifice fashion are still in their infancy and currently should be considered experimental. The current data demonstrate that transanal surgery remains an excellent option in the surgical management of benign rectal disease. However, care should be used when selecting patients with malignant disease. The application of transanal platforms continues to evolve. While the new uses of transanal platforms in TME for more advanced rectal malignancy are exciting, it is important to remain cognizant and not sacrifice long term survival for short term decrease in morbidity and improved cosmesis.

Transanal endoscopic microsurgery: Current application and future prospects

Rectal neoplasms pose serious harm to human health. The options of surgical procedure for these patients have been limited because of the special features of anal and rectal anatomy and physiology. Tumors with a diameter less than 3 cm can be resected through the anus or soft microscope; however, those with a large diameter and wide base which are cancerous and relapse easily still need conventional laparotomy procedures. Transanal endoscopic microsurgery (TEM) was designed to avoid laparotomy for these patients. Using special instruments, TEM allows to totally resect tumors located 4-25 cm from the anus with safe margin and lower rate of complications. Because of minimal invasiveness, shorter operative time and lower rate of complications, TEM can be widely applied in rectal polyps and adenomas. Currently, there are still arguments about TEM usage in early-stage and advanced rectal cancer. This paper reviews the current situation of application and research of TEM, with emphasis put on its indications, clinical efficiency and future development.

Multidisciplinary treatment of rectal cancer in 2014: Where are we going?

In the present review we discuss the recent developments and future directions in the multimodal treatment of locally advanced rectal cancer, with respect to staging and re-staging modalities, to the current role of neoadjuvant chemo-radiation and to the conservative and more limited surgical approaches based on tumour response after neoadjuvant combined therapy. When initial tumor staging is considered a high accuracy has been reported for T pre-treatment staging, while preoperative lymph node mapping is still suboptimal. With respect to tumour re-staging, all the current available modalities still present a limited accuracy, in particular in defining a complete response. The role of short vs long-course radiotherapy regimens as well as the optimal time of surgery are still unclear and under investigation by means of ongoing randomized trials. Observational management or local excision following tumour complete response are promising alternatives to total mesorectal excision, but need further evaluation, and their use outside of a clinical trial is not recommended. The preoperative selection of patients who will benefit from neoadjuvant radiotherapy or not, as well as the proper identification of a clinical complete tumour response after combined treatment modalities,will influence the future directions in the treatment of locally advanced rectal cancer.