Transanal endoscopic microsurgery

Transanal endoscopic microsurgery: a necessary requirement?

INTRODUCTION

There has been a gradual introduction of transanal endoscopic microsurgery (TEM) into UK practice although the uptake remains variable. This study aimed to assess the availability, application and referral pattern of TEM amongst colorectal surgeons.

METHODS

A questionnaire was sent to all consultant members of the Association of Coloproctology. This considered their practice, the availability, application and referral pattern for TEM, and their views on application regarding a selection of rectal tumour scenarios.

RESULTS

There were 142 replies representing 116 hospitals and 297 colorectal surgeons. The median catchment area was 280,000 (range 70,000-1,000,000). TEM was available in 18% of hospitals and 72% either performed or referred patents for TEM. Of 21 units performing TEM, 15 received referrals. From 305 TEM procedures performed over the previous year, 206 were referred cases. Eighty-five per cent of consultants considered TEM a necessary technique for optimum management of rectal lesions. Although 61% of consultants considered endoanal excision optimal for low benign rectal tumours, 58% said TEM was optimal for midrectal lesions and between 30% and 55% for high rectal lesions depending if the tumour position was anterior or posterior, respectively. One-third of consultants would perform TEM for a low T1 rectal carcinoma although half would proceed to anterior resection.

DISCUSSION

TEM is considered to have a significant role in the optimal management of rectal lesions. The presence of the technique in a limited number of hospitals does appear to provide adequate resources although audit should continue to be centralized.

Gasless, video endoscopic transanal excision for carcinoid and laterally spreading tumors of the rectum

BACKGROUND

The aim of this study is to determine whether gasless, video endoscopic transanal-rectal tumor excision (gasless VTEM) is a valid treatment for rectal carcinoid and laterally spreading tumors (LST).

METHODS

Eighty-four patients with an adenoma, adenocarcinoma (Tis/T1), or carcinoid tumor of the rectum were divided into three groups: (i) LST ( n = 17 patients), (ii) carcinoid ( n = 11), and (iii) control with other types of tumors ( n = 56).

RESULTS

The LST group had a longer median operating time than in the control group, whereas the carcinoid group had a shorter operating time. Two patients (11.7%) in LST group developed peritoneal entry during the operation, while 2 patients (3.6%) in the control group experienced postoperative complications. During a median follow-up length of 55.2 months, one patient in the LST group developed a recurrence.

CONCLUSIONS

Gasless VTEM is a simple, minimally invasive procedure used to treat LST and carcinoid tumors of the rectum. However, resection for the LST group had a high risk of peritoneal entry during operation.

Gasless video endoscopic transanal excision of rectal tumors incompletely removed by colonoscopic snare polypectomy

BACKGROUND

This report describes an experience with gasless video transanal endoscopic microsurgery (VTEM) to excise rectal tumors previously incompletely removed with colonoscopic snare polypectomy.

METHODS

Gasless VTEM involves a modification of transanal endoscopic microsurgery (TEM) that incorporates a standard laparoscopic video camera and requires no CO(2) insufflation system. Nineteen patients who had had a rectal tumor removed incompletely by colonoscopic polypectomy with a diathermy snare were enrolled in this prospective study. The patients included 14 men and 5 women whose median age was 63.5 (range, 49-83) years. The rectal tumors included 4 adenomas, 11 adenocarcinomas (Tis, 7; T1, 4), and 4 carcinoid tumors. The median distance from the tumor margin to the dentate line was 5.8 (range, 2.0-13.0) cm.

RESULTS

All rectal lesions were successfully removed by gasless VTEM. No intraoperative complication occurred. The median operating time and blood loss were 40 (range, 15-145) minutes and 5 (range, 0-100) mL, respectively. The median maximal tumor diameter in 9 patients with residual tumors was 1.3 (range, 0.5-2.5) cm. There was no operative mortality. A postoperative complication (bleeding from a suture wound and transient incontinence) developed in 1 (5.3%) of the 19 patients. The median postoperative hospital stay was 5 (range, 2-10) days. Postoperative histology revealed a residual tumor in 10 (52.9%) of the 19 specimens. Complete excision of all tumors was confirmed histologically. During a median follow-up period of 59.5 (range, 12.3-94.9) months, no tumor recurred.

CONCLUSIONS

Gasless VTEM is useful and minimally invasive for the local removal of rectal tumors incompletely resected by colonoscopic snare polypectomy.

Surgical technique and outcome of gasless video endoscopic transanal rectal tumour excision

BACKGROUND

Transanal endoscopic microsurgery (TEM) is unpopular because of its high cost and most surgeons' unfamiliarity with microscopic surgery. This report describes an experience with a modification of TEM, gasless video endoscopic transanal rectal tumour excision (gasless VTEM), which incorporates a standard laparoscopic video camera and requires no carbon dioxide insufflation system.

METHODS

One hundred and one patients with 105 rectal tumours underwent gasless VTEM between 1993 and 2000.

RESULTS

Histological examination revealed 18 adenomas, 75 carcinomas (Tis, 47; T1, 23; T2, five), 11 carcinoid tumours and one lymphoma. The median height above the dentate line and maximum tumour diameter was 5.0 (range 2-14) cm and 2.0 (range 0.4-8.0) cm respectively. The peritoneal cavity was opened intraoperatively in two patients. The median operating time was 53 (range 15-202) min. Bleeding, suture dehiscence and transient incontinence developed after operation in four patients. There was no operative death. Median hospital stay was 5 (range 1-21) days. Eleven patients with T1/T2 staging underwent subsequent radical resection. The median duration of follow-up was 52.3 months. One patient with a carcinoma developed a recurrence.

CONCLUSION

Gasless VTEM is a feasible, safe and minimally invasive procedure for the treatment of selected rectal adenomas and early carcinomas. The suggested modifications may make the procedure more widely available.