Recurrence after transanal endoscopic microsurgery for benign and malignant rectal tumours: experience of a single New Zealand centre

BACKGROUND

Transanal endoscopic microsurgery (TEM) is an established technique for the resection of rectal adenomas and selected malignant tumours. It avoids the morbidity of radical resection for tumours not amenable to endoscopic resection. An important marker of quality is the local recurrence rate. The primary objective was to determine local recurrence rates for benign and malignant rectal tumours.

METHODS

We identified index TEM excisions of rectal adenomas and adenocarcinomas in patients age 18 and over at Dunedin Hospital, New Zealand, between 2000 and 2020, from a prospective database. Surveillance data were collected via chart review. The primary outcome was recurrence rate for adenomas and adenocarcinomas. Secondary outcomes included time to recurrence, association of recurrence with recognized risk factors, and adverse event rates.

RESULTS

We identified 100 patients for analysis. Of 75 benign cases, 11 (14.7%) developed local recurrence, with 63.6% identified within 1 year. Of the 25 malignant cases (19 T1, 5 T2, 1 T3), 9 (36%) developed recurrence, with 77.8% identified within 2 years. Adverse events occurred in 26% of patients, with no reoperations or deaths.

CONCLUSION

Our adenoma recurrence rate was at the higher end of the reported range of 2.4-16%. Minor complications were common, but not major morbidity. The propensity for rectal tumours to recur commonly and early reinforces the importance of regular standardized endoscopic surveillance.

Comparison between Endoscopic Submucosal Dissection and Transanal Endoscopic Microsurgery in Early Rectal Neuroendocrine Tumor Patients: A Meta-Analysis

PURPOSE

To compare the effectiveness, safety and cost-effectiveness of endoscopic submucosal dissection (ESD) with transanal endoscopic microsurgery (TEM) in early rectal neuroendocrine tumor (RNET) patients. This article will provide reliable evidence for surgeons in regards to clinical decision-making.

METHODS

Systematic literature retrieval was performed in Pubmed, Embase and Cochrane database from 2013/4/30 to 2023/4/30. Methodology validation was performed by using the Newcastle-Ottawa Scale (NOS). Data-analysis was conducted by using the Review manager version 5.3 software.

RESULTS

A total of three retrospective studies were included in our meta-analysis. All eligible studies were considered to be high quality. By comparing baseline characteristics between TEM and ESD, patients in the TEM group seemed to be characterized by a larger tumor size and lower tumor level, even though no statistical significance was found. Clear statistical significance favoring TEM was identified in terms of R0 resection rate, procedure time and hospital stay. No statistical significance was found in terms of recurrence rate, adverse events rate and additional treatment rate.

CONCLUSIONS

Compared with ESD, TEM was a more effective treatment modality for early RNET patients; it was associated with a relatively higher R0 resection rate and a similar degree of safety. However, the relatively higher cost and complicated manipulation restricted the promotion of TEM. Surgeons should opt for TEM as a primary treatment in patients with a larger tumor size and deeper degree of tumorous infiltration if the financial condition and hospital facility permit.

Transanal endoscopic microsurgery versus radical resection for early-stage rectal cancer: a systematic review and meta- analysis

PURPOSE

In the treatment of early-stage rectal cancer, a growing number of studies have shown that transanal endoscopic microsurgery is one of the alternatives to radical surgery adhering to total mesorectal excision that can reduce the incidence of adverse events without compromising treatment outcomes. The purpose of this meta-analysis is to compare the safety and treatment effect of transanal endoscopic microsurgery and radical surgery adhering to total mesorectal excision to provide a basis for clinical treatment selections.

METHOD

We searched the literatures of four major databases, PubMed, Embase, Web of science, and Cochrane Library, without limitation of time. The literatures included randomized controlled studies and cohort studies comparing two surgical procedures of transanal endoscopic microsurgery and radical surgery adhering to total mesorectal excision. Treatment effectiveness and safety results of transanal endoscopic microsurgery and radical surgery were extracted from the included literatures and statistically analyzed using RevMan5.4 and stata17.

RESULT

Ultimately, 13 papers were included in the study including 5 randomized controlled studies and 8 cohort studies. The results of the meta-analysis showed that the treatment effect and safety of both transanal endoscopic microsurgery and radical surgery in distant metastasis (RR, 0.59 (0.34, 1.02), P > 0.05), overall recurrence (RR, 1.49 (0.96, 2.31), P > 0.05), disease-specific-survival (RR, 0.74 (0.09, 1.57), P > 0.05), dehiscence of the sutureline or anastomosis leakage (RR, 0.57 (0.30, 1.06), P > 0.05), postoperative bleeding (RR, 0.47 (0.22, 0.99), P > 0.05), and pneumonia (RR, 0.37, (0.10, 1.40), P > 0.05) were not significantly different. However, they differ significantly in perioperative mortality (RR, 0.26 (0.07, 0.93, P < 0.05)), local recurrence (RR, 2.51 (1.53, 4.21), P < 0.05),_overall survival_ (RR, 0.88 (0.74, 1.00), P < 0.05), disease-free-survival (RR, 1.08 (0.97, 1.19), P < 0.05), temporary stoma (RR, 0.05 (0.01, 0.20), P < 0.05), permanent stoma (RR, 0.16 (0.08, 0.33), P < 0.05), postoperative complications (RR, 0.35 (0.21, 0.59), P < 0.05), rectal pain (RR, 1.47 (1.11, 1.95), P < 0.05), operation time (RR, -97.14 (-115.81, -78.47), P < 0.05), blood loss (RR, -315.52 (-472.47, -158.57), P < 0.05), and time of hospitalization (RR, -8.82 (-10.38, -7.26), P < 0.05).

CONCLUSION

Transanal endoscopic microsurgery seems to be one of the alternatives to radical surgery for early-stage rectal cancer, but more high-quality clinical studies are needed to provide a reliable basis.

Inflammatory cloacogenic polyp in an adolescent - case report and review of the literature

Inflammatory cloacogenic polyp is a rare lesion arising in the anal transitional zone. It is usually benign, but rare cases of malignant transformation are known. It is most commonly seen in the adult population from the fourth to the sixth decade of life, but it can be found among children and adolescents as well. The most common clinical symptoms include rectal bleeding and altered bowel habits, although some patients may be asymptomatic. Treatment involves transanal endoscopic microsurgery followed by a bowel regimen with stool softeners. We present the case report of a 14-year-old boy presenting with intermittent rectal bleeding in whom a polypoid lesion was found during digital rectal examination. The patient underwent proctosigmoidoscopy during which the suspicious lesion was removed by transanal endoscopic microsurgery and the histological diagnosis of inflammatory cloacogenic polyp was established. In the postoperative period, the patient was without any further problems. In this case report, we want to raise awareness of this rare diagnosis and emphasize its place in the differential diagnosis of rectal bleeding across all age groups.

Quality of life in patients with loco-regional rectal cancer after ELRR by TEM versus VLS TME after nChRT: long-term results

BACKGROUND

Endoluminal loco-regional resection (ELRR) by transanal endoscopic microsurgery (TEM) may be an alternative treatment option to Laparoscopic total mesorectal excision (LTME), in selected patients with N0 rectal cancer. Post-operative quality of life (QoL) evaluation is an important parameter of outcomes related to high percentage of functional sequelae. We reported, in a previous paper, the short and medium term results of QoL in patients who underwent ELRR or LTME. The aim is to evaluate the 3 year QoL in patients with iT2-T3 N0/+ rectal cancer who underwent ELRR by TEM or LTME after neoadjuvant radio-chemotherapy (nChRT) in a retrospective analysis of prospectively collected data.

METHODS

We enrolled in this study, 39 patients with iT2-T3 rectal cancer who underwent ELRR (n = 19) or LTME (n = 20), according to predefined criteria. QoL was evaluated by EORTC QLQ-C30 and QLQ-CR38 questionnaires at admission, after n-RCT and 1, 6, 12, and 36 months after surgery.

RESULTS

No statistically significant differences in QoL evaluation were observed between the two groups, both at admission and after n-RCT. In short term (1-6 months) period, significantly better results were observed in ELRR group by QLQ-C30 in global health status (p = 0.03), physical functioning (p = 0.026), role functioning (p = 0.04), emotional functioning (p = 0.04), cognitive functioning, fatigue (p < 0.05), dyspnoea (p < 0.001), insomnia (p < 0.05), appetite loss (p < 0.05), constipation (≤ 0.05), and by QLQ-CR38 in: body image (p = 0.03) and defecation (p = 0.025). At 1 year, the two groups were homogenous as assessed by QLQ-C30, whereas the QLQCR38 still showed better results of ELRR versus LTME in body image (p = 0.006), defecation problems (p = 0.01), and weight loss (p = 0.005). At 3 years, no statistically significant differences were observed between the two groups.

CONCLUSIONS

In selected patients with rectal cancer, who underwent ELRR by TEM or LTME, QoL tests at 3 years do not show any statistical differences on examined items.

Safety of transsphenoidal microsurgical approach in patients with an ACTH-secreting pituitary adenoma

PURPOSE

Patients affected by Cushing's disease often have important comorbidities directly linked to hypercortisolism that might enhance the operative risk. We report the safety of transsphenoidal surgery in patients affected by Cushing's disease as compared with patients with nonfunctioning pituitary adenoma.

METHODS

We have retrospectively analyzed 142 patients with Cushing's disease and 299 patients with nonfunctioning pituitary adenoma who underwent transsphenoidal surgery performed by a single experienced neurosurgeon between September 2007 and December 2014. For all of them, an intraoperative computerized anesthetic record for the automatic storage of data was available.

RESULTS

The intraoperative vital parameters and the frequency of drugs administered during anesthesia were comparable between Cushing's disease and nonfunctioning pituitary adenoma groups. The duration of surgery was similar between the two groups (41.2 ± 11.8 vs. 42.9 ± 15.6 min), while the duration of anesthesia was slightly shorter in Cushing's disease patients (97.6 ± 18.1 min) than in nonfunctioning pituitary adenoma patients (101.6 ± 20.6 min, p = 0.04). The total perioperative mortality rate was 0.2% (0% in Cushing's disease vs. 0.3% in nonfunctioning pituitary adenoma). Cushing's disease patients had surgical and medical complication rates of 3.5% each, not different from those occurring in nonfunctioning pituitary adenoma. The postoperative incidence of diabetes insipidus (10.6%) and isolated hyponatremia (10.6%) in Cushing's disease patients was significantly higher than in nonfunctioning pituitary adenoma patients (4.4 and 4.1%; p = 0.02 and p = 0.01, respectively).

CONCLUSIONS

In a large series of unselected and consecutive patients with Cushing's disease, transsphenoidal surgery performed by one dedicated experienced neurosurgeon had a reasonably low risk of complications. In particular, despite the higher burden of comorbidities typically associated with hypercortisolism, medical complications are rare and no more frequent than in patients with nonfunctioning pituitary adenoma.

Transanal endoscopic microsurgery and transanal minimally invasive surgery: is one technique superior?

BACKGROUND

Transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS) have been shown to improve the quality of transanal resections, allowing for improved visibility and access to the proximal rectum. This study compares the short-term outcomes between TEM and TAMIS among experienced colorectal surgeons.

METHOD

A retrospective review was conducted for TEM and TAMIS performed from 2012 to 2015 by local colorectal surgeons. Baseline patient demographics, operative variables, pathology results, and short-term outcomes were assessed.

RESULTS

Sixty-nine patients were identified (40 TEM and 29 TAMIS). Patient demographics, tumor characteristics, operative variables, margin status, and postoperative complications were similar for both. Volume of resection was higher for TAMIS (P < .001). Lymph node retrieval was achieved in 17.2% of TAMIS cases compared with 0% of TEM (P = .01).

CONCLUSIONS

TAMIS appears to have equivalent indications and outcomes compared with TEM. TAMIS is associated with larger specimens and more frequent presence of mesorectal lymph nodes.

Transanal endoscopic microsurgery for advanced polyps and early cancers in the rectum-Long-term outcome: A STROBE compliant observational study

Transanal endoscopic microsurgery (TEM) allows for the resection of large adenomas and early stage cancers in the rectum. The rate of complications and recurrence for malignant tumors compared with benign tumors has been questioned.The objective of our study was to analyze the outcome after TEM procedures for adenomas and cancers with focus on local recurrence and complications.All 280 patients who had a TEM procedure between January 2008 and September 2015 were enrolled in a prospective cohort study. Outcome was described for benign and malignant tumors. Mortality, recurrence, and complications were recorded.Two hundred eighty tumors were treated with TEM, 176 (63%) were benign and 104 (37%) were malignant. Complication rates were significantly different in the 2 groups, 10.8% (n = 19) in the benign and 24.0% (n = 25) in the malignant group (P = 0.003). A significant difference in perforation/penetration to the peritoneal cavity was noted (P = 0.034). There were no significant difference in the recurrence rate of 8.3% (n = 13) in the benign and 9.0% (n = 7) in the malignant groups. Thirty days mortality rates were 1.1% in the benign group versus 1.9% in the malignant. Other complications were noted in 2.8% and 3.8% in the benign and malignant group, respectively.TEM seems to be a safe and viable procedure for removing both benign and malignant lesions from the rectum. TEM offers low mortality and complication rates also recurrence after resection of malignant tumors.

Influence of Local Recurrence and Distant Metastasis on Prognosis After Local Excision of Rectal Carcinoma

BACKGROUND

Influence of local recurrence (LR) on prognosis after a local excision (LE) for rectal cancer is unclear.

PATIENTS AND METHODS

A total of 152 patients were retrospectively assigned to one of three groups: Groups 1 and 2: complete and incomplete resection respectively, for low-risk carcinoma; group 3: high-risk carcinoma. We evaluated LR, distant metastasis (DM), overall survival, and cancer-specific survival (CSS).

RESULTS

LR rates were 10.4%, 43% and 29% for groups 1-3, respectively (p=0.002). In all three groups, DM incidence was low in patients without LR, but high in patients with LR (p<0.0001). Prior LR was an important risk factor for DM (hazard ratio: 14.1, 95% confidence interval=4.3-45.8, p<0.0001). DM significantly reduced CSS.

CONCLUSION

There is a strong association between LR and DM independently in the cause of LR. Avoiding LE for high-risk carcinoma and complete LE of low-risk carcinoma are essential to reduce LR and DM.

[Early Rectal Cancer: Can Transanal Endoscopic Microsurgery (TEM) Become the Standard Treatment?]

Aim

Transanal endoscopic microsurgery (TEM) is a main treatment technique for rectal adenomas, but can also be used for selected malignant tumors. This study presents TEM experience.

Methods

The study enrolled patients with rectal adenomas, and selected adenocarcinomas. Preoperative work-up included: digital rectal examination, rectoscopy with biopsy, colonoscopy, EUS, pelvic MRI.

Results

Three hundred and thirty patients [mean age of 61,4±10 (33–88)] underwent TEM. The mean size ± SD of tumors was 3.2±1.2 cm (0.6–10.0). Mean distance from anal verge was 6.7±2.6 cm (2.0–14.0). Preoperative biopsy revealed: adenoma ― 263/330 (79,7%), adenocarcinoma ― 67/330 (20,3%). The median operating time was 40 (15–220) min. Tumor-free margins were obtained in all operative specimens. In 5/330 (1.5%) cases tumors were fragmented. The morbidity rate was 19/330 (5.7%). Pathological investigation revealed: adenoma in 192/330 (58.1%) cases, adenocarcinoma stage Tis, T1, T2 and T3 in 138/330 (41.9%). Median follow-up lasted for 24 (1–57) months. Five patients (2.0%) with adenoma and four patients (5.2%) with adenocarcinoma had local recurrence.

Conclusion

Transanal endoscopic microsurgery for rectal adenomas and selected malignant tumors is associated with low morbidity and low recurrents rates.

Full-thickness excision using transanal endoscopic microsurgery for treatment of rectal neuroendocrine tumors

AIM: To assess the efficacy of full-thickness excision using transanal endoscopic microsurgery (TEM) in the treatment of rectal neuroendocrine tumors.

METHODS: We analyzed the data of all rectal neuroendocrine tumor patients who underwent local full-thickness excision using TEM between December 2006 and December 2014 at our department. Data collected included patient demographics, tumor characteristics, operative details, postoperative outcomes, pathologic findings, and follow-ups.

RESULTS: Full-thickness excision using TEM was performed as a primary excision (n = 38) or as complete surgery after incomplete resection by endoscopic polypectomy (n = 21). The mean size of a primary tumor was 0.96 ± 0.21 cm, and the mean distance of the tumor from the anal verge was 8.4 ± 1.4 cm. The mean duration of the operation was 57.6 ± 13.7 min, and the mean blood loss was 13.5 ± 6.6 mL. No minor morbidities, transient fecal incontinence, or wound dehiscence was found. Histopathologically, all tumors showed typical histology without lymphatic or vessel infiltration, and both deep and lateral surgical margins were completely free of tumors. Among 21 cases of complete surgery after endoscopic polypectomy, 9 were histologically shown to have a residual tumor in the specimens obtained by TEM. No additional radical surgery was performed. No recurrence was noted during the median of 3 years’ follow-up.

CONCLUSION: Full-thickness excision using TEM could be a first surgical option for complete removal of upper small rectal neuroendocrine tumors.