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Wang C, Huang T, Wang X. Efficacy and safety of transanal endoscopic microsurgery for early rectal cancer: a meta-analysis. Front Oncol 2025; 15:1545547. [PMID: 39995839 PMCID: PMC11847824 DOI: 10.3389/fonc.2025.1545547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2024] [Accepted: 01/17/2025] [Indexed: 02/26/2025] Open
Abstract
Background The gold standard for the treatment of rectal cancer is radical surgery with total mesorectal excision (TME). As one of the alternatives to radical surgery, local resection has been proposed for the treatment of early rectal cancer. The purpose of this article was to evaluate the safety and efficacy of transanal endoscopic microsurgery (TEM) in the treatment of early rectal cancer. Methods By searching the PubMed, Cochrane Library, Web of Science, and China National Knowledge Infrastructure databases, we selected all articles on TEM for early rectal cancer. Two researchers independently completed the entire process from screening, inclusion to data extraction and performed statistical analysis using RevMan 5.3. The primary outcomes included basic patient characteristics, overall survival rate, disease-free survival rate, disease-specific survival rate, recurrence rate, and complication rate and type. Results A total of 33 articles were included in this meta-analysis. The results showed that the overall survival rate was 100% for T0 stage, 98.1% for Tis (carcinoma in situ) stage, and 80.2% for early stage rectal cancer patients (83.9% for T1 and 72.4% for T2). The weighted overall survival rate was 94% (RD = 0.94, 95% CI = 0.93-0.95, I 2 = 80%, P < 0.00001) for all stage patients, the weighted disease-free survival rate was 91% (RD = 0.91, 95% CI = 0.90-0.93, I 2 = 83%, P < 0.00001), and the disease-specific survival rate was 97% (RD = 0.97, 95% CI = 0.96-0.98, I 2 = 63%, P < 0.00001). The recurrence rate was 0.5% for T0 stage, 1.9% for Tis stage, and 11.9% for early stage rectal cancer patients (8.1% for T1 and 19.7% for T2). The weighted recurrence rate was 7% (RD = 0.07, 95% CI = 0.06-0.08, I 2 = 69%, P < 0.00001) for all stage patients. The weighted complications rate was 11% (RD = 0.11, 95% CI = 0.10-0.12, I 2 = 66%, P < 0.00001) for all stage patients, with Clavien-Dindo grade I accounting for 77.7%, Clavien-Dindo grade II accounting for 8%, and Clavien-Dindo grade III accounting for 14.3%. Conclusion The results showed that TEM has a high postoperative survival rate, low recurrence rate, and low complication rate in the T0 stage, Tis stage, and T1 stage, indicating its good safety and efficacy. For the treatment of T2 stage, TEM has a lower overall survival rate and a higher recurrence rate. Our meta-analysis results suggest that TEM alone is not recommended as a curative treatment for T2 stage; on the contrary, TME is more frequently recommended.
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Affiliation(s)
- Chunqiang Wang
- Affiliated Xiaoshan Hospital, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Tianye Huang
- The First Medical University of Shandong Affiliated Linyi Hospital, Linyi, Shandong, China
| | - Xuebing Wang
- The First Medical University of Shandong Affiliated Taian Hospital, Taian, Shandong, China
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Kouladouros K, Jakobs J, Stathopoulos P, Kähler G, Belle S, Denzer U. Endoscopic submucosal dissection versus endoscopic mucosal resection for the treatment of rectal lesions involving the dentate line. Surg Endosc 2024; 38:4485-4495. [PMID: 38914887 PMCID: PMC11289217 DOI: 10.1007/s00464-024-10994-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Accepted: 06/08/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND The ideal treatment of epithelial neoplastic rectal lesions involving the dentate line is a controversial issue. Piecemeal endoscopic mucosal resection (EMR) is the most commonly used resection technique, but it is associated with high recurrence rates. Endoscopic submucosal dissection (ESD) has been shown to be safe and effective for the treatment of rectal lesions, but evidence is lacking concerning its application close to the dentate line. The aim of our study is to compare ESD and EMR for the treatment of epithelial rectal lesions involving the dentate line. METHODS We identified all cases of endoscopic resections of rectal lesions involving the dentate line performed in two German high-volume centers between 2010 and 2022. Periinterventional and follow-up data were collected and retrospectively analyzed. RESULTS We identified 68 ESDs and 62 EMRs meeting our inclusion criteria. ESD showed a significant advantage in en bloc resection rates (89.7% vs. 9.7%; P = 0.001) and complete resection rates (72.1% vs. 9.7%; P = 0.001). The overall curative resection rate was similar between both groups (ESD: 92.6%, EMR: 83.9%; P = 0.324), whereas in the subgroup of low-risk adenocarcinomas ESD was curative in 100% of the cases vs. 14% in the EMR group (P = 0.002). There was one local recurrence after ESD (1,5%) vs. 16 (25.8%) after EMR (P < 0.0001), and the EMR patients required an average of three further interventions. CONCLUSION ESD is superior to EMR for the treatment of epithelial rectal lesions involving the dentate line and should be considered the treatment of choice.
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Affiliation(s)
- Konstantinos Kouladouros
- Central Interdisciplinary Endoscopy Department, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
- Central Interdisciplinary Endoscopy, Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum (CVK), Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Johanna Jakobs
- Endoscopy Unit, Department of Gastroenterology, Endocrinology, Metabolic Diseases and Clinical Infectiology, Marburg University Hospital, Baldingerstrasse, 35043, Marburg, Germany
| | - Petros Stathopoulos
- Endoscopy Unit, Department of Gastroenterology, Endocrinology, Metabolic Diseases and Clinical Infectiology, Marburg University Hospital, Baldingerstrasse, 35043, Marburg, Germany
| | - Georg Kähler
- Central Interdisciplinary Endoscopy Department, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Sebastian Belle
- Central Interdisciplinary Endoscopy Department, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Ulrike Denzer
- Endoscopy Unit, Department of Gastroenterology, Endocrinology, Metabolic Diseases and Clinical Infectiology, Marburg University Hospital, Baldingerstrasse, 35043, Marburg, Germany
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Khalifa M, Gingold-Belfer R, Issa N. The Outcome of Local Excision of Rectal Adenomas with High-Grade Dysplasia by Transanal Endoscopic Microsurgery: A Single-Center Experience. J Clin Med 2024; 13:1419. [PMID: 38592246 PMCID: PMC10934864 DOI: 10.3390/jcm13051419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 02/20/2024] [Accepted: 02/26/2024] [Indexed: 04/10/2024] Open
Abstract
Background: Local excision by transanal endoscopic microsurgery (TEM) is considered an acceptable treatment for rectal adenomas with high-grade dysplasia (HGD). This study aims to assess the likelihood of harboring an invasive carcinoma in preoperatively diagnosed HGD polyps and evaluate the risk factors for tumor recurrence in patients with final HGD pathology. Methods: Data from patients who underwent TEM procedures for adenomatous lesions with HGD from 2005 to 2018 at the Rabin Medical Center, Hasharon Hospital, were analyzed. Collected data included patient demographics, preoperative workup, tumor characteristics and postoperative results. Follow-up data including recurrence assessment and further treatments were reviewed. The analysis included two subsets: preoperative pathology of HGD (sub-group 1) and postoperative final pathology of HGD (sub-group 2) patients. Results: Forty-five patients were included in the study. Thirty-six patients had a preoperative diagnosis of HGD, with thirteen (36%) showing postoperative invasive carcinoma. Thirty-two patients had a final pathology of HGD, and three (9.4%) experienced tumor recurrence. Large tumor size (>5 cm) was significantly associated with recurrence (p = 0.03). Conclusions: HGD rectal polyps are associated with a significant risk of invasive cancer. Tumor size was a significant factor in predicting tumor recurrence in patients with postoperative HGD pathology. The TEM procedure is an effective first-line treatment for such lesions.
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Affiliation(s)
- Muhammad Khalifa
- Department of Surgery, Rabin Medical Center-Hasharon Hospital, Faculty of Medicine, Tel Aviv University, Petach Tikva 49100, Israel;
| | - Rachel Gingold-Belfer
- Department of Gastroenterology, Rabin Medical Center-Hasharon Hospital, Tel Aviv University, Petach Tikva 49100, Israel;
| | - Nidal Issa
- Department of Surgery, Rabin Medical Center-Hasharon Hospital, Faculty of Medicine, Tel Aviv University, Petach Tikva 49100, Israel;
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Kouladouros K, Baral J. Transanal endoscopic microsurgical submucosal dissection (TEM-ESD): A novel approach to the local treatment of early rectal cancer. Surg Oncol 2021; 39:101662. [PMID: 34543918 DOI: 10.1016/j.suronc.2021.101662] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 08/18/2021] [Accepted: 09/10/2021] [Indexed: 12/27/2022]
Abstract
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.
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Affiliation(s)
- Konstantinos Kouladouros
- Central Interdisciplinary Endoscopy Department, Mannheim University Hospital, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Jörg Baral
- Surgery Department, Karlsruhe Municipal Hospital, Moltkestrasse 90, 76133, Karlsruhe, Germany
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Bilkhu A, Robinson JM, Steward MA. 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. Colorectal Dis 2021; 23:1765-1776. [PMID: 33724612 DOI: 10.1111/codi.15631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 02/11/2021] [Accepted: 03/07/2021] [Indexed: 12/18/2022]
Abstract
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.
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The impact of transanal local excision of early rectal cancer on completion rectal resection without neoadjuvant chemoradiotherapy: a systematic review. Tech Coloproctol 2021; 25:997-1010. [PMID: 34173121 DOI: 10.1007/s10151-020-02401-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 12/28/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND The impact of transanal local excision (TAE) of early rectal cancer (ERC) on subsequent completion rectal resection (CRR) for unfavorable histology or margin involvement is unclear. The aim of this study was to provide a comprehensive review of the literature on the impact of TAE on CRR in patients without neoadjuvant chemoradiotherapy (CRT). METHODS We performed a systematic review of the literature up to March 2020. Medline and Cochrane libraries were searched for studies reporting outcomes of CRR after TAE for ERC. We excluded patients who had neoadjuvant CRT and endoscopic local excision. Surgical, functional, pathological and oncological outcomes were assessed. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. RESULTS Sixteen studies involving 353 patients were included. Pathology following TAE was as follows T0 = 2 (0.5%); T1 = 154 (44.7%); T2 = 142 (41.2%); T3 = 43 (12.5%); Tx = 3 (0.8%); T not reported = 9. Fifty-three percent were > T1. Abdominoperineal resection (APR) was performed in 80 (23.2%) patients. Postoperative major morbidity and mortality occurred in 22 (11.4%) and 3 (1.1%), patients, respectively. An incomplete mesorectal fascia resulting in defects of the mesorectum was reported in 30 (24.6%) cases. Thirteen (12%) patients developed recurrence: 8 (3.1%) local, 19 (7.3%) distant, 4 (1.5%) local and distant. The 5-year cancer-specific survival was 92%. Only 1 study assessed anal function reporting no continence disorders in 11 patients. In the meta-analysis, CRR after TAE showed an increased APR rate (OR 5.25; 95% CI 1.27-21.8; p 0.020) and incomplete mesorectum rate (OR 3.48; 95% CI 1.32-9.19; p 0.010) compared to primary total mesorectal excision (TME). Two case matched studies reported no difference in recurrence rate and disease free survival respectively. CONCLUSIONS The data are incomplete and of low quality. There was a tendency towards an increased risk of APR and poor specimen quality. It is necessary to improve the accuracy of preoperative staging of malignant rectal tumors in patients scheduled for TAE.
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Ondhia M, Tamvakeras P, O'Toole P, Montazerri A, Andrews T, Farrell C, Ahmed S, Slawik S, Ahmed S. Transanal endoscopic microsurgery for rectal lesions in a specialist regional early rectal cancer centre: the Mersey experience. Colorectal Dis 2019; 21:1164-1174. [PMID: 31207005 PMCID: PMC6900238 DOI: 10.1111/codi.14730] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 06/14/2019] [Indexed: 12/13/2022]
Abstract
AIM Organ-preserving local excision by transanal endoscopic microsurgery (TEM) for early rectal cancer offers significantly lower morbidity as compared to formal rectal cancer resection with acceptable outcomes. This study presents our 6-year experience of TEM for rectal lesions referred to a specialist early rectal cancer centre in the UK. METHOD Data were collected for all patients referred for TEM of suspected early rectal cancer to a regional specialist early rectal cancer multidisciplinary team (MDT) over a 6-year period. RESULTS One hundred and forty-one patients who underwent full-thickness TEM for suspected or confirmed early rectal cancer were included. Thirty patients were referred for TEM following incomplete endoscopic polypectomy. Final pathology was benign in 77 (54.6%) cases and malignant in 64 (45.4%). Of the 61 confirmed adenocarcinomas, TEM resections were pT0 in 17 (27.9%), pT1 in 32 (51.7%), pT2 in 11 (18.0%) and pT3 in 1 (1.6%). Thirty-eight of 61 patients (62.3%) had one or more poor histological prognostic features and these patients were offered further treatment. Twenty-three of 61 (37.7%) patients with rectal adenocarcinoma required no further treatment following TEM. Forty-three cases of rectal adenocarcinoma were available for establishing recurrence rates. Two of 43 patients (4.7%) developed a recurrence at a median follow-up of 28.7 months (12.1-66.5 months). The overall estimated 5-year overall survival rate was 87.9% and the disease-free survival rate was 82.9%. CONCLUSION Acceptable outcomes are possible for TEM surgery with appropriate patient selection, effective technique, expert histopathology, appropriate referral for adjuvant treatment and meticulous follow-up. This can be achieved through an early rectal cancer MDT in a dedicated specialist regional centre.
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Affiliation(s)
- M. Ondhia
- Royal Liverpool and Broadgreen University Hospital NHS TrustLiverpoolUK
| | - P. Tamvakeras
- Aintree University Hospital NHS Foundation TrustLiverpoolUK
| | - P. O'Toole
- Royal Liverpool and Broadgreen University Hospital NHS TrustLiverpoolUK
| | - A. Montazerri
- Clatterbridge Cancer Centre NHS Foundation TrustWirralUK
| | - T. Andrews
- Royal Liverpool and Broadgreen University Hospital NHS TrustLiverpoolUK
| | - C. Farrell
- Royal Liverpool and Broadgreen University Hospital NHS TrustLiverpoolUK
| | - S. Ahmed
- Aintree University Hospital NHS Foundation TrustLiverpoolUK
| | - S. Slawik
- Aintree University Hospital NHS Foundation TrustLiverpoolUK
| | - S. Ahmed
- Royal Liverpool and Broadgreen University Hospital NHS TrustLiverpoolUK
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Jones HJS, Hompes R, Mortensen N, Cunningham C. Modern management of T1 rectal cancer by transanal endoscopic microsurgery: a 10-year single-centre experience. Colorectal Dis 2018; 20:586-592. [PMID: 29363859 DOI: 10.1111/codi.14029] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Accepted: 01/08/2018] [Indexed: 12/13/2022]
Abstract
AIM Minimally invasive, organ-sparing surgery has been used increasingly for early rectal cancer in recent years. However, local recurrence remains a concern. This study presents a 10-year single-centre experience of recurrence after local excision for T1 rectal cancer. METHOD Data were collected prospectively on all patients undergoing local excision by transanal endoscopic microsurgery (TEM) in a single institution. Data covering a 10-year period were analysed. RESULTS In all, 192 patients underwent TEM for rectal cancer; 70 of these had T1 tumour in the TEM specimen and did not have preoperative radiotherapy. Four were managed with completion surgery following TEM and a further six had radiotherapy; 60 underwent surveillance alone. Local recurrence occurred in six patients; three underwent salvage surgery. Estimated local recurrence at 3 years was 7.2% for the surveillance alone group. CONCLUSIONS Local recurrence rates were lower than previous studies. Better preoperative assessment, more effective local excision surgery and postoperative radiotherapy may be contributory factors to a better-than-predicted outcome. Local excision should be offered as part of standard of care for T1 rectal cancer in the presence of good preoperative selection and meticulous surveillance.
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Affiliation(s)
- H J S Jones
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R Hompes
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - N Mortensen
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - C Cunningham
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Martins BAA, Coura MDMA, de Almeida RM, Moreira NM, de Sousa JB, de Oliveira PG. Pneumoretroperitoneum and Sepsis After Transanal Endoscopic Resection of a Rectal Lateral Spreading Tumor. Ann Coloproctol 2017; 33:115-118. [PMID: 28761873 PMCID: PMC5534495 DOI: 10.3393/ac.2017.33.3.115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Accepted: 02/19/2017] [Indexed: 12/26/2022] Open
Abstract
Transanal endoscopic microsurgery is considered a safe, appropriate, and minimally invasive approach, and complications after endoscopic microsurgery are rare. We report a case of sepsis and pneumoretroperitoneum after resection of a rectal lateral spreading tumor. The patient presented with rectal mucous discharge. Colonoscopy revealed a rectal lateral spreading tumor. The patient underwent an endoscopic transanal resection of the lesion. He presented with sepsis of the abdominal focus, and imaging tests revealed pneumoretroperitoneum. A new surgical intervention was performed with a loop colostomy. Despite the existence of other reports on pneumoretroperitoneum after transanal endoscopic microsurgery, what draws attention to this case is the association with sepsis.
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Affiliation(s)
| | | | | | - Natascha Mourão Moreira
- Division of Colorectal Surgery, School of Medicine, University of Brasília, Brasília, Brazil
| | - João Batista de Sousa
- Division of Colorectal Surgery, School of Medicine, University of Brasília, Brasília, Brazil
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Abstract
Transanal endoscopic surgery (TES) techniques encompass a variety of approaches, including transanal endoscopic microsurgery and transanal minimally invasive surgery. These allow a surgeon to perform local excision of rectal lesions with minimal morbidity and the potential to spare the need for proctectomy. As understanding of the long-term outcomes from these procedures has evolved, so have the indications for TES. In this study, we review the development of TES, its early results, and the evolution of new surgical techniques. In addition, we evaluate the most recent research on indications and outcomes in rectal cancer.
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Affiliation(s)
- Earl V Thompson
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Joshua I S Bleier
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
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D'Hondt M, Yoshihara E, Dedrye L, Vindevoghel K, Nuytens F, Pottel H. Transanal Endoscopic Operation for Benign Rectal Lesions and T1 Carcinoma. JSLS 2017; 21:JSLS.2016.00093. [PMID: 28144126 PMCID: PMC5266515 DOI: 10.4293/jsls.2016.00093] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
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.
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Affiliation(s)
- Mathieu D'Hondt
- Department of General and Digestive Surgery, Groeninge Hospital, Kortrijk, Belgium
| | - Emi Yoshihara
- Department of General and Digestive Surgery, Groeninge Hospital, Kortrijk, Belgium
| | - Lieven Dedrye
- Department of General and Digestive Surgery, Jan Yperman Hospital, Ieper, Belgium
| | - Koen Vindevoghel
- Department of General and Digestive Surgery, OLV van Lourdes Hospital, Waregem, Belgium
| | - Frederiek Nuytens
- Department of General and Digestive Surgery, Groeninge Hospital, Kortrijk, Belgium
| | - Hans Pottel
- Interdisciplinary Research Center, Catholic University Leuven, Kortrijk, Belgium
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12
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Tamaru Y, Oka S, Tanaka S, Hiraga Y, Kunihiro M, Nagata S, Furudoi A, Ninomiya Y, Asayama N, Shigita K, Nishiyama S, Hayashi N, Chayama K. Endoscopic submucosal dissection for anorectal tumor with hemorrhoids close to the dentate line: a multicenter study of Hiroshima GI Endoscopy Study Group. Surg Endosc 2016; 30:4425-31. [PMID: 26895899 DOI: 10.1007/s00464-016-4761-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 01/11/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND The lower rectum close to the dentate line has distinct characteristics, making endoscopic submucosal dissection (ESD) of tumors challenging. We assessed clinical outcomes of ESD for such patients with hemorrhoids. METHODS Sixty-four patients (mean age, 68 years) underwent ESD for anorectal tumors close to the dentate line. We divided patients into those with (Group A, 45 patients) and without hemorrhoids (Group B, 19 patients). We examined en bloc and histological en bloc resection rates, procedure time, complication rates, and postoperative prognosis after ESD. RESULTS The mean tumor size was 43 mm. Histologic diagnoses were adenoma (42 %, 27/64), carcinoma in situ (44 %, 28/64), and T1 carcinoma (14 %, 9/64). There was no significant difference in en bloc resection (93 %, 42/45 vs. 95 %, 18/19) or postoperative bleeding rates (16 %, 7/45 vs. 11 %, 2/19) between Groups A and B, respectively. The mean procedural durations were 120 and 124 min, respectively, in Groups A and B. No perforations occurred. There was no significant difference in postoperative anal pain rate between Groups A (18 %, 8/45) and B (16 %, 3/19), and it resolved within a few days in all cases. There was one case of stricture in Group B. Two patients with T1 carcinoma underwent additional surgery, one underwent chemotherapy, and five had no additional treatment. No recurrence occurred during the follow-up period of 38 months. CONCLUSIONS ESD is safe and effective for anorectal tumors close to the dentate line in patients with hemorrhoids.
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Affiliation(s)
- Yuzuru Tamaru
- Department of Endoscopy, Hiroshima University Hospital, 1-2-3, Kasumi Minami-ku, Hiroshima, Japan.,Hiroshima GI Endoscopy Study Group, Hiroshima, Japan
| | - Shiro Oka
- Department of Endoscopy, Hiroshima University Hospital, 1-2-3, Kasumi Minami-ku, Hiroshima, Japan. .,Hiroshima GI Endoscopy Study Group, Hiroshima, Japan.
| | - Shinji Tanaka
- Department of Endoscopy, Hiroshima University Hospital, 1-2-3, Kasumi Minami-ku, Hiroshima, Japan.,Hiroshima GI Endoscopy Study Group, Hiroshima, Japan
| | - Yuko Hiraga
- Hiroshima GI Endoscopy Study Group, Hiroshima, Japan
| | | | - Shinji Nagata
- Hiroshima GI Endoscopy Study Group, Hiroshima, Japan
| | - Akira Furudoi
- Hiroshima GI Endoscopy Study Group, Hiroshima, Japan
| | - Yuki Ninomiya
- Hiroshima GI Endoscopy Study Group, Hiroshima, Japan.,Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Naoki Asayama
- Hiroshima GI Endoscopy Study Group, Hiroshima, Japan.,Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Kenjiro Shigita
- Hiroshima GI Endoscopy Study Group, Hiroshima, Japan.,Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Soki Nishiyama
- Hiroshima GI Endoscopy Study Group, Hiroshima, Japan.,Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Nana Hayashi
- Hiroshima GI Endoscopy Study Group, Hiroshima, Japan.,Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Kazuaki Chayama
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
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14
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Abstract
BACKGROUND Transanal endoscopic microsurgery is superior to other methods of local excision of rectal cancer, but few studies report long-term follow-up data. OBJECTIVE This study investigated the use of transanal endoscopic microsurgery alone as curative and compromise therapy based on long-term disease recurrence and mortality. DESIGN This was a retrospective review of prospectively collected data. SETTINGS The study was conducted at a tertiary care university medical center. PATIENTS The study included 133 patients treated between 1985 and 2007. There were 3 groups, including transanal endoscopic microsurgery in curative intent (low-risk rectal carcinoma, including pT1, G1/2, L0, and LX with clear margins and a minimal distance between tumor and resection margin of >1 mm (N = 64) or clear margins only (N = 18 ))) and as compromise therapy (high-risk or incompletely resected rectal carcinoma; N = 51). MAIN OUTCOME MEASURES Log-rank tests were used to compare overall and cancer-specific survival. RESULTS The median follow-up time was 8.6 years (range, 0.2-25.1 years), and a total of 131 of 133 patients (98.5%) were followed >5 years or until death. The preoperative diagnosis of carcinoma was not associated with belonging into 1 of the 3 categories. In patients with low-risk completely (>1 mm) resected carcinoma, the 5- and 10-year local recurrence rates were 6.6% and 11.6%. In patients with high-risk or incompletely resected carcinoma, the rates were 32.5% and 35.0% (p = 0.006). The 5- and 10-year cancer-specific survival rates for low-risk patients were 98.0% and 91.0% and 84.3% and 74.3% for high-risk patients (p = 0.05). LIMITATIONS The study was limited by its retrospective design and small subgroups. CONCLUSIONS The high cancer-specific survival justifies transanal endoscopic microsurgery alone as curative treatment in low-risk rectal carcinoma. Complete resection is essential to lower the risk of local recurrence. The high local recurrence rate in patients with high-risk rectal carcinoma restricts the use of TEM alone as compromise therapy.
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15
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Russo S, Blackstock AW, Herman JM, Abdel-Wahab M, Azad N, Das P, Goodman KA, Hong TS, Jabbour SK, Jones WE, Konski AA, Koong AC, Kumar R, Rodriguez-Bigas M, Small W, Thomas CR, Suh WW. ACR Appropriateness Criteria® Local Excision in Early Stage Rectal Cancer. Am J Clin Oncol 2015; 38:520-5. [PMID: 26371522 PMCID: PMC10862362 DOI: 10.1097/coc.0000000000000197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Low anterior resection or abdominoperineal resection are considered standard treatments for early rectal cancer but may be associated with morbidity in selected patients who are candidates for early distal lesions amenable to local excision (LE). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. The panel recognizes the importance of accurate staging to identify patients who may be candidates for a LE approach. Patients who may be candidates for LE alone include those with small, low-lying T1 tumors, without adverse pathologic features. Several surgical approaches can be utilized for LE however none include lymph node evaluation. Adjuvant radiation±chemotherapy may be warranted depending on the risk of nodal metastases. Patients with high-risk T1 tumors, T2 tumors not amenable to radical surgery may also benefit from adjuvant treatment; however, patients with positive margins or T3 lesions should be offered abdominoperineal resection or low anterior resection. Neoadjuvant radiation±chemotherapy followed by LE in higher risk patients results in excellent local control, but it is not clear if this approach reduces recurrence rates over surgery alone.
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Affiliation(s)
- Suzanne Russo
- Department of Radiation Oncology, University Hospitals Case Western Seidman Cancer Center, Cleveland, OH
| | | | - Joseph M. Herman
- Sidney Kimmel Cancer Center, Johns Hopkins University, Baltimore, MD, American Society of Clinical Oncology
| | | | - Nilofer Azad
- Sidney Kimmel Cancer Center, Johns Hopkins University, Baltimore, MD, American Society of Clinical Oncology
| | - Prajnan Das
- MD Anderson Cancer Center, Houston, TX, American College of Surgeons
| | | | | | - Salma K. Jabbour
- Robert Wood Johnson Medical School, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ
| | - William E. Jones
- University of Texas Health Science Center at San Antonio, San Antonio, TX
| | | | - Albert C. Koong
- Department of Radiation Oncology, Stanford University Medical Center, Stanford, CA
| | - Rachit Kumar
- Department of Radiation Oncology, Johns Hopkins University, Baltimore, MD
| | | | - William Small
- Stritch School of Medicine, Loyola University Chicago, Maywood, IL
| | - Charles R. Thomas
- Knight Cancer Institute, Oregon Health and Science University, Portland, OR
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16
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Arezzo A, Arolfo S, Allaix ME, Munoz F, Cassoni P, Monagheddu C, Ricardi U, Ciccone G, Morino M. Results of Neoadjuvant Short-Course Radiation Therapy Followed by Transanal Endoscopic Microsurgery for T1-T2 N0 Extraperitoneal Rectal Cancer. Int J Radiat Oncol Biol Phys 2015; 92:299-306. [DOI: 10.1016/j.ijrobp.2015.01.024] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 01/07/2015] [Accepted: 01/20/2015] [Indexed: 10/23/2022]
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Abstract
Anal and transanal tumor operations are safe and are associated with a very low morbidity. Perianal and anal lesions as well as low rectal tumors can be excised by direct exposure using an anal retractor. For lesions situated in the middle or upper third of the rectum, special instrumentation, such as transanal endoscopic microsurgery (TEM) and transanal endoscopic operation (TEO) should be used to avoid unnecessary R1 resections. Fatal complications are extremely rare and most complications, such as urinary retention or temporary subfebrile temperatures, are minor. Suture line dehiscences are usually clinically unremarkable. Major complications comprise significant hemorrhage and opening of the peritoneal cavity. The latter must be recognized intraoperatively and can usually be managed by primary suturing. Infections, abscess formation, rectovaginal fistula, injury of the prostate or even urethra are extremely rare complications.
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18
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Devaraj B, Kaiser AM. Impact of technology on indications and limitations for transanal surgical removal of rectal neoplasms. World J Surg Proced 2015; 5:1. [DOI: 10.5412/wjsp.v5.i1.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Revised: 12/21/2014] [Accepted: 01/19/2015] [Indexed: 02/06/2023] Open
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19
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Habr-Gama A, São Julião GP, Perez RO. Pitfalls of transanal endoscopic microsurgery for rectal cancer following neoadjuvant chemoradiation therapy. MINIM INVASIV THER 2014; 23:63-9. [PMID: 24635719 DOI: 10.3109/13645706.2014.893891] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Transanal endoscopic microsurgery has become a very useful surgical tool for the management of selected cases of rectal cancer. However, the considerably high local recurrence rates led to the introduction of neoadjuvant therapies including radiation with or without chemotherapy. This treatment strategy may result in significant rates of tumor regression allowing the procedure to be offered to a significant proportion of cases. On the other hand, neoadjuvant chemoradiation (CRT) may also determine wound-healing difficulties with significant postoperative pain. In addition, salvage total mesorectal excision in the case of local recurrence may also be a challenging task. Finally, accurate selection criteria for this minimally invasive approach are still lacking and may be influenced by baseline staging, post-treatment staging and final pathology information. Ultimately, selection of patients for this treatment modality remains a significant challenge for the colorectal surgeon who should be aware of the pitfalls of this procedure in the setting of neoadjuvant CRT.
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Affiliation(s)
- Angelita Habr-Gama
- Angelita & Joaquim Gama Institute/Hospital Alemão Oswaldo Cruz , São Paulo , Brazil
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20
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Hompes R, McDonald R, Buskens C, Lindsey I, Armitage N, Hill J, Scott A, Mortensen NJ, Cunningham C. Completion surgery following transanal endoscopic microsurgery: assessment of quality and short- and long-term outcome. Colorectal Dis 2014; 15:e576-81. [PMID: 24635913 DOI: 10.1111/codi.12381] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Accepted: 04/21/2013] [Indexed: 12/16/2022]
Abstract
AIM Patients with unfavourable pathology after transanal endoscopic microsurgery (TEM) should be offered completion surgery (CS) if appropriate. The aim of this retrospective cohort study was to assess the short-term outcome and long-term oncological results of CS and identify factors compromising the quality of resection specimens. METHOD Data were retrieved and analysed on patients who underwent CS from a comprehensive national TEM database (1992-2008) and the institutional prospective database from the Oxford University Hospitals (2008-2011). RESULTS There were 36 patients eligible for analysis. Postoperative complications occurred in 19 and were minor (grade I-II) in 13 and major (grade III-V) in six patients. The quality of the resected specimen was graded as good in 23 (64%), moderate in six (16.6%) and poor in seven (19.4%). Full-thickness excision by TEM (P = 0.03), an interval to CS greater than 7 weeks (P = 0.05) and distally located lesions (P = 0.04) were associated with increased risk for an inferior surgical specimen. Overall survival after CS was 91% at 1 year and 83% at 5 years. Patients with a 'good' TME specimen had significantly improved disease-free survival compared with patients with an 'inferior' specimen (100 vs 51%, P = 0.001). CONCLUSION Patients having full-thickness TEM excision, distally placed lesions and a long interval (> 7 weeks) to CS were likely to have an inferior TME specimen. The results confirm that CS after TEM does not negatively influence local recurrence and survival, but the reduced disease-free survival in patients with an inferior specimen is of concern.
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Affiliation(s)
- R Hompes
- Department of Colorectal Surgery, Oxford University Hospitals, Oxford, UK
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21
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Tricks to decrease the suture line dehiscence rate during endoluminal loco-regional resection (ELRR) by transanal endoscopic microsurgery (TEM). Surg Endosc 2014; 29:1045-50. [PMID: 25154889 DOI: 10.1007/s00464-014-3776-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 07/23/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND ELRR by TEM is a valid alternative to TME in selected patients with early low rectal cancer, with similar long-term oncological results and better Quality of Life. The authors' policy is to close the residual defect, with possibly a higher risk of dehiscence from tension on the suture line. Aim is to evaluate if a modified technique may reduce the risk of dehiscence. METHODS The latest series of 50 patients undergoing ELRR was analyzed and patients were divided in two consecutive groups. In Group A, 25 patients underwent ELRR by TEM with the authors' standard technique. In Group B, a subsequent series of 25 patients also underwent ELRR, but the perirectal residual cavity was filled with a hemostatic agent prior to rectal wall closure. After suture completion, the rectal ampulla was stuffed with gauzes to avoid the formation of a perirectal fluid collection, by enlarging the volume of the residual rectal ampulla. A transanal Foley catheter was positioned for gas evacuation. RESULTS There were no significant differences in mean tumor distance from the anal verge, mean lesion diameter, mean operative time, and pathological staging between the two groups. Neoadjuvant radio-chemotherapy (n-RCT) in Groups A and B was performed in 6 and 2 patients, respectively. Suture line dehiscence in Group A occurred in 3 patients (12%) and in group B it was nil. In patients who experienced a dehiscence, mean lesion diameter was 6.3 cm (range 6-7). None of these patients had undergone n-RCT. CONCLUSION After ELRR by TEM, suture line dehiscence is presumably related to the wider size of the residual cavity. Obliteration of the residual perirectal space with hemostatic agent and by gauzes' introduction in the rectal ampulla may reduce the risk of postoperative perirectal abscess and thus reduce the suture line dehiscence rate.
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22
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Hompes R, Rauh SM, Ris F, Tuynman JB, Mortensen NJ. Robotic transanal minimally invasive surgery for local excision of rectal neoplasms. Br J Surg 2014; 101:578-81. [PMID: 24633833 DOI: 10.1002/bjs.9454] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Robotic transanal minimally invasive surgery (TAMIS) may be an option for rectum-preserving excision of neoplasms. Recent cadaveric studies showed improved vision, control and manoeuvrability compared with use of laparoscopic instruments. This study reports the clinical application. METHODS Consecutive patients eligible for transanal endoscopic microsurgery (TEM) or TAMIS in three participating centres were operated on using a robotic platform and transanal glove port. Patient demographics, lesion characteristics, perioperative data, complications and follow-up of all patients were recorded prospectively. RESULTS Sixteen patients underwent robotic TAMIS for rectal lesions with a median (range) distance from the anal verge of 8 (range 3-10) cm. The median size of the resected specimen was 5·3 (0·5-21) cm(2) . The median docking time and duration of operation were 36 (18-75) and 108 (40-180) min respectively. One conversion to regular (non-robotic) TAMIS was needed owing to difficulties accessing the rectum. Glove puncture necessitated replacement in four procedures, an unstable pneumorectum arose during one operation and one patient developed a pneumoperitoneum. One patient required catheterization for urinary retention. The median hospital stay was 1·3 (0-4) days. The additional cost of the robotic approach was approximately €1000 per procedure (excluding the capital expenditure on the robotic system and its maintenance). CONCLUSION Robotic TAMIS is feasible in patients with rectal lesions. Potential advantages over TEM and non-robotic TAMIS will need to be balanced against the cost of the robotic system.
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Affiliation(s)
- R Hompes
- Department of Colorectal Surgery, Churchill Hospital, Oxford University Hospitals, Oxford, UK
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23
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Transanal endoscopic microsurgery with 3-D (TEM) or high-definition 2-D transanal endoscopic operation (TEO) for rectal tumors. A prospective, randomized clinical trial. Int J Colorectal Dis 2014; 29:605-10. [PMID: 24676506 DOI: 10.1007/s00384-014-1849-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/09/2014] [Indexed: 02/04/2023]
Abstract
PURPOSE Transanal endoscopic microsurgery (TEM) is a three-dimensional viewing endoscopic system procedure which provides access to rectal tumors through a rectoscope. Two-dimensional transanal endoscopic operation (TEO), with the introduction of high-definition vision, achieves results that are comparable to those of the classical TEM. The main aim of the study was to compare the effectiveness of TEO and TEM systems in a prospective, randomized clinical trial. STUDY POPULATION patients meeting inclusion criteria for diagnosis of rectal tumors with curative intent. Sample size, 36 patients. Patients were randomized to receive one of the two procedures. Study variables recorded were the following: preoperative data (time taken to assemble equipment, surgical time, quality of pneumorectum), postoperative morbidity and mortality, pathology study of the tumors, and economic analysis. RESULTS Thirty-six patients were analyzed according to intention to treat. Two patients were excluded. The final per-protocol analysis was 34 patients. There were no significant differences in the preoperative or operative variables, quality of pneumorectum, postoperative variables, or pathology results. A trend toward benefit was observed in favor of TEO in time required for assembly, surgical suture time, and total surgical time though the differences were not statistically significant. Statistically significant differences were found in terms of the total cost of the procedure, with mean costs of 2,031 <euro> ± 440 for TEO and 2,603 <euro> ± 507 for TEM (95% CI 218.15-926.486 <euro>, p = 0.003). CONCLUSION No technical or clinical differences were observed between the results obtained with the two systems except lower cost with TEO.
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Heidary B, Phang TP, Raval MJ, Brown CJ. Transanal endoscopic microsurgery: a review. Can J Surg 2014; 57:127-38. [PMID: 24666451 PMCID: PMC3968206 DOI: 10.1503/cjs.022412] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2013] [Indexed: 12/18/2022] Open
Abstract
Rectal adenomas and cancers occur frequently. Small adenomas can be removed colonoscopically, whereas larger polyps are removed via conventional transanal excision. Owing to technical difficulties, adenomas of the mid- and upper rectum require radical resection. Transanal endoscopic microsurgery (TEM) was first designed as an alternative treatment for these lesions. However, since its development TEM has been also used for a variety of rectal lesions, including carcinoids, rectal prolapse and diverticula, early stage carcinomas and palliative resection of rectal cancers. The objective of this review is to describe the current status of TEM in the treatment of rectal lesions. Since the 1980s, TEM has advanced substantially. With low recurrence rates, it is the method of choice for resection of endoscopically unresectable adenomas. Some studies have shown benefits to its use in treating early T1 rectal cancers compared with radical surgery in select patients. However, for more advanced rectal cancers TEM should be considered palliative or experimental. This technique has also been shown to be safe for the treatment of other uncommon rectal tumours, such as carcinoids. Transanal endoscopic microsurgery may allow for new strategies in the treatment of rectal pathology where technical limitations of transanal techniques have limited endoluminal surgical innovations.
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Affiliation(s)
- Behrouz Heidary
- From the Department of Surgery, St. Paul’s Hospital, University of British Columbia, Vancouver, BC
| | - Terry P. Phang
- From the Department of Surgery, St. Paul’s Hospital, University of British Columbia, Vancouver, BC
| | - Manoj J. Raval
- From the Department of Surgery, St. Paul’s Hospital, University of British Columbia, Vancouver, BC
| | - Carl J. Brown
- From the Department of Surgery, St. Paul’s Hospital, University of British Columbia, Vancouver, BC
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25
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Gavilanes Calvo C, Manuel Palazuelos JC, Alonso Martín J, Castillo Diego J, Martín Parra I, Gómez Ruiz M, Gómez Fleitas M. [Transanal endoscopic operations for rectal tumours]. Cir Esp 2013; 92:38-43. [PMID: 24169437 DOI: 10.1016/j.ciresp.2013.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Revised: 02/04/2013] [Accepted: 02/05/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND Transanal endoscopic operation (TEO) may be the technique of choice for the treatment of rectal lesions, both benign and selected malignant lesions, with similar survival rates to conventional surgery but with lower morbidity. METHODS In this article we present a series of 70 patients operated on with this procedure (TEO) in our center. The indications were benign rectal lesions and malignant lesions at early stages (T1) 86%. The surgical procedure was performed with the the transanal endoscopic operation platform (TEO; Karl Storz, Tüttlingen, Germany) and ultrasonic scalpel (Harmonic scalpel, Ethicon Endo-surgery,…). RESULTS The indication in 43 patients was a benign lesion (adenoma), in the other 27 the diagnosis was adenocarcinoma. After the resection, 61% of the series had a malignant lesion in the pathology report: 13 patients of the 43 with a benign lesion initially had a malignant lesion in the pathology report. Postoperative morbidity was 36%, Clavien III (5,7%). 3 patients (4%) needed emergency surgery. All of the benign lesions were completely excised, but 7 malignant lesions had resection margin involvement The median follow-up time was 26,4 months (range, 1-71 months), the overall recurrence for benign tumors was 9%, 8% for malignant pT1 and 12,5% for malignant pT2. Early salvage surgery was performed on 8 patients. CONCLUSIONS TEO allows us to excise benign rectal lesions that could not be excised with a conventional approach (endoscopic or transanal resection) with a low morbidity rate. TEO can be used for malignant rectal tumors in early stages (pT1) with pathological confirmation.
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Affiliation(s)
- Carlos Gavilanes Calvo
- Servicio de Cirugía General, Hospital Universitario Marqués de Valdecilla, Santander, España
| | | | - Joaquín Alonso Martín
- Unidad Colorrectal, Servicio de Cirugía General, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - Julio Castillo Diego
- Unidad Colorrectal, Servicio de Cirugía General, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - Ignacio Martín Parra
- Unidad Colorrectal, Servicio de Cirugía General, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - Marcos Gómez Ruiz
- Unidad Colorrectal, Servicio de Cirugía General, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - Manuel Gómez Fleitas
- Unidad Colorrectal, Servicio de Cirugía General, Hospital Universitario Marqués de Valdecilla, Santander, España; Cátedra de Cirugía General, Universidad de Cantabria, Santander, España
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26
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Abstract
Rectal resection with total mesorectal excision is the standard treatment for rectal cancers. Local excision represents an alternative with less post-operative mortality and morbidity and preservation of intestinal and bladder function. However, local excision cannot provide adequate nodal staging. Presently, endorectal ultrasound and magnetic resonance imaging are used to select the appropriate patients for local excision, those with limited T1 rectal tumors. There is general agreement that the ideal tumors for local excision are less or equal to 3 cm in diameter, superficial (usTis and/or usT1N0), infra-peritoneal, located below the middle rectal valve, and involving no more than 40% of the rectal circumference. Transanal tumor excision is suitable for distal tumors and transanal endoscopic microsurgery for mid and upper lesions. The principles of adequate resection margin, non-fragmentation, and full-thickness excision are similar to those for any cancer resection. Unfavorable pathologic criteria, as assessed on the fixed rectal specimen, include depth of tumor invasion (submucosal [T1sm3] or muscular [T2]), positive resection margins, vascular and/or lymphatic invasion, and poor differentiation. Further radical surgery is required in case of unfavorable criteria. Simple surveillance may be advised for superficial tumors (T1sm1) without any unfavorable criteria. Management of T1sm2 tumors without any unfavorable criteria should be discussed on a case-by-case basis.
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Affiliation(s)
- C Lartigau
- Service de chirurgie digestive, CHU de Caen, avenue de la Côte-de-Nacre, 14033 Caen cedex, France
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27
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Coco C, Rizzo G, Mattana C, Gambacorta MA, Verbo A, Barbaro B, Vecchio FM, Pafundi DP, Mastromarino MG, Valentini V. Transanal endoscopic microsurgery after neoadjuvant radiochemotherapy for locally advanced extraperitoneal rectal cancer: short-term morbidity and functional outcome. Surg Endosc 2013; 27:2860-7. [PMID: 23404153 DOI: 10.1007/s00464-013-2842-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Accepted: 01/21/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Transanal endoscopic microsurgery (TEM) after radiochemotherapy (RCT) has been reported in selected cases of locally advanced rectal cancer as an alternative to traditional radical resection with total mesorectal excision with a curative intent or as diagnostic tool to confirm a pathological complete response of the primary tumor. No study has evaluated functional outcome after TEM in preoperatively irradiated patients. METHODS This study was designed to evaluate short-term morbidity (according to Clavien's classifications) and establish (by a questionnaire) continence and evacuative function after RCT and TEM, at 1 year from surgery, analyzing the impact of RCT on postoperative outcomes. Patients with locally advanced rectal cancer treated by RCT and TEM (group 1) or with early T1 or adenomas treated only by TEM (group 2) entered this cohort comparative study. RESULTS Twenty-two patients entered the study as group 1 and 25 as group 2. No postoperative mortality occurred. The morbidity rate was 36.4 % in group 1 vs. 16 % in group 2 (p = 0.114). The rate of suture dehiscence was 22.7 % in group 1 vs. 4 % in group 2 (p = 0.068). No grade III complications, reoperation, or hospital readmission within 30 days was recorded in either group. One year after surgery, continence and evacuative scores in group 1 were 1.05 ± 1.25 and 24.72 ± 2.79, respectively, which were similar to group 2 (p = 0.081 and 0.288, respectively). CONCLUSIONS TEM after RCT in selected rectal cancer patients has an acceptable morbidity and functional results at 1 year from surgery. Preoperative irradiation could increase postoperative short-term morbidity, but it does not seem to influence evacuative or sphincter function after 1 year from surgery.
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Affiliation(s)
- C Coco
- Department of Surgical Sciences, Catholic University of Sacred Heart, Rome, Italy
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29
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Abstract
Endoscopic submucosal dissection (ESD) is widely used in Japan as a minimally invasive treatment for early gastric cancer. The application of ESD has expanded to the esophagus and colorectum. The indication criteria for endoscopic resection (ER) are established for each organ in Japan. Additional treatment, including surgery with lymph node dissection, is recommended when pathological examinations of resected specimens do not meet the criteria. Repeat ER for locally recurrent gastrointestinal tumors may be difficult because of submucosal fibrosis, and surgical resection is required in these cases. However, ESD enables complete resection in 82%-100% of locally recurrent tumors. Transanal endoscopic microsurgery (TEM) is a well-developed surgical procedure for the local excision of rectal tumors. ESD may be superior to TEM alone for superficial rectal tumors. Perforation is a major complication of ESD, and it is traditionally treated using salvage laparotomy. However, immediate endoscopic closure followed by adequate intensive treatment may avoid the need for surgical treatment for perforations that occur during ESD. A second primary tumor in the remnant stomach after gastrectomy or a tumor in the reconstructed organ after esophageal resection has traditionally required surgical treatment because of the technical difficulty of ER. However, ESD enables complete resection in 74%-92% of these lesions. Trials of a combination of ESD and laparoscopic surgery for the resection of gastric submucosal tumors or the performance of sentinel lymph node biopsy after ESD have been reported, but the latter procedure requires a careful evaluation of its clinical feasibility.
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Affiliation(s)
- Michio Asano
- Michio Asano, Endoscopic Center, Colo-proctological Institute, Matsuda Hospital, Hamamatsu, Shizuoka 432-8061, Japan
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30
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Lezoche E, Baldarelli M, Lezoche G, Paganini AM, Gesuita R, Guerrieri M. Randomized clinical trial of endoluminal locoregional resection versus laparoscopic total mesorectal excision for T2 rectal cancer after neoadjuvant therapy. Br J Surg 2012; 99:1211-8. [PMID: 22864880 DOI: 10.1002/bjs.8821] [Citation(s) in RCA: 217] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND In selected patients with early low rectal cancer, locoregional excision combined with neoadjuvant therapy may be an alternative treatment option to total mesorectal excision (TME). METHODS This prospective randomized trial compared endoluminal locoregional resection (ELRR) by transanal endoscopic microsurgery versus laparoscopic TME in the treatment of patients with small non-advanced low rectal cancer. Patients with rectal cancer staged clinically as cT2 N0 M0, histological grade G1-2, with a tumour less than 3 cm in diameter, within 6 cm of the anal verge, were randomized to ELRR or TME. All patients underwent long-course neoadjuvant chemoradiotherapy. RESULTS Fifty patients in each group were analysed. Overall tumour downstaging and downsizing rates after neoadjuvant chemoradiotherapy were 51 and 26 per cent respectively, and were similar in both groups. All patients had R0 resection with tumour-free resection margins. At long-term follow-up, local recurrence had developed in four patients (8 per cent) after ELRR and three (6 per cent) after TME. Distant metastases were observed in two patients (4 per cent) in each group. There was no statistically significant difference in disease-free survival (P = 0·686). CONCLUSION In selected patients, ELRR had similar oncological results to TME. Unique Protocol ID: URBINO-LEZ-1995; registration number: NCT01609504 (http://www.clinicaltrials.gov).
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Affiliation(s)
- E Lezoche
- Department of General Surgery, Surgical Specialities and Organ Transplantation Paride Stefanini at University of Rome, Rome, Italy
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Abstract
The treatment of rectal cancer largely depends on disease stage at diagnosis, based on which patients can be classified as low, intermediate, or high risk. Prognostic and predictive markers, specific to each risk category, can be applied for optimal risk classification and subsequent treatment allocation. These markers are either histopathological, determined with imaging, or have a biomolecular background. This review provides an overview of the current status of treatment options and the use of prognostic and predictive markers in each risk category. An effort was made to identify those markers that are currently lacking in, but have the potential to improve, the clinical decision process by discussing the data from recent studies aimed at the development of new prognostic and predictive markers. At this moment, none of the markers studied has been proven to be of significant, independent value, justifying implementation in daily clinical practice. However, recent developments in imaging techniques and biomolecular research do show great potential.
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Single-incision laparoscopic surgery used to perform transanal endoscopic microsurgery (SILSTEM) for T1 rectal cancer under spinal anesthesia: report of a case. Surg Today 2012; 43:325-8. [PMID: 22706723 DOI: 10.1007/s00595-012-0227-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Accepted: 11/23/2011] [Indexed: 10/28/2022]
Abstract
Transanal endoscopic surgery has slowly gained widespread acceptance among colorectal surgeons, despite the need for specific training and the high costs of specialized instrumentation. At the other extreme, some laparoscopic surgeons recommend single port access surgery using a single-incision laparoscopic surgery port. Single-incision laparoscopic surgery was applied to perform transanal endoscopic microsurgery in a patient with T1 rectal cancer under spinal anesthesia. The patient was a 74-year-old man who presented with a 2-cm elevated lesion in the right anterior portion of the rectum. Ordinary laparoscopic instruments were used to perform submucosal resection. The tumor was completely excised from the rectal wall with the use of an ultrasonic surgical scissors. The patient recovered uneventfully and was discharged 4 days after the operation. There was no fecal incontinence or soiling during the postoperative follow-up. Colonoscopy at 4 months after the operation showed no recurrence of either adenocarcinoma or adenoma.
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Abstract
Transanal endoscopic video-assisted excision of benign and malignant rectal lesions with pneumorectal distension appears to optimize the visual field and avert several of the pitfalls commonly associated with transanal endoscopic microsurgery. Background: Transanal endoscopic microsurgery is a safe and efficacious surgical approach for local excision of benign adenomas and early-stage rectal cancer. However, utilization of the technique has been limited due to the unavailability of high-priced specialized instrumentation at many institutions and the technically demanding training required. To avoid these obstacles, we have explored an alternative approach called Transanal Endoscopic Video-Assisted excision, which combines the merits of single-port access and local transanal excision. Methods: A disposable single-incision port is inserted into the anal canal for transanal access. The port contains 3 cannulae for introducing instrumentation into the rectal lumen, and a supplementary cannula for carbon dioxide insufflation. Pneumorectum results in rectal distention and optimizes the visual field during the procedure. Standard laparoscopic instrumentation is utilized for visualization and transanal excision of rectal pathologies. Conclusions: Transanal endoscopic video-assisted excision is an innovative approach to local excision of benign and malignant rectal lesions. The approach averts several of the pitfalls commonly experienced with transanal endoscopic microsurgery. Continued investigation and development of this novel modality will be important in establishing its role in minimally invasive surgery.
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Affiliation(s)
- Madhu Ragupathi
- Division of Minimally Invasive Colon and Rectal Surgery, Department of Surgery, University of Texas Medical School at Houston, Houston, Texas, USA
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34
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Ferrer Márquez M, Reina Duarte Á, Rubio Gil F, Belda Lozano R, Álvarez García A, Blesa Sierra I. Indicaciones y resultados de la microcirugía endoscópica transanal en el tratamiento de los tumores rectales en una serie consecutiva de 52 pacientes. Cir Esp 2011; 89:505-10. [DOI: 10.1016/j.ciresp.2011.04.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Revised: 03/31/2011] [Accepted: 04/13/2011] [Indexed: 01/17/2023]
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Abstract
Laparoscopy has emerged as a useful tool in the surgical treatment of diseases of the colon and rectum. Specifically, in the application of colon cancer, a laparoscopic-assisted approach offers short-term benefits to patients while maintaining a long-term oncologic outcome. Hand-assisted laparoscopic surgery may help decrease operative times while preserving the benefits of laparoscopy. The literature on the use of laparoscopy for rectal cancer is still in its early stages. Limited data suggest short-term benefits without compromising oncologic outcome; however, data from large multicenter trials will clarify the role of laparoscopy in the treatment of rectal cancer. Robotic proctectomy is a novel technique that may offer considerable advantage and overcome some limitations laparoscopy creates while working in the confines of the pelvis. The improved magnification and visualization offered with the robot may also assist in preserving bladder and sexual function. Transanal endoscopic microsurgery (TEM) for the treatment of T1 rectal cancers with low-risk features appears to be safe. However, TEM has a significantly higher recurrence rate when used to treat invasive cancer. Endoluminal techniques and equipment are under development and could offer more minimally invasive approaches to the treatment of colon and rectal cancer. Credentialing and training of surgeons and teams involved in the use of laparoscopy is important prior to making these techniques ubiquitous.
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Affiliation(s)
- Govind Nandakumar
- Section of Colon and Rectal Surgery, Washington University School of Medicine, St. Louis, Missouri
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36
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de Graaf EJR, Burger JWA, van Ijsseldijk ALA, Tetteroo GWM, Dawson I, Hop WCJ. Transanal endoscopic microsurgery is superior to transanal excision of rectal adenomas. Colorectal Dis 2011; 13:762-7. [PMID: 20345967 DOI: 10.1111/j.1463-1318.2010.02269.x] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Comparison of transanal excision (TE) and transanal endoscopic microsurgery (TEM) of rectal adenomas (RA) has rarely been performed. METHOD From 1990 to 2007, the results of TE (43 RA) and TEM (216 RA) were compared. Rectal adenomas were matched for diameter and distance from the anal verge. RESULTS Operation time was 47.5 min for TE and 35 min for TEM (P < 0.001). Morbidity was 10% after TE and 5.3% after TEM (P < 0.001). Negative resection margins were observed in 50% after TE and 88% after TEM (P < 0.001). Fragmentation of the excised specimen was observed in 23.8% after TE and 1.4% after TEM (P < 0.001). In cases of fragmentation, positive resection margins were observed more frequently. Recurrence was 28.7% after TE and 6.1% after TEM (P < 0.001). After TE, RA with a negative resection margin had a local recurrence rate of 0%, compared with 59.6% with a positive margin (P < 0.001), and after TEM these rates were 3.2 and 7.7% (P = 0.3), respectively. CONCLUSION Transanal endoscopic microsurgery is superior to transanal excision of RA.
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Affiliation(s)
- E J R de Graaf
- Department of General Surgery, IJsselland Hospital, Capelle aan den IJssel, The Netherlands.
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Barker JA, Hill J. Incidence, treatment and outcome of rectal stenosis following transanal endoscopic microsurgery. Tech Coloproctol 2011; 15:281-4. [PMID: 21710207 DOI: 10.1007/s10151-011-0703-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2010] [Accepted: 06/04/2011] [Indexed: 12/16/2022]
Abstract
BACKGROUND As an alternative to more radical abdominal surgery, transanal endoscopic microsurgery (TEM) offers a minimally invasive solution for the excision of certain rectal polyps and early-stage rectal tumours. The patient benefits of TEM as compared to radical abdominal surgery are clear; nevertheless, some drawback is possible. The aim of our study was to determine the risk factors, treatment and outcomes of rectal stenosis following TEM. METHODS We analysed a series of 354 consecutive patients who underwent TEM for benign or malignant rectal tumours between 1997 and 2009. We recorded the maximum histological diameter of the lesion, and whether the lesion was circumferential. Rectal stenosis was defined as a rectal narrowing not allowing passage of a 12 mm sigmoidoscope. RESULTS Histological results with a measured specimen diameter were available in 304 of the 354 cases. There were 11 stenoses in total (3.6%), 7 stenoses due to 9 circumferential lesions (78%) and 4 due to lesions with a maximum diameter ≥ 5 cm (3.2%). Two patients presented as emergencies, and the other 9 patients reported symptoms of increased stool frequency at follow-up. Three of the stenoses were associated with recurrent disease. All stenoses were treated by a combination of endoscopic/radiological balloon dilatation or surgically with Hegar's dilators. A median of two procedures were required to treat stenoses until resolution of symptoms. CONCLUSIONS Rectal stenosis following TEM excision is rare. It is predictable in patients with circumferential lesions but is rare in patients with non-circumferential lesions with a maximum diameter ≥ 5 cm. It is effectively treated with surgical or balloon dilatation. Most patients require repeated treatments.
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Affiliation(s)
- J A Barker
- Department of Surgery, Central Manchester University Hospitals, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK
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Laparoscopic extraperitoneal rectal cancer surgery: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES). Surg Endosc 2011; 25:2423-40. [PMID: 21701921 DOI: 10.1007/s00464-011-1805-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2011] [Accepted: 05/24/2011] [Indexed: 12/25/2022]
Abstract
BACKGROUND The laparoscopic approach is increasingly applied in colorectal surgery. Although laparoscopic surgery in colon cancer has been proved to be safe and feasible with equivalent long-term oncological outcome compared to open surgery, safety and long-term oncological outcome of laparoscopic surgery for rectal cancer remain controversial. Laparoscopic rectal cancer surgery might be efficacious, but indications and limitations are not clearly defined. Therefore, the European Association for Endoscopic Surgery (EAES) has developed this clinical practice guideline. METHODS An international expert panel was invited to appraise the current literature and to develop evidence-based recommendations. The expert panel constituted for a consensus development conference in May 2010. Thereafter, the recommendations were presented at the annual congress of the EAES in Geneva in June 2010 in a plenary session. A second consensus process (Delphi process) of the recommendations with the explanatory text was necessary due to the changes after the consensus conference. RESULTS Laparoscopic surgery for extraperitoneal (mid- and low-) rectal cancer is feasible and widely accepted. The laparoscopic approach must offer the same quality of surgical specimen as in open surgery. Short-term outcomes such as bowel function, surgical-site infections, pain and hospital stay are slightly improved with the laparoscopic approach. Laparoscopic resection of rectal cancer is not inferior to the open in terms of disease-free survival, overall survival or local recurrence. Laparoscopic pelvic dissection may impair genitourinary and sexual function after rectal resection, like in open surgery. CONCLUSIONS Laparoscopic surgery for mid- and low-rectal cancer can be recommended under optimal conditions. Still, most level 1 evidence is for colon cancer surgery rather than rectal cancer. Upcoming results from large randomised trials are awaited to strengthen the evidence for improved short-term results and equal long-term results in comparison with the open approach.
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Moraes RDS, Losso GM, Matias JEF, Mailaender L, Telles JEQ, Malafaia O, Coelho JCU. Microcirurgia endoscópica transanal e tratamento adjuvante no câncer retal precoce. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2011. [DOI: 10.1590/s0102-67202011000200005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
RACIONAL: A excisão total do mesorreto é considerada a operação padrão no tratamento dos tumores do reto, apesar de não existir comprovação científica de que ela deva ser usada para todos os estádios da doença. Tem sido demonstrado que em casos escolhidos de tumores retais, resultados promissores podem ser conseguidos com tratamento local por microcirurgia endoscópica transanal. Tais tumores, denominados de câncer retal precoce, são tumores T1 - menores do que 4 cm -, bem diferenciados sem invasão angiolinfática pT1 Sm1. Como o risco de comprometimento linfonodal nesses tumores é de aproximadamente 3%, a ressecção local teria grande chance de ser curativa. OBJETIVO: Apresentar os resultados de uma série prospectiva não randômica de pacientes portadores de câncer retal precoce submetidos ao tratamento local por microcirurgia endoscópica transanal. MÉTODOS: Entre 2002 e 2010, 38 pacientes avaliados por protocolo pré-operatório como portadores câncer retal precoce foram submetidos à ressecção local endoscópica microcirúrgica de toda a parede retal com o tumor quando localizado entre 2 e 8 cm da linha pectínea. A avaliação pré-operatória consistiu de toque retal, retossigmoidoscopia rígida para macrobiópsias, enema opaco e/ou colonoscopia, ultrassonografia endoretal e abdominal, tomografia axial computadorizada do abdome, radiografia do tórax e dosagem sérica do CEA. Realizou-se seguimento pós-operatório endoscópico e ultrassonográfico endoretal a cada três meses nos dois primeiros anos, e a cada seis nos próximos três anos, além de dosagem do CEA a cada seis meses nesse mesmo período de cinco anos. Avaliou-se a recidiva tumoral, morbidade e mortalidade. RESULTADOS: Após avaliação anatomopatológica da lesão, 29 cânceres retais precoces foram categorizados como de baixo risco e nove sendo de alto. O seguimento na série variou de um a sete anos. Recidiva tumoral foi confirmada em dois casos dos 38 (5,26%), uma lesão considerada de alto e a outra de baixo risco. CONCLUSÃO: Microcirurgia endoscópica transanal, associada ou não à quimioradioterapia, pode ser considerada atualmente o padrão-ouro na ressecção retal local, apresentando resultados animadores em casos escolhidos de tumores retais precoces de baixo risco.
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Perez RO, Habr-Gama A, São Julião GP, Proscurshim I, Scanavini Neto A, Gama-Rodrigues J. Transanal endoscopic microsurgery for residual rectal cancer after neoadjuvant chemoradiation therapy is associated with significant immediate pain and hospital readmission rates. Dis Colon Rectum 2011; 54:545-51. [PMID: 21471754 DOI: 10.1007/dcr.0b013e3182083b84] [Citation(s) in RCA: 111] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Transanal endoscopic microsurgery may represent appropriate diagnostic and therapeutic procedure in selected patients with distal rectal cancer following neoadjuvant chemoradiation. Even though this procedure has been associated with low rates of postoperative complications, patients undergoing neoadjuvant chemoradiation seem to be at increased risk for suture line dehiscence. In this setting, we compared the clinical outcomes of patients undergoing transanal endoscopic microsurgery with and without neoadjuvant chemoradiation. METHODS Thirty-six consecutive patients were treated by transanal endoscopic microsurgery at a single institution. Twenty-three patients underwent local excision after neoadjuvant chemoradiation therapy for rectal adenocarcinoma, and 13 patients underwent local excision without any neoadjuvant treatment for benign and malignant rectal tumors. Chemoradiation therapy included 50.4 to 54 Gy and 5-fluorouracil-based chemotherapy. All patients underwent transanal endoscopic microsurgery with primary closure of the rectal defect. Complications (immediate and late) and readmission rates were compared between groups. RESULTS Overall, median hospital stay was 2 days. Immediate (30-d) complication rate was 44% for grade II/III complications. Patients undergoing neoadjuvant chemoradiation therapy were more likely to develop grade II/III immediate complications (56% vs 23%; P = .05). Overall, the 30-day readmission rate was 30%. Wound dehiscence was significantly more frequent among patients undergoing neoadjuvant chemoradiation therapy (70% vs 23%; P = .03). Patients undergoing neoadjuvant chemoradiation therapy were at significantly higher risk of requiring readmission (43% vs 7%; P = .02). CONCLUSION Transanal local excision with the use of endoscopic microsurgical approach may result in significant postoperative morbidity, wound dehiscence, and readmission rates, in particular, because of rectal pain secondary to wound dehiscence. In this setting, the benefits of this minimally invasive approach either for diagnostic or therapeutic purposes become significantly restricted to highly selected patients that can potentially avoid a major operation but will still face a significantly morbid and painful procedure.
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Efficiency and outcomes of harmonic device in transanal endoscopic microsurgery compared with monopolar scalpel. Surg Endosc 2011; 25:3209-13. [PMID: 21487854 DOI: 10.1007/s00464-011-1695-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2010] [Accepted: 03/21/2011] [Indexed: 02/06/2023]
Abstract
INTRODUCTION An important fact when facing new technologies is their cost for the Health Publishes. The purpose of this paper is to compare the costs of performing TEM with harmonic scalpel and classic monopolar scalpel and to analyze complications. METHODS Operation time, blood loss, and hospital stay were recorded to determine the cost of the TEM procedure. We also recorded early and late complications. Patients were divided in two groups: harmonic scalpel group (UC) and monopolar scalpel group (MS). RESULTS TEM for curative intention was used in 330 rectal tumors from January 1997 to January 2010. A total of 229 patients met the criteria for this study: UC group (n = 87) and MS group (n = 142). Patients from the UC group developed fewer complications (16%) than patients from the MS group (23%). The difference of mean stay between groups was 1.5 days (95% confidence interval, 0.7; 2.2 days; P < 0.001) in favor of the UC group. CONCLUSIONS Harmonic scalpel provides a safer, easier, and more precise surgical section through clean, bloodless, and better visualized operative field. The additional cost of UC was compensated with the decrease in the health resources (mainly hospital stay).
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Peng J, Chen W, Sheng W, Xu Y, Cai G, Huang D, Cai S. Oncological outcome of T1 rectal cancer undergoing standard resection and local excision. Colorectal Dis 2011; 13:e14-9. [PMID: 20860716 DOI: 10.1111/j.1463-1318.2010.02424.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
AIM We studied the outcome and prognostic factors for T1 rectal cancer patients undergoing standard resection or transanal excision. METHOD One hundred and twenty-four patients with T1 rectal cancer were included in the study, of whom 66 (53.2%) underwent standard resection and 58 (46.8%) underwent transanal excision. Survival analysis was performed to compare the outcome. RESULTS The 5-year local recurrence rate was 11.0% in the transanal excision group versus 1.6% in the standard resection group (P = 0.031) but the 5-year disease-free survival and overall survival rates were not significantly different between the two groups. Multivariate analysis suggested that a high tumour grade and perineural or lymphovascular invasion were independent risk factors for local recurrence and recurrence-free survival. For high-risk patients (with at least one of the above risk factors), the 5-year local recurrence and 10-year recurrence-free survival rates were 21.2% and 74.5%, versus 1.2% and 92.0% in low-risk patients (P = 0.00003 and P = 0.003). In patients undergoing transanal excision, none in the low-risk group had local recurrence during follow up, while 40% (6 of 15) of patients in the high-risk group developed local recurrence within 5 years after surgery. The 5-year local recurrence rate was 45.0%. CONCLUSION Transanal excision in T1 rectal cancer may result in a high rate of local failure for patients with a high-grade tumour, or perineural or lymphovascular invasion. Local excision should be avoided as a curative treatment in high-risk patients.
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Affiliation(s)
- J Peng
- Department of Colorectal Surgery, Cancer Hospital Fudan University, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
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Transanal endoscopic microsurgery (TEM) for rectal tumor: the first French single-center experience. ACTA ACUST UNITED AC 2011; 34:488-93. [PMID: 20621428 DOI: 10.1016/j.gcb.2009.07.040] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2009] [Accepted: 07/06/2009] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Transanal endoscopic microsurgery (TEM) allows complete local excision of rectal tumor, especially in the middle and upper part of the rectum, and provides an alternative to conventional surgery. This is a report of the first French single-center experience to assess the feasibility and postoperative results for rectal tumor excised by TEM. METHODS From October 2007 to December 2008, 27 patients underwent TEM for excision of either rectal adenoma (n=19) or carcinoma (n=8). The median distance from the anal verge was 60mm (range: 10-140). RESULTS TEM excision was performed in 26/27 patients. Intraoperative technical difficulties were recorded in two patients (peritoneal perforation and gas leakage, respectively). The morbidity rate was 22% (n=6), including two patients (7%) with major complications (delayed rectal bleeding) requiring readmission to hospital for both, and surgical hemostasis for one. R0 resection rates for adenoma and carcinoma were 84% and 75%, respectively. Immediate salvage surgery was performed in one patient because of a T2R1 carcinoma. At the time of the median follow-up at nine months (range: 2.5-17.5), no patient had experienced a recurrence. CONCLUSION TEM is a safe and effective procedure with low morbidity for local rectal tumor resection. It allows local excision of benign tumors, especially those that are inaccessible to conventional local surgery resection, thereby avoiding radical surgery. In cases of carcinoma, its role in local surgery remains controversial and is yet to be defined.
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Blackstock W, Russo SM, Suh WW, Cosman BC, Herman J, Mohiuddin M, Poggi MM, Regine WF, Saltz L, Small W, Zook J, Konski AA. ACR Appropriateness Criteria: local excision in early-stage rectal cancer. Curr Probl Cancer 2010; 34:193-200. [PMID: 20541057 DOI: 10.1016/j.currproblcancer.2010.04.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Low anterior resection or abdominoperineal resection is considered standard treatment for early rectal cancer. These procedures, however, carry a risk of morbidity and mortality that may not be warranted for early distal lesions, which may be treated with local excision. Emerging data has investigated the efficacy of local excision in patients with early stage rectal cancers. An expert panel designated by the American College of Radiology has reviewed supporting data, from a few prospective multi-institutional trials and a number of single-institution, retrospective reviews. The consensus recognizes the importance of accurate staging to identify patients who may be candidates for a local excision approach. Optimal candidates for local excision alone include small, low-lying T1 tumors, without adverse pathologic features. A number of procedures may be safely used including transanal, posterior trans-sphincteric, posterior proctotomy, transanal excision, or transanal microsurgery. It is important to note that none of these include lymph node evaluation, and depending on the risk of lymph node metastases, adjuvant radiation with or without chemotherapy may be warranted. Patients with positive margins or T3 lesions are at high risk of local recurrence and should be offered immediate APR or LAR. However, patients with high-risk T1 tumors, T2 tumors, or those who are not amenable to more radical surgery may benefit from adjuvant treatment. Data have also reported excellent local control rates for neoadjuvant radiation +/- chemotherapy followed by local excision in higher risk patients, but it is not yet clear if this approach reduces recurrence rates over surgery alone.
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Cahill RA, Mortensen NJ. Natural orifice transluminal endoscopic surgery and localized resection for colorectal neoplasia. World J Gastrointest Surg 2010; 2:199-202. [PMID: 21160874 PMCID: PMC2999237 DOI: 10.4240/wjgs.v2.i6.199] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2009] [Revised: 02/04/2010] [Accepted: 02/11/2010] [Indexed: 02/06/2023] Open
Abstract
Modern methods of surgical intervention have the potential to provide effective, definitive management of early stage colorectal neoplasia by truly minimally invasive means. Margin-free clearance of early colonic neoplasia from within the intestinal lumen can already now be effected by endoscopic submucosal dissection in the colon and transluminal endoscopic microsurgery (TEM) in the rectum. Natural orifice transluminal endoscopic surgery (NOTES) offers the potential for providing transmural, full thickness excision as TEM does but at sites in the colon proximal to the rectum. The next conceptual advance required to make this practice an effective reality lies in evolving surgical regional staging strategies to effectively partner localized resective approaches and allow their deployment as definitive curative therapy. As the most compelling modality for nodal status ascertainment in the absence of lymphatic basin excision for other malignant disease processes, it seems timely to reconsider sentinel node biopsy in cancer of the colon and rectum. Whether by this means or indeed any other, such an ability to confidently identify patients with node negative disease would allow nascent innovative techniques flourish as definitive management for confined (N0) T1 and T2 cancers and so allow the application of available advanced technology for clinical benefit. Conversely, the development of a specific clinical niche for NOTES (whether, as here, for full thickness localized colonic excision or nodal staging alone) would greatly benefit the evolution and incorporation of this surgical strategy into clinical care paradigms.
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Affiliation(s)
- Ronan A Cahill
- Ronan A Cahill, Neil J Mortensen, Department of Colorectal Surgery, John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DU, United Kingdom
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Tarantino I, Warschkow R, Linke GR, Zerz A. Minimally Invasive Approaches to Staging of Locally Excised Distal, Early Rectal Cancers. SEMINARS IN COLON AND RECTAL SURGERY 2010. [DOI: 10.1053/j.scrs.2010.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Ford SJ, Wheeler JMD, Borley NR. Factors influencing selection for a day-case or 23-h stay procedure in transanal endoscopic microsurgery. Br J Surg 2010; 97:410-4. [DOI: 10.1002/bjs.6857] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Abstract
Background
Transanal endoscopic microsurgery (TEMS) is an alternative to radical resection of the rectum for benign lesions and early rectal cancer. This study aimed to identify whether day-case TEMS is safe and which factors dictate patient suitability and length of stay (LOS).
Methods
Details of patients undergoing TEMS resection were retrieved from a tertiary referral prospective database.
Results
Of 96 patients, 46 (48 per cent) were day cases, 24 (25 per cent) had a 23-h stay and 26 (27 per cent) were inpatients. The frequency of day-case surgery increased significantly over the study interval (P = 0·050). Distance of the lesion from the anorectal junction, malignant potential and travel distance had no bearing on LOS. Older age (P = 0·004) and duration of surgery (P = 0·002) correlated significantly with increased LOS. Lesions covering one quadrant involved a significantly shorter stay than those covering two or more quadrants (P = 0·002). Maximum diameter (mean 5·7 cm) was strongly related to LOS (P = 0·009). Day-case and 23-h stay patients had a significantly higher proportion of lower-risk lesions (P = 0·001).
Conclusion
High-volume day-case TEMS appears safe, even when long travel distances are involved. With advances in practice and procedural safety, traditional risk factors may not be as important as currently thought.
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Affiliation(s)
- S J Ford
- Department of General Surgery, Cheltenham General Hospital, Cheltenham, UK
| | - J M D Wheeler
- Department of General Surgery, Cheltenham General Hospital, Cheltenham, UK
| | - N R Borley
- Department of General Surgery, Cheltenham General Hospital, Cheltenham, UK
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Tsai BM, Finne CO, Nordenstam JF, Christoforidis D, Madoff RD, Mellgren A. Transanal endoscopic microsurgery resection of rectal tumors: outcomes and recommendations. Dis Colon Rectum 2010; 53:16-23. [PMID: 20010345 DOI: 10.1007/dcr.0b013e3181bbd6ee] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Transanal endoscopic microsurgery provides a minimally invasive alternative to radical surgery for excision of benign and malignant rectal tumors. The purpose of this study was to review our experience with transanal endoscopic microsurgery to clarify its role in the treatment of different types of rectal pathology. METHODS A prospective database documented all patients undergoing transanal endoscopic microsurgery from October 1996 through June 2008. We analyzed patient and operative factors, complications, and tumor recurrence. For recurrence analysis, we excluded patients with fewer than 6 months of follow-up, previous excisions, known metastases at initial presentation, and those who underwent immediate radical resection following transanal endoscopic microsurgery. RESULTS Two hundred sixty-nine patients underwent transanal endoscopic microsurgery for benign (n = 158) and malignant (n = 111) tumors. Procedure-related complications (21%) included urinary retention (10.8%), fecal incontinence (4.1%), fever (3.8%), suture line dehiscence (1.5%), and bleeding (1.5%). Local recurrence rates for 121 benign and 83 malignant tumors were 5% for adenomas, 9.8% for T1 adenocarcinoma, 23.5% for T2 adenocarcinoma, 100% for T3 adenocarcinoma, and 0% for carcinoid tumors. All 6 (100%) recurrent adenomas were retreated with endoscopic techniques, and 8 of 17 (47%) recurrent adenocarcinomas underwent salvage procedures with curative intent. CONCLUSIONS Transanal endoscopic microsurgery is a safe and effective method for excision of benign and malignant rectal tumors. Transanal endoscopic microsurgery can be offered for (1) curative resection of benign tumors, carcinoid tumors, and select T1 adenocarcinomas, (2) histopathologic staging in indeterminate cases, and (3) palliative resection in patients medically unfit or unwilling to undergo radical resection.
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Affiliation(s)
- Ben M Tsai
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, Minnesota, USA
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Allaix ME, Arezzo A, Caldart M, Festa F, Morino M. Transanal endoscopic microsurgery for rectal neoplasms: experience of 300 consecutive cases. Dis Colon Rectum 2009; 52:1831-6. [PMID: 19966628 DOI: 10.1007/dcr.0b013e3181b14d2d] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE Abdominal resection for rectal neoplasms is associated with significant morbidity. Local excision with retractors can be proposed only for distal rectal lesions. With this retrospective review of our prospective series of transanal endoscopic microsurgery procedures, we wanted to verify the advantages of local treatment in terms of disease recurrence and complication rates. METHODS Indications for transanal endoscopic microsurgery were adenoma, early carcinoma, rectal ulcers, carcinoid tumors, gastrointestinal stromal tumors, and leiomyosarcoma apparently located in the extraperitoneal rectum. We analyzed operating time, morbidity and mortality rates, length of hospital stay, staging discrepancy, recurrence rate, and oncological outcome. RESULTS From January 1993 to January 2007, 300 patients underwent transanal endoscopic microsurgery at our institution. The mean operating time was 66 minutes. The peritoneum was inadvertently opened in 13 cases. The overall morbidity rate was 7.7%. The mean hospital stay was five days. Histology demonstrated cancer in 90 patients. At a mean follow-up of 60 months, the recurrence rate was zero in pT1, 24% in pT2, and 50% in pT3. The overall estimated five-year survival rate was 87%, and the disease-free survival rate was 82%. CONCLUSIONS Transanal endoscopic microsurgery is safe and effective in the treatment of adenoma and pT1 carcinoma; it carries a lower morbidity than conventional surgery and a recurrence rate comparable to that of conventional surgery.
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Affiliation(s)
- Marco Ettore Allaix
- Center for Minimally Invasive Surgery, Dipartimento di Discipline Medico Chirurgiche, Università di Torino, 10126 Torino, Italy
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