Transanal Endoscopic Microsurgery (TEM) for Rectal Neoplasms

Manuel Ferrer-Márquez, Ángel Reina-Duarte, Francisco Rubio-Gil, Ricardo Belda-Lozano, Antonio Álvarez-García

Departments of Colorectal Surgery, General Surgery, Torrecárdenas Hospital, Almería, Spain.

DOI: 10.4236/ss.2012.36057                

Abstract

Introduction: The abdominal approach for the treatment of rectal tumors is associated with a considerable rate of morbidity. Transanal Endoscopic Microsurgery (TEM) is an alternative technique that is less invasive than radical surgery, and therefore has a lower associated morbidity. Moreover, with proper patient selection, TEM presents oncological outcomes comparable to radical surgery. The aim of this study is to review our results obtained with TEM and discuss its role in the treatment of malignant rectal lesions. Patients and Methods: A prospective descriptive study from June 2008 until February 2011. The indications for TEM were: early rectal neoplastic lesions (T1N0M0) with good prognostic factors; neoplastic lesions in more advanced stages in selected patients (high surgical risk, refusal of radical surgery or stoma, and palliative intention). Results: Resection by TEM was performed on 19 patients. The average hospital stay was 5.7 days with an associated morbidity of 16.7%. R0 resection was 88.8%. During the follow-up of 15 (3 - 31) months, no recurrence has been shown. Conclusions: TEM is a safe and effective procedure for the treatment of selected early malignant rectal lesions and is associated with low morbidity. It is a therapeutic strategy based on a multidisciplinary team, careful patient selection, an audited surgical technique and a strict follow-up protocol.

Keywords

Transanal Endoscopic; Microsurgey; TEM; Rectal Neoplasms

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	W. L. Law and K. W. Chu, “Anterior Resection for Rectal Cancer with Mesorectal Excision: A Prospective Evaluation of 622 Patients,” Annals of Surgery, Vol. 240, No. 2, 2004, pp. 260-268. doi:10.1097/01.sla.0000133185.23514.32
[2]	W. E. Enker, N. Merchant, A. M. Cohen, N. M. Lanouette, C. Swallow, J. Guillem, et al., “Safety and Efficacy of Low Anterior Resection for Rectal Cancer: 681 Consecutive Cases from a Specialty Service,” Annals of Surgery, Vol. 230, No. 4, 1999, pp. 544-552. doi:10.1097/00000658-199910000-00010
[3]	C. A. Maurer, “Urinary and Sexual Function after Total Mesorectal Excision,” Recent Results Cancer Research, Vol. 165, 2005, pp. 196-204. doi:10.1007/3-540-27449-9_21
[4]	A. Chiappa, R. Biffi, E. Bertani, A. P. Zbar, U. Pace, C. Crotti, et al., “Surgical Outcomes after Total Mesorectal Excision for Rectal Cancer,” Journal of Surgical Oncology, Vol. 94, No. 3, 2006, pp. 182-193. doi:10.1002/jso.20518
[5]	A. G. Parks, “A Technique for the Removal of Large Villous Tumours in the Rectum,” Proceedings of the Royal Society of Medicine, Vol. 63, 1970, pp. 89-91.
[6]	R. Mittal, B. Perakath, S. Chase, M. R. Jesudason and S. Nayak, “Transanal Excision of Anorectal Lesions—A Single Centre Experience,” Trop Gastroenterology, Vol. 31, No. 1, 2010, pp. 65-68.
[7]	A. Mellgren, P. Sirivongs, D. A. Rothenberger, R. D. Madoff and J. García-Aguilar, “Is Local Excision Adequate Therapy for Early Rectal Cancer?” Diseases of the Colon & Rectum, Vol. 43, 2000, pp. 1064-1074. doi:10.1007/BF02236551
[8]	D. A. Rothenberger and J. Garcia-Aguilar, “Role of Local Excision in the Treatment of Rectal Cancer,” Seminars in Surgical Oncology, Vol. 19, 2000, pp. 367-375. doi:10.1002/ssu.7
[9]	G. Buess, R. Theiss, M. Gunther, F. Hutterer and H. Pilchmaier, “Endoscopic Surgery in the Rectum,” Endoscopy, Vol. 17, 1985, pp. 31-35 doi:10.1055/s-2007-1018451
[10]	X. Serra, J. Bombardó, L. Mora, M. Alcántara, I. Ayguavives and S. Navarros, “Microcirugía Endoscópica Transanal (TEM). Situación Actual y Expectativas de Futuro,” Cir Esp, Vol. 80, No. 3, 2006, pp. 123-132. doi:10.1016/S0009-739X(06)70940-X
[11]	X. Serra Aracil, C. Gómez Díaz, J. Bombardó Junca, L. Mora López, M. Alcántara Moral, I. Ayguavives Garnica, et al., “Surgical Excision of Retrorectal Tumour Using Transanal Endoscopic Microsurgery,” Colorectal Disease, Vol. 12, No. 6, 2010, pp. 594-595. doi:10.1111/j.1463-1318.2009.02126.x
[12]	P. Vavra, J. Dostalik, M. Vavrova, P. Gunkova, M. Pai, A. El-Gendi, et al., “Transanal Endoscopic Microsurgery: A Novel Technique for the Repair of Benign Rectovaginal Fistula,” Surgeon, Vol. 7, No. 2, 2009, pp. 126-127. doi:10.1016/S1479-666X(09)80031-0
[13]	R. Kikuchi, M. Takano, K. Takagi, N. Fujimoto, R. Nozaki and T. Fujiyoshi, “Management of Early Invasive Colorectal Cancer. Risk of Recurrence and Clinical Guidelines,” Diseases of the Colon & Rectum, Vol. 38, No. 12, 1995, pp. 1286-1295. doi:10.1007/BF02049154
[14]	R. C. Haggitt, R. E. Glotzbach, E. E. Soffer and L. D. Wruble, “Prognostic Factors in Colorectal Carcinomas Arising in Adenomas: Implications for Lesions Removed by Endoscopic Polypectomy,” Gastroenterology, Vol. 89, No. 2, 1985, pp. 328-336.
[15]	P. F. Middleton, L. M. Sutherland and G. J. Maddern, “Transanal Endoscopic Microsurgery: A Systematic Review,” Diseases of the Colon & Rectum, Vol. 48, No. 2, 2005, pp. 270-284. doi:10.1007/s10350-004-0804-8
[16]	D. Christoforidis, H. M. Cho, M. R. Dixon, A. F. Mellgren, R. D. Madoff and C. O. Finne, “Transanal Endoscopic Microsurgery versus Conventional Transanal Excision for Patients with Early Rectal Cancer,” Annals of Surgery, Vol. 249, No. 5, 2009, pp. 776-782. doi:10.1097/SLA.0b013e3181a3e54b
[17]	T. J. Saclarides, “TEM/Local Excision: Indications, Techniques, Outcomes, and the Future,” Journal of Surgical Oncology, Vol. 96, No. 8, 2007, pp. 644-650. doi:10.1002/jso.20922
[18]	A. R. Dias, C. S. Nahas, C. F. Marques, S. C. Nahas and I. Cecconello, “Transanal Endoscopic Microsurgery: Indications, Results and Controversies,” Techniques in Coloproctology, Vol. 13, No. 2, 2009, pp. 105-111. doi:10.1007/s10151-009-0466-6
[19]	I. D. Ayodeji, W. C. Hop, G. W. Tetteroo, H. J. Bonjer and E. J. de Graaf, “Ultracision Harmonic Scalpel and Multifunctional Tem400 Instrument Complement in Transanal Endoscopic Microsurgery: A Prospective Study,” Surgical Endoscopy, Vol. 18, No. 12, 2004, pp. 1730-1737. doi:10.1007/s00464-003-9331-2
[20]	J. M. Ramírez, V. Aguilella, D. Arribas and M. Martínez, “Transanal Full-Thickness Excision of Rectal Tumours: Should the Defect Be Sutured? A Randomized Controlled Study,” Colorectal Disease, Vol. 4, 2002, pp. 51-55. doi:10.1046/j.1463-1318.2002.00293.x
[21]	F. Bretagnol, A. Merrie, B. George, B. F. Warren and N. J. Mortensen, “Local Excision of Rectal Tumours by Transanal Endoscopic Microsurgery,” British Journal of Surgery, Vol. 94, No. 5, 2007, pp. 627-633. doi:10.1002/bjs.5678
[22]	J. A. Gavagan, M. H. Whiteford and L. L. Swanstrom, “Full-Thickness Intraperitoneal Excision by Transanal Endoscopic Microsurgery Does Not Increase Short-Term Complications,” American Journal of Surgery, Vol. 187, 2004, pp. 630-634. doi:10.1016/j.amjsurg.2004.01.004
[23]	A. Ramwell, J. Evans, M. Bignell, J. Mathias and J. Simson, “The Creation of a Peritoneal Defect in Transanal Endoscopic Microsurgery Does Not Increase Complications,” Colorectal Disease, Vol. 11, No. 9, 2009, pp. 964-966. doi:10.1111/j.1463-1318.2008.01719.x
[24]	M. E. Allaix, A. Arezzo, M. Caldart, F. Festa and M. Morino “Transanal Endoscopic Microsurgery for Rectal Neoplasms: Experience of 300 Consecutive Cases,” Diseases of the Colon & Rectum, Vol. 52, No. 11, 2009, pp. 1831-1836. doi:10.1007/DCR.0b013e3181b14d2d
[25]	B. M. Tsai, C. O. Finne, J. F. Nordenstam, D. Christoforidis, R. D. Madoff and A. Mellgren, “Transanal Endoscopic Microsurgery Resection of Rectal Tumors: Outcomes and Recommendations,” Diseases of the Colon & Rectum, Vol. 53, No. 1, 2010, pp. 16-23. doi:10.1007/DCR.0b013e3181bbd6ee
[26]	M. B. Bignell, A. Ramwell, J. R. Evans, N. Dastur and N. L. Simson, “Comlications of Tranasanal Endoscopic Microsurgery (TEMS, a Prospective Audit),” Colorectal Disease, Vol. 12, 2010, pp. e99-103.
[27]	M. Cantos, M. Bruna, M. J. García-Coret and F. L. Villalba, “Pneumomediantinum and Subcutaneus Emphysema Like Strange Complications after Transanal Endoscopic Microsurgery,” Revista Espanola de Enfermedades Digestivas, Vol. 101, No. 6, 2009, pp. 439-451.
[28]	J. S. Moore, P. A. Cataldo, T. Osler and N. H. Hyman, “Transanal Endoscopic Microsurgery Is More Effective than Traditional Transanal Excision for Resection of Rectal Masses,” Diseases of the Colon & Rectum, Vol. 51, No. 7, 2008, pp. 1026-1030. doi:10.1007/s10350-008-9337-x
[29]	M. Seman, F. Bretagnol, N. Guedj, L. Maggiori, M. Ferron and Y. Panis, “Transanal Endoscopic Microsurgery (TEM) for Rectal Tumor: The First French Single-Center Experience,” Gastroentérologie Clinique et Biologique, Vol. 34, No. 8-9, 2010, pp. 488-493. doi:10.1016/j.gcb.2009.07.040
[30]	N. D. Floyd and T. J. Saclarides, “Transanal Endoscopic Microsurgical Resection of pT1 Rectal Tumors,” Diseases of the Colon & Rectum, Vol. 49, No. 2, 2006, pp. 164-168. doi:10.1007/s10350-005-0269-4
[31]	N. Demartines, M. O. von Flue and F. H. Harder, “Transanal Endoscopic Microsurgical Excision of Rectal Tumors: Indications and Results,” World Journal of Surgery, Vol. 25, No. 7, 2001, pp. 870-875. doi:10.1007/s00268-001-0043-2
[32]	T. Nakagoe, H. Ishikawa, T. Sawai, T. Tsuji, K. Tanaka and H. Ayabe, “Surgical Technique and Outcome of Gasless Video Endoscopic Transanal Rectal Tumour Excision,” British Journal of Surgery, Vol. 89, No. 6, 2002, pp. 769-774. doi:10.1046/j.1365-2168.2002.02097.x
[33]	L. E. Smith, S. T. Ko, T. Saclarides, P. Caushaj, B. A. Orkin and K. S. Khanduja, “Transanal Endoscopic Microsurgery. Initial Registry Results,” Diseases of the Colon & Rectum, Vol. 39, Suppl. 10, 1996, pp. S79-S84. doi:10.1007/BF02053811
[34]	W. Lee, D. Lee, S. Choi and H. Chun, “Transanal Endoscopic Microsurgery and Radical Surgery for T1 and T2 Rectal Cancer,” Surgical Endoscopy, Vol. 17, No. 8, 2003, pp. 1283-1287. doi:10.1007/s00464-002-8814-x
[35]	C. Langer, P. Markus, T. Liersch, L. Füzesi and H. Becker, “UltraCision or High-Frequency Knife in Transanal Endoscopic Microsurgery (TEM)? Advantages of a New Procedure,” Surgical Endoscopy, Vol. 15, No. 5, 2001, pp. 513-517. doi:10.1007/s004640090015
[36]	G. Winde, H. Nottberg, R. Keller, K. W. Schmid and H. Bünte, “Surgical Cure for Early Rectal Carcinomas (T1). Transanal Endoscopic Microsurgery vs. Anterior Resection,” Diseases of the Colon & Rectum, Vol. 39, No. 9, 1996, pp. 969-976. doi:10.1007/BF02054683
[37]	P. Palma, K. Horisberger, A. Joos, S. Rothenhoefer, F. Willeke and S. Post, “Local Excision of Early Rectal Cancer: Is Transanal Endoscopic Microsurgery an Alternative to Radical Surgery?” Revista Espanola de Enfermedades Digestivas, Vol. 101, No. 3, 2009, pp. 172-178. doi:10.4321/S1130-01082009000300003
[38]	M. G. Tytherleigh, B. F. Warren and N. J. Mortensen, “Management of Early Rectal Cancer,” British Journal of Surgery, Vol. 95, No. 4, 2008, pp. 409-423. doi:10.1002/bjs.6127
[39]	S. D. Duek, N. Issa, D. D. Hershko and M. M. Krausz, “Outcome of Transanal Endoscopic Microsurgery and Adjuvant Radiotherapy in Patients with T2 Rectal Cancer,” Diseases of the Colon & Rectum, Vol. 51, No. 4, 2008, pp. 379-384. doi:10.1007/s10350-007-9164-5
[40]	E. Lezoche, M. Guerrieri, A. M. Paganini, M. Baldarelli, A. De Sanctis and G. Lezoche, “Long-Term Results in Patients with T2-3 N0 Distal Rectal Cancer Undergoing Radiotherapy before Transanal Endoscopic Microsurgery,” British Journal of Surgery, Vol. 92, No. 12, 2005, pp. 1546-1552. doi:10.1002/bjs.5178
[41]	M. Guerrieri, M. Baldarelli, L. Organetti, F. Grillo Ruggeri, G. Mantello and S. Bartolacci, “Transanal Endoscopic Microsurgery for the Treatment of Selected Patients with Distal Rectal Cancer: 15 Years Experience,” Surgical Endoscopy, Vol. 22, No. 9, 2008, pp. 2030-2035. doi:10.1007/s00464-008-9976-y