Fecal incontinence after transanal endoscopic microsurgery

Purpose

Transanal endoscopic microsurgery (TEM) procedure could potentially influence the development of fecal incontinence later in life. The aim of our study was to assess long-term functional outcomes after TEM and to determine possible variables related to incontinence.

Methods

Patients, enrolled in a prospectively collected TEM operation database, were interviewed using a postal questionnaire. The questionnaire consisted of EuroQol (EQ)-5D-5L quality of life questionnaire, Wexner fecal incontinence grading scale, and additional questions about other perianal operations and obstetric history for women. We divided patients into two groups: no or minor fecal incontinence (Wexner score of 2 and less) and non-minor incontinence (Wexner score of 3 or more).

Results

One hundred thirty-two patients were included in the study. Patients’ median follow-up time was 96 (12–168) months from their operation. Thirty-eight patients (28.8%) reported Wexner score of 3 or more, and they reported significantly worse quality of life in all tested life spheres. They were older at the time of the operation (63 (18–82) vs. 68 (50–89) years; p?=?0.004), underwent longer operations (50 (10–140) vs. 60 (15–210) min; p?=?0.017), and more often were operated for malignant lesions (17 (18.3%) vs. 14 (36.8%); p?=?0.040). Older age at the time of operation was an independent risk factor in multivariate model (OR 1.057, 95% CI 1.010–1.106; p?=?0.016).

Conclusions

Fecal incontinence after TEM is more common than thought previously, resulting in significantly impaired quality of life. Older age at the time of operation was an independent risk factor for developing significant fecal incontinence.

     

Functional results after transanal endoscopic microsurgery

PURPOSE: Compared with traditional operations, superior results after transanal endoscopic microsurgery (TEM) for rectal tumors have been demonstrated in terms of morbidity and mortality. However, no data were available on functional outcome after TEM. We, therefore, studied 42 patients who were undergoing TEM. METHODS: Patients were examined by anorectal manometry and participated in a standardized interview preoperatively and three months and one year after surgery. RESULTS: Anorectal function as assessed by manometry was impaired three months after surgery but improved again during the first postoperative year. In parallel, some patients complained of impaired continence or defecation disorders in the interview three months postoperatively. These functions improved during the first year after surgery, too. CONCLUSIONS: Correct comparison of our results with functional outcome after anterior rectal resection is impossible. We feel, however, that functional results after TEM are likely to be superior to those after anterior resection for rectal tumors.     

经肛门内镜微创手术的适应证与并发症

目的探讨经肛门内镜微创手术(transanal endoscopic microsurgery,TEM)的适应证和并发症。 方法回顾2011年5月至2014年5月在我院接受TEM治疗的135例直肠病变患者的临床资料,分析TEM在直肠病变治疗中的主要适应证和常见并发症。 结果本组135例患者均成功实施TEM,其中行直肠壁全层切除115例,黏膜下及肌层部分切除20例。平均手术时间(66.5±25.0)min(25～120 min),术中平均失血量(10.5±5.5)ml(3～50 ml)。术后病理学检查确诊：直肠腺瘤60例,直肠腺瘤癌变(pTis期)10例,早期直肠癌(pT1期)11例,进展期直肠癌(pT2期)10例,直肠癌经术前放化疗后病理完全缓解(ypT0期)2例,直肠类癌或类癌内镜电切后残灶24例,直肠胃肠道间质瘤5例,直肠平滑肌瘤1例,非肿瘤性息肉10例,直肠子宫内膜异位症2例。所有标本切缘均阴性。术中3例上段直肠前壁肿瘤行全层切除时切入腹腔,即刻行腔内缝合修补成功,未并发腹膜炎或盆腔感染。术后继发肛门出血2例,肺部、泌尿系感染和尿潴留各1例。并发症发生率为5.9%(8/135)。术后平均住院日(2.5±1.2)d(2～8 d)。术后平均随访15.5个月(6～36月),未发现肿瘤复发转移。 结论适合局部切除的直肠局限性肿瘤是TEM的主要适应证。严格选择没有淋巴结转移证据的直肠癌行TEM是安全有效的,已成为直肠局部切除术的首选方式。但目前的循证医学证据仍然有限,仍需要进一步研究论证。     

Anorectal functional outcome after repeated transanal endoscopic microsurgery

AIM:To evaluate the status of anorectal function after repeated transanal endoscopic microsurgery(TEM).METHODS:Twenty-one patients undergoing subtotal colectomy with ileorectal anastomosis were included.There were more than 5 large( 1 cm) polyps in the remaining rectum(range:6-20 cm from the anal edge).All patients,19 with villous adenomas and 2 with low-grade adenocarcinomas,underwent TEM with submucosal endoscopic excision at least twice between 2005 and 2011.Anorectal manometry and a questionnaire about incontinence were carried out at week 1 before operation,and at weeks 2 and 3 and 6 mo after the last operation.Anal resting pressure,maximum squeeze pressure,maximum tolerable volume(MTV) and rectoanal inhibitory reflexes(RAIR) were recorded.The integrity and thickness of the internal anal sphincter(IAS) and external anal sphincter(EAS) were also evaluated by endoanal ultrasonography.We determined the physical and mental health status with SF-36 score to assess the effect of multiple TEM on patient quality of life(QoL).RESULTS:All patients answered the questionnaire.Apart from negative RAIR in 4 patients,all of the anorectal manometric values in the 21 patients were normal before operation.Mean anal resting pressure decreased from 38 ± 5 mmHg to 19 ± 3 mmHg(38 ± 5 mmHg vs 19 ± 3 mmHg,P = 0.000) and MTV from 165 ± 19 mL to 60 ± 11 mL(165 ± 19 mL vs 60 ± 11 mL,P = 0.000) at month 3 after surgery.Anal resting pressure and MTV were 37 ± 5 mmHg(38 ± 5 mmHg vs 37 ± 5 mmHg,P = 0.057) and 159 ± 19 mL(165 ± 19 mL vs 159 ± 19 mL,P = 0.071),respectively,at month 6 after TEM.Maximal squeeze pressure decreased from 171 ± 19 mmHg to 62 ± 12 mmHg(171 ± 19 mmHg vs 62 ± 12 mmHg,P = 0.000) at week 2 after operation,and returned to normal values by postoperative month 3(171 ± 19 vs 166 ± 18,P = 0.051).RAIR were absent in 4 patients preoperatively and in 12(2 = 4.947,P = 0.026) patients at month 3 after surgery.RAIR was absent only in 5 patients at postoperative month 6(2 = 0.141,P = 0.707).Endosonography demonstrated that IAS disruption occurred in 8 patients,and 6 patients had temporary incontinence to flatus that was normalized by postoperative month 3.IAS thickness decreased from 1.9 ± 0.6 mm preoperatively to 1.3 ± 0.4 mm(1.9 ± 0.6 mm vs 1.3 ± 0.4 mm,P = 0.000) at postoperative month 3 and increased to 1.8 ± 0.5 mm(1.9 ± 0.6 mm vs 1.8 ± 0.5 mm,P = 0.239) at postoperative month 6.EAS thickness decreased from 3.7 ± 0.6 mm preoperatively to 3.5 ± 0.3 mm(3.7 ± 0.6 mm vs 3.5 ± 0.3 mm,P = 0.510) at month 3 and then increased to 3.6 ± 0.4 mm(3.7 ± 0.6 mm vs 3.6 ± 0.4 mm,P = 0.123) at month 6 after operation.Most patients had frequent stools per day and relatively high Wexner scores in a short time period.While actual fecal incontinence was exceptional,episodes of soiling were reported by 3 patients.With regard to the QoL,the physical and mental health status scores(SF-36) were 56.1 and 46.2(50 in the general population),respectively.CONCLUSION:The anorectal function after repeated TEM is preserved.Multiple TEM procedures are useful for resection of multi-polyps in the remaining rectum.     

经肛门直肠镜下的微创外科技术在直肠癌治疗中的应用

经肛门直肠镜下的微创外科(transanal endoscopic microsurgery,TEM)不仅是经肛切除直肠肿瘤的一种新方法,而且是一种可切除低位、中位和高位直肠的微创技术。和传统的经肛切除相比,TEM暴露的视野更大,复发率更低,并发症更少,具有更好的精准切除等优点。而且对于一些病例来说比开腹或腹腔镜和低位前切除更有效。在严格的病例选择和准确的术前分期的前提下,TEM是一种安全的、可重复的治疗低风险的T1期肿瘤技术。本文介绍了TEM在直肠癌治疗中的应用。     

Retrorectal tumors: excision by transanal endoscopic microsurgery.

Tumours within the retrorectal space are uncommon. Due to their rarity and diverse symptoms they are often misdiagnosed or mistreated.We report three cases of women presenting a variety of symptoms including increased rectal pain, recurrent abscesses/fistulas and constipation. Upon clinical examination and further investigations using MR scan, endorectal ultrasound and endoscopy, a retrorectal mass was suspected in all three cases.In order to achieve a complete excision of the tumor while minimizing trauma, transanal endoscopic microsurgery (TEM) was performed. The histology of the multicystic tumor revealed in all three cases a tailgut cyst. As far as we know this is the first report describing the use of TEM for surgical treatment of tumors located in the retrorectal space.     

Rectal adenocarcinoma and transanal endoscopic microsurgery. Diagnostic challenges,indications and short term results in 142 consecutive patients

PURPOSE: The objective of this study was to present short-term results of transanal endoscopic microsurgery (TEM) of rectal adenocarcinomas registered in a national database. METHODS: A Danish TEM group was established in 1995. The group organized a database for prospective and consecutive registration of all TEM procedures. The perioperative course of all rectal cancers treated with TEM and registered in this database is analysed. RESULTS: One hundred forty-two patients had TEM for rectal cancer. In 43%of the patients, the cancer diagnosis was not recognized before TEM. Eighty-five percent of all tumors were classified as benign based on macroscopic appearance; on digital rectal examination, 35% were benign, rectal ultrasound classified 15% as benign, and the preoperative biopsy was benign in 36%. Forty-three cancers (29%) were classified as low risk cancers. High ages were an indication for TEM in 22% and concurrent disease in 21%. Minor complications were encountered in 39 cases, major complications in 4 cases, and 1 patient died within 30 days. CONCLUSION: All larger rectal tumors should be evaluated for malignancy before treatment, even if TEM is the only surgical option, due to high age and comorbidiy. Rectal ultrasound appears to produce the fewest false negative results, but it should be combined with biopsies and clinical evaluation. Multiple biopsies may be beneficial in the case of larger adenomas. When resecting large sessile tumors, there is a considerable risk of incomplete radicality. The short term mortality and morbidity of TEM is low even in old patients with comorbidiy.     

Resection of multiple rectal carcinoids with transanal endoscopic microsurgery:Case report

Multiple rectal carcinoids are rare.Due to the unreliability of endoscopic polypectomy in treating these submucosal lesions,a laparotomy is usually performed.We present a case report on multiple rectal carcinoids with three carcinoid foci<10 mm in diameter located in the midrectum.Preoperative examination showed the lesions to be confined to the submucosal layer with no perirectal nodal involvement.A transanal endoscopic microsurgerywas successfully performed to remove the three lesions with accurate full-thickness resection followed by secured suture closure.The postoperative pathology revealed neuroendocrine tumors G1(carcinoids)located within the submucosal layer without lymphatic or vessel infiltration.Both the deep and lateral surgical margins were completely free of tumor cells.The patient recovered quickly and uneventfully.No tumor recurrence was observed at the six-month follow-up.For the multiple small rectal carcinoids without muscularis propria or lymphatic invasion,transanal endoscopic microsurgery offers a reliable and efficient alternative approach to traditional laparotomy for select patients,with the added advantages of minimally invasive surgery.     

Repair of a colonoscopic perforation of the rectum with transanal endoscopic microsurgery

Iatrogenic colonic perforations are relatively uncommon but serious complications of diagnostic and therapeutic colonoscopies. Transanal endoscopic microsurgery (TEM) is an useful approach to the rectum and may be used for repair of a rectal perforation during colonoscopy. A 56-year-old male had an iatrogenic perforation of the rectum during a routine follow-up colonoscopy repaired by TEM with an uneventful and rapid recovery.     

Atypical indications for transanal endoscopic microsurgery to avoid major surgery

Background

Transanal endoscopic microsurgery (TEM) was originally designed for the removal of rectal tumors, principally incipient adenomas, and adenocarcinomas up to 20 cm from the anal verge. However, with the evolution of the technique and the increase in surgeons’ experience, new indications have emerged and TEM may now be used in place of other surgical procedures which are associated with higher morbidity. The aim of our study was to evaluate our group’s use of TEM or transanal endoscopic operations (TEO) for conditions other than rectal tumors.

Methods

An observational study of TEM (using Wolf equipment) or TEO (using Storz equipment) for indications other than excision of rectal tumors was conducted from June 2004 to July 2012.

Results

Four hundred twenty-four procedures were performed using TEM/TEO: removal of adenocarcinomas in 148 (34.9 %) patients, adenomas in 236 (55.7 %), post-polypectomy excision in 12 (2.8 %), removal of neuroendocrine tumors in 8 (1.9 %), and atypical indications in 20 (4.7 %). Atypical indications were pelvic abscess (3), benign rectal stenoses (2), rectourethral fistula after prostatectomy (3), gastrointestinal stromal tumor (3), endorectal condylomata acuminata (1), rectal prolapse (2), extraction of impacted fecaloma in the rectosigmoid junction (1), repair of traumatic and iatrogenic perforation of the rectum (2), and presacral tumor (3).

Conclusions

The use of TEM/TEO in atypical indications may benefit patients by avoiding surgical procedures associated with greater morbidity.     

Prospective study of the functional results of transanal endoscopic microsurgery

BACKGROUND/AIMS: Most clinical research addresses the technological advances and oncological outcomes of transanal endoscopic microsurgery. Our aim was to examine the functional results. METHODOLOGY: From August 1999 to November 2000, 22 Taiwanese patients (14 men, 8 women; median age, 68 years) undergoing transanal endoscopic microsurgery were prospectively examined. Functional questionnaires and anorectal manometry were assessed before surgery and at 2 weeks, 6 weeks, 3 months, and 1 year. RESULTS: The median distance from the anal verge to the tumor was 10 cm. The median tumor diameter was 2.0 cm. The median duration of surgery was 120 minutes. No surgical mortality or morbidity and no local recurrence occurred during a median follow-up of 23 months. The mean stool frequency and consistency were significantly better at 3 months after surgery than before surgery. The maximal resting pressure significantly decreased after surgery. The maximal contraction pressure and maximal tolerated volume were significantly lower at 2 and 6 weeks than before surgery; these values recovered at 1 year. CONCLUSIONS: Transanal endoscopic microsurgery is safe for the cure of benign tumors and the palliative excision of malignant tumors in middle and upper rectum. Anorectal function was preserved and improved, though some anorectal manometric parameters changed over time.     

Efficacy of transanal endoscopic microsurgery in the management of rectal polyps

BACKGROUND AND AIM: Transanal endoscopic microsurgery (TEM) was a technique developed to allow the excision of adenomas and early-stage cancers from the rectum and distal sigmoid colon. The aim of this project was to prospectively study surgical morbidity, mortality and the local recurrence rate of all patients treated with this technique. METHODS: All patients undergoing TEM were prospectively evaluated. Endpoints to assess the surgical morbidity and mortality were defined before the study commenced. All patients underwent regular follow up to determine treatment efficacy in terms of the local recurrence rate and survival. RESULTS: The study involved 113 patients, with a mean age of 69 years (standard deviation 14 years, range 30-94 years), and a male to female ratio of 1.4:1. The mean polyp area was 20.5 cm(2) (range 1-169 cm(2)) and the mean height above the anal verge was 9.5 cm (range 4-25 cm). Histology of the tumors found 62 adenomas, 20 carcinomas in situ, and 31 adenocarcinomas. There were no unplanned returns to theater or postoperative deaths. Four patients required readmission within 30 days because of bleeding, and nine patients underwent more radical surgical procedures following histological evaluation of the resected specimens. During a mean follow up of 1.5 +/- 0.8 years (maximum 3.2 years), there have been two recurrences of villous adenomas. The actuarial local recurrence rate at 2 years is 2.4% (95% confidence interval 0.8-4.0%). CONCLUSION: TEM was demonstrated to be a safe surgical procedure, and early follow up has shown it to be an efficacious treatment for benign rectal adenomas and early rectal cancers.     

Sphincter-saving surgery in patients with rectal cancer treated by radiotherapy and transanal endoscopic microsurgery: 10 years’ experience

Background/Aims. Transanal endoscopic microsurgery (TEM) is a technique which allows minimally invasive full-thickness local excision of rectal tumours with perirectal fat dissection.

Methods. Our study examined a group of 137 selected patients with rectal cancer treated by TEM excision combined with preoperative radiotherapy. The definitive histology was as follows: 37 patients with pT1 stage rectal cancer (27%), 59 with pT2 (43%) and 23 with pT3 (17%). In 18 (13%) patients who underwent a full dose of radiotherapy and TEM, the pathologist did not find cancer cells in the specimen (pT0).

Results. Eleven (8%) patients developed minor complications, whereas three (2%) developed major complications. The perioperative mortality was nil. At the mean follow-up of 46 months (range 6–115 months), we observed seven (5%) local recurrences. Of those, three patients died from systemic spread of the disease at follow-up. The disease-free survival rate in T0 and T1 patients was 100%. The disease-free survival rates in T2 and T3 patients were 81 and 59%, respectively, at a mean follow-up of 46 months.

Conclusions. The application of preoperative radiotherapy and TEM in the treatment of rectal tumours appears feasible, safe and effective in the present study, with optimal preservation of anal sphincter function.     

Long-term results of transanal endoscopic microsurgery after endoscopic polypectomy of malignant rectal adenoma

Background

There is no consensus on the treatment and prognosis of malignant rectal polyps. The aim of the present study was to determine the role of transanal endoscopic microsurgery (TEM) after endoscopic complete polypectomy of malignant rectal adenomas with long-term follow-up.

Methods

Of 105 patients with pT1 rectal carcinoma in 32 patients TEM followed complete endoscopic polypectomy while 73 had primary TEM. Local recurrence (LR), distant metastasis, overall and cancer-specific survival were determined by the Kaplan–Meier method.

Results

Median follow-up was 9.1 years. In 32 patients with TEM following complete polypectomy no residual cancer was found. LR occurred in 3/28 (11%) patients with low-risk carcinoma (pT1 G1/2/X, L0/X, R0) and in 1/4 (25%) with high-risk carcinoma (pT1 G3/4 or L1). After primary TEM with complete resection (minimal distance >1 mm) LR occurred in 6/60 (10%) with low-risk carcinoma. After incomplete TEM resection (minimal distance ≤1 mm) LR occurred in 3/8 (38%) patients with low-risk and in 1/5 (20%) patients with high-risk carcinoma. Grading was the only significant risk factor for LR after endoscopic polypectomy followed by TEM (p = 0.002). At all outcomes did not differ between postpolypectomy TEM and primary TEM.

Conclusions

Patients with malignant rectal polyps removed by endoscopic polypectomy have a substantial risk of LR even if TEM of polyp site is cancer free. Risk of LR depends on tumor characteristics. In low-risk carcinoma long-term follow-up is necessary. The high LR rate in patients with high-risk rectal carcinoma restricts the use of TEM alone.

     

Treatment of rectal cancer by transanal endoscopic microsurgery: Experience with 425 patients

AIM: To describe our experience in treating rectal cancer by transanal endoscopic microsurgery (TEM), report morbidity and mortality and oncological outcome.METHODS: A total of 425 patients with rectal cancer (120 T1, 185 T2, 120 T3 lesions) were staged by digital rectal examination, rectoscopy, transanal endosonography, magnetic resonance imaging and/or computed tomography. Patients with T1-N0 lesions and favourable histological features underwent TEM immediately. Patients with preoperative stage T2-T3-N0 underwent preoperative high-dose radiotherapy; from 1997 those aged less than 70 years and in good general health also underwent preoperative chemotherapy. Patients with T2-T3-N0 lesions were restaged 30 d after radiotherapy and were then operated on 40-50 d after neoadjuvant therapy. The instrumentation designed by Buess was used for all procedures.RESULTS: There were neither perioperative mortality nor intraoperative complications. Conversion to other surgical procedures was never required. Major complications (urethral lesions, perianal or retroperitoneal phlegmon and rectovaginal fistula) occurred in six (1.4%) patients and minor complications (partial suture line dehiscence, stool incontinence and rectal haemorrhage) in 42 (9.9%). Postoperative pain was minimal. Definitive histological examination of the 425 malignant lesions showed 80 (18.8%) pT₀, 153 (36%) pT₁, 151 (35.5%) pT₂, and 41 (9.6%) pT₃ lesions. Eighteen (4.2%) patients (ten pT₂ and eight pT₃) had a local recurrence and 16 (3.8%) had distant metastasis. Cancer-specific survival rates at the end of follow-up were 100% for pT₁ patients (253 mo), 93% for pT₂ patients (255 mo) and 89% for pT₃ patients (239 mo).CONCLUSION: TEM is a safe and effective procedure to treat rectal cancer in selected patients without evidence of nodal involvement. T2-T3 lesions require preoperative neoadjuvant therapy.