Transanal endoscopic microsurgery is superior to transanal excision of rectal adenomas

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.     

Transanal endoscopic microsurgery: risk factors for local recurrence of benign rectal adenomas

OBJECTIVE: Transanal endoscopic microsurgery (TEM) is a minimally invasive technique for excision of selected benign and malignant rectal neoplasms. It is considered a safe and effective treatment but recurrence rates of 1-13% are reported for benign lesions. The aim of this study was to assess risk factors for local recurrence of benign rectal lesions and to evaluate mortality and morbidity following TEM. METHOD: Data were prospectively collected from all patients undergoing TEM for benign adenomas from January 1998 to March 2005. The procedure was performed by a single surgeon and patients were regularly followed up. RESULTS: One hundred and forty-six procedures were included, with a median patient age of 74 years (range 22-92 years). The mean lesion area was 16 cm(2) (range 0.3-150 cm(2)) and the median distance from the dentate line was 9 cm (range 0-17 cm). Immediate complications included bleeding (six) and acute urinary retention (six). There has been one (0.68%) procedure-related death. After a median follow up of 39 months (range 4-89 months) there have been seven recurrences (4.8%), recurring at a mean time of 23.3 months (range 5-48 months). Only microscopic involvement of the circumferential resection margin was found to be significantly associated with recurrence (P = 0.0059). Recurrence was not associated with age, size of lesion, previous treatment, severity of dysplasia or use of the harmonic scalpel. CONCLUSION: TEM is a safe and effective treatment for benign rectal adenomas. Circumferential resection margin involvement is associated with recurrence, which tends to occur late. Therefore extended follow up is recommended.     

Transanal endoscopic microsurgery – lessons from a single UK centre series

Objectives Transanal endoscopic microsurgery (TEM), a minimally invasive technique has been employed in the excision of benign and selected malignant rectal tumours since 1983. We present a single surgeon's series of 102 procedures. Patients and methods A retrospective case note review of 102 procedures performed over a 6‐year period between 1996 and 2001. Results One hundred and two TEM procedures were performed on 100 patients. 68 for adenomas, 19 potentially curative excisions for carcinoma, 13 palliative procedures for advanced carcinoma and 2 for solitary rectal ulcer syndrome (SRUS). Four adenomas recurred and were successfully treated by various procedures. None went on to develop malignancy, or a further recurrence. Of the cancers, six T1 and 10 T2 were excised with curative intent. Three T3 cancers were excised before endorectal ultrasound was available in the unit and went on to have definitive procedures. One T1 and two T2 carcinomas were not completely histologically excised. These patients were offered definitive procedure and there have been no recurrences. 11 patients underwent palliative TEM procedures, 2 went on to have a recurrence of symptoms. Both underwent a successful second TEM procedure. Conclusions Although longer term follow up is still required, TEM appears to be an effective method of excising benign tumours and T1 carcinomas of the rectum. The role of TEM in the treatment of T2 carcinomas is, as yet, unclear and needs further evaluation although the results of our series and others are encouraging.     

Transanal endoscopic microsurgery: local recurrence rate following resection of rectal cancer

Objective Transanal endoscopic microsurgery (TEM) is a safe and effective treatment for the excision of benign rectal adenomas. In recent years it has been used for the excision of malignant lesions, although its use in this context remains controversial. The aim of this study was to investigate the local recurrence of rectal cancers following local excision by TEM. Method Forty‐two patients with rectal cancer were treated by TEM between 1998 and 2005. However, six patients went on to have immediate radical surgery and are excluded from the study. Of the remaining 36 the treatment intention was for cure in 16 (38.1%), compromise in 17 patients unfit for radical surgery (40.5%), and palliation in three (7.1%). Results The mean age of patients was 75 years (range 41–90). The mean lesion area was 15 cm² (range 0.8–42) and mean distance from the dentate line was 6.6 cm (range 0–11). The mean follow up was 34 months (range 4–94). During the follow‐up period there have been eight local recurrences (22%). The recurrence rates were 26% (6/23) for pT1, 22% (2/9) for pT2 and 0% (0/4) for pT3 lesions. The mean time to recurrence was 18.3 months (range 5–42). Conclusion Transanal endoscopic microsurgery is a safe procedure with obvious advantages over radical procedures. However, in this study the local recurrence rate is high. The recurrence rate may be an acceptable compromise in elderly or medically unfit patients but is hard to justify for curative intent.     

Transanal endoscopic microsurgery: the first 50 cases

Background: Transanal endoscopic microsurgery is a form of minimally invasive rectal surgery first used at Cabrini Hospital in April 1997. This paper presents a prospective analysis of the first 50 cases with a median follow up of 33 months (range 20?48 months). Methods: Prospective data was obtained from all cases between April 1997 and June 2000. Results: Forty‐nine patients (30 men and 19 women) underwent 50 procedures. Thirty‐six had benign lesions and 14 malignant. The mean distance of the lower edge of the lesion from the anal verge was 8.7 cm. Three cases were converted to traditional transanal or transabdominal operations. Full‐thickness excision was performed on 26 patients and the rectal wound was closed in 13 cases. The mean duration of transanal endoscopic microsurgery was 67 min (range 20?175), with a mean blood loss of 24 mL (0?300). The mean diameter and area of the fixed specimen was 3.7 cm (1.5?9.8) and 11.4 cm² (0.8?18.9), respectively. Complications included postoperative fever (3), urinary retention (1) and per rectum bleeding (1). There was one death. The mean length of stay was 4 days. Histology confirmed complete excision in 39 (78%) cases and there have been two instances of local recurrence of adenoma (5%). Conclusions: Transanal endoscopic microsurgery is an effective, safe and cost‐beneficial procedure for local excision of selected lesions in the middle and upper thirds of the rectum.     

Factors predicting early recurrence after transanal endoscopic microsurgery excision for rectal adenoma

INTRODUCTION: Transanal endoscopic microsurgery (TEM) is an accepted way of excising rectal adenomas with low morbidity and mortality, avoiding major resectional surgery. However, there are no agreed criteria for surveillance following TEM. The purpose of this study was to identify criteria to guide surveillance programmes, thus reducing the surveillance burden for those patients at low risk of recurrence. PATIENTS AND METHODS: Patients who had undergone TEM for rectal adenomas were identified, and a retrospective review of patient, pathological and histological parameters was performed. RESULTS: Seventy-five (40 male) patients were identified; median age 70 years (39-85). There were seven tubular, 33 tubulo-villous and 35 villous adenomas. All were considered completely excised by the operating surgeon. Forty-seven (62.7%) were reported as being completely excised histologically. There was no significant association between recurrence at 6 months and sex, age, type or position of adenoma, height above the anal verge, or degree of dysplasia. Recurrence rates at six months were 0% for the completely excised adenomas and 21.4% for the incompletely excised ones; this was statistically significant (Pearson chi(2), P < 0.001). In all there were 12 recurrences, 10 in the incompletely excised group at a median follow up of 31 (6-80) months (P < 0.001). In addition, a significant association for large adenomas to recur was noted at median follow up (Armitage Trend test, P = 0.019). CONCLUSIONS: Histological assessment of completeness of excision of rectal adenoma and size of adenoma are important predictors of early recurrence and have potential to guide follow-up strategies after TEM.     

Transanal endoscopic microsurgery in early rectal cancer: time for a trial?

Objective The optimal aim of oncological surgery is to balance cancer outcomes with preservation of function and quality of life. Radical resection (RR) offers the best curative procedure in colorectal cancer but at significant morbidity. Transanal endoscopic microsurgery (TEM) offers an alternative with less morbidity and better function. Its role remains unclear and needs to be established in the light of new emerging trends in rectal cancer. This review aims to evaluate the use of TEM and its limitations. Method PubMed and MEDLINE search was performed. Results Strongest level of evidence (Level II) favoured TEM over RR and laparoscopic resection in term of mortality and morbidity. There was no difference in recurrence at follow-up of 41 and 56 months but neither study was adequately powered to detect a difference in recurrence/survival. Three retrospective case comparisons (Level III) also favoured TEM over RR but were subject to selection bias. Twenty eight published case series (Level IV) reported varying results due to different cancer stages, study population, full excision, adjuvant therapy and treatment indication. The oncological outcomes in TEM are similar to RR in highly selected cases but with far less mortality (near 0%), morbidity, blood loss, hospital stay and genitourinary/gastrointestinal dysfunction. TEM alone (+/− adjuvant therapy) appears sufficient for ‘favourable’ T1 tumours. ‘Unfavourable’ T1 or T2 tumours require adjuvant treatment. TEM should only be used for palliation in T3+ cancers. Seven functional studies reported significant transient dysfunction following TEM with full clinical recovery within a year. TEM is cost-effective providing sufficient cases are performed. Conclusion Significant heterogeneity limits conclusions from current literature. A trial is required. Alternate end-points to local recurrence may be required in assessing the optimal surgical approach, which balances disease control with quality of life, and probability of noncancer related death.     

Transanal endoscopic microsurgery for carcinoma of the rectum

Background The authors present their experience with rectal cancers managed by transanal endoscopic microsurgery (TEM). Methods This prospective study investigated patients undergoing primary TEM excision for definitive treatment of rectal cancer between January 1996 and December 2003 by a single surgeon in a tertiary referral colorectal surgical unit. Results For this study, 52 patients (30 men and 22 women) underwent TEM excision of a rectal cancer. Their mean age was 74.3 years (range, 48–93 years). The median diameter of the lesions was 3.44 cm (range, 1.6–8.5 cm). The median distance of the lesions from the anal verge was 8.8 cm (range, 3–15 cm), with the tumor more than 10 cm from the anal verge in 36 patients. The median operating time was 90 min (range, 20–150 min), and the median postoperative stay was 2 days. All patients underwent full-thickness excisions. There were 11 minor complications, 2 major complications, and no deaths. The mean follow-up period was 40 months (range, 22–82 months). None of the pT1 rectal cancers received adjuvant therapy. Eight patients with pT2 rectal cancer and two patients with pT3 rectal cancer received postoperative adjuvant therapy. The overall local rate of recurrence was 14%, and involved cases of T2 and T3 lesions, with no recurrence after excision of T1 cancers. Three patients died during the follow-up period, but no cancer-specific deaths occurred. Conclusions The findings warrant the conclusion that TEM is a safe, effective treatment for selected cases of rectal cancer, with low morbidity and no mortality. The TEM procedure broadens the range of lesions suitable for local resection to include early cancers (pTis and pT1) and more advanced cancers only in frail people.     

Transanal endoscopic microsurgery

Transanal endoscopic microsurgery (TEM) permits precise excision of favorable tumors from the mid and proximal rectum, thus avoiding transsacral and low anterior resection in select cases. Ten patients underwent TEM resection of rectal tumors by a single surgeon between April 1992 and August 1993. All patients first underwent endorectal ultrasound. Villous adenomas ranging from 3.2 to 4.5 cm in size (mean, 3.9 cm) in eight patients and T₁ adenocarcinomas of 1.5 and 2.5 cm (mean, 2 cm) in two patients were excised. Resection was performed using the mucosectomy method in three and by full-thickness excision in seven patients. Distal extent of tumors ranged from 6 to 11 cm from the anal verge. The operative time in these initial ten cases ranged from 75 to 220 min (mean, 138 min). Estimated blood loss ranged from 0 to 550 cc (mean, 85 cc). Complications occurred in two patients (pseudomembranous colitis; fever of unknown origin). The mean length of hospital stay was 2.7 days. To date, one tumor has recurred, requiring an abdominoperineal resection. In no case was conversion to conventional method of resection necessary at the time of TEM resection. TEM is a safe and effective method for resecting favorable tumors in select cases.     

The creation of a peritoneal defect in transanal endoscopic microsurgery does not increase complications

Introduction  During Transanal Endoscopic Microsurgical (TEMS) full-thickness excision of a rectal lesion above the peritoneal reflection, entrance to the peritoneal cavity is inevitable. This has been regarded as a complication that requires conversion to an open procedure. We describe our experience of full thickness intraperitoneal excision of rectal lesions where the peritoneal defect was sutured endoscopically.
Method  Data were collected prospectively on 15 patients in whom a peritoneal defect was created intraoperatively during TEMS excision of a rectal lesion. When a defect was recognized, it was closed by endoscopic suture. If there was any doubt regarding security of the closure, a defunctioning loop stoma was fashioned.
Results  Between November 1998 and January 2008, a total of 257 patients underwent TEMS during which a peritoneal defect was created in 15 patients. Six patients had a defunctioning stoma formed at the time of TEMS. No patient was defunctioned postoperatively and there were no deaths. The mean hospital stay was 8 days (range 3 to 19 days). A contrast enema showed sub-clinical leaks in two patients for which no treatment was required. No patient developed pelvic or peritoneal sepsis, but one patient had to return to theatre for postoperative bleeding when a single bleeding vessel was coagulated.
Conclusion  Full thickness excision of lesions in the intraperitoneal rectum with endoscopic suture of the defect is a safe procedure. Lesions in the upper rectum should not be excluded from TEMS excision because of the chance of peritoneal breach.     

Transanal endoscopic microsurgery: clinical and functional results

OBJECTIVE: Transanal endoscopic microsurgery (TEM) has become increasingly common in the management of rectal adenomas and also in selected cases of rectal carcinomas. The aim of this study was to assess the results in a consecutive series of patients after introducing the TEM technique. PATIENTS AND METHODS: All 58 patients operated with TEM from January 1996 to January 1999 were evaluated in a retrospective review. Forty-eight patients answered a clinically validated questionnaire a median of 22 months after TEM. Eighty patients who had undergone transanal excision and 12 who had undergone York Mason's procedure served as a reference group with respect to recurrence rates. RESULTS: The complication rate was 5% (immediate) and 14% (long-term). The overall 30-day mortality rate was zero. An impairment of continence was seen in 18 (37%) patients. Of these, all 18 experienced varying degree of incontinence to liquid stool, 14 also to flatus and 5 of them even to solid stool. The recurrence rate was 11% in adenomas and 14% in cancers; T1, 1 (10%) recurrence and T2, 1 (50%) recurrence. There was a correlation between operating time and impairment of continence as well as recurrence rate. CONCLUSION: TEM is a safe procedure, having a low recurrence rate and an acceptable functional outcome.     

经肛门内镜手术治疗结直肠肿瘤可行性研究

目的 评估经肛门内镜显微手术治疗结直肠肿瘤的临床应用可行性,探讨手术中操作困难的处理策略。方法 回顾性分析上海交通大学医学院附属瑞金医院外科2006年9月至2008年6月期间36例经肛门内镜显微手术病人的临床资料。结果 36例病人均成功完成经肛门内镜显微手术,无中转开腹病例。平均手术时间为71（20~200）min。术后病理：腺瘤22例,腺癌8例,类癌5例,炎性肿块1例。术后平均住院时间为4.7（3~9）d。并发症方面：1例术后有肛门内出血,1例术后有暂时性排便失禁感。1例术后5个月发现直肠肿瘤复发。结论 经肛门内镜显微手术是一种对直肠中、上段及乙状结肠下段肿瘤有效、安全、可行性强的微创切除手术。严格选择病例,注意临床处理策略,经肛门内镜显微手术可取得和传统手术相仿甚至更优的结果,且住院时间短,并发症少,有良好的临床应用前景。     

Transanal endoscopic microsurgery in large,sessile adenomas of the rectum

The clinical and long-term results of 286 cases encountered from 1983 to 1993 in our Department of Surgery regarding the local excision of large, sessile rectal adenomas (>2cm²) by the endoscopic surgical method and the influence of this selected series of adenomas on age, sex, size, grade of dysplasia, and architecture are subjects of this study. Histologically proven rectal carcinomas as well as nonneoplastic polyps were excluded from this trial.Early postoperative complications amounted to 3.4%. The 1-year and 5-year recurrence rates ±SE of adenomas were 1.2±0.7% and 7.0±1.9%, respectively. Remarkably, there was no significant relationship between the histological type of the adenoma and the grade of dysplasia nor between the size and grade of dysplasia. However, there was a significant relationship between the size and histological type of the adenoma (P<0.01).With the endoscopic minimal-invasive system, we are able to achieve a superior rate of recurrence compared to any other local treatment as well as a more favorable operative result compared to extensive surgical procedures.     

Transanal endoscopic microsurgery for rectal carcinoids: the largest reported United States experience

Aim Rectal carcinoids are often inadequately resected by snare excision during colonoscopy. Transanal endoscopic microsurgery is a minimally invasive procedure with low morbidity that offers full‐thickness excision with a low rate of negative margins. It presents an excellent alternative to radical surgery for mid and proximally located lesions. We report the largest United States (US) experience in the use of transanal endoscopic microsurgery for rectal carcinoids. Method Data of patients who had undergone transanal endoscopic microsurgery for rectal carcinoids were prospectively collected and retrospectively analyzed. Patient and tumour characteristics, operative and perioperative details, as well as oncological outcomes were reviewed. Results Over a 12‐year period, 24 patients underwent transanal endoscopic microsurgery for rectal carcinoids. Of these, six (25%) were primary surgical resections and 18 (75%) were performed after incomplete snare excisions during colonoscopy. Three (17%) patients who underwent full‐thickness resection after snare excision had residual tumour on histopathological examination. Negative margins were obtained in all cases. No recurrences were noted. Conclusion Transanal endoscopic microsurgery is effective and safe for the surgical resection of rectal carcinoids < 2 cm in diameter, with typical features and located more than 5 cm from the anal verge. Transanal endoscopic microsurgery can be used for primary resection or for resection after incomplete colonoscopic snare excision.     

经肛门内镜显微手术在直肠肿瘤局部切除术中的应用

目的初步评价经肛门内镜显微手术(transanalendoscopicmicrosurgery,TEM)在直肠肿瘤局部切除术中的应用。方法2006年4月至9月对8例直肠肿瘤患者采用TEM行局部切除术。术前根据直肠腔内超声肿瘤分期uT0期6例,uTis期和uT1期各1例。肿瘤距肛缘距离平均7(4~9)cm;肿瘤直径平均1.5(1~2.5)cm;肿瘤占据肠腔周径比例平均20%(10%~30%)。结果8例直肠肿瘤均获完整切除(粘膜下切除3例,全层切除5例),各切缘均阴性。手术时间平均50(40~60)min;术中平均出血量30(10~50)ml。术后住院天数平均5(2~7)d。无一例出现手术并发症。术后病理分期pT0期5例,pTis期、pT1期和pT2期各1例。8例术后随访平均3(1~5)个月,肿瘤无局部复发。结论TEM显露良好、切除精确,手术安全、创伤小,经严格选择病例可用于良性直肠肿瘤和早期直肠癌的彻底切除。     

Endoscopic mucosal resection vs transanal endoscopic microsurgery for the treatment of large rectal adenomas

Aim Large (> 2 cm) rectal adenomas are currently treated by transanal endoscopic microsurgery (TEM) or piecemeal endoscopic mucosal resection (EMR). The potential lower morbidity of EMR becomes irrelevant if it is less effective. We aimed to compare the safety and effectiveness of EMR and TEM for large rectal adenomas. Method Data from patients undergoing TEM or EMR for a rectal adenoma > 2 cm in eight hospitals were retrospectively collected. Patient‐ and procedure‐related characteristics, complications and recurrences were recorded. As EMR may require several attempts to achieve complete resection, early (after a single intervention) and late (permitting re‐treatment for residual adenoma within 6 months) recurrence rates were determined. Results Two hundred and ninety‐two (292) patients (49% male; mean age 67 years) were included; 219 were treated by TEM and 73 by EMR. Adenomas treated by EMR were smaller (median 30 vs 40 mm; P = 0.007). Perioperative complication rates were 2% for TEM and 6% for EMR (P = 0.171). Postoperative complications occurred in 24% of TEM patients and in 13% of EMR patients (P = 0.038). Median hospitalization after TEM was 3 days vs 0 days after EMR (P < 0.001). Median follow‐up was 12.6 months (0–47 months); Early recurrence rates were 10.2% in TEM patients and 31.0% in EMR patients (P < 0.001); late recurrence rates were 9.6% and 13.8%, respectively (P = 0.386). Conclusion After a single intervention, EMR of large rectal adenomas seems less effective, but safer than TEM. When allowing re‐treatment of residual adenoma within 6 months, EMR and TEM seem equally effective. A prospective randomized comparison seems to be necessary.