Cost analysis of transanal endoscopic microsurgery for rectal tumours

OBJECTIVE: Transanal endoscopic microsurgery (TEM) is considered to be a safe and effective treatment for selected rectal neoplasms. We demonstrate that in addition to the recognized clinical benefits of the less invasive TEM approach, there are substantial economic benefits. METHOD: We reviewed our prospective database of patients undergoing TEM excision of a rectal lesion between July 1997 and December 2003. A cost analysis was undertaken, including procedural and related costs of TEM and compared with the relevant open procedures. RESULTS: 124 patients (80 men, 44 women) with a median age of 71.5 years underwent TEM excision of rectal lesions (52 cancers and 72 adenomas). The morbidity rate was 8% and mortality was zero. A controlled case series of 52 patients undergoing open resection for early rectal cancers with similar characteristics as above was compared in terms of clinical outcome. The morbidity rate in these patients was 29.5%. The cost analysis comparison was undertaken using National Health Service mean reference costs for major large intestinal surgery, Intensive care unit/high dependency unit and hospital accommodation for each procedure. The average cost of open resection was 4135 pound, vs 567 pound for TEM excision. Our total saving over the series was 525,576 pound. Although the initial capital cost of the TEM equipment is high at approximately 40,000 pound given the massive cost savings, these initial equipment costs are recovered within a rapid time frame. CONCLUSION: This study has shown that TEM is a safe and extremely cost-effective approach for excision of selected rectal tumours including rectal adenomas and early well differentiated rectal cancers (pTis & pT1).     

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.     

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 – 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

Transanal endoscopic microsurgery (TEM) is a minimally invasive surgical technique that was developed more than two decades ago to manage distal colorectal neoplasias. The aim of the current study was to present a prospective review of 7 years of experience in using this equipment. All patients undergoing TEM between 1999 and 2007 were prospectively evaluated. Patients underwent regular endoscopic follow up. Cumulative incidence probability analysis was used to calculate rates of recurrence. The study involved 232 patients, median age 68 years (interquartile range (IQR), 37–90). The median neoplasia area was 12 cm² (IQR, 6–25 cm²) and the median height above the anal verge was 9 cm (IQR, 3–17 cm). Histology indicated 128 adenomas, 52 carcinomas in situ, and 52 adenocarcinomas. The median postoperative stay was 1 day (IQR, 1–3 days). There was one (0.5%) unplanned return to theatre and no postoperative deaths. Sixteen patients (6.9%) underwent more radical surgical procedures following the identification of carcinoma in the resected specimen. During a median follow up of 4.2 years (IQR, 2.6–6.2 years), the 5‐year cumulative incidence for local recurrence for benign pathology was 3.1% (95% confidence interval (CI): 1.2–6.7%, n = 180) and for cancers managed primarily by TEM excision it was 8.5% (95%CI: 1.4–23.9%, n = 36). TEM is an excellent treatment modality for benign rectal neoplasias of any size, and in any location. TEM is an oncologically inferior treatment for rectal cancer, however, when compared to more radical treatments. Its principal advantage in this setting is that it is associated with relatively minimal morbidity and mortality.     

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: 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.     

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: 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.     

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.     

经肛门内窥镜下微创外科技术治疗直肠肿瘤120例临床经验

目的评价经肛门内窥镜微创外科技术（TEM）治疗直肠宽基腺瘤和早期直肠癌的应用效果。方法分析评价2005年5月至2009年2月120例TEM手术的临床资料。结果本组患者肿瘤直径中位值2．5cm，肿瘤下缘距齿状线距离（8．4±3．2）cm，肿瘤侵犯直肠周径范围（32．3±18．5）％。平均手术时间（80±45）min。平均住院日5．2d。无围手术期死亡。手术并发症有直肠穿孔、创面裂开和短暂性大便失禁。病理示直肠腺瘤72例、直肠腺癌34例、直肠类癌12例、直肠间质瘤2例。34例腺癌中pTis9例，pT119例和pT26例。直肠癌术前腔内超声分期符合率为83．3％。平均随访21个月，有2例患者有局部复发。结论TEM手术创伤小、痛苦少、住院时间短、保留肛门括约肌；既可作为直肠宽基腺瘤和pT1期直肠癌的治愈性手术，也可作为pT2直肠癌的姑息性治疗手段。     

Mapping the rectum: Spatial analysis of transanal endoscopic microsurgical outcomes using GIS technology

Transanal endoscopic microsurgery (TEM) is a technically challenging procedure hindered by rectal anatomic constraints. To study the relationship of lesion position with performance of TEM, a novel approach of spatial analysis using Geographic Information Systems (GIS) was developed. A retrospective review was conducted on 144 consecutive TEMs, analyzing clinical, pathologic, and positional characteristics. Two- and three-dimensional maps of rectal topology were developed. GIS was used for spatial analysis, accounting for regional position and clustering of lesions. Lesions were located at a mean distance of 9.3 ± 4.9 (SD) cm from the dentate line, with an average size of 3.1 ± 1.4 cm. Proximal regions were associated with prolonged operative time. Regions between the rectosigmoid junction and the peritoneal reflection were associated with peritoneal breach. In spatial regression analysis, regional characteristics that were significantly associated with operative time included distance, presence of cancers, and positive margins; peritoneal breach was significantly associated with lesion size and location; conversions were associated with distance (P < 0.05). Specific knowledge of lesion size and location in the context of anatomic relationships is important for optimizing operative intervention. GIS provides a valuable tool in organizing spatial information and can be extended into clinical research topics involving the distinction of anatomic relationships. Presented at the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, Illinois, May 14–18, 2005 (poster presentation).     

A critical appraisal of endorectal ultrasound and transanal endoscopic microsurgery and decision-making in early rectal cancer

Aim Transanal endoscopic microsurgery (TEM) for early rectal cancer (ERC) gives results similar to major surgery in selected cases. Endorectal ultrasound (ERUS) is an important part of the preoperative selection process. This study reports its accuracy and impact for patients entered on the UK TEM database. Method The UK TEM database comprises prospectively collected data on 494 patients. This data set was used to determine the prevalence of ERUS in preoperative staging and its accuracy by comparing preoperative T‐stage with definitive pathological staging following TEM. Results ERUS was performed in 165 of 494 patients who underwent TEM for rectal cancer. It inaccurately staged rectal cancer in 44.8% of tumours: 32.7% were understaged and 12.1% were overstaged. There was no significant difference in the depth of TEM excision or R1 rate between the patients who underwent ERUS before TEM and those who did not (P = 0.73). Conclusion The data show that ERUS is employed in a minority of patients with rectal cancers undergoing TEM in the UK and its accuracy in this ‘Real World’ practice is disappointing.     

Quality of life after transanal endoscopic microsurgery and total mesorectal excision in early rectal cancer

OBJECTIVE: Total mesorectal excision (TME) is the gold standard in rectal cancer, if curation is intended. Transanal endoscopic microsurgery (TEM) is a much safer technique and seems to have comparable survival in early rectal cancer. The impact of both procedures on quality of life has never been compared. In this study we compared quality of life after TEM and TME. METHOD: Fifty-four patients underwent TEM for a T1 carcinoma. Only patients without known locoregional or distant recurrences were included, resulting in 36 eligible patients in whom quality of life after TEM was studied. The questionnaires used included the EuroQol EQ-5D, EQ-VAS, EORTC QLQ-C30 and EORTC QLQ-CR38. The results were compared with a sex-and age-matched sample of T+N0 rectal cancer patients who had undergone sphincter saving surgery by TME and a sex- and age matched community-based sample of healthy persons. RESULTS: Thirty-one patients after TEM returned completed questionnaires (overall response rate 86%). Quality of life was compared with 31 TME patients and 31 healthy controls. From the patients' and social perspective quality of life did not differ between the three groups. Compared with TEM, significant defecation problems were seen after TME (P < 0.05). A trend towards better sexual functioning after TEM, compared with TME, was seen, especially in male patients, although it did not reach statistical significance. CONCLUSION: Transanal endoscopic microsurgery and TME do not seem to differ in quality of life postoperatively, but defecation disorders are more frequently encountered after TME. This difference could play a role in the choice of surgical therapy in (early) rectal cancer. Further prospective studies are needed to confirm our conclusions.     

Transanal endoscopic microsurgery for the treatment of selected patients with distal rectal cancer: 15 years experience

Background  Local therapy for early rectal cancer is a valid alternative to the classical radical operation, which has a higher morbidity and mortality rate. The use of high-dose preoperative radiation appears to enhance the options for sphincter-saving surgery even for T2–T3 rectal cancer patients with effective local control. The authors report their experience with transanal endoscopic microsurgery (TEM) used to manage selected cases of distal rectal cancer without evidence of nodal or distant metastasis (N0–M0). Methods  The study enrolled 196 patients with rectal cancer (51 T1, 84 T2, and 61 T3). All the patients staged preoperatively as T2 and T3 underwent preoperative high-dose radiotherapy, and since 1997, patients younger than 70 years in good general condition also have undergone preoperative chemotherapy. Results  Minor complications were observed in 17 patients (8.6%) and major complications in only 3 patients (1.5%). The definitive histology was 33 pT0 (17%), 73 pT1 (37%), 66 pT2 (34%), and 24 pT3 (12%). Eight patients (5 pT2 and 3 pT3) experienced local recurrence (4.1%). The rectal cancer-specific survival rate at the end of the follow-up period was 100% for pT1, 90% for pT2, and 77% for pT3 patients. Conclusions  Patients with T1 cancer and favorable histologic features may undergo local excision alone, whereas those with T2 and T3 rectal cancer require preoperative radiochemotherapy. The results in the authors’ experience after TEM appear not to be substantially different in terms of local recurrence and survival rate from those described for conventional surgery.     

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.