Transanal endoscopic microsurgery for rectal tumors: the St. Mary's experience

BACKGROUND: The aim of this study is to describe a single institution's experience in the use of transanal endoscopic microsurgery for rectal tumors. METHODS: Between 1996 and 2005, transanal endoscopic microsurgery was performed in 76 patients. The histologic diagnosis was adenoma in 48 and adenocarcinoma in 28 patients. RESULTS: Clear resection margins were achieved in 71 of 74 patients (95.9%). Overall morbidity was 18.9% because 14 patients developed minor (10 patients) or major complications (4 patients). During the follow-up, benign tumor recurrence was detected in 3 patients (6.3%). The recurrence rates among patients with T1, T2, and T3 malignant tumors were 7.1%, 42.8%, and 66.6%, respectively. COMMENTS: Transanal endoscopic microsurgery is a safe and feasible technique with low incomplete excision rates and may be the preferred method in patients with benign rectal tumors. Its role in the management of malignant tumors should be limited to selected patients with T1 lesions.     

Transanal endoscopic microsurgery for the treatment of rectal cancer: comparison of wound complication rates with and without neoadjuvant radiation therapy

Background  Neoadjuvant therapy for rectal cancer has led to improved tumor downstaging and higher complete pathologic response rates. At the same time, the introduction of transanal endoscopic microsurgery (TEM) technique has renewed interest in local excision of rectal cancer. There has been concern that radiation may make the more radical local excision with TEM unsuitable. Our study compared morbidity rates and wound complication rates for patients undergoing TEM and local excision with and without neoadjuvant radiation to determine whether this could be accomplished safely. Methods   Data for all patients undergoing TEM are prospectively entered into a database. This database was queried for patients with rectal cancer undergoing TEM from November 1997 to June 2007. Of 64 patients identified, 2 were excluded because of previous radiation to the pelvis. Results   The study enrolled 62 patients with a final pathologic diagnosis of rectal cancer: 43 treated using neoadjuvant therapy with radiation (XRT) and 19 patients treated with TEM alone. The patients in the XRT group were 67 years of age (range, 29–86 years) and included 13 women. The patients in the non-XRT group were 66 years of age (range, 40–89 years) and included 8 women. Neither group had any mortalities. The overall morbidity rate was 33% for the XRT group and 5.3% for the non-XRT group, and this difference was statistically significant (p < 0.05). The wound complication rates were 25.6% for the XRT group (11 patients) and 0% for the non-XRT group (p = 0.015). Nine patients in the XRT group (82%) had minor wound separations, and two patients (18%) had major wound separation. Ten patients with wound separations were treated as outpatients and administered long-term oral antibiotics. One patient required additional surgery (diverting stoma). Conclusions  Not unexpectedly, the wound complication rate was higher in the XRT group. However, 82% of those wounds were minor, and 91% were treated without any additional surgery or intervention. Although a significant concern, wound complications do not prohibit TEM treatment after neoadjuvant treatment. Presented orally at the 2008 meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES).     

经肛门微创外科手术在直肠癌的临床应用

相对于直肠癌根治术而言,直肠癌局部切除术具有手术创伤小、风险低、能保肛以及术后无性功能和泌尿功能障碍等优点。经肛门内镜微创手术（TEM）是近年来国际上较为盛行的一种直肠癌局部切除技术．同传统的局部切除术相比．TEM具有优良的术野显露和宽敞的操作空间,更配有制造精良、性能优越的多种手术器械,为外科医师在术中精细的组织解剖、精准的肿瘤切除、降低和避免肿瘤切缘不足或切缘阳性提供了极佳的手术条件和技术上的保障。术前准确评估、仔细遴选病例以及严格掌握手术指征是获得良好疗效的基础。TEM最佳的适应证为直肠腺瘤高级别瘤变（Tis期）、T1期中低危组直肠癌以及癌仅侵及sm1和sin2的患者。经过新辅助治疗后降期明显（肿块缩小大于50％者）的T,期和L期直肠癌也可进入TEM的研究性治疗。TEM术中对病灶行局部根治性切除是预防肿瘤术后复发的关键。     

经肛手套通路联合结肠镜微创手术治疗直肠肿瘤

目的：探讨经肛手套通路联合结肠镜微创手术治疗直肠肿瘤的可行性及疗效。方法杭州市第三人民医院肛肠外科自2012年10月至2013年3月,选择经评估适合行局部切除的直肠肿瘤患者8例,使用经肛手套通路联合结肠镜微创手术治疗。经肛手套通路的建立：将手套袖口连同扩肛器缝合固定于肛周,再将手套5指经由透明肛门镜翻转出肛门,将超声刀、无损伤肠钳和肠镜镜头分别从3个指套伸入并结扎固定。结果8例患者均成功完成肿瘤切除手术,制作手套入路装置平均耗时12．5（10．0～15．0） min,平均手术时间55．6（30．0～110．0） min,平均住院时间为5．0（3．0～8．0） d,术后病理提示绒毛状腺瘤3例,管状腺瘤2瘤,管状绒毛状腺瘤2例,锯齿状腺瘤1例,其中2例伴低级别上皮内瘤变,1例高级别上皮内瘤变,所有肿瘤组织标本边缘及基底部均为阴性。术后2例患者少量便血,随访1～5（中位3．1）月,无肿瘤复发。结论采用经肛手套通路联合结肠镜微创手术治疗直肠早期肿瘤具有简单和安全的特点,具有一定的应用价值。     

Transanal endoscopic microsurgery in the treatment of rectal carcinoid tumor

Background This study aimed to assess the efficacy of transanal endoscopic microsurgery (TEM) in the treatment of rectal carcinoid tumor. Methods Between May 1994 and April 2006, 27 patients with rectal carcinoid tumor underwent TEM, and their clinical data were reviewed retrospectively. Results The TEM procedure was performed as a primary excision (n = 14) or as completion surgery after incomplete resection by endoscopic polypectomy (n = 13). The average size of a primary tumor was 9.1 mm (range, 5–13 mm), and the average distance of the tumor from the anal verge was 8.5 cm. The mean duration of the operation was 51.6 min. Minor morbidities, transient soilage, and mild dehiscence occurred in two cases (7.4%). Histopathologically, all tumors were localized within the submucosal layer showing typical histology without lymphatic or vessel infiltration, and both deep and lateral surgical margins were completely free of tumors. Among 13 cases of completion surgery after endoscopic polypectomy, 4 (30.8%) were histologically shown to have a residual tumor in the specimens obtained by TEM. No additional radical surgery was performed. The mean follow-up period was 70.6 months, and no recurrence was noted. Conclusion The results indicate that TEM is a safe, minimally invasive procedure for the local excision of rectal carcinoid tumors, particularly those in the proximal rectum. Furthermore, for patients with microscopic positive margins after endoscopic polypectomy, TEM can be an effective surgical option for complete removal of residual tumors.     

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 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 in 143 consecutive patients with rectal adenocarcinoma: results from a Danish multicenter study

Objective  The long-term results are presented on total survival, cancer-specific survival and recurrence in 143 consecutive patients treated with transanal endoscopic microsurgery (TEM) for adenocarcinoma of the rectum.
Method  Four Danish centres established in 1995 a database for registration of all TEM procedures. Data were supplemented from pathology reports and death certificates were checked in the Danish patient registry. Data were analysed with multivariance regression and survival analysis.
Results  The T stage was as follows: T1 50%, T2 33%, T3 14%, and stage unknown 3%. TEM was performed with curative intent in 43%, for compromise in 52% and for palliation in 5%. Five-year total survival was 66% and 5-year cancer-specific survival 87%. Cancer-specific survival for T1 was 94%. The significant predictors for total survival were age and tumour size. For cancer-specific survival T stage, radical resection, tumour size and recurrence were significant predictors. Eighteen per cent had recurrence and 15% had immediate reoperation.
Conclusion  The TEM provides good long-term results for pT1 cancers. In old patients and patients with co-morbidity TEM may provide acceptable long-term results for T2 cancers. Tumours larger than 3 cm should not be treated with TEM for cure.     

经肛门内镜微创手术在治疗局限性直肠肿瘤中的应用

探讨经肛门内镜显微手术(TEM)在治疗局限性直肠肿瘤中的应用效果.方法 总结分析2006年4月至2008年12月接受TEM的75例直肠肿瘤患者的临床资料,分析TEM在直肠肿瘤治疗中的应用效果.结果 患者病灶平均直径为(1.6±0.8)cm(0.5～5.0 cm).病灶距肛缘平均(7.6±2.8)cm(5～20 cm).病灶在直肠内的部位:前壁25例,后壁24例,左侧壁14例,右侧壁12例.手术方式包括:肠壁全层切除64例,黏膜下及肌层部分切除11例.平均手术时间(73.7±32.1)min(30～180 min),术中平均失血(9.8±7.7)ml(3～50 ml).术后病理检查:直肠腺瘤28例,直肠腺瘤癌变和直肠癌25例(其中Tis期14例,T1期5例,T2期6例),直肠类癌7例,炎性息肉等15例.所有标本切缘均为阴性.全组术后4例(5.3%)发生并发症,其中并发肛门出血2例,肺部和泌尿系感染各1例.术后平均住院(3.4±1.2)d(2～7 d).术后平均随访8.4个月(3～26个月),未发现疾病或肿瘤有复发转移.结论 TEM治疗直肠肿瘤具有手术损伤小,出血少、疗效好、恢复快等优点,是目前直肠肿瘤局部切除的较佳方法.     

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.     

Outcomes for early rectal cancer managed with transanal endoscopic microsurgery

Background This study aimed to evaluate the long-term risk of local and distant recurrence as well as the survival of patients with early rectal cancer treated using transanal endoscopic microsurgery (TEM). Methods The study reviewed 69 patients with T_is/T₁/T₂ rectal cancer treated using full-thickness excision between 1991 and 1999. The pathology T-stages included 25 T_is, 23 T₁, and 21 T₂. The median follow-up period was 6.5 years (range 5–10.2 years). Results The overall local recurrence rate was 8.7%. The 5-year local recurrence rate was 8% for T_is, 8.6% for T₁, and 9.5% for T₂. All six patients with recurrence were managed surgically. The 5-year disease-specific survival rate was 100% for T_is, 100% for T₁, and 70% for T₂. The overall cancer-related mortality rate was 7.2%. Conclusions After local excision of early rectal cancer, a substantial local recurrence rate is observed. Patients with recurrent T_is/T₁ cancers who undergo a salvage operation may achieve good long-term outcome. Local treatment without adjuvant therapy for T₂ rectal cancers appears inadequate. Presented in part at the Annual Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) meeting, Ft Lauderdale, FL, USA, 13–16 April 2005     

Transanal endoscopic microsurgery and radical surgery for T1 and T2 rectal cancer

Background: Transanal endoscopic microsurgery (TEM) has gained increasing acceptance as a local treatment of early rectal cancer. The purpose of this study was to compare the results of TEM and radical surgery in patients with T1 and T2 rectal cancer. Methods: From October 1994 to December 2000, 74 patients with T1 and T2 rectal adenocarcinoma treated with TEM were compared with 100 patients with T1N0M0 and T2N0M0 rectal adenocarcinoma treated with radical surgery. Retrospective analysis was performed regarding to recurrence and survival rate. Neither group received adjuvant chemoradiation. There was no significant difference in age, gender, tumor location, or follow-up period between the two groups. The only difference was in tumor size. Results: Of the 74 patients in TEM group, 52 were T1 (70.3%) and 22 were T2 (29.7%). Of the 100 patients in radical surgery group, 17 were T1 (17%) and 83 patients were T2 (83%). The 5-year local recurrence rates were 4.1% for T1, 19.5% for T2 after TEM, 0% for T1, and 9.4% for T2 after radical surgery. There was no statistical difference between the TEM and radical surgery groups for T1 rectal cancer (p = 0.95), but for T2 rectal cancer, the 5-year local recurrence rate was higher after TEM than after radical surgery (p = 0.04). There were no significant statistical difference between the two groups in terms of the 5-year disease-free survival rate and the survival rate. Conclusions: For T1 rectal cancer, there was no difference in recurrence or 5-year survival rate between the TEM and the radical surgery groups. For T2 rectal cancer, there was no statistical difference in the 5-year survival rate between the two groups, but TEM carried higher risk of local recurrence. Therefore, careful selection of the patients is required for TEM, and when proper muscle invasion is proven, the TEM procedure should be supplemented by further treatment, or radical surgery should be performed. Presented at the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) meeting and the 8th World Congress of Endoscopic Surgery, New York, New York, USA, 13–16 March 2002     

Transanal minimally invasive surgery using laparoscopic instruments of the rectum: A review

Transanal minimally invasive surgery (TAMIS) was first described in 2010 as an alternative to transanal endoscopic microsurgery (TEM). The TAMIS technique can be access to the proximal and mid-rectum for resection of benign and early-stage malignant rectal lesions and also used for noncurative intent surgery of more advanced lesions in patients who are not candidates for radical surgery. TAMIS has a shorter learning curve, reduced device setup time, flexibility in instrument use, and versatility in application than TEM. Also, TAMIS shows similar results in a view of the operation time, conversion rate, reoperation rate, and complication to TEM. For these reasons, TAMIS is an easily accessible, technically feasible, and cost-effective alternative to TEM. Overall, TAMIS has enabled the performance of high-quality local excision of rectal lesions by many colorectal surgeons. As TAMIS becomes more broadly utilized such as pelvic abscess drainage, rectal stenosis, and treatment of anastomotic dehiscence, the acquisition of appropriate training must be ensured, and the continued assessment and assurance of outcome must be maintained.     

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 the treatment of select rectal cancers or tumors suspicious for cancer

Background: This study describes a personal experience with the use of transanal endoscopic microsurgery to facilitate surgical access, and to determine the ability of this technique to reduce the need for major abdominal procedure and prevent the need for a temporary or permanent colostomy in select patients with known or suspected rectal cancer. Methods: The subjects of this study were 43 patients with rectal cancer or tumors who had a high likelihood of malignancy. The 24 men and 19 women comprised two groups: patients with known cancer (n = 16) and patients with tumors suspicious for cancer (n = 27), six of whom proved to have invasive malignancy. The tumors ranged in size from 1 to 7 cm (average, 3.5 cm). The tumors inferior level in the rectum ranged from –1 to 21 cm (average, 6.5 cm). Eleven patients known to have rectal cancer were treated with preoperative radiation or chemoradiation. By ordinary standards, 22 patients would have received an abdominal perineal resection; 14 patients would have qualified for abdominal sphincter–preserving operations; and 7 patients were indeterminate. Full-thickness local excisions were disk excisions (n = 23), hemicircumferential excisions (n = 19), and sleeve resection (n = 1). The ages of the patients ranged from 30 to 91 years (average, 66.7 years). Results: In this study, 90% avoided a major abdominal operation (39/43), and 90% avoided an abdominal perineal resection of the patients (20/22). The complications were as follows: mortality (n = 10), morbidity (n = 9), minor wound separation (n = 6), and major wound separation (n = 3). Two of these complications were rectovaginal fistulas: the one in a 91-year-old patient who presented with a fistula and the other in a 77-year-old patient who presented with a previously irradiated and incompletely excised cancer. A single instance of locally recurrent cancer required an abdominal perineal resection. There were no other recurrences. Overall, three patients required a stoma (7%). Conclusion: Transanal endoscopic microsurgery promises to offer a safe and effective option for the selective treatment of patients with rectal cancer after preoperative chemoirradiation, and for the management of tumors suspicious for rectal cancer. Transanal endoscopic microsurgery used selectively can reduce the need for major abdominal surgery and colostomy.     

经肛门内镜微创手术的临床应用现状及前景展望

随着人们对健康关注度的提高及术前影像学（如超声内镜、CT、MRI 等）的广泛应用,越来越多的直肠肿瘤患者特别是 Tis期、T1期、直肠良性腺瘤患者被发现。由于外科手术器械及手术技巧的重大进步,经肛门内镜微创手术（TEM）逐渐成为治疗 Tis 期、T1期、直肠良性腺瘤的首选手术方式,国内外部分医院已开展这项手术。而新辅助放化疗联合 TEM 能否用于 T2期直肠癌的治疗是目前人们关注的焦点。本文综述近30年来 TEM 的临床应用并展望其治疗直肠恶性肿瘤的前景。     

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.     

An evaluation of transanal endoscopic microsurgery for rectal adenoma and carcinoma.

BACKGROUND: Transanal endoscopic microsurgery was introduced in the early 1980s. Since then, increasing numbers of rectal adenomas are being excised by this technique. The aim of this study was to evaluate our institution's experience with transanal endoscopic microsurgery for rectal adenoma and carcinoma. METHODS: Seventy-five patients (adenomas, n = 58) underwent more than 90 TEM resections over a period of 5 years. RESULTS: Postoperative complications were minimal with 3% (n = 2) in the adenoma group requiring transfusion and 0% 30-day mortality. One patient in each group developed transient fecal incontinence. During the follow-up period, 6 patients (10%) in the adenoma group underwent further local resections for their recurrences. Two patients in the carcinoma group (1 each of pathological T1 and T2 stage) developed recurrence at 24 months. A female with a T2 tumor was found to have an inoperable lesion and underwent sigmoid colostomy. Five of 17 patients had postoperative radiotherapy, and 2 patients developed radiation enteritis. Four patients died during follow-up due to unrelated reasons. CONCLUSION: The transanal endoscopic microsurgery technique appears to be safe and associated with minimal morbidity. Careful selection of patients with thorough preoperative assessment is necessary for carcinoma patients. Patients with T1 lesions and favorable histology should only be considered for curative resection by this technique.     

直肠癌经肛门内镜显微手术疗效及复发危险因素分析

目的 分析直肠癌经肛门内镜显微手术（TEM）疗效及复发危险因素,以探讨直肠癌TEM适应证.方法 对2006年6月至2009年6月间山东省千佛山医院胃肠外科收治的60例行TEM的直肠癌患者的临床资料进行回顾性分析.结果 本组直肠癌pTis期12例,pT1期38例 pT2期10例.全部病灶均一次性全层整块切除,标本切缘均阴性.手术时间30～190（65.0±36.5）min,术中失血量9～75（10.5±5.8）ml,住院时间3～9（4.5±2.7）d,无手术死亡和严重并发症出现.随访时间12～48（平均28.5）个月,无一例死亡.pTis患者均未现复发 38例pT1期患者中1例（2.6%）出现局部复发 10例pT2期患者中有4例（40.0%）出现局部复发,显著高于pT1期患者（P＜0.05）.肿瘤直径大于3 cm的21例患者中有4例复发,显著高于肿瘤直径小于3 cm者（1/39,P＜0.05）.多因素复发危险因素分析证实,浸润深度和肿瘤大小是TEM术后复发的独立风险因素.结论 对pTis、pT1期及肿瘤小于3 cm的早期直肠癌患者,TEM安全有效,值得推广.     

A prospective randomized study with a 5-year minimum follow-up evaluation of transanal endoscopic microsurgery versus laparoscopic total mesorectal excision after neoadjuvant therapy

Background This study aimed to compare the oncologic results for local excision via transanal endoscopic microsurgery (TEM) and those for laparoscopic resection (LR) via total mesorectal excision in the treatment of T₂ N₀, G_1-2 rectal cancer after neoadjuvant therapy with both treatments, incorporating a 5-year minimum follow-up period. Methods The study enrolled 70 patients whose malignancy was staged at admission as T₂ N₀, G_1-2 rectal cancer located within 6 cm of the anal verge with a tumor diameter less than 3 cm. Of these patients, 35 were randomized to TEM and 35 to LR. The patients in both groups previously had undergone high-dose radiotherapy (5,040 cGy in 28 fractions over 5 weeks) combined with continuous infusion of 5-flurouracil (200 mg/m²/day). Results The median follow-up period was 84 months (range, 72–96 months). Two local recurrences (5.7%) were observed after TEM and 1 (2.8%) after LR. Distant metastases (2.8%) occurred in one case each after TEM and LR. The probability of survival for rectal cancer was 94% for TEM and 94% for LR. Conclusions The study shows similar results between the two treatments in terms of local recurrences, distant metastases, and probability of survival for rectal cancer. An erratum to this article can be found at