Transanal endoscopic microsurgery: indications, results and controversies

Dias, André Roncon; Nahas, Caio Sérgio Rizkallah; Marques, Carlos Frederico Sparapan; Nahas, Sérgio Carlos; Cecconello, Ivan

doi:10.1007/s10151-009-0466-6

Cited by 53 publications

(41 citation statements)

References 48 publications

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“…In our series, the cases in which abdominal surgery was not contraindicated were promptly referred for total mesorectal excision. Of the 9 patients who underwent immediate further abdominal surgery, 3 (33%) died of the disease, in line with that reported elsewhere [9,12,14,34]. On the other hand, in a recent multicenter study, when TME followed TEM, the odds of recurrence were reduced 15-fold [30].…”

Section: Discussionsupporting

confidence: 82%

“…Unfortunately, the conventional transanal excision is characterized by a high incidence of remnant disease or early recurrence [8,9]. For more than 25 years, transanal endoscopic microsurgery (TEM) had revolutionized the technique and outcome of transanal surgery, becoming the standard of treatment for large rectal adenomas [10][11][12], then offering a possibly curative treatment for early rectal cancer [13,14], and, finally, generating discussion on the potential role in the treatment of more invasive cancer in combination with neoadjuvant treatments [15][16][17][18]. The aim of this study was to identify risk factors associated with local recurrence after TEM and consequently to improve selection criteria for TEM.…”

Section: Introductionmentioning

confidence: 99%

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Risk factors for recurrence after transanal endoscopic microsurgery for rectal malignant neoplasm

et al. 2011

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BackgroundIndications and results of local excision of rectal lesions are currently under debate. Transanal endoscopic microsurgery (TEM), allowing a precise, full-thickness excision, could improve oncological results in early rectal tumors. Methods A prospective database was analyzed with the intent to identify risk factors for recurrence after TEM. Results Among 355 patients subjected to TEM, 107 had an adenocarcinoma: 48 pT1, 43 pT2, and 16 pT3. Comparing pre-and postoperative data, histological discrepancy was 20% and staging discrepancy was 34%. Mortality was nil, morbidity was 9%. Mean follow-up was 54.2 months (range = 12-164), follow-up rate was 100%. The 5-year disease-free survival rate was 85.9, 78.4, and 49.4% for pT1, pT2, and pT3, respectively (p = 0.006). Recurrence rate was 0% (0/26) in pT1sm1 cancers and 22.7% (5/22) in sm2-3 (p < 0.05). A submucosal infiltration represented a significant risk factor for recurrences: 0% sm1, 16.7% sm2, and 30% sm3. Recurrence in pT2 was 0% in patients who had neoadjuvant therapy and 26% in the others. At univariate analysis, diameter, sm stage, pT stage, tumor grading, margin infiltration, and lymphovascular invasion demonstrated statistical significance. Multivariate analysis indicated sm stage, pT stage, and tumor grading as independent predictors of recurrence. Conclusions TEM represents an effective curative treatment for pT1 sm1 rectal malignancies. pT1 sm2-3 patients should be considered high-risk cases if treated only by TEM. A consistent improvement in the preoperative assessment of the risk factors identified by the present study will be a crucial development for optimal treatment of early rectal cancers. Keywords Transanal endoscopic microsurgery Malignant rectal neoplasm Recurrence Risk factors The goal of oncological surgery is to achieve the best cancer control with preservation of function and quality of life. In the field of malignant rectal neoplasms, radical resection, consisting of anterior resection with total mesorectal excision (TME) when feasible and abdominoperineal resection (APR) when mandatory, represents the best curative treatment. Nevertheless, these procedures are burdened with a consistent morbidity rate, including genitourinary and sexual dysfunction (30-40%) [1][2][3][4], anastomotic leakage (5-17%) [5], and long-term functional bowel disturbance [6]. Up to 40% of patients experience perineal wound complications and long-term discomfort following APR, while stoma and stoma appliance-related complications occur in up to 66%. There is also significant psychological morbidity associated with change in body image and depression in 30% [7].A transanal approach to rectal malignant neoplasms, if suitable, would lower risks and improve functional results. Unfortunately, the conventional transanal excision is characterized by a high incidence of remnant disease or early recurrence [8,9]. For more than 25 years, transanal endoscopic microsurgery (TEM) had revolutionized the technique and outcome of transanal surgery, becoming the ...

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Section: Discussionsupporting

confidence: 82%

Section: Introductionmentioning

confidence: 99%

Risk factors for recurrence after transanal endoscopic microsurgery for rectal malignant neoplasm

et al. 2011

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“…The reports of even complete responders, rendering surgery unnecessary or at least limiting the extent of the surgical procedure, could challenge the neoadjuvant strategies to further refinement. Limited surgical approach such as TEM (Transanal Endoscopic Microsurgery) can be an option for selected patients with small and early tumours which have favourable characteristics [5,6]. Neoadjuvant treatment has then been used in this setting to improve local control [7].…”

Section: Introductionmentioning

confidence: 99%

A phase I/II study of neoadjuvant chemotherapy with Pemetrexed (Alimta) in rectal cancer

Derwinger

Kodeda

Swartling

et al. 2011

European Journal of Surgical Oncology (EJSO)

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AimThe aim was to assess the feasibility of preoperative chemotherapy and possible tumour response using Pemetrexed (Alimta) in rectal cancer. MethodThe study was a prospective, non-randomized, single centre phase I/II feasibility trial. 37 patients with resectable rectal cancer were recruited and given three 3 week cycles of preoperative Pemetrexed therapy. Tumour size and stage were assessed by MRI scans before and after chemotherapy. Treatment tolerability and response such as changes in tumour size and symptoms were assessed. ResultsAll patients completed the chemotherapy. Whilst mild side effects were frequent (grade 1, 34/37), the risk of severe effects was limited (grade 3 or 4, 4/37). Overall, there was a significant reduction in tumour size (p<0.001). By RECIST criteria, one patient had tumour progression, 23/36 had stable disease and 12 patients had a response of up to 65%. There was also a significant decrease in the number of pretreatment symptoms (p<0.018) including reduction of bleeding and diarrhoea/constipation. ConclusionPreoperative (Neoadjuvant) treatment with Pemetrexed was feasible in studied patients. Serious side effects were limited and a radiological tumour response or stable disease was seen in a majority of patients.

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“…If peritoneum is entered, the defect should be always closed, while the resection bed below the peritoneal reflection, may be left open [64] . Finally, the surgical specimen is pinned out and oriented for pathological analysis of the margins [74] . TEM has not become universally adopted by colorectal surgeons due to the considerable cost of the apparatus and the steep learning curve required for the mastering of the technique [75] .…”

Section: Surgical Techniquementioning

confidence: 99%

Low rectal cancer: Sphincter preserving techniques-selection of patients, techniques and outcomes

Dimitriou

Michail

Moris

et al. 2015

WJGO

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Low rectal cancer is traditionally treated by abdominoperineal resection. In recent years, several new techniques for the treatment of very low rectal cancer patients aiming to preserve the gastrointestinal continuity and to improve both the oncological as well as the functional outcomes, have been emerged. Literature suggest that when the intersphincteric resection is applied in T1-3 tumors located within 30-35 mm from the anal verge, is technically feasible, safe, with equal oncological outcomes compared to conventional surgery and acceptable quality of life. The Anterior Perineal PlanE for Ultra-low Anterior Resection technique, is not disrupting the sphincters, but carries a high complication rate, while the reports on the oncological and functional outcomes are limited. Transanal Endoscopic MicroSurgery (TEM) and TransAnal Minimally Invasive Surgery (TAMIS) should represent the treatment of choice for T1 rectal tumors, with specific criteria according to the NCCN guidelines and favorable pathologic features. Alternatively to the standard conventional surgery, neoadjuvant chemo-radiotherapy followed by TEM or TAMIS seems promising for tumors of a local stage T1sm2-3 or T2. Transanal Total Mesorectal Excision should be performed only when a board approved protocol is available by colorectal surgeons with extensive experience in minimally invasive and transanal endoscopic surgery. Core tip: The present review presents the most recent advances in the field of sphincter preserving surgery for the treatment of low rectal cancer patients, providing indications, patients' selection, surgical techniques, multimodality approaches, postoperative course and oncological and functional outcomes. In particular, the review focuses on data deriving from prospective EDITORIAL

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Transanal endoscopic microsurgery: indications, results and controversies

Cited by 53 publications

References 48 publications

Risk factors for recurrence after transanal endoscopic microsurgery for rectal malignant neoplasm

Risk factors for recurrence after transanal endoscopic microsurgery for rectal malignant neoplasm

A phase I/II study of neoadjuvant chemotherapy with Pemetrexed (Alimta) in rectal cancer

Low rectal cancer: Sphincter preserving techniques-selection of patients, techniques and outcomes

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