Transanal Endoscopic Microsurgery Versus Standard Transanal Excision for the Removal of Rectal Neoplasms

Clancy, Cillian; Burke, John P.; Albert, Mathew R.; O’Connell, P. R.; Winter, Desmond C.

doi:10.1097/dcr.0000000000000309

Cited by 185 publications

(96 citation statements)

References 29 publications

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“…It also has the potential to further reduce the cost of TAMIS, since it is performed with a conventional laparoscopic video system, which is widely available in most institutions. Recently, a meta-analysis was performed of TEM vs. the standard TAE procedure (22). No difference was found between the techniques in the postoperative complication rate.…”

Section: Discussionmentioning

confidence: 99%

Transanal minimally invasive surgery (TAMIS) with a GelPOINT® Path for lower rectal cancer as an alternative to transanal endoscopic microsurgery (TEM)

Noura

Ohue

Miyoshi

et al. 2016

Molecular and Clinical Oncology

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Abstract. Transanal endoscopic microsurgery (TEM) is a minimally invasive technique. However, TEMhas not yet achieved widespread use. Recently, transanal minimally invasive surgery (TAMIS) using single-port surgery devices has been reported. In the present study, TAMIS using a GelPOINT ® Path was performed in six patients with lower rectal cancer. A complete full-thickness excision was performed in all cases. The patient characteristics, operative techniques and operative outcomes were evaluated. The mean age of the patients was 63.0 years (range: 48-76). The mean operating time and blood loss were 86 min (range: 55-110) and 5 ml (range 0-10), respectively. There were no instances of morbidity or mortality. Additional transabdominal rectal resection was not performed, and adjuvant chemoradiotherapy was performed in all cases. The mean Wexner score was 0.6 (range: 0-3; n=5) at 6 months, and 0 (range: 0; n=4) at 12 months. TAMIS using a GelPOINT ® Path was revealed to be easy and safe to perform. Although only a small number of cases were treated, the anal function following surgery was shown to be favorable, and the operation was demonstrated to be sufficiently feasible. Based on these results, TAMIS may, in time, assume a major role in the resection of large adenomas and early rectal cancers. IntroductionThe rectum is a challenging area for surgeons to operate on due to its limited access. Although advances in conventional surgery have broadened the choice of sphincter-preserving procedures, definitive colostomy is still necessary in 10-30% of patients (1). Furthermore, the postoperative morbidity and mortality rates remain high (2). Besides urinary dysfunction, the disturbance of bowel function proves a major problem in ~30% of patients (3,4).Benign neoplasia and early-stage rectal cancer located in the rectum have been traditionally managed with transanal excision (TAE) using a conventional instrument, such as a Parks retractor. This approach, however, has several limitations, as exposure and visibility within the rectal lumen curtail the surgeon's ability to perform a high-quality oncological excision. Since the introduction of transanal endoscopic microsurgery (TEM), which was first described by Buess et al (5), TEM has become the treatment of choice for benign lesions and early-stage cancers that are not suited to TAE using a conventional Parks retractor or flexible endoscope (6,7). TEM has also become a valuable option in selected patients with malignant rectal disease, in whom it may provide an acceptable oncological outcome with minimal postoperative morbidity and an improved functional outcome compared with standard radical resection (8,9). However, nearly 30 years after the introduction of TEM, this transanal platform has not achieved widespread adoption due to the cost and the complexity of the instruments, the steep learning curve and the requirement of specialized training to master the operation (10,11).Although the instruments and procedures that are used in resection with TEM have remained largel...

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Section: Discussionmentioning

confidence: 99%

Transanal minimally invasive surgery (TAMIS) with a GelPOINT® Path for lower rectal cancer as an alternative to transanal endoscopic microsurgery (TEM)

Noura

Ohue

Miyoshi

et al. 2016

Molecular and Clinical Oncology

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“…specifically, it has been demonstrated that le using any of the advanced transanal platforms (tem/transanal endoscopic operation/transanal minimally invasive surgery) results in less specimen fragmentation with a higher rate of completely intact, marginnegative excisions. 20,21,25 thus, the technique of using an advanced transanal platform seems to provide improved resection quality when compared with the Parks tae.…”

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confidence: 94%

Why the Conventional Parks Transanal Excision for Early Stage Rectal Cancer Should Be Abandoned

Atallah

Keller

2015

Diseases of the Colon &Amp; Rectum

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t he impetus for local excision (le) for early stage, histologically favorable rectal cancer stems from the early work by morson et al, 1 who, in 1977, demonstrated that curative-intent le could result in equivalent oncologic outcomes when compared with radical resection. it was also borne from data obtained in the 1990s from the Cancer and leukemia Group B (CalGB) 8984, 2 which, at the time, was the only prospective, multi-institutional study to lend credence to the concept of le for stage i rectal cancer.CalGB 8984 was a pendulum swing in the direction of organ preservation and it proposed a treatment paradigm analogous to the management of early stage breast cancer whereby the national surgical adjuvant Breast and Bowel Project-06 demonstrated that local treatment (ie, breast-conservation surgery coupled with adjuvant radiation) was equivalent to modified radical mastectomy. 3,4 CalGB 8984 accrued 180 patients, and 161 underwent le for cure of early stage rectal cancer using the fullthickness circumferential bowel wall removal technique of the primary lesion with perianal, transsphincteric, or transrectal approaches. use of an advanced platform, such as transanal endoscopic microsurgery (tem), 5 was not required, and whether it was used for any of the 161 patients who underwent curative-intent le was not reported.in this landmark study, patients with t1 cancer underwent le alone, whereas patients with t2 lesions underwent le followed by long-course external beam radiotherapy. the 6-year survival (85%) and failure-free rates (78%) for this treatment seemed acceptable, particularly during an era when local failure after standard oncologic resection with the abdominoperineal resection, in prospective series, had shown failure rates on the order of 20% to 30%. 6 thus, le seemed to be an attractive alternative to radical resection, the latter a procedure that was more invasive, inarguably more morbid, and at the time resulted in lackluster oncologic outcomes. 7 With the backing of CalGB 8984, and coupled with a frenzy toward minimally invasive surgical approaches that embraced the less-is-more doctrine, the rate of le for early stage rectal cancer increased at an alarming rate. 8 however, with the passage of the decades, it became clear that le for even the most appropriately selected stage i lesions (managed with the same approach set forth by CalGB) resulted in inferior outcomes, 8-10 and this even included the long-term data from CalGB that practically issued an about face on the recommendation of le for t2 cancer with adjuvant radiotherapy. 11 meanwhile, modern rectal cancer management, with the advent of the total mesorectal excision 12 and its eventual painstaking implementation, 13 was proving to be oncologically effective, with local recurrence rates after standard resection alone using total mesorectal excision falling to 7.1% for stage i disease. 14 With failures after le for cure significantly higher, 15,16 it left one to ponder this question: had the original, time-tested end points of rectal cancer sur...

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“…Since then it has gradually gained acceptance and replaced the standard transanal excision due to its benefits of quick learning curve and better augmentation of the excised area. In a meta-analysis, Clancy et al [73] proved better oncological results when using TEM instead of standard excision. TEM is consequently an established approach, which offers a stable operating platform with magnified stereoscopic view, thus allowing precise full-thickness excision of the rectal wall as far as 15-20 cm from the anal verge.…”

Section: Advanced Clinically Approved Laparoscopic Techniquesmentioning

confidence: 99%

Minimally Invasive Surgery for the Treatment of Colorectal Cancer

Karcz

Braun

2016

Visc Med

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Background: Reduction in operative trauma along with an improvement in endoscopic access has undoubtedly occupied surgical minds for at least the past 3 decades. It is not at all surprising that minimally invasive colon surgery has come a long way since the first laparoscopic appendectomy by Semm in 1981. It is common knowledge that the recent developments in video and robotic technologies have significantly furthered advancements in laparoscopic and minimally invasive surgery. This has led to the overall acceptance of the treatment of benign colorectal pathology via the endoscopic route. Malignant disease, however, is still primarily treated by conventional approaches. Methods and Results: This review article is based on a literature search pertaining to advances in minimally invasive colorectal surgery for the treatment of malignant pathology, as well as on personal experience in the field over the same period of time. Our search was limited to level I and II clinical papers only, according to the evidence-based medicine guidelines. We attempted to present our unbiased view on the subject relying only on the evidence available. Conclusion: Focusing on advances in colorectal minimally invasive surgery, it has to be stated that there are still a number of unanswered questions regarding the surgical management of malignant diseases with this approach. These questions do not only relate to the area of boundaries set for the use of minimally invasive techniques in this field but also to the exact modality best suited to the treatment of every particular case whilst maintaining state-of-the-art oncological principles.

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Transanal Endoscopic Microsurgery Versus Standard Transanal Excision for the Removal of Rectal Neoplasms

Abstract: Available data are limited because of a lack of randomized controlled trials. However, based on current evidence, transanal endoscopic microsurgery is oncologically superior to transanal excision for the excision of rectal neoplasms.

Cited by 185 publications

References 29 publications

Transanal minimally invasive surgery (TAMIS) with a GelPOINT® Path for lower rectal cancer as an alternative to transanal endoscopic microsurgery (TEM)

Transanal minimally invasive surgery (TAMIS) with a GelPOINT® Path for lower rectal cancer as an alternative to transanal endoscopic microsurgery (TEM)

Why the Conventional Parks Transanal Excision for Early Stage Rectal Cancer Should Be Abandoned

Minimally Invasive Surgery for the Treatment of Colorectal Cancer

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