Eight years experience of transanal endoscopic microsurgery

Introduction: Transanal Endoscopic Microsurgery (TEM) is a minimally invasive method for management of different proctologic conditions. Despite widespread use of this method, it is not used widely in Iran. This report is about to describe the application of TEM in managing different proctologic conditions in a tertiary colorectal referral center in Iran regarding methods and complications. Methods: All of the patients' documents such as procedure, method, early postop complications and further operations were actively reviewed and the data were entered in to the database. Results: Since 2012 till the end of 2020 chart review was done and 150 cases of TEM operation were found. The most frequent procedure that was done was resection procedure. Using different energy devices during surgery or suturing versus not suturing the defect were not associated with complication. There was a case of in hospital mortality and one case delayed perianal fistula following TEM. Measurement of lesion distance from anal verge was not significantly different using TEM or colonoscopy. Villous adenomas detected in colonoscopy were mostly associated with malignancy. In evaluated resected lesions most of cases had free base and distance from anal verge or using different energy devices were not associated with obtaining free base. Conclusion: TEM is a safe minimal invasive procedure with acceptable complications that could be helped in managing different proctologic conditions and the results of reviewing our patients revealed the same results that is reported from other colorectal centers. (AU)

Microcirugía transanal endoscópica en el tratamiento para el cáncer del recto / Transanal Endoscopic Microsurgery for Treating Rectal Cancer

Introducción: La microcirugía transanal endoscópica es un procedimiento mínimamente invasivo que se aplica para el tratamiento local del cáncer del recto en estadios iniciales. Su utilización en estadios más avanzados del cáncer del recto resulta controversial. Sin embargo, con el uso rutinario del tratamiento neoadyuvante constituye una opción atractiva que se ha comenzado a considerar. Objetivo: Evaluar los resultados de la microcirugía transanal endoscópica para el tratamiento del cáncer del recto en el Centro Nacional de Cirugía de Mínimo Acceso. Métodos: Se realizó un estudio retrospectivo de una base de datos prospectiva de 18 años. La muestra fue de 150 pacientes que cumplieron con los criterios de selección y las variables estudiadas fueron: edad, sexo, indicación, tiempo quirúrgico, entre otras. Resultados: La principal indicación fue el adenocarcinoma del recto T1. La edad media fue 63 años (32-93); el tiempo quirúrgico, 76 minutos (25-240) y el tamaño tumoral, 2,8 cm (1-4). La estancia hospitalaria fue de 1 día (12 horas-7 días), la morbilidad fue 6,7 porciento y las principales complicaciones posoperatorias fueron el sangramiento, la dehiscencia de sutura, el absceso, la fístula rectovaginal y la estenosis. La recurrencia local fue 8,2 porciento, 7,1 porciento y 2,5 porciento para los adenocarcinomas T1, T2 y T3 respectivamente. La supervivencia global a los 5 años fue 97,5 porciento y la supervivencia libre de enfermedad fue 95,5 porciento. Conclusión: La microcirugía transanal endoscópica es una técnica factible y segura en el tratamiento de los adenocarcinomas T1, mientras que en los T2 y T3 se requiere de la radioquimioterapia preoperatoria(AU)

Introduction: Transanal endoscopic microsurgery is a minimally invasive procedure applied for the local treatment of rectal cancer at early stages. Its use in more advanced stages of rectal cancer is controversial. However, with the routine use of neoadjuvant treatment, it is an attractive option that has begun to be considered. Objective: To assess the outcomes of transanal endoscopic microsurgery for the treatment of rectal cancer at Centro Nacional de Cirugía de Mínimo Acceso. Methods: A retrospective study of an 18-year prospective database was performed. The sample consisted of 150 patients who met the selection criteria and the variables studied were age, sex, indication, surgical time, among others. Results: The main indication was T1 rectal adenocarcinoma. The mean age was 63 years (32-93); surgical time, 76 minutes (25-240); and tumor size, 2.8 cm (1-4). Hospital stay was 1 day (12 hours-7 days), morbidity was 6.7 percent, and the main postoperative complications were bleeding, suture dehiscence, abscess, rectovaginal fistula and stenosis. Local recurrence was 8.2 percent, 7.1 percent and 2.5 percent for T1, T2 and T3 adenocarcinomas, respectively. Overall survival at 5 years was 97.5 percent and disease-free survival was 95.5 percent . Conclusion: Transanal endoscopic microsurgery is a feasible and safe technique for treating T1 adenocarcinomas, while T2 and T3 adenocarcinomas require preoperative radiochemotherapy(AU)

La escisión total del mesorrecto transanal en el tratamiento del cáncer del recto como nueva técnica en Cuba / Total Excision of the Transanal Mesorectum as a New Technique for Treating Rectal Cancer in Cuba

Introducción: Las indicaciones de la Microcirugía Transanal Endoscópica han evolucionado desde la cirugía de tumoraciones rectales hasta otras enfermedades pélvicas. La asociación de esta y la escisión total del mesorrecto transanal ofrece una serie de ventajas. Objetivo: Determinar las indicaciones, describir la técnica quirúrgica y mostrar los resultados a largo plazo obtenidos en la realización de la escisión total del mesorrecto transanal en el tratamiento del cáncer del recto medio y bajo. Métodos: Se realizó un estudio observacional descriptivo y prospectivo de los pacientes con cáncer del recto medio y bajo sometidos a esta técnica quirúrgica en el período comprendido entre febrero de 2017 y febrero de 2022 en el Centro Nacional de Cirugía de Mínimo Acceso. Resultados: Se operaron 13 pacientes, 9 con cáncer del recto bajo y 4 con cáncer del recto medio y un promedio de edad de 56,2 años (rango 28-76). El promedio de tiempo quirúrgico fue de 183 minutos (rango 120-270) y las pérdidas hemáticas estimadas de 68 mililitros. La incidencia de morbilidad mayor fue de 15,4 por ciento y la media de estadía hospitalaria de 5,4 días. La media del período de seguimiento fue de 35 (rango 9-69) meses con una recidiva local de 7,7 por ciento y una supervivencia global a los 5 años de 100 por ciento. Conclusiones: La escisión total del mesorrecto transanal combinado con cirugía laparoscópica es una técnica factible y segura. La introducción de la variante técnica utilizando el instrumental de la Microcirugía Transanal Endoscópica es más ergonómica y disminuye los costos(AU)

Introduction: The indications for transanal endoscopic microsurgery have evolved from surgery of rectal tumors to other pelvic diseases. The association between this and total excision of the transanal mesorectum offers a series of advantages. Objective: To determine the indications, to describe the surgical technique and to show the long-term outcomes obtained in the performance of total excision of the transanal mesorectum for treating cancer of the middle and lower rectum. Methods: A descriptive and prospective observational study was carried out of patients with cancer of the middle and lower rectum who underwent this surgical technique in the period from February 2017 to February 2022 at Centro Nacional de Cirugía de Mínimo Acceso. Results: Thirteen patients were operated on, 9 with cancer of the lower rectum and 4 with cancer of the middle rectum, as well as an average age of 56.2 years (range 28-76). The average surgical time was 183 minutes (range 120-270) and estimated blood loss was 68 milliliters. The incidence of highest morbidity was 15.4 percent and mean hospital stay was 5.4 days. The median follow-up period was 35 (range 9-69) months, with a local recurrence of 7.7 percent and an overall 5-year survival of 100 percent . Conclusions: Total excision of the transanal mesorectum combined with laparoscopic surgery is a feasible and safe technique. The introduction of the variant technique using the instruments of endoscopic transanal microsurgery is more ergonomic and reduces costs(AU)

Excisão total de mesorreto transanal combinada à dissecção laparoscópica: resultados perioperatórios e avaliação da qualidade do mesorreto / Transanal total mesorectal excision combined with laparoscopic dissection: perioperative results and assessment of the mesorectal quality

RESUMO Objetivo: avaliar os resultados perioperatórios e pós-operatórios relacionados à excisão total do mesorreto transanal, bem como, qualidade dos espécimes obtidos pela excisão total do mesorreto transanal através da análise histopatológica da qualidade do mesorreto, acometimento das margens proximal e distal e positividade da margem circunferencial. Métodos: estudo prospectivo, descritivo, em pacientes consecutivos portadores de adenocarcinoma de reto localizados até 10cm da borda anal, sem metástase à distância, submetidos ou não à quimioterapia e radioterapia neoadjuvantes. Foram avaliados a presença de dificuldades técnicas, índice de conversão para via abdominal, tempo cirúrgico e intercorrências intra e pós-operatórias. A qualidade do mesorreto foi classificada em ressecção completa, parcialmente completa ou incompleta. Resultados: entre dezembro de 2016 e maio de 2019, 41 pacientes foram submetidos à excisão total do mesorreto transanal, dos quais 75% foram classificados como estágio clínico III, 13% estágio clínico II e 12% estágio clínico I. A média de distância entre borda anal e borda inferior do tumor foi de 6,2cm. Quarenta por cento dos tumores encontravam-se na parede retal anterior e 17% foram classificados como circunferenciais. A média de tempo operatório foi de 189 minutos. A média de internação hospitalar foi de 4,6 dias. Não houve óbitos intra-hospitalares. Oitenta e dois por cento dos espécimes foram classificados como ressecção completa. Conclusão: a excisão total do mesorreto transanal demonstra adequada qualidade do mesorreto e adequadas margens cirúrgicas, estando associada a baixos índices de complicações perioperatórias, tempo cirúrgico aceitável e curto tempo de hospitalização.

ABSTRACT Objective: to assess the perioperative and postoperative results of transanal total mesorectal excision, as well as the quality of the specimens obtained by this technique. Methods: we conducted a prospective, descriptive study in consecutive patients with rectal adenocarcinoma located up to 10cm from the anal verge, without distant metastasis, subjected or not to neoadjuvant chemoradiotherapy. We evaluated the presence of technical difficulties, conversion to open abdominal route, surgical time and intra and postoperative complications. Through histopathological analysis, we assessed the quality of the mesorectum, involvement of the proximal and distal margins and positivity of the circumferential, classifying quality of the mesorectum as complete, partially complete or incomplete resection. Results: between December 2016 and May 2019, 41 patients underwent transanal total mesorectal excision, of which 75% were classified as clinical stage III, 13% clinical stage II and 12% clinical stage I. The average distance between the anal verge and the lower border of the tumor was 6.2cm. Forty percent of the tumors were in the anterior rectal wall and 17% were circumferential. The average operative time was 189 minutes. The average hospital stay was 4.6 days. There were no in-hospital deaths. Eighty-two percent of the specimens were classified as complete resection. Conclusion: transanal total mesorectal excision demonstrates adequate specimen quality and surgical margins, being associated with lower rates of perioperative complications, acceptable surgical time and short hospitalization.

An initial exploration of the application of transanal endoscopic microsurgery in rectal cancer patients with clinical complete response after neoadjuvant chemoradiotherapy / 中华胃肠外科杂志

Objective@#To preliminarily explore the value of transanal endoscopic microsurgery (TEM) in rectal cancer patients with clinical complete response (cCR) following neoadjuvant chemoradiotherapy (nCRT).@*Methods@#Using descriptive case series method, Clinical data of 13 patients who met the criteria of nCRT and were considered to be cCR after MRI or CT scanning, digital rectal examination and colonoscopic biopsy, as well as no lymph node or distant metastasis were found, then underwent TEM from 2013 to 2016 at the Department of General Surgery of Peking Union Medical College Hospital were collected retrospectively. A 3-course combination of capecitabine and oxaliplatin (XELOX) was used for chemotherapy. Besides, a 6MV-X ray radiation was used as radiotherapy simultaneously. Six to eight weeks after completion of radiotherapy, a preoperative assessment was carried out with intrarectal ultrasound, MRI, or pelvic abdominal CT examination. TEM was performed afterwards with informed consent. Postoperative pathological findings and follow-up results were used to evaluate the value of diagnosis and treatment of TEM on those patients.@*Results@#There were 8 males and 5 females with a median age of 63 (27-80) years. Preoperative examination showed that the lesions were located in the anterior wall in 3 cases, the posterior wall in 3 cases, the left side wall in 4 cases, and the right side wall in 3 cases. Before nCRT, the distance between tumor and anal margin was (4.8±1.1) (2.0-7.5) cm; after nCRT, this distance was (5.2±1.3) (3.0-7.5) cm. All the 13 patients underwent extended local resection of rectal cancer via TEM with the placement of urethral catheter. The average operative time was (52.2±3.7) (42-70) minutes, and the average intraoperative blood loss was (19.2±2.8) (5-30) ml. All the patients could engage in daily activities on postoperative day 1, and could cater themselves orally on postoperative day 2. The main discomfort was postoperative anal pain and foreign body sensation (n=5), which could be alleviated by non-steroidal anti-inflammatory drugs. One case had postoperative lung infection and was cured by antibiotic treatment. One case had urinary retention after removing urine catheter, and then a urine catheter was re-inserted. Average postoperative hospital stay was (2.8±2.4) (2-12) days. All specimens were completely resected via TEM. Histopathological examination confirmed that 7 specimens had achieved pathologic complete response (pCR) and the other 6 specimens had obtained partial tumor response of CAP grade 2. Seven patients with pCR received a median follow-up of 24 (8-48) months and no local recurrence or distant metastasis was reported during follow-up period. Among these 7 cases, one developed defecation dysfunction after discharge, mainly for defecation pain and even dare to defecate, who returned to normal defecation within 2 months after surgery; One developed severe anal pain within six months after surgery and the pain disappeared after symptomatic pain relief. The other 6 patients with CAP grade 2 refused to undergo further radical operation because of their strong desire in preserving anus, and received remedial adjuvant chemotherapy instead.@*Conclusion@#For rectal cancer patients with cCR after nCRT, TEM does have certain application values if the patient has a strong desire to preserve anus.

Continence changes following transanal endoscopic microsurgery result from the impact on rectal capacity: clinical and functional evaluation before and after surgical treatment / Alterações da continência após microcirurgia endoscópica transanal resultam do impacto sobre a capacidade retal: avaliação clínica e funcional antes e após tratamento cirúrgico

ABSTRACT Introduction: Described in 1983 and with a stable clinical application, the impact of Transanal Endoscopic Microsurgery on anorectal function remains unknown. The objectives of the present study were to evaluate the impact of Transanal Endoscopic Microsurgery on anorectal function according to clinical (Wexner score) and functional (anorectal manometry) evaluations before and after surgery. Method: Prospectively, 23 consecutive patients with rectal lesions were operated using TEO® equipment (Karl Storz, Tuttlingen, Germany). For all patients, the value of Wexner score was obtained before and after surgery (7, 30 and 90 days) and anorectal electromanometry was performed before surgery, and also postoperatively (30 and 90 days). Results: Fourteen patients were men. The mean age was 53.7 (24-81) years. The mean distance from the lesion to the pectineal line was 7 (2-15) cm. The histopathologic analysis revealed adenoma in 14 (61%); neuroendocrine tumor in 5 (21.7%); invasive carcinoma in 3 (13%); and hyperplastic polyp in 1 (4.3%) case. The mean duration of postoperative follow-up was 5 (3-7) months. Wexner score was significantly lower at 30 days compared to 7 days (Wilcoxon; p = 0.03). Rectal capacity was significantly lower 30 days after surgery and recovered at 90 days of surgery (ANOVA; p = 0.04). Conclusions: After Transanal Endoscopic Microsurgery, a modest impact on anorectal function can be observed. The transient impairment results from loss of rectal capacity and not from impairment of the anal sphincters, being completely resolved 90 days after surgery.

RESUMO Introdução: Descrita em 1983 e de sólida aplicação clínica, o impacto da Microcirurgia Endoscópica Transanal sobre a função anorretal permanece pouco conhecido. Os objetivos do presente estudo foram avaliar o impacto da Microcirurgia Endoscópica Transanal na função anorretal conforme avaliações clínica (Wexner score) e funcional (manometria anorretal) antes e após a cirurgia. Método: Prospectivamente, 23 pacientes consecutivos com lesões retais foram operados com o uso do equipamento TEO® (Karl Storz, Tuttlingen, Alemanha). Para todos os pacientes, o valor do escore de Wexner foi obtido antes e após a cirurgia (7, 30 e 90 dias) e a eletromanometria anorretal foi realizada antes da cirurgia e também no pós-operatório (30 e 90 dias). Resultados: Quatorze pacientes eram homens. A idade média foi 53,7 (24-81) anos. A distância média da lesão à linha pectínea foi de 7 (2-15) cm. A histopatológica revelou adenoma em 14 (61%), tumor neuroendócrino em 5 (21,7%); carcinoma invasivo em 3 (13%) e pólipo hiperplásico em 1 (4,3%) caso. A duração média do seguimento pós-operatório foi de 5 (3-7) meses. O escore de Wexner foi significativamente menor aos 30 dias em comparação com 7 dias (Wilcoxon; p = 0,03). A capacidade retal foi significativamente menor aos 30 dias após a cirurgia e recuperada aos 90 dias após a cirurgia (ANOVA; p = 0,04). Conclusões: Após Microcirurgia Endoscópica Transanal, um impacto modesto na função anorretal pode ser observado. O comprometimento transitório resulta de perda de capacidade retal e não por comprometimento dos esfíncteres anais cessando completamente 90 dias após a cirurgia.

Abordaje microquirúrgico transanal. Experiencia inicial. Indicaciones y resultados / Transanal microsurgical approach. Initial experience. Indications and results

Introducción: El tratamiento quirúrgico de las afecciones del recto bajo se encuentra en permanente revisión intentando mantener una adecuada función de continencia y urogenital. Una opción reciente es el abordaje microquirúrgico transanal. El objetivo del trabajo es evaluar una serie de pacientes tratados mediante dicho abordaje, analizando indicaciones, resultados inmediatos y alejados. Material y método: Se seleccionaron 41 pacientes operados en el período comprendido entre febrero de 2009 y febrero de 2015. Resultados: En 41 pacientes, las afecciones tratadas fueron: pólipos, 22; cáncer de recto, 14; estenosis de anastomosis, 2; absceso retrorrectal, 1; endometriosis, 1; poliposis adenomatosa familiar, 1. Los pacientes con pólipos llegaron a consulta: por primera vez, 15; recidivados, 4; segunda recidiva, 2; tercera recidiva, 1. Los procedimientos realizados fueron: resección local, 29; microcirugía transanal transabdominal (TATA), 6; dilatación de estenosis, 4; biopsia transrectal, 3; drenaje de absceso retrorrectal, 1; control de hemorragia, 1; colocación de stent, 1. En cáncer de recto: resección local, 7; biopsia transrectal, 2; TATA, 4; colocación de stent, 1. El tiempo operatorio promedio fue 48,6 minutos, y la estadía hospitalaria promedio 2,21 días. De los 29 pacientes en quienes se realizó resección local, fueron controlados 25 durante un período de 6 a 72 meses. Se complicaron 11 pacientes, sin mortalidad ni recidivas locales. Conclusiones: Este abordaje permite tratar lesiones del recto y último segmento del colon sigmoides. Otorga mejor visión permitiendo una disección más exacta, mejorando resultados postoperatorios inmediatos y alejados en patología benigna y maligna, minimizando la posibilidad de recidivas. (AU)

Introduction: The surgical treatment of conditions located at the low rectum is in constant review, triying to maintain proper urogenital and continence function. One of the most recent options is the transanal microsurgical. The aim of this paper is to analyze a series of patients treated with this approach, its indications, immediate and long term results. Material and Methods: 41 patients were analyzed retrospectively in the period between February 2009 and February 2015. Results: In these patients, treated conditions were polyps: 22; rectal cancer: 14; anastomotic stricture: 2; retrorectal abscess: 1; endometriosis: 1; familial adenomatous polyposis: 1. Patients affected with polyps reached the first consultation in 15 opportunities; 4 on first recurrence; 2 with second recurrence; 1 with third recurrence. The procedures were 29 local resections; 6 transanal transabdominal resections (TATA); 4 dilations of stenosis; 3 transrectal biopsies; 1 retrorectal abscess drainage; 1 hemorrhage control; 1 stent placement. In rectal cancer were: 7 local resection; 2 transrectal biopsies; 4 TATA; 1 stent placement. Mean operative time was 48.6 minutes and mean hospital stay was 2.21 days. Of the 29 patients in whom local resection was performed, 25 were controlled for a period of 6 to 72 months. 11 patients were complicated; no deaths or local recurrences were registered. Conclusions: This approach allows to treat lesions located throughout the rectum and the last segment of sigmoid colon. A better insight is obtained allowing a more accurate dissection, thus improving the immediate and remote postoperative results and minimizes the possibility of recurrence, particularly when it comes to benign conditions. (AU)

Pneumoretroperitoneum and Sepsis After Transanal Endoscopic Resection of a Rectal Lateral Spreading Tumor

Transanal endoscopic microsurgery is considered a safe, appropriate, and minimally invasive approach, and complications after endoscopic microsurgery are rare. We report a case of sepsis and pneumoretroperitoneum after resection of a rectal lateral spreading tumor. The patient presented with rectal mucous discharge. Colonoscopy revealed a rectal lateral spreading tumor. The patient underwent an endoscopic transanal resection of the lesion. He presented with sepsis of the abdominal focus, and imaging tests revealed pneumoretroperitoneum. A new surgical intervention was performed with a loop colostomy. Despite the existence of other reports on pneumoretroperitoneum after transanal endoscopic microsurgery, what draws attention to this case is the association with sepsis.

Transanal Endoscopic Microsurgery for Patients With Rectal Tumors: A Single Institution's Experience

PURPOSE: The purpose of this study was to look at our complication rates and recurrence rates, as well as the need for further radical surgery, in treating patients with benign and early malignant rectal tumors by using transanal endoscopic microsurgery (TEM). METHODS: Our study included 130 patients who had undergone TEM for rectal adenomas and early rectal cancer from December 2009 to December 2015 at the Department of Surgical Oncology, National Cancer Institute, Lithuania. Patients underwent digital and endoscopic evaluation with multiple biopsies. For preoperative staging, pelvic magnetic resonance imaging or endorectal ultrasound was performed. We recorded the demographics, operative details, final pathologies, postoperative lengths of hospital stay, postoperative complications, and recurrences. RESULTS: The average tumor size was 2.8 ± 1.5 cm (range, 0.5–8.3 cm). 102 benign (78.5%) and 28 malignant tumors (21.5%) were removed. Of the latter, 23 (82.1%) were pT1 cancers and 5 (17.9%) pT2 cancers. Of the 5 patients with pT2 cancer, 2 underwent adjuvant chemoradiotherapy, 1 underwent an abdominoperineal resection, 1 refused further treatment and 1 was lost to follow up. No intraoperative complications occurred. In 7 patients (5.4%), postoperative complications were observed: urinary retention (4 patients, 3.1%), postoperative hemorrhage (2 patients, 1.5%), and wound dehiscence (1 patient, 0.8%). All complications were treated conservatively. The mean postoperative hospital stay was 2.3 days. CONCLUSION: TEM in our experience demonstrated low complication and recurrence rates. This technique is recommended for treating patients with a rectal adenoma and early rectal cancer and has good prognosis.

Resección de tumoración rectal mediante cirugía transanal mínimamente invasiva (TAMIS) / Rectal tumor resected by transanal minimally invasive surgery (TAMIS)

La microcirugía endoscópica transanal (TEM, por sus siglas en inglés) es una técnica que se ha desarrollado desde los años 80 y tiene múltiples indicaciones. La cirugía transanal mínimamente invasiva (TAMIS, por sus siglas en inglés) se ha introducido como un enfoque alternativo al TEM, con las mismas indicaciones y algunas ventajas. Se reporta aquí el primer caso en Costa Rica de TAMIS, practicada exitosamente en un paciente de 85 años con una tumoración rectal de 4 cm de diámetro.

Transanal Endoscopic Microsurgery (TEM, for its acronym in English) is a technique developed in the 80s, which has many uses. Transanal Minimally Invasive Surgery (TAMIS, for its acronym in English) has been introduced as an alternative approach to TEM, with the same indications and some advantages. The case of an 85-yearold male with a 4 cm in diameter rectal tumor successfully resected by TAMIS is herein reported, which is the first case treated in this manner in Costa Rica.

Clinical efficacy of transanal endoscopic microsurgery for the rectal tumor / 中华消化外科杂志

Objective To explore the clinical efficacy of transanal endoscopic microsurgery (TEM) for the rectal tumor.Methods The clinical data of 35 patients with rectal tumors who were admitted to the Second Affiliated Hospital of Nanchang University between November 2012 and March 2014 were retrospectively analyzed.The preoperative endorectal ultrasonography (ERUS) was applied to patients for evaluating local invasion and lymph node metastasis,and confirming the pathological types of tumors,size and location of tumors,depth of invasion and with or without lymph node enlargement around the rectal wall,and then patients underwent TEMs.Patients were followed up by outpatient examination,telephone interview and instant messenger (WeChat) till August 2014.Results The tumors of 6 patients were located in the anterior wall of rectum,11 were in the posterior wall of rectum,9 were in the left and 9 in the right side walls of rectum.The diameter of tumor,distances between distal margin of tumor and anal verge,volume of intraoperative blood loss and operation time were (2.3 ± 0.9) cm (range,0.7-4.8 cm),(8 ±4)cm(range,4-17 cm),(32 ±19)mL (range,5-60 mL) and (79 ±35)minutes (range,31-150 minutes),respectively.Tumors with positive margin showed the negative margin after supplementary resection.All the patients didn't receive the specific analgesic therapy with the intake of liquid diets at postoperative day 1-3,and they were discharged after anal exsufflation.The duration of hospital stay was (4.2 ±1.2)days (range,2.0-9.0 days).The results of pathological examination showed that rectal adenoma were detected in 12 patients,rectal carcinoma in situ in 2 patients (Tis stage),rectal carcinoid in 2 patients,low-risk T1 stage of rectal cancer in 9 patients,high-risk T1 stage in 7 patients and T2 stage in 3 patients who received chemotherapy.Seventeen patients had postoperative complications,including 9 with perineum swelling and frequent defecation,4 with functional impairment of anal sphincter,2 with acute urinary retention and 2 with mild errhysis with the eased symptoms after symptomatic treatment.A total of 35 patients were followed up for 5-22 months with a median time of 11 months.The recurrence rate of rectal cancer was 2/19,including in the low-and high-risk T1 stage of 1/16 and in T2 stage of 1/3.Two of 12 patients without adjuvant therapy had recurrence of tumors,and other patients had no recurrence of tumors after adjuvant therapy.Conclusion TEM is safe and feasible in the treatment of rectal adenoma,carcinoma in situ,rectal carcinoid as well as rectal cancer in the low-and high-risk T1 stage.

Cost comparison between endoscopic submucosal dissection and transanal endoscopic microsurgery for the treatment of rectal tumors

PURPOSE: To compare medical costs of endoscopic submucosal dissection (ESD) and transanal endoscopic microsurgery (TEM) for the treatment of rectal tumors. METHODS: The records of 80 patients who underwent ESD and 32 who underwent TEM for the treatment of rectal tumors were collected. Factors compared in the two groups included patient age, sex and clinical characteristics, as well as hospital stay, procedure time, instrument use, medications, postoperative complications, and imaging and laboratory findings. Costs were analyzed based on medical insurance fees, as set publicly by the Ministry of Health & Welfare, Korea. Medical costs were also divided into patient copayments and National Health Insurance (NHI) Corporation charges. RESULTS: Patient characteristics, including age, sex, and comorbidities, were similar in the two groups, as were procedure time, histologic diagnosis, tumor size and distance from the anal verge, hospital stay, and complication rates. Median total hospital costs were significantly lower in the ESD than in the TEM group (1,214 United State dollars [USD] vs. 1,686 USD, P < 0.001). The costs for consumables, drugs and laboratory as well as operation fee were also significantly lower in the ESD than in the TEM group. However, patient copayments in the ESD group were significantly higher than in the TEM group (928 USD vs. 496 USD, P < 0.001), because ESD procedure for rectal tumors is not yet covered by the Korean NHI. CONCLUSION: Overall direct medical costs were significantly lower for ESD than for TEM in the treatment of rectal tumors.

Perioperative nursing of patients undergoing resection of rectal neoplasms with transanal endoscopic microsurgery / 现代临床护理

Objective To introduce the application and the surgical cooperation of the transanal endoscopic microsurgery in resection of rectal neoplasms and summarize the nursing points.Method The clinical histories of 135 patients undergoing resection of rectal neoplasms with transanal endoscopic microsurgery were reviewed and analyzed.Results All the surgeries were successful. Four patients developed with wound infections,three of them getting better after treatment and one of them diagnosed with poorly differentiated adenocarcinoma and selected another operation.Conclusion Well-prepared、pre-operation,skillful operation and instrument procedure and postoperative nursing were critical to the success of operations.

Transanal Endoscopic Microsurgery for the Treatment of Well-Differentiated Rectal Neuroendocrine Tumors

PURPOSE: Recently, an increase in well-differentiated rectal neuroendocrine tumors (WRNETs) has been noted. We aimed to evaluate transanal endoscopic microsurgery (TEM) for the treatment of WRNETs. METHODS: Between December 1995 and August 2009, 109 patients with WRNETs underwent TEM. TEM was performed for patients with tumors sizes of up to 20 mm and without a lymphadenopathy. These patients had been referred from other clinics after having been diagnosed with WRNETs by using a colonoscopic biopsy; they had undergone a failed endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR) and exhibited an involved resection margin and remaining tumor after ESD or EMR, regardless of the distance from the anal verge. This study included 38 patients that had more than three years of follow-up. RESULTS: The mean age of the patients was 51.3 +/- 11.9 years, the mean tumor size was 8.0 +/- 3.9 mm, and no morbidity occurred. Thirty-five patients were asymptomatic. TEM was performed after a colonoscopic resection in 13 cases because of a positive resection margin, a residual tumor or a non-lifting lesion. Complete resections were performed in 37 patients; one patient with a positive margin was considered surgically complete. In one patient, liver metastasis and a recurrent mesorectal node occurred after five and 10 years, respectively. CONCLUSION: TEM might provide an accessible and effective treatment either as an initial or as an adjunct after a colonoscopic resection for a WRNET.

Microcirurgia endoscópica transanal e tratamento adjuvante no câncer retal precoce / Transanal endoscopic microsurgery and adjuvant therapy in the treatment of early rectal cancer

RACIONAL: A excisão total do mesorreto é considerada a operação padrão no tratamento dos tumores do reto, apesar de não existir comprovação científica de que ela deva ser usada para todos os estádios da doença. Tem sido demonstrado que em casos escolhidos de tumores retais, resultados promissores podem ser conseguidos com tratamento local por microcirurgia endoscópica transanal. Tais tumores, denominados de câncer retal precoce, são tumores T1 - menores do que 4 cm -, bem diferenciados sem invasão angiolinfática pT1 Sm1. Como o risco de comprometimento linfonodal nesses tumores é de aproximadamente 3 por cento, a ressecção local teria grande chance de ser curativa. OBJETIVO: Apresentar os resultados de uma série prospectiva não randômica de pacientes portadores de câncer retal precoce submetidos ao tratamento local por microcirurgia endoscópica transanal. MÉTODOS: Entre 2002 e 2010, 38 pacientes avaliados por protocolo pré-operatório como portadores câncer retal precoce foram submetidos à ressecção local endoscópica microcirúrgica de toda a parede retal com o tumor quando localizado entre 2 e 8 cm da linha pectínea. A avaliação pré-operatória consistiu de toque retal, retossigmoidoscopia rígida para macrobiópsias, enema opaco e/ou colonoscopia, ultrassonografia endoretal e abdominal, tomografia axial computadorizada do abdome, radiografia do tórax e dosagem sérica do CEA. Realizou-se seguimento pós-operatório endoscópico e ultrassonográfico endoretal a cada três meses nos dois primeiros anos, e a cada seis nos próximos três anos, além de dosagem do CEA a cada seis meses nesse mesmo período de cinco anos. Avaliou-se a recidiva tumoral, morbidade e mortalidade. RESULTADOS: Após avaliação anatomopatológica da lesão, 29 cânceres retais precoces foram categorizados como de baixo risco e nove sendo de alto. O seguimento na série variou de um a sete anos. Recidiva tumoral foi confirmada em dois casos dos 38 (5,26 por cento), uma lesão considerada de alto...

BACKGROUND: The total mesorectal excision is considered the standard operation in the treatment of rectal tumors, although there is no scientific proof that it should be used for all stages of the disease. It has been demonstrated that in selected cases of rectal tumors, promising results can be achieved with local treatment by transanal endoscopic microsurgery. These tumors, called early rectal cancer, T1 tumors, are less than 4 cm, well differentiated without angiolymphatic invasion - pT1 SM1. As the risk of lymph node involvement in these tumors is approximately 3 percent, local resection would have a great chance to be curative. AIM: To present the results of a non-random prospective series of patients with early rectal cancer treated by transanal endoscopic microsurgery. METHODS: Between 2002 and 2010, 38 patients evaluated by preoperative protocol as patients with early rectal cancer underwent endoscopic microsurgical resection of the entire rectal wall including the tumor when located between 2 and 8 cm from the dentate line. The preoperative evaluation consisted of digital rectal examination, rigid sigmoidoscopy macrobiopsies, barium enema and/or colonoscopy, endorectal ultrasound and abdominal computed tomography of the abdomen, chest radiography and serum CEA. Was conducted follow-up with endoscopy and endorectal ultrasound every three months during the first two years, and every six in the next three years, and CEA every six months during the same period of five years. Was evaluated the tumor recurrence, morbidity and mortality. RESULTS: Pathologic evaluation considered 29 categorized as low risk and nine being high. The follow-up in the series ranged from one to seven years. Tumor recurrence was confirmed in two of the 38 cases (5.26 percent), in one the lesion was considered high and another low risk. CONCLUSION: Transanal endoscopic microsurgery associated or not to adjuvant therapy, may be, currently, considered the gold standard in...

Comparison of Conventional Transanal Resection with Transanal Endoscopic Microsurgery in Patients with Rectal Neoplasm / 대한내시경복강경외과학회지

PURPOSE: Compared to traditionally used abdominoperineal resection and low anterior resection for the treatment of rectal neoplasm, transanal excision (TAE) has several benefits such as a lower complication rate, a shorter average hospital stay and improved quality of life. Transanal endoscopic microsurgery (TEM) was recently introduced for resecting rectal neoplasm. The aim of this study was to compare the therapeutic results between TAE and TEM in patients with rectal neoplasm. METHODS: From October 2000 to December 2008, 115 patients underwent TEM or TAE at the NCC. Among the patient with rectal neoplasm, the patients with recurred rectal cancer and pathologic T2 or T3 stage were excluded. Thirty four and 33 patients were included for this study in the TAE and TEM groups, respectively. The locations of the lesion, the average number of fragmented specimens, the resection margin, postoperative complications and recurrence were retrospectively compared between the TEM and TAE groups. For the patients with T1 cancer, the disease-free survival rates were compared between the TAE and TEM groups. RESULTS: The median distance of lesions from the anal verge in the TEM group was higher than that in the TAE group: (mean distance: 6.75 cm, range: 3~15 cm) for TEM group and (mean distance: 3.13 (range: 1~8 cm) for the TAE group, p<0.001). The TAE group had more fragmented specimens than the TEM group (mean for the TAE: 1.44 (range: 1~4), mean for the TEM group: 1.06 (range: 1~2), p=0.031). For the patients with T1 cancer, the 3 year disease-free survival rate was not significantly different between the two groups (83.9% for the TAE group and 91.7% for the TEM group p=0.734). CONCLUSION: TEM can remove higher located rectal neoplasm and a less fragmented specimen was aquired that that in TAE. TEM seems to have similar oncologic outcomes as compared with TAE.

Transanal Endoscopic Microsurgery after Preoperative Concurrent Chemoradiation Therapy in Selected Distal Rectal Cancer Patients

PURPOSE: Preoperative concurrent chemoradiation (CCRT) therapy may allow higher rates of tumor resectability and sphincter-saving procedures. Transanal endoscopic microsurgery (TEM) has become increasingly common in the management of selected patients with early rectal cancer. The aim of this study is to evaluate the clinical outcomes of selected patients with distal rectal cancer treated with TEM after CCRT. METHODS: Between June 2000 and August 2004, 7 patients with clinically T2 or T3 rectal cancer underwent TEM after CCRT. Pretreatment and preoperative clinical stages were estimated by using endorectal ultrasound or computed tomography and digital rectal exam. CCRT was performed with radiation therapy of 4,500 cGy/25 fractions over 5 weeks with 5-FU based chemosensitization. TEM was performed 4~7 weeks following the completion of therapy. RESULTS: The mean age was 54.9 (35~70) years and the median follow-up period was 23.0 (5~57) months. The lesions were located between 2 to 6 cm above the anal verge (median 3.0 cm). Pre- treatment T staging was estimated as T3 in 1 case and T2 in 6 cases, and post-treatment T staging was estimated as complete remission (CR) in 2 cases, T1 in 3 cases, and T2 in 2 patients. Pathologic evaluation revealed tumor downstaging in 6 patients, including 3 patients (42.9%) with CR. In all cases, there was no tumor on the resection margin. There have been no recurrences during the follow-up period. CONCLUSIONS: TEM after CCRT therapy appears to be an effective alternative treatment to radical resection for highly selected patients with T2 and T3 distal rectal cancer.

Decision of Salvage Treatment after Transanal Endoscopic Microsurgery: Clinical Experience on 36 Cases of Rectal Cancer

PURPOSE: Local excision, including transanal endoscopic microsurgery (TEM), has become an alternative to the classic radical operation for early rectal cancer. However, radical resection for rectal cancer is necessary for advanced tumor, poor differentiation, a narrow resection margin, and positive lymphovascular invasion. This study presents the factors related to recurrence in patients who required secondary radical surgery after TEM, but did not undergo the operation. METHODS: From November 1994 to December 2004, 167 patients underwent TEM for rectal cancer. Thirty-six of those patients were included in this study. Inclusion criteria were poor differentiation, a mucinous carcinoma, invasion to a proper muscle layer, lymphovascular invasion, and a positive resection margin. RESULTS: Twelve of the 36 patients underwent a secondary radical operation, but 24 of them did not due to poor general condition or refusal. One of 12 patients (8.3%) who underwent a secondary radical operation had a systemic recurrence. Five of 24 patients (20.8%) who did not receive surgery had recurrences; 3 of 5 were local recurrence, and the others were distant metastases. Among the 24 patients who did not undergo a secondary radical operation, there were no recurrences in 2 cases of poor differentiation or mucinous carcinoma and in 2 cases of positive resection margin. There were 2 cases of recurrences in the 7 patients (25.0%) who had lymphovascular invasion, 1 case in the 1 patient (100%) who had a T3 lesion, 3 cases in the 17 patients (12.5%) who had T2 lesions. CONCLUSIONS: In high-risk patients, TEM followed by radical surgery is most beneficial in preventing local recurrence. A radical operation is strongly recommended especially if pathologic results after TEM shows T3 lesions or lymphovascular invasion.

Therapeutic Results of Transanal Endoscopic Microsurgery and Radical Surgery for T1, T2 Rectal Cancer

PURPOSE: Transanal endoscopic microsurgery (TEM) has gained increasing acceptance as a treatment of choice for 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 made regarding to recurrence and survival rate. Neither group received adjuvant chemo-radiation. There was no significant difference in age, gender, tumor location and follow-up period between two groups, except tumor size. RESULTS: Of 74 patients in TEM group, 52 patients were T1 (70.3%) and 22 patients were T2 (29.7%). Of 100 patients in radical surgery group, 17 patients were T1 (17.0%) and 83 patients were T2 (83.0%). Five-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 T1 rectal cancer (P=0.95), but in T2 rectal cancer, it was higher after TEM than after radical surgery (P=0.04). Five-year disease free survival rates showed no statistical difference between two groups (TEM group: 95.9% for T1, 80.5% for T2, radical surgery group: 94.1% for T1, 83.3%for T2; P=0.35, P=0.12). Five-year survival rate were 100% for T1, 94.7% for T2 after TEM and 92.9% for T1, 96.1% for T2 after radical surgery. There were no significant statistical difference between two groups (P=0.07, P=0.48). CONCLUSIONS: In T1 rectal cancer, there were no difference in recurrence and five-year survival rate between TEM and radical surgery group. In T2 rectal cancer, five-year survival rate showed no statistical difference between 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 after TEM, further treatment should be considered.

Clinical Results of Transanal Endoscopic Microsurgery (TEM)

PURPOSE: Local treatment of rectal tumors have become an alternative to the classic radical operation. However, conventional transanal procedures are limited to tumors located in the lower rectum and the precision of the excision is restricted by the limitation of the surgeon's visualization during the procedure. This report will present our surgical management and functional results after TEM, a new minimally invasive technique for the treatment of rectal tumors. METHODS: From December 1994 to January 2000, 136 patients underwent TEM. All patients were evaluated preoperatively with sigmoidoscopy or colonoscopy with biopsy. The indications for TEM were benign rectal tumors and T1 and T2 malignant rectal tumors with well or moderately differentiation. All patients were followed up 1 month postoperatively and every 3 months thereafter. RESULTS: The mean operation time was 56.5 minutes (25~150 minutes) and the mean postoperative hospital stay was 3.6 days (2~10 days). On the basis of the postoperative evaluations, 56 of the 136 patients proved to have benign tumors while the remaining 80 patients had malignant tumors. One hundred thirty five patients were removed with adequate resection margins. One patient had cancer cell involvement at the resection margin. There were no serious complications. After a mean observation time of 29 months (12~42 months), there were five noted recurrences. Functional results were excellent; 24 of the 136 patients complained of impaired continence or defecation disorders in a review one month postoperatively. These problems improved during the first 6 months after the surgery. CONCLUSIONS: We feel that TEM is an adequate method for removal of benign rectal tumors, and properly selected early rectal cancers.