Abstract
The resection of the rectum and its mesorectal envelope, an operation known as total mesorectal excision (TME), is the optimal surgical treatment for most rectal cancer patients. However, this procedure is associated with multiple complications and high rates of bowel and genitourinary alterations that significantly impact quality of life. In addition, some patients with early tumors that have not penetrated the rectal wall or reached the mesorectal lymph nodes may not benefit from TME. Some of these tumors, particularly those invading the submucosa but not beyond, can be treated by means of local excision (LE).
Transanal endoscopic microsurgery (TEM) was developed in the 1980s as a way to improve the outcomes of LE and expand the possibility of organ preservation for tumors located up to 20 cm from the anal verge. The TEM equipment provides direct vision through a stereoscopic rectoscope and allows precise excision and suturing with the help of specially designed instrumentation. Transanal endoscopic operation (TEO), which uses standard laparoscopic instrumention and insufflation, emerged later as a simplification of TEM.
In this chapter we offer a step-by-step description of the standard TEM/TEO technique, outline the different types of equipment used in TEM and TEO, and examine the technical limitations. We also provide an overview of the pre- and postoperative management and discuss outcomes.
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References
Heald RJ, Ryall RD. Recurrence and survival after total mesorectal excision for rectal cancer. Lancet. 1986;1(8496):1479–82.
Law WL, Chu KW. Anterior resection for rectal cancer with mesorectal excision: a prospective evaluation of 622 patients. Ann Surg. 2004;240(2):260–8.
Kneist W, Junginger T. Residual urine volume after total mesorectal excision: an indicator of pelvic autonomic nerve preservation? results of a case-control study. Colorectal Dis. 2004;6(6):432–7. doi:10.1111/j.1463-1318.2004.00711.x.
Shah EF, Huddy SP. A prospective study of genito-urinary dysfunction after surgery for colorectal cancer. Colorectal Dis. 2001;3(2):122–5.
Mellgren A, Sirivongs P, Rothenberger DA, Madoff RD, Garcia-Aguilar J. Is local excision adequate therapy for early rectal cancer? Dis Colon Rectum. 2000;43(8):1064–71; discussion 71–4.
Mason AY. Surgical access to the rectum—a transsphincteric exposure. Proc R Soc Med. 1970;63(Suppl):91–4.
Kraske P, Perry EG, Hinrichs B. A new translation of professor Dr P. Kraske’s Zur Exstirpation Hochsitzender Mastdarmkrebse 1885. Aust N Z J Surg. 1989;59(5):421–4.
Buess G, Hutterer F, Theiss J, Bobel M, Isselhard W, Pichlmaier H. [A system for a transanal endoscopic rectum operation]. Chirurg. 1984;55(10):677–80.
Lee W, Lee D, Choi S, Chun H. Transanal endoscopic microsurgery and radical surgery for T1 and T2 rectal cancer. Surg Endosc. 2003;17(8):1283–7. doi:10.1007/s00464-002-8814-x.
Serra Aracil X, Bombardo Junca J, Mora Lopez L, Alcantara Moral M, Ayguavives Garnica I, Navarro SS. Transanal endoscopic microsurgery (TEM). Current situation and future expectations. Cir Esp. 2006;80(3):123–32.
Hildebrandt U, Feifel G. Preoperative staging of rectal cancer by intrarectal ultrasound. Dis Colon Rectum. 1985;28(1):42–6.
Jorge JM, Wexner SD. Etiology and management of fecal incontinence. Dis Colon Rectum. 1993;36(1):77–97.
Mora Lopez L, Serra Aracil J, Rebasa Cladera P, Puig Divi V, Hermoso Bosch J, Bombardo Junca J, et al. [Anorectal disorders in the immediate and late postoperative period after transanal endoscopic microsurgery]. Cir Esp. 2007;82(5):285–9.
Serra-Aracil X, Mora-Lopez L, Alcantara-Moral M, Caro-Tarrago A, Gomez-Diaz CJ, Navarro-Soto S. Transanal endoscopic surgery in rectal cancer. World J Gastroenterol. 2014 Sep 7;20(33):11538–11545.
Winawer SJ, Zauber AG, Ho MN, O’Brien MJ, Gottlieb LS, Sternberg SS, et al. Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. N Engl J Med. 1993;329(27):1977–81. doi:10.1056/nejm199312303292701.
Zheng S, Liu XY, Ding KF, Wang LB, Qiu PL, Ding XF, et al. Reduction of the incidence and mortality of rectal cancer by polypectomy: a prospective cohort study in Haining County. World J Gastroenterol. 2002;8(3):488–92.
Serra-Aracil X, Caro-Tarrago A, Mora-Lopez L, Casalots C, Rebasa P, Navarro-Soto S. Transanal endoscopic surgery with total wall excision is required in rectal adenomas due to the high frequency of adenocarcinoma. Dis Colon Rectum. 2014;57(7):823–9.
Absar MS, Haboubi NY. Colonic neoplastic polyps: biopsy is not efficient to exclude malignancy. The Trafford experience. Tech Coloproctol. 2004;8 Suppl 2:s257–60. doi:10.1007/s10151-004-0172-3.
Barendse RM, van den Broek FJ, Dekker E, Bemelman WA, de Graaf EJ, Fockens P, et al. Systematic review of endoscopic mucosal resection versus transanal endoscopic microsurgery for large rectal adenomas. Endoscopy. 2011;43(11):941–9. doi:10.1055/s-0030-1256765.
Borschitz T, Gockel I, Kiesslich R, Junginger T. Oncological outcome after local excision of rectal carcinomas. Ann Surg Oncol. 2008;15(11):3101–8. doi:10.1245/s10434-008-0113-x.
De Graaf EJ, Doornebosch PG, Tollenaar RA, Meershoek-Klein Kranenbarg E, de Boer AC, Bekkering FC, et al. Transanal endoscopic microsurgery versus total mesorectal excision of T1 rectal adenocarcinomas with curative intention. Eur J Surg Oncol. 2009;35(12):1280–5. doi:10.1016/j.ejso.2009.05.001.
Garcia-Aguilar J, Mellgren A, Sirivongs P, Buie D, Madoff RD, Rothenberger DA. Local excision of rectal cancer without adjuvant therapy: a word of caution. Ann Surg. 2000;231(3):345–51.
Madbouly KM, Remzi FH, Erkek BA, Senagore AJ, Baeslach CM, Khandwala F, et al. Recurrence after transanal excision of T1 rectal cancer: should we be concerned? Dis Colon Rectum. 2005;48(4):711–9. doi:10.1007/s10350-004-0666-0; discussion 9–21.
Christoforidis D, Cho HM, Dixon MR, Mellgren AF, Madoff RD, Finne CO. Transanal endoscopic microsurgery versus conventional transanal excision for patients with early rectal cancer. Ann Surg. 2009;249(5):776–82. doi:10.1097/SLA.0b013e3181a3e54b.
Lezoche G, Paganini AM, Campagnacci R, Ghiselli R, Pelloni M, Rombini A, et al. Treatment of rectal cancer by transanal endoscopic microsurgery: review of the literature. Minerva Chir. 2013;68(1):1–9.
Doornebosch PG, Ferenschild FT, de Wilt JH, Dawson I, Tetteroo GW, de Graaf EJ. Treatment of recurrence after transanal endoscopic microsurgery (TEM) for T1 rectal cancer. Dis Colon Rectum. 2010;53(9):1234–9. doi:10.1007/DCR.0b013e3181e73f33.
Serra Aracil X, Bombardo Junca J, Mora Lopez L, Alcantara Moral M, Ayguavives Garnica I, Darnell Marti A, et al. Site of local surgery in adenocarcinoma of the rectum T2N0M0. Cir Esp. 2009;85(2):103–9. doi:10.1016/j.ciresp.2008.09.007.
Tytherleigh MG, Warren BF, Mortensen NJ. Management of early rectal cancer. Br J Surg. 2008;95(4):409–23. doi:10.1002/bjs.6127.
National Comprehensive Cancer Network. Rectal Cancer (Version 3.2014). www.nccn.org/professionals/physician_gls/PDF/rectal.pdf. Accessed 26 Apr 2014.
Borschitz T, Wachtlin D, Mohler M, Schmidberger H, Junginger T. Neoadjuvant chemoradiation and local excision for T2-3 rectal cancer. Ann Surg Oncol. 2008;15(3):712–20. doi:10.1245/s10434-007-9732-x.
Garcia-Aguilar J, Shi Q, Thomas Jr CR, Chan E, Cataldo P, Marcet J, et al. A phase II trial of neoadjuvant chemoradiation and local excision for T2N0 rectal cancer: preliminary results of the ACOSOG Z6041 trial. Ann Surg Oncol. 2012;19(2):384–91. doi:10.1245/s10434-011-1933-7.
Saclarides TJ. TEM/local excision: indications, techniques, outcomes, and the future. J Surg Oncol. 2007;96(8):644–50. doi:10.1002/jso.20922.
Serra-Aracil X, Mora-Lopez L, Alcantara-Moral M, Corredera-Cantarin C, Gomez-Diaz C, Navarro-Soto S. Atypical indications for transanal endoscopic microsurgery to avoid major surgery. Tech Coloproctol. 2014;18(2):157–64. doi:10.1007/s10151-013-1040-9.
Langer C, Markus P, Liersch T, Fuzesi L, Becker H. Ultra Cision or high-frequency knife in transanal endoscopic microsurgery (TEM)? Advantages of a new procedure. Surg Endosc. 2001;15(5):513–7. doi:10.1007/s004640090015.
Gavagan JA, Whiteford MH, Swanstrom LL. Full-thickness intraperitoneal excision by transanal endoscopic microsurgery does not increase short-term complications. Am J Surg. 2004;187(5):630–4. doi:10.1016/j.amjsurg.2004.01.004.
Serra-Aracil X, Mora-Lopez L, Alcantara-Moral M, Caro-Tarrago A, Navarro-Soto S. Transanal endoscopic microsurgery with 3-D (TEM) or high-definition 2-D transanal endoscopic operation (TEO) for rectal tumors. A prospective, randomized clinical trial. Int J Colorectal Dis. 2014;29(5):605–10.
Floyd ND, Saclarides TJ. Transanal endoscopic microsurgical resection of pT1 rectal tumors. Dis Colon Rectum. 2006;49(2):164–8. doi:10.1007/s10350-005-0269-4.
Guerrieri M, Baldarelli M, Morino M, Trompetto M, Da Rold A, Selmi I, et al. Transanal endoscopic microsurgery in rectal adenomas: experience of six Italian centres. Dig Liver Dis. 2006;38(3):202–7. doi:10.1016/j.dld.2005.11.01439.
Endreseth BH, Wibe A, Svinsas M, Marvik R, Myrvold HE. Postoperative morbidity and recurrence after local excision of rectal adenomas and rectal cancer by transanal endoscopic microsurgery. Colorectal Dis. 2005;7(2):133–7. doi:10.1111/j.1463-1318.2004.00724.x.
Stipa F, Burza A, Lucandri G, Ferri M, Pigazzi A, Ziparo V, et al. Outcomes for early rectal cancer managed with transanal endoscopic microsurgery: a 5-year follow-up study. Surg Endosc. 2006;20(4):541–5.
Beets-Tan RG, Beets GL, Vliegen RF, Kessels AG, Van Boven H, De Bruine A, et al. Accuracy of magnetic resonance imaging in prediction of tumour-free resection margin in rectal cancer surgery. Lancet. 2001;357(9255):497–504.
Kumar AS, Coralic J, Kelleher DC, Sidani S, Kolli K, Smith LE. Complications of transanal endoscopic microsurgery are rare and minor: a single institution’s analysis and comparison to existing data. Dis Colon Rectum. 2013;56(3):295–300. doi:10.1097/DCR.0b013e31827163f7.
Ramwell A, Evans J, Bignell M, Mathias J, Simson J. The creation of a peritoneal defect in transanal endoscopic microsurgery does not increase complications. Colorectal Dis. 2009;11(9):964–6. doi:10.1111/j.1463-1318.2008.01719.x.
Baatrup G, Borschitz T, Cunningham C, Qvist N. Perforation into the peritoneal cavity during transanal endoscopic microsurgery for rectal cancer is not associated with major complications or oncological compromise. Surg Endosc. 2009;23(12):2680–3. doi:10.1007/s00464-008-0281-6.
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In this video, the surgeon demonstrates his approach to transanal endoscopic surgery (TEM). (MP4 149228 kb)
Key Operative Steps
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Place Foley catheter and decompress the bladder.
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Position the patient according to the location of the tumor.
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Place the rectoscope over the lesion to gain access to the entire perimeter.
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4.
Initiate dissection by marking a circumferential dotted line 10–15 mm from the tumor.
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Perform a full-thickness wall excision.
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After completing excision, irrigate with povidone-iodine solution to induce cytolysis.
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After completing excision, mark and orient the specimen to ensure all margins are appropriately analyzed by pathology.
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Close the rectal mucosal defect with technique to avoid stenosis of the lumen.
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Serra-Aracil, X., Mora-Lopez, L. (2015). Transanal Endoscopic Surgery for Rectal Cancer. In: Kim, J., Garcia-Aguilar, J. (eds) Surgery for Cancers of the Gastrointestinal Tract. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-1893-5_28
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