Transanal endoscopic surgery using a rigid rectoscope: TEO and TEM

Transanal endoscopic surgery using a rigid rectoscope: TEO and TEM

Transanal endoscopic surgery
using a rigid rectoscope:
TEO and TEM
Outline
• Introduction
• Full thickness transanal excision
• Indications for TEM and TEO
• TEO
• TEM vs TEO
• Our TEO experience
Introduction
• Advancements in rectal cancer treatment
– Improved rectal imaging
• ERUS
• MRI
Introduction
• Advancements in rectal cancer treatment
– Improved rectal imaging
– Advantages of neoadjuvant chemoradiation
• Stage 2 and 3
Introduction
• Advancements in rectal cancer treatment
– Improved rectal imaging
– Advantages of neoadjuvant chemoradiation
– Better surgical technique:
• Total mesorectal excision
• 1-2 cm distal margin = Sphincter sparing
techniques
JoRSM 1988
Introduction
• Total mesorectal excision:
Local Recurrence
2 years : TME vs. CRAB = 16% vs. 9%
Overall Survival
2 years : TME = better OS
Dutch TME/CRAB-study - BJS 2002
Introduction
• The early rectal cancer dilemma
The cost for cure:
– Long hospital stay and convalescence
– Infectious complications
– Urinary dysfunction
– Sexual dysfunction
– Defecatory dysfunction (Low Anterior Resection Syndrome)
– Some need permanent ostomy
Hendren et al, Ann Surg 2005
Temple et al, DCR 2005
Emmertsen et al, Ann Surg 2012
Full thickness local excision
Transanal Parks excision
TEM (Richard Wolf)
TEO (Karl Storz)
Full Thickeness Local Excision
• Is appealing
– Low morbidity
– Quick recovery
– Minimal effect on long term bowel function
– Organ sparing technique
• Indications
– How do we know there is no tumor in the lymph nodes
– the surgery should be curative!
• How? TAE - TEM - TEO
Full thickness local excision?
TEM
TEO
Transanal Excision
Transanal Parks Excision:
• Limited to lesions distal rectum
• small tumors
• However…
• lighting and exposure is poor
• surgical field collapses
• Recurrence rates: …30%
Advantage TEM vs TAE:
• Nonfragmented specimen
• Clear resection margins
• Feasable throughout the entire rectum
• Lower recurrence rates
• No increase in operative morbidity
Advantage TEM vs TAE:
• Lower recurrence rates: Case series adenomas:
Polyp size:
Fragmentation:
Clear Margins:
Recurrence:
TEM
n=82
14 cm2
12%
83%
3%
TAE
n=89
15 cm2
26%
61%
32%
Moore et al, Dis Col Rectum 2008
• Confirmed by several series:
– TEM: 3-16% RR
– TAE parks excision: 4-30% RR
Benoist et al. Gastroenterol Clin Biol 2001
Endreseth et al. Colorectal Dis 2004
Guerrieri et al. Dig Liver Dis 2006
Steele et al. Br J Surg 1996
Gavagan et al. Am J.Surg 2004
Pigot et al. Dis Colon Rectum 2003
Indications for TEM and TEO
• Adenoma
• Selective cases of pT1 adenocarcinoma
• T1 sm2-3 and T2
only in prospective trials or palliative resection
• Small Carcinoid tumors
• Small GIST
Indications for TEM/TEO
• Adenoma = “THE” indication
Indications
• Adenoma: case series
Said 1995
Mentges 1996
Morschel 1998
Buess 2001
Lloyd 2002
Palma 2004
Endreseth 2005
Whitehouse 2006
Ramirez 2009
Recurrence
7%
2%
3.6%
1.7%
5.9%
5%
13%
4.8%
5.4 %
F/U (mo)
60
24
67
24
29
30
24
39
35
Indications
• Selective cases of pT1 adenocarcinoma:
– Depth op submucosal invasion –Sm1
– < 3 cm
– Well differentiated grading (G1/G2)
– No lymphovascular invasion (L0)
– No vascular invasion (V0)
– No mucinous component
Kikuchi et al. Dis Colon Rectum 1995
Morino et al. Tech Coloproctol 2013
Indications
• Selective cases of pT1 adenocarcinoma:
Even a T1 can be an ugly guy in some way… (LN+)
Blomqvist L. et al. The 'good', the 'bad', and the 'ugly' rectal cancers.
Acta Oncol 2008
Indications
• Selective cases of pT1 adenocarcinoma:
T stage related to lymph node status:
Morson BC Proc R Soc Med 1966
Hojo K Am J Surg 1982
Minsky BD Cancer 1989
Huddy SPJ BJS 1993
T1
10.9%
17.9%
0%
11%
T2
12.1%
37.8%
28%
23%
T3
58.3%
>50%
36%
ns
The Good
The Bad
The Ugly
pT1 lesion:
Submucosal Depth of Invasion
Kikuchi Classification:
1-3%
8-10%
23-25%
Kikuchi et al. Dis Colon Rectum 1995
Morino et al. Tech Coloproctol 2013
Indications
• Selective cases of pT1 adenocarcinoma:
T stage related to lymph node status:
Morson BC Proc R Soc Med 1966
Hojo K Am J Surg 1982
Minsky BD Cancer 1989
Huddy SPJ BJS 1993
pT1 lesion:
Submucosal Depth of Invasion
Kikuchi Classification:
T1
10.9%
17.9%
0%
11%
1-3%
T2
12.1%
37.8%
28%
23%
8-10%
T3
58.3%
>50%
36%
ns
23-25%
Kikuchi et al. Dis Colon Rectum 1995
Morino et al. Tech Coloproctol 2013
Indications
• Recurrence rates for pT1 adenocarcinoma:
Year
Patients (N)
Local
Recurrence
Rates (%)
Buess et al.
1988
12
0
Buess et al.
1992
25
4
Winde et al.
1996
24
4.2
Smith et al.
1996
30
10
Langer et al.
2001
16
12.5
Demartines et al.
2001
9
8.3
Lee et al.
2003
52
4.1
Stipa et al.
2006
23
8.6
Floyd et al.
2006
53
7.5
Baatrup et al.
2008
72
6
Dutch TME tria
T1 : 1.7 % RR
Indications
• T1 sm2-3 and T2 only in prospective trials or
palliative resection
• Small Carcinoid tumors
• Small NET
Indications
• Predictive model for local recurrence following TEM:
Bach SP, et al. Br J Surg 2009
Indications
• Predictive model for local recurrence following TEM:
local recurrence rate
after TME is 6%
• STRINGENT PATIENT SELECTION
Bach SP, et al. Br J Surg 2009
Depth op submucosal invasion –Sm1
< 3 cm
Well differentiated grading (G1/G2)
No lymphovascular invasion (L0)
No vascular invasion (V0)
No mucinous component
Indications:
Adenoma
&
Favorable
uT1
Favorable
uT2
prospective trials
Chemo
radiation
TEM/TEO
Pathologic
evaluation
Surveillance
Radical Surgery
rescue
• TME / APRA
• Na 6-8 weken (heling van de wonde anorectaal)
Levic et al (Tech Coloproctol 2013 Aug;17(4): 397-403
No difference in outcome TME after TEMS vs TME primair
Transanal Endoscopic Operation
TEO (Karl Storz)
TEO
• Equipment:
– High Definition direct 2-D vision
(achieves images = 3D)
– Rigid elongated rectoscope
• Diameter 4 cm
• 8 – 15 cm
– 30° camera
– Standard laparoscopic (intermitent) sufflation and irrigation
– System attached to table: 1 single surgeon…
Our TEO experience
TEO experience
• Pooled TEO data:
OLV, Waregem (K Vindevoghel)
Jan Yperman, Ieper (L Dedrye)
AZ Groeninge, Kortrijk (M D’Hondt)
2012-2014:
56TEO procedures
TEO experience
• 2012-2014: Patient and Tumor characteristics
Total
N = 55 patients
Age
67 (39-88)
Male/Female
34/21
Distance from AV
5.5 cm (2-15)
High rectum
6
Mid rectum
18
Low rectum
30
Location
Anterior
17
Left lateral
8
Right lateral
3
Posterior
26
TEO experience
• 2012-2014: Postoperative results
Total
N=56 (61 lesions)
Pathology
Adenoma
32
low/mild grade dysplasia
21
High grade dysplasia
11
Adenocarcinoma
27
GIST
1
NE tumor
1
Maximal Ø (cm)
4 (0.5 – 9.2)
Histologic Radicality (R0)
1
Recurrence rate
1
Hospital stay
3 (2-8)
Postop complications
5
Follow-up (months)
13 (2-27)
TEO experience
• 2012-2014: Pathology (detailed)
Total
N=
Tubulovillous adenoma
32
Adenocarcinoma
27
Tis
7
T1- sm1
6
T1 – sm2
3
T1 –sm3
6
T2
4
T3
1*
GIST
1
NET
1
TEO experience
• Cured by TEO
Total
N=
Tubulovillous adenoma
32
Adenocarcinoma
27
Tis
7
T1- sm1
6
T1 – sm2
3
T1 –sm3
6
T2
4
T3
1*
GIST
1
NET
1
Voorstel PRE en POST OP T1, Tis
• PREOP bij voorkeur VOOR biopsiename
– MRI (N)
– ERUS (T)
• POSTOP (na TEO)
– Eerste 3 jaar
• 1*/ 3 m Klinisch, Rectoscopie, CEA
– Daarna (4-5)
• 1*/ 6 m Klinisch, Rectoscopie, CEA
– Daarna Jaarlijks
– MRI 1*/ 6m – 12m (?)
– ERUS op indicatie