docTransanal Endoscopic Microsurgery
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Transanal Endoscopic Microsurgery
Transanal Endoscopic Microsurgery Dana R. Sands, MD, FACS, FASCRS Director, Colorectal Physiology Center Staff Surgeon Department of Colorectal Surgery Cleveland Clinic Florida What is TEM? Minimally invasive Transanal technique Access to the entire rectum and rectosigmoid junction Specialized instrumentation Transanal Endoscopic Microsurgery Initially reported 1983 Gerhard Buess Tubingen, Germany 25 years later… 106 US Sites 61 last 5 years Transanal Endoscopic Microsurgery Hard to learn Expensive equipment Limited indication Resurgence of interest in the era of minimally invasive surgery and natural orifice surgery Transanal Endoscopic Microsurgery What’s so special? Optimal visualization 3D Image Balanced insufflation Access to mid and upper rectum Potential for lymphadenectomy TEM Instrumentation Proctoscope Stereoscope Operating Instruments Suction/ Insufflator Indications Rectal Cancer Treatment Options TME TAE TEM Rectal Cancer Treatment Options TME Removal of all node bearing tissue Local Excision Disc excision of the rectal wall Lower Local recurrence rates Higher Local recurrence rates Definitive staging ? Staging Increased Operative morbidity Decreased Operative morbidity Functional compromise Improved functional outcome TAE Gordon & Nivatvongs. Principles & Practice of Surgery for the Colon, Rectum & Anus. 1999. TEM TEM vs TAE 1990-2005 171 patients (89 TAE, 82 TEM) TEM (%) TAE (%) p Clear Margins 90 71 =0.001 Nonfragmented Specimen 94 65 <0.001 Recurrence 5 27 =0.004 “Transanal endoscopic microsurgery is the technique of choice for local excision of rectal neoplasms “ Moore JS, et al. Dis Col Rectum. 2008 Jul;51(7):1026-30 Indications for TEM Any benign rectal lesion above the dentate line within reach of the operating proctoscope Selected T1 lesions T2 lesions with combined therapy (??) Patient Selection Accurate staging is essential • Endorectal ultrasound Careful characterization of the primary lesion • Rigid proctoscopy TEM Full Thickness Excision TEM Submucosal Excision TEM for Benign Disease Year Patients (N) Local Recurrence Rates (%) Menteges et al 1996 236 2 Morshel et al 1998 226 3.6 Nagy et al 1999 80 2.5 Buess et al 2001 362 1.7 Lloyd et al 2002 68 5.9 Langer et al 2003 57 8.8 Palma et al 2004 71 5 Platell et al 2004 62 2.4 Endreseth et al 2005 64 13 Whitehouse et al 2006 146 4.8 TEM for T1 Cancer 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 TEM vs TME for T2 Cancer 70 patients with T2 rectal cancer • 35 TEM • 35 Laparoscopic resection All received neoadjuvant tx Median follow-up 84 (72-96) months 5.7 TME (%) 2.8 2.8 2.8 9 9 94 94 TEM (%) Local Failure Distant Metastases Local or Distant Failure Survival Lezoche E et al. Surg Endosc. 2008. TEM vs TME Stoma n (%) None Temporary Permanent TEM 35(100) 0 0 TME 18 (51) 8 (23) 9 (26) Lezoche E et al. Surg Endosc. 2008. TEM vs TME Important Considerations All tumors were G1-2 Not just a rectal wall excision • RV septum or prostate anterior • “Holy plane” posterior • Specimen “truncated pyramid” Larger tumors, poor histology, lack of response to neoadjuvant tx • Higher risk for recurrence Lezoche E et al. Surg Endosc. 2008. Complications Bleeding Suture line dehiscence Extraperitoneal Intraperitoneal Functional Complications Delayed respiratory failure CO2 absorption from emphysema Kerr K, Mills GH. Br J Anaesth. 2001. Rectourethral fistula Lev-Chelouche D, Margel D, et al. DCR. 2000. Peritoneal Entry Initially regarded as a complication No difference in morbidity or mortality Does not mandate conversion to laparotomy Extends the reach of TEM from 4-24cm above the anal verge Gavagan JA, Whiteford MH, Swanstrom LL. Am J Surg. 2004. Functional Results Prospective evaluation 41 patients # bm pre vs. post op FISI FIQOL Ability to defer defecation No changes pre vs post op No detrimental effect on anorectal function after TEM Cataldo PA, O’Brien S, Osler T. Dis Col Rectum. 2005. Follow-up Flexible sigmoidoscopy • Every 3 months x 2yrs • Colonoscopy at 1 year Endorectal Ultrasound • Every 6 months x 2 years • Every year x 5 years Recommended Treatment Plan Rectal Lesion Benign At Dentate Line Malignant Above Dentate Line TAE TEM T1 Favorable Histology T2 TEM T3 Any N TME ?TEM/XRT TME Conclusions Advanced endoscopic technique Utilizes highly specialized instrumentation Can spare selected patients laparotomy and anterior resection Adequate training is imperative Patient selection is paramount Accurate staging is essential
