Transanal endoscopic microsurgery resection of rectal tumors: outcomes and recommendations

Sphincter preservation in distal CT2N0 rectal cancer after preoperative chemoradiotherapy

BACKGROUND

Preoperative chemoradiotherapy is usually not indicated for cT2N0 rectal cancer. Abdominoperineal resection is the standard treatment for distal rectal tumors. The aim of the study was to evaluate the actual sphincter-preservation rate in patients with distal cT2N0 rectal cancer given neoadjuvant chemoradiotherapy.

METHODS

Data were retrospectively collected for all patients who were diagnosed with distal cT2N0 rectal cancer at a tertiary medical center in 2000-2008 and received chemoradiotherapy followed by surgery (5-7 weeks later).

RESULTS

Thirty-three patients (22 male) of median age 65 years (range, 32-88) were identified. Tumor distance from the anal verge ranged from 0 to 5 cm. R0 resection with sphincter preservation was accomplished in 22 patients (66%), with a 22% pathological complete response rate. Median follow-up time was 62 months (range 7-120). There were no local failures. Crude disease-free and overall survival were 82% and 86%, respectively. Factors associated with sphincter preservation were tumor location (OR=0.58, p=0.02, 95% CI=0.37-0.91) and pathological downstaging (OR=7.8, p=0.02, 95% CI=1.35-45.85). Chemoradiotherapy was well tolerated.

CONCLUSION

High rates of sphincter preservation can be achieved after preoperative chemoradiotherapy for distal cT2N0 rectal cancer, with tolerable toxicity, without compromising oncological outcome.

Transanal endoscopic microsurgery: Current application and future prospects

Rectal neoplasms pose serious harm to human health. The options of surgical procedure for these patients have been limited because of the special features of anal and rectal anatomy and physiology. Tumors with a diameter less than 3 cm can be resected through the anus or soft microscope; however, those with a large diameter and wide base which are cancerous and relapse easily still need conventional laparotomy procedures. Transanal endoscopic microsurgery (TEM) was designed to avoid laparotomy for these patients. Using special instruments, TEM allows to totally resect tumors located 4-25 cm from the anus with safe margin and lower rate of complications. Because of minimal invasiveness, shorter operative time and lower rate of complications, TEM can be widely applied in rectal polyps and adenomas. Currently, there are still arguments about TEM usage in early-stage and advanced rectal cancer. This paper reviews the current situation of application and research of TEM, with emphasis put on its indications, clinical efficiency and future development.

Palliative care and end-stage colorectal cancer management: The surgeon meets the oncologist

Colorectal cancer (CRC) is a common neoplasia in the Western countries, with considerable morbidity and mortality. Every fifth patient with CRC presents with metastatic disease, which is not curable with radical intent in roughly 80% of cases. Traditionally approached surgically, by resection of the primitive tumor or stoma, the management to incurable stage IV CRC patients has significantly changed over the last three decades and is nowadays multidisciplinary, with a pivotal role played by chemotherapy (CHT). This latter have allowed for a dramatic increase in survival, whereas the role of colonic and liver surgery is nowadays matter of debate. Although any generalization is difficult, two main situations are considered, asymptomatic (or minimally symptomatic) and severely symptomatic patients needing aggressive management, including emergency cases. In asymptomatic patients, new CHT regimens allow today long survival in selected patients, also exceeding two years. The role of colonic resection in this group has been challenged in recent years, as it is not clear whether the resection of primary CRC may imply a further increase in survival, thus justifying surgery-related morbidity/mortality in such a class of short-living patients. Secondary surgery of liver metastasis is gaining acceptance since, under new generation CHT regimens, an increasing amount of patients with distant metastasis initially considered non resectable become resectable, with a significant increase in long term survival. The management of CRC emergency patients still represents a major issue in Western countries, and is associated to high morbidity/mortality. Obstruction is traditionally approached surgically by colonic resection, stoma or internal by-pass, although nowadays CRC stenting is a feasible option. Nevertheless, CRC stent has peculiar contraindications and complications, and its long-term cost-effectiveness is questionable, especially in the light of recently increased survival. Perforation is associated with the highest mortality and remains mostly matter for surgeons, by abdominal lavage/drainage, colonic resection and/or stoma. Bleeding and other CRC-related symptoms (pain, tenesmus, etc.) may be managed by several mini-invasive approaches, including radiotherapy, laser therapy and other transanal procedures.

Transanal minimally invasive surgery for benign and malignant rectal neoplasia

BACKGROUND

Transanal minimally invasive surgery (TAMIS), an alternative technique to transanal endoscopic microsurgery, was developed in 2009. Herein, we describe our initial experience using TAMIS for benign and malignant rectal neoplasia.

METHODS

This is an institutional review board approved, retrospective case series report.

RESULTS

TAMIS was performed in 32 patients for rectal adenoma (13), adenocarcinoma (16), and carcinoid (3). There were 14 women, with mean age 62 ± 15 years and body mass index 28 ± 5 kg/m(2). Lesion size ranged from .5 to 8.5 cm, distance from the dentate line 1 to 11 cm, and circumference of the lesion 10% to 100%. The mean operative time was 123 ± 62 minutes. Mean hospital length of stay was 2.5 ± 2 days. Complications included urinary tract infection (1), Clostridium difficile diarrhea (1), atrial fibrillation (1), rectal stenosis (1), and rectal bleeding (1).

CONCLUSION

TAMIS using a disposable transanal access platform is a safe and effective method to remove rectal lesions in this case series.

Future directions in surgery for colorectal cancer: the evolving role of transanal endoscopic surgery

SUMMARY 

The morbidity associated with radical surgery for rectal cancer has launched a revolution in increasingly less-invasive methods of resection, including a recent resurgence in transanal endoscopic surgical approaches. The next evolution in transanal surgery for rectal cancer is natural orifice translumenal endoscopic surgery (NOTES). To date, 14 series of transanal NOTES total mesorectal excision (TME) for rectal cancer have been published (n = 76). Overall, the intraoperative and postoperative complication rates of 8 and 28%, respectively, compare favorably to those expected from laparoscopic and open TME. Short-term follow-up after NOTES TME has yielded no cancer recurrence in average-risk patients. High-risk patients have cancer recurrence rates similar to those after laparoscopic TME. Overall, these early data support transanal NOTES TME as a safe and viable alternative to conventional TME. Advances in instrumentation, surgical expertise and neoadjuvant treatment may expand current indications for NOTES even further.

Outcomes after transanal endoscopic microsurgery with intraperitoneal anastomosis

BACKGROUND

Transanal endoscopic microsurgery has gained increasing popularity as a treatment alternative for early stage rectal neoplasms. With continued advances in technique and experience, more proximal rectal tumors are being surgically managed by using transanal endoscopic microsurgery with an intraperitoneal anastomosis.

OBJECTIVE

The purpose of this study was to review the outcomes of patients who have undergone intraperitoneal anastomosis with the use of the transanal endoscopic microsurgery technique.

DESIGN

A prospective, single-surgeon database documented 445 consecutive patients undergoing transanal endoscopic microsurgery from October 1, 1996 through January 1, 2012. We retrospectively reviewed information from all patients who underwent transanal endoscopic microsurgery with an intraperitoneal anastomosis in this prospective database.

SETTINGS

All procedures took place in an inpatient hospital setting.

PATIENTS

All patients satisfied workup criteria to undergo surgery for rectal neoplasm.

INTERVENTIONS

All patients underwent transanal endoscopic microsurgery for rectal neoplasm.

MAIN OUTCOME MEASURES

Size and pathology of lesion, length of procedure, hospital stay, estimated blood loss, margin status, and complications were the outcomes measured.

RESULTS

Twenty-eight patients who underwent transanal endoscopic microsurgery had definitively documented intraperitoneal entry and anastomosis. Median follow-up was 12 months (range, 0.5-111 months). There were no operative mortalities. Procedure-related complications included urinary retention (11%), fever (11%), and fecal seepage (4%). Four patients (14%) had positive margins on final pathology. One patient (3%) required abdominal exploration for an anastomotic leak but did not require diversion.

LIMITATIONS

Although this study analyzes prospectively collected data, it is nonetheless a retrospective analysis that can introduce bias. Because this is a single-center study with a relatively homogenous population, the results may not be generalizable. Our sample size may also be underpowered to detect clinically significant outcomes.

CONCLUSIONS

Transanal endoscopic microsurgery with intraperitoneal anastomosis can be safely performed without fecal diversion by experienced surgeons.

Transanal endoscopic microsurgery colorectal anastomosis: a critical step to natural orifice colorectal surgery in humans

BACKGROUND

Transanal endoscopic microsurgery is used in the surgical management of advanced rectal polyps and early rectal cancers. There are case reports of transanal endoscopic microsurgery colorectal anastomoses being performed with laparoscopic assistance in humans.

METHODS

The concept of a transanal endoscopic microsurgery colorectal anastomosis without laparoscopic assistance has been discussed and trialed on animal and cadaveric specimens; however, to date, there have been no technical reports of this particular procedure in the literature.

RESULTS

We present a technical note describing a transanal endoscopic microsurgery intraperitoneal colorectal anastomosis in a live human without laparoscopic assistance.

Transanal endoscopic microsurgery: a review

Rectal adenomas and cancers occur frequently. Small adenomas can be removed colonoscopically, whereas larger polyps are removed via conventional transanal excision. Owing to technical difficulties, adenomas of the mid- and upper rectum require radical resection. Transanal endoscopic microsurgery (TEM) was first designed as an alternative treatment for these lesions. However, since its development TEM has been also used for a variety of rectal lesions, including carcinoids, rectal prolapse and diverticula, early stage carcinomas and palliative resection of rectal cancers. The objective of this review is to describe the current status of TEM in the treatment of rectal lesions. Since the 1980s, TEM has advanced substantially. With low recurrence rates, it is the method of choice for resection of endoscopically unresectable adenomas. Some studies have shown benefits to its use in treating early T1 rectal cancers compared with radical surgery in select patients. However, for more advanced rectal cancers TEM should be considered palliative or experimental. This technique has also been shown to be safe for the treatment of other uncommon rectal tumours, such as carcinoids. Transanal endoscopic microsurgery may allow for new strategies in the treatment of rectal pathology where technical limitations of transanal techniques have limited endoluminal surgical innovations.

Transanal endoscopic microsurgery

Transanal endoscopic microsurgery (TEMS) is a well established method of accurate resection of specimens from the rectum under binocular vision. This review examines its role in the treatment of benign conditions of the rectum and the evidence to support its use and compliment existing endoscopic treatments. The evolution of TEMS in early rectal cancer and the concepts and outcomes of how it has been utilised to treat patients so far are presented. The bespoke nature of early rectal cancer treatment is changing the standard algorithms of rectal cancer care. The future of TEMS in the organ preserving treatment of early rectal cancer is discussed and how as clinicians we are able to select the correct patients for neoadjuvant or radical treatments accurately. The role of radiotherapy and outcomes from combination treatment using TEMS are presented with suggestions for areas of future research.

Transanal colorectal resection using natural orifice translumenal endoscopic surgery (NOTES)

The surgical management of rectal cancer has evolved over the past century, with total mesorectal excision (TME) emerging as standard of care. As a result of the morbidity associated with open TME, minimally invasive techniques have become popular. Natural orifice translumenal endoscopic surgery (NOTES) has been held as the next revolution in surgical techniques, offering the possibility of 'incisionless' TME. Early clinical series of transanal TME with laparoscopic assistance (n = 72) are promising, with overall intraoperative and postoperative complication rates of 8.3% and 27.8%, respectively, similar to laparoscopic TME. The mesorectal specimen was intact in all patients, and 94.4% had negative margins. There was no oncological recurrence in average-risk patients at short-term follow up, and 2-year survival rates in high-risk patients were comparable to that after laparoscopic TME. These preliminary studies demonstrate transanal NOTES TME with laparoscopic assistance to be clinically feasible and safe given careful patient selection, surgical expertise, and appropriate procedural training. We are hopeful that with optimization of transanal instruments and surgical techniques, pure transanal NOTES TME will become a viable alternative to open and laparoscopic TME in the future.

Learning curve for transanal endoscopic microsurgery: a single-center experience

INTRODUCTION

Transanal endoscopic microsurgery (TEM) was first published by the late Professor Buess in 1983. The procedure initially had a slow acceptance due to its perceived difficulty, the cost of the equipment, and limited indications. However, the widespread adoption of laparoscopic colorectal surgery provided an impetus to increase the penetration of the platform. The purpose of this study was to evaluate the TEM learning curve (LC).

METHODS

After institutional review board approval, all patients who underwent TEM, from November 2005 to October 2008 were identified from a prospective database. The operations were performed by a single, board-certified colorectal surgeon (DRS), after learning the technique from Professor Buess. Patient, operative, and postoperative variables were obtained by retrospective chart review. Rates of excision in minutes per cm(2) of tissue were calculated. The CUSUM method was used to plot the LC. Variables were compared using χ (2) and Student's t test. A p < 0.05 was considered significant.

RESULTS

Twenty-three patients underwent TEM (median age 61 years, 69.5 % male). Mean operative time was 130.5 (range 39-254) min, and the mean specimen size was 16.6 (7.4-42) cm(2). Average rate of excision (ARE) was 8.9 min/cm(2). A stabilization of the LC was observed after the first four cases, showing an ARE of 13.8 min/cm(2) for the first four cases versus 7.9 min/cm(2) for the last 19 cases (p = 0.001). An additional rising and leveling of the LC was observed after the first 10 cases, when an increasing number of lesions located cephalad to 8 cm from the dentate line were being resected (lesions above 8 cm in the first 10 cases: 20 % vs. last 13 cases: 61 %; p = 0.04).

CONCLUSIONS

The ARE significantly declined after the first four cases. The LC for TEM is associated with a significant decrease in operative time after four cases.

Which endoscopic treatment is the best for small rectal carcinoid tumors?

The incidence of rectal carcinoids is rising because of the widespread use of screening colonoscopy. Rectal carcinoids detected incidentally are usually in earlier stages at diagnosis. Rectal carcinoids estimated endoscopically as < 10 mm in diameter without atypical features and confined to the submucosal layer can be removed endoscopically. Here, we review the efficacy and safety of various endoscopic treatments for small rectal carcinoid tumors, including conventional polypectomy, endoscopic mucosal resection (EMR), cap-assisted EMR (or aspiration lumpectomy), endoscopic submucosal resection with ligating device, endoscopic submucosal dissection, and transanal endoscopic microsurgery. It is necessary to carefully choose an effective and safe primary resection method for complete histological resection.

Transanal single-port microsurgery for rectal tumors: minimal invasive surgery under spinal anesthesia

BACKGROUND

Transanal minimally invasive surgery (TAMIS) for rectal tumors has been introduced as an alternative approach to transanal endoscopic microsurgery (TEM). TEM has some limitations, such as the need for special equipment, expensive cost, and steep learning curve. In this study, we address the technical feasibility of TAMIS under spinal anesthesia and its short-term postoperative outcomes.

METHODS

From July 2011 to September 2012, 25 consecutive patients with middle or upper third rectal masses underwent TAMIS. Tumors were located 6-17 cm from the anal verge. After spinal anesthesia, a single-incision laparoscopic surgery port was inserted into the anal canal. With this access, conventional laparoscopic instruments, including a grasper and monopolar electrocautery and suction device, were used to perform the transanal excision. A hook-type monopolar electrocautery or harmonic scalpel was used for dissection. The defect of the rectum was closed by interrupted sutures. Data concerning demographics, details of operative procedure, postoperative pain, and pathologic results were collected prospectively. To evaluate anal sphincter injury, an endoanal ultrasonography and fecal incontinence severity index survey were performed at 3-6 months after the operation.

RESULTS

Of the 25 patients, nine had adenocarcinomas, nine had neuroendocrine tumors, three had tubular adenomas with high-grade dysplasia, three had tubular adenomas, one had a tubulovillous adenoma, and one had a gastrointestinal stromal tumor. The median distance from the tumor mass to the anal verge was 9.0 (range 6-17) cm. The median operative time was 45.0 (range 20-120) min. All patients received TAMIS without conversion to laparoscopic resection. There were no intraoperative complications or postoperative morbidity. The median postoperative hospital stay was 3.0 (range 2-7) days. No sphincter injury was detected by endoanal ultrasonography.

CONCLUSIONS

TAMIS under spinal anesthesia is a safe and feasible technique for resection of middle and upper rectal masses. Spinal anesthesia is adequate for this procedure.

Local resection for small rectal cancer

Rectal resection with total mesorectal excision is the standard treatment for rectal cancers. Local excision represents an alternative with less post-operative mortality and morbidity and preservation of intestinal and bladder function. However, local excision cannot provide adequate nodal staging. Presently, endorectal ultrasound and magnetic resonance imaging are used to select the appropriate patients for local excision, those with limited T1 rectal tumors. There is general agreement that the ideal tumors for local excision are less or equal to 3 cm in diameter, superficial (usTis and/or usT1N0), infra-peritoneal, located below the middle rectal valve, and involving no more than 40% of the rectal circumference. Transanal tumor excision is suitable for distal tumors and transanal endoscopic microsurgery for mid and upper lesions. The principles of adequate resection margin, non-fragmentation, and full-thickness excision are similar to those for any cancer resection. Unfavorable pathologic criteria, as assessed on the fixed rectal specimen, include depth of tumor invasion (submucosal [T1sm3] or muscular [T2]), positive resection margins, vascular and/or lymphatic invasion, and poor differentiation. Further radical surgery is required in case of unfavorable criteria. Simple surveillance may be advised for superficial tumors (T1sm1) without any unfavorable criteria. Management of T1sm2 tumors without any unfavorable criteria should be discussed on a case-by-case basis.

Repeated transanal endoscopic microsurgery is feasible and safe

BACKGROUND

The benefits of transanal endoscopic microsurgery (TEM) for the excision of benign and low-grade malignant lesions in the low and middle rectum are well recognized. This study examined the feasibility and safety of a repeated TEM procedure.

PATIENTS AND METHODS

Patients who underwent a repeat TEM for excision of rectal lesions, either for involved resection margins or for local recurrence, between the years 2000 and 2010, were identified. Rectal lesion characteristics were retrieved. Mean operative times, length of hospital stay, and intra- and postoperative complications were compared between primary and repeated procedures. The postoperative histopathology reports were reviewed, and the adequacy of resection was determined. All patients completed a questionnaire based on the Wexner score for anal sphincter function evaluation.

RESULTS

Fourteen patients (3 female, 11 male) underwent a repeat TEM operation during the study period. All procedures were completed endoscopically. Indications for repeated TEM were involved margins in 12 patients and recurrence of benign tumor in 2. Mean operative time, mean length of hospital stay, and rate of postoperative complications were similar for primary and repeated TEM procedures (62.5 ± 17 versus 55 ± 23 minutes, P=.181; 1.7 ± 1.3 versus 1.7 ± 1.12 days, P=.99; and 35.7% versus 21.4%, P=.66, respectively). The Wexner score was comparable at baseline and after the first and the second TEM procedures (1.5 ± 2.3, 1.5 ± 2.3, and 3.3 ± 3.1, respectively; P=.188). No cases of fecal incontinence following a repeat TEM were documented.

CONCLUSIONS

Repeated TEM is feasible and safe and may be appropriate for selected patients.

Transanal endoscopic microsurgery for the resection of submucosal and retrorectal tumors

BACKGROUND

Transanal endoscopic microsurgery (TEM) was originally designed for local endoscopic excision of benign and low-grade mucosal rectal lesions through an endoscopic system. The procedure is particularly challenging for submucosal and retrorectal lesions, as the tumor margins are not well defined.

OBJECTIVE

To investigate patient and surgical characteristics of TEM as a treatment for submucosal rectal and retrorectal lesions.

METHODS

All the patients in our department of general surgery who underwent TEM for a submucosal rectal or retrorectal lesion, between the years 2001 and 2011, were identified. Their charts were reviewed and data pertaining to demographic characteristics and medical history, including tumor characteristics, were collected. Operative notes and histopathology reports were also reviewed. The adequacy of the tumor resection, that ism attainment of free margins, endoscopic completion of the procedure, and perioperative complications, were assessed.

RESULTS

Fifteen patients (5 females, 10 males), mean age 53.9 ± 16.9 years, were identified. The main indications for surgery were gastrointestinal stromal tumor (5 patients) and tailgut or duplication cyst (4 patients). All procedures were completed endoscopically. The median distance from the anal verge was 7.3 cm (range, 5 to 10 cm), and the mean diameter of the tumors was 3 ± 1.1 cm. The one patient in whom the margins presented tumoral involvement underwent repeated TEM. No intraoperative complications were reported. The postoperative complication rate was 13.3%, and the mean length of hospital stay was 1.85 ± 1.77 days.

CONCLUSIONS

TEM for retrorectal and submucosal rectal lesions is feasible and safe. A remarkably low morbidity rate and limited surgical injury favor TEM in selected patients.

Transanal minimally invasive surgery (TAMIS) using a new disposable device: our initial experience

Disposable single-port surgery devices have been used for transanal minimally invasive surgery (TAMIS). Their advantage, compared to transanal endoscopic microsurgery, is that they do not require special equipment or training. The aim of this study was to assess our initial experience using the single-site laparoscopic (SSL™) access system (Ethicon Endo-Surgery, Cincinnati, OH, USA) for TAMIS. Five patients eligible for local excision of rectal tumors, four males and one female, mean age 58 years (range 50-78), underwent surgery using the SSL™ device. The average distance from anal verge was 4 cm (range 1-6). Four patients had an initial diagnosis of adenoma, and one had a previous endoscopic excision of a T1 adenocarcinoma with positive margins. In one patient, due to the lack of exposure, the procedure was converted to a low anterior resection. In the remaining four patients, average setup time was 7 minutes (range 4-15) and average operative time was 52 minutes (range 38-72). All resection margins were tumor free. There were no postoperative complications. Two of the presumed adenomas were intramucosal adenocarcinomas, while one patient had a T2 tumor and underwent radical surgery. Although at the present time the appropriate use of local excision is still under debate, TAMIS is a technique with great potential. Because of its simplicity and similarity with conventional laparoscopic surgery, it can be learned easily by surgeons not trained in transanal endoscopic microsurgery.

Complications of transanal endoscopic microsurgery are rare and minor: a single institution's analysis and comparison to existing data

BACKGROUND

Transanal endoscopic microsurgery, a minimally invasive procedure for treatment of early-stage rectal cancer, carcinoid tumors, and adenomas, is shown to be a safe procedure with very low perioperative morbidity.

OBJECTIVE

We aimed to compare the outcomes of transanal endoscopic microsurgery at a large volume tertiary care center with the existing literature.

DESIGN

We retrospectively reviewed a prospectively collected database of 325 transanal endoscopic microsurgery procedures and looked for risk factors associated with complications. Indications for transanal endoscopic microsurgery included rectal adenocarcinomas, adenomas, and carcinoids.

SETTING

Procedures were performed by a single surgeon at a large-volume tertiary care center.

PATIENTS

Patients were enrolled over a 20-year period, and data were collected on demographics, perioperative details, tumor characteristics, and complications.

INTERVENTIONS

Transanal endoscopic microsurgery was performed on all 325 patients.

MAIN OUTCOME MEASURES

Main outcome measures were urinary retention, late bleeding requiring intervention, dehiscence, peritoneal cavity entry, conversion to abdominal approach, fecal soiling, and rectovaginal fistula.

RESULTS

Intraoperative bleeding was associated with larger tumor size, whereas postoperative bleeding requiring intervention was not associated with any factors studied. Peritoneal cavity entry and urinary retention were more likely if the tumor was in either the anterior or lateral position in the rectum. The peritoneal cavity was entered in 9 patients, and conversion to abdominal approach occurred in 1 patient. Intraoperative bleeding, by surgeon's choice, and urinary retention, by patient's choice, were associated with a greater likelihood of admission to the inpatient ward. Fecal soiling was not reported by patients and not recorded.

LIMITATIONS

This study was limited because it was a retrospective analysis

CONCLUSIONS

Transanal endoscopic microsurgery is an extremely safe procedure, offering very low perioperative morbidity. The overall morbidity found in our study was 10.5%, on par with published data for large series of 21%, 7.7%, and 14.9%. In contrast, complications from radical resection are reported at 18% to 55%.

First report of transvaginal endoscopic microsurgery in a patient with squamous cell carcinoma of the vagina

Transanal endoscopic microsurgery has been used by surgeons since 1983. All these years of experience and research have shown that this is a safe and successful approach for rectal neoplasms, both benign and malignant. The advantage of this procedure is the excellent view and hence precise surgical margins in an operative field that is otherwise difficult to reach. Furthermore, selected patients who used to require major rectal surgery now may be treated using this minimally invasive technique. These advantages may also be favorable for the gynecological field, especially in intravaginal surgery. Our case report describes the first successfully performed transvaginal endoscopic microsurgery in a woman with residual disease after treatment with chemoradiation for squamous cell carcinoma of the vagina. Despite the difficulty of operating in tissue with post-radiation effect, the rest of the tumor was excised with clear surgical margins without damage to the rectum. The patient was discharged from the hospital 2 days after the procedure and recovered without complications.

Prognostic significance of EpCAM-positive disseminated tumor cells in rectal cancer patients with stage I disease

Here we evaluated the prevalence and prognostic impact of epithelial cell adhesion molecule (EpCAM)-positive disseminated tumor cells (DTCs) in stage I rectal cancer. Further we tested the association of these single tumor cells or small tumor cell groups with the extent of peritumoral lymphangiogenesis. A total of 845 regional lymph nodes (LN) of 44 patients classified as negative on conventional histopathology were retrospectively reanalyzed with immunohistochemistry (IHC) using the monoclonal antibody Ber-Ep4 directed against EpCAM for the detection of DTCs. The degree of lymphangiogenesis in the primary tumors was assessed by IHC of the primary tumor tissue using the monoclonal antibody D2-40, which reacts with the lymphatic endothelium. The IHC results were correlated with clinico-pathologic parameters and clinical follow-up data. EpCAM-positive DTCs in LNs were detected in 8 (18.2%) of the 44 patients. During a median follow-up of 59 months, 3 (37.5%) of the 8 patients with EpCAM-positive DTCs relapsed, whereas none of the DTC-negative patients developed tumor recurrence (P=0.004). Survival analysis revealed a significant effect of the prevalence of DTCs on overall survival (P=0.0009) and on recurrence-free survival (P=0.0001). Finally, the prevalence of EpCAM-positive DTCs in perirectal LNs was significantly correlated with a high density of peritumoral lymphatic vessels (P=0.015). Our results show that DTCs may occur in stage I of rectal cancer and are associated with poor prognosis. Their occurrence seems to be linked to a high density of newly formed lymphatic vessel at the primary tumor site. According to our data, patients with DTCs in their LN might benefit from adjuvant therapy.

Transanal endoscopic microsurgery for residual rectal cancer (ypT0-2) following neoadjuvant chemoradiation therapy: another word of caution

BACKGROUND

Significant tumor downstaging among patients with rectal cancer following neoadjuvant chemoradiation has raised the issue of offering patients with small residual cancers restricted to the bowel wall an alternative treatment strategy to total mesorectal excision. Transanal endoscopic microsurgery may allow proper primary tumor resection with promising oncological outcomes, less postoperative morbidity, and minimal long-term sexual, urinary, and fecal continence disorders in comparison with radical resection.

OBJECTIVE

The aim of this study was to determine the oncological outcomes of patients with residual rectal cancers restricted to the rectal wall (ypT0-2) following neoadjuvant chemoradiation and transanal endoscopic microsurgery.

DESIGN

This study considered a prospective cohort of patients with residual rectal cancers following neoadjuvant chemoradiation treated by transanal endoscopic microsurgery and no additional systemic therapy.

SETTINGS

This study was a single-institution experience.

PATIENTS

Patients with adenocarcinoma of the rectum located no more than 7 cm from the anal verge and endorectal ultrasound- or magnetic resonance-staged cT2-4N0-2M0 treated by neoadjuvant chemoradiation (50.4-54 Gy and 5-fluorouracil-based chemotherapy) were eligible for the study. Patients with small residual tumors (≤3 cm) radiologically staged ycT0-2N0 were treated by transanal endoscopic microsurgery.

INTERVENTIONS

Transanal endoscopic microsurgery was performed.

MAIN OUTCOME MEASURES

The primary outcome measured was local recurrence.

RESULTS

Of the 27 patients treated by transanal endoscopic microsurgery, 3 had ypT0, 6 had ypT1, and 18 had ypT2 cancers. All patients underwent R0 transanal endoscopic microsurgery excision. Local recurrence was observed in 4 (15%) patients after a median follow-up of 15 months. Only lymphovascular invasion was an independent predictive factor for local failure (p = 0.04). Tumor size, ypT status, T-status downstaging, lateral/radial margins, and tumor regression grade were not predictors of local failure.

LIMITATIONS

This study was limited by the small sample size and limited follow-up.

CONCLUSIONS

A local failure rate of 15% after transanal endoscopic microsurgery for patients with residual rectal cancers restricted to the bowel wall (ypT0-2) may limit the indication of this procedure to highly selected patients as an alternative to standard radical total mesorectal excision.

Lymphatic drainage of the rectum, preoperative assessment and its relevance to malignant polyp and rectal cancer management

SUMMARY The importance of lymph node metastasis in rectal cancer is well recognized with regards to prognosis, staging and treatment. Accurate staging is particularly important where neoadjuvant treatment has been shown to downsize and downstage locally advanced tumors. Vascular invasion, poor differentiation and increasing depth of invasion are related to a higher risk of lymph node metastasis in early cancers while advanced, poorly differentiated and low rectal cancers are more likely to have lateral pelvic sidewall nodal involvement. Nodal staging is crucial in the management of malignant rectal polyps, as is the deferral of surgery in patients who have a complete clinical and radiological response to chemoradiotherapy. In all of these situations nodal staging is vital and warrants ongoing evaluation to improve its accuracy.

eTAMIS: endoscopic visualization for transanal minimally invasive surgery

BACKGROUND

Transanal endoscopic microsurgical (TEM) resection is associated with improved outcomes compared to transanal excision of rectal lesions. However, TEM equipment requires additional operative setup time, and tumor location dictates patient positioning. In 2010, Drs. Attallah, Albert, and Larach developed an alternative technique, transanal minimally invasive surgery (TAMIS). Herein, we describe our novel experience using endoscopic visualization to perform TAMIS (eTAMIS) to remove a large rectal polyp.

METHODS

This is a technical note describing a new surgical technique, eTAMIS. The technique is performed with the Gelpoint Path TAMIS platform (Applied Medical, Rancho Santa Margarita, CA) and a standard single-channel endoscope for visualization. Patient demographics, operative data, and pathologic data were recorded.

RESULTS

eTAMIS was initially performed in a 50-year-old woman with an endoscopically defiant rectal mass discovered on routine screening colonoscopy. The lesion was a tubulovillous adenoma, 10 cm from the anal verge, anterior, and occupied 15-20 % of the circumference. The rectal mass was removed by eTAMIS. The operative time was 101 minutes, and the patient was discharged within 24 h without event. Final pathology revealed a focus of well-differentiated rectal adenocarcinoma with focal invasion into the muscularis mucosa (Haggit level 0, pTis) arising in the head of a pedunculated tubulovillous adenoma. At 1-year follow-up endoscopy, the patient had no evidence of recurrent mass or polyp.

CONCLUSIONS

This is the first technical report describing endoscopic visualization for TAMIS. Endoscopic visualization facilitates intraluminal articulation and lens cleaning while minimizing extraluminal instrument collisions. eTAMIS is a practical and logical evolution of the visual approach to natural orifice transluminal endoscopic surgery and laparoendoscopic surgery.

Surveillance of small rectal carcinoid tumors in the absence of metastatic disease

BACKGROUND

The incidence of rectal carcinoids is rapidly increasing, typically presenting as small (<1.0 cm), localized tumors. Although the evaluation of rectal carcinoids on presentation is well standardized, surveillance after resection has not been well established.

METHODS

A prospective database documented patients with rectal carcinoids at our institution between January 1995 and September 2011. Information collected included patient and tumor characteristics, treatment method, surveillance schedule, recurrence, and survival.

RESULTS

Twenty-eight patients with rectal carcinoid were identified. Ten patients were excluded for tumors >1 cm, known metastases at presentation, <6 months follow-up, or previous resections. The mean age of the remaining patients was 56 ± 3 years, and 61% of the patients were female. All patients were diagnosed at endoscopy, with 50% diagnosed incidentally on screening endoscopy. Treatment methods included endoscopic therapy (n = 13, 72%), transanal excision (n = 3, 17%), and transanal endoscopic microsurgery (n = 1, 5.5%). One patient (5.5%) received no additional invasive therapy after diagnostic endoscopy. The mean tumor diameter was 4.6 ± 0.5 mm. The average length of follow-up was 5.4 ± 0.9 years, with a median number of 2 follow-up endoscopies (range 0-6). Two patients (11%) died within the follow-up period from noncarcinoid causes. Importantly, no surviving patients developed local or distant recurrence with up to 12.3 years of follow-up.

CONCLUSIONS

On the basis of this experience, patients presenting with small (≤1.0 cm), nonmetastatic rectal carcinoids are unlikely to develop local or distant recurrence after resection. Aggressive surveillance with repeat endoscopies or other imaging studies after resection may be unnecessary in this patient population.

Transanal endoscopic microsurgery for rectal carcinoids: the largest reported United States experience

AIM

Rectal carcinoids are often inadequately resected by snare excision during colonoscopy. Transanal endoscopic microsurgery is a minimally invasive procedure with low morbidity that offers full-thickness excision with a low rate of negative margins. It presents an excellent alternative to radical surgery for mid and proximally located lesions. We report the largest United States (US) experience in the use of transanal endoscopic microsurgery for rectal carcinoids.

METHOD

Data of patients who had undergone transanal endoscopic microsurgery for rectal carcinoids were prospectively collected and retrospectively analyzed. Patient and tumour characteristics, operative and perioperative details, as well as oncological outcomes were reviewed.

RESULTS

Over a 12-year period, 24 patients underwent transanal endoscopic microsurgery for rectal carcinoids. Of these, six (25%) were primary surgical resections and 18 (75%) were performed after incomplete snare excisions during colonoscopy. Three (17%) patients who underwent full-thickness resection after snare excision had residual tumour on histopathological examination. Negative margins were obtained in all cases. No recurrences were noted.

CONCLUSION

Transanal endoscopic microsurgery is effective and safe for the surgical resection of rectal carcinoids<2 cm in diameter, with typical features and located more than 5 cm from the anal verge. Transanal endoscopic microsurgery can be used for primary resection or for resection after incomplete colonoscopic snare excision.

Management and outcome of local recurrence following transanal endoscopic microsurgery for rectal cancer

BACKGROUND

Transanal endoscopic microsurgery is a faster and safer alternative to traditional surgical treatment of adenomas and low-risk (T1) rectal tumors. However, although overall survival appears similar, transanal endoscopic microsurgery has been shown to have higher recurrence rates.

OBJECTIVE

The aim of this study was to investigate the management of patients with local recurrence after transanal endoscopic microsurgery and to evaluate their long-term outcome.

DESIGN

This study was a retrospective review of medical records.

SETTING

Patients were treated at a large tertiary-care hospital in Rome, Italy, between 1990 and 2011.

PATIENTS

Of 298 patients who underwent local excision with transanal endoscopic microsurgery, 144 patients with rectal adenocarcinoma were included in the study.

INTERVENTION

Local excision was performed with transanal endoscopic microsurgery. In all cases complete full-thickness excision was attempted.

MAIN OUTCOME MEASURES

Patient characteristics, operative record, pathology report, and tumor recurrence were analyzed. Survival was calculated using the Kaplan-Meyer method and groups were compared with the log-rank test.

RESULTS

Tumors were classified as pT1 in 86 patients (59.7%), pT2 in 38 (26.4%), and pT3 in 20 (13.9%). Median follow-up was 85 (range, 3-234) months. Median time to recurrence was 11.5 (range, 1-62) months; 44 patients had local or distal recurrence or both. The rate of local recurrence for patients with pT1 tumors was 11.6% (10/86). A total of 27 patients (18.8%) with local recurrence were eligible for salvage surgery: 17 had radical salvage resection, 9 had transanal re-excision, and 1 refused surgery. Overall 5-year survival was 83% in all 144 patients, and 92% in patients with pT1 tumors. The overall 5-year survival rate was higher in patients who had the radical salvage procedure than in those who had transanal re-excision (69% vs 43%; p = 0.05).

LIMITATIONS

The study was limited by its retrospective nature, lack of technology at the beginning of the study, and the mixed nature of the study group.

CONCLUSIONS

The outcome after transanal excision for rectal cancer depends on close surveillance for early detection of recurrence. In patients able to undergo surgery, endoluminal or pelvic recurrence should be treated with an immediate radical salvage operation. Overall long-term survival after local excision with transanal endoscopic microsurgery followed by radical salvage surgery in cases of local recurrence is comparable to overall survival after initial radical surgery.

Transanal endoscopic microsurgery via TriPort Access System with no general anesthesia and without sphincter damage

The aim of this study was to develop a less-invasive transanal endoscopic microsurgery (TEM) operative technique that could be applied in severely ill patients. Modified technique of TEM operation with use of the TriPort Access System in place of the operative rectoscope was designed. Harmonic scalpel and regular laparoscopic instruments were used. Resection of the rectal stump tumor was performed. A 71-year-old male patient with recurrent adenocarcinoma T2N0M0 in rectal stump and ASA 4 was operated using presented technique with good outcome. Total operating time was 25 minutes. There were no adverse events during or after the procedure. Patient was fully mobilized directly after the procedure. Proposed technique can be performed in severely ill patients as it avoids anal sphincter divulsion and therefore general anesthesia. Standard laparoscopic instruments can be used at no extra cost and no need for additional skills.

Initial experience with transanal endoscopic microsurgery: the need for understanding the limitations

INTRODUCTION

Transanal endoscopic microsurgery is an alternative to transanal excision or radical surgery for benign and carefully selected malignant rectal tumors. Advantages over transanal excision include better visualization, access to more proximal lesions, higher likelihood of negative margins, and lower recurrence rates. Compared to radical resection, patients experience lower rates of morbidity and mortality but may have higher rates of local recurrence.

METHODS

A review of a prospectively maintained database of patients scheduled for transanal endoscopic microsurgery was performed.

RESULTS

Ninety-three patients underwent 96 procedures for 13 carcinoid tumors, 1 submucosal mass, 46 adenomas, 12 in situ adenocarcinomas, and 21 invasive adenocarcinomas. Of these cases, 81.2% was successfully completed. There were nine complications (11.5%). Final pathology demonstrated 33 in situ and invasive adenocarcinomas. The mean follow-up was 25.9 months. The four recurrences (12.1%) occurred in: one tubulovillous adenoma, two in situ carcinomas, and one T2 lesion.

CONCLUSIONS

Transanal endoscopic microsurgery is appropriate for benign lesions such as carcinoid tumors and adenomas and can also be curative in carefully selected patients with early-stage invasive rectal cancer. In cases of invasive adenocarcinoma, it should be reserved for low-risk cancers in patients who accept the possible increased risk of recurrence.

Management of stage IV rectal cancer: Palliative options

Approximately 30% of patients with rectal cancer present with metastatic disease. Many of these patients have symptoms of bleeding or obstruction. Several treatment options are available to deal with the various complications that may afflict these patients. Endorectal stenting, laser ablation, and operative resection are a few of the options available to the patient with a malignant large bowel obstruction. A thorough understanding of treatment options will ensure the patient is offered the most effective therapy with the least amount of associated morbidity. In this review, we describe various options for palliation of symptoms in patients with metastatic rectal cancer. Additionally, we briefly discuss treatment for asymptomatic patients with metastatic disease.

New developments in colorectal surgery

PURPOSE OF REVIEW

New developments in colorectal surgery have been driven primarily by technical innovations, which in turn are responsible for changes in practice. This review examines recent publications that describe and have contributed to these changes.

RECENT FINDINGS

We identified and reviewed recent publications in the areas of fecal incontinence, constipation, single incision and robotic surgical techniques, complex anal fistulas, diverticulitis, local excision techniques for rectal neoplasms, surgical care improvement, use of mechanical bowel preparation, and magnetic resonance imaging after neoadjuvant chemoradiotherapy for rectal cancer.

SUMMARY

New technologies and practice innovations will enhance patient outcomes and quality of life. Multiinstitutional studies, randomized when practical, will be necessary to further define the safety and efficacy of these new surgical techniques and to further define best practices in colon and rectal surgery.

Rectum-conserving surgery in the era of chemoradiotherapy

BACKGROUND

A complete pathological response occurs in 10-30 per cent of patients with locally advanced rectal cancer undergoing neoadjuvant chemoradiotherapy (CRT). The standard of care has been radical surgery with high morbidity risks and the challenges of stomata despite the favourable prognosis. This review assessed minimalist approaches (transanal excision or observation alone) to tumours with a response to CRT.

METHODS

A systematic review was performed using PubMed and Embase databases. Keywords included: 'rectal', 'cancer', 'transanal', 'conservative', 'complete pathological response', 'radiotherapy' and 'neoadjuvant'. Original articles from all relevant listings were sourced. These were hand searched for further articles of relevance. Main outcome measures assessed were rates of local recurrence and overall survival, and equivalence to radical surgery.

RESULTS

Purely conservative 'watch and wait' strategies after CRT are still controversial. Originally used for elderly patients or those who refused surgery, the data support transanal excision of rectal tumours showing a good response to CRT. A complete pathological response in the T stage (ypT0) indicates < 5 per cent risk of nodal metastases.

CONCLUSION

Rectal tumours showing an excellent response to CRT may be suitable for local excision, with equivalent outcomes to radical surgery. This approach should be the subject of prospective clinical trials in specialist centres.

Laparoscopic surgery for rectal cancer: The state of the art

At present time, there is evidence from randomized controlled studies of the success of laparoscopic resection for the treatment of colon cancer with reported smaller incisions, lower morbidity rate and earlier recovery compared to open surgery. Technical limitations and a steep learning curve have limited the wide application of mini-invasive surgery for rectal cancer. The present article discusses the current status of laparoscopic resection for rectal cancer. A review of the more recent retrospective, prospective and randomized controlled trial (RCT) data on laparoscopic resection of rectal cancer including the role of trans-anal endoscopic microsurgery and robotics was performed. A particular emphasis was dedicated to mid and low rectal cancers. Few prospective and RCT trials specifically addressing laparoscopic rectal cancer resection are currently available in the literature. Improved short-term outcomes in term of lesser intraoperative blood loss, reduced analgesic requirements and a shorter hospital stay have been demonstrated. Concerns have recently been raised in the largest RCT trial of the oncological adequacy of laparoscopy in terms of increased rate of circumferential margin. This data however was not confirmed by other prospective comparative studies. Moreover, a similar local recurrence rate has been reported in RCT and comparative series. Similar findings of overall and disease free survival have been reported but the follow-up time period is too short in all these studies and the few RCT trials currently available do not draw any definitive conclusions. On the basis of available data in the literature, the mini-invasive approach to rectal cancer surgery has some short-term advantages and does not seem to confer any disadvantage in term of local recurrence. With respect to long-term survival, a definitive answer cannot be given at present time as the results of RCT trials focused on long-term survival currently ongoing are still to fully clarify this issue.

Advances in cancer surgery: natural orifice surgery (NOTES) for oncological diseases

Natural orifice transluminal endoscopic surgery (NOTES) is a new concept that attempts to reduce the impact of surgery on the patient. In surgical oncology several studies have already revealed that a minimally invasive approach provides at least the same, if not a better, long-term outcome. One could hypothesize that a less invasive approach such as NOTES could further enhance such advantages. Since its initial description, NOTES has become clinical reality and today nearly every organ is accessible by a transluminal approach, in at least the experimental setting. Subsequent to published research, first clinical studies on NOTES in oncology were reported and the accuracy of transgastric peritoneoscopy for staging of pancreas cancer was shown to be similar to laparoscopy in humans. A NOTES gastro-jejunostomy via transgastric access has also been proposed to decrease invasiveness of palliative treatment of duodenal, biliary and pancreatic cancers. Colorectal cancer resection via transanal access would offer a clear-cut patient advantage over laparoscopic and would not be subject to the frequent criticism of violating an innocent second organ, as the colon or rectum is always breached in a colectomy. Natural orifice endoluminal therapies, such as endoscopic submucosal dissection, already have been clinically applied for several years. Improved techniques or instruments evolving from NOTES technology might enhance its widespread use for the treatment of early malignancies and thereby again will provide a tremendous benefit for the patient. Although still somewhat controversial, the subject of natural orifice surgery in oncological disease indicates that current laboratory efforts to introduce NOTES into cancer surgery could be ready for cautious clinical investigations. The final determination of patient benefit will need well-constructed prospective study.

Treatment of recurrence after transanal endoscopic microsurgery (TEM) for T1 rectal cancer

PURPOSE

The aim of this study was to evaluate the management and outcome of local recurrences after transanal endoscopic microsurgery for T1 rectal cancer.

METHODS

Consecutive patients who underwent transanal endoscopic microsurgery for pT1 rectal cancer at a Dutch referral center (IJsselland Hospital) were registered in a prospective database. Follow-up was according to Dutch guidelines on rectal cancer, with additional rigid rectoscopy and endorectal ultrasound examinations every 3 months for the first 2 years, and every 6 months thereafter. Annual MRI of the lesser pelvis was added during the last 2 years of the study. Patients with local recurrence during follow-up were selected for individual analysis of outcome.

RESULTS

Of a total of 88 patients who underwent transanal endoscopic microsurgery for pT1 rectal cancer, 18 patients (20.5%) had a local recurrence. Median time to local recurrence was 10 (range, 4-50) months. Median age at diagnosis of recurrence was 74 (range, 56-84) years. Of the 18 patients, 2 did not undergo further surgery because of concomitant metastatic disease, and 16 underwent salvage surgery, without need for multivisceral resections. No postoperative mortality was observed. In 15 patients (94%), a microscopically negative excision margin was obtained; in 1 patient, the excision margin was microscopically positive. Median follow-up after salvage surgery was 20 (range, 2-112) months. One patient had a local renewal of recurrence, and 7 patients (39%) had distant metastases. At 3 years, overall survival was 31%; cancer-related survival was 58%.

CONCLUSIONS

Recurrent disease after transanal endoscopic microsurgery for T1 rectal cancer is a major problem. Although salvage surgery for achieving local control is feasible in most patients, survival is limited, mainly because of distant metastases. Tailoring selection of T1 rectal cancers and exploring possible adjuvant treatment strategies following salvage procedures should be the next steps toward improving survival.

[Transsigmoid access for NOTES]

Transsigmoidal access for NOTES operations is not limited by gender and offers an outstanding controllability of the entry point. Practically all anatomical regions of the abdomen are easily accessible. However, it is particularly prone to contamination and leakage and insufficiency of the access mean that it is far more prone to complications than using alternative access points. Currently, only few data are available on the results of animal experiments and differing technical approaches have been employed. Dedicated surgical instruments are required which should be modified according to the well proven transanal endoscopic microsurgery (TEM) set of instruments. In addition, specialized instrumentation (overtubes/trocars) and the use of transanal ultrasound seem to be recommendable.

The NANETS consensus guidelines for the diagnosis and management of gastrointestinal neuroendocrine tumors (nets): well-differentiated nets of the distal colon and rectum

Neuroendocrine tumors (NETs) of the distal colon and rectum are also known as hindgut carcinoids based on their common embryologic derivation. Their annual incidence in the United States is rising, primarily as a result of increased incidental detection. Symptoms of rectal NETs include hematochezia, pain, and change in bowel habits. Most rectal NETs are small, submucosal in location, and associated with a very low malignant potential. Tumors larger than 2 cm or those invading the muscularis propria are associated with a significantly higher risk of metastatic spread. Colonic NETs proximal to the rectum are rarer and tend to behave more aggressively. The incidence of rectal NETs in African Americans and Asians is substantially higher than in Caucasians. Colorectal NETs are generally not associated with a hormonal syndrome such as flushing or diarrhea. A multidisciplinary approach is recommended in diagnosing and managing hindgut NETs.