Transanal endoscopic microsurgery for rectal tumors: experience at Korea's National Cancer Center. Surg Endosc. 2009;23:2575-2579. [PMID: 19347399 DOI: 10.1007/s00464-009-0466-7]

Efficacy and safety of transanal endoscopic microsurgery for early rectal cancer: a meta-analysis

Background

The gold standard for the treatment of rectal cancer is radical surgery with total mesorectal excision (TME). As one of the alternatives to radical surgery, local resection has been proposed for the treatment of early rectal cancer. The purpose of this article was to evaluate the safety and efficacy of transanal endoscopic microsurgery (TEM) in the treatment of early rectal cancer.

Methods

By searching the PubMed, Cochrane Library, Web of Science, and China National Knowledge Infrastructure databases, we selected all articles on TEM for early rectal cancer. Two researchers independently completed the entire process from screening, inclusion to data extraction and performed statistical analysis using RevMan 5.3. The primary outcomes included basic patient characteristics, overall survival rate, disease-free survival rate, disease-specific survival rate, recurrence rate, and complication rate and type.

Results

A total of 33 articles were included in this meta-analysis. The results showed that the overall survival rate was 100% for T0 stage, 98.1% for Tis (carcinoma in situ) stage, and 80.2% for early stage rectal cancer patients (83.9% for T1 and 72.4% for T2). The weighted overall survival rate was 94% (RD = 0.94, 95% CI = 0.93-0.95, I 2 = 80%, P < 0.00001) for all stage patients, the weighted disease-free survival rate was 91% (RD = 0.91, 95% CI = 0.90-0.93, I 2 = 83%, P < 0.00001), and the disease-specific survival rate was 97% (RD = 0.97, 95% CI = 0.96-0.98, I 2 = 63%, P < 0.00001). The recurrence rate was 0.5% for T0 stage, 1.9% for Tis stage, and 11.9% for early stage rectal cancer patients (8.1% for T1 and 19.7% for T2). The weighted recurrence rate was 7% (RD = 0.07, 95% CI = 0.06-0.08, I 2 = 69%, P < 0.00001) for all stage patients. The weighted complications rate was 11% (RD = 0.11, 95% CI = 0.10-0.12, I 2 = 66%, P < 0.00001) for all stage patients, with Clavien-Dindo grade I accounting for 77.7%, Clavien-Dindo grade II accounting for 8%, and Clavien-Dindo grade III accounting for 14.3%.

Conclusion

The results showed that TEM has a high postoperative survival rate, low recurrence rate, and low complication rate in the T0 stage, Tis stage, and T1 stage, indicating its good safety and efficacy. For the treatment of T2 stage, TEM has a lower overall survival rate and a higher recurrence rate. Our meta-analysis results suggest that TEM alone is not recommended as a curative treatment for T2 stage; on the contrary, TME is more frequently recommended.

Risk of recurrence after local resection of T1 rectal cancer: a meta-analysis with meta-regression

BACKGROUND

T1 rectal cancer (RC) patients are increasingly being treated by local resection alone but uniform surveillance strategies thereafter are lacking. To determine whether different local resection techniques influence the risk of recurrence and cancer-related mortality, a meta-analysis was performed.

METHODS

A systematic search was conducted for T1RC patients treated with local surgical resection. The primary outcome was the risk of RC recurrence and RC-related mortality. Pooled estimates were calculated using mixed-effect logistic regression. We also systematically searched and evaluated endoscopically treated T1RC patients in a similar manner.

RESULTS

In 2585 unique T1RC patients (86 studies) undergoing local surgical resection, the overall pooled cumulative incidence of recurrence was 9.1% (302 events, 95% CI 7.3-11.4%; I2 = 68.3%). In meta-regression, the recurrence risk was associated with histological risk status (p < 0.005; low-risk 6.6%, 95% CI 4.4-9.7% vs. high-risk 28.2%, 95% CI 19-39.7%) and local surgical resection technique (p < 0.005; TEM/TAMIS 7.7%, 95% CI 5.3-11.0% vs. other local surgical excisions 10.8%, 95% CI 6.7-16.8%). In 641 unique T1RC patients treated with flexible endoscopic excision (16 studies), the risk of recurrence (7.7%, 95% CI 5.2-11.2%), cancer-related mortality (2.3%, 95% CI 1.1-4.9), and cancer-related mortality among patients with recurrence (30.0%, 95% CI 14.7-49.4%) were comparable to outcomes after TEM/TAMIS (risk of recurrence 7.7%, 95% CI 5.3-11.0%, cancer-related mortality 2.8%, 95% CI 1.2-6.2% and among patients with recurrence 35.6%, 95% CI 21.9-51.2%).

CONCLUSIONS

Patients with T1 rectal cancer may have a significantly lower recurrence risk after TEM/TAMIS compared to other local surgical resection techniques. After TEM/TAMIS and endoscopic resection the recurrence risk, cancer-related mortality and cancer-related mortality among patients with recurrence were comparable. Recurrence was mainly dependent on histological risk status.

Preservation of the rectum is possible in early rectal cancer with neoadjuvant radiotherapy, delay and local excision-a 12-year single-centre experience of the evolution of early rectal cancer treatment

AIM

Treatment of early rectal cancer (ERC) is undergoing a revolution towards rectum preservation. Adjuvant and neoadjuvant therapy alongside local excision (LE) means that organ preservation is a real possibility for most patients and a viable alternative for frailer patients. This study presents our 12-year experience as a specialist regional ERC unit, evolving towards organ preservation.

METHOD

Data were collected prospectively between 2006 and 2018 for all patients referred to the regional ERC multidisciplinary team with suspected or confirmed ERC. Patients considered suitable for LE, or those declining radical surgery, were offered LE or neoadjuvant short-course radiotherapy (SCRT), delay and LE with subsequent rescue surgery or contact brachytherapy for unfavourable histopathology.

RESULTS

In all, 102 patients underwent LE. Ten patients were excluded (N = 92). 45 patients underwent LE directly and 47 patients received SCRT and LE. After SCRT and LE, a pathological complete response was achieved in 44.7%. This approach also resulted in a lower rate of lymphovascular invasion (22.2% vs. 6.4%), fewer distant recurrences (4.4% vs. 0%) and a better disease-specific mortality (11.1% vs. 0%) (P < 0.05). Although statistically insignificant, fewer patients required rescue surgery after SCRT (15.6% vs. 4.3%).

CONCLUSION

Organ preservation with a good oncological outcome is better achieved by neoadjuvant radiotherapy, delay and LE. To achieve this, careful patient selection, thorough preoperative investigation, experienced surgical technique and a deep appreciation of tumour biology managed via a dedicated ERC network is paramount.

Neoadjuvant radiotherapy for rectal cancer management

Thirty per cent of all colorectal tumours develop in the rectum. The location of the rectum within the bony pelvis and its proximity to vital structures presents significant therapeutic challenges when considering neoadjuvant options and surgical interventions. Most patients with early rectal cancer can be adequately managed by surgery alone. However, a significant proportion of patients with rectal cancer present with locally advanced disease and will potentially benefit from down staging prior to surgery. Neoadjuvant therapy involves a variety of options including radiotherapy, chemotherapy used alone or in combination. Neoadjuvant radiotherapy in rectal cancer has been shown to be effective in reducing tumour burden in advance of curative surgery. The gold standard surgical rectal cancer management aims to achieve surgical removal of the tumour and all draining lymph nodes, within an intact mesorectal package, in order to minimise local recurrence. It is critically important that all rectal cancer cases are discussed at a multidisciplinary meeting represented by all relevant specialties. Pre-operative staging including CT thorax, abdomen, pelvis to assess for distal disease and magnetic resonance imaging to assess local involvement is essential. Staging radiology and MDT discussion are integral in identifying patients who require neoadjuvant radiotherapy. While Neoadjuvant radiotherapy is potentially beneficial it may also result in morbidity and thus should be reserved for those patients who are at a high risk of local failure, which includes patients with nodal involvement, extramural venous invasion and threatened circumferential margin. The aim of this review is to discuss the role of neoadjuvant radiotherapy in the management of rectal cancer.

Appraisal and Current Considerations of Robotics in Colon and Rectal Surgery

BACKGROUND

Robotic technology aims to obviate some of the limitations of conventional laparoscopic surgery, yet the role of robotics in colorectal surgery is still largely undefined and varies with respect to its application in abdominal versus pelvic surgery.

METHODS

With this review, we aimed to highlight current developments in colorectal robotic surgery. We systematically searched the following databases: PubMed, EMBASE, and Cochrane Library. We critically reviewed the available literature on the use of robotic technology in colon and rectal surgery.

RESULTS

Robotic colorectal surgery is oncologically safe and has short-term outcomes comparable to conventional laparoscopy, with potential benefits in rectal surgery. It has a shorter learning curve but increased operative times and costs. It offers potential advantages in the resection of rectal cancer, due to lower conversion rates. There is also a trend toward better outcomes in anastomotic leak rates, circumferential margin positivity, and perseveration of autonomic function.

CONCLUSION

Laparoscopy remains technically challenging and conversion rates are still high. Therefore, most cases of colorectal surgery are still performed open. Robotic surgery aims to overcome the limits of the laparoscopic technique. This new technology has many advantages in terms of articulating instruments, advanced three-dimensional optics, surgeon ergonomics, and improved accessibility to narrow spaces, such as the pelvis. However, further studies are needed to assess long-term results and benefits.

Management of locally advanced rectal cancer in the elderly: a critical review and algorithm

Colorectal cancer incidence and death rates have been declining over the past 10 years. However, it remains the second leading cause of death in men ages 60-79 and the third leading cause of death in men over 80 and in women over 60 years old. However, there is little data specific to the treatment of the elder patient, since few of these patients are included in trials. With the advent of improved therapies, there are many alternative options available. Still, no definitive consensus or guidelines have been defined for this particular patient population. The goal of this study is to review the literature on the management of rectal cancer in the elderly and to propose treatment algorithms to help the oncology team in treatment decision-making.

Transanal Minimally Invasive Surgery

Transanal endoscopic surgery (TES) techniques encompass a variety of approaches, including transanal endoscopic microsurgery and transanal minimally invasive surgery. These allow a surgeon to perform local excision of rectal lesions with minimal morbidity and the potential to spare the need for proctectomy. As understanding of the long-term outcomes from these procedures has evolved, so have the indications for TES. In this study, we review the development of TES, its early results, and the evolution of new surgical techniques. In addition, we evaluate the most recent research on indications and outcomes in rectal cancer.

The implementation of a transanal endoscopic microsurgery programme: initial experience with surgical performance

AIM

Despite transanal endoscopic microsurgery (TEM) being used for over 30 years, there has been slow adoption of this modality in many centres. There remains a paucity of research regarding the learning curve and early performance of surgeons who begin to offer TEM. We sought to determine predictors of longer rates of tumour excision and improvements in operative time in a newly established TEM programme.

METHOD

All patients who underwent TEM at the Ottawa Hospital, Ottawa, Canada, between October 2009 and September 2014 were included. Data were abstracted through a retrospective chart review. The average rate of lesion excision (ARE) was calculated to standardize the operation time by size of the pathological specimen (min/cm³ ), representing a measure of surgical efficiency. Surgical efficiency was plotted using restricted cubic splines. Predictors of higher ARE were determined using multivariable regression.

RESULTS

During the study period 108 patients underwent TEM. ARE was available for 95 patients of mean age 67.2 years. The mean ARE was 18.6 min/cm³ . On adjusting for important covariates, the ARE improved with each additional case until 16 cases were completed. Significant predictors of higher ARE on multivariable analysis were age < 50 years, experience of fewer than five cases, and carcinoid/gastrointestinal stromal tumour or scar histology.

CONCLUSION

Operative efficiency appears to improve as surgeons completed 16 TEM cases. We have identified important factors that result in longer operating time. The study has important implications with regard to surgical training and operative planning for new TEM programmes.

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.

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.

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.

A single surgeon's experience with transanal endoscopic microsurgery over 20 years with 153 early cancer cases

BACKGROUND

The first author performed transanal endoscopic surgery (TEM) in 302 patients in Japan for the last 20 years, 153 of which were early rectal cancer cases. The short- and long-term outcomes of the early rectal cancer cases are herein reported.

MATERIAL AND METHODS

The original technique of TEM developed by Gerhard Buess was performed in all cases. The hospital records were reviewed to assess the clinical outcomes. A questionnaire was sent to the patients to analyze the long-term outcomes.

RESULTS

One-hundred and fifty-three early cancer cases included 115 T0 and 38 T1 lesions. Full-thickness resection was performed in 36 patients, while 117 underwent submucosal dissection. Conversion to laparoscopic low anterior resection occurred in one case. Mortality was nil. Major operative complication was noted in only one patient, who developed stenosis. Seven patients underwent immediate salvage surgery. Six patients died of recurrence of rectal cancer. Disease-free survival rate at year 5 was 93.7%.

CONCLUSIONS

Our study, one of the largest series in the world, confirms that TEM is a preferable option in the surgical treatment of T0 and T1a rectal carcinoma. As long as early cancer cases are treated, submucosal resection seems to be sufficient. When risk of recurrence is found by pathological examination, immediate salvage operation is mandatory to improve the prognosis.

Outcomes of local excision for early rectal cancer: a 6-year experience from the largest university hospital in Thailand

BACKGROUND

This study aimed to determine clinical outcomes of local excision for early rectal cancer from a University Hospital in Thailand.

MATERIALS AND METHODS

We performed a retrospective review of 22 consecutive patients undergoing local excision for early rectal cancer (clinical and radiological T1/T2) from 2005-2010 at the Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok. Data were collected from patients' medical records, including demographic and clinical characteristics, pathological report and surgical outcomes.

RESULTS

This study included 10 males and 12 females, with average age of 68 years. Nineteen patients (86%) underwent transanal excision and the others had trans-sacral excision. Median operative time was 45 minutes. Postoperative complications occurred in 2 patients (9%); 1 fecal fistula and 1 wound infection following trans-sacral excision. There was no 30-day postoperative mortality. Median hospital stay was 5 days. Pathological reports revealed T1 lesion in 12 cases (55%), T2 lesion in 8 cases (36%) and T3 lesion in 2 cases (9%). Eight patients received additional treatment; one re-do transanal excision, two proctectomies, and five adjuvant chemoradiation. During the median follow-up period of 25 months, local recurrence was detected in 4 patients (18%); two cases of T2 lesions with close or positive margins, and two cases of T3 lesions. Three patients with local recurrence underwent salvage abdominoperineal resection. No local recurrence was found in T1/T2 lesions with free surgical margins.

CONCLUSIONS

Local excision is a feasible and acceptable alternative to radical resection only in early rectal cancer with free resection margins and favorable histopathology.

Single-incision laparoscopic surgery used to perform transanal endoscopic microsurgery (SILSTEM) for T1 rectal cancer under spinal anesthesia: report of a case

Transanal endoscopic surgery has slowly gained widespread acceptance among colorectal surgeons, despite the need for specific training and the high costs of specialized instrumentation. At the other extreme, some laparoscopic surgeons recommend single port access surgery using a single-incision laparoscopic surgery port. Single-incision laparoscopic surgery was applied to perform transanal endoscopic microsurgery in a patient with T1 rectal cancer under spinal anesthesia. The patient was a 74-year-old man who presented with a 2-cm elevated lesion in the right anterior portion of the rectum. Ordinary laparoscopic instruments were used to perform submucosal resection. The tumor was completely excised from the rectal wall with the use of an ultrasonic surgical scissors. The patient recovered uneventfully and was discharged 4 days after the operation. There was no fecal incontinence or soiling during the postoperative follow-up. Colonoscopy at 4 months after the operation showed no recurrence of either adenocarcinoma or adenoma.