Incidence, treatment and outcome of rectal stenosis following transanal endoscopic microsurgery

The outcome of local excision of large rectal polyps by transanal endoscopic microsurgery

Introduction

Local excision of large rectal polyps can be an alternative for radical rectal resection with total mesorectal excision. We aim to report the functional and oncological outcomes of transanal endoscopic microsurgery (TEM) for patients with large rectal polyps.

Methods

All demographic and clinical data of patients who underwent TEM for rectal polyp of 5 cm or more at the Hasharon Hospital from 2005 to 2018 were retrospectively reviewed.

Results

Twenty-eight patients were included. The mean age was 66 years. The mean polyp size was 6.2 cm (range: 5-8.5 cm) with a mean distance of 8.3 cm from the anal verge. Peritoneal entry during TEM was observed in five patients and additional laparoscopy after the completion of the TEM was performed in four patients. There were no major perioperative complications. Seven patients had minor complications. Final pathology revealed T1 carcinoma in five patients and T2 carcinoma in three patients. Re-TEM was performed in one patient with involved margins with adenoma. After a median follow-up of 64 months, one patient had local recurrence.

Conclusion

TEM is an acceptable technique for the treatment of large polyps with minor complications and a reasonable recurrence rate. TEM may be considered regardless of the size of the rectal polyp.

Transanal endoscopic microsurgical submucosal dissection (TEM-ESD) for rectal adenomas: a retrospective cohort study of 145 consecutive cases

PURPOSE

Transanal endoscopic microsurgery (TEM) and endoscopic submucosal dissection (ESD) are currently the two most popular methods for resecting large rectal adenomas en bloc. However, damage to the mesorectum in the case of TEM, plus the technical challenges and long procedure times of flexible ESD, are major disadvantages of these procedures. Transanal endoscopic microsurgical submucosal dissection (TEM-ESD) is a new technique, combining the ergonomic features of TEM with the minimally invasive approach of ESD. The aim of our study was to assess the feasibility and safety of TEM-ESD for resection of large rectal adenomas.

METHODS

We retrospectively analyzed all TEM-ESD procedures performed in Karlsruhe Municipal Hospital between 2012 and 2019, isolated all cases of adenomas, and analyzed the perioperative and follow-up data of the patients.

RESULTS

We identified 145 cases matching our criteria. The median size of the lesions was 4.2 cm, and the median operating time was 45 min. The en bloc resection rate was 100%, and the complete en bloc resection rate was 78.6%. The overall morbidity rate was 6.9%. In a median follow-up period of 24 months, there was a local recurrence in 4.8% of the cases.

CONCLUSIONS

TEM-ESD is a safe and feasible therapeutic option for resecting large rectal adenomas, offering high en bloc resection and low recurrence rates combined with short operating time and low morbidity. TRIAL REGISTRATION NUMBER (CLINICALTRIALS.GOV): NCT04870931.

Long-term outcomes of open versus closed rectal defect after transanal endoscopic microscopic surgery

AIM

Management of the rectal defect after transanal endoscopic microsurgery (TEM) is a matter of debate. Data are lacking on long term outcomes and continence of patients with open or closed rectal defect. We sought to analyse these in a retrospective cohort study.

METHODS

Patients undergoing TEM via the Specialist Early Rectal Cancer (SERC) MDT between 2012 and 2019 were included from a prospectively maintained database. These were divided into two groups - open and closed, based on management of rectal defect. Patient demographics and outcomes, including pre- and postoperative oncological staging, morbidity, mortality, length of stay and faecal incontinence severity score (FISI) scores were assessed.

RESULTS

A total of 170 matched patients were included (70-open, 100-closed rectal defects). Short-term complications (bleeding, infection, urinary retention and infection, length of stay and pain) were 18.8% with no significant difference between the two groups (22% vs. 16%). Most of the defects were well healed upon endoscopic follow-up; more unhealed/sinus formation was noticed in the open group (p = 0.01); more strictures were encountered in the closed group (p = 0.04). Comparing the open and closed defect groups, there was no difference in the functional outcome of patients in those who developed sinus (p = 0.87) or stricture (p = 0.79) but a significant difference in post-TEMS FISI scores in those with healed scar, with those in closed rectal defect group with worsening function (p = 0.02).

CONCLUSION

There are pros and cons associated with both rectal defect management approaches. Long-term complications should be expected and actively followed up. Patients should be thoroughly counselled about these and possible deterioration in continence post-TEM.

Transanal endoscopic surgery for complications of prior rectal surgery

BACKGROUND

Long-term complications of previous rectal surgery (e.g., enterovisceral fistula, anastomotic stricture, rectal stenosis) can be challenging problems for which transabdominal or transperineal surgery with or without definitive fecal diversion is often required. Transanal endoscopic surgery (TES) might allow for local treatment of these complications, thereby saving patients from otherwise major surgery.

PATIENTS AND METHODS

All patients undergoing TES in the IJsselland Hospital (NL) since 1996 were recorded in a prospective database, of which twenty patients were treated for complications after previous rectal surgery. Data on prior treatment, surgical techniques, outcomes, and need for additional surgery were collected.

RESULTS

Twenty patients were identified from the database (rectourinary fistula n = 3, rectovaginal fistula n = 5, anastomotic stricture n = 8, and rectal stenosis n = 4). One of the three (33 %) rectourinary fistulas and two of five (40 %) rectovaginal fistulas were successfully treated with TES. Anastomotic strictures were successfully treated in 5/8 (63 %) patients. Strictures after local excision of rectal tumors were successfully treated in 3/4 (75 %) patients. No minor complication and one major complication occurred (rectovaginal fistula after stenoplasty eventually requiring Hartmann's procedure).

CONCLUSIONS

Transanal treatment of anastomotic strictures, rectal stenosis, and fistula after prior rectal surgery is safe and effective in a large proportion of patients. TES should be considered as a first step in all patients presenting with these late complications after rectal surgery.

Endoscopic submucosal dissection for anorectal tumor with hemorrhoids close to the dentate line: a multicenter study of Hiroshima GI Endoscopy Study Group

BACKGROUND

The lower rectum close to the dentate line has distinct characteristics, making endoscopic submucosal dissection (ESD) of tumors challenging. We assessed clinical outcomes of ESD for such patients with hemorrhoids.

METHODS

Sixty-four patients (mean age, 68 years) underwent ESD for anorectal tumors close to the dentate line. We divided patients into those with (Group A, 45 patients) and without hemorrhoids (Group B, 19 patients). We examined en bloc and histological en bloc resection rates, procedure time, complication rates, and postoperative prognosis after ESD.

RESULTS

The mean tumor size was 43 mm. Histologic diagnoses were adenoma (42 %, 27/64), carcinoma in situ (44 %, 28/64), and T1 carcinoma (14 %, 9/64). There was no significant difference in en bloc resection (93 %, 42/45 vs. 95 %, 18/19) or postoperative bleeding rates (16 %, 7/45 vs. 11 %, 2/19) between Groups A and B, respectively. The mean procedural durations were 120 and 124 min, respectively, in Groups A and B. No perforations occurred. There was no significant difference in postoperative anal pain rate between Groups A (18 %, 8/45) and B (16 %, 3/19), and it resolved within a few days in all cases. There was one case of stricture in Group B. Two patients with T1 carcinoma underwent additional surgery, one underwent chemotherapy, and five had no additional treatment. No recurrence occurred during the follow-up period of 38 months.

CONCLUSIONS

ESD is safe and effective for anorectal tumors close to the dentate line in patients with hemorrhoids.

[Transanal endoscopic microsurgery]

AIM

To analyze the immediate and remote results of transanal endoscopic microsurgical intervantions and its role in treatment of rectal tumors.

MATERIAL AND METHODS

The results of transanal endoscopic microsurgery in 56 patients with rectal tumors were studied. Adenoma and adenocarcinoma were observed in 45 (80%) and 11 (20%) patients respectively. Mean height of tumor lower edge placement was 8.6 ± 0.3 cm from anus, mean diameter - 3.7 ± 0.3 cm. All patients underwent full-layer resection of rectum.

RESULTS

Postoperative complications were observed in 4 (7%) patients. There were no deaths. Transanal endoscopic microsurgery is modern, adequate and effective treatment of benign and early forms of malignant rectal tumors. It is associated with lower incidence of complications and recurrence under condition of careful selection of patients. Based on obtained results we recommend surgeons to apply this technique only in case of tumor placement below 10-11 cm from anus and tumor's diameter up to 3-4 cm to minimize risk of complications and recurrences. Full-layer resection of rectum is recommended in all cases of operations for benign tumors because of there is high risk of latent malignancy.

Local excision by transanal endoscopic surgery

Transanal endoscopic surgery (TES) consists of a series of anorectal surgical procedures using different devices that are introduced into the anal canal. TES has been developed significantly since it was first used in the 1980s. The key point for the success of these techniques is how accurately patients are selected. The main indication was the resection of endoscopically unresectable adenomas. In recent years, these techniques have become more widespread which has allowed them to be applied in conservative rectal procedures for both benign diseases and selected cases of rectal cancer. For more advanced rectal cancers it should be considered palliative or, in some controlled trials, experimental. The role of newer endoscopic techniques available has not yet been defined. TES may allow for new strategies in the treatment of rectal pathology, like transanal natural orifice transluminal endoscopic surgery or total mesorectal excision.

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.

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.