Advertisement

Surgical Endoscopy

, Volume 28, Issue 5, pp 1407–1412 | Cite as

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

  • Antonio Maya
  • Andrew Vorenberg
  • Myrian Oviedo
  • Giovanna da Silva
  • Steven D. Wexner
  • Dana Sands
Review

Abstract

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 cm2 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) cm2. Average rate of excision (ARE) was 8.9 min/cm2. A stabilization of the LC was observed after the first four cases, showing an ARE of 13.8 min/cm2 for the first four cases versus 7.9 min/cm2 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.

Keywords

Learning curve Transanal endoscopic microsurgery Single center Rectal cancer Rectal tumor Recurrence Dysplasia Adenocarcinoma 

Notes

Disclosures

Andrew Vorenberg: Davinci Surgery, Intuitive Surgical. Steven Wexner receives consulting fees and royalties from Karl Storz Endoscopy. Antonio Maya, Myrian Oviedo, Giovanna DaSilva, and Dana Sands have no conflicts of interest or financial ties to disclose.

References

  1. 1.
    Buess G, Theiss R, Gunther M, Hutterer F, Pichlmaier H (1985) Endoscopic surgery in the rectum. Endoscopy 17(1):31–35PubMedCrossRefGoogle Scholar
  2. 2.
    Buess G, Mentges B, Manncke K, Starlinger M, Becker HD (1992) Technique and results of transanal endoscopic microsurgery in early rectal cancer. Am J Surg 163:63–70PubMedCrossRefGoogle Scholar
  3. 3.
    Lee W, Lee D, Choi S, Chun H (2003) Transanal endoscopic microsurgery and radical surgery for T1 and T2 rectal cancer. Surg Endosc 17:1283–1287PubMedCrossRefGoogle Scholar
  4. 4.
    Langer C, Liersch T, Suss M et al (2003) Surgical cure for early rectal carcinoma and large adenoma: transanal endoscopic microsurgery (using ultrasound or electrosurgery) compared to conventional local and radical resection. Int J Colorectal Dis 18:222–229PubMedGoogle Scholar
  5. 5.
    Winde G, Nottberg H, Keller R et al (1996) Surgical cure for early rectal carcinomas (T1): transanal endoscopic microsurgery vs. anterior resection. Dis Colon Rectum 39:969–976PubMedCrossRefGoogle Scholar
  6. 6.
    Neary P, Makin GB, White TJ et al (2003) Transanal endoscopic microsurgery: a viable operative alternative in selected patients with rectal lesions. Ann Surg Oncol 10(9):1106–1111PubMedCrossRefGoogle Scholar
  7. 7.
    Saclarides TJ (2007) TEM/local excision: indications, techniques, outcomes, and the future. J Surg Oncol 96:644–650PubMedCrossRefGoogle Scholar
  8. 8.
    Saclarides T (1998) Transanal endoscopic microsurgery: a single surgeon’s experience. Arch Surg 133(6):595–598 (discussion 598–599)PubMedCrossRefGoogle Scholar
  9. 9.
    Smith LE, Ko ST, Saclarides T, Caushaj P, Orkin BA, Khanduja KS (1996) Transanal endoscopic microsurgery: initial registry results. Dis Colon Rectum 39(10 Suppl):S79–S84PubMedCrossRefGoogle Scholar
  10. 10.
    Kreissler-Haag D, Schuld J, Lindemann W, Konig J, Hildebrandt U, Schilling M (2008) Complications after transanal endoscopic microsurgical resection correlate with location of rectal neoplasms. Surg Endosc 22(3):612–616PubMedCrossRefGoogle Scholar
  11. 11.
    Porcher R, Nizard RS, Schlup MM et al (2008) Quantitative and individualized assessment of the learning curve using LC-CUSUM. Br J Surg 95(7):925–929PubMedCrossRefGoogle Scholar
  12. 12.
    Koebrugge B, Bosscha K, Ernst MF (2009) Transanal endoscopic microsurgery for local excision of rectal lesions: is there a learning curve? Dig Surg 26(5):372–377PubMedCrossRefGoogle Scholar
  13. 13.
    Watters DA, Colson ME, Yap C (2007) Cumulative sum techniques for surgeons: a brief review. ANZ J Surg 77(7):583–586PubMedCrossRefGoogle Scholar
  14. 14.
    Wan F, Chen Y (2009) Off-pump coronary artery bypass graft surgery: a training course for novices and its learning curve. Thorac Cardiovasc Surg 57(3):141–147PubMedCrossRefGoogle Scholar
  15. 15.
    Blake GO, Kanchev E, Valentine CS et al (2009) Sentinel lymph node biopsy for breast cancer using methylene blue dye manifests a short learning curve among experienced surgeons: a prospective tabular cumulative sum (CUSUM) analysis. BMC Surg 27(9):2Google Scholar
  16. 16.
    Colquhoun PH (2008) CUSUM analysis of J-pouch surgery reflects no learning curve after board certification. Can J Surg 51(4):296–299PubMedCentralPubMedGoogle Scholar
  17. 17.
    Tekkis PP, Fazio VW, Laveri IC et al (2005) Evaluation of the learning curve in ileal pouch-anal anastomosis surgery. Ann Surg 241(2):262–268PubMedCentralPubMedCrossRefGoogle Scholar
  18. 18.
    Cataldo P (2006) Transanal endoscopic microsurgery. Surg Clin North Am 86(4):915–925PubMedCrossRefGoogle Scholar
  19. 19.
    Buess G, Kipfmuller K, Ibald R et al (1988) Clinical results of transanal endoscopic microsurgery. Surg Endosc 2(4):245–250PubMedCrossRefGoogle Scholar
  20. 20.
    Moore JS, Cataldo P, Osler T, Hyman N (2008) Transanal endoscopic microsurgery is more effective than traditional transanal excision for resection of rectal masses. Dis Colon Rectum 51(7):1026–1030 (discussion 1030–1031)PubMedCrossRefGoogle Scholar
  21. 21.
    De Graaf EJR, Doornebosch PG, Tetteroo GWM, Geldof H, Hop WCJ (2009) Transanal endoscopic microsurgery is feasible for adenomas throughout the entire rectum: a prospective study. Dis Colon Rectum 52:1107–1113PubMedCrossRefGoogle Scholar
  22. 22.
    Lezoche G, Baldarelli M, Paganini M et al (2008) A prospective randomized study with a 5-year minimum follow-up evaluation of transanal endoscopic microsurgery versus laparoscopic total mesorectal excision after neoadjuvant therapy. Surg Endosc 22(2):352–358PubMedCrossRefGoogle Scholar
  23. 23.
    Stipa F, Giaccaglia V, Burza A (2012) Management and outcome of local recurrence following transanal endoscopic microsurgery for rectal cancer. Dis Colon Rectum 55:262–269PubMedCrossRefGoogle Scholar
  24. 24.
    Tsai BM, Finne CO, Nordenstam JF, Christoforidis D, Madoff R, Mellgren A (2010) Transanal endoscopic microsurgery of rectal tumors: outcomes and recommendations. Dis Colon Rectum 53:16–23PubMedCrossRefGoogle Scholar
  25. 25.
    Doornebosch PG, Gosselink MP, Neijenhius PA, Schouten WR, Tollenaar RAEM, de Graaf EJR (2008) Impact of transanal endoscopic microsurgery on functional outcome and quality of life. Int J Colorectal Dis 23(7):709–713PubMedCentralPubMedCrossRefGoogle Scholar
  26. 26.
    Lim TO, Soraya A, Ding LM, Morad Z (2002) Assessing doctors’ competence: application of CUSUM technique in monitoring doctors’ performance. Int J Qual Health Care 14(3):251–258PubMedCrossRefGoogle Scholar
  27. 27.
    Mentges B, Buess G, Schäfer D, Manncke K, Becker HD (1996) Local therapy of rectal tumors. Dis Colon Rectum 39(8):886–892PubMedCrossRefGoogle Scholar
  28. 28.
    Mörschel M, Heintz A, Bussmann M, Junginger T (1998) Follow-up after transanal endoscopic microsurgery or transanal excision of large benign rectal polyps. Langenbecks Arch Surg 383(5):320–324PubMedCrossRefGoogle Scholar
  29. 29.
    Nagy A, Kovács T, Berki C, Jánó Z (1999) Surgical management of villous and tubulovillous adenomas of the rectum. Orv Hetil 140(40):2215–2219PubMedGoogle Scholar
  30. 30.
    Buess GF, Raestrup H (2001) Transanal endoscopic microsurgery. Surg Oncol Clin North Am 10(3):709–731Google Scholar
  31. 31.
    Lloyd GM, Sutton CD, Marshall LJ et al (2002) Transanal endoscopic microsurgery—lessons from a single UK centre series. Colorectal Dis 4(6):467–472PubMedCrossRefGoogle Scholar
  32. 32.
    Palma P, Freudenberg S, Samel S, Post S (2004) Transanal endoscopic microsurgery: indications and results after 100 cases. Colorectal Dis 6(5):350–355PubMedCrossRefGoogle Scholar
  33. 33.
    Platell C, Denholm E, Makin G (2004) Efficacy of transanal endoscopic microsurgery in the management of rectal polyps. J Gastroenterol Hepatol 19(7):767–772PubMedCrossRefGoogle Scholar
  34. 34.
    Endreseth BH, Wibe A, Svinsãs M, Mãrvik R, Myrvold HE (2005) Postoperative morbidity and recurrence after local excision of rectal adenomas and rectal cancer by transanal endoscopic microsurgery. Colorectal Dis 7(2):133–137PubMedCrossRefGoogle Scholar
  35. 35.
    Whitehouse PA, Tilney HS, Armitage JN, Simson JN (2006) Transanal endoscopic microsurgery: risk factors for local recurrence of benign rectal adenomas. Colorectal Dis 8(9):795–799PubMedCrossRefGoogle Scholar
  36. 36.
    Langer C, Markus P, Liersch T, Füzesi L, Becker H (2001) Ultracision or high-frequency knife in transanal endoscopic microsurgery (TEM)? Advantages of a new procedure. Surg Endosc 15(5):513–517PubMedCrossRefGoogle Scholar
  37. 37.
    Demartines N, Von Flüe MO, Harder FH (2001) Transanal endoscopic microsurgical excision of rectal tumors: indications and results. World J Surg 25(7):870–875PubMedCrossRefGoogle Scholar
  38. 38.
    Stipa F, Burza A, Lucandri G et al (2006) Outcomes for early rectal cancer managed with transanal endoscopic microsurgery: a 5-year follow-up study. Surg Endosc 20(4):541–545PubMedCrossRefGoogle Scholar
  39. 39.
    Floyd ND, Saclarides TJ (2006) Transanal endoscopic microsurgical resection of pT1 rectal tumors. Dis Colon Rectum 49(2):164–168PubMedCrossRefGoogle Scholar
  40. 40.
    Baatrup G, Breum B, Qvist N et al (2009) Transanal endoscopic microsurgery in 143 consecutive patients with rectal adenocarcinoma: results from a Danish multicenter study. Colorectal Dis 11(3):270–275PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Antonio Maya
    • 1
  • Andrew Vorenberg
    • 1
  • Myrian Oviedo
    • 1
  • Giovanna da Silva
    • 1
  • Steven D. Wexner
    • 1
  • Dana Sands
    • 1
  1. 1.Department of Colorectal SurgeryCleveland Clinic FloridaWestonUSA

Personalised recommendations