Advertisement

Functional Outcomes After Local Excision for Rectal Neoplasia

  • Elizabeth R. Raskin
Chapter

Abstract

Transanal surgery is a viable option for most benign and select malignant rectal neoplasms. While a large focus has been placed on the safety, feasibility, and oncologic soundness of transanal techniques compared to traditional proctectomy, functional outcomes following transanal surgery have received much less attention. This chapter aims to define anorectal function, elucidate preoperative and intraoperative factors that contribute to functional outcomes, and compare postoperative outcomes after traditional transanal surgery, transanal endoscopic microsurgery (TEM), and transanal minimally invasive surgery (TAMIS). The insertion and utilization of either an anoscope or a minimally invasive platform can affect the sphincter complex and potentially cause postoperative dysfunction. Careful consideration to preoperative functional status should be paid to avoid exacerbation of existing continence issues and for setting appropriate expectations for potential disturbances in continence and quality of life in the postoperative setting. Size of tumor, location within the rectum, extent of resection, duration of surgery, age, and female sex have been postulated to affect functional outcomes; however, no strong data exist to uniformly vilify any preoperative or intraoperative factor. The sole exception: Patients who have received chemoradiation therapy prior to transanal excision have been shown to have an elevated risk for postoperative anorectal dysfunction. While injury to the sphincter complex and rectal wall is possible during transanal excisional surgery, the majority of continence and quality of life data demonstrates acceptable results and supports the use of transanal surgical approaches over traditional proctectomy when oncologically appropriate.

Keywords

Local excision Rectal neoplasia Transanal surgery Anorectal function Transanal endoscopic microsurgery Transanal minimally invasive surgery 

References

  1. 1.
    Christoforidis D, Cho HM, Dixon MR, Mellgren AF, Madoff RD, Finne CO. Transanal endoscopic microsurgery versus conventional transanal excision for patients with early rectal cancer. Ann Surg. 2009;249(5):776–82.  https://doi.org/10.1097/SLA.0b013e3181a3e54b.CrossRefPubMedGoogle Scholar
  2. 2.
    Saclarides TJ, Smith L, Ko ST, Orkin B, Buess G. Transanal endoscopic microsurgery. Dis Colon Rectum. 1992;35(12):1183–91.CrossRefGoogle Scholar
  3. 3.
    Barendse RM, Oors JM, de Graaf EJ, Bemelman WA, Fockens P, Dekker E, Smout AJ. The effect of endoscopic mucosal resection and transanal endoscopic microsurgery on anorectal function. Color Dis. 2013;15(9):e534–41.  https://doi.org/10.1111/codi.12311.CrossRefGoogle Scholar
  4. 4.
    Rockwood TH, Church JM, Fleshman JW, Kane RL, Mavrantonis C, Thorson AG, et al. Patient and surgeon ranking of the severity of symptoms associated with fecal incontinence: the fecal incontinence severity index. Dis Colon Rectum. 1999;42(12):1525–32.CrossRefGoogle Scholar
  5. 5.
    Rockwood TH, Church JM, Fleshman JW, Kane RL, Mavrantonis C, Thorson AG, et al. Fecal incontinence quality of life scale: quality of life instrument for patients with fecal incontinence. Dis Colon Rectum. 2000;43(1):9–16; discussion 16–17CrossRefGoogle Scholar
  6. 6.
    Doornebosch PG, Gosselink MP, Neijenhuis PA, Schouten WR, Tollenaar RA, de Graaf EJ. Impact of transanal endoscopic microsurgery on functional outcome and quality of life. Int J Color Dis. 2008;23(7):709–13.  https://doi.org/10.1007/s00384-008-0442-z.CrossRefGoogle Scholar
  7. 7.
    Planting A, Phang PT, Raval MJ, Brown CJ. Transanal endoscopic microsurgery: impact on fecal incontinence and quality of life. Can J Surg. 2013;56(4):243–8.CrossRefGoogle Scholar
  8. 8.
    Vaizey CJ, Carapeti E, Cahill JA, Kamm MA. Prospective comparison of faecal incontinence grading systems. Gut. 1999;44(1):77–80.CrossRefGoogle Scholar
  9. 9.
    Mora Lopez L, Serra-Aracil X, Navarro Soto S. Sphincter lesions observed on ultrasound after transanal endoscopic surgery. World J Gastroenterol. 2015;21(46):13160–5.  https://doi.org/10.3748/wjg.v21.i46.13160.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Thomas GP, Gould LE, Casunuran F, Kumar DA. A retrospective review of 1495 patients with obstetric anal sphincter injuries referred for assessment of function and endoanal ultrasonography. Int J Color Dis. 2017;32(9):1321–5.  https://doi.org/10.1007/s00384-017-2851-3.CrossRefGoogle Scholar
  11. 11.
    Herman RM, Richter P, Walega P, Popiela T. Anorectal sphincter function and rectal barostat study in patients following transanal endoscopic microsurgery. Int J Color Dis. 2001;16(6):370–6.CrossRefGoogle Scholar
  12. 12.
    MacDonald A, Smith A, McNeill AD, Finlay IG. Manual dilatation of the anus. Br J Surg. 1992;79(12):1381–2.CrossRefGoogle Scholar
  13. 13.
    Speakman CT, Burnett SJ, Kamm MA, Bartram CI. Sphincter injury after anal dilatation demonstrated by anal endosonography. Br J Surg. 1991;78(12):1429–30.CrossRefGoogle Scholar
  14. 14.
    van Tets WF, Kuijpers JH, Tran K, Mollen R, van Goor H. Influence of Parks’ anal retractor on anal sphincter pressures. Dis Colon Rectum. 1997;40(9):1042–5.CrossRefGoogle Scholar
  15. 15.
    Fenech DS, Takahashi T, Liu M, Spencer L, Swallow CJ, Cohen Z, et al. Function and quality of life after transanal excision of rectal polyps and cancers. Dis Colon Rectum. 2007;50(5):598–603.  https://doi.org/10.1007/s10350-006-0865-y.CrossRefPubMedGoogle Scholar
  16. 16.
    Buess G, Theiss R, Hutterer F, Pichlmaier H, Pelz C, Holfeld T, et al. Transanal endoscopic surgery of the rectum - testing a new method in animal experiments. Leber Magen Darm. 1983;13(2):73–7.PubMedGoogle Scholar
  17. 17.
    Allaix ME, Rebecchi F, Giaccone C, Mistrangelo M, Morino M. Long-term functional results and quality of life after transanal endoscopic microsurgery. Br J Surg. 2011;98(11):1635–43.  https://doi.org/10.1002/bjs.7584.CrossRefPubMedGoogle Scholar
  18. 18.
    Hemingway D, Flett M, McKee RF, Finlay IG. Sphincter function after transanal endoscopic microsurgical excision of rectal tumours. Br J Surg. 1996;83(1):51–2.CrossRefGoogle Scholar
  19. 19.
    Dafnis G, Pahlman L, Raab Y, Gustafsson UM, Graf W. Transanal endoscopic microsurgery: clinical and functional results. Color Dis. 2004;6(5):336–42.  https://doi.org/10.1111/j.1463-1318.2004.00629.x.CrossRefGoogle Scholar
  20. 20.
    Ghiselli R, Ortenzi M, Cardinali L, Skrami E, Gesuita R, Guerrieri M. Functional outcomes after TEM in patients with complete clinical response after neoadjuvant chemoradiotherapy. Surg Endosc. 2017;31(7):2997–3003.  https://doi.org/10.1007/s00464-016-5321-z.CrossRefPubMedGoogle Scholar
  21. 21.
    Cataldo PA, O’Brien S, Osler T. Transanal endoscopic microsurgery: a prospective evaluation of functional results. Dis Colon Rectum. 2005;48(7):1366–71.  https://doi.org/10.1007/s10350-005-0031-y.CrossRefPubMedGoogle Scholar
  22. 22.
    Verseveld M, Barendse RM, Gosselink MP, Verhoef C, de Graaf EJ, Doornebosch PG. Transanal minimally invasive surgery: impact on quality of life and functional outcome. Surg Endosc. 2016;30(3):1184–7.  https://doi.org/10.1007/s00464-015-4326-3.CrossRefPubMedGoogle Scholar
  23. 23.
    Habr-Gama A, Lynn PB, Jorge JM, Sao Juliao GP, Proscurshim I, Gama-Rodrigues J, et al. Impact of organ-preserving strategies on anorectal function in patients with distal rectal cancer following neoadjuvant chemoradiation. Dis Colon Rectum. 2016;59(4):264–9.  https://doi.org/10.1097/DCR.0000000000000543.CrossRefPubMedGoogle Scholar
  24. 24.
    Gornicki A, Richter P, Polkowski W, Szczepkowski M, Pietrzak L, Kepka L, et al. Anorectal and sexual functions after preoperative radiotherapy and full-thickness local excision of rectal cancer. Eur J Surg Oncol. 2014;40(6):723–30.  https://doi.org/10.1016/j.ejso.2013.11.010.CrossRefPubMedGoogle Scholar
  25. 25.
    Albert MR, Atallah SB, deBeche-Adams TC, Izfar S, Larach SW. Transanal minimally invasive surgery (TAMIS) for local excision of benign neoplasms and early-stage rectal cancer: efficacy and outcomes in the first 50 patients. Dis Colon Rectum. 2013;56(3):301–7.  https://doi.org/10.1097/DCR.0b013e31827ca313.CrossRefPubMedGoogle Scholar
  26. 26.
    Atallah S, Martin-Perez B, Albert M, deBeche-Adams T, Nassif G, Hunter L, Larach S. Transanal minimally invasive surgery for total mesorectal excision (TAMIS-TME): results and experience with the first 20 patients undergoing curative-intent rectal cancer surgery at a single institution. Tech Coloproctol. 2014;18(5):473–80.  https://doi.org/10.1007/s10151-013-1095-7.CrossRefPubMedGoogle Scholar
  27. 27.
    Martin-Perez B, Andrade-Ribeiro GD, Hunter L, Atallah S. A systematic review of transanal minimally invasive surgery (TAMIS) from 2010 to 2013. Tech Coloproctol. 2014;18(9):775–88.  https://doi.org/10.1007/s10151-014-1148-6.CrossRefPubMedGoogle Scholar
  28. 28.
    Schiphorst AH, Langenhoff BS, Maring J, Pronk A, Zimmerman DD. Transanal minimally invasive surgery: initial experience and short-term functional results. Dis Colon Rectum. 2014;57(8):927–32.  https://doi.org/10.1097/DCR.0000000000000170.CrossRefPubMedGoogle Scholar
  29. 29.
    Clermonts S, van Loon YT, Schiphorst AHW, Wasowicz DK, Zimmerman DDE. Transanal minimally invasive surgery for rectal polyps and selected malignant tumors: caution concerning intermediate-term functional results. Int J Color Dis. 2017;32(12):1677–85.  https://doi.org/10.1007/s00384-017-2893-6.CrossRefGoogle Scholar
  30. 30.
    Karakayali FY, Tezcaner T, Moray G. Anorectal function and outcomes after transanal minimally invasive surgery for rectal tumors. J Minim Access Surg. 2015;11(4):257–62.  https://doi.org/10.4103/0972-9941.152094.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Biviano I, Balla A, Badiali D, Quaresima S, D’Ambrosio G, Lezoche E, et al. Anal function after endoluminal locoregional resection by transanal endoscopic microsurgery and radiotherapy for rectal cancer. Color Dis. 2017;19(6):O177–85.  https://doi.org/10.1111/codi.13656.CrossRefGoogle Scholar
  32. 32.
    Verseveld M, de Graaf EJ, Verhoef C, van Meerten E, Punt CJ, de Hingh IH, et al. Chemoradiation therapy for rectal cancer in the distal rectum followed by organ-sparing transanal endoscopic microsurgery (CARTS study). Br J Surg. 2015;102(7):853–60.  https://doi.org/10.1002/bjs.9809.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Elizabeth R. Raskin
    • 1
    • 2
  1. 1.Loma Linda UniversityLoma LindaUSA
  2. 2.VA Hospital Loma Linda, Department of SurgeryLoma LindaUSA

Personalised recommendations