Transanal Endoluminal Total Mesorectal Resection (TETMR) by Transanal Endoscopic Microsurgery (TEM)

  • Emanuele Lezoche
  • Giancarlo D’Ambrosio
  • Pietro Ursi
  • Giovanni Lezoche
Chapter

Abstract

On the basis of the experience achieved with ELRR the authors have developed a technique to perform transanally the TME utilizing modified-TEM instrumentations. To perform this operation the shape of the 12 cm rectoscope has been cut with a vertical section and the rectoscope becomes significantly shorter, the “working insert” has been modified to introduce a standard laparoscope locking it. Surgery starts with a mucosal transverse circular incision at 1 cm from the lower margin of the neoplasia. A full-thickness incision is performed by electrocautery down to reach the “Holy plane” described by Heald. The smooth dissection is facilitated by the CO2 insufflation that cranially pushing back the rectal stump. Dissection continues to the peritoneal reflection. From October 2008 eight patients (5 males and 3 females) with ultralow rectal cancer underwent to TETMR. All patients underwent a long course of neoadjuvant Radiochemoterapy (nRCT) and were enrolled in a 3 months program of close follow up with an imaging and clinical check planning. At present only one patient died of cardiac disease. All others are disease free.

In our opinion TETMR represents a remarkable innovation in the treatment of RC is a feasible operation for surgeons expert in TEM procedures and it is possible that, for the advantages that it offers, it will become in a few years the most chosen operation to treat low/ultralow RC.

Keywords

Luminal Ampicillin Washout Sulbactam Betadine 

References

  1. 1.
    Dixon CF. Anterior resection for malignant lesions of the upper part of the rectum and lower part of the sigmoid. Ann Surg. 1948;128(3):425–42.PubMedCrossRefGoogle Scholar
  2. 2.
    Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery—the clue to pelvic recurrence? Br J Surg. 1982;69(10):613–6.PubMedCrossRefGoogle Scholar
  3. 3.
    Williams NS, Dixon MF, Johnston D. Reappraisal of the 5 centimeter rule of distal excision for carcinoma of the rectum: a study of distal intramural spread and of patients’ survival. Br J Surg. 1983;70(3):150–4.PubMedCrossRefGoogle Scholar
  4. 4.
    Andreola S, Leo E, Belli F, Lavarino C, Bufalino R, Tomasic G, Baldini MT, Valvo F, Navarria P, Lombardi F. Distal intramural spread in adenocarcinoma of the lower third of the rectum treated with total rectal resection and coloanal anastomosis. Dis Colon Rectum. 1997;40(1):25–9.PubMedCrossRefGoogle Scholar
  5. 5.
    Wilson SM, Beahrs OH. The curative treatment of carcinoma of the sigmoid, recto sigmoid, and rectum. Ann Surg. 1976;183(5):556–65.PubMedCrossRefGoogle Scholar
  6. 6.
    Guillem JG, Chessin DB, Shia J, Suriawinata A, Riedel E, Moore HG, Minsky BD, Wong WD. A prospective pathologic analysis using whole-mount sections of rectal cancer following preoperative combined modality therapy: implications for sphincter preservation. Ann Surg. 2007;245(1):88–93.PubMedCrossRefGoogle Scholar
  7. 7.
    Griffen FD, Knight Sr CD, Whitaker JM, Knight Jr CD. The double stapling technique for low anterior resection. Results, modifications, and observations. Ann Surg. 1990;211(6):745–51.PubMedCrossRefGoogle Scholar
  8. 8.
    Marks G, Mohiuddin M, Borenstein BD. Preoperative radiation therapy and sphincter preservation by the combined abdominotranssacral technique for selected rectal cancers. Dis Colon Rectum. 1985;28(8):565–71.PubMedCrossRefGoogle Scholar
  9. 9.
    Buess G, Theiss R, Günther M, Hutterer F, Pichlmaier H. Transanal endoscopic microsurgery. Leber Magen Darm. 1985;15(6):271–9.PubMedGoogle Scholar
  10. 10.
    Dias AR, Nahas CS, Marques CF, Nahas SC, Cecconello I. Transanal endoscopic microsurgery: indications, results and controversies. Tech Coloproctol. 2009;13(2):105–11.PubMedCrossRefGoogle Scholar
  11. 11.
    Hiroko K. Transanal endoscopic microsurgery for rectal tumors: a review. Perm J. 2012;16(2):45–50.Google Scholar
  12. 12.
    Lezoche E, et al. Transanal endoscopic microsurgery for 135 patients with small nonadvanced low rectal cancer (iT1-iT2, iN0): short- and long-term results. Surg Endosc. 2011;25(4):1222–9. Epub 7 Oct 2010.PubMedCrossRefGoogle Scholar
  13. 13.
    Lezoche E, et al. Randomized clinical trial of endoluminal locoregional resection versus laparoscopic total mesorectal excision for T2 rectal cancer after neoadjuvant therapy. Br J Surg. 2012;99(9):1211–8.PubMedCrossRefGoogle Scholar
  14. 14.
    Williams NS, Murphy J, Knowles CH. Anterior perineal PlanE for ultra-low anterior resection of the rectum (the APPEAR technique): a prospective clinical trial of a new procedure. Ann Surg. 2008;247(5):750–8.PubMedCrossRefGoogle Scholar
  15. 15.
    Whiteford MH, Denk PM, Swanström LL. Feasibility of radical sigmoid colectomy performed as natural orifice translumenal endoscopic surgery (NOTES) using transanal endoscopic microsurgery. Surg Endosc. 2007;21(10):1870–4. Epub 21 Aug 2007.PubMedCrossRefGoogle Scholar
  16. 16.
    Sylla P, Rattner DW, Delgado S, Lacy AM. NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance. Surg Endosc. 2010;24(5):1205–10.PubMedCrossRefGoogle Scholar
  17. 17.
    Lacy AM, Adelsdorfer C. Totally transrectal endoscopic total mesorectal excision (TME). Colorectal Dis. 2011;13 Suppl 7:43–6.PubMedCrossRefGoogle Scholar
  18. 18.
    Marks JH. TEM as a Platform for NOTES. J Gastrointest Surg. 2011;15(8):1313–5.PubMedCrossRefGoogle Scholar
  19. 19.
    Rouanet P, Mourregot A, Azar CC, Carrere S, Gutowski M, Quenet F, Saint-Aubert B, Colombo PE. Transanal endoscopic proctectomy: an innovative procedure for difficult resection of rectal tumors in men with narrow pelvis. Dis Colon Rectum. 2013;56(4):408–15.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Emanuele Lezoche
    • 1
  • Giancarlo D’Ambrosio
    • 1
  • Pietro Ursi
    • 1
  • Giovanni Lezoche
    • 2
  1. 1.Department “Paride Stefanini”“Sapienza” University of RomeRomeItaly
  2. 2.Clinica Chirurgica, Ospedale “le Torrette”Politecnico delle Marche UniversityAnconaItaly

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