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Transanal endoscopic microsurgical excision of rectal tumors: Indications and results

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Abstract

Transanal endoscopic microsurgery (TEM) allows local excision of rectal tumors located 4 to 18 cm above the anal verge. The technique is not yet generally established because of the necessary special instrumentation and tools, the unusual technical aspects of the approach, and the stringent patient selection criteria. The aim of this prospective, descriptive study was to analyze the currently accepted indications for TEM and to evaluate the use of this procedure for treating rectal cancer. Over a 4-year period 50 patients aged 31 to 86 years (mean 64 years) underwent TEM for treatment of rectal tumors located 12 cm above the anal verge (range 4–18 cm). The local complication rate was 4%. Altogether, 76% of lesions were benign, and 24% were T1 and T2 tumors. Of 12 cancer cases, 4 required reoperation by total mesorectal resection; the other 8 are currently under follow-up management. Over the follow-up period of 30.6 months (range 11–54 months) the recurrence rate of T1 tumors was 8.3%. TEM is a minimally invasive surgical technique that may benefit a small, specific population of patients with rectal tumors. Compared with conventional transanal resection, TEM provides superior exposure of tumors higher up in the rectum (i.e., up to 18 cm from the anal verge). The greater precision of resection combined with low morbidity (10%, relative to that of anterior resection) and short duration of hospitalization (5.5 days) make this technique a reliable and in some cases more effective surgical approach than laparotomy and low anterior resection.

Résumé

La microchirurgie transanale endoscopique (MTE) permet une excision locale des tumeurs situées entre 4 et 18 cm au-dessus de la ligne anocutanée. La technique n’est pas encore très répandue en raison du besoin d’une instrumentation et d’outils spécifiques, une technique un peu spéciale, et une sélection stricte des patients. Le but de cette étude prospective, descriptive, a été d’analyser les indications actuelles de cette technique et d’évaluer l’utilisation de ce procédé pour le traitement du cancer du rectum. En quatre ans, nous avons traité 50 patients âgés entre 31 et 86 ans (âge moyen =64 ans) par MTE pour tumeur rectale située à 12 cm (en moyenne) de la marge anale (extrêmes 4–18 cm). Le taux de complications locales a été de 4%. Soixante-six pourcent des lésions étaient bénignes et 24% des tumeurs T1 et T2. Parmi les 12 cas de cancer, quatre ont nécessité une réopération pour excision totale du mésorectum, les huit autres patients sont actuellement sous surveillance. Pendant la période de suivi de 30,6 mois (extrêmes =11–54 mois), le taux de récidive des tumeurs T1 a été de 8,3%. La MTE est une technique chirurgicale mini-invasive qui pourrait être appliquée à un sous-groupe de la population atteint de tumeur rectale. Comparée à la résection transanale conventionnelle, la MTE permet une meilleure exposition des tumeurs du haut rectum, c’est-à-dire jusqu’à 18 cm de la marge anale. Une grande précision dans la résection, combinée à une morbidité basse (par rapport à la résection antérieure) (10%) et une courte hospitalisation (5,5 jours) rendent cette technique fiable, et dans certains cas, plus efficace que la résection antérieure par laparotomie.

Resumen

La microcirugía endoscópica transanal (TEM) permite la resección de tumores rectales localizados de 4 a 18 cm por encima del margen anal. Este procedimiento hasta ahora no se ha generalizado debido a la necesidad de desarrollar instrumentos y herramientas especiales, aspectos técnicos inusuales de abordaje y criterios estrictos para la selección de los pacientes. El objetivo de este estudio prospectivo y drescriptivo es analizar las indicaciones actualmente aceptadas para las TEM y evaluar la eficacia de esta técnica en el tratamiento del cáncer de recto. En un periodo de 4 años, 50 pacientes con edades comprendidas entre 31 y 86 años (media =64 años) fueron tratados mediante el procedimiento quirúrgico TEM, por padecer tumores rectales situados a 12 cm por encima del margen anal (rango: 4–18 cm). La tasa de complicaciones locales fue del 4%. En el 76% las lesiones fueron benignas y en el 24% malignas: tumores T1 y T2. De los 12 casos de cáncer, 4 requirieron una reintervención con resección total del mesorrecto; los otros 8 están actualmente controlados y sometidos a tratamiento. Tras un periodo de seguimiento de 30.6 meses (rango: 11–54 meses) la tasa de recidivas de tumores T1 fue del 8.3%. La TEM es una técnica quirúrgica mínimamente invasiva que puede ser muy útil en un número reducido y escogido de pacientes con cáncer de recto. Comparada con la resección transanal convencional, la TEM permite la exposición de tumores del alto recto i.e. hasta 18 cm de los márgenes del ano. La gran precisión de la resección, junto con la baja morbilidad (en comparación con la resección anterior) 10% y la corta hospitalización (5.5 días) hace que esta técnica sea, fiable y, en algunos casos, más eficaz que la laparotomía con resección anterior baja del recto.

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Authors and Affiliations

  1. Department of Surgery, University Hospital of Basel, Spitalstrasse 21, CH-4031, Basel, Switzerland

    Nicolas Demartines M.D. & Felix H. Harder M.D.

  2. Department of Surgery A, Kantonsspital of Lucerne, Lucerne, Switzerland

    Marcus O. von Flüe M.D.

  3. Department of Surgery, University Hospital of Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland

    Nicolas Demartines M.D.

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  1. Nicolas Demartines M.D.
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  2. Marcus O. von Flüe M.D.
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Correspondence to Nicolas Demartines M.D..

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Demartines, N., von Flüe, M.O. & Harder, F.H. Transanal endoscopic microsurgical excision of rectal tumors: Indications and results. World J. Surg. 25, 870–875 (2001). https://doi.org/10.1007/s00268-001-0043-2

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