Skip to main content

Advertisement

SpringerLink
Log in

Transanal endoscopic microsurgery: long-term experience, indication expansion, and technical improvements

  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

This study aimed to review the authors’ 16-year experience with transanal endoscopic microsurgery (TEM). Mortality, morbidity, recurrence rate, and functional outcome were assessed. New indications and technical improvements are presented.

Methods

From November 1991 to August 2008, 123 patients (72 men and 51 women; median age, 68 years; range, 21–91 years) underwent TEM for excision of 105 adenomas with low- or high-grade dysplasia, 9 invasive adenocarcinomas (5 curative and 4 palliative resections), 2 neuroendocrine tumors, and 2 extramucosal lesions. Five additional patients had excisional biopsies, allowing staging after previous endoscopic resection. Most of the resections were full-thickness rectal resections using electrocautery or, more recently, the Harmonic scalpel. The latest mucosectomies were performed using the endoscopic submucosal dissection (ESD) technique. In addition, nontumoral indications included pelvic abscess (7 patients) and rectal strictures, which were either anastomotic or chemical. Pelvic abscesses were drained transrectally, whereas rectal stenoses were treated by strictureplasty. Foreign object retrieval and collagen plug placement for anal fistulas were performed using TEM in three patients.

Results

No mortality occurred. One intraoperative rectal perforation required conversion to laparotomy. The postoperative complications included one pneumoperitoneum, which was treated medically, and one rectal perforation requiring Hartmann’s procedure. In the polyp subgroup, six patients (6/91, 7%) experienced local recurrence. Pelvic abscesses were successfully treated, and stenosis did not recur after strictureplasty. Anorectal manometry showed functional alterations without significant clinical impact.

Conclusions

The findings showed TEM to be a safe and effective procedure for local excision of rectal lesions with a low recurrence rate and minimal consequences in terms of anorectal function. In addition, TEM proved to be feasible and effective for pelvic abscess drainage and rectal stenosis treatment. New technologies such as the Harmonic scalpel and ESD increase the precision already offered by this approach.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Similar content being viewed by others

References

  1. Buess G, Hutterer F, Theiss J, Bobel M, Isselhard W, Pichlmaier H (1984) A system for a transanal endoscopic rectum operation. Chirurg 55:677–680

    PubMed  CAS  Google Scholar 

  2. Buess G, Theiss R, Gunther M, Hutterer F, Pichlmaier H (1985) Endoscopic surgery in the rectum. Endoscopy 17:31–35

    Article  PubMed  CAS  Google Scholar 

  3. Buess G, Theiss R, Hutterer F, Gunther M, Hepp M, Pichlmaier H (1985) Endoscopic microsurgery in broad-base rectal adenoma. Internist Berlin 26:670–674

    PubMed  CAS  Google Scholar 

  4. Mellgren A, Sirivongs P, Rothenberger DA, Madoff RD, Garcia-Aguilar J (2000) Is local excision adequate therapy for early rectal cancer? Dis Colon Rectum 43:1064–1071 (discussion 1071–1064)

    Article  PubMed  CAS  Google Scholar 

  5. Middleton PF, Sutherland LM, Maddern GJ (2005) Transanal endoscopic microsurgery: a systematic review. Dis Colon Rectum 48:270–284

    Article  PubMed  Google Scholar 

  6. Buess G (1993) Review: transanal endoscopic microsurgery (TEM). J R Coll Surg Edinb 38:239–245

    PubMed  CAS  Google Scholar 

  7. Langer C, Markus P, Liersch T, Fuzesi L, Becker H (2001) UltraCision or high-frequency knife in transanal endoscopic microsurgery (TEM)? Advantages of a new procedure. Surg Endosc 15:513–517

    Article  PubMed  CAS  Google Scholar 

  8. Kikuchi R, Takano M, Takagi K, Fujimoto N, Nozaki R, Fujiyoshi T, Uchida Y (1995) Management of early invasive colorectal cancer: risk of recurrence and clinical guidelines. Dis Colon Rectum 38:1286–1295

    Article  PubMed  CAS  Google Scholar 

  9. Kudo S (1993) Endoscopic mucosal resection of flat and depressed types of early colorectal cancer. Endoscopy 25:455–461

    Article  PubMed  CAS  Google Scholar 

  10. Nascimbeni R, Burgart LJ, Nivatvongs S, Larson DR (2002) Risk of lymph node metastasis in T1 carcinoma of the colon and rectum. Dis Colon Rectum 45:200–206

    Article  PubMed  Google Scholar 

  11. Lanthier P, Detry R, Debongnie JC, Mahieu P, Vanheuverzwyn R (1987) Solitary lesions of the rectum caused by suppositories combining acetylsalicylic acid and paracetamol. Gastroenterol Clin Biol 11:250–253

    PubMed  CAS  Google Scholar 

  12. van den Broek FJ, de Graaf EJ, Dijkgraaf MG, Reitsma JB, Haringsma J, Timmer R, Weusten BL, Gerhards MF, Consten EC, Schwartz MP, Boom MJ, Derksen EJ, Bijnen AB, Davids PH, Hoff C, van Dullemen HM, Heine GD, van der Linde K, Jansen JM, Mallant-Hent RC, Breumelhof R, Geldof H, Hardwick JC, Doornebosch PG, Depla AC, Ernst MF, van Munster IP, de Hingh IH, Schoon EJ, Bemelman WA, Fockens P, Dekker E (2009) Transanal endoscopic microsurgery versus endoscopic mucosal resection for large rectal adenomas (TREND-study). BMC Surg 9:4

    Article  PubMed  Google Scholar 

  13. Bond JH (1993) Polyp guideline: diagnosis, treatment, and surveillance for patients with nonfamilial colorectal polyps. The practice parameters committee of the American college of gastroenterology. Ann Intern Med 119:836–843

    PubMed  CAS  Google Scholar 

  14. Nivatvongs S (2002) Surgical management of malignant colorectal polyps. Surg Clin North Am 82:959–966

    Article  PubMed  Google Scholar 

  15. Kartheuser A, Priso R, Plennevaux G, Querton M, Wese S, Sempoux C (2002) Le cancer du rectum: options chirurgicales nouvelles. Louvain Med 121:286–300

    Google Scholar 

  16. Law WI, Chu KW, Ho JW, Chan CW (2000) Risk factors for anastomotic leakage after low anterior resection with total mesorectal excision. Am J Surg 179:92–96

    Article  PubMed  CAS  Google Scholar 

  17. Makela JT, Kiviniemi H, Laitinen S (2003) Risk factors for anastomotic leakage after left-sided colorectal resection with rectal anastomosis. Dis Colon Rectum 46:653–660

    Article  PubMed  Google Scholar 

  18. Matthiessen P, Hallbook O, Andersson M, Rutegard J, Sjodahl R (2004) Risk factors for anastomotic leakage after anterior resection of the rectum. Colorectal Dis 6:462–469

    Article  PubMed  CAS  Google Scholar 

  19. Matthiessen P, Hallbook O, Rutegard J, Sjodahl R (2006) Population-based study of risk factors for postoperative death after anterior resection of the rectum. Br J Surg 93:498–503

    Article  PubMed  CAS  Google Scholar 

  20. Poon RT, Chu KW, Ho JW, Chan CW, Law WL, Wong J (1999) Prospective evaluation of selective defunctioning stoma for low anterior resection with total mesorectal excision. World J Surg 23:463–467 (discussion 467–468)

    Article  PubMed  CAS  Google Scholar 

  21. Rullier E, Laurent C, Garrelon JL, Michel P, Saric J, Parneix M (1998) Risk factors for anastomotic leakage after resection of rectal cancer. Br J Surg 85:355–358

    Article  PubMed  CAS  Google Scholar 

  22. Endreseth BH, Myrvold HE, Romundstad P, Hestvik UE, Bjerkeset T, Wibe A (2005) Transanal excision vs major surgery for T1 rectal cancer. Dis Colon Rectum 48:1380–1388

    Article  PubMed  Google Scholar 

  23. Madbouly KM, Remzi FH, Erkek BA, Senagore AJ, Baeslach CM, Khandwala F, Fazio VW, Lavery IC (2005) Recurrence after transanal excision of T1 rectal cancer: should we be concerned? Dis Colon Rectum 48:711–719 (discussion 719–721)

    Article  PubMed  Google Scholar 

  24. Nash GM, Weiser MR, Guillem JG, Temple LK, Shia J, Gonen M, Wong WD, Paty PB (2009) Long-term survival after transanal excision of T1 rectal cancer. Dis Colon Rectum 52:577–582

    Article  PubMed  Google Scholar 

  25. Lezoche G, Baldarelli M, Guerrieri M, Paganini AM, De Sanctis A, Bartolacci S, Lezoche E (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 22:352–358

    Article  PubMed  CAS  Google Scholar 

  26. Winde G, Nottberg H, Keller R, Schmid KW, Bunte H (1996) Surgical cure for early rectal carcinomas (T1): transanal endoscopic microsurgery vs. anterior resection. Dis Colon Rectum 39:969–976

    Article  PubMed  CAS  Google Scholar 

  27. Rasheed S, Bowley DM, Aziz O, Tekkis PP, Sadat AE, Guenther T, Boello ML, McDonald PJ, Talbot IC, Northover JM (2008) Can depth of tumour invasion predict lymph node positivity in patients undergoing resection for early rectal cancer? A comparative study between T1 and T2 cancers. Colorectal Dis 10:231–238

    Article  PubMed  CAS  Google Scholar 

  28. Borschitz T, Heintz A, Junginger T (2006) The influence of histopathologic criteria on the long-term prognosis of locally excised pT1 rectal carcinomas: results of local excision (transanal endoscopic microsurgery) and immediate reoperation. Dis Colon Rectum 49:1492–1506 (discussion 1500–1495)

    Article  PubMed  Google Scholar 

  29. Friel CM, Cromwell JW, Marra C, Madoff RD, Rothenberger DA, Garcia-Aguilar J (2002) Salvage radical surgery after failed local excision for early rectal cancer. Dis Colon Rectum 45:875–879

    Article  PubMed  Google Scholar 

  30. Weiser MR, Landmann RG, Wong WD, Shia J, Guillem JG, Temple LK, Minsky BD, Cohen AM, Paty PB (2005) Surgical salvage of recurrent rectal cancer after transanal excision. Dis Colon Rectum 48:1169–1175

    Article  PubMed  Google Scholar 

  31. Bach SP, Hill J, Monson JR, Simson JN, Lane L, Merrie A, Warren B, Mortensen NJ (2009) A predictive model for local recurrence after transanal endoscopic microsurgery for rectal cancer. Br J Surg 96:280–290

    Article  PubMed  CAS  Google Scholar 

  32. Baatrup G, Endreseth BH, Isaksen V, Kjellmo A, Tveit KM, Nesbakken A (2009) Preoperative staging and treatment options in T1 rectal adenocarcinoma. Acta Oncol 48:328–342

    Article  PubMed  Google Scholar 

  33. Borschitz T, Wachtlin D, Mohler M, Schmidberger H, Junginger T (2008) Neoadjuvant chemoradiation and local excision for T2–3 rectal cancer. Ann Surg Oncol 15:712–720

    Article  PubMed  Google Scholar 

  34. Hatch KF, Blanchard DK, Hatch GF III, Wertheimer-Hatch L, Davis GB, Foster RS Jr, Skandalakis JE (2000) Tumors of the rectum and anal canal. World J Surg 24:437–443

    Article  PubMed  CAS  Google Scholar 

  35. Le Borgne J, Guiberteau-Canfrere V, Lehur PA, Bitar O, Serraz H, Thoulouzan E, Le Bodic MF (1993–1994) Leiomyoma of the rectum. Chirurgie 119:212–215

  36. Kinoshita T, Kanehira E, Omura K, Tomori T, Yamada H (2007) Transanal endoscopic microsurgery in the treatment of rectal carcinoid tumor. Surg Endosc 21:970–974

    Article  PubMed  CAS  Google Scholar 

  37. Kwaan MR, Goldberg JE, Bleday R (2008) Rectal carcinoid tumors: review of results after endoscopic and surgical therapy. Arch Surg 143:471–475

    Article  PubMed  Google Scholar 

  38. Anvari M (1998) Endoscopic transanal rectal stricturoplasty. Surg Laparosc Endosc 8:193–196

    Article  PubMed  CAS  Google Scholar 

  39. Garcea G, Sutton CD, Lloyd TD, Jameson J, Scott A, Kelly MJ (2003) Management of benign rectal strictures: a review of present therapeutic procedures. Dis Colon Rectum 46:1451–1460

    Article  PubMed  CAS  Google Scholar 

  40. Kato K, Saito T, Matsuda M, Imai M, Kasai S, Mito M (1997) Successful treatment of a rectal anastomotic stenosis by transanal endoscopic microsurgery (TEM) using the contact Nd:YAG laser. Surg Endosc 11:485–487

    Article  PubMed  CAS  Google Scholar 

  41. Rubay R, Colin JF, Remacle G, Tran Ba T, Lienard JC, Melange M, Detry R, Kartheuser A (2003) Transanal endoscopic microsurgery (TEM): extending its use in rectal surgery. Tech Coloproctol 7:S34

    Google Scholar 

  42. Alexander AA, Eschelman DJ, Nazarian LN, Bonn J (1994) Transrectal sonographically guided drainage of deep pelvic abscesses. AJR Am J Roentgenol 162:1227–1230 (discussion 1231–1222)

    PubMed  CAS  Google Scholar 

  43. Hovsepian DM, Steele JR, Skinner CS, Malden ES (1999) Transrectal versus transvaginal abscess drainage: survey of patient tolerance and effect on activities of daily living. Radiology 212:159–163

    PubMed  CAS  Google Scholar 

  44. Beunis A, Pauli S, Van Cleemput M (2008) Anastomotic leakage of a colorectal anastomosis treated by transanal endoscopic microsurgery. Acta Chir Belg 108:474–476

    PubMed  CAS  Google Scholar 

  45. Clarke DL, Buccimazza I, Anderson FA, Thomson SR (2005) Colorectal foreign bodies. Colorectal Dis 7:98–103

    Article  PubMed  CAS  Google Scholar 

  46. Lake JP, Essani R, Petrone P, Kaiser AM, Asensio J, Beart RW Jr (2004) Management of retained colorectal foreign bodies: predictors of operative intervention. Dis Colon Rectum 47:1694–1698

    Article  PubMed  Google Scholar 

  47. Rodriguez-Hermosa JI, Codina-Cazador A, Ruiz B, Sirvent JM, Roig J, Farres R (2007) Management of foreign bodies in the rectum. Colorectal Dis 9:543–548

    Article  PubMed  CAS  Google Scholar 

  48. Sharma H, Banka S, Walton R, Memon MA (2007) A novel technique for nonoperative removal of round rectal foreign bodies. Tech Coloproctol 11:58–59

    Article  PubMed  CAS  Google Scholar 

  49. Gracia Solanas JA, Ramirez Rodriguez JM, Aguilella Diago V, Elia Guedea M, Martinez Diez M (2006) A prospective study about functional and anatomic consequences of transanal endoscopic microsurgery. Rev Esp Enferm Dig 98:234–240

    Article  PubMed  CAS  Google Scholar 

  50. Kennedy ML, Lubowski DZ, King DW (2002) Transanal endoscopic microsurgery excision: is anorectal function compromised? Dis Colon Rectum 45:601–604

    Article  PubMed  CAS  Google Scholar 

Download references

Acknowledgments

The authors are grateful to Professor Christine Sempoux and Professor Anne Jouret for their pathologic analysis of all the specimens resected by TEM. They also wish to thank Professor Claire Craddock-de Burbure for revising the manuscript.

Disclosures

Daniel Léonard, Jean-François Colin, Christophe Remue, Jacques Jamart, and Alex Kartheuser have no conflicts of interest or financial ties to disclose.

Author information

Authors and Affiliations

  1. Colorectal Surgery Unit, Department of Abdominal Surgery and Transplantation, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, 10, Avenue Hippocrate, 1200, Brussels, Belgium

    Daniel Léonard, Christophe Remue & Alex Kartheuser

  2. Colorectal Cancer Board, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, 10, Avenue Hippocrate, 1200, Brussels, Belgium

    Daniel Léonard, Jean-François Colin, Christophe Remue & Alex Kartheuser

  3. Department of Gastroenterology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, 10, Avenue Hippocrate, 1200, Brussels, Belgium

    Jean-François Colin

  4. Department of Biostatistics, Cliniques Universitaires Mont-Godinne, Université Catholique de Louvain, 5530, Yvoir, Belgium

    Jacques Jamart

Authors
  1. Daniel Léonard
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jean-François Colin
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Christophe Remue
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Jacques Jamart
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Alex Kartheuser
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Alex Kartheuser.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Léonard, D., Colin, JF., Remue, C. et al. Transanal endoscopic microsurgery: long-term experience, indication expansion, and technical improvements. Surg Endosc 26, 312–322 (2012). https://doi.org/10.1007/s00464-011-1869-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-011-1869-9

Keywords

Search

Navigation