Transanal Endoscopic Microsurgery

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1 Transanal Endoscopic Microsurgery Dana R. Sands, MD, FACS, FASCRS Director, Colorectal Physiology Center Staff Surgeon Department of Colorectal Surgery Cleveland Clinic Florida

2 What is TEM? Minimally invasive Transanal technique Access to the entire rectum and rectosigmoid junction Specialized instrumentation

3 Transanal Endoscopic Microsurgery Initially reported 1983 Gerhard Buess Tubingen, Germany 25 years later 106 US Sites 61 last 5 years

4 Transanal Endoscopic Microsurgery Hard to learn Expensive equipment Limited indication Resurgence of interest in the era of minimally invasive surgery and natural orifice surgery

5 Transanal Endoscopic Microsurgery What s s so special? Optimal visualization 3D Image Balanced insufflation Access to mid and upper rectum Potential for lymphadenectomy

6 TEM Instrumentation Proctoscope Operating Instruments Stereoscope Suction/ Insufflator

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8 Indications

9 Rectal Cancer Treatment Options TME TAE TEM

10 Rectal Cancer Treatment Options TME Removal of all node bearing tissue Lower Local recurrence rates Definitive staging Increased Operative morbidity Functional compromise Local Excision Disc excision of the rectal wall Higher Local recurrence rates? Staging Decreased Operative morbidity Improved functional outcome

11 TAE TEM Gordon & Nivatvongs. Principles & Practice of Surgery for the Colon, Rectum & Anus

12 TEM vs TAE patients (89 TAE, 82 TEM) TEM (%) TAE (%) p Clear Margins =0.001 Nonfragmented Specimen Recurrence <0.001 =0.004 Transanal endoscopic microsurgery is the technique of choice for local excision of rectal neoplasms Moore JS, et al. Dis Col Rectum Jul;51(7):

13 Indications for TEM Any benign rectal lesion above the dentate line within reach of the operating proctoscope Selected T1 lesions T2 lesions with combined therapy (??)

14 Patient Selection Accurate staging is essential Endorectal ultrasound Careful characterization of the primary lesion Rigid proctoscopy

15 TEM Full Thickness Excision

16 TEM Submucosal Excision

17 TEM for Benign Disease Year Patients (N) Local Recurrence Rates (%) Menteges et al Morshel et al Nagy et al Buess et al Lloyd et al Langer et al Palma et al Platell et al Endreseth et al Whitehouse et al

18 TEM for T1 Cancer Year Patients (N) Local Recurrence Rates (%) Buess et al Buess et al Winde et al Smith et al Langer et al Demartines et al Lee et al Stipa et al Floyd et al Baatrup et al

19 TEM vs TME for T2 Cancer 70 patients with T2 rectal cancer 35 TEM 35 Laparoscopic resection All received neoadjuvant tx Median follow-up 84 (72-96) months Local Failure Distant Metastases Local or Distant Failure Survival TEM (%) TME (%) Lezoche E et al. Surg Endosc

20 TEM vs TME Stoma n (%) TEM TME None 35(100) 18 (51) Temporary 0 8 (23) Permanent 0 9 (26) Lezoche E et al. Surg Endosc

21 TEM vs TME Important Considerations All tumors were G1-2 Not just a rectal wall excision RV septum or prostate anterior Holy plane posterior Specimen truncated pyramid Larger tumors, poor histology, lack of response to neoadjuvant tx Higher risk for recurrence Lezoche E et al. Surg Endosc

22 Complications Bleeding Suture line dehiscence Extraperitoneal Intraperitoneal Functional

23 Complications Delayed respiratory failure CO2 absorption from emphysema Kerr K, Mills GH. Br J Anaesth Rectourethral fistula Lev-Chelouche D, Margel D, et al. DCR

24 Peritoneal Entry Initially regarded as a complication No difference in morbidity or mortality Does not mandate conversion to laparotomy Extends the reach of TEM from 4-24cm 4 above the anal verge Gavagan JA, Whiteford MH, Swanstrom LL. Am J Surg

25 Functional Results Prospective evaluation 41 patients # bm pre vs. post op FISI FIQOL Ability to defer defecation No changes pre vs post op No detrimental effect on anorectal function after TEM Cataldo PA, O Brien S, Osler T. Dis Col Rectum

26 Follow-up Flexible sigmoidoscopy Every 3 months x 2yrs Colonoscopy at 1 year Endorectal Ultrasound Every 6 months x 2 years Every year x 5 years

27 Recommended Treatment Plan Rectal Lesion Benign Malignant At Dentate Line Above Dentate Line T1 Favorable Histology T2 T3 Any N TAE TEM TEM TME?TEM/XRT TME

28 Conclusions Advanced endoscopic technique Utilizes highly specialized instrumentation Can spare selected patients laparotomy and anterior resection Adequate training is imperative Patient selection is paramount Accurate staging is essential

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