What are TEMS/TEO/TAMIS and Who should it? Neil Borley Consultant Surgeon General Hospital
Is more actually less? Neil Borley Consultant Surgeon General Hospital
Key questions Does the equipment matter? Does the procedure matter? Does the volume matter?
accessible for every surgeon with an interest * *Hompes, Ris, Cunningham et al Brit J Surg 2012;(99):1429-33
Technical comparisons TEMS TEO TAMIS Binoccular vision (inc depth perception) Flexible/precision excision plane Monoccular vision?excision plane Monoccular vision?excision plane Dedicated instruments Dedicated instruments?laparoscopic instruments Rigid platform Rigid platform Flexible platform No lower cuff No lower cuff Lower exclusion cuff High lesions High lesions??high lesions Expensive Fairly expensive Cheaper Learning curve?learning curve?learning curve
Does the excision plane matter? Protocol driven Allowing for what if worst case scenarios
Mucosectomy excision
Mucosectomy excision
Mucosectomy excision
Mucosectomy excision
Does the excision plane matter? Protocol driven Allowing for what if worst case scenarios Risk of procedure
Risk in mucosectomy vs FThExc Mucosectomy* Full Th Exc* Death 0% 0.8% Sepsis/stoma 0% 3% Bleeding (Tx) 2% 3% Stenosis 3% 1.5% * Darwood, Wheeler, Borley Brit J Surg 2008;95:915-18 +Bignell, Ramwell, Evans, Dastur, Simson Colorect Dis 2010;12:e99-103
Does volume matter??outcomes?risk?efficacy
TAMIS for SRN? Martinez-Perez et al Tech Coloproctol 2014;(18):775-788
Outcomes TAMIS for SRN? 36 studies/series Mean series n = 10.8 Mode series n = 1 SRN 36 studies/series Mean series n = 4.2 Mode series n = 1 15 studies/series n>10 Mean series n = 21.9 Mode series n = 12 SRN 6 studies/series n>10 Mean series n = 14 Mode series n/a Martinez-Perez et al Tech Coloproctol 2014;(18):775-788
Early outcomes TAMIS for SRN? n (benign) SRN size R1 % Conv % Comp % FU Median/m 14 3 7 0 5 N/G 25? 6-6 20 14? 9-6 10 10 2.9?0 16 25* N/G 11 2.5 8 0 8??6 10 3.5 7 0 21 N/G Derived from Martinez-Perez et al Tech Coloproctol 2014;(18):775-788
Late outcomes TAMIS for SRN? n (benign) SRN size R1 % Recurr % FU Median/m 14 3 7? N/G 25? 6 4 20 14? 9?0 10 10 2.9?0 N/G N/G 11 2.5 8 N/G??6 10 3.5 7?7 N/G Derived from Martinez-Perez et al Tech Coloproctol 2014;(18):775-788
Outcomes Existing high volume data Complex SRN (high, recurrent, multiquadrant) - TEMS N = 289, FU median = 21 mo Early Comps 4% - bleed (2% failed procedure) Late Comps Recurr 1.5%, stenosis 5% Darwood et al Br J Surg 2008;95(7):915-8
Outcomes Existing high volume data Chichester Benign lesions (SRN) - TEMS N = 279, FU median = 21 mo Early outcome R0 90.3% Early Comps 0.3% mort Late Comps Recurr size dependent, at 3 yrs 3.2 9.1% Scala et al Arch Surg 2012;147(12):1093-100
Outcomes Don t we know volume matters? Rectal cancer Rectal Ca CRM +ve 11% vs 7.7% p<0.001 The Influence of Hospital Volume on Circumferential Resection Margin Involvement: Results of the Dutch Surgical Audit Gietelink et al Ann Surg 2014 17 epub Rectal cancer higher volume better survival Patient survival after surgical treatment of rectal cancer: impact of surgeon and hospital characteristics Etzioni et al Cancer 2014; 120(16):2472-81 Overall surv, stoma rate better in high volume surgeons Impact of surgeon volume on outcomes of rectal cancer surgery : a systematic review and meta-analysis Archampong et al Surgeon 2010; 8(6):341-852
Outcomes Don t we know volume matters? EMR High complication and recurrence rates (23% 25%) with low mean case vol (2.6 p.a.) emphasize the importance of training and centralization. suboptimal diagnostic workup Endoscopic mucosal resection of large rectal adenomas in the era of centralization: Results of a multicenter collaboration Barendse et al United European Gastroenterol J 2014;2(6):497-504 Effect of surgeon volume of long term outcome Endoscopic management of early gastric cancer; endoscopic mucosal resection or endoscopic submucosal dissection: data from a Japanese high volume center and literature review Uedo et al Ann Gastroenterol 2012; 25(4):281-90 R0, perf and LR equal in HV vs LV Endoscopic mucosal resection in high and low volume centres: a prospective multicentre study Masci et al Surg Endosc 2013 27(10);3799-805
Volume and experience So what does matter? Decisions not Incisions Minimize whoops surgery and minimize risk Offsets issues of learning curve with more demanding equipment / procedures Surgical plane approach What if options Safety avoiding unnecessary deep excisions Equipment What best matches your approach/protocols (SPECC MDT)