Langer C, Liersch T, Süss M, et al. Surgical cure for early rectal carcinoma and large adenoma: transanal endoscopic microsurgery (using ultrasound or electrosurgery) compared to conventional local and radical resection

Department of General Surgery, Georg August University Göttingen, Robert-Koch-Strasse 40, 37075 Göttingen, Germany.
International Journal of Colorectal Disease (Impact Factor: 2.42). 06/2003; 18(3):222-9. DOI: 10.1007/s00384-002-0441-4
Source: PubMed

ABSTRACT The minimally invasive technique of transanal endoscopic microsurgery (TEM) combines the benefits of local resections, a low complication rate and high patient comfort, with low recurrence rate and excellent survival rate after radical surgery (RS). The use of an ultrasonically activated scalpel rather than electrosurgery further improves the results of TEM.
A retrospective study was performed of 182 operations on 162 patients with early rectal carcinoma (pT1, G1/2) or adenoma to compare the outcome following four different kinds of surgical resection techniques: RS (anterior or abdominoperineal resection; n=27), conventional transanal resection using Park's retractor (TP; n=76), transanal endoscopic microsurgery (TEM) with electrosurgery (TEM-ES; n=45), and TEM with UltraCision (TEM-UC; n=34). One-third of the patients with RS (33%) received either a colostomy or a protective loop-ileostomy.
Operation time with TEM-UC was significantly shorter than with TEM-ES or RS. Hospitalization was significantly longer with RS than for TEM or TP. Complication rate with TEM was significantly lower than with RS. Recurrence rate with RS and TEM was significantly lower than with TP, with a trend to TEM-UC being better than TEM-ES. Mortality rate was 3.7% with RS and 0 with TP and TEM. The 2-year survival rate was 96.3% with RS and 100% each with TP and TEM.
TEM using UC seems to be the technique of choice. TP leads to an unacceptable recurrence rate, and RS results in a higher incidence of complication and impairment of life quality.

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    • "It represents an attractive minimally invasive alternative to more radical resection of solitary rectal ulcers, adenomas and other benign lesions as well as early rectal cancers [18]. Based on the results published over the past two decades, conversion rates to open surgery during TEM procedures have remained below 1% with a less than 5% incidence of major complications [19] [20]. Even when full-thickness excision of upper rectal lesions located above the peritoneal reflection is complicated by inadvertent peritoneal entry, with adequate closure of the defect, peritoneal entry is not associated with an increase in infectious complications [21] [22]. "
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    ABSTRACT: BACKGROUND: With a rapidly expanding international registry of cases, Natural Orifice Translumenal Endoscopic Surgery (NOTES) continues to be held as the next phase in minimally invasive surgery. While pure and hybrid transvaginal procedures predominate clinically, there is growing interest in transanal NOTES as it may potentially minimize the morbidity of colorectal resections. METHODS: Extensive experimental and clinical evidence support the fact that septic complications from intentional colotomy during colorectal procedures are minimized with adequate closure. Other advantages of transanal NOTES include the favorable ergonomics of transanal endoscopy and availability of Transanal Endoscopic Microsurgery (TEM) as a particularly well-suited endoscopic platform. RESULTS: Since the description of transanal endoscopic rectosigmoid resection using TEM in 2007, extensive evaluation in swine acute and survival studies has demonstrated that this technique is feasible, safe, and easily reproducible using conventional instrumentation. Validation of this approach in human cadavers has confirmed the feasibility of transanal total mesorectal excision using a standardized technique. In the first clinical report published to date, transanal endoscopic rectosigmoid resection with TME was performed using laparoscopic assistance in a female patient with a stage III mid-rectal cancer treated with neoadjuvant therapy. CONCLUSIONS: Although preliminary, these results highlight the potential impact of this approach in minimizing the morbidity associated with rectal cancer resection, and warrant further investigation with respect to safety and long-term oncologic outcomes. Improvements in the design of currently available endoscopic platforms and instrumentation will be important for widespread clinical application in the future, and if pure NOTES transanal resection remains the ultimate goal. KeywordsNOTES–Transanal–Rectal cancer–TME–TEM
    European Surgery 06/2011; 43(3):146-152. DOI:10.1007/s10353-011-0012-4 · 0.26 Impact Factor
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    • "In contrast to the above series, Langer et al. found residual status (R0 vs.R1 or Rx) to be a nonsignificant factor (p 00.071) [20]. They mitigated their conclusions, as follow-up might have been inadequate, as well as the limited number of patients. "
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    ABSTRACT: Driven by the aim to avoid a permanent colostomy and also the morbidity and mortality of major radical surgery for rectal cancer, the proportion of patients with rectal cancer treated by local excision has increased the last ten years or so. In T1 carcinomas local excision is considered a curative option in selected tumors. However, the scientific base upon which this treatment regimen is built remains controversial. In this systematic review we try to elucidate current literature regarding local excision for T1 rectal carcinomas. Several questions are addressed. First, is there enough evidence to propagate LE as a curative option in selected (T1) rectal carcinomas? Second, if LE is justified, which technique should be the method of choice? Third, can we adequately identify, pre- and postoperatively, tumors suitable for LE? Finally, future perspectives are discussed.
    Acta oncologica (Stockholm, Sweden) 11/2008; 48(3):343-53. DOI:10.1080/02841860802342408 · 3.71 Impact Factor
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    ABSTRACT: Aim-BackgroundThe objective was to evaluate Transanal Endoscopic Microsurgery as a surgical strategy for stage I rectal cancer and its associated perioperative morbidity and oncologic outcomes. MethodsThe present meta-analysis pooled the effects of outcomes of 986 patients enrolled in 3 randomized controlled trials, 1 prospective and 6 retrospective comparative studies. ResultsThe Meta-analysis revealed an advantage to Transanal Endoscopic Microsurgery over Standard Resection in lessening the number of patients presenting with major (O.R= 0,24 (0,07–0,91) and overall postoperative complications (O.R= 0,16 (0,06–0,38) and prolonging the disease-free survival (O.R= 0,46 (0,24–0,88). On the contrary, Standard Resection was superior in terms of the number of patients with positive margins (O.R= 6,49 (1,49–24,91), local recurrence (O.R= 4,92 (1,81–13,41) and overall (local and distant recurrence: O.R= 2,03 (1,15–3,57). No survival advantage was observed in favour of either procedure. The number of patients with positive margins was less in Transanal Endoscopic Microsurgery when compared to Transanal Excision whilst the reverse applied to the disease-free survival. ConclusionsIn selected cases of early rectal cancer Transanal Endoscopic Microsurgery is superior to Standard Resection concerning morbidity and disease- free survival whilst the reverse applies to positive surgical margins, local and overall recurrence. No survival advantage was observed in favour of either procedure. Taking into consideration the comparison of Transanal Endoscopic Microsurgery versus Transanal Excision, Transanal Endoscopic Microsurgery performs better for negative surgical margins, whereas Transanal Excision shows a greater disease-free survival. KeywordsTEM-Transanal endoscopic microsurgery-Total mesorectal excision-rectal cancer-Transanal excision-Low anterior resection
    Hellēnikē cheirourgikē. Acta chirurgica Hellenica 06/2010; 82(3):161-171. DOI:10.1007/s13126-010-0028-4
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