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1. Rozhl Chir. 2011 Aug;90(8):450-6.
[Transanal endoscopic microsurgery and its significance in rectal surgery--a review].
[Article in Czech]
Ondrák M, Sefr R, Eber Z.
Source
Oddĕlení chirurgické onkologie, Masarykův onkologický ústav, Brno. martin...@seznam.cz
Abstract
Transanal endoscopic microsurgery is a novel endoscopic method. Primarily, it has been developed to manage pathological middle rectum conditions. Over the time, indication criteria for this procedure have become wider and, due to technical progress, more extensive procedures on distal and middle rectum, as well as perirectal transanal procedures, could be performed. At the present time, there are clearly specified technical conditions which limit the procedure's extent, in particular the distance from the anus and the extent of rectal circumference affection. At the same time, when the method started to be used for surgical management of malignant tumors, a question arised, i.e. when the use of surgical rectoscope remains beneficial for a patient and when this method shows inferior long-term outcomes, considering the rate of local relapses and long- term survival rates. Based on the 2007-2010 literature review, the author aims to present principles to be used in the process of making a decision when the miniinvasive approach should be used and, vice versa, in which conditions the benefit of radical surgery has been demonstrated.
PMID: 22272474 [PubMed - indexed for MEDLINE]
Related citations
2. Cir Esp. 2011 Oct;89(8):505-10. Epub 2011 Aug 31.
[Indications and results of transanal endoscopic microsurgery in the treatment of rectal tumours in a consecutive series of 52 patients].
[Article in Spanish]
Márquez MF, Duarte AR, Gil FR, Lozano RB, García AA, Sierra IB.
Source
Servicio de Cirugía General y del Aparato Digestivo, Hospital Torrecárdenas, Almería, España. manufe...@hotmail.com
Abstract
INTRODUCTION:
The abdominal approach for the treatment of rectal tumours is associated with considerable morbidity. Transanal endoscopic microsurgery (TEM) is a technical alternative, and less invasive than radical surgery, and thus, with a lower associated morbidity. Also, with the correct selection of patients, TEM shows similar oncological results to radical surgery. The objective of this study is to review our results with TEM and discuss its indications in the treatment of rectal tumours.
PATIENTS AND METHOD:
An observational, retrospective study with prospective collection of data conducted from June 2008 to January 2011. TEM indications were: benign rectal tumours non-resectable using colonoscopy; early malignant rectal tumours (T(1)N(0)M(0)) with good prognostic factors: neoplastic tumours in more advanced stages in selected patients (high surgical risk, refused radical surgery or stoma and palliative care).
RESULTS:
A resection was performed using TEM on 52 patients (35 benign and 17 malignant tumours). The mean hospital stay was 4.9 days, with an associated morbidity of 15.3%. The R(0) resection in adenomas and carcinomas was 97.1% and 88.8% respectively. During a follow-up of 15 (3-31) months, one recurrence of an adenoma was observed which was re-operated on using TEM.
CONCLUSIONS:
TEM is a safe and effective procedure for the treatment of benign and selected early malignant rectal tumours, and is associated with a low morbidity. However, it is a therapeutic strategy based on a multidisciplinary team, basically with careful selection of patients, a validated technique and a strict follow-up protocol.
Copyright © 2011 AEC. Published by Elsevier Espana. All rights reserved.
Free Article
PMID: 21885045 [PubMed - indexed for MEDLINE]
Related citations

3. Surg Endosc. 2011 Nov;25(11):3683-90. Epub 2011 Jun 7.
Risk factors for recurrence after transanal endoscopic microsurgery for rectal malignant neoplasm.
Morino M, Allaix ME, Caldart M, Scozzari G, Arezzo A.
Source
Digestive Surgery and Centre for Minimal Invasive Surgery, Dipartimento di Discipline Medico-Chirurgiche, University of Torino, Corso A M Dogliotti 14, 10126 Torino, Italy. mario....@unito.it
Abstract
BACKGROUND:
Indications and results of local excision of rectal lesions are currently under debate. Transanal endoscopic microsurgery (TEM), allowing a precise, full-thickness excision, could improve oncological results in early rectal tumors.
METHODS:
A prospective database was analyzed with the intent to identify risk factors for recurrence after TEM.
RESULTS:
Among 355 patients subjected to TEM, 107 had an adenocarcinoma: 48 pT1, 43 pT2, and 16 pT3. Comparing pre- and postoperative data, histological discrepancy was 20% and staging discrepancy was 34%. Mortality was nil, morbidity was 9%. Mean follow-up was 54.2 months (range = 12-164), follow-up rate was 100%. The 5-year disease-free survival rate was 85.9, 78.4, and 49.4% for pT1, pT2, and pT3, respectively (p = 0.006). Recurrence rate was 0% (0/26) in pT1sm1 cancers and 22.7% (5/22) in sm2-3 (p < 0.05). A submucosal infiltration represented a significant risk factor for recurrences: 0% sm1, 16.7% sm2, and 30% sm3. Recurrence in pT2 was 0% in patients who had neoadjuvant therapy and 26% in the others. At univariate analysis, diameter, sm stage, pT stage, tumor grading, margin infiltration, and lymphovascular invasion demonstrated statistical significance. Multivariate analysis indicated sm stage, pT stage, and tumor grading as independent predictors of recurrence.
CONCLUSIONS:
TEM represents an effective curative treatment for pT1 sm1 rectal malignancies. pT1 sm2-3 patients should be considered high-risk cases if treated only by TEM. A consistent improvement in the preoperative assessment of the risk factors identified by the present study will be a crucial development for optimal treatment of early rectal cancers.
PMID: 21647814 [PubMed - indexed for MEDLINE]
Related citations

4. Microsurgery. 2011 Jul;31(5):413-6. doi: 10.1002/micr.20887. Epub 2011 May 25.
A unique deep inferior epigastric artery perforator and implications for a muscle and fascia sparing vertical rectus abdominis myocutaneous flap: a case report.
Iyengar AJ, Rozen WM, Kapila S, Donahoe S, Heriot AG.
Source
Department of Surgical Oncology, Peter MacCallum Cancer Centre, East Melbourne, Victoria, Australia.
Abstract
Despite the sacrifice of rectus abdominis muscle, the vertical rectus abdominis musculocutaneous (VRAM) flap is still a preferred option for perineal reconstruction. This journal has previously reported on the utility of preoperative computed tomographic angiography (CTA) in this setting to identify cases that are both suitable and unsuitable for rectus abdominis flaps after previous surgery. We report a case which highlights a unique example of the benefits of such imaging, with the largest deep inferior epigastric artery (DIEA) perforator described to date identified on imaging, and used to potentiate a donor-site sparing procedure. The use of this dominant perforator was able to limit donor site harvest to only a small cuff of anterior rectus sheath and a small segment of rectus abdominis, potentiating a muscle-sparing and fascia-sparing VRAM flap for perineal reconstruction. As such, preoperative CTA was found to be a useful tool in identifying a unique anatomical variant in the largest DIEA perforator described to date, and was used to potentiate a muscle-sparing and fascia-sparing VRAM flap for perineal reconstruction.
Copyright © 2011 Wiley-Liss, Inc.
PMID: 21618278 [PubMed - indexed for MEDLINE]
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1.	Rozhl Chir. 2011 Aug;90(8):450-6. [Transanal endoscopic microsurgery and its significance in rectal surgery--a review]. [Article in Czech] Ondrák M, Sefr R, Eber Z. Source Oddĕlení chirurgické onkologie, Masarykův onkologický ústav, Brno. martin...@seznam.cz Abstract Transanal endoscopic microsurgery is a novel endoscopic method. Primarily, it has been developed to manage pathological middle rectum conditions. Over the time, indication criteria for this procedure have become wider and, due to technical progress, more extensive procedures on distal and middle rectum, as well as perirectal transanal procedures, could be performed. At the present time, there are clearly specified technical conditions which limit the procedure's extent, in particular the distance from the anus and the extent of rectal circumference affection. At the same time, when the method started to be used for surgical management of malignant tumors, a question arised, i.e. when the use of surgical rectoscope remains beneficial for a patient and when this method shows inferior long-term outcomes, considering the rate of local relapses and long- term survival rates. Based on the 2007-2010 literature review, the author aims to present principles to be used in the process of making a decision when the miniinvasive approach should be used and, vice versa, in which conditions the benefit of radical surgery has been demonstrated.
	PMID: 22272474 [PubMed - indexed for MEDLINE]
	Related citations

2.	Cir Esp. 2011 Oct;89(8):505-10. Epub 2011 Aug 31. [Indications and results of transanal endoscopic microsurgery in the treatment of rectal tumours in a consecutive series of 52 patients]. [Article in Spanish] Márquez MF, Duarte AR, Gil FR, Lozano RB, García AA, Sierra IB. Source Servicio de Cirugía General y del Aparato Digestivo, Hospital Torrecárdenas, Almería, España. manufe...@hotmail.com Abstract INTRODUCTION: The abdominal approach for the treatment of rectal tumours is associated with considerable morbidity. Transanal endoscopic microsurgery (TEM) is a technical alternative, and less invasive than radical surgery, and thus, with a lower associated morbidity. Also, with the correct selection of patients, TEM shows similar oncological results to radical surgery. The objective of this study is to review our results with TEM and discuss its indications in the treatment of rectal tumours. PATIENTS AND METHOD: An observational, retrospective study with prospective collection of data conducted from June 2008 to January 2011. TEM indications were: benign rectal tumours non-resectable using colonoscopy; early malignant rectal tumours (T(1)N(0)M(0)) with good prognostic factors: neoplastic tumours in more advanced stages in selected patients (high surgical risk, refused radical surgery or stoma and palliative care). RESULTS: A resection was performed using TEM on 52 patients (35 benign and 17 malignant tumours). The mean hospital stay was 4.9 days, with an associated morbidity of 15.3%. The R(0) resection in adenomas and carcinomas was 97.1% and 88.8% respectively. During a follow-up of 15 (3-31) months, one recurrence of an adenoma was observed which was re-operated on using TEM. CONCLUSIONS: TEM is a safe and effective procedure for the treatment of benign and selected early malignant rectal tumours, and is associated with a low morbidity. However, it is a therapeutic strategy based on a multidisciplinary team, basically with careful selection of patients, a validated technique and a strict follow-up protocol. Copyright © 2011 AEC. Published by Elsevier Espana. All rights reserved. Free Article
	PMID: 21885045 [PubMed - indexed for MEDLINE]
	Related citations

3.	Surg Endosc. 2011 Nov;25(11):3683-90. Epub 2011 Jun 7. Risk factors for recurrence after transanal endoscopic microsurgery for rectal malignant neoplasm. Morino M, Allaix ME, Caldart M, Scozzari G, Arezzo A. Source Digestive Surgery and Centre for Minimal Invasive Surgery, Dipartimento di Discipline Medico-Chirurgiche, University of Torino, Corso A M Dogliotti 14, 10126 Torino, Italy. mario....@unito.it Abstract BACKGROUND: Indications and results of local excision of rectal lesions are currently under debate. Transanal endoscopic microsurgery (TEM), allowing a precise, full-thickness excision, could improve oncological results in early rectal tumors. METHODS: A prospective database was analyzed with the intent to identify risk factors for recurrence after TEM. RESULTS: Among 355 patients subjected to TEM, 107 had an adenocarcinoma: 48 pT1, 43 pT2, and 16 pT3. Comparing pre- and postoperative data, histological discrepancy was 20% and staging discrepancy was 34%. Mortality was nil, morbidity was 9%. Mean follow-up was 54.2 months (range = 12-164), follow-up rate was 100%. The 5-year disease-free survival rate was 85.9, 78.4, and 49.4% for pT1, pT2, and pT3, respectively (p = 0.006). Recurrence rate was 0% (0/26) in pT1sm1 cancers and 22.7% (5/22) in sm2-3 (p < 0.05). A submucosal infiltration represented a significant risk factor for recurrences: 0% sm1, 16.7% sm2, and 30% sm3. Recurrence in pT2 was 0% in patients who had neoadjuvant therapy and 26% in the others. At univariate analysis, diameter, sm stage, pT stage, tumor grading, margin infiltration, and lymphovascular invasion demonstrated statistical significance. Multivariate analysis indicated sm stage, pT stage, and tumor grading as independent predictors of recurrence. CONCLUSIONS: TEM represents an effective curative treatment for pT1 sm1 rectal malignancies. pT1 sm2-3 patients should be considered high-risk cases if treated only by TEM. A consistent improvement in the preoperative assessment of the risk factors identified by the present study will be a crucial development for optimal treatment of early rectal cancers.
	PMID: 21647814 [PubMed - indexed for MEDLINE]
	Related citations

4.	Microsurgery. 2011 Jul;31(5):413-6. doi: 10.1002/micr.20887. Epub 2011 May 25. A unique deep inferior epigastric artery perforator and implications for a muscle and fascia sparing vertical rectus abdominis myocutaneous flap: a case report. Iyengar AJ, Rozen WM, Kapila S, Donahoe S, Heriot AG. Source Department of Surgical Oncology, Peter MacCallum Cancer Centre, East Melbourne, Victoria, Australia. Abstract Despite the sacrifice of rectus abdominis muscle, the vertical rectus abdominis musculocutaneous (VRAM) flap is still a preferred option for perineal reconstruction. This journal has previously reported on the utility of preoperative computed tomographic angiography (CTA) in this setting to identify cases that are both suitable and unsuitable for rectus abdominis flaps after previous surgery. We report a case which highlights a unique example of the benefits of such imaging, with the largest deep inferior epigastric artery (DIEA) perforator described to date identified on imaging, and used to potentiate a donor-site sparing procedure. The use of this dominant perforator was able to limit donor site harvest to only a small cuff of anterior rectus sheath and a small segment of rectus abdominis, potentiating a muscle-sparing and fascia-sparing VRAM flap for perineal reconstruction. As such, preoperative CTA was found to be a useful tool in identifying a unique anatomical variant in the largest DIEA perforator described to date, and was used to potentiate a muscle-sparing and fascia-sparing VRAM flap for perineal reconstruction. Copyright © 2011 Wiley-Liss, Inc.
	PMID: 21618278 [PubMed - indexed for MEDLINE]
	Related citations