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1. Surg Endosc. 2012 Feb;26(2):551-7. Epub 2011 Oct 13.
Transanal endoscopic microsurgery for T1 rectal cancer: size matters!
Doornebosch PG, Zeestraten E, de Graaf EJ, Hermsen P, Dawson I, Tollenaar RA, Morreau H.
Source
Department of Surgery, IJsselland Hospital, Prins Constantijnweg 2, 2906 ZC, Capelle aan den IJssel, The Netherlands. pdoorn...@ysl.nl
Abstract
BACKGROUND:
Transanal endoscopic microsurgery (TEM) is considered a curative option for selected T1 rectal cancer. Although TEM is safe, local recurrence (LR) rates after TEM are unacceptably high. Evidence on selection criteria, however, is not abundant. To expand evidence on low- versus high-risk T1 rectal cancer with respect to LR, this study aimed to identify predictive histopathologic factors in a selected group of T1 rectal cancers treated with TEM only.
METHODS:
The study enrolled 62 patients for whom specimens of the primary tumor containing an invasive T1 carcinoma could be reevaluated. Tumors were scored according to predefined criteria, and analysis of predictive factors for locoregional failure was performed.
RESULT:
Local recurrence rates at 3 years for tumors 3 cm in size or smaller were significantly lower than for tumors larger than 3 cm (16 vs. 39%; P < 0.03). Combining smaller tumors with submucosal invasion depth and budding led to identifying tumors that likely will not recur (3-year LR rates, 7 and 10%, respectively).
CONCLUSIONS:
The findings showed that low- and high-risk criteria are too robust for identifying tumors at risk for LR. Tumor size alone or in combination with submucosal invasion depth or tumor budding appeared to be a significant predictive factor for locoregional failure after TEM for T1 rectal cancer.
PMID: 21993932 [PubMed - indexed for MEDLINE]
Related citations

2. Surg Endosc. 2012 Feb;26(2):582-3; author reply 584-5.
Exploring the role of minimally invasive treatment strategies in early rectal cancer: the significance of functional outcome and quality of life.
Hompes R, Mortensen N, Cunningham C.
Comment on
Surg Endosc. 2011 Apr;25(4):1222-9.
PMID: 21909853 [PubMed - indexed for MEDLINE]
Related citations

3. Surg Endosc. 2012 Feb;26(2):312-22. Epub 2011 Sep 5.
Transanal endoscopic microsurgery: long-term experience, indication expansion, and technical improvements.
Léonard D, Colin JF, Remue C, Jamart J, Kartheuser A.
Source
Colorectal Surgery Unit, Department of Abdominal Surgery and Transplantation, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, 10, Avenue Hippocrate, 1200, Brussels, Belgium.
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.
PMID: 21898025 [PubMed - indexed for MEDLINE]
Related citations

4. J Laparoendosc Adv Surg Tech A. 2011 Nov;21(9):835-40. Epub 2011 Aug 19.
Transanal endoscopic microsurgery-based transanal access for colorectal surgery: experience on human cadavers.
Bhattacharjee HK, Kirschniak A, Storz P, Wilhelm P, Kunert W.
Source
Section of Minimal Invasive Surgery, University Hospital Tuebingen, Tuebingen, Germany.
Abstract
Transanal endoscopic microsurgery (TEM) was described in 1983 for local excision of rectal tumors. In the context of natural orifice translumenal endoscopic surgery, we have modified the original TEM system and developed a new set of instruments. These are more curved and, in addition, steerable. After extensive studies in an ex-vivo model, we developed a novel technique for transanal rectosigmoid resection and colorectal anastomosis. The technique comprises closure of the rectal lumen by purse-string suture, transection of the rectal wall distal to the closure, circumferential mobilization of rectum and mesorectal tissue in the anatomical plane from below upward, control of the inferior mesenteric vessel, removal of mobilized colorectum through the anus, and, finally, the colorectal anastomosis by either stapled or hand-sutured technique. This procedure was performed on three alcohol-glycerol preserved well-built human cadavers (M:F=2:1). The average operating time was 190 minutes. The average length of the resected specimen was 23 cm. There was no fecal contamination or injury to the resected specimen. Postprocedure laparotomy revealed adequate mesorectal resection and no inadvertent injury to other viscera. During dissection in the pelvis, as the resected rectum was pushed upward, an unobstructed "empty pelvis" situation was developed in the operating site, thus facilitating the mesorectal resection. Transanal access for colorectal surgery seems feasible. It provides a precise definition of the distal safety margin, good view of the pelvis for meticulous mesorectal resection, and reduces the abdominal wall trauma. These may enhance the outcome of colorectal resection. However, further clinical studies can only substantiate these findings.
PMID: 21854206 [PubMed - indexed for MEDLINE]
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1.	Surg Endosc. 2012 Feb;26(2):551-7. Epub 2011 Oct 13. Transanal endoscopic microsurgery for T1 rectal cancer: size matters! Doornebosch PG, Zeestraten E, de Graaf EJ, Hermsen P, Dawson I, Tollenaar RA, Morreau H. Source Department of Surgery, IJsselland Hospital, Prins Constantijnweg 2, 2906 ZC, Capelle aan den IJssel, The Netherlands. pdoorn...@ysl.nl Abstract BACKGROUND: Transanal endoscopic microsurgery (TEM) is considered a curative option for selected T1 rectal cancer. Although TEM is safe, local recurrence (LR) rates after TEM are unacceptably high. Evidence on selection criteria, however, is not abundant. To expand evidence on low- versus high-risk T1 rectal cancer with respect to LR, this study aimed to identify predictive histopathologic factors in a selected group of T1 rectal cancers treated with TEM only. METHODS: The study enrolled 62 patients for whom specimens of the primary tumor containing an invasive T1 carcinoma could be reevaluated. Tumors were scored according to predefined criteria, and analysis of predictive factors for locoregional failure was performed. RESULT: Local recurrence rates at 3 years for tumors 3 cm in size or smaller were significantly lower than for tumors larger than 3 cm (16 vs. 39%; P < 0.03). Combining smaller tumors with submucosal invasion depth and budding led to identifying tumors that likely will not recur (3-year LR rates, 7 and 10%, respectively). CONCLUSIONS: The findings showed that low- and high-risk criteria are too robust for identifying tumors at risk for LR. Tumor size alone or in combination with submucosal invasion depth or tumor budding appeared to be a significant predictive factor for locoregional failure after TEM for T1 rectal cancer.
	PMID: 21993932 [PubMed - indexed for MEDLINE]
	Related citations

2.	Surg Endosc. 2012 Feb;26(2):582-3; author reply 584-5. Exploring the role of minimally invasive treatment strategies in early rectal cancer: the significance of functional outcome and quality of life. Hompes R, Mortensen N, Cunningham C. Comment on Surg Endosc. 2011 Apr;25(4):1222-9.
	PMID: 21909853 [PubMed - indexed for MEDLINE]
	Related citations

3.	Surg Endosc. 2012 Feb;26(2):312-22. Epub 2011 Sep 5. Transanal endoscopic microsurgery: long-term experience, indication expansion, and technical improvements. Léonard D, Colin JF, Remue C, Jamart J, Kartheuser A. Source Colorectal Surgery Unit, Department of Abdominal Surgery and Transplantation, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, 10, Avenue Hippocrate, 1200, Brussels, Belgium. 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.
	PMID: 21898025 [PubMed - indexed for MEDLINE]
	Related citations

4.	J Laparoendosc Adv Surg Tech A. 2011 Nov;21(9):835-40. Epub 2011 Aug 19. Transanal endoscopic microsurgery-based transanal access for colorectal surgery: experience on human cadavers. Bhattacharjee HK, Kirschniak A, Storz P, Wilhelm P, Kunert W. Source Section of Minimal Invasive Surgery, University Hospital Tuebingen, Tuebingen, Germany. Abstract Transanal endoscopic microsurgery (TEM) was described in 1983 for local excision of rectal tumors. In the context of natural orifice translumenal endoscopic surgery, we have modified the original TEM system and developed a new set of instruments. These are more curved and, in addition, steerable. After extensive studies in an ex-vivo model, we developed a novel technique for transanal rectosigmoid resection and colorectal anastomosis. The technique comprises closure of the rectal lumen by purse-string suture, transection of the rectal wall distal to the closure, circumferential mobilization of rectum and mesorectal tissue in the anatomical plane from below upward, control of the inferior mesenteric vessel, removal of mobilized colorectum through the anus, and, finally, the colorectal anastomosis by either stapled or hand-sutured technique. This procedure was performed on three alcohol-glycerol preserved well-built human cadavers (M:F=2:1). The average operating time was 190 minutes. The average length of the resected specimen was 23 cm. There was no fecal contamination or injury to the resected specimen. Postprocedure laparotomy revealed adequate mesorectal resection and no inadvertent injury to other viscera. During dissection in the pelvis, as the resected rectum was pushed upward, an unobstructed "empty pelvis" situation was developed in the operating site, thus facilitating the mesorectal resection. Transanal access for colorectal surgery seems feasible. It provides a precise definition of the distal safety margin, good view of the pelvis for meticulous mesorectal resection, and reduces the abdominal wall trauma. These may enhance the outcome of colorectal resection. However, further clinical studies can only substantiate these findings.
	PMID: 21854206 [PubMed - indexed for MEDLINE]
	Related citations