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Dec 1, 2014, 1:56:53 PM12/1/14

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Ricardo Belda Lozano

MD,PhD, MS.

Master en Cirugía Laparoscópica

Master en Coloproctología

http://coloprocto.wordpress.com/

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Asunto: What's new for ' Actualizaci??n TEM' in PubMed
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Sender's message: Nueva Bibliografía del TEM
Sent on Monday, 2014 December 01
Search: "Rectum"[Mesh] OR "Rectal Neoplasms"[Mesh] AND "Microsurgery"[Mesh]

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PubMed Results
Items 1 - 4 of 4

1. Dis Colon Rectum. 2014 Oct;57(10):1176-82. doi: 10.1097/DCR.0000000000000208.
Transanal endoscopic microsurgery with entrance into the peritoneal cavity: is it safe?
Marks JH¹, Frenkel JL, Greenleaf CE, D'Andrea AP.
Author information:
¹Lankenau Medical Center, Wynnewood, Pennsylvania.

Abstract
BACKGROUND:
Relative contraindications for transanal endoscopic microsurgery include high, anterior-based lesions for full-thickness excisions because of worries about entering the peritoneal cavity. Concerns exist regarding safety and oncological outcome.
OBJECTIVE:
We examined the outcomes of transanal endoscopic microsurgery excisions with entry into the peritoneal cavity and compared them with those that did not to address our hypothesis that entry is safe with no ill infectious or oncological consequences.
DESIGN:
This single-institution retrospective review uses a prospectively maintained database.
SETTINGS:
This study was conducted at a tertiary colorectal surgery referral center.
PATIENTS:
From 1997 to 2012, we identified 303 patients who underwent transanal endoscopic microsurgery resections, with 26 patients having entrance into the peritoneal cavity.
MAIN OUTCOME MEASURES:
Perioperative data, postoperative morbidities, delayed morbidities, and oncological outcomes were the primary outcomes measured.
RESULTS:
Of 26 patients, there were 8 women with a mean age of 67.5 years. Mean BMI was 31 kg/m, and ASA class was III or IV in 69%. Mean superior border of the lesion was 10.4 cm (4.5-16). Forty-eight percent had anterior-based lesions. Anterior location, level from anorectal ring, and diagnosis of cancer were significantly higher in the peritoneal entry group (p = 0.003, p = 0.007, and p = 0.007). Preoperative diagnoses included 16 adenocarcinomas, 8 polyps, and 2 carcinoid tumors. Thirteen patients had preoperative chemoradiation. Median estimated blood loss was 15 mL (5-400), and 3 patients underwent diversions. Median time to discharge was 3 days (2-10). There were no perioperative mortalities. Median follow-up time was 21.0 months. There was 1 local recurrence (3.8%), and there was no development of carcinomatosis.
LIMITATIONS:
This review was limited by its retrospective nature.
CONCLUSIONS:
High anterior location rectal lesions should be considered candidates for transanal endoscopic microsurgery excision in experienced hands. After obtaining considerable transanal endoscopic microsurgery experience, our use of transanal endoscopic microsurgery in a high-risk patient population allowed us to definitively treat 88% of patients without an abdominal operation and the need for a temporary or permanent colostomy. Theoretic concerns of abscess or carcinomatosis were not experienced (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A154).
PMID: 25203373 [PubMed - indexed for MEDLINE]
Related citations

2. Recent Results Cancer Res. 2014;203:31-8. doi: 10.1007/978-3-319-08060-4_4.
Transanal endoscopic microsurgery.
Cunningham C.
Author information:
Oxford University Hospitals NHS Trust, Oxford, OX3 7LJ, UK, chriscu...@nhs.net.
Abstract
There is increasing interest in organ-preserving options in the management of rectal cancer. Excision of small, early stage cancers by transanal endoscopic microsurgery (TEM) is an important part of this approach. Carefully selected cancers can be treated successfully by TEM with acceptably low risk of recurrent disease and overall cancer outcomes similar to radical surgery. The impact of recurrence can be mitigated by early detection of luminal or nodal disease for which a robust surveillance programme is essential. However, patients with high risk features on post-TEM pathology should be offered completion radical surgery which is associated with good oncological results. There may be an opportunity to expand the population of patients who can be offered rectal preservation with the use of radiotherapy in either adjuvant or neo-adjuvant context. Full thickness excision by TEM may be particularly valuable in those demonstrating a clinical complete response to radiotherapy, where diagnosis of complete pathological response can be confirmed. The use of TEM in managing more advanced rectal cancers is exciting, but must be tested within formal clinical trials before being adopted as routine practice.
PMID: 25102997 [PubMed - indexed for MEDLINE]
Related citations
3. Colorectal Dis. 2013;15(10):e576-81. doi: 10.1111/codi.12381.
Completion surgery following transanal endoscopic microsurgery: assessment of quality and short- and long-term outcome.
Hompes R¹, McDonald R, Buskens C, Lindsey I, Armitage N, Hill J, Scott A, Mortensen NJ, Cunningham C; Association of Coloproctology of Great Britain and Ireland Transanal Endoscopic Microsurgery Collaboration.
Author information:
¹Department of Colorectal Surgery, Oxford University Hospitals, Oxford, UK.
Abstract
AIM:
Patients with unfavourable pathology after transanal endoscopic microsurgery (TEM) should be offered completion surgery (CS) if appropriate. The aim of this retrospective cohort study was to assess the short-term outcome and long-term oncological results of CS and identify factors compromising the quality of resection specimens.
METHOD:
Data were retrieved and analysed on patients who underwent CS from a comprehensive national TEM database (1992-2008) and the institutional prospective database from the Oxford University Hospitals (2008-2011).
RESULTS:
There were 36 patients eligible for analysis. Postoperative complications occurred in 19 and were minor (grade I-II) in 13 and major (grade III-V) in six patients. The quality of the resected specimen was graded as good in 23 (64%), moderate in six (16.6%) and poor in seven (19.4%). Full-thickness excision by TEM (P = 0.03), an interval to CS greater than 7 weeks (P = 0.05) and distally located lesions (P = 0.04) were associated with increased risk for an inferior surgical specimen. Overall survival after CS was 91% at 1 year and 83% at 5 years. Patients with a 'good' TME specimen had significantly improved disease-free survival compared with patients with an 'inferior' specimen (100 vs 51%, P = 0.001).
CONCLUSION:
Patients having full-thickness TEM excision, distally placed lesions and a long interval (> 7 weeks) to CS were likely to have an inferior TME specimen. The results confirm that CS after TEM does not negatively influence local recurrence and survival, but the reduced disease-free survival in patients with an inferior specimen is of concern.
Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland.
PMID: 24635913 [PubMed - indexed for MEDLINE]
Related citations

4. Surg Endosc. 2013 Dec;27(12):4469-77. doi: 10.1007/s00464-013-3092-3. Epub 2013 Sep 21.
Sphincter-sparing surgery for adenocarcinoma of the distal 3 cm of the true rectum: results after neoadjuvant therapy and minimally invasive radical surgery or local excision.
Marks J¹, Nassif G, Schoonyoung H, DeNittis A, Zeger E, Mohiuddin M, Marks G.
Author information:
¹Section of Colorectal Surgery, Lankenau Medical Center, Wynnewood, PA, USA, mar...@mlhs.org.
Abstract
BACKGROUND:
Ideal treatment of rectal cancer includes controlling the cancer; minimizing trauma, morbidity, and mortality; and avoiding a colostomy with preservation of adequate function. These goals become more challenging the further distal in the rectum the cancer is located. We sought to determine whether minimally invasive sphincter-preservation surgery (SPS) can accomplish good cancer control, maintaining sphincter function with minimal morbidity and mortality in rectal cancers of the distal 3 cm after receiving neoadjuvant chemoradiotherapy.
METHODS:
We retrospectively reviewed a prospectively maintained rectal cancer database of a single colorectal surgeon to identify all patients with cancers of the distal 3 cm undergoing SPS via a laparoscopic total mesorectal excision or transanal endoscopic microsurgery (TEM). All patients received neoadjuvant chemoradiotherapy. Patient data, including demographics, initial tumor characteristics, staging, radiation dose, perioperative morbidity and mortality, and local recurrence (LR) and survival, were analyzed.
RESULTS:
A total of 161 patients (108 men) underwent SPS via 3 techniques: transanal abdominal transanal proctosigmoidectomy (TATA, n = 106), TEM (n = 49), or ultralow anterior resection (LAR, n = 6). Average age was 62 years (range 22-90 years). The mean levels in rectum from the anorectal ring were as follows: TATA, 1.3 cm (range -1.0 to 3.0 cm), TEM, 1.5 cm (range -0.5 to -3.0 cm), and LAR, 2.9 cm (range 2.5-3.0 cm) (p > 0.05). Preoperative T stage was as follows: T3, n = 108 (TATA 83, TEM 20, LAR 5), T2, n = 48 (TATA 22, TEM 25, LAR 1), T1, n = 3 (TATA 1, TEM 2), and T4, n = 2 (both TEM). All patients received concomitant 5-fluorouracil-based chemotherapy and radiotherapy (mean, 5300 cGy; range 3,000-7,295 cGy). The mean estimated blood loss was 376 ml (range 10-3,600 ml). There were no mortalities. Morbidity rates were as follows: LAR, 0; TATA, 13.2%; and TEM, 32 % (wound disruption: major, 10%; minor, 16%). Pathologic staging was as follows: ypCR: uT2, 34%, and uT3, 19%. Overall LR was 3.7%. By procedure, the follow-up, LR, and KM5YAS, respectively, were: TATA, 37.9 months, 3 and 95%; TEM, 36.3 months, 6 and 88%; and LAR, 63.1 months, 0 and 75% (p > 0.05).
CONCLUSIONS:
This study demonstrates positive oncologic outcomes, low LR rates, and high KM5YS after minimally invasive SPS. A colostomy-free lifestyle and cancer control make the minimally invasive surgical approach an excellent treatment option for complex distal rectal cancers.
PMID: 24057070 [PubMed - indexed for MEDLINE]
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1.	Dis Colon Rectum. 2014 Oct;57(10):1176-82. doi: 10.1097/DCR.0000000000000208. Transanal endoscopic microsurgery with entrance into the peritoneal cavity: is it safe? Marks JH¹, Frenkel JL, Greenleaf CE, D'Andrea AP. Author information: ¹Lankenau Medical Center, Wynnewood, Pennsylvania. Abstract BACKGROUND: Relative contraindications for transanal endoscopic microsurgery include high, anterior-based lesions for full-thickness excisions because of worries about entering the peritoneal cavity. Concerns exist regarding safety and oncological outcome. OBJECTIVE: We examined the outcomes of transanal endoscopic microsurgery excisions with entry into the peritoneal cavity and compared them with those that did not to address our hypothesis that entry is safe with no ill infectious or oncological consequences. DESIGN: This single-institution retrospective review uses a prospectively maintained database. SETTINGS: This study was conducted at a tertiary colorectal surgery referral center. PATIENTS: From 1997 to 2012, we identified 303 patients who underwent transanal endoscopic microsurgery resections, with 26 patients having entrance into the peritoneal cavity. MAIN OUTCOME MEASURES: Perioperative data, postoperative morbidities, delayed morbidities, and oncological outcomes were the primary outcomes measured. RESULTS: Of 26 patients, there were 8 women with a mean age of 67.5 years. Mean BMI was 31 kg/m, and ASA class was III or IV in 69%. Mean superior border of the lesion was 10.4 cm (4.5-16). Forty-eight percent had anterior-based lesions. Anterior location, level from anorectal ring, and diagnosis of cancer were significantly higher in the peritoneal entry group (p = 0.003, p = 0.007, and p = 0.007). Preoperative diagnoses included 16 adenocarcinomas, 8 polyps, and 2 carcinoid tumors. Thirteen patients had preoperative chemoradiation. Median estimated blood loss was 15 mL (5-400), and 3 patients underwent diversions. Median time to discharge was 3 days (2-10). There were no perioperative mortalities. Median follow-up time was 21.0 months. There was 1 local recurrence (3.8%), and there was no development of carcinomatosis. LIMITATIONS: This review was limited by its retrospective nature. CONCLUSIONS: High anterior location rectal lesions should be considered candidates for transanal endoscopic microsurgery excision in experienced hands. After obtaining considerable transanal endoscopic microsurgery experience, our use of transanal endoscopic microsurgery in a high-risk patient population allowed us to definitively treat 88% of patients without an abdominal operation and the need for a temporary or permanent colostomy. Theoretic concerns of abscess or carcinomatosis were not experienced (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A154).
	PMID: 25203373 [PubMed - indexed for MEDLINE]
	Related citations

2.	Recent Results Cancer Res. 2014;203:31-8. doi: 10.1007/978-3-319-08060-4_4. Transanal endoscopic microsurgery. Cunningham C. Author information: Oxford University Hospitals NHS Trust, Oxford, OX3 7LJ, UK, chriscu...@nhs.net. Abstract There is increasing interest in organ-preserving options in the management of rectal cancer. Excision of small, early stage cancers by transanal endoscopic microsurgery (TEM) is an important part of this approach. Carefully selected cancers can be treated successfully by TEM with acceptably low risk of recurrent disease and overall cancer outcomes similar to radical surgery. The impact of recurrence can be mitigated by early detection of luminal or nodal disease for which a robust surveillance programme is essential. However, patients with high risk features on post-TEM pathology should be offered completion radical surgery which is associated with good oncological results. There may be an opportunity to expand the population of patients who can be offered rectal preservation with the use of radiotherapy in either adjuvant or neo-adjuvant context. Full thickness excision by TEM may be particularly valuable in those demonstrating a clinical complete response to radiotherapy, where diagnosis of complete pathological response can be confirmed. The use of TEM in managing more advanced rectal cancers is exciting, but must be tested within formal clinical trials before being adopted as routine practice.
	PMID: 25102997 [PubMed - indexed for MEDLINE]
	Related citations

3.	Colorectal Dis. 2013;15(10):e576-81. doi: 10.1111/codi.12381. Completion surgery following transanal endoscopic microsurgery: assessment of quality and short- and long-term outcome. Hompes R¹, McDonald R, Buskens C, Lindsey I, Armitage N, Hill J, Scott A, Mortensen NJ, Cunningham C; Association of Coloproctology of Great Britain and Ireland Transanal Endoscopic Microsurgery Collaboration. Author information: ¹Department of Colorectal Surgery, Oxford University Hospitals, Oxford, UK. Abstract AIM: Patients with unfavourable pathology after transanal endoscopic microsurgery (TEM) should be offered completion surgery (CS) if appropriate. The aim of this retrospective cohort study was to assess the short-term outcome and long-term oncological results of CS and identify factors compromising the quality of resection specimens. METHOD: Data were retrieved and analysed on patients who underwent CS from a comprehensive national TEM database (1992-2008) and the institutional prospective database from the Oxford University Hospitals (2008-2011). RESULTS: There were 36 patients eligible for analysis. Postoperative complications occurred in 19 and were minor (grade I-II) in 13 and major (grade III-V) in six patients. The quality of the resected specimen was graded as good in 23 (64%), moderate in six (16.6%) and poor in seven (19.4%). Full-thickness excision by TEM (P = 0.03), an interval to CS greater than 7 weeks (P = 0.05) and distally located lesions (P = 0.04) were associated with increased risk for an inferior surgical specimen. Overall survival after CS was 91% at 1 year and 83% at 5 years. Patients with a 'good' TME specimen had significantly improved disease-free survival compared with patients with an 'inferior' specimen (100 vs 51%, P = 0.001). CONCLUSION: Patients having full-thickness TEM excision, distally placed lesions and a long interval (> 7 weeks) to CS were likely to have an inferior TME specimen. The results confirm that CS after TEM does not negatively influence local recurrence and survival, but the reduced disease-free survival in patients with an inferior specimen is of concern. Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland.
	PMID: 24635913 [PubMed - indexed for MEDLINE]
	Related citations

4.	Surg Endosc. 2013 Dec;27(12):4469-77. doi: 10.1007/s00464-013-3092-3. Epub 2013 Sep 21. Sphincter-sparing surgery for adenocarcinoma of the distal 3 cm of the true rectum: results after neoadjuvant therapy and minimally invasive radical surgery or local excision. Marks J¹, Nassif G, Schoonyoung H, DeNittis A, Zeger E, Mohiuddin M, Marks G. Author information: ¹Section of Colorectal Surgery, Lankenau Medical Center, Wynnewood, PA, USA, mar...@mlhs.org. Abstract BACKGROUND: Ideal treatment of rectal cancer includes controlling the cancer; minimizing trauma, morbidity, and mortality; and avoiding a colostomy with preservation of adequate function. These goals become more challenging the further distal in the rectum the cancer is located. We sought to determine whether minimally invasive sphincter-preservation surgery (SPS) can accomplish good cancer control, maintaining sphincter function with minimal morbidity and mortality in rectal cancers of the distal 3 cm after receiving neoadjuvant chemoradiotherapy. METHODS: We retrospectively reviewed a prospectively maintained rectal cancer database of a single colorectal surgeon to identify all patients with cancers of the distal 3 cm undergoing SPS via a laparoscopic total mesorectal excision or transanal endoscopic microsurgery (TEM). All patients received neoadjuvant chemoradiotherapy. Patient data, including demographics, initial tumor characteristics, staging, radiation dose, perioperative morbidity and mortality, and local recurrence (LR) and survival, were analyzed. RESULTS: A total of 161 patients (108 men) underwent SPS via 3 techniques: transanal abdominal transanal proctosigmoidectomy (TATA, n = 106), TEM (n = 49), or ultralow anterior resection (LAR, n = 6). Average age was 62 years (range 22-90 years). The mean levels in rectum from the anorectal ring were as follows: TATA, 1.3 cm (range -1.0 to 3.0 cm), TEM, 1.5 cm (range -0.5 to -3.0 cm), and LAR, 2.9 cm (range 2.5-3.0 cm) (p > 0.05). Preoperative T stage was as follows: T3, n = 108 (TATA 83, TEM 20, LAR 5), T2, n = 48 (TATA 22, TEM 25, LAR 1), T1, n = 3 (TATA 1, TEM 2), and T4, n = 2 (both TEM). All patients received concomitant 5-fluorouracil-based chemotherapy and radiotherapy (mean, 5300 cGy; range 3,000-7,295 cGy). The mean estimated blood loss was 376 ml (range 10-3,600 ml). There were no mortalities. Morbidity rates were as follows: LAR, 0; TATA, 13.2%; and TEM, 32 % (wound disruption: major, 10%; minor, 16%). Pathologic staging was as follows: ypCR: uT2, 34%, and uT3, 19%. Overall LR was 3.7%. By procedure, the follow-up, LR, and KM5YAS, respectively, were: TATA, 37.9 months, 3 and 95%; TEM, 36.3 months, 6 and 88%; and LAR, 63.1 months, 0 and 75% (p > 0.05). CONCLUSIONS: This study demonstrates positive oncologic outcomes, low LR rates, and high KM5YS after minimally invasive SPS. A colostomy-free lifestyle and cancer control make the minimally invasive surgical approach an excellent treatment option for complex distal rectal cancers.
	PMID: 24057070 [PubMed - indexed for MEDLINE]
	Related citations