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10.1245/ASO.2003.01.441
Annals of Surgical Oncology 10:1106-1111 (2003)
© 2003 Society of Surgical Oncology
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ORIGINAL ARTICLES

Transanal Endoscopic Microsurgery: A Viable Operative Alternative in Selected Patients With Rectal Lesions

P. Neary, MD, G.B. Makin, MD, T.J. White, MD, E. White, MD, J. Hartley, MD, A. MacDonald, MD, P.W. R. Lee, MD and J.R. T. Monson, MD, FRCS, FRCSI, FACS

From the Academic Surgical Unit, University of Hull, East Yorkshire, United Kingdom.

Correspondence: Address correspondence and reprint requests to: J. R. T. Monson, MD, FRCS, FRCSI, FACS, University of Hull, Academic Surgical Unit, Castle Hill Hospital, Cottingham, East Yorkshire HU16 5JQ, United Kingdom; Fax: 44-1482-623274; E-mail: j.r.monson{at}medschool.hull.ac.uk


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Background: Local excision of rectal lesions is being increasingly undertaken, especially in those unfit for major surgery. The traditional transanal approach is often cumbersome and limited to low and mid rectal lesions. Transanal endoscopic microsurgery (TEMS) is being used to excise both benign and malignant rectal lesions, including those in the upper rectum.

Methods: Prospective analysis of all patients undergoing a TEMS excision between January 1997 and December 2000 in a specialized colorectal unit.

Results: Forty patients underwent a TEMS resection, with a mean age of 72 years (SD, 10 years). The mean distance of the lesions from the anal verge was 9.8 cm (SD, 3.1 cm). In 24 patients, the lesion was located >=10 cm from the anal verge, making them unsuitable for traditional transanal resection. The mean operative time was 91 minutes (SD, 34 minutes), and the mean postoperative stay was 3 days (SD, 1.5 days). No mortality was associated with the procedure, and there was minimal morbidity in 15%. There has been no recurrence in the 18 patients who had a malignant lesion excised.

Conclusions: The TEMS operating system provides the surgeon with a suitable alternative for the resection of benign and malignant rectal neoplasms in selected patients. It has the advantage of providing visual clarity of the operative field, allowing more precise dissection and a minimally invasive approach to mid and upper rectal lesions. There has been no mortality and minimal morbidity. We advocate its inclusion as part of a colorectal surgeon’s operative armamentarium for these selected cases.

Key Words: Rectal tumors • Early rectal cancer • Local excision • Transanal endoscopic microsurgery (TEMS) • Minimally invasive


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
The local resection of rectal lesions unsuitable for endoscopic polypectomy may be undertaken by using either a transanal open surgical approach or modifications of the urological resectoscope. For lesions located in the middle and, particularly, in the upper rectum, these techniques are frequently unsatisfactory. The lesions often prove inaccessible because of their distance from the anal verge, and attempted excisions suffer from inadequate surgical exposure, confinement of the operating field, and uncertainty of the surgical clearance margin achieved. The alternative surgical approach for the resection of these lesions is traditionally an anterior or an abdominoperineal resection. These have an attendant mortality of up to 5% and 20% in patients <70 and >80 years of age, respectively.1 The transanal endoscopic microsurgery (TEMS) operating system has been advocated as providing a minimally invasive approach to middle and upper rectal lesions. It has minimal morbidity and, to date, no mortality reported and would consequently seem suitable for the formal resection of benign rectal lesions.

For rectal cancers, the mortality associated with a total mesorectal excision or abdominoperineal resection varies from 1.5% to 5%2,3 in elective cases, and the local recurrence rate after attempted surgical clearance varies from 2.6% to 32%.4,5 Several authors have addressed the possibility of minimizing this morbidity by using local excision.6 The reduction in the morbidity associated with local excision of rectal cancers must, however, be viewed in the context of maintaining an oncologically satisfactory resection. Several series have demonstrated that the failure rate for local resection varies from 0% to 26%, with a mean of 20%. These figures are for pT1 and pT2 lesions; approximately 50% of these cases are salvageable with more formal surgery.7 Careful selection of patients undergoing local excision for a malignant rectal lesion results in overall survival and local control similar to those with transabdominal resection. The 5-year actuarial survival studies comparing patients with pT1 and pT2 carcinomas with favorable histological features and who are resected locally or by transabdominal resection demonstrate a recurrence-free survival of 87% and 91%, respectively, and a local control rate of 96% and 91%, respectively.8 Local excision for early-stage rectal lesions is undergoing continued evaluation in several centers.9,10

Local resection of rectal lesions, whether benign or malignant, not amenable to colonoscopic excision is currently achieved through the application of either some form of transanal excision or TEMS. Standard transanal excision is limited to small tumors (<4 cm) within 6 to 8 cm from the anal verge, because access to tumors of the mid and upper rectum is limited to those that can be pulled down toward the anal verge.11 TEMS offers an alternative approach for local resection, especially for tumors of the mid and upper rectum that cannot be delivered toward the anus.12 The TEMS procedure has been advocated for the local excision of rectal lesions since the 1980s.13 We report our own experience and outcome with this technique in regard to resection of both selected benign and malignant rectal lesions.


   PATIENTS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
A prospectively maintained database (Oxford Database) of all cases undergoing TEMS for rectal tumors was analyzed. The setting was within a tertiary-level referral center in a dedicated specialized colorectal unit. Two groups of patients were included. First were those patients with benign rectal neoplasms unsuitable for colonoscopic polypectomy and otherwise requiring transabdominal rectal excision. Second was a highly selected group of patients with malignant rectal lesions—usually patients with a high comorbidity or with advanced age. All patients underwent preoperative endoscopic lesion biopsy and radiological staging, either by magnetic resonance imaging or endoscopic ultrasound. The mean follow-up was 21 months (SD, 14 months), with a range of 1 to 48 months.

The TEMS operating endoscope consists of a 40-mm rectoscope with an attached stereoscopic binocular viewing eyepiece. This permits 6-fold magnification of the operative field. The rectum is maintained dilated with constant-flow carbon dioxide insufflation. The TEMS instruments are specifically adapted to use via the rectoscope, and both the instruments used and the principles of operative technique are as described by Beuss.14 We use a standard Wolfe TEMS operating endoscope with a fixed Martin stabilizing arm (Richard Wolf GmbH Germany). Patients undergo a general anesthetic and are then positioned to orient the lesion at the inferior aspect of the operative field.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Forty patients underwent TEMS resection between January 1997 and December 2000. The mean age of the patients was 72 years (range, 49–90 years), with an equal number of men and women. The age and sex distribution of the patients is shown in Fig. 1. Preoperative histology was benign in 21 cases and malignant in 19. The mean distance form the anal verge was 9.8 cm (SD, 3.1 cm), with a range of 4 to 17 cm. The position of the lesions, patient orientation, and operative times are listed in Tables 1 and 2Go. The distance from the anal verge is shown in Fig. 2. The location of the lesions was as follows: 9 anterior, 19 posterior, 8 left lateral, and 4 right lateral. Patients were positioned in the Lloyd-Davies position in 26 cases, reverse Lloyd-Davies position in 8, left lateral Sims position in 2, and right lateral in 4. The mean operative time was 91 minutes (SD, 34 minutes), with a range of 35 to 175 minutes. The mean postoperative stay was 3.2 days (SD, 1.5 days), with a range of 1 to 6 days. The postoperative course was uncomplicated in most cases, with no mortality and morbidity in 8 (20%) of the 40 cases. The morbidity is listed in Table 3.



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  		FIG. 1. The age and sex distribution of patients undergoing the TEMS procedure.

 

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  		TABLE 1. Patient position
 

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  		TABLE 2. Position of lesion
 


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  		FIG. 2. The distance of the resected lesion from the anal verge (cm).

 

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  		TABLE 3. Postoperative complications
 
Benign Lesions
There were 21 benign cases resected. The mean age of these patients was 69 years (SD, 8 years), with a range of 57 to 86 years. The morphology of the lesions included 16 polypoid, 3 villous, and 2 flat tumors. The preoperative histology of the lesions obtained on endoscopic biopsy was as follows: 10 villous adenomas, 2 tubular adenomas, 6 tubulovillous adenomas, 2 adenomas nonspecified, and 1 dysplasia-associated lesion or mass. The preoperative staging, based on digital and sigmoidoscopic rectal examination, demonstrated the lesions to be freely mobile in 11 cases, mobile in 8, tethered in 1, and fixed in 1. The tethered lesion was a large villous adenoma. The fixed lesion, thought to be benign on preoperative histology and radiology, turned out to be a pT1 adenocarcinoma. The mean size of the lesions resected was 3.9 cm (SD, 2.6 cm). The mean distance from the anal verge was 10.1 cm (SD, 3.5 cm), with a range of 5 to 17 cm. Of the 21 lesions, 8 were located in the middle rectum (5–10 cm), and 13 were located in the upper rectum. Most cases had a full-thickness resection (n = 19); mucosectomy and partial-thickness resection was performed in each of the remaining two cases. The mean operation time was 95 minutes (SD, 36 minutes). The postoperative histology differed markedly from the preoperative biopsy findings in one case. This was the aforementioned adenocarcinoma (pT1). The subsequent identification of focal carcinomas, inapparent on the biopsy specimen, is in keeping with the findings of other studies.15 Seventeen of the resected lesions were graded as moderate dysplasia, three as mild or low-grade dysplasia, and one as severe dysplasia. A histological clear resection margin was achieved in 19 cases. Because of tumor fragmentation, the efficacy of the clearance margin could not be determined in two further cases. The mean length of hospital stay was 3.2 days (SD, 1.8 days), with a range of 1 to 6 days. The only morbidity was in two patients who had a postoperative hemorrhage; both settled spontaneously, and one requiring a blood transfusion. In all, one patient developed local recurrence during the period of follow-up.

Malignant Lesions
There were 19 cases of preoperatively diagnosed rectal carcinoma excised with the TEMS technique, 17 with the intention of cure. The mean age of this group was 75 years (SD, 11 years), with a range of 49 to 90 years. The morphology of these lesions was polypoid in 10, ulcerated in 6, and flat in 3. The mean size of the lesions was 3.2 cm (SD, 1.5 cm), with a range of 1 to 6.5 cm. The mean distance from the anal margin was 9.5 cm (SD, 2.6 cm), with a range of 4 to 14 cm. Seven lesions were located in the mid rectum and 12 in the upper rectum. On initial clinical assessment, the lesions were considered to be freely mobile in 4 cases, mobile in 13 cases, and fixed in 2 cases. All had a full-thickness resection, and only four wounds were closed; the remainder were left to heal by secondary intention. Seventeen were confirmed to be invasive adenocarcinoma on histology: three pTis, five pT1, eight pT2, and one pT3 (Table 4). In remaining two cases, the subsequent TEMS excision specimen did not show any further evidence of carcinoma. One was a carcinoid tumor, and the second showed normal mucosa. The lesions were histologically graded as moderately to well differentiated in 15 cases and poorly differentiated in 3 cases; there was 1 carcinoid. All lesions were completely excised radially, but two had carcinoma involving the deep resection margin. The mean length of hospital stay was 3.3 days (SD, 1.2 days), with a range of 2 to 6 days. There was no mortality in this group. One patient developed postoperative urinary retention, and five patients had postoperative hemorrhage: three while in the hospital and two after discharge (this required readmission). All five of these patients settled spontaneously, although two had a repeat examination under anesthesia, and one of these needed a blood transfusion. The mean follow-up of these patients was 20 months (SD, 13.5 months), with a range of 1 to 47 months, and no local recurrence has been demonstrated.


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  		TABLE 4. Tumor histology
 
Eight patients (mean age, 73 years; SD, 13 years; range, 49–90 years) had a pT2 tumor. The mean American Society of Anesthesiologists (ASA) score was III (range, II to IV). The lesions resected included seven moderately differentiated carcinomas and 1 poorly differentiated carcinoma. A clearance margin with a full-thickness excision was achieved in seven of these patients. The single case with deep margin involvement refused subsequent proctectomy and underwent a long postoperative course of combined chemoradiotherapy. A second patient with a pT2 adenocarcinoma underwent a long course of postoperative radiotherapy. He was 49 years old and physically unfit for an abdominoperineal resection (ASA status IV). Patient follow-up included a magnetic resonance scan of the pelvis and abdomen 6 months after surgery. The mean follow-up for this subgroup of patients was 22 months (SD, 16 months), with a range of 1 to 47 months, and there has been no local or distant recurrence.

The one patient who had a pT3 adenocarcinoma excised was a frail 89-year-old woman who was also unfit for an anterior resection (ASA status IV). She was the other patient with tumor at the deep resection margin and is currently receiving long-course radiotherapy.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
In the United Kingdom, colorectal cancer accounts for 10% of cancer deaths. The mortality associated with colorectal resections has been reported as varying from 0% to 20%.16 The possibility of using a local resection technique, such as TEMS, to achieve comparable outcome with minimal morbidity for rectal lesions is an attractive proposal. Beuss et al.13 have advocated the TEMS procedure both for benign and early-stage malignant rectal lesions. These authors state that the reduction in morbidity after TEMS—particularly in impaired bladder function/micturition difficulties, absence of sexual problems, and a low incidence of prolonged incontinence17—would firmly establish this technique as part of the therapeutic repertoire for rectal carcinoma.18 In this series, we assessed the technical application of the TEMS procedure for the formal resection of both benign and early-stage malignant lesions. We examined the efficacy of the surgical resection and postoperative morbidity in a selected group of patients within a dedicated colorectal unit.

This minimally invasive technique is clearly applicable in selected benign neoplasms. This is particularly advantageous for lesions of the middle and upper rectum. During the same time period, 538 rectal polyps were treated through our standard colonoscopy program. This identified nine benign cases suitable for TEMS resection (1.5%). The remaining 12 cases of benign polyps that underwent TEMS were referred from other centers. Most of the benign cases were villous adenomas, and a completed resection was possible in 100% of the cases. Twelve of these patients had lesions located >=10 cm from the anal verge. There was no mortality and minimal morbidity (10%) in our series: one patient needed a transfusion after bleeding, and one patient was readmitted for observation with minor bleeding. The length of hospital stay was short (mean, 3 days). There has been one case of local recurrence of a villous adenoma. This was despite having initially histologically proven clear margins. This patient went on to have a further TEMS without incident. The TEMS system, therefore, provides easy access to the middle and upper rectum, permits good exposure of the operative field, and enables the operator to delineate a macroscopically clear resection margin.

The small number of cases that could not be addressed by colonoscopic resection reflects the specialization of the application of this technique. Traditional transanal approaches are capable of removing most low-lying rectal polyps. However, the TEMS approach allows excision of much higher lesions with the same degree of ease. In addition, the excellence of the image allows for more precise excision. We believe that this is responsible for the low level of local recurrence in a group of polyps notorious for recurrence after local excision (i.e., large villous polyps).

We have shown that the TEMS procedure is safe; there were no deaths. This is better than the published mortality (.6% to 8%) of elective abdominal colorectal resections.19,20 This must represent an advantage for patients who would otherwise face a transabdominal rectal excision for benign disease. Because there are only a few cases involved, its routine use may be more practical in a specialized center. It does, however, provide a viable minimally invasive surgical alternative for the local resection and cure of benign rectal lesions.

The use of local resection for rectal carcinoma is controversial. We undertook 310 curative resections for rectal cancers during the same period as that studied in this series. This indicates that 6.1% of our cases considered for curative surgery underwent local resection in the form of TEMS. It has been our policy to offer local excision for cure of rectal cancer only when transabdominal resection is contraindicated. These few patients were selected on the basis of advanced age and high comorbidity. The cases were staged as pTis (n = 3), pT1 (n = 5), pT2 (n = 8), and pT3 (n = 1). One carcinoid tumor was diagnosed on preoperative endoscopic biopsy, but there was no evidence of any abnormality in the TEMS resected specimen. Two patients, however, had deep margin involvement on histology and consequently had postoperative radiotherapy. One refused a transabdominal rectal excision, and the other was deemed too high an operative risk. A third patient underwent postoperative radiotherapy on the basis of his pT2 carcinoma with clear margins and his young age (49 years).

The local excision of rectal cancers remains a controversial issue, and we do not routinely advocate this approach. For pT1 lesions, however, we believe that the evidence supports this approach. The incidence of nodal involvement in pT1 tumors was studied by Hermanek.21 He reviewed 1588 cases of rectal tumors and concluded that pT1 lesions of a favorable histological grade had a 3% risk of nodal involvement, whereas a pT1 lesion with a poor prognostic grade had a 12% risk of nodal involvement. These findings do not take into account the health status of the patient and the mortality associated with undergoing a transabdominal resection. The rate of local recurrence after local resection of pT1 lesions is reported as 4%.22 One prospective randomized trial examining local resection compared with anterior resection of pT1 carcinomas did not show any survival benefit over a 5-year follow-up period. This study advocated TEMS for pT1 lesions because of lower morbidity, similar local recurrence rates, and a survival benefit similar to that of a major resection.23 In view of the comparable recurrence rate and low risk of nodal involvement, TEMS for pT1 rectal adenocarcinomas seems a suitable alternative to a transabdominal resection.

Local excision of pT2 and pT3 tumors is more controversial. Tumors staged as pT2 and pT3 have a high risk of lymph node metastases: approximately 17% and 50%,24 respectively. The treatment of pT2 lesions by local excision followed by postoperative radiotherapy yields variable results, with local recurrence rates reported as 10%.25 In our subset of eight patients with a pT2 lesion, seven have had a curative procedure, on the basis of clear histological margins. These eight patients were of advanced age (mean, 73 years) and a high ASA grade (mean, III). Undertaking a radical resection in these patients has a minimum 11% to 16% risk of mortality.26,27 In view of this, we therefore elected to perform a TEMS procedure. The subsequent follow-up of these patients has shown no evidence of local recurrence. Two patients received postoperative radiotherapy. One received radiotherapy on the basis of deep margin involvement and the other on the basis of his young age. The use of postoperative adjuvant radiotherapy to the operative field has been shown to reduce the incidence of local recurrence to the order of 10%.28 The remaining patients were deemed not to require further intervention on the basis of their high comorbid status (mean age, 80 years; mean ASA status, III).

Although technically feasible, the routine use of the TEMS procedure for pT2 and higher T-stage lesions leaves the significant risk of missing nodal involvement and, therefore, is not an oncologically curative resection. In the healthy patient with a pT3 tumor, a formal total mesorectal excision is more appropriate than the TEMS resection. In patients with a pT2 tumor, we suggest that the TEMS procedure be undertaken only in selected cases. In a study of 73 patients undergoing TEMS in a tertiary-level referral center, TEMS resection alone in the treatment of pT2 rectal cancers was considered inappropriate.29 In our center, the TEMS procedure in pT2 lesions is reserved for patients of high comorbidity or advanced age, in whom the lesion is not suitable for colonoscopic resection.

The TEMS procedure clearly has the benefits of minimal morbidity, decreased hospital stay, and, to date, no mortality. It permits surgical resection of high rectal lesions that are unattainable by transanal excision. This makes it very amenable to the resection of benign lesions not treatable by colonoscopic polypectomy. The TEMS technique for early-stage rectal cancers also has a definite but selected role to play. For pTis and pT1 lesions, the technique offers a minimally invasive procedure with oncological results comparable to those with the more traditional formal resection of rectal cancers. The use of TEMS alone as a routine procedure for the excision of pT2 carcinomas still remains to be justified. For pT2 resected specimens, adjuvant radiotherapy should be considered. This improves both the 5-year actuarial local control and recurrence-free survival rates from 72% and 66%, respectively, in cases with local excision to 90% and 74%, respectively, for cases treated with adjuvant irradiation.30

The cost of the TEMS equipment must be mentioned. The capital outlay of more than $50,000 is considerable. However, this is offset by several factors. There is no doubt that some patients—surgeons will argue about how many—have rectal lesions that are definitely reachable only with the TEMS system. These patients are clearly saved a transabdominal rectal excision and realize a very significant cost saving. In addition, there are no disposable costs per case, and the equipment is robust, requiring minimal maintenance (our own system is now 10 years old). The imaging stack is compatible with the laparoscopic surgical system available in most operating suites. However, in view of the limited number of patients undergoing a TEMS in a tertiary referral center, we believe that this is not a suitable approach for every colorectal unit and suggest that only larger centers would have enough patients to justify the costs. However, in this setting, the benefits are such that this technique has a rightful place as part of the colorectal surgeon’s operative armamentarium.


   FOOTNOTES
 
The use of transanal endoscopic microsurgery excision in a specialized colorectal unit is reviewed. We show the advantage of this technology in selected cases, particularly in patients with significant comorbidity or in lesions located in the upper rectum.

Received for publication August 23, 2000. Accepted for publication July 14, 2003.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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S. Ganai, P. Kanumuri, R. S. Rao, and A. I. Alexander
Local Recurrence After Transanal Endoscopic Microsurgery for Rectal Polyps and Early Cancers
Ann. Surg. Oncol., April 1, 2006; 13(4): 547 - 556.
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