All patients who had a TEM procedure between January and September were enrolled in a prospective cohort study. Outcome was described for benign and malignant tumors. Mortality, recurrence , and complications were recorded. Complication rates were significantly different in the 2 groups, There were no significant difference in the recurrence rate of 8. Thirty days mortality rates were 1. Other complications were noted in 2. TEM seems to be a safe and viable procedure for removing both benign and malignant lesions from the rectum.
TEM offers low mortality and complication rates also recurrence after resection of malignant tumors. The work cannot be changed in any way or used commercially. TME is the standard procedure for the treatment of rectal cancers more advanced than T1sm2 due to its good oncological outcome in respect to recurrence and cure,  but the rate of major complications , and procedure related mortality has motivated a careful selection of patients to TME. One well-established alternative surgical procedure to remove adenomas and early stage cancer in the rectum is TEM.
The TEM procedure has existed for more than 30 years. One major limitation is the lack of lymph node harvesting from the mesorectum, although locoregional excision including parts of the mesorectum has been described. If pathology reports do not show radical resection, or reveals a more advanced T stage or substage than anticipated, a completion TME is performed. The correct selection of patients for a TEM procedure, or a major bowel resection like a TME, relies therefore on a correct preoperative staging and early completion surgery in case of preoperative under staging.
The objectives of this study are to ensure the quality of the TEM procedure, by assessing the surgical outcomes for patients treated with TEM in terms of radical surgery, local recurrence , mortality, and complications. Informed consent was given from the patients before data were entered in the database.
Data were prospectively collected in the period of January to September Data were entered into a dedicated database and, in cases of missing data, they were crosschecked with the patient's file. The data collected during the in-hospital period were: Demographical data and American Society of Anesthesiologists ASA -score determined by the anesthesiologist, size, and location of the neoplasm and the intention of treatment as cure, compromise, or palliation.
Histopathological data on the completeness of the excision and on T stage were entered into the database at the first follow-up appointment. Data on complications , recurrence , and mortality were collected at all follow-up appointments. The follow-up program for benign tumors included a rectoscopy after 3 and 12 months if the tumor was excised by a piecemeal technique or in cases of borderline complete histological resection.
Otherwise a follow-up endoscopy was made after 1 and 3 years. If they were without recurrence , the patient were offered a follow-up endoscopy every 5th year. For malignant tumors, follow-up were every 3rd month during the first year and then every 6th month for 2 years and every 12th month for 2 years.
Follow-up included endoscopy, digital rectal examination, and ERUS. A computed tomography CT scan of the thorax and abdomen was offered after 1 and 3 years to all patients with a malignant tumor. These follow-up regiments were organized according to national guidelines for benign and malignant tumors.
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The indication for TEM was the presence of advanced large tumor where malignancy could not be safely excluded or an early stage carcinoma in the rectum, not more advanced than T1 N0M0, was demonstrated by ERUS. Some patients refused further treatment after TEM. All TEM procedures were performed by 1 of 5 certified and formally trained consultants. The inclusion criteria were: All patients who underwent TEM in the 2 departments of surgery, from January to September Complications during surgery were registered by the TEM surgeon.
Complications were stratified in peri- and postoperative complications and are classified as bleeding, unintentional perforation to the peritoneal cavity, delayed discharge from the hospital because of pain, or infections, anal incontinence, or anal stenosis. Intended penetrations to the peritoneal cavity were registered, but not regarded as a complication, only unintended perforations were defined as a complication.
Complications after the TEM procedure were registered if reported within 30 days by any doctor or nurse attending the patient or if the patient contacted the surgical department. Patient reported complications at the 3-month follow-up were also registered.
All complications experienced by the patient within the first 30 days were registered without regards to severity or the need for intervention. Patients, who did not participate in a follow-up program, were registered as lost to follow-up. Tumor recurrence and time to tumor recurrence were registered, and stratified according to the intention of the treatment cure, compromise, palliative. Tumor recurrence is defined as a new tumor in the rectum following the TEM procedure. Data were analyzed using exact methods for binomial data. A Fischer exact test was used to assess the hypothesis of no difference in risk for the outcomes of benign and malignant tumors, with an assumption of categorical data.
A total of patients underwent a TEM procedure.
- Transanal Endoscopic Microsurgery (TEM).
- Transanal endoscopic microsurgery (TEM);
- Transanal Endoscopic Microsurgery for Colorectal Cancer.
Mean ASA score for benign and malignant groups were 1. Per-operative complications were observed in 4.
Unintended penetration to the peritoneal cavity occurred in 2. The total postoperative complication rates were These included perforation 2. Bleeding occurring before hospital discharge was 2. One patient with bleeding was treated with blood transfusion, and 2 patients treated with a reendoscopy and a hemostatic procedure. The mean in-hospital time for the patients treated with an open procedure was 15 days 5—36 , and 2. Other complications were present in 2.
Radical resection was determined by the surgeon, and the pathologist. There were missing data in 8 cases in that group. Seven cases had missing data. All the resections determined not complete resection by the pathologist, were piecemeal resections. Radical resections were noted in cases according to the pathologist compared to according to the surgeons. All cases of pathological nonradical resections were piecemeal resections.
The mean follow-up was Recurrence were noted in 8. In the benign cases the size of the tumors that recurred was Four tumors had pathological-free margins, 10 were excised by a piecemeal technique. In the malignant cases the size of the tumors that recurred was Six tumors had pathological-free margins, 7 were excised by a piecemeal technique.
Mean time to recurrence was 14 months SD: Ten patients received preoperative radiation therapy and 3 of them had a recurrence. Time to recurrence was 5.
Transanal Endoscopic Microsurgery
Four deaths were reported; 2 in the benign and 2 in the malignant group 1. One of them was related to the surgical procedure, 3 of them died of an advanced cancer disease. One patient with benign disease died from an advanced, but unrelated malignancy. All of them had TEMs for palliation or compromise. Postoperative complications were more frequent after cancer resections than after resection of adenomas.
The overall complication rates were higher in cancer surgery. In particular the rates of unintended perforations to the peritoneum were more frequent during cancer resections. Our data show no significant difference in perioperative bleeding in the benign and malignant TEM 's. The complication rates were low, and comparable to existing results from similar studies. Other complications were described, most notably anal incontinence and stenosis. However, these were too infrequent to be of statistical significance. It should be noted that preoperative anal function was not assessed.
Bleeding was not significantly different in the 2 groups, neither before nor after hospital discharge. However, there is a nonsignificant tendency toward more frequent bleeding in the malignant group. Restivo et al  found cancer to be the only risk factor for bleeding when performing TEM , but in our clinic TEM is performed only when cancer is expected or likely. Few patients were treated for a rectal bleeding indicating that bleeding is a self-limiting minor complication and most often manageable conservatively. The higher occurrence of perforation in the malignant group was expected due to the full thickness approach and intended wider lateral margins when dealing with a cancer.
Intraperitoneal perforation is often described as a major complication in TEM surgery and may require rescue surgery. In our data 5 patients were treated for a perforation with open surgery. The remaining cases were managed by suturing during the TEM procedure. Perhaps the latter cases should not be considered as a complication, but as part of the procedure.
Our rate of complications would then be overestimated. The patient should have information and be aware of this before the TEM operation. In very old patients and patients with poor general condition TEM may be appropriate as a compromise operation also for deep T1 and at T2 tumors. This should be assessed individually based on the risk of side effects.
Disadvantage of TEM is that the surgery usually requires general anesthesia, and therefore is more straining for the patient than other endoscopic techniques. TEM is technically difficult because of the small space in the rectoscope with three working intruments which easily collide with each other. When the rectoscope is mounted, there is a limited area of access to the rectal wall.
It is therefore necessary to move and angle the rectoscope repeated times to reach the areas to be dissected or sutured. When everything functions optimally there is however good overview, and the different layers of the bowel wall are defined and it is possible to dissect submucosa or between the muscle layers in the muscularis propria or perirectal fat tissue full wall resection. Full wall resection is the quickest and most simple method and is preferred in the areas of the rectum where the entire wall can be removed. Distally, the external sphincter will be damaged and cranially on the anterior rectal wall, the abdominal cavity will be opened with a full wall resection.
In these two areas, only a mucosal resection should be performed. Oral analgesics is administered if required. There is usually minimal pain associated with the postoperative phase, but sutures in and close to the dentate line may be painful. Patients are usually discharged on the first postoperative day. For very large resections or increased risk of infection the patient stays hospitalized for three-four days for observation. The patients should have follow- up controls at the surgical ward which carried out the operation. There should be controls at least every six months for three years.
Thereafter annually up to the fifth follow-up year.
Transanal Endoscopic Microsurgery (TEM): Approach to Rectal Sleeve Resection
At every control a rectal examination, endoscopy and possibly rectal ultrasound are performed. This is sufficient if R0 resection with good margins at T1 sm1 is performed. If a TEM is performed as a compromise at deep T1 or T2 tumor, and new treatment is relevant in case of local-regional recurrence, a control with MRI of the pelvis should be considered, particularly if the tumor was above the level that can be reached with the fingers during exploration. Additionally the CEA may be controlled. CT for detection of distant metastases may be considered individually. Oslo University Hospital shall not be liable for any loss whether direct, indirect, incidental or consequential, arising out of access to, use of, or reliance upon any of the content on this website.
Similarly in colon.
Transanal endoscopic microsurgery | Radiology Reference Article | myxalyleby.gq
For Haggitt level 3 the resection margins is often questionable. In rectum a resection of the area can then be performed by TEM, and histology will clarify whether this is adequate treatment. In colon a formal resection must be performed. Haggitt level 4 is treated as a sessile tumor. Cancer of sessile polyp TEM is the main method for removing large premalignant polyps in the rectum. Equipment A operating rectoscope ,4 centimeter in diameter and 15 or 25 centimeter in length, is used.
This is fixed on a movable holder mounted to the operation table. The optical system is put into place, there is binocular optics with six times magnification and a good three-dimensional image.