Comparative Efficacy and Acceptability of Endoscopic Methods for Rectal Neuroendocrine Neoplasms with Low Malignant Potential: A Network Meta-analysis.

BACKGROUND/AIMS:  Although endoscopic resection is an effective treatment of rectal neuroendocrine neoplasms (R-NENs) with low malignant potential, there is no consensus on the most recommended endoscopic method. This study aimed to assess the efficacy and acceptability of different endoscopic treatments for R-NENs with low malignant potential. MATERIALS AND METHODS:  We searched databases for studies on treatments of R-NENs using endoscopic resection. These studies comprised techniques such as endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), modified endoscopic mucosal resection (EMRM), modified endoscopic submucosal dissection (ESDM), and transanal endoscopic microsurgery (TEM). The primary outcomes assessed were histological complete resection (HCR). RESULTS:  Overall, 38 retrospective studies (3040 R-NENs) were identified. Endoscopic mucosal resection with a cap (EMRC), endoscopic mucosal resection with ligation (EMRL), ESD, ESDM, and TEM demonstrated higher resectability than did EMR in achieving HCR. Endoscopic mucosal resection, EMRC, EMRL, EMRP, EMRD, and EMRU required shorter operation times than did ESD. Endoscopic mucosal resection, EMRC, ESDM, and TEM incurred lower risks than did ESD. CONCLUSION:  Regarding R-NENs <20 mm with low malignant potential, ESD could be used as the primary treatment. However, TEM may be more effective if supported by economic conditions and hospital facility. With respect to R-NENs <16 mm with low malignant potential, EMRL could be used as the primary treatment. In regard to R-NENs <10 mm with low malignant potential, EMRL, EMRC, and ESD could be used as the primary treatment. However, EMRL and EMRC might be better when operational difficulties and economic conditions were considered.

Local Excision for Early-Stage Rectal Adenocarcinomas.

ABSTRACT: Although total mesorectal excision (TME) remains the standard of care for rectal cancer, including early-stage T1/T2 rectal adenocarcinoma, local excision may be warranted for these early-stage tumors in a select group of patients who may decline surgery or may be nonoptimal surgical candidates. Operative approaches for transanal local excision include transanal endoscopic microsurgery or transanal minimally invasive surgery for tumors <4 cm, occupying <40% of the rectal circumference and <10 cm from the dentate line. The use of preoperative chemoradiation therapy may help to downstage tumors and allow for more limited resections, and chemoradiation may also be employed postoperatively. Local excision approaches appear to result in improved quality of life compared with TME, but limited resections may also compromise survival rates compared with TME. Multidisciplinary management and shared decision-making can allow for the desired patient outcomes.

Comparing advanced platforms for local excision of rectal lesions.

BACKGROUND: Transanal surgery facilitates organ preservation in select patients with benign and early malignant rectal lesions to avoid the functional consequences of radical surgery. The transanal endoscopic microsurgery (TEM) platform created a standard for local excision with lower margin positivity and recurrence rates than traditional transanal excision. The single-port robot (SP r) presents a promising alternative transanal platform. The goal of this study was to compare perioperative and pathologic outcomes of TEM and SP r for excision of rectal lesions. METHODS: A review of consecutive patients who underwent local excision of rectal lesions at a tertiary referral center from 1/2001 to 5/2022 was performed. Cases were stratified into TEM or SP rTAMIS in a 1:1 propensity score-matched cohort, adjusting for all baseline characteristics. Clinical, tumor-specific, and perioperative outcomes were compared using χ2, and Mann-Whitney U-tests. The main outcomes were oncologic quality measures, complications, and operative time. RESULTS: Matching resulted 50 patients in each cohort. Groups had similar age, gender, body mass index, comorbidity, diagnosis, lesion characteristics, and neoadjuvant chemoradiation rates. There were no intraoperative complications in either cohort. Three SP rTAMIS cases were converted intraoperatively; there were no conversions in TEM. SP rTAMIS had significantly shorter operative times than TEM (mean 104 vs. 245, p = 0.027). The rates of positive distal margins (2% TEM, 0% SP rTAMIS) and piecemeal resection (4% TEM, 0% SP rTAMIS) were similar. SP rTAMIS had significantly lower postoperative morbidity rates than TEM (9% vs. 20%, p = 0.031). There was no mortality in either cohort. CONCLUSIONS: SP robotics provided high-quality outcomes similar to TEM for local excision of rectal lesions. SP robotics had faster operative time with comparable clinical and oncologic outcomes to TEM. These early data are promising for expanding use of SP robotic platforms.

[Transanal Endoscopic Microsurgery (TEM) is a surgical option to preserve fecal continence in selected low rectal cancers]. / Die Transanale Endoskopische Mikrochirurgie (TEM) ist eine chirurgische Option zur Erhaltung der Stuhlkontinenz bei ausgewählten tiefsitzenden Rektumkarzinomen.

INTRODUCTION: Despite its existence for more than 40 years, the TEM method has not become widespread. The main reasons are the high acquisition costs, the sophisticated technology and alternative procedures (especially radical resection procedures), which provide greater oncological safety. However, avoiding major abdominal surgery with the creation of a stoma and higher complication rates can outweigh the higher risk of recurrence for some patients. We examined the results using V-TEM with reduced acquisition costs in the resection of adenomas and carcinomas and discussed its importance by literature . METHOD: From 2003 to 2019, 154 patients with 170 findings were operated by V-TEM technology. Data on the operation and follow-up were collected and analyzed retrospectively. RESULTS: The median age was 67 years, 89 patients were male and 65 female. V-TEM was performed on 79 carcinomas, 77 adenomas and 14 other findings. The complication rate was 21.2 %. R0 resection was achieved in 78.8 %. The adenoma recurrence rate was 7.3 %, the overall recurrence rate for carcinomas 11.9 %, local recurrences were observed in 6.8 %. The disease-specific survival is 100 % at 5 years and 94.2 % at ten years. DISCUSSION: The successful use of TEM in adenomas and early carcinomas is undisputed. When treating carcinomas from a T1 high risk stage using TEM, recurrence rates higher than 10 % must be expected. Better results can be achieved with radical procedures, this is why they are considered the therapy of choice in these cases. However, there are no differences in terms of survival rates and TEM offers proven better postoperative quality of life. In particular, the combination of neoadjuvant procedures with TEM delivered promising results in more advanced stages. Further studies on TEM and the possibility of lower acquisition costs through modification to V-TEM could make the method more popular in the future.

Recurrence after transanal endoscopic microsurgery for benign and malignant rectal tumours: experience of a single New Zealand centre.

BACKGROUND: Transanal endoscopic microsurgery (TEM) is an established technique for the resection of rectal adenomas and selected malignant tumours. It avoids the morbidity of radical resection for tumours not amenable to endoscopic resection. An important marker of quality is the local recurrence rate. The primary objective was to determine local recurrence rates for benign and malignant rectal tumours. METHODS: We identified index TEM excisions of rectal adenomas and adenocarcinomas in patients age 18 and over at Dunedin Hospital, New Zealand, between 2000 and 2020, from a prospective database. Surveillance data were collected via chart review. The primary outcome was recurrence rate for adenomas and adenocarcinomas. Secondary outcomes included time to recurrence, association of recurrence with recognized risk factors, and adverse event rates. RESULTS: We identified 100 patients for analysis. Of 75 benign cases, 11 (14.7%) developed local recurrence, with 63.6% identified within 1 year. Of the 25 malignant cases (19 T1, 5 T2, 1 T3), 9 (36%) developed recurrence, with 77.8% identified within 2 years. Adverse events occurred in 26% of patients, with no reoperations or deaths. CONCLUSION: Our adenoma recurrence rate was at the higher end of the reported range of 2.4-16%. Minor complications were common, but not major morbidity. The propensity for rectal tumours to recur commonly and early reinforces the importance of regular standardized endoscopic surveillance.

Microcirugía transanal endoscópica en el tratamiento para el cáncer del recto / Transanal Endoscopic Microsurgery for Treating Rectal Cancer

Introducción: La microcirugía transanal endoscópica es un procedimiento mínimamente invasivo que se aplica para el tratamiento local del cáncer del recto en estadios iniciales. Su utilización en estadios más avanzados del cáncer del recto resulta controversial. Sin embargo, con el uso rutinario del tratamiento neoadyuvante constituye una opción atractiva que se ha comenzado a considerar. Objetivo: Evaluar los resultados de la microcirugía transanal endoscópica para el tratamiento del cáncer del recto en el Centro Nacional de Cirugía de Mínimo Acceso. Métodos: Se realizó un estudio retrospectivo de una base de datos prospectiva de 18 años. La muestra fue de 150 pacientes que cumplieron con los criterios de selección y las variables estudiadas fueron: edad, sexo, indicación, tiempo quirúrgico, entre otras. Resultados: La principal indicación fue el adenocarcinoma del recto T1. La edad media fue 63 años (32-93); el tiempo quirúrgico, 76 minutos (25-240) y el tamaño tumoral, 2,8 cm (1-4). La estancia hospitalaria fue de 1 día (12 horas-7 días), la morbilidad fue 6,7 porciento y las principales complicaciones posoperatorias fueron el sangramiento, la dehiscencia de sutura, el absceso, la fístula rectovaginal y la estenosis. La recurrencia local fue 8,2 porciento, 7,1 porciento y 2,5 porciento para los adenocarcinomas T1, T2 y T3 respectivamente. La supervivencia global a los 5 años fue 97,5 porciento y la supervivencia libre de enfermedad fue 95,5 porciento. Conclusión: La microcirugía transanal endoscópica es una técnica factible y segura en el tratamiento de los adenocarcinomas T1, mientras que en los T2 y T3 se requiere de la radioquimioterapia preoperatoria(AU)

Introduction: Transanal endoscopic microsurgery is a minimally invasive procedure applied for the local treatment of rectal cancer at early stages. Its use in more advanced stages of rectal cancer is controversial. However, with the routine use of neoadjuvant treatment, it is an attractive option that has begun to be considered. Objective: To assess the outcomes of transanal endoscopic microsurgery for the treatment of rectal cancer at Centro Nacional de Cirugía de Mínimo Acceso. Methods: A retrospective study of an 18-year prospective database was performed. The sample consisted of 150 patients who met the selection criteria and the variables studied were age, sex, indication, surgical time, among others. Results: The main indication was T1 rectal adenocarcinoma. The mean age was 63 years (32-93); surgical time, 76 minutes (25-240); and tumor size, 2.8 cm (1-4). Hospital stay was 1 day (12 hours-7 days), morbidity was 6.7 percent, and the main postoperative complications were bleeding, suture dehiscence, abscess, rectovaginal fistula and stenosis. Local recurrence was 8.2 percent, 7.1 percent and 2.5 percent for T1, T2 and T3 adenocarcinomas, respectively. Overall survival at 5 years was 97.5 percent and disease-free survival was 95.5 percent . Conclusion: Transanal endoscopic microsurgery is a feasible and safe technique for treating T1 adenocarcinomas, while T2 and T3 adenocarcinomas require preoperative radiochemotherapy(AU)

La escisión total del mesorrecto transanal en el tratamiento del cáncer del recto como nueva técnica en Cuba / Total Excision of the Transanal Mesorectum as a New Technique for Treating Rectal Cancer in Cuba

Introducción: Las indicaciones de la Microcirugía Transanal Endoscópica han evolucionado desde la cirugía de tumoraciones rectales hasta otras enfermedades pélvicas. La asociación de esta y la escisión total del mesorrecto transanal ofrece una serie de ventajas. Objetivo: Determinar las indicaciones, describir la técnica quirúrgica y mostrar los resultados a largo plazo obtenidos en la realización de la escisión total del mesorrecto transanal en el tratamiento del cáncer del recto medio y bajo. Métodos: Se realizó un estudio observacional descriptivo y prospectivo de los pacientes con cáncer del recto medio y bajo sometidos a esta técnica quirúrgica en el período comprendido entre febrero de 2017 y febrero de 2022 en el Centro Nacional de Cirugía de Mínimo Acceso. Resultados: Se operaron 13 pacientes, 9 con cáncer del recto bajo y 4 con cáncer del recto medio y un promedio de edad de 56,2 años (rango 28-76). El promedio de tiempo quirúrgico fue de 183 minutos (rango 120-270) y las pérdidas hemáticas estimadas de 68 mililitros. La incidencia de morbilidad mayor fue de 15,4 por ciento y la media de estadía hospitalaria de 5,4 días. La media del período de seguimiento fue de 35 (rango 9-69) meses con una recidiva local de 7,7 por ciento y una supervivencia global a los 5 años de 100 por ciento. Conclusiones: La escisión total del mesorrecto transanal combinado con cirugía laparoscópica es una técnica factible y segura. La introducción de la variante técnica utilizando el instrumental de la Microcirugía Transanal Endoscópica es más ergonómica y disminuye los costos(AU)

Introduction: The indications for transanal endoscopic microsurgery have evolved from surgery of rectal tumors to other pelvic diseases. The association between this and total excision of the transanal mesorectum offers a series of advantages. Objective: To determine the indications, to describe the surgical technique and to show the long-term outcomes obtained in the performance of total excision of the transanal mesorectum for treating cancer of the middle and lower rectum. Methods: A descriptive and prospective observational study was carried out of patients with cancer of the middle and lower rectum who underwent this surgical technique in the period from February 2017 to February 2022 at Centro Nacional de Cirugía de Mínimo Acceso. Results: Thirteen patients were operated on, 9 with cancer of the lower rectum and 4 with cancer of the middle rectum, as well as an average age of 56.2 years (range 28-76). The average surgical time was 183 minutes (range 120-270) and estimated blood loss was 68 milliliters. The incidence of highest morbidity was 15.4 percent and mean hospital stay was 5.4 days. The median follow-up period was 35 (range 9-69) months, with a local recurrence of 7.7 percent and an overall 5-year survival of 100 percent . Conclusions: Total excision of the transanal mesorectum combined with laparoscopic surgery is a feasible and safe technique. The introduction of the variant technique using the instruments of endoscopic transanal microsurgery is more ergonomic and reduces costs(AU)

"Transanal endoscopic microsurgery" with a flexible colonoscope (F-TEM): a new endoscopic treatment for suspicious deep submucosal invasion T1 rectal carcinoma.

BACKGROUND: Endoscopic techniques allow resections of deep submucosal invasion rectal carcinoma, but mostly are facing issues such as costs, follow-up care or size limit. Our aim was to design a new endoscopic technique, which retains the advantages over surgical resections while eliminating the disadvantages mentioned above. PATIENTS AND METHODS: We propose a technique for the resection of the superficial rectal tumours, with highly suspicious deep submucosal invasion. It combines steps of endoscopic submucosal dissection, muscular resection and edge-to-edge suture of the muscular layers, finally performing the equivalent of a "transanal endoscopic microsurgery" with a flexible colonoscope (F-TEM). RESULTS: A 60-year-old patient was referred to our unit, following the discovery of a 15 mm distal rectum adenocarcinoma. The computed tomography and the endoscopic ultrasound examination revealed a T1 tumour, without secondary lesions. Considering that the initial endoscopic evaluation highlighted a depressed central part of the lesion, with several avascular zones, an F-TEM was performed, without severe complication. The histopathological examination revealed negative resection margins, without risk factors for lymph node metastasis, no adjuvant therapy being proposed. CONCLUSION: F-TEM allows endoscopic resection of highly suspicious deep submucosal invasion T1 rectal carcinoma and it proves to be a feasible alternative to surgical resection or other endoscopic treatments as endoscopic submucosal dissection or intermuscular dissection.

Management of rectal neuroendocrine tumours by transanal endoscopic microsurgery.

AIM: The objective of this study was to evaluate the safety and effectiveness of transanal endoscopic microsurgery for rectal neuroendocrine tumours. METHOD: A retrospective cohort study of all pathology-confirmed rectal neuroendocrine tumours treated by transanal endoscopic microsurgery from April 2007 to December 2020 at a tertiary care centre was performed. Demographic, clinical, radiographic and pathological data were collected. Characteristics of patients with recurrence were examined. Descriptive statistics were performed. RESULTS: There were 58 patients treated by transanal endoscopic microsurgery excision. Referrals were for primary excision (15, 25.9%), completion re-excision after incomplete endoscopic removal (38, 65.5%) or locally recurrent rectal neuroendocrine tumours (5, 8.6%). The mean age of patients was 56.4 ± 11.9 years and 26 patients were women (44.8%). Mean tumour size was 7.4 ± 3.8 mm (range 1.0-15.0 mm). Most (86.4%) were Grade 1 tumours. Mean operative time was 37.2 ± 17.2 min and 56 patients (96.6%) were discharged on the same day. All patients had negative margins on final pathology. Of the 38 patients who were referred for completion re-excision after incomplete endoscopic removal, eight (21.1%) had residual tumour on final pathology. Three recurrences were diagnosed at 2.1, 4.5 and 12.5 years after excision. All recurrences were from Grade 1 or 2 primary tumours, less than 2 cm, and diagnosed radiographically. CONCLUSION: To date, this is the largest North American study looking at transanal endoscopic microsurgery for rectal neuroendocrine tumours. This technique is effective in managing primary, incompletely excised and recurrent tumours with good clinical and oncological outcomes.

Transanal endoscopic microsurgery technique: an acceptable approach for retrorectal tumors.

INTRODUCTION: Retrorectal lesions (RRLs) are rare lesions that originate from the tissue present in the retrorectal space. The gold standard of care is complete resection regardless of pathology. The traditional approaches (anterior, posterior, and combined) are relatively well described. Transanal Endoscopic Microsurgery (TEM) is a minimally invasive technique offered as an alternative approach for RRLs. AIM: To evaluate the outcomes of patients diagnosed with RRL and treated by the TEM approach, especially postoperative complications, and the recurrence rate. METHODS: Patients with RRLs treated with the TEM technique in one medical center between 2000 and 2020 were identified. Their postoperative outcomes were compared with historical controls. RESULTS: Thirty-nine patients diagnosed with RRL were operated on using the TEM platform. Thirty-seven RRLs were benign, and two were malignant. Their median size (IQR) was 20 mm (15, 32.5). The median distance (IQR) from the anal verge was 50 mm (50, 72.5). The median operative time (IQR) was 48.5 min (41.75, 60). All, except one lesion, were completely resected. The median length of stay (IQR) was one day (1, 1 day). Postoperative complications were diagnosed in three patients, two of which resolved following a second operation. CONCLUSIONS: The implementation of TEM for the resection of RRLs demonstrated excellent overall results with acceptable complication and recurrence rate and represented a viable alternative surgical approach.

Short-term outcomes of chemoradiotherapy and local excision versus total mesorectal excision in T2-T3ab,N0,M0 rectal cancer: a multicentre randomised, controlled, phase III trial (the TAU-TEM study).

BACKGROUND: The standard treatment of T2-T3ab,N0,M0 rectal cancers is total mesorectal excision (TME) due to the high recurrence rates recorded with local excision. Initial reports of the combination of pre-operative chemoradiotherapy (CRT) and transanal endoscopic microsurgery (TEM) have shown reductions in local recurrence. The TAU-TEM study aims to demonstrate the non-inferiority of local recurrence and the improvement in morbidity achieved with CRT-TEM compared with TME. Here we describe morbidity rates and pathological outcomes. PATIENTS AND METHODS: This was a prospective, multicentre, randomised controlled non-inferiority trial including patients with rectal adenocarcinoma staged as T2-T3ab,N0,M0. Patients were randomised to the CRT-TEM or the TME group. Patients included, tolerance of CRT and its adverse effects, surgical complications (Clavien-Dindo and Comprehensive Complication Index classifications) and pathological results (complete response in the CRT-TEM group) were recorded in both groups. Patients attended follow-up controls for local and systemic relapse. TRIAL REGISTRATION: NCT01308190. RESULTS: From July 2010 to October 2021, 173 patients from 17 Spanish hospitals were included (CRT-TEM: 86, TME: 87). Eleven were excluded after randomisation (CRT-TEM: 5, TME: 6). Modified intention-to-treat analysis thus included 81 patients in each group. There was no mortality after CRT. In the CRT-TEM group, one patient abandoned CRT, 1/81 (1.2%). The CRT-related morbidity rate was 29.6% (24/81). Post-operative morbidity was 17/82 (20.7%) in the CRT-TEM group and 41/81 (50.6%) in the TME group (P < 0.001, 95% confidence interval 42.9% to 16.7%). One patient died in each group (1.2%). Of the 81 patients in the CRT-TEM group who received the allocated treatment, 67 (82.7%) underwent organ preservation. Pathological complete response in the CRT-TEM group was 44.3% (35/79). In the TME group, pN1 were found in 17/81 (21%). CONCLUSION: CRT-TEM treatment obtains high pathological complete response rates (44.3%) and a high CRT compliance rate (98.8%). Post-operative complications and hospitalisation rates were significantly lower than those in the TME group. We await the results of the follow-up regarding cancer outcomes and quality of life.

[Results of total mesorectal excision and transanal endoscopic microsurgery for rectal adenocarcinoma with submucosal invasion]. / Rezul'taty total'noi mezorektumektomii i transanal'noi endomikrokhirurgii pri adenokartsinomakh pryamoi kishki s invaziei v podslizistyi sloi.

OBJECTIVE: To analyze early and long-term outcomes after total mesorectal excision (TME) and transanal endoscopic microsurgery (TEM) in patients with T1 rectal cancer. MATERIAL AND METHODS: A retrospective non-randomized comparative study included 2 groups of patients: group 1 - total mesorectal excision, group 2 - transanal endoscopic microsurgery. In the second group, total mesorectal excision was proposed for patients with tumor invasion depth pT1sm3 and/or lymphovascular invasion and/or low differentiation. If total mesorectal excision was performed as a salvage surgery, the patient was excluded from further analysis. RESULTS: There were 156 patients with rectal adenocarcinoma pT1 between October 2011 and August 2019 (102 cases - TEM, 54 cases - TME). We excluded 10 patients from the TEM group due to salvage surgery. Duration of TEM was 40.0 (34; 50) min, TME - 139 (120; 180) min (p=0.00001). Postoperative hospital-stay was also significantly less in the TEM group (7 (6; 9) vs. 10 (7; 11) days, p=0.00001). Six (6.5%) patients in the TEM group and 1 (1.8%) patient in the TME group developed a local recurrence in pelvic cavity (p=0.1). There were no distant metastases. Disease-free 3-year survival was 92% after TEM and 96% after TME (p=0.058). CONCLUSION: Transanal endoscopic microsurgery is a relatively safe alternative to total mesorectal excision for early rectal cancer.

Short-term clinical and functional results of rectal wall suture defect after transanal endoscopic microsurgery-a prospective cohort study.

PURPOSE: Our goal was to assess the outcomes of rectal wall suture during the early and late periods after transanal endoscopic microsurgery (TEM) and long-term bowel function. METHODS: Patients who underwent TEM for rectal neoplasms from May 2017 to March 2021 were prospectively included. A total of 70 patients were enrolled. Seven to 10 days after TEM, clinical data were recorded, and digital rectal examination and rigid proctoscopy were performed. After at least 6 months, bowel function was evaluated using low anterior resection syndrome (LARS) and Wexner questionnaires. RESULTS: Forty-five men with an average age of 67 ± 10.1 (40-85) were included. TEM sutures were recorded as intact in 48/70 (68%) and as dehiscent in 22/70 (32%). It did not have any significant clinical manifestation and was not related with longer postoperative stay or incidence of postoperative complications. Eight of 22 (36.4%) patients with suture dehiscence had per rectal bleeding or febrile temperature without any need for intervention or treatment. The only risk factor for wound dehiscence was a posteriorly located defect. In late postoperative period, there was no difference between groups in LARS or Wexner questionnaire (p value 0.72 and 0.85, respectively). CONCLUSIONS: Our study suggests that 1/3 of the patients' rectal wall defect after TEM will undergo dehiscence in early postoperative period and will not transfer to clinically significant manifestation (without a need of hospitalization or prolonging it). In late postoperative period, there is no difference in bowel function.

Microcirugía transanal endoscópica como tratamiento de los tumores benignos del recto / Endoscopic Transanal Microsurgery as a Treatment of Benign Rectal Tumors

Introducción: La microcirugía transanal endoscópica es un procedimiento mínimamente invasivo para el tratamiento local de los grandes adenomas y los cánceres en estadios iniciales del recto. Objetivo: Evaluar los resultados de la microcirugía transanal endoscópica en los pacientes con tumores benignos del recto en el Centro Nacional de Cirugía de Mínimo Acceso de La Habana. Método: Se realizó un estudio retrospectivo de una base de datos prospectiva de 15 años. Se les ejecutó a un total de 91 pacientes con tumores benignos del recto la microcirugía transanal endoscópica entre abril de 2004 y diciembre de 2019. Se incluyeron las variables: edad, sexo, indicación, tiempo quirúrgico, localización del tumor, tamaño tumoral, estancia hospitalaria, complicaciones posoperatorias y recidiva local. Resultados: La principal indicación fue el adenoma del recto con 70 (76,9 por ciento) pacientes. La edad media fue de 63,4 años, el tiempo quirúrgico 81,1 minutos y el tamaño tumoral 3,5 cm. La estancia hospitalaria fue de 1 día y las complicaciones posoperatorias fueron 4 (4,3 por ciento): dos sangramientos, una dehiscencia de sutura y una estenosis. Dos pacientes (2,8 por ciento) tuvieron recidiva local en el grupo de los adenomas y no se realizaron conversiones a cirugía laparoscópica o cirugía abierta. Conclusión: La microcirugía transanal endoscópica fue una técnica factible y segura en el tratamiento de los adenomas del recto no resecables endoscópicamente, adenomas con displasia de alto grado y en otros tumores del recto(AU)

Introduction: Endoscopic transanal microsurgery is a minimally invasive procedure for local treatment of large adenomas and early-stage rectal cancers. Objective: To assess the outcomes of endoscopic transanal microsurgery in patients with benign rectal tumors at the National Center for Minimal Access Surgery in Havana. Methods: A retrospective study of a 15-year prospective database was carried out. A total of 91 patients with benign rectal tumors underwent endoscopic transanal microsurgery between April 2004 and December 2019. The following variables were included: age, sex, indication, surgical time, tumor location, tumor size, hospital stay, postoperative complications and local recurrence. Results: The main indication was rectal adenoma, accounting for 70 (76.9 percent) patients. The mean age was 63.4 years, surgical time was 81.1 minutes and tumor size was 3.5 cm. Hospital stay was one day. Postoperative complications were four (4.3 percent): two bleedings, one suture dehiscence and one stenosis. Two patients (2.8 percent) had local recurrence in the adenoma group. No conversions to laparoscopic or open surgery were performed. Conclusion: Endoscopic transanal microsurgery was a feasible and safe technique in the treatment of endoscopically unresectable rectal adenomas, adenomas with high-grade dysplasia and other rectal tumors.

Advances in Rectal Cancer Surgery.

Surgical resection is the cornerstone of curative intent therapy for rectal cancer. The introduction of the concept of total mesorectal excision (TME) led to significant decreases in local recurrence. However, TME carries substantial morbidity. The advent of transanal endoscopic techniques, such as transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS), has allowed patients with early-stage disease to be managed with local excision and avoid the morbidity of TME. Advances in surgery such as laparoscopy, robotic surgery, and transanal approaches have also broadened the options for achieving TME. However, there is significant debate within the literature regarding the optimal approach and oncologic outcomes of these modalities.

Non-conventional applications for transanal endoscopic microsurgery. A single center experience and a systematic review of literature.

INTRODUCTION: Transanal endoscopic microsurgery (TEM) and transanal endoscopic operation (TEO) have been initially described for local excision of rectal adenomas and selected cases of rectal carcinomas. In the past decade, however, several new indications raised, and others could raise in the future. The aim of this review was to evaluate, both in the literature and in our personal experience, the use of TEM and TEO for non-conventional applications, different from rectal tumors. EVIDENCE ACQUISITION: We conducted a systematic review of published papers and we selected articles reporting patients who underwent endoscopic surgery for other medical reason than polyp cancer resection, with TEM or TEO. PubMed, MEDLINE, EMBASE and bibliographies of the selected studies were searched for articles in English published up to May 2020 to identify all relevant articles. We excluded articles reporting TEM and TEO used for classical indications. We finally report our experience of non-conventional use of TEO in 5 patients with different diseases. EVIDENCE SYNTHESIS: The research revealed 800 papers and among them we selected 52 articles for a total of 697 patients. Of all patients, only 52 had intraoperative or postoperative complications, with only 10 patients requiring major surgery. CONCLUSIONS: Our study suggests that TEM and TEO may be valid alternatives to traditional surgery in situations other than its classical indication. These findings can positively impact on the care of patients, who could benefit from less invasive surgical procedures associated with lower morbidity.

Robotic endoscopic submucosal dissection and full-thickness excision for laterally spreading tumors of the rectum.

Endoscopic submucosal dissection (ESD) is technically demanding and time-consuming. Moreover, it bears a high risk of adverse events compared to other endoscopic methods, due to the lack of tissue manipulation. Robotic technology can significantly reduce the time of the procedure and increase the rate of complete resection for ESD. In the case of an unclear deep margin it allows to proceed to the full-thickness excision of the bowel wall. While the gain over transanal endoscopic microsurgery (TEM) is limited today, the longer systems currently under development will allow these complex procedures to be performed at least in the left side of the colon. The Supplementary video shows the application of the Flex Robotic System to perform an ESD and a full-thickness excision.

Trans-anal minimally invasive surgery (TAMIS) versus trans-anal endoscopic microsurgery (TEM): a comparative case-control matched-pairs analysis.

AIM: Since its introduction, transanal endoscopic microsurgery (TEM) has become the treatment of choice for rectal benign lesions not amenable to flexible endoscopic excision and for early rectal cancer. Disposable soft devices as the Trans-anal Minimally Invasive Surgery (TAMIS) are a valid alternative to non-disposable rigid trans-anal endoscopic microsurgery (TEM) platforms. The aim of the present study is to compare TEM and TAMIS in terms of incidence of R1 resection and lesion fragmentation which were combined in a composite outcome called quality resection. Perioperative complication and operative time were also investigated. METHODS: A total of 132 patients were eligible for this study of whom 63 (47.7%) underwent TAMIS and 69 (52.3%) underwent TEM. Patients were extracted for from a prospective maintained database and groups resulted homogenous after matching using propensity score in terms of size of the lesion, height from the anal verge, position within the rectal lumen, preoperative histology, neoadjuvant treatment. A multivariate logistic and linear regression analysis was carried out using those variables that have significant independent relationship with the quality of surgical resection and operative time. RESULTS: The incidence of R0 resection and lesion fragmentation was similar between groups. No differences were found in terms of perioperative complication. TAMIS was associated with less setup time and less operative time compared with TEM. Variables influencing quality resection at the multivariate analysis were larger lesion (> 5 cm) and ≥ T2 stage. Variables influencing operative time were surgical procedure (TEM vs TAMIS), height from the anal verge and size of the lesion. CONCLUSION: The present study shows that TEM and TAMIS are equally effective in terms of quality of local excision and perioperative complication. TAMIS resulted less operative time consuming compared to TEM.

Oncological outcome after local treatment for early stage rectal cancer.

BACKGROUND: Treatment of early rectal cancer is evolving towards organ-preserving therapy which includes endoscopic resection and transanal approaches. We aimed to explore the role of local treatments such as endoscopic polypectomy (Endoscopic Mucosal Resection (EMR) or Endoscopic submucosal dissection (ESD)) and transanal endoscopic microsurgery/ transanal minimal invasive surgery (TEM/TAMIS) in patients who had early rectal cancer. We considered these outcomes alongside conventional major surgery using total mesorectal excision (TME) for early stage disease. METHODS: All patients identified at MDT with early stage rectal cancer at our institution between 2010 and 2019 were included. Long-term outcomes in terms of local recurrence, survival and procedure-specific morbidity were analysed. RESULTS: In total, 536 patients with rectal cancer were identified, of which 112 were included based on their pre-operative identification at the MDT on the basis that they had node-negative early rectal cancer. Among these, 30 patients (27%) had the lesion excised by flexible endoscopic polypectomy techniques (EMR/ESD), 67 (60%) underwent TEM/TAMIS and 15 (13%) had major surgery. There were no differences in patient demographics between the three groups except for TEM/TAMIS patients being more likely to be referred from another hospital (p < 0.001) and they were less active (WHO performance status p = 0.04). There were no significant differences in overall survival rates and cancer-specific survival between the three treatment groups. The 5-year overall survival rate for endoscopic polypectomy, TEM/TAMIS or major resection was 96% versus 90% and 88%, respectively (p = 0.89). The 5- year cancer-specific survival rate was 96%, versus 96% and 100%, respectively (p = 0.74). CONCLUSION: Endoscopic polypectomy by EMR/ESD is an appropriate local treatment for early stage rectal cancer in selected patients. It is possible to achieve good oncological outcomes with a polypectomy similar to TEM/TAMIS and major surgery; however, a multidisciplinary approach is necessary enabling close surveillance and the use of adjuvant radiotherapy.