Transanal Excision SPECC Training day

Stephan Korsgen Good Hope Hospital, Sutton Coldfield

Scope of presentation

TART: Transanal excision (using retractors)

TEMS: Transanal endoscopic microsurgery

TEO: Transanal endoscopic operation

TAMIS: Transanal minimally invasive surgery

Which one to choose?

TART inferior to TEMS

TEO same principle as TEMS but not binocular vision and less stable platform

TAMIS early days, but seems to be less versatile and difficult to get stable platform

Scope of presentation

Know your audience

Scope of presentation

Basics of TEMS/TEO

Indications

Limitations

Complications

Case selection

TEMS -what is it?

Endoluminal rectal surgery

Rectoscope tube 12 or 20cm long, 40mm

Stereoscopic optics with magnification

Channels for CO2 insufflation, rectal pressure measurements, irrigation

3 ports for grasper, diathermy, suction

Specialised instrumentation

Gerhard Bueß (1948 -2010)

Developed in Cologne, West Germany 1980 – 1983

First NOTES (natural orifice transluminal endoscopic surgery), using a natural orifice to gain access to the gut i.e. rectum

Ignored outside Germany until early 1990’ies

Introduced at Good Hope Hospital by Arthur Allan in 1994

Indications and limitations

For excision of rectal tumours up to 18cm from anal verge

Allows full thickness excision and suturing

Adenoma even circumferential

Carcinoma

Carcinoid

GIST

Advantages

Excellent access and binocular view of whole rectum

Sphincters less compromised than using retractors

Constant gas insufflation stable platform

Ability to dissect and suture

Limitations

Anal stenosis

Narrow / rigid rectum

Fixed rectosigmoid jct

Lesion out of reach

TEM and rectal cancer

For cure: low risk T1 ca: G1/G2 SM1 ?SM2

For compromise: high risk T1/T2 with (chemo)radiation possibly cure

For palliation: T3 with (chemo)radiation

Unresolved:

?accurate preop staging

?when to add preop DXR/chemorad

Pathway

Referral > Assessment plus ERUS

Review of staging plus histology at MDT

If low risk / benign: TEMS

If high risk / not suitable; refer back

Review TEMS histology at MDT

If high risk, discuss standard surgery

Why local excision

It’s fun!

And it’s beautiful!

Complications/pitfalls

Bleeding

Perforation/dehiscence

Rectal stricture

Urinary retention

Impaired continence

Recurrence

How to refer

Via network proforma MDT coordinator

E-mail / fax / phone call

Letter in the post takes a long time!

Fax: 0121 4249548 (surgical secretaries)

E-mail: Stephan.korsgen@heartofengland.nhs.uk

Mobile: 07801 654781

Try to see within the week

Problem patients a little local excision gone wrong

K.W. 42F

Soiling of mesorectum

Settled with i.v. antibiotics

M.S. 80y F

Faecal impaction in mesorectum (ypT3)

Patient died from sepsis

H.M. 80y M Soiling of mesorectum (ypT1)

Wound breakdown > fistula into seminal vesicle 2 months later

Settled with defunctioning colostomy

Videos

Gerhard Buess teaching video

Rectal cancer pT2

Mucosectomy for recurrence of recurrent TVA

pT1SM1

ypT0 (post 25/5 DXR)

yPt3

pT1SM2

TVA HGD

TVA LGD

Take care:

Start with small benign lesions

Can you close the defect if peritoneum is opened?

Can you safely perform further surgery if malignancy dictates so?

Rectal cancer treated with TEMS at GHH 1995 - 2012

154 patients (93 men):

91 without DXR

38 short course DXR

17 long course chemoradiation

8 post op DXR

No preop DXR (91)

59 pT1:

16 after prev. polyp cancer: no residual ca

33 favourable histology: no further treatment

2 local recurrences (11-51m); 1 salvage, 1 too frail

2 incompletely excised (too high): too frail for resection

8 poor prognostic features > radical resection: no recurrences, no mets

No preop DXR (91)

30 pT2:

18 radical surgery:

2 lung mets (2-18m) > 1 resected

12 too frail for radical surgery:

5 died unrelated (3-25m)

1 local recurrence (4m), 2 metastases (3-11m)> died

4 alive and well

2 pT3: radical surgery: alive and well

Preop DXR (55)

16 ypT0: complete pathological response (29%): NSR

10 ypT1: no local recurrence, 1 lung met (27m)> resected

21 ypT2:

4 local recurrence (6-27m)

3 salvage (2 further recurrence, 1 alive, 1 died)

1 stent > died from disease

3 metastatic disease (22-27m)

2 metastasectomy (1 died post op)

1 died from disease

Preop DXR (55)

8 ypT3:

2 radical surgery: one disease free, one died from metastatic disease (no LR)

1 died post op (day 11)

2 local recurrence (7-18m)> 1 salvage APR, 1 died

1 died metastatic disease (2m)

1 died unrelated (9m)

Summary excluding patients radical surgery and post

op DXR (N=116)

pT1 / ypT0 / ypT1 (75 pat):

2 local recurrences, 1 lung met (4%)

pT2 / ypT2 (33 pat):

5 local recurrence, 5 mets (30%)

pT3 / ypT3 (6 pat):

1 died post op, 2 local rec, 1 mets (67%)