Colorectal

TAS in SRN

Cheltenham

“What are TEMS/TEO/TAMIS and

Who should it? ”

Neil Borley Consultant Colorectal Surgeon Cheltenham General Hospital

Colorectal

TAS in SRN

Cheltenham

“Is more actually less? ”

Neil Borley Consultant Colorectal Surgeon Cheltenham General Hospital

Colorectal

TAS in SRN

Cheltenham

Key questions

• Does the equipment matter? • Does the procedure matter? • Does the volume matter?

Colorectal

TAS in SRN

Cheltenham

Colorectal

TAS in SRN

Cheltenham

– “accessible for every surgeon with an interest”*

*Hompes, Ris, Cunningham et al Brit J Surg 2012;(99):1429-33

Colorectal

TAS in SRN

Cheltenham

Colorectal

TAS in SRN

Cheltenham

Colorectal

TAS in SRN

Cheltenham

Colorectal

TAS in SRN

Cheltenham

Colorectal

TAS in SRN

Cheltenham

Colorectal

TAS in SRN

Cheltenham

Technical comparisons

TEMS TEO TAMIS Binoccular vision

(inc depth perception) Monoccular vision Monoccular vision

Flexible/precision excision plane

?excision plane ?excision plane

Dedicated instruments Dedicated instruments ?laparoscopic instruments

Rigid platform Rigid platform Flexible platform No lower ‘cuff’ No lower ‘cuff’ Lower exclusion ‘cuff’ High lesions High lesions ??high lesions Expensive Fairly expensive Cheaper

Learning curve ?learning curve ?learning curve

Colorectal

TAS in SRN

Cheltenham

Does the excision plane matter?

• Protocol driven • Allowing for ‘what if’ worst case scenarios

Colorectal

TAS in SRN

Cheltenham

Colorectal

TAS in SRN

Cheltenham

Colorectal

TAS in SRN

Cheltenham

Colorectal

TAS in SRN

Cheltenham

Mucosectomy excision

Colorectal

TAS in SRN

Cheltenham

Mucosectomy excision

Colorectal

TAS in SRN

Cheltenham

Mucosectomy excision

Colorectal

TAS in SRN

Cheltenham

Mucosectomy excision

Colorectal

TAS in SRN

Cheltenham

Does the excision plane matter?

• Protocol driven • Allowing for ‘what if’ worst case scenarios • Risk of procedure

Colorectal

TAS in SRN

Cheltenham

Risk in mucosectomy vs FThExc

Mucosectomy* Full Th Exc*

Death 0% 0.8%

Sepsis/stoma 0% 3%

Bleeding (Tx) 2% 3%

Stenosis 3% 1.5%

* Darwood, Wheeler, Borley Brit J Surg 2008;95:915-18 +Bignell, Ramwell, Evans, Dastur, Simson Colorect Dis 2010;12:e99-103

Colorectal

TAS in SRN

Cheltenham

Does volume matter?

• ?outcomes • ?risk

• ?efficacy

Colorectal

TAS in SRN

Cheltenham Martinez-Perez et al Tech Coloproctol 2014;(18):775-788

‘TAMIS’ for SRN?

Colorectal

TAS in SRN

Cheltenham Martinez-Perez et al Tech Coloproctol 2014;(18):775-788

Outcomes

• 36 studies/series • Mean series n = 10.8 • Mode series n = 1

• ‘SRN’ 36 studies/series • Mean series n = 4.2 • Mode series n = 1

• 15 studies/series n>10 • Mean series n = 21.9 • Mode series n = 12

• ‘SRN’ 6 studies/series n>10 • Mean series n = 14 • Mode series n/a

‘TAMIS’ for SRN?

Colorectal

TAS in SRN

Cheltenham Derived from Martinez-Perez et al Tech Coloproctol 2014;(18):775-788

Early outcomes

n (benign)

‘SRN’

size R1 %

Conv %

Comp %

FU Median/m

14 3 7 0 5 N/G

25 ? 6 - 6 20

14 ? 9 - 6 10

10 2.9 ?0 16 25* N/G

11 2.5 8 0 8 ??6

10 3.5 7 0 21 N/G

‘TAMIS’ for SRN?

Colorectal

TAS in SRN

Cheltenham Derived from Martinez-Perez et al Tech Coloproctol 2014;(18):775-788

Late outcomes

n (benign)

‘SRN’

size R1 %

Recurr %

FU Median/m

14 3 7 ? N/G

25 ? 6 4 20

14 ? 9 ?0 10

10 2.9 ?0 N/G N/G

11 2.5 8 N/G ??6

10 3.5 7 ?7 N/G

‘TAMIS’ for SRN?

Colorectal

TAS in SRN

Cheltenham

Outcomes

• Cheltenham – Complex SRN (high, recurrent, multiquadrant) - TEMS – N = 289, FU median = 21 mo – Early Comps

• 4% - bleed (2% failed procedure) – Late Comps

• Recurr 1.5%, stenosis 5%

Existing ‘high volume’ data

Darwood et al Br J Surg 2008;95(7):915-8

Colorectal

TAS in SRN

Cheltenham

Outcomes

• Chichester – Benign lesions (SRN) - TEMS – N = 279, FU median = 21 mo – Early outcome

• R0 90.3% – Early Comps

• 0.3% mort – Late Comps

• Recurr – size dependent, at 3 yrs 3.2 – 9.1%

Existing ‘high volume’ data

Scala et al Arch Surg 2012;147(12):1093-100

Colorectal

TAS in SRN

Cheltenham

Outcomes

• Rectal Ca CRM +ve 11% vs 7.7% p<0.001 – The Influence of Hospital Volume on Circumferential Resection Margin

Involvement: Results of the Dutch Surgical Colorectal Audit Gietelink et al Ann Surg 2014 17 epub

• Rectal cancer “higher volume… better survival” – Patient survival after surgical treatment of rectal cancer: impact of

surgeon and hospital characteristics Etzioni et al Cancer 2014; 120(16):2472-81

• Overall surv, stoma rate better in high volume surgeons – Impact of surgeon volume on outcomes of rectal cancer surgery : a

systematic review and meta-analysis Archampong et al Surgeon 2010; 8(6):341-852

Don’t we know volume matters? Rectal cancer

Colorectal

TAS in SRN

Cheltenham

Outcomes

• High complication and recurrence rates (23% 25%) with low mean case vol (2.6 p.a.) “emphasize the importance of training and centralization …. suboptimal diagnostic workup”

– Endoscopic mucosal resection of large rectal adenomas in the era of centralization: Results of a multicenter collaboration Barendse et al United European Gastroenterol J 2014;2(6):497-504

• Effect of surgeon volume of long term outcome – Endoscopic management of early gastric cancer; endoscopic mucosal

resection or endoscopic submucosal dissection: data from a Japanese high volume center and literature review Uedo et al Ann Gastroenterol 2012; 25(4):281-90

• R0, perf and LR equal in HV vs LV – Endoscopic mucosal resection in high and low volume centres: a

prospective multicentre study Masci et al Surg Endosc 2013 27(10);3799-805

Don’t we know volume matters? EMR

Colorectal

TAS in SRN

Cheltenham

So what does matter? • Volume and experience

– “Decisions not Incisions” – Minimize ‘whoops’ surgery and minimize risk – Offsets issues of learning curve with more

demanding equipment / procedures • Surgical plane approach

– ‘What if’ options – Safety – avoiding unnecessary deep excisions

• Equipment – What best matches your approach/protocols

(SPECC MDT)

Colorectal

TAS in SRN

Cheltenham

Colorectal

TAS in SRN

Cheltenham