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Endoscopy 2006; 38(4): 418-423
DOI: 10.1055/s-2005-921212
Review
© Georg Thieme Verlag KG Stuttgart · New York

Transanal Endoscopic Microsurgery: A Review

D.  Casadesus1
  • 1 Coloproctology Department, Calixto Garcia University Hospital, Havana, Cuba
Further Information

D. Casadesus, M. D.

Washington Str. 156 · Infanta y Churrucas · Cerro · Havana · Cuba

Fax: +537-333319 ·

Email: dcasadesus@hotmail.com

Publication History

Submitted 12 February 2005

Accepted after revision 28 July 2005

Publication Date:
05 May 2006 (online)

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Table of Contents

Since G. Buess introduced transanal endoscopic microsurgery (TEM) in 1984, the technique has been increasingly used in the management of rectal adenomas and in selected cases of rectal carcinoma, with good results. For the purposes of this review a Medline literature search was performed in order to locate articles on the indications and the clinical and functional results of TEM. Further articles were obtained by manually searching the reference lists of identified papers. Emphasis was placed on reports from the past decade. Reviewing these papers, TEM appears to be an effective method of excising benign tumors and selected T1 carcinomas of the rectum. The place of this technique in the resection of advanced carcinomas has yet to be properly evaluated but its use for this indication has produced similar or better results than radical techniques. In conclusion, TEM is a safe procedure and can achieve good results in terms of local tumor resection, with lower recurrences rates, lower complication rates, and better survival rates than those of radical techniques.

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Introduction

In response to the high number of early-stage rectal cancers and benign adenomas that are not amenable to removal during colonoscopy, a number of alternative techniques have been developed for their removal. In the lower rectum, transanal excision of benign lesions is a common procedure. Transanal excision has also been offered to selected patients with a malignant lesion of the lower rectum for decades, with low morbidity and mortality, but with high local recurrence rates for T2 lesions in some series [1] [2]. In the middle and upper thirds of the rectum, benign and malignant lesions are difficult to reach transanally and standard radical surgical options, such as low-anterior resection, or a posterior trans-sphincteric or trans-sacral approach and abdominoperineal resection, with or without sphincter preservation, are traditionally offered to the patient. These procedures are associated with significant mortality and high morbidity, including anastomotic leakage, urinary and sexual dysfunction, fecal and urinary incontinence, and the rejection of colostomy by the patient.

With the introduction of transanal endoscopic microsurgery (TEM) techniques by Professor Buess in 1984 [3], new horizons were opened up in the treatment of middle and upper rectal neoplasms. It was proposed that TEM would enable local excision of adenomas up to 24 cm from the anal verge and could be used to excise suitable early-stage rectal cancers, offering a minimally invasive alternative to transanal excision and radical surgery, with superior endoscopic magnification, accurate and complete resection with secure suture closure.

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TEM and Benign Rectal Lesions

The risk of carcinoma developing in a colorectal polyp that is 1 cm or larger is 2.5 % at 5 years and 8 % at 10 years [4], and this potential for malignancy is an indication for the excision of such polyps. The first-line treatment of adenomatous colorectal polyps is endoscopic removal during the diagnostic procedure, which is safe, relatively inexpensive, and associated with the lowest complication rate. When the size and/or location of the tumor limits standard endoscopic resection, a number of different transanal approaches are used to remove adenomatous polyps in the lower rectum, but adenomas in the middle or upper rectum are difficult to remove using the standard transanal excision instruments. If TEM was not available, these inaccessible neoplasms might require trans-sphincteric or trans-sacral resection, or anterior or low-anterior resection. Even for recurrent or large adenomas less than 7 cm from the anal verge, TEM has now become the first-line elective treatment.

Some series have reported high incidences of residual margin tumor, recurrence, and complications after transanal resection. Sakamoto et al. [5] reported a series of 117 procedures in which 27 % of patients had to be treated for residual disease and 30 % for recurrence, with a 10 % rate of serious complications. A more recent study reported lower recurrence and complication rates after non-TEM rectal adenoma resection: they excised apparently benign rectal adenomas from 207 consecutive patients, with a 3.6 % recurrence rate, five major and three minor inmediate postoperative complications, and one death [6].

TEM has produced satisfactory results, however, with better recurrence rates and low morbidity and mortality. In the largest study I found of adenoma resection using TEM, the authors reported a 3.4 % early postoperative complication rate, and 1.2 % and 7 % recurrence rates after 1 year and 5 years respectively in a series of 286 cases [7]. In a review of 273 adenoma resection procedures (Table [1]), 17 patients were found to have residual adenoma in the surgical margin, 15 had a recurrence, and the complication rate was up to 11 %.

Table 1 Adenomas resected by transanal endoscopic microsurgery (TEM): rates for residual ademoma in the surgical margin, local recurrence, and complications
First author, year [ref.] No. of lesions Residual adenoma in surgical margin (%) Local recurrence (%) Complications (%)
Madhala, 1995 [8] 16 - 0 10
Steele, 1996 [9] 77 9 5.1 d. n. o.
Farmer, 2002 [10] 36 25 5.6 d. n. o.
Nakagoe, 2003 [11] 9 0 0 11.1
Cocilovo, 2003 [12] 56 1.7 3.5 1.7
Neary, 2003 [13] 21 0 4.7 9.5
Katti, 2004 [14] 58 - 10 6.8
d. n. o., data not obtained.

Local recurrence occurs in up to 14 % of patients after adenoma resection, and a histologically positive resection margin is highly significant in terms of local recurrence rates. Galandiuk et al. [15] found that adenoma recurred in 34 % of tumors with positive resection margins, compared with only 3 % of tumors with negative resection margins. Out of the 15 patients with adenoma recurrence found in the review (Table [1]), four patients presented with residual adenoma in the surgical margin and three recurrences occurred in patients whose procedure had been performed for recurrent disease. Adenoma extending to the surgical margin of locally excised polyps was found in 25 % of cases in a series reported by Farmer et al. [10], and in 30.7 % of cases in a study by Morschel et al. [16], a large series of 238 patients (226 patients treated by TEM and 12 by transanal excision). It is remarkable that, with such high positive residual margin rates, the recurrence rates in these series were only 5.6 % after 33 months’ follow-up [10] and 3.6 % after 67.5 months’ follow-up [16], lower than the rates reported in series with lower positive residual margin rates. Dafnis et al. [17] found adenoma recurrence in 11 % of patients after TEM resection in a series of patients in whom the resection had been classified as “not microscopically radical” in 19 % of patients and “of uncertain microscopical radicality” in 23 %.

In three studies comparing adenoma resection with TEM and another procedure, the lower or similar recurrence rates, and the residual tumor and the early complication rates favor TEM resection [8] [11] [18]. Late complication rates were higher after TEM due to the increased incidence of transient incontinence in the postoperative period [8] [18]. TEM has also been used with satisfactory results for the treatment of residual tumor, recurrent adenoma, and other benign conditions, such as rectal prolapse, rectal ulcer, angiodysplasia, and hyperplasic polyp [9] [19] [20].

TEM and local peranal resection offer different advantages and they are associated with lower morbidity and mortality than trans-sphincteric, trans-sacral, and low-anterior resection of rectal adenomas. TEM offers better access to lesions in the middle and upper rectum, with better illumination, superior visualization and pneumorectum, and lower recurrence rates, morbidity and mortality. However, randomized controlled studies should be done in order to compare TEM with other techniques with respect to the location of the adenoma in the rectum.

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TEM and Malignant Rectal Lesions

Different studies advocate the use of TEM for treating cancers that are smaller than 3 cm, well to moderately differentiated on previous biopsy, situated up to 25 cm from the anal verge, located in the extraperitoneal portion of the rectum, without lymphovascular invasion, or infiltrating as far as the submucosa on endoanal ultrasound [20] [21] [22] [23]. The preoperative endoluminal ultrasound stage is often impossible to determine because of destruction or stricture of the rectum caused by the tumor, or by scarring from a previous operation, multiple biopsy, or fulguration. However, results for TEM resection of T0 and T1 rectal cancers have been promising so far, with low recurrence rates and survival rates of over 90 %.

Authors have strongly recommended TEM resection for the treatment of patients with low-risk T1 tumors because survival rates are higher with TEM than they are with other treatment techniques in such patients. Heintz et al. [24] compared the treatment of high-risk and low-risk T1 carcinomas by resection with local excision (TEM and Park’s resection) with treatment by radical excision. In terms of 5-year survival, they found no difference betwen local excision and radical surgery in either T1 carcinoma group, but patients with low-risk T1 carcinoma had better survival rates than patients with high-risk T1 carcinoma.

Studies of T2 carcinomas resected by TEM had enrolled very heterogeneous groups of patients and survival rates varied between 75 % and 100 %; the patients had followed different radiotherapy and/or chemotherapy plans before or after TEM, according to the criteria set out by each surgeon, making it difficult to evaluate the treatment of T2 rectal tumors by TEM alone [11] [25] [26]. Saclarides [27], however, considered TEM alone as an inappropriate resection method to use in patients with T2 tumors, based on his results in 73 patients.

Local and distant recurrences have a great bearing on survival rates. Lymph node metastases, the depth of mural infiltration, and the full-thickness tumor resection are important factors in the development of recurrence. Unfortunately, studies reporting recurrence rates according to the stage of the tumor (Table [2]) have not had similar follow-up periods, many have been single descriptive investigations, they have not had similar numbers of patients in each stage group to allow for a detailed analysis, and they show different and contradictory recurrence rates. Because a cancer-free surgical margin plays such an important role in both recurrence and survival, two studies recommend a that an anterior resection should be performed as a secondary procedure if a positive resection margin is suspected [20] [28]. In the series reported by Mentges et al. [20], 39 patients underwent an anterior resection immediately after TEM and residual tumor was found in 2/8 patients with low-risk pT1 carcinoma, in 2/18 patients with low-risk T2 tumors, and in 1/9 patients with low-risk T3 carcinoma; lymph node infiltration was found in only 7 of patients with T2 and T3 tumors. In another study, by Buess et al. [30], eight patients with pT1 tumors showed neither residual tumor nor lymph node metastasis at secondary radical surgery.

Table 2 Recurrence rates according to rectal cancer stage
First author, year [ref.] Recurrence of malignant tumor (%)
Tis T1 T2 T3
Lev-Chelouche, 2000 [19] - 0 20 22.2
Mentges, 1996 [22] - 4.1 0 14.2
Schafer, 2004 [23] - 5 - -
Stipa, 2004 [25] 0 13 17 50
Lee, 2003 [26] - 4.1 19.5 -
Saclarides, 1998 [27] 15.3 25 80 0
Demartines, 2001 [28] - 8.3 0 -
Smith, 1996 [29] - 10 40 66

Most authors avoided much discussion about TEM and T3-stage rectal cancer treatment, some not even mentioning it. Survival rates of between 59 % and 69 % indicate that TEM is not a valid option in this situation, but these results are similar to the results described in studies of T3 rectal cancer treated by anterior resection and mesorectal excision [31].

Endoscopic resection has been used in the palliative treatment of rectal cancer [32] [33]. It has a clear role in patients with rectal cancer in whom age, extent of disease, or concurrent illness preclude conventional surgical resection. This technique allows complete excision of the tumor, reduces the chance of recurrence, and improves the quality of remaining life at home, affording comfort and good symptom control. Other standard treatments for advanced rectal cancer are often only suitable for small lesions, can result in inaccurate tumor destruction, often require multiple applications, and are associated with high mortality and morbidity compared with TEM.

Rectal tumor recurrences have also been resected by TEM. According to Graham et al. [34], there is a 50 % chance of cure by further treatment of recurrence following local resection. Lev-Chelouche et al. [19] described two patients with cancer recurrence who underwent repeat TEM. One patient with a T2 tumor was alive with no evidence of the disease and a patient with a T3 tumor required a salvage abdominoperineal resection because of a complication of the second TEM. Other malignant rectal lesions, including carcinoid tumor and epithelioma have also been successfully resected by TEM [20].

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Studies Comparing TEM with Radical Surgery

Only three studies (one prospective randomized, one randomized, and one retrospective) have compared the resection of T1 and T2 cancers by TEM with resection using other radical procedures (Table [3]) [11] [26] [35]. In spite of the higher recurrence rate after TEM that was reported in two of the studies, all three studies advocated the use of TEM for resecting T1 lesions because of the lower complication rate and better long-term survival rate after TEM. Heintz et al. [24] compared local excision with radical surgery in 103 patients. The complication rate and mortality were higher for radical resection than for TEM, but the local recurrence rate was lower and there was no difference in 5-year survival between both treatment groups. In addition, when Langer et al. [36] compared abdominal or abdominoperineal resection, conventional transanal resection, and TEM, they also showed that radical resection gave excellent results with respect to recurrence and residual tumor. Compared with radical resection, however, TEM was associated with a lower complication rate and lower perioperative mortality and afforded patients a better quality of life. In the same study, TEM also showed better results than conventional transanal excision in terms of recurrence rate, residual margin infiltration, and complication rate.

Table 3 TEM vs. radical surgery (RS) for stage T1 and T2 rectal tumors with respect to recurrence (local and distant), complications (early and late), and 5-year survival
First author, year [ref.] Study type Treatment method Stage Recurrence (%) Complications (%) Survival
T1 T2 T1 T2 T1 T2
Nakagoe, 2003 [11] Prospective TEM 8 2 0 0 10 100 100
RS 10 5 10 0 66.6 90 100
Lee, 2003 [26] Retrospective TEM 52 22 4.1 19.5* 4.1 100 94.7
RS 17 83 0 9.4* 48 92.9 96.1
Winde, 1996 [35] Prospective randomized TEM 24 4.1 25 96
RS 26 3.8 53.8 96
* TEM vs. RS for T2 tumors, P = 0.04.
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TEM and Preoperative Radiotherapy

The combination of preoperative radiotherapy with TEM for the treatment of rectal tumors appears to be feasible and safe, and also effective in terms of preserving anal sphincter function, but the survival rates after this type of treatment have been found to be similar or lower than after TEM without radiotherapy. In three series of 95, 35, and 137 patients treated with radiotherapy and TEM in the same institution (with probably some double recording of patients), the results were similar in all three series [37] [38] [39] and they are also similar to results of treatment with TEM alone. Others studies have described treatment with a combination of radiotherapy and TEM but no details were given of these patients' subsequent management, morbidity, and mortality.

In one preliminary study, patients who received preoperative radiotherapy and local resection had a recurrence-free 5-year survival rate of 81 %, compared with 52 % in those treated by local resection alone [40]. A similar overall survival rate was found in 33 patients who underwent preoperative radiotherapy or chemotherapy followed by either TEM or manual transanal resection [41]. Although the different treatment groups did not undergo similar follow-up regimens in this study, similar cancer-specific survival rates were reported for surgery alone (92 %), radiotherapy or chemotherapy followed by surgery (94 %), surgery followed by radiotherapy (96 %), and radical radiotherapy alone (96.6 %), masking the apparent advantages of the radiotherapy and TEM combination [41].

If preoperative radiotherapy can lead to downgrading of tumor stage, shrinkage of tumors, induction of complete remission, or an improvement in locoregional disease, TEM has an important role to play after radiotherapy according to oncological principles of local resection in well-selected and followed-up patients. In this regard, endoscopy and endorectal ultrasound scans are mandatory in the follow-up regimen during radiotherapy, the group must be homogeneous for proper analysis, a minimum of 5 years' follow-up is necessary in all patient series, and patients should be correctly selected without compromising their chance of cure. Further randomized studies should be done, but sufficient numbers of patients could probably only be accrued in the setting of a multicenter international trial.

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Advantages of TEM

The low complication rate is without doubt one of the greatest advantages of TEM. In a review of 12 studies involving a total of 893 patients (Table [4]), complications were recorded in 142 patients (15.9 %), more than 50 % of these being urinary retention and temporary incontinence. Excluding the study with the highest urinary retention rate, this complication accounted for only 10 patients (7 %); it occurred occasionally in the early postoperative period and few patients subsequently required surgery or catheterization to resolve it. Sexual problems have not yet been reported following TEM. Bleeding was the third most common complication, but few patients required blood transfusion or another surgical intervention to control it. Other complications, such as perforation or wound leakage were less common.

Table 4 Complications of TEM, notably incontinence (fecal/flatus), bleeding, and urinary retention. (Postoperative fever, pelvic pain, and myocardial infarction were not included)
First author, year [ref.] No. of patients Total no. of complications Incontinence Bleeding Urinary retention
Steele, 1996 [9] 100 9 2 - -
Farmer, 2002 [10] 49 2 - 1 1
Neary, 2003 [13] 40 8 - 7 1
Lev-Chelouche, 2000 [19] 75 18 5 4 4
Saclarides, 1998 [27] 73 13 4 2 1
Demartines, 2001 [28] 50 13 6 - -
Swanstrom, 1997 [42] 27 5 2 3 -
Arribas del Amo, 2000 [43] 42 8 6 1 -
De Graff, 2002 [44] 76 15 1 4 2
Platell, 2004 [45] 113 31 1 4 26
Araki, 2003 [46] 217 12 12 - -
Meng, 2004 [47] 31 8 2 1 1
Total 893 142 (15.9 %) 41 (28.4 %) 27 (18.7 %) 36 (25.3 %)

Mortality associated with TEM is rare. Only one study reported a death and this was of a patient with a retroperitoneal phlegmon which occurred after TEM resection of a rectal adenoma, who died in septic shock after 28 days [48].

Although results are not expressed uniformly, 702 TEM procedures that were reported in ten studies showed other important advantages (Table [5]). There were only 27 patients (3.7 %) in whom attempted TEM procedures were unsuccessful or had to be converted to radical surgery or conventional transanal resection as a result of inadequate exposure, inability to see the complete lesion, perforation, or for reasons related to the oncological risk. The mean hospital stay was less than 6 days, the maximum being 21 days. The short duration of the procedure and the low blood loss, which obviates the need for blood transfusion, are also important advantages of this procedure. Others advantages of TEM include: complete resection and secure suture closure; a shorter time to the patient being able to walk, sit, take solid food, and defecate; less postoperative pain and use of analgesia; and the avoidance of a major abdominal operation and colostomy.

Table 5 Features of TEM procedures in ten studies: duration of the TEM procedure, blood loss, the number of patients whose TEM procedure had to be converted to a more radical procedure, duration of hospital stay, and disease recurrence
First author, year [ref.] No. of procedures Duration of TEM procedure (range), minutes Blood loss (range), ml No. converted to radical procedure Hospital stay (range), days No. of cases with recurrence
Steele, 1996 [9] 100 79* (30 - 240) - 8 4† (1 - 21) 6
Farmer, 2002 [10] 50 67* (20 - 175) 24* (0 - 300) 3 3.6* (1 - 11) 2
Neary, 2003. [13] 40 91* (35 - 175) - - 3.2* (1 - 6) 1
Lev-Chelouche, 2000 [19] 75 - - 7 5.5* (2 - 13) 8
Swanstrom, 1997 [42] 27 127* (49 - 280) 20* (5 - 150) - 1.7* (0 - 5) 1
Arribas del Amo, 2000 [43] 42 85* (25 - 180) 100* (10 - 350) - 4* (2 - 15) 3
Araki, 2003 [46] 217 63* - 7 5.8* 2
Meng, 2004 [47] 31 95† (45 - 200) - - 4† (2 - 10) 1
Toreson, 1996 [49] 20 85† (55 - 140) - - 3† (1 - 5) 0
Palma, 2004 [50] 100 98* ± 24 - 2 5.5† (3 - 21) 5
* Mean. † Median.
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Effect of TEM on Sphincter Function

Up to now, studies of TEM have tended to emphasize the results in terms of oncology outcomes and operation time, and technical improvements, rather than the functional results. Without maintaining continence and sphincter function after what is a sphincter-preserving operation, however, the quality of life will be seriously affected. Manometric results before and after TEM have identified the main risk factors of anal dysfunction after TEM as: preoperative anal disorders in older patients or caused by the tumor, postoperative internal sphincter defects, the extent and the depth of the tumor excision, the anal mucosa loss, and the duration of the procedure [51] [52] [53]. The transient incontinence observed after TEM can be explained by changes in rectoanal perception and coordination, and electrosensitivity of the anal mucosa, all factors which affect sphincter function. The increase in bowel frequency observed after the TEM procedure is probably related to low rectal compliance after full-thickness or circumferential excisions with significant reduction of the rectal diameter.

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Discussion

The cost of the instrument limits the extension of its use to a few institutions, but the many advantages of this technique can cover the high capital cost. The original TEM instruments were technically demanding, complex to set up, and expensive, and surgeons who were unfamiliar with advanced laparoscopic surgery had no experience of them. The use of standard laparoscopic instruments with low pressure insufflation and the conversion to video TEM, however, have resulted in reduced costs and have also meant that the equipment is more familiar to general and colorectal surgeons [11] [42]. Nevertheless, the operation and the manipulation required are performed in parallel and there is no facility for counter-traction from an assistant or another port, making the technique difficult both to learn and to teach to a new generation of surgeons. Other modifications to the instruments will have an important role in the future of TEM if they reduce costs, if they make the technique easier to learn, and if they conserve the low morbidity and mortality associated with the TEM technique.

Kipfmuller et al. [54] developed a multi-stage, video-supported training course for teaching TEM, with a special introduction and intensive training, that should be extended and included in training curricula for residents, fellows, and nurses, along with training in other advanced laparoscopic procedures. Once you have learned how to use TEM for resecting rectal neoplasms and after experiencing its good results it is difficult to go back to doing it in the old-fashioned way. Nevertheless, favorable outcomes have also been obtained with other techniques, such as minimally invasive transanal surgery, endoscopic transanal resection, and transanal resection. These are also good options for treatment that should not be forgotten in our daily practice and in training. In conclusion, TEM is a safe, minimally invasive technique and a convenient alternative in well-selected patients, but its satisfactory results should not necessarily make its use routine.

Competing interests: None

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References

  • 1 Mellgren A, Sirivongs P, Rothenberger D A. et al . Is local excision adequate therapy for early rectal cancer?.  Dis Colon Rectum. 2000;  43 1064-1074
    CrossrefPubMedSearch in Google Scholar
  • 2 Minsky B D, Rich T, Recht A. et al . Selection criteria for local excision with or without adjuvant radiation therapy for rectal cancer.  Cancer. 1989;  63 1421-1429
    PubMedSearch in Google Scholar
  • 3 Buess G, Hutterer F, Theiss J. et al . A system for a transanal endoscopic rectum operation [in German].  Chirurg. 1984;  55 677-680
    PubMedSearch in Google Scholar
  • 4 Gordon P H, Nivatvongs S. Principles and practice of surgery for the colon, rectum, and anus. 2nd edn. New York; Marcel Dekker 1999:
    Search in Google Scholar
  • 5 Sakamoto G D, MacKeigan J M, Senagore A J. Transanal excision of large, rectal villous adenomas.  Dis Colon Rectum. 1991;  34 880-885
    PubMedSearch in Google Scholar
  • 6 Pigot F, Bouchard D, Mortaji M. et al . Local excision of large rectal villous adenomas: long-term results.  Dis Colon Rectum. 2003;  46 1345-1350
    CrossrefPubMedSearch in Google Scholar
  • 7 Said S, Stippel D. Transanal endoscopic microsurgery in large, sessile adenomas of the rectum: a 10-year experience.  Surg Endosc. 1995;  9 1106-1112
    PubMedSearch in Google Scholar
  • 8 Madhala O, Lelcuk S, Rabau M. Transanal endoscopic microsurgery for local excision of rectal neoplasms.  Harefuah. 1995;  129 236-237
    PubMedSearch in Google Scholar
  • 9 Steele R JC, Hershman M J, Mortensen N J. et al . Transanal endoscopic microsurgery: initial experience from three centers in the United Kingdom.  Br J Surg. 1996;  83 207-210
    PubMedSearch in Google Scholar
  • 10 Farmer K C, Wale R, Winnet J. et al . Transanal endoscopic microsurgery: the first 50 cases.  ANZ J Surg. 2002;  72 854-856
    CrossrefPubMedSearch in Google Scholar
  • 11 Nakagoe T, Sawai T, Tsiju T. et al . Local rectal tumor resection results: gasless, video-endoscopic transanal excision versus the conventional posterior approach.  World J Surg. 2003;  27 197-202
    PubMedSearch in Google Scholar
  • 12 Cocilovo C, Smith L E, Stahl T, Douglas J. Transanal endoscopic excision of rectal adenomas.  Surg Endosc. 2003;  17 1461-1463
    CrossrefPubMedSearch in Google Scholar
  • 13 Neary P, Makin G B, White T J. et al . Transanal endoscopic microsurgery: a viable operative alternative in selected patients with rectal lesions.  Ann Surg Oncol. 2003;  10 1106-1111
    CrossrefPubMedSearch in Google Scholar
  • 14 Katti G. An evaluation of transanal endoscopic microsurgery for rectal adenoma and carcinoma.  JSLS. 2004;  8 123-126
    PubMedSearch in Google Scholar
  • 15 Galandiuk S, Fazio V W, Jagelman D G. et al . Villous and tubulovillous adenomas of the colon and rectum: a retrospective review, 1964 - 1985.  Am J Surg. 1987;  153 41-47
    CrossrefPubMedSearch in Google Scholar
  • 16 Morschel M, Heintz A, Bussmann M, Junginger T. Follow-up after transanal endoscopic microsurgery or transanal excision of large benign rectal polyps.  Langenbeck’s Arch Surg. 1998;  383 320-324
    PubMedSearch in Google Scholar
  • 17 Dafnis G, Pahlman L, Raab Y. et al . Transanal endoscopic microsurgery: clinical and functional results.  Colorectal Dis. 2004;  6 336-342
    CrossrefPubMedSearch in Google Scholar
  • 18 Nagy A, Kovacs T, Berki C, Jano Z. Surgical management of villous and tubulovillous adenomas of the rectum.  Orv Hetil. 1999;  140 2215-2219
    PubMedSearch in Google Scholar
  • 19 Lev-Chelouche D, Margel D, Goldman G, Rabau M J. Transanal endoscopic microsurgery: experience with 75 rectal neoplasms.  Dis Colon Rectum. 2000;  43 662-667
    CrossrefPubMedSearch in Google Scholar
  • 20 Mentges B, Buess G, Effinger K. et al . Indications and results of local treatment of rectal cancer.  Br J Surg. 1997;  84 348-351
    CrossrefPubMedSearch in Google Scholar
  • 21 Buess G F, Raestrup H. Transanal endoscopic microsurgery.  Surg Oncol Clin N Am. 2001;  10 709-731
    PubMedSearch in Google Scholar
  • 22 Mentges B, Buess G, Schafer D. et al . Local therapy of rectal tumors.  Dis Colon Rectum. 1996;  39 886-892
    CrossrefPubMedSearch in Google Scholar
  • 23 Schafer H, Baldus S E, Gasper F, Holscher A H. Submucosal infiltration and local recurrence in pT1 low-risk rectal cancer treated by transanal endoscopic microsurgery.  Chirurg. 2004;  76 379-384
    PubMedSearch in Google Scholar
  • 24 Heintz A, Mörschel M, Junginger T. Comparison of results after transanal endoscopic microsurgery and radical resection for T1 carcinoma of the rectum.  Surg Endosc. 1998;  12 1145-1148
    CrossrefPubMedSearch in Google Scholar
  • 25 Stipa F, Lucandri G, Ferri M. et al . Local excision of rectal cancer with transanal endoscopic microsurgery (TEM).  Anticancer Res. 2004;  24 1167-1172
    PubMedSearch in Google Scholar
  • 26 Lee W, Lee D, Choi S, Chun H. Transanal endoscopic microsurgery and radical surgery for T1 and T2 rectal cancer.  Surg Endosc. 2003;  17 1283-1287
    CrossrefPubMedSearch in Google Scholar
  • 27 Saclarides T J. Transanal endoscopic microsurgery: a single surgeon’s experience.  Arch Surg. 1998;  133 595-599
    CrossrefPubMedSearch in Google Scholar
  • 28 Demartines N, von Flüe M O, Harder F H. Transanal endoscopic microsurgical excision of rectal tumors: indications and results.  World J Surg. 2001;  25 870-875
    CrossrefPubMedSearch in Google Scholar
  • 29 Smith L E, Ko S T, Saclarides T J. et al . Transanal endoscopic microsurgery: initial registry results.  Dis Colon Rectum. 1996;  39 79-84
    CrossrefPubMedSearch in Google Scholar
  • 30 Buess G, Kipfmuller K, Ibald R. et al . Clinical results of transanal endoscopic microsurgery.  Surg Endosc. 1998;  2 245-250
    PubMedSearch in Google Scholar
  • 31 Pacelli F, Giorgio A, Papa V. et al . Preoperative radiotherapy combined with intraoperative radiotherapy improves results of total mesorectal excision in patients with T3 rectal cancer.  Dis Colon Rectum. 2004;  47 170-179
    CrossrefPubMedSearch in Google Scholar
  • 32 Turler A, Schafer H, Pichlmaier H. Role of transanal endoscopic microsurgery in the palliative treatment of rectal cancer.  Scand J Gastroenterol. 1997;  32 58-61
    PubMedSearch in Google Scholar
  • 33 Dickinson A J, Savage A P, Mortensen N J, Kettlewell M G. Long-term survival after endoscopic transanal resection of rectal tumors.  B J Surg. 1993;  80 1401-1404
    PubMedSearch in Google Scholar
  • 34 Graham R A, Garnsey L, Jessup J M. Local excision of rectal carcinoma.  Am J Surg. 1990;  160 306-312
    CrossrefPubMedSearch in Google Scholar
  • 35 Winde G, Nottberg H, Keller R. et al . Surgical cure for early rectal carcinoma (T1): transanal endoscopic microsurgery vs. anterior resection.  Dis Colon Rectum. 1996;  39 969-976
    CrossrefPubMedSearch in Google Scholar
  • 36 Langer C, Liersch T, Süss M. et al . Surgical cure for early rectal carcinoma and large adenoma: transanal endoscopic microsurgery (using ultrasound or electrosurgery) compared to conventional local and radical resection.  Int J Colorectal Dis. 2003;  18 222-229
    PubMedSearch in Google Scholar
  • 37 Lezoche E, Guerrieri M, Feliciotti F. et al . Local excision of rectal cancer by transanal endoscopic microsurgery (TEM) combined with radiotherapy: new concept of therapeutic approach.  Przegl Lek. 2000;  57 Suppl 5 72-74
    PubMedSearch in Google Scholar
  • 38 Lezoche E, Guerrieri M, Paganini A M, Feliciotti F. Long-term results of patients with pT2 rectal cancer treated with radiotherapy and transanal endoscopic microsurgical excision.  World J Surg. 2002;  26 1170-1174
    CrossrefPubMedSearch in Google Scholar
  • 39 Guerrieri M, Feliciotti F, Baldarelli M. et al . Sphincter-saving surgery in patients with rectal cancer treated by radiotherapy and transanal endoscopic microsurgery: 10 years’ experience.  Dig Liver Dis. 2003;  35 876-880
    CrossrefPubMedSearch in Google Scholar
  • 40 Taylor R H, Hay J H, Larsson S N. Transanal local excision of selected low rectal cancers.  Am J Surg. 1998;  175 360-363
    CrossrefPubMedSearch in Google Scholar
  • 41 Hersman M J, Sun Myint A, Makin C A. Multi-modality approach in curative local treatment of early rectal carcinomas.  Colorectal Dis. 2003;  5 445-450
    CrossrefPubMedSearch in Google Scholar
  • 42 Swanstrom L L, Smiley P, Zelko J, Cagle L. Video endoscopic transanal-rectal tumor excision.  Am J Surg. 1997;  173 383-385
    CrossrefPubMedSearch in Google Scholar
  • 43 Arribas del Amo D, Ramirez Rodriguez J M, Aguilella Diago V. et al . Transanal endoscopic surgery for rectal tumors.  Rev Esp Enferm Dig. 2000;  92 526-535
    PubMedSearch in Google Scholar
  • 44 De Graaf E JR, Doornebosch P G, Stassen L PS. et al . Transanal endoscopic microsurgery for rectal cancer.  Eur J Cancer. 2002;  38 904-910
    CrossrefPubMedSearch in Google Scholar
  • 45 Platell C, Denholm E, Makin G. Efficacy of transanal endoscopic microsurgery in the management of rectal polyps.  J Gastroenterol Hepatol. 2004;  19 767-772
    CrossrefPubMedSearch in Google Scholar
  • 46 Araki Y, Isomoto H, Shirouzu K. Video-assisted gasless transanal endoscopic microsurgery: a review of 217 cases of rectal tumors over the past 10 years.  Dig Surg. 2003;  20 48-52
    PubMedSearch in Google Scholar
  • 47 Meng W CS, Lau P YY, Yip A WC. Treatment of early tumours by transanal endoscopic microsurgery in Hong Kong: prospective study.  Hong Kong Med J. 2004;  10 239-243
    PubMedSearch in Google Scholar
  • 48 Klaue H J, Bauer E. Retroperitoneal phlegmon after transanal endoscopic microsurgery excision of rectal adenoma.  Chirurg. 1997;  68 84
    CrossrefPubMedSearch in Google Scholar
  • 49 Toresen J E, Marvik R, Sahlin Y, Myrvold H E. Transanal endoscopic microsurgery.  Tidsskr Nor Laegeforen. 1996;  116 52-53
    PubMedSearch in Google Scholar
  • 50 Palma P, Freudenberg S, Samel S, Post S. Transanal endoscopic microsurgery: indications and results after 100 cases.  Colorectal Dis. 2004;  6 350-355
    CrossrefPubMedSearch in Google Scholar
  • 51 Herman R M, Richter P, Walega P, Popiela T. Anorectal sphincter function and rectal barostat study in patients following transanal endoscopic microsurgery.  Int J Colorectal Dis. 2001;  16 370-376
    CrossrefPubMedSearch in Google Scholar
  • 52 Kreis M E, Jehle E C, Haug V. et al . Functional results after transanal endoscopic microsurgery.  Dis Colon Rectum. 1996;  39 1116-1120
    PubMedSearch in Google Scholar
  • 53 Kennedy M L, Lubowski D Z, King D W. Transanal endoscopic microsurgery excision. Is anorectal function compromised?.  Dis Colon Rectum. 2002;  45 601-605
    CrossrefPubMedSearch in Google Scholar
  • 54 Kipfmuller K, Buess G, Naruhn M, Junginger T. Training program for transanal endoscopic microsurgery.  Surg Endosc. 1988;  2 24-27
    CrossrefPubMedSearch in Google Scholar

D. Casadesus, M. D.

Washington Str. 156 · Infanta y Churrucas · Cerro · Havana · Cuba

Fax: +537-333319 ·

Email: dcasadesus@hotmail.com

#

References

  • 1 Mellgren A, Sirivongs P, Rothenberger D A. et al . Is local excision adequate therapy for early rectal cancer?.  Dis Colon Rectum. 2000;  43 1064-1074
    CrossrefPubMedSearch in Google Scholar
  • 2 Minsky B D, Rich T, Recht A. et al . Selection criteria for local excision with or without adjuvant radiation therapy for rectal cancer.  Cancer. 1989;  63 1421-1429
    PubMedSearch in Google Scholar
  • 3 Buess G, Hutterer F, Theiss J. et al . A system for a transanal endoscopic rectum operation [in German].  Chirurg. 1984;  55 677-680
    PubMedSearch in Google Scholar
  • 4 Gordon P H, Nivatvongs S. Principles and practice of surgery for the colon, rectum, and anus. 2nd edn. New York; Marcel Dekker 1999:
    Search in Google Scholar
  • 5 Sakamoto G D, MacKeigan J M, Senagore A J. Transanal excision of large, rectal villous adenomas.  Dis Colon Rectum. 1991;  34 880-885
    PubMedSearch in Google Scholar
  • 6 Pigot F, Bouchard D, Mortaji M. et al . Local excision of large rectal villous adenomas: long-term results.  Dis Colon Rectum. 2003;  46 1345-1350
    CrossrefPubMedSearch in Google Scholar
  • 7 Said S, Stippel D. Transanal endoscopic microsurgery in large, sessile adenomas of the rectum: a 10-year experience.  Surg Endosc. 1995;  9 1106-1112
    PubMedSearch in Google Scholar
  • 8 Madhala O, Lelcuk S, Rabau M. Transanal endoscopic microsurgery for local excision of rectal neoplasms.  Harefuah. 1995;  129 236-237
    PubMedSearch in Google Scholar
  • 9 Steele R JC, Hershman M J, Mortensen N J. et al . Transanal endoscopic microsurgery: initial experience from three centers in the United Kingdom.  Br J Surg. 1996;  83 207-210
    PubMedSearch in Google Scholar
  • 10 Farmer K C, Wale R, Winnet J. et al . Transanal endoscopic microsurgery: the first 50 cases.  ANZ J Surg. 2002;  72 854-856
    CrossrefPubMedSearch in Google Scholar
  • 11 Nakagoe T, Sawai T, Tsiju T. et al . Local rectal tumor resection results: gasless, video-endoscopic transanal excision versus the conventional posterior approach.  World J Surg. 2003;  27 197-202
    PubMedSearch in Google Scholar
  • 12 Cocilovo C, Smith L E, Stahl T, Douglas J. Transanal endoscopic excision of rectal adenomas.  Surg Endosc. 2003;  17 1461-1463
    CrossrefPubMedSearch in Google Scholar
  • 13 Neary P, Makin G B, White T J. et al . Transanal endoscopic microsurgery: a viable operative alternative in selected patients with rectal lesions.  Ann Surg Oncol. 2003;  10 1106-1111
    CrossrefPubMedSearch in Google Scholar
  • 14 Katti G. An evaluation of transanal endoscopic microsurgery for rectal adenoma and carcinoma.  JSLS. 2004;  8 123-126
    PubMedSearch in Google Scholar
  • 15 Galandiuk S, Fazio V W, Jagelman D G. et al . Villous and tubulovillous adenomas of the colon and rectum: a retrospective review, 1964 - 1985.  Am J Surg. 1987;  153 41-47
    CrossrefPubMedSearch in Google Scholar
  • 16 Morschel M, Heintz A, Bussmann M, Junginger T. Follow-up after transanal endoscopic microsurgery or transanal excision of large benign rectal polyps.  Langenbeck’s Arch Surg. 1998;  383 320-324
    PubMedSearch in Google Scholar
  • 17 Dafnis G, Pahlman L, Raab Y. et al . Transanal endoscopic microsurgery: clinical and functional results.  Colorectal Dis. 2004;  6 336-342
    CrossrefPubMedSearch in Google Scholar
  • 18 Nagy A, Kovacs T, Berki C, Jano Z. Surgical management of villous and tubulovillous adenomas of the rectum.  Orv Hetil. 1999;  140 2215-2219
    PubMedSearch in Google Scholar
  • 19 Lev-Chelouche D, Margel D, Goldman G, Rabau M J. Transanal endoscopic microsurgery: experience with 75 rectal neoplasms.  Dis Colon Rectum. 2000;  43 662-667
    CrossrefPubMedSearch in Google Scholar
  • 20 Mentges B, Buess G, Effinger K. et al . Indications and results of local treatment of rectal cancer.  Br J Surg. 1997;  84 348-351
    CrossrefPubMedSearch in Google Scholar
  • 21 Buess G F, Raestrup H. Transanal endoscopic microsurgery.  Surg Oncol Clin N Am. 2001;  10 709-731
    PubMedSearch in Google Scholar
  • 22 Mentges B, Buess G, Schafer D. et al . Local therapy of rectal tumors.  Dis Colon Rectum. 1996;  39 886-892
    CrossrefPubMedSearch in Google Scholar
  • 23 Schafer H, Baldus S E, Gasper F, Holscher A H. Submucosal infiltration and local recurrence in pT1 low-risk rectal cancer treated by transanal endoscopic microsurgery.  Chirurg. 2004;  76 379-384
    PubMedSearch in Google Scholar
  • 24 Heintz A, Mörschel M, Junginger T. Comparison of results after transanal endoscopic microsurgery and radical resection for T1 carcinoma of the rectum.  Surg Endosc. 1998;  12 1145-1148
    CrossrefPubMedSearch in Google Scholar
  • 25 Stipa F, Lucandri G, Ferri M. et al . Local excision of rectal cancer with transanal endoscopic microsurgery (TEM).  Anticancer Res. 2004;  24 1167-1172
    PubMedSearch in Google Scholar
  • 26 Lee W, Lee D, Choi S, Chun H. Transanal endoscopic microsurgery and radical surgery for T1 and T2 rectal cancer.  Surg Endosc. 2003;  17 1283-1287
    CrossrefPubMedSearch in Google Scholar
  • 27 Saclarides T J. Transanal endoscopic microsurgery: a single surgeon’s experience.  Arch Surg. 1998;  133 595-599
    CrossrefPubMedSearch in Google Scholar
  • 28 Demartines N, von Flüe M O, Harder F H. Transanal endoscopic microsurgical excision of rectal tumors: indications and results.  World J Surg. 2001;  25 870-875
    CrossrefPubMedSearch in Google Scholar
  • 29 Smith L E, Ko S T, Saclarides T J. et al . Transanal endoscopic microsurgery: initial registry results.  Dis Colon Rectum. 1996;  39 79-84
    CrossrefPubMedSearch in Google Scholar
  • 30 Buess G, Kipfmuller K, Ibald R. et al . Clinical results of transanal endoscopic microsurgery.  Surg Endosc. 1998;  2 245-250
    PubMedSearch in Google Scholar
  • 31 Pacelli F, Giorgio A, Papa V. et al . Preoperative radiotherapy combined with intraoperative radiotherapy improves results of total mesorectal excision in patients with T3 rectal cancer.  Dis Colon Rectum. 2004;  47 170-179
    CrossrefPubMedSearch in Google Scholar
  • 32 Turler A, Schafer H, Pichlmaier H. Role of transanal endoscopic microsurgery in the palliative treatment of rectal cancer.  Scand J Gastroenterol. 1997;  32 58-61
    PubMedSearch in Google Scholar
  • 33 Dickinson A J, Savage A P, Mortensen N J, Kettlewell M G. Long-term survival after endoscopic transanal resection of rectal tumors.  B J Surg. 1993;  80 1401-1404
    PubMedSearch in Google Scholar
  • 34 Graham R A, Garnsey L, Jessup J M. Local excision of rectal carcinoma.  Am J Surg. 1990;  160 306-312
    CrossrefPubMedSearch in Google Scholar
  • 35 Winde G, Nottberg H, Keller R. et al . Surgical cure for early rectal carcinoma (T1): transanal endoscopic microsurgery vs. anterior resection.  Dis Colon Rectum. 1996;  39 969-976
    CrossrefPubMedSearch in Google Scholar
  • 36 Langer C, Liersch T, Süss M. et al . Surgical cure for early rectal carcinoma and large adenoma: transanal endoscopic microsurgery (using ultrasound or electrosurgery) compared to conventional local and radical resection.  Int J Colorectal Dis. 2003;  18 222-229
    PubMedSearch in Google Scholar
  • 37 Lezoche E, Guerrieri M, Feliciotti F. et al . Local excision of rectal cancer by transanal endoscopic microsurgery (TEM) combined with radiotherapy: new concept of therapeutic approach.  Przegl Lek. 2000;  57 Suppl 5 72-74
    PubMedSearch in Google Scholar
  • 38 Lezoche E, Guerrieri M, Paganini A M, Feliciotti F. Long-term results of patients with pT2 rectal cancer treated with radiotherapy and transanal endoscopic microsurgical excision.  World J Surg. 2002;  26 1170-1174
    CrossrefPubMedSearch in Google Scholar
  • 39 Guerrieri M, Feliciotti F, Baldarelli M. et al . Sphincter-saving surgery in patients with rectal cancer treated by radiotherapy and transanal endoscopic microsurgery: 10 years’ experience.  Dig Liver Dis. 2003;  35 876-880
    CrossrefPubMedSearch in Google Scholar
  • 40 Taylor R H, Hay J H, Larsson S N. Transanal local excision of selected low rectal cancers.  Am J Surg. 1998;  175 360-363
    CrossrefPubMedSearch in Google Scholar
  • 41 Hersman M J, Sun Myint A, Makin C A. Multi-modality approach in curative local treatment of early rectal carcinomas.  Colorectal Dis. 2003;  5 445-450
    CrossrefPubMedSearch in Google Scholar
  • 42 Swanstrom L L, Smiley P, Zelko J, Cagle L. Video endoscopic transanal-rectal tumor excision.  Am J Surg. 1997;  173 383-385
    CrossrefPubMedSearch in Google Scholar
  • 43 Arribas del Amo D, Ramirez Rodriguez J M, Aguilella Diago V. et al . Transanal endoscopic surgery for rectal tumors.  Rev Esp Enferm Dig. 2000;  92 526-535
    PubMedSearch in Google Scholar
  • 44 De Graaf E JR, Doornebosch P G, Stassen L PS. et al . Transanal endoscopic microsurgery for rectal cancer.  Eur J Cancer. 2002;  38 904-910
    CrossrefPubMedSearch in Google Scholar
  • 45 Platell C, Denholm E, Makin G. Efficacy of transanal endoscopic microsurgery in the management of rectal polyps.  J Gastroenterol Hepatol. 2004;  19 767-772
    CrossrefPubMedSearch in Google Scholar
  • 46 Araki Y, Isomoto H, Shirouzu K. Video-assisted gasless transanal endoscopic microsurgery: a review of 217 cases of rectal tumors over the past 10 years.  Dig Surg. 2003;  20 48-52
    PubMedSearch in Google Scholar
  • 47 Meng W CS, Lau P YY, Yip A WC. Treatment of early tumours by transanal endoscopic microsurgery in Hong Kong: prospective study.  Hong Kong Med J. 2004;  10 239-243
    PubMedSearch in Google Scholar
  • 48 Klaue H J, Bauer E. Retroperitoneal phlegmon after transanal endoscopic microsurgery excision of rectal adenoma.  Chirurg. 1997;  68 84
    CrossrefPubMedSearch in Google Scholar
  • 49 Toresen J E, Marvik R, Sahlin Y, Myrvold H E. Transanal endoscopic microsurgery.  Tidsskr Nor Laegeforen. 1996;  116 52-53
    PubMedSearch in Google Scholar
  • 50 Palma P, Freudenberg S, Samel S, Post S. Transanal endoscopic microsurgery: indications and results after 100 cases.  Colorectal Dis. 2004;  6 350-355
    CrossrefPubMedSearch in Google Scholar
  • 51 Herman R M, Richter P, Walega P, Popiela T. Anorectal sphincter function and rectal barostat study in patients following transanal endoscopic microsurgery.  Int J Colorectal Dis. 2001;  16 370-376
    CrossrefPubMedSearch in Google Scholar
  • 52 Kreis M E, Jehle E C, Haug V. et al . Functional results after transanal endoscopic microsurgery.  Dis Colon Rectum. 1996;  39 1116-1120
    PubMedSearch in Google Scholar
  • 53 Kennedy M L, Lubowski D Z, King D W. Transanal endoscopic microsurgery excision. Is anorectal function compromised?.  Dis Colon Rectum. 2002;  45 601-605
    CrossrefPubMedSearch in Google Scholar
  • 54 Kipfmuller K, Buess G, Naruhn M, Junginger T. Training program for transanal endoscopic microsurgery.  Surg Endosc. 1988;  2 24-27
    CrossrefPubMedSearch in Google Scholar

D. Casadesus, M. D.

Washington Str. 156 · Infanta y Churrucas · Cerro · Havana · Cuba

Fax: +537-333319 ·

Email: dcasadesus@hotmail.com

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