Transanal Endoscopic Operation

Indication – Technique – Results

M. SailerDepartment of Surgery

Bethesda Hospital – Hamburg, Germany

• Preoperative Staging• Differentiated surgical therapy• Control of local recurrence• (Neo-) adjuvant therapy • Improvement of survival• Functional aspects• Improvement of quality of life (QoL)

TEO

Stage adapted concepts in rectal surgery

TEO

Preoperative Staging

Crucial for planning of therapy

Operative strategies• Local resection techniques (e.g. TEO or TEM)• Sphincter preserving resection• Abdominoperineal resection (APR)• Multivisceral resection• Palliative operations (e.g. stoma, stent)

Neoadjuvant therapy• Radio- / chemotherapy (long course)• Short course radiation (5 x 5 Gy)

TEO

Rectal adenoma or T1 – Carcinoma EUS

TEO

T3 – Carcinoma EUS

TEO

T4 – Carcinoma EUS

TEO

Operative Procedures – Rectal Cancer

• Transanal excision (T1-Ca)

• Low anterior resection (LAR)

• Ultralow or intersphincteric resection

• Abdominoperineal resection (APR)

• Compulsary for all resecting procedures Total Mesorectal Excision (TME)

TEO

Indications for local excision

• Adenomas• Carcinomas of the mucosa or

submukosa• Well differentiated grading (G1 / 2)• No lymphangiosis carcinomatosa (L0)• No vascular invasion (V0)• Tumor size < 3 cm• Apropriate localisation

TEO

Small T1 - Carcinoma (G2)

TEO

T1 – Carcinomas EUS

TEO

Original device for TEM (Buess et al.)

TEO

New device for TEO by Storz Co.

Low risk High risk

(%) (%)

T1 (Submucosa) 2 17

T2a (inner muscularis) 10 42

T2b (outer muscularis) 20 45

T3a (< 10 mm perirectal) 23 71

T3b (> 10 mm perirectal) 30 89

TEO

Incidence of loco-regional LN Mets (n = 3.241 Hermanek 2000)

Lokale Therapieprinzipien beim Rektumkarzinom

TEO

Transatlantic Dispute

K. E. Matzel1, 2     , S. Merkel1 und W. Hohenberger1

TEO

Outcome Sengupta, Dis Colon Rectum 2001; Nastro, Dig Surg 2005

• > 10 studies und > 300 patients

• Local recurrence rate: 4,2 - 25 %

• Overall survival: 62 - 100%

• Inclusion criteria very variable (T1 to T3; also high-risk)

• Excellent results with stringent selection criteria

TEO

Outcome Sengupta, Dis Colon Rectum 2001; Nastro, Dig Surg 2005

• > 10 studies und > 300 patients

• Local recurrence rate: 4,2 - 25 %

• Overall survival: 62 - 100%

• Inclusion criteria very variable (T1 to T3; also high-risk)

• Excellent results with stringent selection criteria

TEO

Postoperative function Cataldo et al, Dis Colon Rectum 2005

• Prospective study of 39 patients

• Standardized scores for continence and QoL

• Evaluation preoperatively and 6 weeks postop.

• No differences preop. vs. postop. regarding:• Frequency, -consistence• Urgency• Episodes of incontinence• Quality of Life

• Prospective evaluation of 134 patients (67 J.)

• TEO n = 113 Anal retractor n = 21

• Preoperative staging accuracy (EUS): 93 %

• Complications: • 4 anastomotic dehiscences, 1 stoma formation

• 9 haemorrhages: 3 x transfusions 3 x operative revisions

• 9 urinary retention (max. 6 days catheter)

• 7 (6,2 %) Local recurrences (5 adenomas, 2 T1-Ca)

TEO Outcome – own experience

TEO

New Aspects Lezoche et al. Surgical Endocopy 2005

• Randomised controlled trial n = 40

• RCHTx + TEM versus RCHTx + Laparoscop. resection

• Inclusion criteria: T2 N0 Rectal cancer

• Downstaging to T0 and / or T1 in 24 patients

• 1 Local recurrence and 1 distant metastasis per arm

• Median follow-up 56 months (44 – 67)

TEO

Conclusion

• Therapeutic goal: R0 – resection

• Locale excision only for adenomas and well differen-tiated T1 – Ca of apropriate localisation and size

• Low local failure rate and excellent oncologic outcome

• In studies neoadjuvant radiochemotherapy (T2)

• Good postoperative function and Qol

• Patient selection crucial