Transanal Endoscopic Operation Indication – Technique – Results M. Sailer Department of Surgery Bethesda Hospital – Hamburg, Germany
Jan 03, 2016
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