Transanal Surgery for Large Rectal Polyps and Early Rectal Cancer AB Harikrishnan Consultant Colorectal Surgeon, Sheffield Honorary Clinical Senior Lecturer, Sheffield University Associate TPD General Surgery, Yorkshire Deanery ACPGBI Yorkshire Chapter Representative Sheffield Colorectal
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Transanal Surgery for Rectal Polyps and Early Rectal Cancer · 2017-12-12 · Transanal Surgery for Large Rectal Polyps and Early Rectal Cancer AB Harikrishnan Consultant Colorectal
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Transanal Surgery for Large Rectal Polyps
and Early Rectal Cancer
AB HarikrishnanConsultant Colorectal Surgeon, Sheffield
Honorary Clinical Senior Lecturer, Sheffield University
Associate TPD General Surgery, Yorkshire Deanery
ACPGBI Yorkshire Chapter Representative
Sheffield Colorectal
Clinicopathologic assessment
• What is it?• TVA / HGD / T1 / T2
• How does it look?• Size, sessile, flat, stalk, residual scar from previous surgery or
EMR
• Where is it?• Rectum / rectosigmoid / peritoneal reflection• Distance from anal verge• Rectal folds• Lateral orientation• Circumference
• TEMS – shorter op time & LoS, reduced complications
Sajid et al. Colorectal Dis. 2014 Jan;16(1):2-14. Sheffield Colorectal
TEMS vs ESD – SR and MA
• n=2077, 11 ESD and 10 TEM series
ESD TEM
• En bloc resection rate * 88% 99%
• R0 resection rate * 75% 88%
• Complication rate 8% 8%
• Recurrence rate * 2.6% 5.2%
• Post trt abd resection rate * 8.4% 1.8%
Arezzo et al. Surg Endosc (2014) 28:427–438
The ESD procedure appears to be a safe technique, but TEM achieves a higher R0 resection rate when performed in full-thickness fashion, significantly reducing the need for further abdominal treatment.
• Major complications <2%• Rectal wound dehiscence• Bleeding – reactionary and delayed• Rectal pain• Perirectal abscess and fistula• Rectovaginal fistula• Rectal stricture
• Minor complications <10%• Urinary retention• Mucus discharge• Minor bleeding
• Functional outcomes• QOL preserved at 1 year and 5 years• QOL and sexual function impaired for post RTX group
Sheffield Colorectal
TEMS for rectal Ca – new perspectives
• Lymph node staging• Endoscopic posterior mesorectal excision (EPMR). Tarantino et al, 2008.• Safe, low morbidity, comparable oncological data !
• Sentinel lymph node biopsy• NTEMS – nucleotide guided TEMS and LN sampling. Lezoche et al, 2013.• Indocyanine Green (ICG) / near IR camera sampling. Arezzo et al, 2014.
• Predictive biomarkers• Chromosome 8q23-24 gain = marker for LN +ve. Ghadimi et al, 2003.• Chromosomal copy number. Chen et al, 2013.
• PROGRESSS – perirectal oncologic gateway for RP endoscopic single-site surgery. Leroy et al 2013.
• Robotic assisted transanal surgery (RATS). Atallah et al, 2015.Sheffield Colorectal
Early Rectal Cancer – other treatment options
• Selective post op radiotherapy
• Neoadjuvant radiotherapy followed by TEM
• Neoadjuvant chemorad followed by TEM• Rectal wound complications are high• Oncological outcome similar to standard resection• Functional outcomes are poor
• TrialsSheffield Colorectal
Trials
• TREC• T1-2N0 • TME/APER vs SCRT + TEMS
• STAR-TREC• T1-3bN0• TME vs SCRT/CRT followed by w&w or TEMS
• TESAR• T1-2, medium risk• Post TEMS – Adjuvant chemorad vs TME
• TREND• Large rectal adenomas• TEMS vs EMR
• CARTS• Neoadjuvant long course chemorad followed by TEMS