Transanal endoscopic microsurgery in the treatment of patients with benign neoplasms and early rectal cancer

Introduction. Transanal endoscopic microsurgery (tem) is a method that allows the specialists to clearly visualize a tumor and bimanually remove the tumor using a set of special instruments. For a number of patients with a good tumor response to chemoradiation therapy (crt), tem is used as an advanced biopsy technique for tumor verification. The purpose of the study was to analyze the results of tem performed at a. Tsyb mrrc. Material and methods. Between 2015 and 2020, 64 patients (men – 42.2 % and women – 57.8 %) underwent tem. Forty patients had rectal cancer and 25 patients had benign rectal tumors. The indication for tem in patients with rectal cancer was the evidence of tis-t1 tumor by postoperative examination findings (mri and endosonography). Eleven patients with stage ii–iii rectal cancer received chemoradiation therapy. The indication for performing tem after rt in patients with rectal cancer was a good tumor response (mri trg1- 2). For statistical processing, commercial biomedical packages prism 3.1 and instat (graphpad software, inc., san diego, usa) were used. The significance of the differences between the indicators was assessed using the pearson χ2 test. Differences were considered significant if the p value was less than 0.05. Results. The median duration of surgery was 110 minutes (30–385). The volume of blood loss did not exceed 40 ml. Postoperative complications were observed in 15 cases (23.4 %). Grade 3 complications according to the clavien-dindo classification were observed in 5 (7.8 %) cases. Postoperative complications occurred more frequently in patients after crt (10.7 and 18.2 %; p=0.603), however, the differences were not statistically significant. At a median follow-up of 18 months (7–30), local relapses developed in 6 out of 26 (23 %) patients who underwent surgery alone. There were no signs of local recurrence in patients with adenocarcinomas after neoadjuvant chemotherapy and rectal adenomas. When comparing patients with the depth of tumor invasion tis-t1sm2 and t1sm3-t2, local relapses occurred in 1 of 21 (4.7 %) and 5 of 12 (41.6 %) cases, respectively (p=0.015). Conclusion. The analysis of the results of tem interventions in patients with rectal neoplasms allows us to conclude that this method of treatment is a priority for patients with benign rectal neoplasms and early rectal cancer. The method can also be used after rt or crt in patients with tumor invasion ≥t1sm3, provided a complete or almost complete tumor response to the treatment.

A Meta-analysis of Transanal Endoscopic Microsurgery versus Total Mesorectal Excision in the Treatment of Rectal Cancer

Background Transanal endoscopic microsurgery (TEMS) has been suggested as an alternative to total mesorectal excision (TME) in the treatment of early rectal cancers. The extended role of TEMS for higher stage rectal cancers after neoadjuvant therapy is also experimented. The aim of this meta-analysis was to compare the oncological outcomes and report on the evidence-based clinical supremacy of either technique. Methods Medline, Embase, and Cochrane databases were searched for the randomized controlled trials comparing the oncological and perioperative outcomes of TEMS and a radical TME. A local recurrence and postoperative complications were analyzed as primary end points. Intraoperative blood loss, operation time, and duration of hospital stay were compared as secondary end points. Results There was no statistical difference in the local recurrence or postoperative complications with a risk ratio of 1.898 and 0.753 and p-values of 0.296 and 0.306, respectively, for TEMS and TME. A marked statistical significance in favor of TEMS was observed for secondary end points. There was standard difference in means of −4.697, −6.940, and −5.685 with p-values of 0.001, 0.005, and 0.001 for blood loss, operation time, and hospital stay, respectively. Conclusion TEMS procedure is a viable alternative to TME in the treatment of early rectal cancers. An extended role of TEMS after neoadjuvant therapy may also be offered to a selected group of patients. TME surgery remains the standard of care in more advanced rectal cancers.

Cost Analysis of Laparoscopic Low Anterior Resection vs. Transanal Endoscopic Microsurgery for Rectal Neoplasms

Despite the increasing application of transanal endoscopic microsurgery (TEM) for rectal lesions, the cost of the equipment may play a role in a hospital’s hesitancy to invest in the platform. This study compares the cost of TEM to laparoscopic low anterior resection (LAR). Patients who underwent laparoscopic LAR (n = 24) for rectal neoplasm between 2006 and 2014 were case-matched based on sex, age, comorbidities, lesion size and location to patients who underwent TEM at a busy secondary care urban hospital. Procedure-related costs and costs associated with readmissions for complications and related subsequent surgeries in the first 3 years were calculated. There were 42 hospital admissions for 24 LAR patients, totalling 326 hospital days. For 24 TEM patients, there were 25 hospital admissions, totalling 56 hospital days. Subsequent operations for LAR patients included 2 washout and diverting ileostomies (8%), 2 adhesionolysis (8%), 4 ventral hernia repairs (16%) and 11 ileostomy reversals (46%). In the TEM group, there was one operation for recurrence (4%). The mean cost of LAR, including all related hospital costs in the subsequent 3 years, was CAD 14,851 (95% CI: CAD 10,124–19,579). The mean cost of TEM was CAD 2449 (95% CI: CAD 2133–2767; p < 0.0001), with a savings of CAD 12,402 per patient. TEM for rectal neoplasm is associated with significantly lower hospital costs, which far outweigh the costs of acquiring and maintaining the technology.