Transanal Endoscopic Microsurgery: A 15 Year Experience Evaluating Indications and Outcomes

Renee Huang, MD, Cynthia Sulzbach, BS, Dominique McKeever, BA, John Marks, MD, FACS, FASCRS

Section of Colorectal Surgery, Lankenau Medical Center, Wynnewood, PA

Background: This study reviews a 15 year experience with Transanal Endoscopic Microsurgery (TEM). Indications, perioperative outcomes, morbidity and mortality are presented.

Methods: From 1997-2012, 304 patients, 174 men and 130 women, mean age of 65 years old (27-91), were operated on with TEM. Data was maintained in a prospective database. Indications included 147 polyps (48.3%), 130 adenocarcinomas (42.7%), 25 carcinoids (8.2%) and 2 other lesions. Mean BMI was 28.9 (15.8-53.8). Patients were referred for: APR 15%, sphincter preservation 29%, our primary assessment 41% and TEM directly only 15% of the time. Mean distal level of the lesion from the anal verge was 8.4 cm (1-21 cm). Level in the rectum was as follows: distal 1/3 55%; middle 1/3 30%; proximal 1/3 8%; sigmoid colon 2%; unknown 5%. Mean size of the lesions was 3.4 cm (0.3-14.0). The lesion was 3-6 cm 44% of the time; 6-10 cm 12% of the time; greater than 10 cm 1% of the time. For the adenocarcinomas preoperative staging was as follows: T1 30; T2 68; T3 30. Preoperative radiation was used in 95 patients (mean 5240 cGy). ASA was III or IV in 55% of patients.

Results: Surgery was performed under general anesthesia in 99% of cases. Resection was full thickness 81% and submucosal 18%. Extent of excision was disc 60%, hemicircumferential 32%, circumferential/sleeve 4%, and other 4%. Median OR time was 120 minutes (23-523 min) with median EBL of 25 ml (0-700). No patients were transfused. The wound was closed 92.4% of the time. Entry into the peritoneal cavity occurred 9.5% of the time. In two patients, planned diverting stomas were created at the time of TEM because of patient frailty and size of resection. There were no unplanned abdominal surgeries. Mean time in days to: clears 0.65 (0-8); house diet 1.48 (0-9); flatus 1.31 (0-7); BM 2.02 (0-9); discharge 2.53 (0-22). There were no mortalities. Overall morbidity rate was 20.7%. Fever occurred in 2% of patients. There were two rectovaginal fistulas; 52.4% of morbidities were wound separations, of these 73% were in patients after preoperative irradiation. Wound separation in the irradiated group occurred in 25.3% vs. 4.3% in the non-irradiated group (p<0.05). Overall local recurrence rate was 2.6%. LR occurred in 4 adenocarcinomas (4.2%) and 4 adenomas (2.7%). Piecemeal excision occurred in 7.2% of patients. Positive margins occurred in 5 (1.6%). Stomas occurred in six patients (2.0%): 2 for recurrent cancers, 1 for a rectovaginal fistula, 1 for a wound separation, and 2 were protective. In all, 97% of patients had their pathology treated without the need for any abdominal surgery.

Conclusion: These findings show TEM to be a highly successful procedure in a challenging patient population. As evidenced by the high ASA and BMI in this experience, TEM attracts unfavorable surgical candidates. The most common complications are wound separations which are more common after radiation therapy. However TEM can be employed with highly successful outcomes, avoiding the need for colostomy or any abdominal surgery in over 95% of patients.

Session: Poster Presentation

Program Number: P087

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