Endoluminal TransAnal Total Mesorectal Resection (ETATMR) by Transanal Endoscopic Microsurgery (TEM)

Giovanni Lezoche, *Lino Polese, Giancarlo D’Ambrosio, Alessandro M Paganini, Andrea Balla, Daniele Scoglio, Silvia Quaresima, *Lorenzo Norberto, Emanuele Lezoche

Department of General Surgery, Surgical Specialties and Organ Transplantation Paride Stefanini, Sapienza University of Rome. *Department of Surgical and Gastroenterological Sciences, University of Padova, Padua, Italy.

Introduction
Several technological advances have radically modified the management of low rectal cancer. In 1984 Marks proposed the TransAbdominal TransAnal (TATA) approach to treat rectal cancer. Transanal Endoscopic Microsurgery (TEM) provides Endoluminal Loco-Regional Resection (ELRR) with excellent view of the entire rectum and it has proven to be technically superior to conventional transanal approaches. The authors have developed a new sphincter preserving technique: ETATMR by TEM.

Methods
The TEM rectoscope (Buess 1983) has been modified to facilitate the surgical approach. According to the TEM technique, the lesion must be placed at six o’clock position in the operative field. In case of posterior lesions, the patient is placed in lithotomy position and dissection starts 1 cm below the lower tumor margin. The aboral dissection plane may partially or totally include the internal sphincter. The cutting line reaches the pelvic floor and the dissection follows the same plane as described by Heald (“Holy Plane”). Complete mesorectum excision with preservation of presacral fascia and parasymphathetic pelvic plexus is achieved on the posterior plane. When the lesion is located anteriorly, the patient is initially placed in prone position. The anterior plane of incision follows the recto-vaginal septum in females and the prostatic capsule and seminal vesicles in males, removing Denonvilliers’ fascia. Then, the patient is turned in the supine position and complete mesorectum excision is performed. The dissection reaches the peritoneal reflection. Splenic flexure mobilization and incision of the peritoneal reflection are performed by laparoscopy. The specimen is usually removed by mini laparotomy and in favourable cases it can be removed transanally. Frozen-section histology will evaluate the margins. The colon is pulled out through the anus to perform colo-anal anastomosis. Diverting ileostomy is carried out.

Preliminary results
The technique of ETATMR was developed in four cadavers. From October 2008 ETATMR by TEM was performed in eight patients with rectal cancer (5 males, 3 females, median age 66 years, range 41-77). Seven patients underwent neoadjuvant radiochemotherapy (nRCT) and one patient (T3N0) with recurrent rectal cancer after local excision received adjuvant radiochemotherapy. Final staging was pT3N1 (1), pT3N0 (1), pT2N0 (4), pT0N0 (1), pT0NX (1). Mean tumor diameter was 3 cm (range 1 – 5 cm). Mean tumor distance from the anal verge was 2.9 cm (range 2-4 cm). In five patients a protective ileostomy was performed. Mean operative time was 450 min (range 360-600 min). No severe intraoperative complication occurred. Postoperative complications included anastomotic leakage (3) and temporary urinary incontinence (1). Mean hospital stay was 16.6 days (range 9 – 22 days). Late complications included anastomotic stenosis (2) and recto-vaginal fistula (1) treated by stent.

Conclusion
ETATMR by TEM seems to be a safe and effective approach for the treatment of low rectal cancer. Adequate experience in ELRR by TEM is mandatory.


Session: Poster Presentation

Program Number: ETP026

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