Radical Transanal Endoscopic Microsurgey (tem): Endoluminal Surgery for Complex Rectal Lesions

Introduction: TEM represents the only longstanding approach to endoluminal surgery. Guidelines excluding large lesions and those that may require entry into the peritoneal cavity limit the applicability of TEM surgery. This study evaluates the feasibility, safety, and efficacy of radical application of TEM for the treatment of complex rectal lesions.

Methods: From a prospective TEM database between 1996-2009, patients with complex lesions were identified. Inclusion criteria were: size >5cm (N=54), entrance into the peritoneal cavity (N=14), resection requiring ≥50% of the rectal circumference (N=79) and level in the rectum ≥ 15 cm (N=8).

Results: 103 consecutive patients were identified including 47 women and 53 men. Mean age was 69 years (41-91) with a mean BMI of 27 (15-50). 41% of patients had ≥ 2 inclusion criteria and 5% ≥ 3. Diagnosis was Carcinoma In Situ N=10, Adenoma N=52, Adenocarcinoma=4; of whom 30 had neoadjuvant therapy. 64% of the patients were referred by outside surgeons for the following procedures: APR: 30%, LAR: 48% and TEM: 21%. Level in the rectum ranged from 1-25cm. There was no mortality. No operations were converted to abdominal resections. There were 4 sleeve resections.Four patients had elective diverting colostomies created at time of TEM, all of whom had neoadjuvant chemoradiation, >50% rectal resection, and significant comorbidities. Median operative time was 164 minutes (40-523 min) with mean EBL of 50cc (0-100cc). Mean LOS was 3 days. 2 patients with large circumferential lesions required staged TEMs. Major morbidity = 3.8% (rectovaginal fistula=1, major wound disruptions=3), 3 of whom required stomas. 1 patient required staged radical resection for advanced pathology. Overall local recurrence was 2.9%. 92% of patients were treated without the need for any abdominal surgery.

Conclusions: Radical TEM surgery is a viable treatment option in patients with complex rectal lesions avoiding the need for major abdominal surgery. It is a safe, effective, and feasible approach with low recurrence rate, morbidity, and mortality. The expanded use of TEM for challenging rectal and sigmoid lesions appears to realize the full benefits of endoluminal or NOTES surgery.

Session: Poster

Program Number: P262

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