1. Transanal endoscopic microsurgery (TEM) is a minimally invasive technique for resection of rectal tumors with low risks of complications and mortality even in high-risk patients. 2. TEM is indicated for cure in low-risk T1 cancers and for compromise in high-risk T1 and possible T2 cancers to avoid stoma or major surgery risks. 3. The document discusses prerequisites, results, and indications for TEM and concludes that while technically demanding, TEM is appropriate for select early stage rectal cancers and large adenomas.

1. Indications for TEM Gunnar Baatrup Cascais feb. 2010

2. Disposition 1. What is TEM 2. Prerequisite for TEM 3. Results and recommendations 4. Conclusion 5. Discussion

3. Transanal Endoscopic Microsurgery

4. Transanal Endoscopic Microsurgery

5. Why consider TEM 1 Can be performed in spinal anaestsia 2. Discharge after 24 hours 3. Complication and mortality in normal and high risk patients are low 4. Stoma can be avoided in low tumors 5. Low hospital costs

6. Prerequisite for TEM surgery for cancer Equipment Experience from benign tumors Safe preoperative staging

8. Minor: 11/148

9. Bleeding > 50 ml.

10. Fewer

11. Temporary incontinence < 3 months

12. Major: 3/148

13. 2 ascending infections – temporary stoma

14. 1 acute myocardial infarction

15. Dead: 1/148

17. Results after TEM surgery 1. Polypoid tumors 2. Villous adenomas 2. Low risk T1 cancers 3. High risk T1 and T2 cancers 4. Combined with neoadjuvant radio-chemotherapy 5. Complete responders

19. Risk of + lymphnodes is < 1%

20. Haggits 1 and 2 are safely removed during colonocopy

21. 1 mm resction margin is ok.

23. Risk factors in T1 cancers Preoperative/operative informations 1. Diameter larger than 5 ( or 4 or 3) cm. 2. Incomplete or borderline resection margin. 3. Pathological lymph nodes on ul. Postoperative informations 4. Tumour budding 5. Vascular and nervous invasion 6. Poor differentiation/mucinous/signet – ring cells 7. Many new markers for poor prognosis

24. Size and recurrence

26. Theoretical survival after TEM and major surgery corrected for dead from other causes Conditions: 15% og 25% cancer specific 5-year mortality

29. Low risk T1

30. 2. For compromise (that is oncological compromise)

31. High risk T1 and possible T2

32. 3. For palliation

34. Surgery for local recurrence/late salvage TME for evident local recurrence is associated with significantly higher risk of positive lymph nodes and for distant metastasis at the time of surgery. Early detection and no-mesorectal resection during TEM increases the chance of cure.

35. Combination with neoadjuvant treatment Combination with postoperative chemo-radiation: Insufficient evidence. Combination of TEM and neoadjuvant chemo-radiation is very promising: Neoadjuvant and TEM in T2 and T3 lead to 11% recurrences. Very low recurrence rate in responders. Low level of evidence.

36. TEM and neoadjuvant treatment More evidence on oncological outcome needed. More information on side effects needed. Prospective randomised trials needed.

37. Complete responders Complete response can be achieved in up to 20% of early and medium size cancers No results so far.

38. Conclusion/take home message 1 TEM is technically demanding TEM require a high patient load and dedicated surgeons TEM require access to high quality ERUS

39. Conclusion/ take home message 2 TEM for cure is indicated for high risk adenomas and low risk T1 cancers TEM for compromise is indicated for high risk T1 and for T2 depending upon the age, co-morbidity and patient preference TEM for palliation is experimental

40. Conclusion/take home message 3 Indications for TEM are likely to expand in the coming years