Trans-anal Endoscopic Microsurgery TEM; Trans-anal Endoscopic operation TEO; Trans-anal Endoscopic Surgery TES.

1. Dr. Khaled Mestareehy, General & Colorectal Surgery
Jordanian Royal Medical Services

2. Transanal Endoscopic Microsurgery

3. Outlines
Case presentation
Guidelines for management
Rectal Anatomy
Preoperative Workup
Indications & Contraindications for TEM
Platforms
Introduction

4. First Case
•23 Year old male patient
•No significant previous medical or surgical Hx.
• C/O: feeling of incomplete rectal evacuation, perianal discomfort,
Minimal Bleeding (fresh blood) during rectal evacuation.
•P/E: DRE: Palpable 2 cm mobile Rectal mass at 3 o’clock; 6 cm From
anal verge.
•Colonoscopy: polyp at the same site.
•Biopsy: IMDA
•TRUS: Mobile mass Not invading muscular layer
•Pelvic MRI: T1, N0
•CT: No Metastasis
Case Presentation
•Treatment : Transanal Endoscopic rectal mass excision.

5. •49 Year old male patient
•No significant previous medical or surgical Hx.
• C/O: Heavy mucos discharge Per-anum, Minimal Bleeding
during rectal evacuation.
•P/E: DRE: Palpable irregular Rectal mucosa posteriorly.
•Colonoscopy: Multiple variable in size polyps at posterior
rectal circumference.
•Biopsy: tubulovillous polyps.
Second Case
Case Presentation
•Treatment : Transanal Endoscopic Mucosectomy – Posterior circumference.

6. Transanal Endoscopic Microsurgery
Previously these cases treated with
trans-abdominal LAR.

7. Transanal Endoscopic Microsurgery
Transabdominal LAR
•Hospital stay
•Post op pain
•Post op nausea & vomiting
•Wound complications (infection, hematoma, and dehiscence...)
•Anastomotic leak
•Ilius
•Cardiorespiratory complications
•Venous thrombosis
• Adhesions
• Scar....
•
•
•

8. • Low anterior resection syndrome (LARS)
Chronic
Pain
Frequency of BM
Perianal Pain
↓Anal sensitivity
Feeling of incomplete rectal evacuation
Incontinence

9. ■ Transanal endoscopic microsurgery (TEM) is a minimally invasive technique that was
originally developed to extend transanal access to benign and selected malignant tumors.
■ Performed transanally with specially designed microsurgical instrumentation.
Introduction

10. ■ TEM is both a single-port surgery and a natural orifice
transluminal endoscopic surgery (NOTES).
■ TEM used for benign adenoma, low-risk carcinoma, and
more advanced cancers after neoadjuvant therapy.
■ TEM is preferable over radical resection in select
patients due to the ability to safely eradicate the disease
with a wide full-thickness local excision while
simultaneously sparing the morbidity of a major
transabdominal surgery and preserving sphincter
function.
Introduction

11. In the early ‘80s a novel technique for resection of
polyps from within the rectum was conceived by
Professor Gerhard Buess from Germany. Prior to this
transanal resection of polypoid tissue, that was not
amenable to flexible endoscopic resection, was
restricted to the distal rectum in patients with
favourable lesions.
10. 4.1948 – 30.10.2010
Introduction

12. Buess developed a specific surgical rectoscope and instruments to address this problem.
This facilitated a new way of operating in the rectum.
• Very precise and accurate.
• Binocular vision and 3D visualisation.
Traditional instruments (conventional transanal mass excision)
•Limitations in their indications
•Limitations in success of removal of the pathological specimen in mid/upper rectum,
•Resulting in piecemeal excision, positive margins and high recurrence rates.
Introduction

13. Rectum
The rectum follows the shape of the sacrum
Begins at the rectosigmoid junction – at level
of third sacral vertebra
Ends at the anorectal junction – 2-3 cm in
front of and a little below the coccyx
Length – 13 – 15 cm.
 Diameter – 4 cm (in the upper part)
– Dilated (in the lower part)
Rectal anatomy

14. Rectal anatomy

15.  Inferior 1/3rd of the rectum – Subperitoneal – Devoid
of peritoneum
Middle 1/3rd of the rectum – Covered by peritoneum
on the anterior surface
Superior 1/3rd of the rectum – Covered by peritoneum
on the anterior and lateral surfaces
Peritoneal Relation
Rectal anatomy

16. Richard Wolf TEM Instrument System.
Two 4 cm-diameter working proctoscopes
of varying lengths
Face plate with three working ports
High-definition camera
Specifically modified laparoscopic
equipment
Combination pump/insufflator

17. The currently available technologies include:
• TEM (Transanal Endoscopic Microsurgery)
• TEO (Transanal Endoscopic Operations)
• SILS (Single Incision Laparoscopic Surgery) - port rectal operations.
• Glove-port rectal surgery
Platforms

18. TEO® (Transanal Endoscopic Operation).
The equipment is similar to the Wolf system in that it consists of a rigid 4 cm proctoscope,
a faceplate with three working channels, and a stationary arm that holds it in place.
However, it can utilize conventional laparoscopic equipment.
Platforms

19. Single-incision laparoscopic surgery port (SILS Port), ((Covidien))
Advantages:
•The reduced cost.
•Ability to perform the procedure in lithotomy for the majority of patients.
Disadvantages:
•The technique requires an assistant to drive the camera.
•The SILS port obscures the distal rectum making it difficult to use for distal lesions.
Platforms

20. Glove-port rectal surgery
Platforms

21. 1) Excision of benign lesions, of the rectum, that cannot be removed with conventional
techniques including large or carpet type lesions.
2) Excision of the specimen in the management of early rectal cancers.
3) Repair of a rectovaginal fistula and in an experimental setting, as a platform for Natural
Orifice Transluminal Endoscopic Surgery (NOTES) including Transanal Total Mesorectal
Excision (TaTME Procedure).
4) As palliative surgery for advanced rectal lesions - (for patients with comorbid conditions
and disseminated disease who are otherwise unfit for more radical surgery).
Main indications for TEM
Indications

22. <30 % circumference of bowel
 <3 cm in size
 Mobile, non-fixed
 Within 8 cm of anal verge
 Tumor limited to Submucosa (T1)
 No evidence of lymphadenopathy (N0)
 Margin clear (>3 mm)
 Endoscopically removed polyp with cancer or indeterminate pathology
 No lymphovascular invasion or perineural invasion
 Well to moderately differentiated
NCCN guidelines requirements for TEM for rectal cancers :
Physical examination
Imaging (TRUS, MRI)
Histology

23. Contraindications for TEM:
•Positive lymph nodes
•Distant metastasis
•Ulcerated tumor
•Large tumor extending into muscularis propria (contraindicated owing to
the increased risk of lymph node invasion)
•Poorly differentiated tumor
•Lymphovascular invasion
Contraindications

27. Preoperative Workup
Full history and physical exam. (history of any pelvic radiation or prior surgery such as
prostatectomy, which may complicate transanal excision).
Endoscopic exam by operating surgeon to determine the patients’ appropriateness
for the procedure.
• Colonoscopy
•In malignancy, CT of the chest, abdomen, and pelvis along CEA.
•Endoscopic Rectal Ultrasound (ERUS)
• Rectal protocol MRI.
•Rigid proctoscopy or flexible sigmoidoscopy in the office to determine the
location of the lesion in question.
•The distance from the anal verge. (location of the lesion relative to the valves of
Houston when assessing candidacy for TEM. TEM can be used to reach most any
lesion distal to the third valve of Houston.

28. SURGICAL MANAGEMENT
Preoperative Planning
■ Patient preparation for TEM is the same for benign or malignant lesions.
■ Bowel preparation.
■ Preoperative antibiotics.
■ Discuss with patient the potential need for laparoscopy or laparotomy and a
possible diverting stoma.

29. Patient Positioning
■ Depends on the tumor location. (the tumor is in the dependent position during the
procedure).
■ The tumor should be at the centre of the operating rectoscope . (the operating
proctoscope limiting the reach of the instruments to the bottom 180 to 210 degrees of
the lumen).
SURGICAL MANAGEMENT

32. Marking

33. Excision with energy device

34. Excision with energy device

35. Excision with energy device

36. Good hemostasis

37. Closure of the defect

38. Closure of the defect

39. Closure of the defect

41. Safety and morbidity profile
 Initially there were concerns (incontinence) using the 4 cm rectoscope- being placed through the
sphincter complex into rectum for potentially long operations . There is data to show reduced anorectal
manometric pressures in patients who have undergone TEM, particularly the internal anal sphincter resting
pressure and that this is correlated to the length of their procedure. However this did not change
continence scores or other anorectal parameters.
Several studies have demonstrated anorectal function is preserved with the TEM technique,
even after repeat surgery in the same patients.
Some patients will develop anorectal dysfunction but this is multifactorial and associated with
excision of large specimens from the rectum and with resultant changes in capacity and
compliance

42.  Morbidity from TEM has been shown to range from 7.7% to 21% with the
commonest reported problems being urinary retention, suture line dehiscence
and bleeding.
 Entry into the peritoneal cavity occurs in 5.8% of cases and is associated with
higher anterior tumours .This may in fact be planned and is not regarded as a
definitively morbid event. The defect is simply sutured and antibiosis
administered.
 TEM can be employed for excision of lesions up to 20 cm from the anal verge
and for large lesion over 8 cm. Even in these challenging situations it has been
demonstrated to be safe and efficacious .
 The use of a harmonic scalpel can be employed through a standard TEM port
and may help reduce the incidence of bleeding during resection of lesions.
Safety and morbidity profile

43. Overall pre-operative radiotherapy with TEM is appealing as:
(1) Radiotherapy may effectively treat microscopic mesorectal nodal metastases
(2) Tumour downsizing should facilitate local excision with clear margins
(3) Tumour downstaging is measured objectively rather than relying upon clinical examination,
(4) Histopathological non-responders are converted to radical completion surgery.
Neoadjuvant radiotherapy is proven to reduce local recurrence following radical surgery by
approximately half and it may also be effective in improving oncological outcomes for local
excision, organ preserving techniques.
Neoadjuvant radiotherapy
With chemo-radiotherapy (CRT) In patients with rectal cancer high rates of complete
pathological response (ypCR) of 15–27% .

44. TEM excision following neoadjuvant treatment
Cons....
•Routine TEM resects the scar or residual abnormality so that no primary tumour cells
remain.
• Addition of TEMS following radiotherapy inevitably increases treatment related morbidity
with wound dehiscence being the most troublesome side effect .
•TEMS excision may also disrupt planes for future radical surgery. It may commit a patient
to an abdomino-perineal excision where a low anterior resection may have been possible
pre-TEM excision.
•Given this, there may be role for observation within this group of clinical complete
response, depending on tumour position and patient preference.

45. TEM has been widely adopted by colorectal surgeons over the last 30 years.
TEM requires specialist training and potentially expensive set up costs.
 TEM provides an invaluable resource for coloproctology. Its precise nature and resilient
technique has ensured it has a major role in the resection of benign and malignant neoplasms of
the rectum.
Its role in the management of early rectal cancer is increasing as the indication for local
excision combined with neoadjuvant therapies is growing.
TEM alone will treat a percentage of early rectal cancers and it will provide a lower risk option
for patients, with better functional outcome.
 On going research will dictate how we identify higher risk tumours pre operatively and who
will benefit from neoadjuvant radiotherapy or not.
Summary

46. Thank You

50. Completion surgery
 Demonstrated to be safe and return oncological outcome to that of primary TME surgery for
matched tumour groups.
In a series of 105 patients undergoing TEM for T1 rectal cancer the local recurrence rate was
6% for low risk T1 tumours with R0 resection whereas rate in the high risk group was 39%.
10 year follow up the cancer free survival was 93% in the reoperation
group and 89% in the TEMS alone group. This effect is seen in series where local excision
(other than TEMS) is used where immediate reoperation in high risk groups reduced
recurrence from 50% (non-operated) to 7.7% (operated). A recent case matched study no
difference was found in outcome between patients with rectal cancer undergoing completion
TME after TEMS (n ¼ 25) compared to those undergoing primary TME (n ¼ 25), with similar
pre and peri-operative parameters.
Recurrence was 0% in the completion group and 8% (p ¼ 0.49) in the primary group. Follow up
was short however, with a median of only 25 months (range of 3–126) but no difference in rates
of distant metastases was observed (4% v 12%, p0.61) [66].