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18 TAMIS: Current Controversies andChallenges
177
Complete muscle paralysis, decompression of
the pneumoperitoneum with a Veress needle, and
higher insufation pressures can also help maintain a stable pneumorectum in the face of peritoneal entry [8]. With increasing experience, the
rate of conversion following peritoneal entry during TEM has steadily decreased to below 10%
[16, 26, 27].
It is unclear whether TAMIS has an increased
risk of peritoneal entry as compared to TEM.Two
recent case-matched studies comparing TEM/
TEO and TAMIS did not nd any difference in
the rate of peritoneal entry between the two
methods [10, 28]. The larger of these studies
compared 181 TAMIS resections to 247 matched
TEM resections and found similar rates of peritoneal entry (3% versus 3%, p= 0.97) for lesions
with a median tumor distance of 7.0cm from the
anal verge in both groups [10]. However, other
studies have indicated that TAMIS is associated
with a higher risk of peritoneal entry. Molina
etal. examined this issue in 78 transanal resec-
tions using both TEO/TEM and TAMIS platforms [29]. They found that peritoneal entry
occurred in 22 cases (28%) and the use of a
TAMIS platform was associated with a higher
risk of peritoneal entry. Furthermore, of four
cases where peritoneal entry occurred during
TAMIS, all four required conversion to a rigid
platform to adequately expose and suture the
defect. Overall, the risk of peritoneal entry during
TAMIS appears to increase with distance from
the anal verge, as does the risk of conversion to
an alternative transanal or transabdominal
approach (Table18.1).
When it does occur, peritoneal entry during
TAMIS has been identied as a particular challenge [29]. In a training model comparing TEM
and TAMIS, surgeons consistently found TEM to
be superior for dissection, quality of vision, and
suturing difculty and found that TAMIS was not
effective for suture of the simulated rectal lesion
[30]. However, others have argued that this
exvivo study did not account for either the variety
Table 18.1 Summarization of recent, larger TAMIS series and rates of peritoneal entry, as well as the need for conversion to an alternative surgical approach
Median distance
from anal verge
Series N Platform
Albert etal. [8] 50 Gelpoint path 8.1 1 (2%) Not converted
Lee etal. [3] 25 SILS 9 0 N/A
McLemore etal.
[11]
Hahnloser etal. [2] 75 SILS 6.4 3 (4%) 3/3 (100%) converted to
Schiphorst etal.
[12]
Gill etal. [59] 65 Gelpoint path 7.5 0 N/A
Sumrien etal. [60] 28 Gelpoint path,
Haugvik etal. [61] 51 Gelpoint path,
Verseveld etal. [35] 24 SSL 8
Quaresima etal.
[62]
Keller etal. [32] 75 Gelpoint path,
CaycedoMarulanda etal.
[13]
Total 545 22 (4%) 11/22 (50%)
a
Distance from the dentate line
34 Gelpoint path 4 3 (9%) 3/3 (100%) converted to
37 SILS, SSL 7
SILS
SILS
31 Gelpoint path,
SILS
SILS
50 Gelpoint path 7 5 (10%) No conversions
(cm)
a
NR 1 (4%) Not converted
8 0 N/A
a
9.5 5 (16%) 1/5 (20%) converted to
10 3 (4%) 3/3 (100%) converted to
Rate of
peritoneal entry
1 (3%) 1/1 (100%) converted to
0 N/A
Rate of conversion
following peritoneal entry
laparoscopic
laparoscopic or open
laparoscopic
transanal excision (TAE)
laparoscopy
178
H. Carmichael and P. Sylla
of TAMIS platforms available or the use of automated suturing and knot-forming devices [31].
Worryingly, multiple TAMIS series have reported
conversion to laparoscopy or laparotomy for an
inability to close a rectal defect, detailed in
Table18.1 [2, 11, 12, 32]. In contrast to TEM, the
overall rate of conversion following peritoneal
entry in TAMIS appears to be as high as 50%
across larger series. It is unclear if this difculty
is primarily reective of the long learning curve
required for managing complex rectal lesions via
TAMIS.In a large series of 50 TAMIS cases by
Caycedo-Marundo etal., there were ve cases of
peritoneal entry, and all defects were closed
transanally via TAMIS [13]. The authors noted
that for this to be feasible, the surgeon must have
considerable experience suturing using TAMIS.
Thus, a reasonable approach may be to recognize that there may be increased risk of peritoneal
entry with TAMIS as compared to TEO and TEM
and that when TAMIS is used for lesions in the
upper rectum, particularly larger and more anterior lesions, the surgeon should have experience
and comfort with closing the defect using the
TAMIS platform [23, 26]. If the surgeon does not
have extensive experience with TAMIS, it may be
worthwhile to consider prone positioning, availability and experience with TEM equipment if
difculty is encountered in closing via TAMIS,
or discussing the risk of conversion to an abdominal approach with the patient prior to surgery.
Oncologic Outcomes After Peritoneal Entry During TAMIS
Risk of peritoneal entry is similar or even
increased with TAMIS as compared to TEM, as
previously mentioned [28, 33]. Thus, peritoneal
seeding is also a concern in TAMIS. However,
the literature on long-term oncologic impacts of
peritoneal entry during TEM for rectal cancer is
sparse, and there is no published literature related
specically to the concern of tumor seeding in
the abdominal cavity with TAMIS.With regard
to TEM, Morino etal. followed 13 patients where
peritoneal perforation occurred during TEM performed for rectal adenocarcinoma [26]. Although
there were cases of local recurrence and lung
metastases, no cases of liver or peritoneal metastases occurred with a median follow-up of
48 months. Similarly, Mege et al. followed 13
patients where peritoneal perforation occurred
after TEM for adenocarcinoma, with no cases of
local recurrence or distant metastasis after a
median follow-up of 11.5 months [23]. Again,
even with regard to TEM, long-term oncologic
outcomes after peritoneal perforation are sparse.
Fecal Incontinence
There is an ongoing debate with regard to whether
functional outcomes differ between TAMIS and
TEM, particularly with regard to fecal incontinence. TAMIS has been hypothesized to be less
likely to result in damage to the anal sphincter
given the relative exibility of the disposable
transanal ports as compared to the rigid TEM
design [34]. Alternatively, outcomes could theoretically be worse given the more extreme movements and stretch exerted on the sphincter in
TAMIS. Although the literature on functional
outcomes after TEM, both short and long term, is
robust, there are few studies that have explored
functional outcomes after TAMIS.
Short-term functional outcomes after TAMIS
have been explored in two small prospective
studies [12, 35]. Schiphorst etal. examined outcomes in 37 patients using the fecal incontinence
severity index (FISI) and found that 88% of
patients with abnormal baseline function experienced improvement in FISI scores, while 5% of
patients overall experienced postoperative
impaired continence [12]. Similarly, Verseveld
etal. examined functional outcomes in 24 patients
after TAMIS and found that 79% of patients with
abnormal baseline FISI experienced improvement in continence after TAMIS, while 21% of
patients overall experienced postoperative
impaired continence [35]. These studies had a
median follow-up of 11 and 6 months, respectively. These short-term results appear to be
comparable to TEM, which has been shown to
have rates of postoperative impaired continence
ranging from 0% to 21% [36–39].
18 TAMIS: Current Controversies andChallenges
179
However, a recent study by Clermonts et al.
was the rst to examine long-term functional
outcomes of TAMIS, with 42 patients and
median follow-up of 36months [40]. The authors
found that FISI score 1 year after TAMIS was
similar to preoperative FISI (5.4 vs. 8.3,
p = 0.501), although worse at 3 years (10.1,
p=0.01). In this study, 80% of patients with an
abnormal FISI prior to TAMIS exhibited
improved FISI at 3 years; however, 63% of
patients with normal continence at baseline
experienced worsened incontinence at 3 years.
This far exceeds the number of patients found to
have impaired continence in studies with longterm follow-up after TEM [41–43]. However, the
authors noted that most of the functional impairment that developed after TAMIS was minor and
perhaps with minimal impact on quality-of-life
(QOL) measures. Indeed, a recent follow-up
demonstrated that the worsened FISI scores did
not affect broader QOL measures for these
patients [44]. Given the current lack of head-tohead comparisons of TEM and TAMIS, it is
unclear if one approach is superior in regard to
functional outcomes.
Sleeve Resections
forCircumferential Lesions
There are currently no published reports of the
use of TAMIS for circumferential or “sleeve”
resections. Arezzo etal. reported the use of TEO
for resection of 17 circumferential rectal adenomas encompassing greater than three-quarters of
the rectal wall circumference [45]. Lesions were
at a median of 4 cm from the anal verge, with
lesions’ longitudinal extent of 7cm. Sleeve resection was performed, with circumferential fullthickness dissection of the distal margin, followed
by tunneling through perirectal fat to the proximal margin, and then circumferential incision of
the rectal wall at the proximal margin. The anastomosis was performed transanally using a fullthickness running suture with 3–0 Maxon secured
with silver clips (Richard Wolf, Knittlingen,
Germany). All patients had negative margins.
Two patients were upstaged to T2 rectal cancer
and underwent radical resection, with no recurrence at 42 and 24 months follow-up, respectively. One patient who was upstaged to a T3
lesion and did not undergo resection due to
comorbidities developed a local recurrence at
18months. One patient with high-grade dysplasia on nal pathology had a local recurrence that
was salvaged with transanal excision, with no
recurrence at 30 months. No other patients had
local recurrence on follow-up.
The authors reported no incidence of fecal
incontinence or sexual dysfunction. However,
stenosis at the level of the anastomosis occurred
in four patients. These patients were all treated
with endoscopic balloon dilation. One patient
developed a urinary stula after dilation that was
managed conservatively. Similarly, Mege et al.
documented 6 cases of rectal stenosis managed
with endoscopic or surgical dilatation in a series
of 194 patients undergoing resection with TEM,
all of which occurred in large, circumferential
adenomas (>50% of the rectal lumen) [23].
Although there are no published reports of
the use of TAMIS for resection of circumferential adenomas, it is reasonable to believe that
this could be a feasible and effective option
given the prior experience with the use of TEM
for this purpose, provided the surgeon has experience with suturing via a TAMIS platform.
Furthermore, TAMIS platforms have been used
for transanal total mesorectal excision (taTME),
which required full-thickness and circumferential rectal dissection, indicating the technical
feasibility of performing the anastomosis transanally [46, 47]. The concerns about the high rate
of stenosis observed in the previously described
study of TEM for circumferential adenomas,
however, would also be germane to the application of TAMIS for these lesions. The use of
TEM or TAMIS to accomplish full-thickness
excision of these lesions, as compared to partial-thickness excisions using endoscopic submucosal dissection (ESD) or endoscopic
mucosal resection (EMR), has the advantage of
avoiding the need for further surgery if lesions
are upstaged to early and low-risk rectal cancer,
as is frequently the case for these bulkier lesions
[48, 49].
180
H. Carmichael and P. Sylla
Partial- Versus Full-Thickness
Resections andRisk ofStenosis
Overall, the risk of rectal stenosis with either
TEM or TAMIS appears low, but it is much more
common in patients undergoing TEM for circumferential lesions, with rates as high as 78%
reported in the literature [50]. Some have argued
that TAMIS should not be used for circumferential adenomas because of this high risk of rectal
stenosis [18]. Management of rectal stenosis after
TAMIS or TEM is similar to stenosis seen after
low anterior resection. Most cases described in
the literature have been treated endoscopically
with balloon dilatation or stenting, or as a procedure under general anesthesia using Hegar dilators. The stenosis usually improves with one to
two treatment sessions [50].
It is unclear if partial-thickness resection in
cases of larger, circumferential lesions is associated with lower rates of stenosis when compared
to full-thickness resection. Given concerns for
higher rates of upstaging in such large adenomas,
full-thickness resection may be preferable. For
esophageal and gastric lesions involving more
than three-quarters of the luminal circumference,
endoscopic submucosal dissection (ESD) is associated with higher rates of stenosis as compared
to endoscopic mucosal resection (EMR).
However, these ndings may not be true for
colorectal lesions, perhaps because the presence
of stool in the rectum provides a dilating pressure
as the scar heals. Ohara et al. found that only
about 20% of ESD resections for these circumferential colorectal lesions developed stenosis at
1 month [51]. However, others have found that
while asymptomatic stenosis may occur, symptomatic stenosis requiring intervention was rare,
and the role of prophylactic endoscopic dilatation
is unclear [52]. It is also unclear what role endoluminal injection of steroids might play in preventing stenosis for colorectal lesions, although
this has been used after ESD for esophageal and
gastric lesions to prevent stenosis [53, 54].
Currently, there is no published evidence comparing stenosis rates after full-thickness resection
using TAMIS to those seen after partial-thickness
resection using ESD or EMR.Although there is a
theoretical benet to full-thickness resection of
large adenomas over partial-thickness resection
given higher rates of occult malignancy in these
lesions, it is unclear if this benet is outweighed
by the risk of stenosis.
Economics
There are no formal cost analyses comparing
TAMIS to TEM, although it is broadly accepted
that TAMIS is less expensive. The upfront cost of
the TEM platform is approximately $80,000,
while the cost per disposable transanal port is
approximately $500 to $800 [11]. Other authors
have noted that the cost of the insufation tubing
to TEM is equivalent to the cost per disposable
port [20]. A matched analysis comparing TEM
and TAMIS found that TAMIS had signicantly
lower median operative time (70 min versus
108min, p<0.001) as well as lower median hospital length of stay (0 days versus 1 day,
p<0.001) [10]. So while it appears that TAMIS
is likely cost-effective relative to TEM, there are
no published studies showing this.
Unusual Applications
Typical indications for transanal endoscopic surgery have been for removal of rectal adenomas
not amenable to standard endoscopic resection,
treatment of early rectal cancer, and scar excision
following neoadjuvant therapy [55]. However,
TEM has been used for a variety of rectal lesions
including neuroendocrine tumors, gastrointestinal stromal tumors (GIST), presacral tumors,
benign stricture, rectourethral stula, endorectal
condylomas, rectal prolapse, pelvic abscess, and
management of traumatic or iatrogenic rectal
perforation [55]. TEM has also been used in the
management of even more rare rectal lesions
such as isolated rectal ulceration, rectal endometriosis, ganglioneuroma, and melanoma [56].
Considering TAMIS specically, published
applications have been more limited, but the use
of TAMIS has been reported in the management
of neuroendocrine tumors [8, 11, 57] as well as
18 TAMIS: Current Controversies andChallenges
181
GIST excision and pelvic abscess drainage [57].
TAMIS has also been used to correct stenosis
occurring after low anterior resection as well as
pouch-related issues after proctocolectomy for
inammatory bowel disease [58]. Finally, technology developed for use in TAMIS has now
been used for transanal total mesorectal excision
(taTME), which will be the topic of the remainder of this book.
References
1. Martin-Perez B, Andrade-Ribeiro GD, Hunter
L, Atallah S. A systematic review of Transanal
Minimally Invasive Surgery (TAMIS) from 2010 to
2013. Tech Coloproctol. 2014;18:775–88.
2. Hahnloser D, Cantero R, Salgado G, Dindo D, Rega
D, Delrio P. Transanal minimal invasive surgery for
rectal lesions: should the defect be closed? Color Dis.
2015;17:397–402.
3. Lee T-G, Lee S-J.Transanal single-port microsurgery
for rectal tumors: minimal invasive surgery under spinal anesthesia. Surg Endosc. 2014;28:271–80.
4. Ragupathi M, Vande Maele D, Nieto J, Pickron
TB, Haas EM. Transanal Endoscopic VideoAssisted (TEVA) excision. Surg Endosc.
2012;26:3528–35.
5. Barendse RM, Doornebosch PG, Bemelman WA,
Fockens P, Dekker E, de Graaf EJR. Transanal
employment of single access ports is feasible for rectal surgery. Ann Surg. 2012;256:1030–3.
6. van den Boezem PB, Kruyt PM, Stommel MWJ,
Tobon Morales R, Cuesta MA, Sietses C.Transanal
single-port surgery for the resection of large polyps.
Dig Surg. 2011;28:412–6.
7. Lorenz C, Nimmesgern T, Langwieler TE.Transanal
endoscopic surgery using different single-port
devices. Surg Technol Int. 2011;21:107–11.
8. Albert MR, Atallah SB, deBeche-Adams TC,
Izfar S, Larach SW. Transanal Minimally Invasive
Surgery (TAMIS) for local excision of benign neoplasms and early-stage rectal cancer: efcacy and
outcomes in the rst 50 patients. Dis Colon Rectum.
2013;56:301–7.
9. Bridoux V, Schwarz L, Suaud L, Dazza M, Michot F,
Tuech J-J.Transanal minimal invasive surgery with
the endorec(TM) trocar: a low cost but effective technique. Int J Color Dis. 2014;29:177–81.
10. Lee L, Edwards K, Hunter IA, Hartley JE, Atallah SB,
Albert MR, etal. Quality of local excision for rectal
neoplasms using transanal endoscopic microsurgery
versus transanal minimally invasive surgery: a multiinstitutional matched analysis. Dis Colon Rectum.
2017;60:928–35.
11. McLemore EC, Weston LA, Coker AM, Jacobsen GR,
Talamini MA, Horgan S, etal. Transanal minimally
invasive surgery for benign and malignant rectal neoplasia. Am J Surg. 2014;208:372–81.
12. Schiphorst AHW, Langenhoff BS, Maring J, Pronk
A, Zimmerman DDE. Transanal minimally invasive
surgery: initial experience and short-term functional
results. Dis Colon Rectum. 2014;57:927–32.
13. Caycedo-Marulanda A, Jiang HY, Kohtakangas
EL. Transanal minimally invasive surgery for
benign large rectal polyps and early malignant rectal cancers: experience and outcomes from the rst
Canadian Centre to adopt the technique. Can J Surg.
2017;60:416–23.
14. Lee L, Burke JP, deBeche-Adams T, Nassif G,
Martin-Perez B, Monson JRT, Albert MR, Atallah
SB. Transanal minimally invasive surgery for local
excision of benign and malignant rectal neoplasia:
outcomes from 200 consecutive cases with midterm
follow up. Ann Surg. 2018;267(5):910–6. https://doi.
org/10.1097/SLA.0000000000002190.
15. São Julião GP, Celentano JP, Alexandre FA, Vailati
BB. Local excision and endoscopic resections
for early rectal cancer. Clin Colon Rectal Surg.
2017;30:313–23.
16. Serra-Aracil X, Gràcia R, Mora-López L, Serra-Pla S,
Pallisera-Lloveras A, Labró M, etal. How to deal with
rectal lesions more than 15 cm from the anal verge
through transanal endoscopic microsurgery. Am J
Surg. 2019;217(1):53–8.
17. Serra-Aracil X, Mora-Lopez L, Alcantara-Moral
M, Caro-Tarrago A, Navarro-Soto S. Transanal
Endoscopic Microsurgery with 3-D (TEM) or highdenition 2-D Transanal Endoscopic Operation
(TEO) for rectal tumors. A prospective, randomized
clinical trial. Int J Color Dis. 2014;29:605–10.
18. Serra-Aracil X, Mora-Lopez L, Alcantara-Moral
M, Caro-Tarrago A, Gomez-Diaz CJ, Navarro-Soto
S. Transanal endoscopic surgery in rectal cancer.
World J Gastroenterol. 2014;20:11538–45.
19. Thompson E, Bleier J. Transanal minimally invasive
surgery. Clin Colon Rectal Surg. 2017;30:112–9.
20. DeBeche-Adams T, Nassif G. Transanal minimally invasive surgery. Clin Colon Rectal Surg.
2015;28:176–80.
21. Bignell MB, Ramwell A, Evans JR, Dastur N,
Simson JNL.Complications of Transanal Endoscopic
Microsurgery (TEMS): a prospective audit. Color
Dis. 2010;12:e99–103.
22. Gavagan JA, Whiteford MH, Swanstrom LL. Fullthickness intraperitoneal excision by transanal endoscopic microsurgery does not increase short-term
complications. Am J Surg. 2004;187:630–4.
23. Mege D, Petrucciani N, Maggiori L, Panis
Y. Peritoneal perforation is less a complication than
an expected event during transanal endoscopic microsurgery: experience from 194 consecutive cases. Tech
Coloproctol. 2017;21:729–36.
24. Allaix ME, Arezzo A, Caldart M, Festa F, Morino
M. Transanal endoscopic microsurgery for rectal
neoplasms: experience of 300 consecutive cases. Dis
Colon Rectum. 2009;52:1831–6.
182
H. Carmichael and P. Sylla
25. Barendse RM, Dijkgraaf MG, Rolf UR, Bijnen AB,
Consten ECJ, Hoff C, et al. Colorectal surgeons’
learning curve of transanal endoscopic microsurgery.
Surg Endosc. 2013;27:3591–602.
26. Morino M, Allaix ME, Famiglietti F, Caldart M,
Arezzo A.Does peritoneal perforation affect shortand long-term outcomes after transanal endoscopic
microsurgery? Surg Endosc. 2013;27:181–8.
27. Salm R, Lampe H, Bustos A, Matern U.Experience
with TEM in Germany. Endosc Surg Allied Technol.
1994;2:251–4.
28. Mege D, Bridoux V, Maggiori L, Tuech JJ, Panis
Y. What is the best tool for Transanal Endoscopic
Microsurgery (TEM)? A case-matched study in 74
patients comparing a standard platform and a disposable material. Int J Color Dis. 2017;32:1041–5.
29. Molina G, Bordeianou L, Shellito P, Sylla P.Transanal
endoscopic resection with peritoneal entry: a word of
caution. Surg Endosc. 2016;30(5):1816–25.
30. Rimonda R, Arezzo A, Arolfo S, Salvai A, Morino
M.TransAnal Minimally Invasive Surgery (TAMIS)
with SILSTM port versus Transanal Endoscopic
Microsurgery (TEM): a comparative experimental study. Surg Endosc Other Interv Tech.
2013;27:3762–8.
31. Atallah SB, Albert MR.Transanal Minimally Invasive
Surgery (TAMIS) versus Transanal Endoscopic
Microsurgery (TEM): is one better than the other?
Surg Endosc. 2013;27:4750–1.
32. Keller DS, Tahilramani RN, Flores-Gonzalez JR,
Mahmood A, Haas EM. Transanal minimally invasive surgery: review of indications and outcomes
from 75 consecutive patients. J Am Coll Surg.
2016;222:814–22.
33. Molina G, Bordeianou L, Shellito P, Sylla P.Transanal
endoscopic resection with peritoneal entry: a
word of caution. Surg Endosc Other Interv Tech.
2016;30:1816–25.
34. Atallah S, Albert M, Larach S.Transanal minimally
invasive surgery: a giant leap forward. Surg Endosc.
2010;24:2200–5.
35. Verseveld M, Barendse RM, Gosselink MP, Verhoef
C, de Graaf EJR, Doornebosch PG. Transanal
minimally invasive surgery: impact on quality of life and functional outcome. Surg Endosc.
2016;30:1184–7.
36. Herman RM, Richter P, Walȩga P, Popiela T.Anorectal
sphincter function and rectal barostat study in patients
following transanal endoscopic microsurgery. Int J
Color Dis. 2001;16:370–6.
37. Doornebosch PG, Tollenaar RAEM, Gosselink MP,
Stassen LP, Dijkhuis CM, Schouten WR, etal. Quality
of life after transanal endoscopic microsurgery and
total mesorectal excision in early rectal cancer. Color
Dis. 2007;9:553–8.
38. Planting A, Phang PT, Raval MJ, Brown CJ.Transanal
endoscopic microsurgery: impact on fecal incontinence and quality of life. Can J Surg. 2013;56:243–8.
39. Hompes R, Ashraf SQ, Gosselink MP, van Dongen
KW, Mortensen NJ, Lindsey I, etal. Evaluation of qual-
ity of life and function at 1 year after transanal endoscopic microsurgery. Color Dis. 2015;17:O54–61.
40. Clermonts SHEM, van Loon YT, Schiphorst AHW,
Wasowicz DK, Zimmerman DDE. Transanal
minimally invasive surgery for rectal polyps and
selected malignant tumors: caution concerning
intermediate-term functional results. Int J Color Dis.
2017;32:1677–85.
41. Dafnis G, Påhlman L, Raab Y, Gustafsson U-M, Graf
W. Transanal endoscopic microsurgery: clinical and
functional results. Color Dis. 2004;6:336–42.
42. Allaix ME, Rebecchi F, Giaccone C, Mistrangelo M,
Morino M.Long-term functional results and quality
of life after transanal endoscopic microsurgery. Br J
Surg. 2011;98:1635–43.
43. Restivo A, Zorcolo L, D’Alia G, Cocco F, Cossu A,
Scintu F, etal. Risk of complications and long-term
functional alterations after local excision of rectal
tumors with Transanal Endoscopic Microsurgery
(TEM). Int J Color Dis. 2016;31:257–66.
44. Clermonts SHEM, van Loon Y-T, Wasowicz DK,
Langenhoff BS, Zimmerman DDE. Comparative
quality of life in patients following transanal minimally invasive surgery and healthy control subjects. J
Gastrointest Surg. 2018;22:1089–97.
45. Arezzo A, Arolfo S, Allaix ME, Bullano A, Miegge A,
Marola S, et al. Transanal endoscopic microsurgery
for giant circumferential rectal adenomas. Color Dis.
2016;18:897–902.
46. Penna M, Knol JJ, Tuynman JB, Tekkis PP, Mortensen
NJ, Hompes R.Four anastomotic techniques following Transanal Total Mesorectal Excision (TaTME).
Tech Coloproctol. 2016;20:185–91.
47. Penna M, Hompes R, Arnold S, Wynn G, Austin R,
Warusavitarne J, et al. Transanal total mesorectal
excision: international registry results of the rst 720
cases. Ann Surg. 2017;266(1):111–7.
48. Baatrup G, Elbrønd H, Hesselfeldt P, Wille-Jørgensen
P, Møller P, Breum B, etal. Rectal adenocarcinoma and
transanal endoscopic microsurgery. Diagnostic challenges, indications and short term results in 142 consecutive patients. Int J Color Dis. 2007;22:1347–52.
49. Arezzo A, Passera R, Marchese N, Galloro G, Manta
R, Cirocchi R.Systematic review and meta-analysis
of endoscopic submucosal dissection vs endoscopic
mucosal resection for colorectal lesions. United
European Gastroenterol J. 2016;4:18–29.
50. Barker JA, Hill J.Incidence, treatment and outcome
of rectal stenosis following transanal endoscopic
microsurgery. Tech Coloproctol. 2011;15:281–4.
51. Ohara Y, Toyonaga T, Tanaka S, Ishida T, Hoshi N,
Yoshizaki T, etal. Risk of stricture after endoscopic
submucosal dissection for large rectal neoplasms.
Endoscopy. 2016;48:62–70.
52. Abe S, Sakamoto T, Takamaru H, Yamada M,
Nakajima T, Matsuda T, et al. Stenosis rates after
endoscopic submucosal dissection of large rectal
tumors involving greater than three quarters of the
luminal circumference. Surg Endosc Other Interv
Tech. 2016;30:5459–64.
18 TAMIS: Current Controversies andChallenges
183
53. Hashimoto S, Kobayashi M, Takeuchi M, Sato
Y, Narisawa R, Aoyagi Y. The efficacy of endoscopic triamcinolone injection for the prevention of esophageal stricture after endoscopic
submucosal dissection. Gastrointest Endosc.
2011;74:1389–93.
54. Mori H, Raq K, Kobara H, Fujihara S, Nishiyama
N, Kobayashi M, etal. Local steroid injection into the
articial ulcer created by endoscopic submucosal dissection for gastric cancer: prevention of gastric deformity. Endoscopy. 2012;44:641–8.
55. Serra-Aracil X, Mora-Lopez L, Alcantara-Moral
M, Corredera-Cantarin C, Gomez-Diaz C, NavarroSoto S. Atypical indications for transanal endoscopic microsurgery to avoid major surgery. Tech
Coloproctol. 2014;18:157–64.
56. Ortenzi M, Ghiselli R, Cappelletti Trombettoni MM,
Cardinali L, Guerrieri M. Transanal endoscopic
microsurgery as optimal option in treatment of rare
rectal lesions: a single centre experience. World J
Gastrointest Endosc. 2016;8:623.
57. García-Flórez LJ, Otero-Díez JL, Encinas-Muñiz AI,
Sánchez-Domínguez L. Indications and outcomes
from 32 consecutive patients for the treatment of rec-
tal lesions by transanal minimally invasive surgery.
Surg Innov. 2017;24:336–42.
58. Borstlap WAA, Harran N, Tanis PJ, Bemelman
WA. Feasibility of the TAMIS technique for redo
pelvic surgery. Surg Endosc Other Interv Tech.
2016;30:5364–71.
59. Gill S, Stetler JL, Patel A, Shaffer VO, Srinivasan J,
Staley C, etal. Transanal Minimally Invasive Surgery
(TAMIS): standardizing a reproducible procedure. J
Gastrointest Surg. 2015;19:1528–36.
60. Sumrien H, Dadnam C, Hewitt J, McCarthy
K. Feasibility of Transanal Minimally Invasive
Surgery (TAMIS) for rectal tumours and its impact
on quality of life– the Bristol series. Anticancer Res.
2016;36:2005–9.
61. Haugvik S-P, Groven S, Bondi J, Vågan T,
Brynhildsvoll SO, Olsen OC.A critical appraisal of
Transanal Minimally Invasive Surgery (TAMIS) in
the treatment of rectal adenoma: a 4-year experience
with 51 cases. Scand J Gastroenterol. 2016;51:855–9.
62. Quaresima S, Balla A, Franceschilli L, La Torre M,
Iafrate C, Shalaby M, etal. Transanal minimally invasive surgery for rectal lesions. J Soc Laparoendosc
Surg (JSLS). 2016;20:e2016.00032.
Part II
Transanal Total Mesorectal
Excision (taTME)
Indications for Malignant Neoplasia of the Rectum
Reagan L. Robertson and Carl J. Brown
19
The surgical management of rectal cancer continues to present surgeons with many challenges.
Total mesorectal excision (TME) is the standard
of care in rectal cancer surgery, with the goal of
negative circumferential and distal resection margins (CRM and DRM) and clearance of the associated lymph nodes. High-quality TME is
associated with lower locoregional recurrence
rates and improved patient outcomes [1].
Innovations in rectal cancer surgery have led to
the introduction of laparoscopic and robotic techniques of TME dissection. Regardless of operative approach, the traditional “top-down” TME
retains several signicant challenges. Operating
in the conned space of the pelvis is technically
challenging due to several tumor- and patientrelated factors, particularly for low lesions. High
rates of conversion, positive margins, and suboptimal TME quality remain ongoing issues.
Additionally, as transanal minimally invasive
approaches to rectal neoplasms are increasingly
used, radical resection following local excision is
more common, which poses new technical challenges related to perirectal inammation and
brosis.
The “bottom-up” approach of taTME has
several advantages in overcoming the chal-
R. L. Robertson · C. J. Brown(*)
St. Paul’s Hospital, Department of Colorectal
Surgery, Vancouver, BC, Canada
lenges of abdominal TME.The novel transanal
vantage point, in theory, could facilitate better
margins and higher rates of success with minimally invasive procedures in patients with rectal cancer. Currently, long-term outcomes of the
procedure are not known, and there are no standardized methods for patient selection. The
procedure should not be applied to all patients,
and careful consideration of the potential risks
and benets to the individual patient is required.
This chapter reviews the various indications for
taTME in malignant disease of the rectum and
its proposed advantages for certain patient
populations.
Operative Approach for TME
Abdominal TME
The gold standard for rectal cancer resection is
high-quality TME, as described by Heald [1].
Conventionally, TME has been performed via an
open abdominal approach in the “top-down” fashion. Laparoscopic and robotic TME have recently
become more widely adopted in recent years.
Whatever the approach, low pelvic dissection
presents many well-described technical challenges. The bony pelvis creates a rigid and narrow
operative eld, and visualization is often suboptimal. The use of long instruments leads to problems
with conict and angulation. Delineation of the
© Springer Nature Switzerland AG 2019
S. Atallah (ed.), Transanal Minimally Invasive Surgery (TAMIS) and Transanal Total Mesorectal
Excision (taTME), https://doi.org/10.1007/978-3-030-11572-2_19
187
188
R. L. Robertson and C. J. Brown
distal margin and rectal transection with stapling
devices can be difcult and imprecise. These difculties become further exaggerated in the narrow male pelvis or in obese patients with a bulky
mesorectum [2, 3]. In laparoscopic surgery, the
traction required to obtain adequate visualization
may lead to mesorectal tearing and defects.
Multiple laparoscopic stapler rings may also be
required for distal transection, which may lead to
more anastomotic complications [3–6]. These
challenges may have negative effects on patients’
pathologic and oncologic outcomes. Correct
plane of dissection is critical when performing
TME. Wrong plane dissection can lead to poor
quality TME (incomplete mesorectal envelope),
which is associated with worse long-term oncologic outcomes [1, 7]. Alternatively, dissecting
outside the mesorectal plane can lead to injury to
other critical structures such as the pelvic nerves,
presacral and side-wall vasculature, or urogynecologic structures. Such injuries can have important deleterious effects on patient function and
quality of life.
Laparoscopic TME (lapTME) has some shortterm advantages over open TME, including
shorter length of stay and return of bowel function, less postoperative pain, and lower rates of
wound infection [8]. Multiple studies have also
shown that lapTME appears to be a safe alternative to open TME for rectal cancer in terms of
morbidity and oncologic outcomes [9, 10].
Regardless, lapTME continues to pose some signicant challenges. A need for conversion to an
open procedure has been reported in 10–34% of
patients, particularly for males, the morbidly
obese, and those with a narrow pelvis [9, 11, 12].
In the COLOR II trial, 16% of patients were converted to open; a narrow pelvis (22%), obesity
(10%), and issues with visualization and tumor
bulk were also cited as common reasons [9].
Robotic TME hoped to address some of the issues
seen with lapTME, but conversion rates remain
high in certain patients with predictors of difcult TME, such as obesity [13]. Converted procedures are known to have worse oncologic
outcomes than both their open and laparoscopic
counterparts [2]. These results raise concern
regarding the use of lapTME, especially in these
patient populations. In addition, two recent studies, the ALaCaRT and ACOSOG Z6051, failed to
show non-inferiority of lapTME over open TME
for rectal cancer when assessing margin status
and TME quality [14, 15]. Traction injuries to the
mesorectum sustained while attempting to gain
exposure in the deep pelvis and difculty with
accurate denition of the distal resection margin
from above are thought to have contributed to the
results. Abdominal TME has reported rates of
positive CRM of 1.2–18.1% and incomplete or
near-complete TME in 11–13% and 25–28% of
patients, respectively [16]. These ndings highlight the ongoing challenges with performing
TME dissection and the need for alternate operative strategies that may improve outcomes.
Transanal TME
including lapTME, open and endoscopic transanal dissection, and natural orice surgery. It has
become apparent that the “bottom-up” dissection
addresses some of the problems inherent to
abdominal TME.Precise delineation of the distal
margin is easily accomplished with the transanal
operating scope and placement of a distal purse
string (Fig.19.1). Accurate denition of a clear
Fig. 19.1 Demonstration of delineation of the distal margin with the purse-string suture during taTME.The rectal
tumor is visible in the proximal rectal lumen with a clear
distal margin between the lesion and the proximal pursestring suture