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FIGURE24-4Meticuloushemostasisoftheexcisionbed
isimportantpriortotransverseclosure.
Thedefectistransverselyclosedwithrunningabsorbablesutures.For largedefects,itishelpfultoorientthetransverseclosurebystartingwith asinglesutureinthecentertoapproximatethetwoedgesandorientthe lineofclosure.
Followingtheclosure,thesuturelineshouldbeinspectedand interrogatedforanydefects.Therectallumenabovethelineofclosure shouldalsobeinspectedtoconfirmthattherectallumenhasnotbeen obliteratedbytheclosure.
Inmanycases,theclosureofthewoundisdifficultorresultsin significantnarrowingoftherectallumen.Inthesecases,itissafetoleave thesewoundsopentohealbysecondaryintention;however,inour experience,thesepatientshavesignificantlymorepainpostoperatively.
Intherarecasesofapedunculatedorextremelymobilerectalpolyp,it issometimespossibletoevertthepolypthroughtheanalcanalandexcise thelesionwithanEndoGIAstapler.
Althoughmoreproximalrectalpolypsshouldoftenbeexcisedby transanalendoscopicmicrosurgeryorlowanteriorresection,itispossible toexciselesionsusinganoperatingproctoscopeandatransanalsnare.As thisisnotafull-thicknessexcision,itshouldbereservedforbenign tumors.Whileattemptingtoremovealesionwiththesnare,greatcare shouldbetakenwithanteriorandanterolateraltumorstoavoidentering theperitonealcavity.Largerlesionsshouldbeexcisedinapiecemeal fashionasanenblocsnareexcisioncanoftenresultinafull-thickness injurytotherectalwall.
POSTOPERATIVEMANAGEMENT
Themajorityofpatientscanbetreatedintheoutpatientsetting.As urinaryretentionisacommonpostoperativecomplication,patients shouldbeabletovoidpriortodischarge.Inourpractice,patientswho haveanopenwoundaredischargedon7daysoforalantibiotics.Patients shouldbegivenanamplesupplyofpainmedicationsandstoolsofteners. Sitzbathsmayprovidesomereliefforpatientswithlowlesionsthat extenddownintotheanalcanal.

COMPLICATIONS

Complicationswithtransanalexcisionsaresimilartothoseofother anorectalproceduresandincludeurinaryretentionandbleeding. Althoughpelvicsepsisisrare,itshouldbeconsideredinpatientswho developfever,worseningpain,ordelayedurinaryretention.Ifsepsisis suspected,thepatientshouldbeexpeditiouslytakentotheoperating roomforanexaminationunderanesthesia.Rectaloranalstenosisaftera transanalexcisionisararecomplicationthatisusuallycorrectedwith simpledilation.

RESULTS

Theutilityoftraditionaltransanalexcisionhascomeintoquestionwith theemergenceofothertransanaltechniquessuchastransanalendoscopy surgery(TES).Severalsmall,single-institutioncomparativestudieshave beenperformedwithrelativelyconsistentresults.Theseresultshavealso beenvalidatedinarecentsystematicreview.ThedataindicatethatTES issuperiortotransanalexcisionwithsignificantlyhighernegativemargin rates(OR5.3,95%CI3.2–8.7)anddecreasedspecimenfragmentation rates(OR0.096,95%CI0.044–0.21).TEMisalsosuperiortotransanal excisionwithadecreasedrateoftumorrecurrence(OR0.25,95%CI
0.15–0.40).Theredoesnotappeartobeanydifferencebetweenthetwo proceduresintermsofcomplications.
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AlthoughtheliteratureclearlysupportstheefficacyofTESover transanalexcision,itshouldbenotedthatTEScanbetechnicallydifficult toperformforlowlesionsintheanalcanal.Giventheseresults,one shouldconsiderTESinsteadoftransanalexcisionforneoplasmsinthe rectumabovetheanalcanal.

CONCLUSIONS

Transanalexcisionisaminimallyinvasivemeansbywhichtoremovea rectaltumor,butitisbynomeansasimpleprocedure.Thekeytothe surgeryliesinadequateexposureandlighting.Althoughappropriatefor benigndistalrectallesions,carefulselectionshouldbeusedformalignant lesionsthataretobetreatedwithlocalexcisionalone.Alternativemeans ofresectionsuchasTESshouldbeconsideredforlesionscephaladtothe analcanal.
RECOMMENDEDREFERENCESAND READINGS
BledayR,BreenE,JessupJM,BurgessA,SentovichSM,SteeleGJr.Prospectiveevaluationof
localexcisionforsmallrectalcancers.DisColonRectum1997;40:388–92. BonnenM,CraneC,VautheyJN,etal.Long-termresultsusinglocalexcisionafterpreoperative
chemoradiationamongselectedT3rectalcancerpatients.IntJRadiatOncolBiolPhys
2004;60:1098–105. BorschitzT,HeintzA,JungingerT.Theinfluenceofhistopathologiccriteriaonthelong-term
prognosisoflocallyexcisedpT1rectalcarcinomas:resultsoflocalexcision(transanal
endoscopicmicrosurgery)andimmediatereoperation.DisColonRectum2006;49:1492–506;
discussion500–5. ChristoforidisD,ChoHM,DixonMR,MellgrenAF,MadoffRD,FinneCO.Transanalendoscopic
microsurgeryversusconventionaltransanalexcisionforpatientswithearlyrectalcancer.Ann
Surg2009;249:776–82. ClancyC,BurkeJP,AlbertMR,etal.Transanalendoscopicmicrosurgeryversusstandard
transanalexcisionfortheremovalofrectalneoplasms:asystematicreviewandmeta-analysis.
DisColonRectum2015;58:254–61. GordonP,NivatvongS,eds.NeoplasmsoftheColon,Rectum,andAnus.NewYork,NY:Informa
Healthcare,2007:328–39. GordonP,NivatvongS,eds.PrinciplesandPracticeofSurgeryfortheColon,Rectum,andAnus.
NewYork,NY:InformaHealthcare,1999:491–9. HanJ,NohGT,CheongC,etal.Transanalendoscopicoperationversusconventionaltransanal
excisionforrectaltumors:case-matchedstudywithpropensityscorematching.WorldJSurg
2017;41:2387–94. MadboulyKM,RemziFH,ErkekBA,etal.RecurrenceaftertransanalexcisionofT1rectalcancer:
shouldwebeconcerned?DisColonRectum2005;48:711–9;discussion9–21. MooreJS,CataldoPA,OslerT,HymanNH.Transanalendoscopicmicrosurgeryismoreeffective
thantraditionaltransanalexcisionforresectionofrectalmasses.DisColonRectum
2008;51:1026–30. NascimbeniR,BurgartLJ,NivatvongsS,LarsonDR.RiskoflymphnodemetastasisinT1
carcinomaofthecolonandrectum.DisColonRectum2002;45:200–6. NastroP,BeralD,HartleyJ,MonsonJR.Localexcisionofrectalcancer:reviewofliterature.Dig
Surg2005;22:6–15. RothenbergerD,Garcia-AguilarJ.Rectalcancer:localtreatment.In:FazioV,ChurchJ,Delaney
C,eds.CurrentTherapyinColonandRectalSurgery.Philadelphia,PA:ElsevierMosby,
2005:179–84. SaclaridesTJ.TEM/localexcision:indications,techniques,outcomes,andthefuture.JSurg
Oncol2007;96:644–50.
Chapter25
TransanalEndoscopic Operating
DeborahS.KellerandSamAtallah

INTRODUCTION

Advancedlocalexcisiontechniquesforbenignandearlystagerectal tumorsareincreasinglybeingutilizedbecauseoftheirlowmorbidity,and excellentfunctionalandoncologicoutcomesforwell-selectedlesions. excellentfunctionalresults,andexcellentoncologicoutcomesforwell­selectedlesions.Thevideoendoscopicplatformsforlocalexcision— transanalendoscopicmicrosurgery(TEM),transanalminimallyinvasive surgery,andtransanalendoscopicoperation(TEO)—havebeenshownto offersuperiorvisualization,precision,andlowerratesofspecimen fragmentationandmarginpositivityinmalignantdiseasecomparedwith traditionaltransanalexcision(TAE).Althoughtheadvancedvideo endoscopicplatformsallprovidethesamehigh-qualitylocalexcision, thereareimportantdifferencesanddistinctionsamongplatforms.

INDICATIONS/CONTRAINDICATIONS

Indications
TEOisanadvancedvideoendoscopicplatformusedforTAEofrectal tumors.TEOhasgainedinterestamongcolorectalsurgeonsbecauseof theenhancedvisibility,superioroptics,andlongerreachintherectum thataffordsamorecomplete,full-thicknessexcisionandpreciseclosure oftherectaldefect.TEOcanbeusedineitherbenignormalignant disease,andreachesmostlesionsinthelow,mid,andupperrectum (Table25-1).
TABLE25-1 IndicationsforTEO
Earlystagerectaltumors
Largevillousadenomas
Rectalcarcinoidtumors
Palliativetreatmentforadvancedrectal cancerorpatientsmedicallyunfitformajor surgery
NaturalOrificeTransluminalEndoscopic Surgery
Transanalportionofcombinedabdominal andtransanalresections
Inmalignantdisease,theindicationsforTEOgenerallyfollowthe NationalCancerComprehensiveNetwork(NCCN)guidelinesforlocal excisionofrectalmasses:benignandwelltomoderatelydifferentiatedT1 tumors<3cminsize,thatoccupylessthanathirdofthebowelwall circumference,andwithouthigh-riskfeatures.Specifically,TEOaloneis supportedforTisandfavorablecT1lesions.Onlypatientswithmagnetic resonanceimaging(MRI)orultrasoundstagingrulingoutinvasionofthe muscularispropriaaresuitableforTEOforcurativeintent.Forthese earlycancers,TEOtreatmentissafeandcanachievelowlocalrecurrence andhighsurvivalrateswhencomparedwithconventionaltransanal excisional.InhighergradeT2tumorsorunfavorableT1tumors,TEOcan beusedwithneoadjuvantoradjuvanttreatmentonaclinicaltrialbasis. TEOcanbeusedforpalliativeresectioninadvancedrectalcancers.In patientswithadvancedormetastaticrectaltumorsthatprecludecurative
resection,orpatientsmedicallyunabletotoleratemoreextensive surgery,localexcisioncansignificantlyrelievesymptomsoftenesmus, obstruction,andbleedingandimprovequalityoflife.Rectalcarcinoid tumors<10mminsizethathavenotinvadedthesubmucosacanbe resectedwithcurativeintentbyTEO.
TEOisindicatedforresectionoflargeadenomatouslesions.Larger polyps,especiallythevilloustype,haveasignificantrateofcontaining invasivecarcinomas,evenwhenpelvicMRIandendorectalultrasound confirmaT0N0mass.TEOiscapableofresectinglesionsspanning acrossthreequadrantsorupto10–12cmindiameter.Thefull-thickness en-blocspecimencanserveasa“completebiopsy,”allowingforamore accuratepathologicassessmentanddiseasestaging.Wheninvasive canceroradversepathologicfactorsarefound,TEMcansafelybeusedas abridgetoradicalresection,asappropriate.
Withtheincreasingadoptionoftransanaltotalmesorectaldissection, TEOhasfoundanindicationinthetransanalportionoftheresection. TEOgivestheadvantagesofsuperiorvisualizationandidentificationof theanatomyinthedeeppelvis,foranoptimalmesorectaloncologic dissectionwithsphincterpreservation.TheprogressionofNaturalOrifice TransluminalEndoscopicSurgeryalsoprovidesanindicationforTEO, wherespecimenextractioncanbeperformedthroughthistransanal platform.
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Contraindications
TheabsolutecontraindicationstoTEOarebasedonlocationand invasion.Thelengthoftherectoscopedeterminestheproximallimits whilethedistallimitisattheanalverge.Anatomicalfeaturescanbea relativecontraindication,withanarrowrectosigmoidjunction,small rectalampulla,andpriorabdominalorpelvicprocedureslimitingthe abilitytoplacetherectoscope.Foradvancedlesionswithinvasion throughthesubmucosa(T1)andintothemuscularispropria(T2)or lesionswithhigh-riskhistologicfeatures,TEOisnotappropriatefor curativeintentandshouldbeofferedonlyforpalliationorinmedically unfitpatientsunabletotoleratemoreextensivesurgery.
PREOPERATIVEPLANNING
Preoperativeplanningisparamountforalllocalexcision.Propercase selectionismandatoryfortheuseofTEOinthecurativetreatmentof earlyrectalcancers.AllpossibleTEOcandidatesshouldundergofull preoperativestagingaccordingtotheNCCNguidelines.Acomplete colonoscopywithmultifocalbiopsyshouldbeperformedfortissue diagnosis.Rigidproctoscopyisnecessarytoconfirmtheproximalextent ofthemass,distancefromtheanalverge,size,andlocationbyquadrant (anterior,posterior,rightorleftlateral).Endorectalultrasoundisadvised foraccuratetumorandregionallymphnodestaging,whereaspelvicMRI isavaluablecomplementtoconfirmtumorstageandlymphnodestatus. Ifinvasivecancerissuspectedorconfirmed,acomputedtomography scanofthethorax,abdominal,andpelvisisperformedtoruleout distancemetastasis.Hematologicanalysisisperformed,includinga completebloodcountandthetumormarkercarcinoembryonicantigen (CEA)forabaselinevalue.
Forallpatients,functionalstatusiselicitedthroughavalidatedfecal incontinencescale,suchastheClevelandClinic(Wexner)Fecal IncontinenceScore.Ifsignsoffecalincontinencearepresent,anorectal manometryisperformedtoobtainbaselinepressureandfunctional values,andassuretheprocedureisappropriate.
Patientsareadvisedtoabstainfromnonsteroidalanti-inflammatory drugs(NSAIDs)andprophylacticaspirinforaweekpreoperatively. Therapeuticanticoagulationisnotstopped,andcarefulhemostasisis ensuredinthesepatients.
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