Transanal Endoscopic Operation Indication

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Transanal Endoscopic Operation Indication
Technique Results M. Sailer

• Department of Surgery
• Bethesda Hospital Hamburg, Germany

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TEO Stage adapted concepts in rectal surgery

• Preoperative Staging
• Differentiated surgical therapy
• Control of local recurrence
• (Neo-) adjuvant therapy
• Improvement of survival
• Functional aspects
• Improvement of quality of life (QoL)

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TEOPreoperative Staging

• Crucial for planning of therapy
• Operative strategies
• Local resection techniques (e.g. TEO or TEM)
• Sphincter preserving resection
• Abdominoperineal resection (APR)
• Multivisceral resection
• Palliative operations (e.g. stoma, stent)
• Neoadjuvant therapy
• Radio- / chemotherapy (long course)
• Short course radiation (5 x 5 Gy)

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TEORectal adenoma or T1 Carcinoma EUS
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TEOT3 Carcinoma EUS
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TEOT4 Carcinoma EUS
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TEOOperative Procedures Rectal Cancer

• Transanal excision (T1-Ca)
• Low anterior resection (LAR)
• Ultralow or intersphincteric resection
• Abdominoperineal resection (APR)
• Compulsary for all resecting procedures
• Total Mesorectal Excision (TME)

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TEOIndications for local excision

• Adenomas
• Carcinomas of the mucosa or submukosa
• Well differentiated grading (G1 / 2)
• No lymphangiosis carcinomatosa (L0)
• No vascular invasion (V0)
• Tumor size lt 3 cm
• Apropriate localisation

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TEO Small T1 - Carcinoma (G2)
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TEOT1 Carcinomas EUS
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TEO Original device for TEM (Buess et al.)
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TEO New device for TEO by Storz Co.
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TEO Incidence of loco-regional LN Mets (n
3.241 Hermanek 2000)

• Low risk High risk
• 
  () ()
• T1 (Submucosa) 2 17
• T2a (inner muscularis) 10 42
• T2b (outer muscularis) 20
  45
• T3a (lt 10 mm perirectal) 23
  71
• T3b (gt 10 mm perirectal) 30
  89

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TEO Transatlantic Dispute
Lokale Therapieprinzipien beim Rektumkarzinom
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TEO Outcome Sengupta, Dis Colon Rectum 2001
Nastro, Dig Surg 2005

• gt 10 studies und gt 300 patients
• Local recurrence rate 4,2 - 25
• Overall survival 62 - 100
• Inclusion criteria very variable
• (T1 to T3 also high-risk)
• Excellent results with stringent selection
  criteria

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TEO Outcome Sengupta, Dis Colon Rectum 2001
Nastro, Dig Surg 2005

• gt 10 studies und gt 300 patients
• Local recurrence rate 4,2 - 25
• Overall survival 62 - 100
• Inclusion criteria very variable
• (T1 to T3 also high-risk)
• Excellent results with stringent selection
  criteria

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TEO Postoperative function Cataldo et al, Dis
Colon Rectum 2005

• Prospective study of 39 patients
• Standardized scores for continence and QoL
• Evaluation preoperatively and 6 weeks postop.
• No differences preop. vs. postop. regarding
• Frequency, -consistence
• Urgency
• Episodes of incontinence
• Quality of Life

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TEO Outcome own experience

• Prospective evaluation of 134 patients (67 J.)
• TEO n 113 Anal retractor n 21
• Preoperative staging accuracy (EUS) 93
• Complications
• 4 anastomotic dehiscences, 1 stoma formation
• 9 haemorrhages 3 x transfusions 3 x operative
  revisions
• 9 urinary retention (max. 6 days catheter)
• 7 (6,2 ) Local recurrences (5 adenomas, 2 T1-Ca)

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TEO New Aspects Lezoche et al. Surgical
Endocopy 2005

• Randomised controlled trial n 40
• RCHTx TEM versus RCHTx Laparoscop. resection
• Inclusion criteria T2 N0 Rectal cancer
• Downstaging to T0 and / or T1 in 24 patients
• 1 Local recurrence and 1 distant metastasis per
  arm
• Median follow-up 56 months (44 67)

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TEO Conclusion

• Therapeutic goal R0 resection
• Locale excision only for adenomas and well
  differen-
• tiated T1 Ca of apropriate localisation and
  size
• Low local failure rate and excellent oncologic
  outcome
• In studies neoadjuvant radiochemotherapy (T2)
• Good postoperative function and Qol
• Patient selection crucial