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MANAGEMENT

ANORECTAL CANCER :
LOCAL EXCISION AND
TEM
Kunsemedi Setyadi

Sub Bagian Bedah Digestif RSUP Dr.


Kariadi / FK UNDIP Semarang 2014

Introduction

60.000 new cases of CRC


in Germany each year,
incidence is rising, annual
death toll 30.000
Rectal Ca account for
35% CRC
27% rectal Ca are at UICC
stage I

Introduction

Rectal Ca: relatively good long-term


oncologic prognosis following
primary treatment with curative
intent.
Disease-free 5-year survival rate
Stage I-III : 73%, highly stagedependent
Stage

I : 82%
Stage II : 76%
Stage III : 61%

Improved prognosis early

Trends in Oncologic Surgery

Breast Ca
Radical mastectomy MRM
Lumpectomy & axillary dissection +
ER Lumpectomy + Sentinel Node
+ ER

Rectal Ca
Miles op Sphincter
preservation surgery ?
Full thickness local excision
ER

Freud :
Those surgeons are highly
conflicted, even
schizophrenic.... In their
approach to low T1 rectal

Which the best technique


Radical resection

?
Minimal invasive
laparoscopy

Local excision

Sphincter preservation

TEM

Challenges for local


therapy of Rectal cancer
1. Adequate resection of Ca circumferential
- cephalad
2. Avoidance of tumor implantation
3. Lymph node resection : perirectal
4. Lymph node staging

Local procedures

Low extrarectal approach described


by Mason (anterolateral) & Kraska
(posterior)
Self retaining retractors (Park,
Lonestar etc) : satisfactory view for
lower third of rectum.
Endoscopic local excision/TEO :
Are

not accessible to endoscopic


mucosal resection/submucosal
dissection
Have not infiltrated the muscularis
propria/metastasized to lymph nodes

Local excision / Traditional


Trans Anal Excision (TAE)

Local excision /
Traditional Trans Anal
Excision (TAE)

Limited access & visibility


<8-10cm from anal verge
< 40% of rectal
circumference

Local/radical excision >< TEM

Oncological efficacy
Recurrence rate
Preservation of anorectal &
genito-urinary function (quality of
life)
Morbidity/complication rate &
mortality
Longterm
survival
tal Mesorectal
Excision
(TME) remains the gold standa

TEM:

Transanal Endoscopic
Microsurgery development

Early 1980 : Gerhard Buess & Richard Wolf


Medical Instrument Company in Tbingen,
Germany.
Widespread of laparoscopic surgery &
view/optical system with flat screen make
it more feasible.
1998 TEO (Transanal Endoscopic Operation)
set from Karl Storz was specifically
developed for surgical method &
represents an advancement of the
original TEM
2010, TAMIS (Trans Anal Minimal Invasive

Application / Clinical usage

Firstly, preferred for distal rectal


cancer.
Other indication such as benign rectal
lesions, complex fistulas &
rectourethral and rectovaginal
fistulas; natural orifice transluminal
endoscopic surgery (NOTES).
Expense & cost low popularity
Colonoscopically unresectable
polyps / transanal local excision of
rectal tumors APR/Miles op.
For removal of lesions in the middle &

Indications for TEM

Resection of colonoscopically
unresectable rectal adenomas
Selected rectal cancers
T1-2 rectal cancer
Palliative excision of T3
cancer
Resection of rectal & distal
sigmoid adenomas
Complex extra sphincteric
fistula (rectourethra/vaginal &
supralevator)
Anastomotic strictures

Selected Rectal Cancer

T1 well / moderately differentiate


(G1-2)
T1 poorly differetiated (G3) after
neoadjuvant treatment
T2N0M0 <3cm after neoadjuvant
treatment
T3N0M0 <3cm after significant
response to neoadjuvant
treatment
Independent of the stage as
palliative treatment in high risk

Contraindications

Unfit for general / regional anesthesia


Uncorrected coagulopathy
Rectal varices
Anal stenosis
Careful history of prior surgery with
pelvic mesh
High dose pelvic radiation therapy
rectal compliance, stenosis, friability
& impaired wound healing

Instrumentation for TEM

Operating rectoscopes 7,5; 15 & 20 cm;


40 mm
Articulated support arm
Working attachment

Luer lock connector for CO2 insufflation


3 working channels, 2 for 5mm & 1 for
12mm, self-sealing silicone-leaflet valve

5mm 30 rod-lens telescope

Laparoscopy set + instrument

Camera system with cold light source +


fiberoptic light

Insuflator/suction/irrigation/electrocautery
machine

Preoperative
preparations

Tumor localization :
Tumor

should be in 6 oclock position


Length of rectoscope : distance of
upper & lower tumor margins from
anocutaneous line
Degree of circumferential wall
involvement
Degree of stenosis

Pre-operative staging: depth of


invation (T) & lymph node status
(N)
ERUS

(Endo Rectal Ultrasound Scan)

Pre op Staging

Digital examination (to evaluate


tumor fixation & location)
Total colonoscopy rigid
rectoscopy
distance from anal verge,
biopsy
Transanal US
For cancer : MRI / CT scan with

Resection option
-Mucosectomy
-Partial rectal wall
excision
-Full thickness excision
- Full thickness excision
with perirectal fat

Consent

Incontinence, bleeding
etc (Complications)
Formal celiotomy &
resection colostomy
Risk of incomplete
removal / inaccessibility

odified lithotomy for dorsal lesio

odified prone postion for ventral lesi

ght /left lateral decubitus positio

Sphincter dilation

CO2 gas flow 8 l/mnt


Gas pressure 14 mmHg on insufflator
Light intensity 50%

Principle of procedure (1)

Lesion is visible in the lower half


of the viewing field
Injection local anesthesi
containing epinephrine, infiltrate
around & under the lesion to aid
in hemostasis
5-10mm margin are marked by
electrocauter
Excision in submucosal plane /
full-thickness
Dissection proceeds from distal to

Principle of procedure (2)

Correct operative plane:


Submucosal : transversely oriented inner
circular rectal muscular fiber
Full thickness : yellow perirectal fat

Important to correctly identify the


proximal extent : frequently visualize
the premarked margin
All defects are closed transversely
Large defects are bisected with a
single suture to bring the proximal &
distal ends into proximity & to ensure
proper orientation
Completion rigid proctoscopy to ensure

Complications

Intraperitoneal
sepsis/peritoneal entry
Rectovaginal fistula
Suture line disruption /
anastomotic dehiscence 15%
Hemorrhage
Fecal incontinence, usually
transient 5%
Rectal stenosis
Conversion to laparotomy 2,6%
Urinary retention (temporary),

Semarang experience

Female, 50 yo, AdenoCa recti at


6 cm
(Feb 9, 2011)
Male, 29 yo, Adeno Ca recti at 8
cm
(May 28, 2011)

Result following TEM


Local
recurrence
T1 T2 T3
Buess
4%
20
%
Steele et 0% 14 0% T2,T3 --> post op
al
%
chemoradiothera
py
Floyd & 2,7
Middleton et al local recurrence significantly
Saclaride
less
common%(6%) following TEM compare with
transanal
approaches (22%)
s

Direct Comparation of TEM and Resection


TEM

Resection

T1

T2

T1

T2

51

22

17

83

Disease-free survival (%)

4
96

19
80

0
94

9.4
83

Mean distance from verge (cm)

6.7 3.2

7.5 4

Mean size (cm)

2.3 0.95

3.78 1.5

Complications (%)

48

46 low risk

34 low risk

Recurrence

2 (4%)

2 (6%)

5-year survival (%)

79

81

Tumor size (cm)

2.5 1.5

2.9 1.6

Complications

1 (2%)

5 (15%), 2 deaths

20

18

Recurrence

2 (10%)

None

2-year survival (%)

100

96

Lee et al. [94] (2003)


Number Recurrence (%)

Heintz et al. [92]


Number

Langer et al. [43]


Number

Summary

TEM in malignant rectal


resection is evolving over the
last 30 years & gives superior
result.
TEM is superior to local excision
in treating rectal Ca
T2-3 lesions require preop
neoadjuvant therapy
Early detection

Future direction

Rectal prolapse
Rectovaginal fistula /
extrasphincteric fistula in ano
Anastomotic stricture
Extended application for Cancer
NOTES portal

Thank you