Transanal endoscopic microsurgery in the treatment of patients with benign neoplasms and early rectal cancer

Introduction. Transanal endoscopic microsurgery (tem) is a method that allows the specialists to clearly visualize a tumor and bimanually remove the tumor using a set of special instruments. For a number of patients with a good tumor response to chemoradiation therapy (crt), tem is used as an advanced biopsy technique for tumor verification. The purpose of the study was to analyze the results of tem performed at a. Tsyb mrrc. Material and methods. Between 2015 and 2020, 64 patients (men – 42.2 % and women – 57.8 %) underwent tem. Forty patients had rectal cancer and 25 patients had benign rectal tumors. The indication for tem in patients with rectal cancer was the evidence of tis-t1 tumor by postoperative examination findings (mri and endosonography). Eleven patients with stage ii–iii rectal cancer received chemoradiation therapy. The indication for performing tem after rt in patients with rectal cancer was a good tumor response (mri trg1- 2). For statistical processing, commercial biomedical packages prism 3.1 and instat (graphpad software, inc., san diego, usa) were used. The significance of the differences between the indicators was assessed using the pearson χ2 test. Differences were considered significant if the p value was less than 0.05. Results. The median duration of surgery was 110 minutes (30–385). The volume of blood loss did not exceed 40 ml. Postoperative complications were observed in 15 cases (23.4 %). Grade 3 complications according to the clavien-dindo classification were observed in 5 (7.8 %) cases. Postoperative complications occurred more frequently in patients after crt (10.7 and 18.2 %; p=0.603), however, the differences were not statistically significant. At a median follow-up of 18 months (7–30), local relapses developed in 6 out of 26 (23 %) patients who underwent surgery alone. There were no signs of local recurrence in patients with adenocarcinomas after neoadjuvant chemotherapy and rectal adenomas. When comparing patients with the depth of tumor invasion tis-t1sm2 and t1sm3-t2, local relapses occurred in 1 of 21 (4.7 %) and 5 of 12 (41.6 %) cases, respectively (p=0.015). Conclusion. The analysis of the results of tem interventions in patients with rectal neoplasms allows us to conclude that this method of treatment is a priority for patients with benign rectal neoplasms and early rectal cancer. The method can also be used after rt or crt in patients with tumor invasion ≥t1sm3, provided a complete or almost complete tumor response to the treatment.

1. Kaprin A.D., Starinskiy V.V., Shakhzadova A.O. Malignant neoplasms in Russia in 2019 (morbidity and mortality). Moscow, 2020. P. 9–10. (in Russian).

2. Sgourakis G., Lanitis S., Gockel I., Kontovounisios C., Karaliotas C., Tsiftsi K., Tsiamis A., Karaliotas C.C. Transanal endoscopic microsurgery for T1 and T2 rectal cancers: a meta-analysis and meta-regression analysis of outcomes. Am Surg. 2011 Jun; 77(6): 761–72.

3. Doornebosch P.G., Tollenaar R.A., De Graaf E.J. Is the increasing role of Transanal Endoscopic Microsurgery in curation for T1 rectal cancer justified? A systematic review. Acta Oncol. 2009; 48(3): 343–53. doi: 10.1080/02841860802342408.

4. Stipa F., Tierno S.M., Russo G., Burza A. Trans-anal minimally invasive surgery (TAMIS) versus trans-anal endoscopic microsurgery (TEM): a comparative case-control matched-pairs analysis. Surg Endosc. 2021 Apr 12. doi: 10.1007/s00464-021-08494-y.

5. Zhandarov K.N., Zhdonets S.V., Belyuk K.S., Mitskevich V.A., Pakulnevich Y.F. Transanal Endoscopic Microsurgery of Benign and Malignant Rectal Tumors. Novosti Khirurgii. 2017; 25(1): 78–86. (in Russian).

6. Allaix M.E., Arezzo A., Morino M. Transanal endoscopic microsurgery for rectal cancer: T1 and beyond? An evidence-based review. Surg Endosc. 2016 Nov; 30(11): 4841–4852. doi: 10.1007/s00464-016-4818-9.

7. Chiniah M., Ganganah O., Cheng Y., Sah S.K. Transanal endoscopic microsurgery is an oncologically safe alternative to total mesorectal excision for stage I rectal cancer: results of a meta-analysis of randomized controlled trials. Int J Colorectal Dis. 2016; 31(8): 1501–4. doi: 10.1007/s00384-016-2530-9.

8. Keeping A.C., Johnson P.M., Kenyon C.R., Neumann K. Timing of recurrences of TEM resected rectal neoplasms is variable as per the surveillance practices of one tertiary care institution. Sci Rep. 2021 Mar 22; 11(1): 6509. doi: 10.1038/s41598-021-85885-0.

9. Peltrini R., Sacco M., Luglio G., Bucci L. Local excision following chemoradiotherapy in T2-T3 rectal cancer: current status and critical appraisal. Updates Surg. 2020 Mar; 72(1): 29–37. doi: 10.1007/s13304-019-00689-2.

10. Serra-Aracil X., Pericay C., Golda T., Mora L., Targarona E., Delgado S., Reina A., Vallribera F., Enriquez-Navascues J.M., Serra-Pla S., Garcia-Pacheco J.C.; TAU-TEM study group. Non-inferiority multicenter prospective randomized controlled study of rectal cancer T2-T3s (superficial) N0, M0 undergoing neoadjuvant treatment and local excision (TEM) vs total mesorectal excision (TME). Int J Colorectal Dis. 2018 Feb; 33(2): 241–249. doi: 10.1007/s00384-017-2942-1.

11. Veereman G., Vlayen J., Robays J., Fairon N., Stordeur S., Rolfo C., Bielen D., Bols A., Demetter P., D’hoore A., Haustermans K., Hendlisz A., Lemmers A., Leonard D., Penninckx F., Van Cutsem E., Peeters M. Systematic review and meta-analysis of local resection or transanal endoscopic microsurgery versus radical resection in stage i rectal cancer: A real standard? Crit Rev Oncol Hematol. 2017 Jun; 114: 43–52. doi: 10.1016/j.critrevonc.2017.03.008.

12. Kidane B., Chadi S.A., Kanters S., Colquhoun P.H., Ott M.C. Local resection compared with radical resection in the treatment of T1N0M0 rectal adenocarcinoma: a systematic review and meta-analysis. Dis Colon Rectum. 2015 Jan; 58(1): 122–40. doi: 10.1097/DCR.0000000000000293.

13. Glynne-Jones R., Wyrwicz L., Tiret E., Brown G., Rödel C., Cervantes A., Arnold D.; ESMO Guidelines Committee. Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and followup. Ann Oncol. 2017 Jul 1; 28(suppl_4): iv22–iv40. doi: 10.1093/annonc/mdx224.

14. Melnikov P.V., Savenkov S.V., Kanner D.Yu., Eresko D.V., Tamrazov R.I. Transanal operations in the treatment of rectal tumors. Oncology Coloproctology. 2016; 6 (1): 36–42 (in Russian).

15. Heintz A., Mörschel M., Junginger T. Comparison of results after transanal endoscopic microsurgery and radical resection for TI carcinoma of the rectum. Surg Endoscopy. 1998; 12(9): 1145–1148.

16. Ministry of Health of the Russian Federation. Clinical guidelines. Rectal cancer [Internet]. URL: https://cr.minzdrav.gov.ru/schema/554_2 (cited: 01.07.2021). (in Russian).

17. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Rectal Cancer (version 1.2021) [Internet]. URL: http://www.nccn.org (cited: 02.02.2021).

18. Bach S.P., Gilbert A., Brock K., Korsgen S., Geh I., Hill J., Gill T., Hainsworth P., Tutton M.G., Khan J., Robinson J., Steward M., Cunningham C., Levy B., Beveridge A., Handley K., Kaur M., Marchevsky N., Magill L., Russell A., Quirke P., West N.P., Sebag-Montefiore D.; TREC collaborators. Radical surgery versus organ preservation via short-course radiotherapy followed by transanal endoscopic microsurgery for earlystage rectal cancer (TREC): a randomised, open-label feasibility study. Lancet Gastroenterol Hepatol. 2021 Feb; 6(2):92–105. doi: 10.1016/S2468-1253(20)30333-2.

19. Xiong X., Wang C., Wang B., Shen Z., Jiang K., Gao Z., Ye Y. Can transanal endoscopic microsurgery effectively treat T1 or T2 rectal cancer?A systematic review and meta-analysis. Surg Oncol. 2021 Jun; 37: 101561. doi: 10.1016/j.suronc.2021.101561.

20. Rizzo G., Pafundi D.P., Sionne F., D’Agostino L., Pietricola G., Gambacorta M.A., Valentini V., Coco C. Preoperative chemoradiotherapy affects postoperative outcomes and functional results in patients treated with transanal endoscopic microsurgery for rectal neoplasms. Tech Coloproctol. 2021 Mar; 25(3): 319–331. doi: 10.1007/s10151-020-02394-4.

21. Hallam S., Messenger D.E., Thomas M.G. A Systematic Review of Local Excision After Neoadjuvant Therapy for Rectal Cancer: Are ypT0 Tumors the Limit? Dis Colon Rectum. 2016 Oct; 59(10): 984–97. doi: 10.1097/DCR.0000000000000613.

22. Chernyshov S.V., Maynovskaya O.A., Shelygin Yu.A., Rybakov Y.G. Organ-preserving treatment of early rectal cancer. Russian Journal of Gastroenterology, Hepatology, Coloproctology. 2017; 27(2): 91–101. (in Russian). doi: 10.22416/1382-4376-2017-27-2-91-101.

23. Heafner T.A., Glasgow S.C.A critical review of the role of local excision in the treatment of early (T1 and T2) rectal tumors. J Gastrointest Oncol. 2014 Oct; 5(5): 345–52. doi: 10.3978/j.issn.2078-6891.2014.066.

24. Garcia-Aguilar J., Renfro L.A., Chow O.S., Shi Q., Carrero X.W., Lynn P.B., Thomas C.R.Jr., Chan E., Cataldo P.A., Marcet J.E., Medich D.S., Johnson C.S., Oommen S.C., Wolff B.G., Pigazzi A., McNevin S.M., Pons R.K., Bleday R. Organ preservation for clinical T2N0 distal rectal cancer using neoadjuvant chemoradiotherapy and local excision (ACOSOG Z6041): results of an open-label, single-arm, multi-institutional, phase 2 trial. Lancet Oncol. 2015 Nov; 16(15): 1537–1546. doi: 10.1016/S1470-2045(15)00215-6.

25. Deng Y., Chi P., Lan P., Wang L., Chen W., Cui L., Chen D., Cao J., Wei H., Peng X., Huang Z., Cai G., Zhao R., Huang Z., Xu L., Zhou H., Wei Y., Zhang H., Zheng J., Huang Y., Zhou Z., Cai Y., Kang L., Huang M., Wu X., Peng J., Ren D., Wang J. Neoadjuvant Modified FOLFOX6 With or Without Radiation Versus Fluorouracil Plus Radiation for Locally Advanced Rectal Cancer: Final Results of the Chinese FOWARC Trial. J Clin Oncol. 2019 Dec 1; 37(34): 3223–3233. doi: 10.1200/JCO.18.02309.

26. Perez R.O., Habr-Gama A., São Julião G.P., Proscurshim I., Fernandez L.M., de Azevedo R.U., Vailati B.B., Fernandes F.A., GamaRodrigues J. Transanal Endoscopic Microsurgery (TEM) Following Neoadjuvant Chemoradiation for Rectal Cancer: Outcomes of Salvage Resection for Local Recurrence. Ann Surg Oncol. 2016 Apr; 23(4): 1143–8. doi: 10.1245/s10434-015-4977-2.