Research progress of transanal endoscopic microsurgery for rectal tumors_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

ZHENG Guanpeng , HU Xuchen ,  LIU Tianyou

The First Department of General Surgery, Qunli Hospital, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, P. R. China;

Corresponding author：

LIU Tianyou, Email: doctorlty@126.com

Keywords：

transanal endoscopic microsurgery; rectal tumor; research progress

DOI：

10.7507/1007-9424.202109017

Video：

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Objective To summarize the research progress of transanal endoscopic microsurgery in the treatment of rectal tumors. Method The literatures on transanal endoscopic treatment of rectal tumors was collected and reviewed. Results Transanal endoscopic microsurgery was one of the local resection methods. It was a minimally invasive surgery combining laparoscopy and endoscopy. Transanal endoscopic microsurgery equipment was mainly composed of special rectal mirror lens and high-pressure pneumoperitoneum machine. After full-thickness resection of the lesion, the defect was sutured under endoscopy, so as to avoid serious postoperative complications caused by radical surgery. Transanal endoscopic microsurgery was suitable for T1 stage rectal cancer with benign lesions such as rectal adenoma and rectal polyps and no lymph node metastasis. There was still some controversy about the treatment of higher-grade rectal cancer. Neoadjuvant radiotherapy and chemotherapy combined with transanal endoscopic microsurgery is being actively carried out in the treatment of rectal cancer. Conclusions Transanal endoscopic microsurgery is a safe and effective method for some rectal tumors. It has the characteristics of low perioperative complication rate, fast postoperative recovery and low recurrence rate.

Citation： ZHENG Guanpeng, HU Xuchen, LIU Tianyou. Research progress of transanal endoscopic microsurgery for rectal tumors. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2022, 29(6): 835-840. doi: 10.7507/1007-9424.202109017 Copy

1.	Sung H, Ferlay J, Siegel RL, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin, 2021, 71(3): 209-249.
2.	李梦奇, 陈洪生, 魏九峰. 直肠癌手术方式的发展历程. 中国普外基础与临床杂志, 2021, 28(8): 1114-1120.
3.	Buess G, Theiss R, Hutterer F, et al. Transanal endoscopic surgery of the rectum - testing a new method in animal experiments. Leber Magen Darm, 1983, 13(2): 73-77.
4.	中国抗癌协会大肠癌专业委员会 TEM 学组. 经肛门内镜微创手术(TEM)技术专家共识(2016). 消化肿瘤杂志(电子版), 2016, 8(3): 136-138.
5.	Ang ZH, De Robles MS, Kang S, et al. Accuracy of pelvic magnetic resonance imaging in local staging for rectal cancer: a single local health district, real world experience. ANZ J Surg, 2021, 91(1-2): 111-116.
6.	Oien K, Forsmo HM, Rösler C, et al. Endorectal ultrasound and magnetic resonance imaging for staging of early rectal cancers: how well does it work in practice? Acta Oncol, 2019, 58(sup1): S49-S54.
7.	朱林, 朱冬梅, 刘学彬. 直肠内超声联合核磁共振成像对中低位直肠癌术前T分期的诊断价值. 现代医药卫生, 2020, 36(20): 3301-3303.
8.	杨盈赤, 王阳, 张忠涛. 结肠直肠外科微创治疗的现状与发展. 外科理论与实践, 2020, 25(3): 184-188.
9.	李昀昊, 林国乐. 经肛门内镜显微手术治疗直肠肿瘤的现状及进展. 中华腔镜外科杂志(电子版), 2019, 12(6): 326-329.
10.	李昀昊, 白雪杉, 林国乐, 等. 经肛门内镜显微手术治疗直肠腺瘤癌变的临床价值. 结直肠肛门外科, 2020, 26(1): 22-27.
11.	Tanaka S, Kashida H, Saito Y, et al. Japan Gastroenterological Endoscopy Society guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection. Dig Endosc, 2020, 32(2): 219-239.
12.	Yu JX, Russell WA, Ching JH, et al. Cost effectiveness of endoscopic resection vs transanal resection of complex benign rectal polyps. Clin Gastroenterol Hepatol, 2019, 17(13): 2740-2748.
13.	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(2): 254-261.
14.	Chernyshov SV, Shelygin YA, Mainovskaya OA, et al. Possibilities of transanal endoscopic microsurgery: the experience of 202 operations. Vopr Onkol, 2015, 61(6): 998-1005.
15.	Serra-Aracil X, Flores-Clotet R, Mora-López L, et al. Transanal endoscopic microsurgery in very large and ultra large rectal neoplasia. Tech Coloproctol, 2019, 23(9): 869-876.
16.	Dulskas A, Kilius A, Petrulis K, et al. Transanal endoscopic microsurgery for giant benign rectal tumours: is large size a contraindication? Int J Colorectal Dis, 2017, 32(12): 1759-1761.
17.	Arezzo A, Arolfo S, Allaix ME, et al. Transanal endoscopic microsurgery for giant circumferential rectal adenomas. Colorectal Dis, 2016, 18(9): 897-902.
18.	Kudo S. Endoscopic mucosal resection of flat and depressed types of early colorectal cancer. Endoscopy, 1993, 25(7): 455-461.
19.	Maggiori L, Panis Y. Transanal endoscopic microsurgery (TEM) for T1 rectal cancer. Acta Chir Iugosl, 2012, 59(2): 87-90.
20.	Beets GL, Figueiredo NF, Beets-Tan RG. Management of rectal cancer without radical resection. Annu Rev Med, 2017, 68: 169-182.
21.	彭丽洁, 李国胜. 直肠癌保肛术后低位前切除综合征研究进展. 医学研究杂志, 2021, 50(4): 13-16, 42.
22.	蒋伟, 官海迪, 邱远, 等. 直肠癌术后低位前切除综合征的评估与治疗进展. 中国普外基础与临床杂志, 2020, 27(5): 624-628.
23.	Xiong X, Wang C, Wang B, et al. Can transanal endoscopic microsurgery effectively treat T1 or T2 rectal cancer? A systematic review and meta-analysis. Surg Oncol, 2021, 37: 101561. doi: 10.1016/j.suronc.2021.101561.
24.	Levic Souzani K, Bulut O, Kuhlmann TP, et al. Completion total mesorectal excision following transanal endoscopic microsurgery does not compromise outcomes in patients with rectal cancer. Surg Endosc, 2021 Feb 24. doi: 10.1007/s00464-021-08385-2. Online ahead of print.
25.	Chaouch MA, Khan J, Gill TS, et al. Early salvage total mesorectal excision (sTME) after organ preservation failure in rectal cancer does not worsen postoperative outcomes compared to primary TME: systematic review and meta-analysis. Int J Colorectal Dis, 2021, 36(11): 2375-2386.
26.	Levic K, Bulut O, Hesselfeldt P, et al. The outcome of rectal cancer after early salvage surgery following transanal endoscopic microsurgery seems promising. Dan Med J, 2012, 59(9): A4507.
27.	Hompes R, McDonald R, Buskens C, et al. Completion surgery following transanal endoscopic microsurgery: assessment of quality and short- and long-term outcome. Colorectal Dis, 2013, 15(10): e576-e581. doi: 10.1111/codi.12381.
28.	Heidary B, Phang TP, Raval MJ, et al. Transanal endoscopic microsurgery: a review. Can J Surg, 2014, 57(2): 127-138.
29.	Benson AB, Venook AP, Al-Hawary MM, et al. Rectal Cancer, Version 2. 2018, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw, 2018, 16(7): 874-901.
30.	Jones HJS, Goodbrand S, Hompes R, et al. Radiotherapy after local excision of rectal cancer may offer reduced local recurrence rates. Colorectal Dis, 2019, 21(4): 451-459.
31.	Jeong JU, Nam TK, Kim HR, et al. Adjuvant chemoradiotherapy instead of revision radical resection after local excision for high-risk early rectal cancer. Radiat Oncol, 2016, 11(1): 114. doi: 10.1186/s13014-016-0692-9.
32.	Allaix ME, Arezzo A, Morino M. Transanal endoscopic microsurgery for rectal cancer: T1 and beyond? An evidence-based review. Surg Endosc, 2016, 30(11): 4841-4852.
33.	Xu K, Liu Y, Yu P, et al. Oncological outcomes of transanal endoscopic microsurgery plus adjuvant chemoradiotherapy for patients with high-risk T1 and T2 rectal cancer. J Laparoendosc Adv Surg Tech A, 2021, 31(9): 1006-1013.
34.	Glynne-Jones R, Hughes R. Complete response after chemoradiotherapy in rectal cancer (watch-and-wait): have we cracked the code? Clin Oncol (R Coll Radiol), 2016, 28(2): 152-160.
35.	Peltrini R, Sacco M, Luglio G, et al. Local excision following chemoradiotherapy in T2-T3 rectal cancer: current status and critical appraisal. Updates Surg, 2020, 72(1): 29-37.
36.	Stijns RCH, de Graaf EJR, Punt CJA, et al. Long-term oncological and functional outcomes of chemoradiotherapy followed by organ-sparing transanal endoscopic microsurgery for distal rectal cancer: The CARTS study. JAMA Surg, 2019, 154(1): 47-54.
37.	González JEB, Lavernia HC, Fraga JGP, et al. Long-term outcomes of transanal endoscopic microsurgery for clinical complete response after neoadjuvant treatment in T2-3 rectal cancer. Surg Endosc, 2021 Jul 6. doi: 10.1007/s00464-021-08583-y. Online ahead of print.
38.	Bach SP, Gilbert A, Brock K, et al. Radical surgery versus organ preservation via short-course radiotherapy followed by transanal endoscopic microsurgery for early-stage rectal cancer (TREC): a randomised, open-label feasibility study. Lancet Gastroenterol Hepatol, 2021, 6(2): 92-105.
39.	Trépanier JS, Fernandez-Hevia M, Lacy AM. Transanal total mesorectal excision: surgical technique description and outcomes. Minim Invasive Ther Allied Technol, 2016, 25(5): 234-240.
40.	Perdawood SK, Kroeigaard J, Eriksen M, et al. Transanal total mesorectal excision: the Slagelse experience 2013-2019. Surg Endosc, 2021, 35(2): 826-836.
41.	Park SC, Sohn DK, Kim MJ, et al. Phase Ⅱ clinical trial to evaluate the efficacy of transanal endoscopic total mesorectal excision for rectal cancer. Dis Colon Rectum, 2018, 61(5): 554-560.
42.	Aubert M, Mege D, Panis Y. Total mesorectal excision for low and middle rectal cancer: laparoscopic versus transanal approach—a meta-analysis. Surg Endosc, 2020, 34(9): 3908-3919.
43.	Ortenzi M, Ghiselli R, Cappelletti Trombettoni MM, et al. Transanal endoscopic microsurgery as optimal option in treatment of rare rectal lesions: A single centre experience. World J Gastrointest Endosc, 2016, 8(17): 623-627.
44.	Wu X, Lin G, Qiu H, et al. Transanal endoscopic microsurgery for patients with rare rectal tumors. J Laparoendosc Adv Surg Tech A, 2018, 28(5): 546-552.
45.	van der Graaf WTA, Tielen R, Bonenkamp JJ, et al. Nationwide trends in the incidence and outcome of patients with gastrointestinal stromal tumour in the imatinib era. Br J Surg, 2018, 105(8): 1020-1027.
46.	Bai X, Zhou W, Li Y, et al. Transanal endoscopic microsurgery with alternative neoadjuvant imatinib for localized rectal gastrointestinal stromal tumor: a single center experience with long-term surveillance. Surg Endosc, 2021, 35(7): 3607-3617.
47.	Nam S, Kim D, Jung K, et al. Analysis of the incidence and clinical features of colorectal nonadenocarcinoma in Korea: A national cancer registry-based study. Ann Coloproctol, 2020, 36(6): 390-397.
48.	Zhang HP, Wu W, Yang S, et al. Endoscopic treatments for rectal neuroendocrine tumors smaller than 16 mm: a meta-analysis. Scand J Gastroenterol, 2016, 51(11): 1345-1353.

1. Sung H, Ferlay J, Siegel RL, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin, 2021, 71(3): 209-249.
2. 李梦奇, 陈洪生, 魏九峰. 直肠癌手术方式的发展历程. 中国普外基础与临床杂志, 2021, 28(8): 1114-1120.
3. Buess G, Theiss R, Hutterer F, et al. Transanal endoscopic surgery of the rectum - testing a new method in animal experiments. Leber Magen Darm, 1983, 13(2): 73-77.
4. 中国抗癌协会大肠癌专业委员会 TEM 学组. 经肛门内镜微创手术(TEM)技术专家共识(2016). 消化肿瘤杂志(电子版), 2016, 8(3): 136-138.
5. Ang ZH, De Robles MS, Kang S, et al. Accuracy of pelvic magnetic resonance imaging in local staging for rectal cancer: a single local health district, real world experience. ANZ J Surg, 2021, 91(1-2): 111-116.
6. Oien K, Forsmo HM, Rösler C, et al. Endorectal ultrasound and magnetic resonance imaging for staging of early rectal cancers: how well does it work in practice? Acta Oncol, 2019, 58(sup1): S49-S54.
7. 朱林, 朱冬梅, 刘学彬. 直肠内超声联合核磁共振成像对中低位直肠癌术前T分期的诊断价值. 现代医药卫生, 2020, 36(20): 3301-3303.
8. 杨盈赤, 王阳, 张忠涛. 结肠直肠外科微创治疗的现状与发展. 外科理论与实践, 2020, 25(3): 184-188.
9. 李昀昊, 林国乐. 经肛门内镜显微手术治疗直肠肿瘤的现状及进展. 中华腔镜外科杂志(电子版), 2019, 12(6): 326-329.
10. 李昀昊, 白雪杉, 林国乐, 等. 经肛门内镜显微手术治疗直肠腺瘤癌变的临床价值. 结直肠肛门外科, 2020, 26(1): 22-27.
11. Tanaka S, Kashida H, Saito Y, et al. Japan Gastroenterological Endoscopy Society guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection. Dig Endosc, 2020, 32(2): 219-239.
12. Yu JX, Russell WA, Ching JH, et al. Cost effectiveness of endoscopic resection vs transanal resection of complex benign rectal polyps. Clin Gastroenterol Hepatol, 2019, 17(13): 2740-2748.
13. 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(2): 254-261.
14. Chernyshov SV, Shelygin YA, Mainovskaya OA, et al. Possibilities of transanal endoscopic microsurgery: the experience of 202 operations. Vopr Onkol, 2015, 61(6): 998-1005.
15. Serra-Aracil X, Flores-Clotet R, Mora-López L, et al. Transanal endoscopic microsurgery in very large and ultra large rectal neoplasia. Tech Coloproctol, 2019, 23(9): 869-876.
16. Dulskas A, Kilius A, Petrulis K, et al. Transanal endoscopic microsurgery for giant benign rectal tumours: is large size a contraindication? Int J Colorectal Dis, 2017, 32(12): 1759-1761.
17. Arezzo A, Arolfo S, Allaix ME, et al. Transanal endoscopic microsurgery for giant circumferential rectal adenomas. Colorectal Dis, 2016, 18(9): 897-902.
18. Kudo S. Endoscopic mucosal resection of flat and depressed types of early colorectal cancer. Endoscopy, 1993, 25(7): 455-461.
19. Maggiori L, Panis Y. Transanal endoscopic microsurgery (TEM) for T1 rectal cancer. Acta Chir Iugosl, 2012, 59(2): 87-90.
20. Beets GL, Figueiredo NF, Beets-Tan RG. Management of rectal cancer without radical resection. Annu Rev Med, 2017, 68: 169-182.
21. 彭丽洁, 李国胜. 直肠癌保肛术后低位前切除综合征研究进展. 医学研究杂志, 2021, 50(4): 13-16, 42.
22. 蒋伟, 官海迪, 邱远, 等. 直肠癌术后低位前切除综合征的评估与治疗进展. 中国普外基础与临床杂志, 2020, 27(5): 624-628.
23. Xiong X, Wang C, Wang B, et al. Can transanal endoscopic microsurgery effectively treat T1 or T2 rectal cancer? A systematic review and meta-analysis. Surg Oncol, 2021, 37: 101561. doi: 10.1016/j.suronc.2021.101561.
24. Levic Souzani K, Bulut O, Kuhlmann TP, et al. Completion total mesorectal excision following transanal endoscopic microsurgery does not compromise outcomes in patients with rectal cancer. Surg Endosc, 2021 Feb 24. doi: 10.1007/s00464-021-08385-2. Online ahead of print.
25. Chaouch MA, Khan J, Gill TS, et al. Early salvage total mesorectal excision (sTME) after organ preservation failure in rectal cancer does not worsen postoperative outcomes compared to primary TME: systematic review and meta-analysis. Int J Colorectal Dis, 2021, 36(11): 2375-2386.
26. Levic K, Bulut O, Hesselfeldt P, et al. The outcome of rectal cancer after early salvage surgery following transanal endoscopic microsurgery seems promising. Dan Med J, 2012, 59(9): A4507.
27. Hompes R, McDonald R, Buskens C, et al. Completion surgery following transanal endoscopic microsurgery: assessment of quality and short- and long-term outcome. Colorectal Dis, 2013, 15(10): e576-e581. doi: 10.1111/codi.12381.
28. Heidary B, Phang TP, Raval MJ, et al. Transanal endoscopic microsurgery: a review. Can J Surg, 2014, 57(2): 127-138.
29. Benson AB, Venook AP, Al-Hawary MM, et al. Rectal Cancer, Version 2. 2018, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw, 2018, 16(7): 874-901.
30. Jones HJS, Goodbrand S, Hompes R, et al. Radiotherapy after local excision of rectal cancer may offer reduced local recurrence rates. Colorectal Dis, 2019, 21(4): 451-459.
31. Jeong JU, Nam TK, Kim HR, et al. Adjuvant chemoradiotherapy instead of revision radical resection after local excision for high-risk early rectal cancer. Radiat Oncol, 2016, 11(1): 114. doi: 10.1186/s13014-016-0692-9.
32. Allaix ME, Arezzo A, Morino M. Transanal endoscopic microsurgery for rectal cancer: T1 and beyond? An evidence-based review. Surg Endosc, 2016, 30(11): 4841-4852.
33. Xu K, Liu Y, Yu P, et al. Oncological outcomes of transanal endoscopic microsurgery plus adjuvant chemoradiotherapy for patients with high-risk T1 and T2 rectal cancer. J Laparoendosc Adv Surg Tech A, 2021, 31(9): 1006-1013.
34. Glynne-Jones R, Hughes R. Complete response after chemoradiotherapy in rectal cancer (watch-and-wait): have we cracked the code? Clin Oncol (R Coll Radiol), 2016, 28(2): 152-160.
35. Peltrini R, Sacco M, Luglio G, et al. Local excision following chemoradiotherapy in T2-T3 rectal cancer: current status and critical appraisal. Updates Surg, 2020, 72(1): 29-37.
36. Stijns RCH, de Graaf EJR, Punt CJA, et al. Long-term oncological and functional outcomes of chemoradiotherapy followed by organ-sparing transanal endoscopic microsurgery for distal rectal cancer: The CARTS study. JAMA Surg, 2019, 154(1): 47-54.
37. González JEB, Lavernia HC, Fraga JGP, et al. Long-term outcomes of transanal endoscopic microsurgery for clinical complete response after neoadjuvant treatment in T2-3 rectal cancer. Surg Endosc, 2021 Jul 6. doi: 10.1007/s00464-021-08583-y. Online ahead of print.
38. Bach SP, Gilbert A, Brock K, et al. Radical surgery versus organ preservation via short-course radiotherapy followed by transanal endoscopic microsurgery for early-stage rectal cancer (TREC): a randomised, open-label feasibility study. Lancet Gastroenterol Hepatol, 2021, 6(2): 92-105.
39. Trépanier JS, Fernandez-Hevia M, Lacy AM. Transanal total mesorectal excision: surgical technique description and outcomes. Minim Invasive Ther Allied Technol, 2016, 25(5): 234-240.
40. Perdawood SK, Kroeigaard J, Eriksen M, et al. Transanal total mesorectal excision: the Slagelse experience 2013-2019. Surg Endosc, 2021, 35(2): 826-836.
41. Park SC, Sohn DK, Kim MJ, et al. Phase Ⅱ clinical trial to evaluate the efficacy of transanal endoscopic total mesorectal excision for rectal cancer. Dis Colon Rectum, 2018, 61(5): 554-560.
42. Aubert M, Mege D, Panis Y. Total mesorectal excision for low and middle rectal cancer: laparoscopic versus transanal approach—a meta-analysis. Surg Endosc, 2020, 34(9): 3908-3919.
43. Ortenzi M, Ghiselli R, Cappelletti Trombettoni MM, et al. Transanal endoscopic microsurgery as optimal option in treatment of rare rectal lesions: A single centre experience. World J Gastrointest Endosc, 2016, 8(17): 623-627.
44. Wu X, Lin G, Qiu H, et al. Transanal endoscopic microsurgery for patients with rare rectal tumors. J Laparoendosc Adv Surg Tech A, 2018, 28(5): 546-552.
45. van der Graaf WTA, Tielen R, Bonenkamp JJ, et al. Nationwide trends in the incidence and outcome of patients with gastrointestinal stromal tumour in the imatinib era. Br J Surg, 2018, 105(8): 1020-1027.
46. Bai X, Zhou W, Li Y, et al. Transanal endoscopic microsurgery with alternative neoadjuvant imatinib for localized rectal gastrointestinal stromal tumor: a single center experience with long-term surveillance. Surg Endosc, 2021, 35(7): 3607-3617.
47. Nam S, Kim D, Jung K, et al. Analysis of the incidence and clinical features of colorectal nonadenocarcinoma in Korea: A national cancer registry-based study. Ann Coloproctol, 2020, 36(6): 390-397.
48. Zhang HP, Wu W, Yang S, et al. Endoscopic treatments for rectal neuroendocrine tumors smaller than 16 mm: a meta-analysis. Scand J Gastroenterol, 2016, 51(11): 1345-1353.

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