Download PDF
Zentralbl Chir 2023; 148(03): 244-253
DOI: 10.1055/a-2063-3578
Übersicht

Transanale Tumorresektion: Indikation, Operationstechniken und Komplikationsmanagement

Transanal Tumor Resection: Indication, Surgical Technique and Management of Complications
Marco Sailer
1   Klinik für Chirurgie, Agaplesion Bethesda Krankenhaus Bergedorf, Hamburg, Deutschland
› Author Affiliations
› Further Information
Also available at
    Permissions and Reprints

Zusammenfassung

Bei den transanalen Resektionsverfahren handelt es sich um spezielle Operationsmethoden der minimalinvasiven Therapie von Rektumtumoren. Neben gutartigen Tumoren eignet sich diese Operationsmethode für die Resektion von sog. Low-Risk-T1-Rektumkarzinomen, wenn diese aufgrund ihrer Größe und Lokalisation sicher im Gesunden (R0) entfernt werden können. Bei stringenter Patientenselektion werden sehr gute onkologische Ergebnisse erzielt. Derzeit wird in diversen internationalen Studien evaluiert, ob lokale Resektionsverfahren onkologisch ausreichend sind, wenn eine komplette oder fast komplette Remission nach neoadjuvanter Radio-/Chemotherapie vorliegt. Zahlreiche Untersuchungen belegen, dass insbesondere die funktionellen Resultate und die postoperative Lebensqualität nach lokalen Resektionen hervorragend sind, zumal als Alternativoperationen die tiefe Rektumresektion bzw. die abdominoperineale Exstirpation zu diskutieren sind, die bekanntermaßen sehr häufig mit funktionellen Defiziten einhergehen.

Schwere Komplikationen sind sehr selten. Typische Minorkomplikationen sind ein postoperativer Harnverhalt oder transiente Temperaturerhöhungen. Eine Nahtdehiszenz verläuft i. d. R. klinisch inapparent. Als relevante Komplikationen sind vor allem Nachblutungen und die Eröffnung des Peritoneums zu nennen. Letztere müssen intraoperativ erkannt und entsprechend versorgt werden, was meist transanal oder minimalinvasiv gelingt. Sehr selten kommt es zu Infektionen, Abszessen, rektovaginalen Fisteln oder Verletzungen von Prostata und Harnröhre.

Abstract

Transanal resection procedures are special operations for the minimally invasive treatment of rectal tumours. Apart from benign tumours, this procedure is suitable for the excision of low-risk T1 rectal carcinomas, if these can be completely removed (R0 resection). With stringent patient selection, very good oncological results are achieved. Various international trials are currently evaluating whether local resection procedures are oncologically sufficient if there is a complete or near complete response after neoadjuvant radio-/chemotherapy. Numerous studies have shown that the functional results and the postoperative quality of life after local resection are excellent, especially considering the well-known functional deficits of alternative operations, such as low anterior or abdominoperineal resection.

Severe complications are very rare. Most complications, such as urinary retention or subfebrile temperatures, are minor in nature. Suture line dehiscences are usually clinically unremarkable. Major complications comprise significant haemorrhage and the opening of the peritoneal cavity. The latter must be recognized intraoperatively and can usually be managed by primary suture. Infection, abscess formation, rectovaginal fistula, injury of the prostate or even urethra are extremely rare complications.

Schlüsselwörter

Rektumkarzinom - transanale Tumorresktion - Komplikationsmanagement - neoadjuvante Therapie

Keywords

rectal cancer - transanal surgery - management of complications - neoadjuvant treatment


Publication History

Received: 19 December 2022

Accepted after revision: 25 March 2023

Article published online:
02 June 2023

© 2023. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • Literatur

  • 1 Parks AG. A technique for excising extensive villous papillomatous change in the lower rectum. Proc R Soc Med 1968; 61: 441-442
    PubMedSearch in Google Scholar
  • 2 Bueß G, Kipfmüller K, Hack D. et al. Technique of transanal endoscopic microsurgery. Surg Endosc 1988; 2: 71-75
    CrossrefPubMedSearch in Google Scholar
  • 3 BachSPHill J, Monson JRT. et al. A predictive model for local recurrence after transanal endoscopic microsurgery for rectal cancer. Br J Surg 2009; 96: 280-290
    CrossrefPubMedSearch in Google Scholar
  • 4 Christoferidis D, Hyeon-Min C, Dixon M. et al. Transanal endoscopic microsurgery versus conventional transanal excision for patients with early rectal cancer. Ann Surg 2009; 249: 776-782
    CrossrefPubMedSearch in Google Scholar
  • 5 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: 1026-1031
    CrossrefPubMedSearch in Google Scholar
  • 6 Dekkers N, Dang H, van der Kraan J. et al. Risk of recurrence after local resection of T1 rectal cancer: a meta-analysis with meta-regression. Surg Endosc 2022; 36: 9156-9168
    CrossrefPubMedSearch in Google Scholar
  • 7 Atallah S, Albert M, Larach S. Transanal minimally invasive surgery: giant leap forward. Surg Endosc 2010; 24: 2200-2205
    CrossrefPubMedSearch in Google Scholar
  • 8 Van den Eynde F, Jaekers J, Fieuws S. et al. TAMIS is a valuable alternative to TEM for resection of intraluminal rectal tumors. Techniques in Coloproctology 2019; 23: 161-166
    CrossrefPubMedSearch in Google Scholar
  • 9 Borschitz T, Junginger T. Stellenwert der lokalen Exzision von Rektumkarzinomen. Viszeralchirurgie 2006; 41: 306-312
    Thieme ConnectPubMedSearch in Google Scholar
  • 10 Kim E, Hwang JM, Garcia-Aguilar J. Local excision of rectal carcinoma. Clin Colorectal Cancer 2008; 7: 376-385
    CrossrefPubMedSearch in Google Scholar
  • 11 Tytherleigh MG, Warren BF, Mortensen NJ. Management of early rectal cancer. Br J Surg 2008; 95: 409-423
    CrossrefPubMedSearch in Google Scholar
  • 12 Matzel KE, Merkel S, Hohenberger W. Lokale Therapieprinzipien beim Rektumkarzinom. Chirurg 2003; 10: 897-904
    CrossrefPubMedSearch in Google Scholar
  • 13 Ramirez JM, Aguilella V, Arribas D. et al. Transanal full-thickness excision of rectal tumors: should the defect be sutured? A randomized controlled trial. Colorectal Dis 2002; 4: 51-55
    CrossrefPubMedSearch in Google Scholar
  • 14 Marks JH, Frenkel JL, Greenleaf CE. et al. Transanal endoscopic microsurgery with entrance into the peritoneal cavity: Is it safe?. Dis Colon Rectum 2014; 57: 1176-1182
    CrossrefPubMedSearch in Google Scholar
  • 15 Baatrup G, Borschitz T, Cunningham C. et al. Perforation into the peritoneal cavity during transanal endoscopic microsurgery for rectal cancer is not associated with major complications or oncological compromise. Surg Endosc 2009; 23: 2680-2683
    CrossrefPubMedSearch in Google Scholar
  • 16 Hermanek P, Gall FP. Early (microinvasive) colorectal carcinoma. Pathology, diagnosis, surgical treatment. Int J Colorectal Dis 1986; 1: 79-84
    CrossrefPubMedSearch in Google Scholar
  • 17 Kikuchi R, Takano M, Takagi K. et al. Management of early invasive colorectal cancer. Risk of recurrence and clinical guidelines. Dis Colon Rektum 1995; 38: 1286-1295
    CrossrefPubMedSearch in Google Scholar
  • 18 Probst A, Messmann H. Kolorektale Adenome: Pro endoskopische Abtragung. Chirurg 2011; 82: 514-519
    CrossrefPubMedSearch in Google Scholar
  • 19 Repici A, Hassan C, De Paula Pessoa D. et al. Efficacy and safety of endoscopic submucosal dissection for colorectal neoplasia: a systematic review. Endoscopy 2012; 44: 137-150
    Thieme ConnectPubMedSearch in Google Scholar
  • 20 Repici A, Pellicano R, Strangio G. et al. Endoscopic mucosal resection for early colorectal neoplasia: pathologic basis, procedures, and outcomes. Dis Colon Rectum 2009; 52: 1502-1515
    CrossrefPubMedSearch in Google Scholar
  • 21 Barendse RM, Musters GD, de Graaf EJR. et al. Randomised controlled trial of transanal endoscopic microsurgery versus endoscopic mucosal resection for large rectal adenomas (TREND Study). Gut 2018; 67: 837-846
    CrossrefPubMedSearch in Google Scholar
  • 22 Arezzo A, Passera R, Saito Y. et al. Systematic review und meta-analysis of endoscopic submucosal dissection versus transanal endoscopic microsurgery for large noninvasive rectal lesions. Surg Endosc 2014; 28: 427-438
    CrossrefPubMedSearch in Google Scholar
  • 23 Sagae VMT, Ribeiro IB, de Moura DTH. et al. Endoscopic submucosal dissection versus transanal endoscopic surgery for the treatment of early rectal tumor: a systematic review and meta-analysis. Surg Endosc 2020; 34: 1025-1034
    CrossrefPubMedSearch in Google Scholar
  • 24 Baral J. Transanal endoscopic microsurgical submucosa dissection in the treatment of rectal adenomas and T1 rectal cancer. Coloproctology 2018; 40: 364-372
    CrossrefPubMedSearch in Google Scholar
  • 25 Léonard D, Colin J-F, Remue C. et al. Transanal endoscopic microsurgery: long-term experience, indication expansion, and technical improvements. Surg Endosc 2012; 26: 312-322
    CrossrefPubMedSearch in Google Scholar
  • 26 Goertz R, Fein M, Sailer M. Impact of biopsy on the accuracy of endorectal ultrasound staging of rectal tumors. Dis Colon Rectum 2008; 51: 1125-1129
    CrossrefPubMedSearch in Google Scholar
  • 27 Sailer M, Leppert R, Kraemer M. et al. The value of endorectal ultrasound in the assessment of adenomas, T1 and T2 carcinomas. Int J Colorect Dis 1997; 12: 214-219
    CrossrefPubMedSearch in Google Scholar
  • 28 Hahnloser D, Wolff BG, Larson DW. et al. Immediate radical resection after local excision of rectal cancer: an oncologic compromise?. Dis Colon Rectum 2005; 48: 429-437
    CrossrefPubMedSearch in Google Scholar
  • 29 Wyatt JNR, Powell SG, Altaf K. et al. Completion total mesorectal excision after transanal local excision of early rectal cancer: A systematic review and meta-analysis. Dis Colon Rectum 2022; 65: 628-640
    CrossrefPubMedSearch in Google Scholar
  • 30 Stipa F, Giaccaglia V, Burza A. Management and outcome of local recurrence following transanal endoscopic microsurgery for rectal cancer. Dis Colon Rectum 2012; 55: 262-269
    CrossrefPubMedSearch in Google Scholar
  • 31 Allaix ME, Rebecci F, Giaccone C. et al. Long-term results and quality of life after transanal endoscopic microsurgery. Br J Surg 2011; 98: 1635-1643
    CrossrefPubMedSearch in Google Scholar
  • 32 Cataldo PA, O’Brian S, Turner O. Transanal Endoscopic Microsurgery: A prospective evaluation of functional results. Dis Colon Rectum 2005; 48: 1366-1371
    CrossrefPubMedSearch in Google Scholar
  • 33 Jin Z, YinL Xue L. et al. Anorectal functional results after transanal endoscopic microsurgery in benign and early malignant tumors. World J Surg 2010; 34: 1128-1132
    CrossrefPubMedSearch in Google Scholar
  • 34 Kreis ME, Jehle EC, Haug V. Functional results after transanal endoscopic microsurgery. Dis Colon Rectum 1996; 39: 1116-1121
    CrossrefPubMedSearch in Google Scholar
  • 35 Brachet S, Meillat H, Chanez B. et al. Case-matched comparison of functional and quality of life outcomes of local excision and total mesorectal excision following chemoradiotherapy for rectal cancer. Dis Colon Rectum 2022; 65: 1464-1474
    CrossrefPubMedSearch in Google Scholar
  • 36 Hoerske C, Weber K, Goehl J. et al. Long-term outcomes and quality of life after rectal carcinoma surgery. Br J Surg 2010; 97: 1295-1303
    CrossrefPubMedSearch in Google Scholar
  • 37 Smits LJH, van Lieshout AS, Grüter AAJ. et al. Multidisciplinary management of early rectal cancer – The role of surgical local excision in current and future clinical practice. Surg Oncol 2022; 40: 101687
    CrossrefPubMedSearch in Google Scholar
  • 38 Habr-Gama A, Perez RO, Nadalin W. et al. Operative versus nonoperative treatment for stage 0 distal rectal cancer following chemoradiation therapy; long-term results. Ann Surg 2004; 240: 711-717
    CrossrefPubMedSearch in Google Scholar
  • 39 Borschitz T, Wachtlin D, Möhler M. et al. Neoadjuvant chemoradiation and local excision for T2–3 rectal cancer. Ann Surg Oncol 2008; 15: 712-720
    CrossrefPubMedSearch in Google Scholar
  • 40 Borstlap WAA, Coeymans TJ, Tanis PJ. et al. Meta-analysis of oncological outcomes after local excision of pT1–2 rectal cancer requiring adjuvant (chemo)radiotherapy or completion surgery. Br J Surg 2016; 103: 1105-1116
    CrossrefPubMedSearch in Google Scholar
  • 41 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: 29-37
    CrossrefPubMedSearch in Google Scholar
  • 42 Rouleau-Fournier F, Brown CJ. Can less be more? Organ preservation strategies in the management of rectal cancer. Curr Oncol 2019; 26 (Suppl. 01) S16-S23
    CrossrefPubMedSearch in Google Scholar
  • 43 Smith FM, Waldron D, Winter DC. Rectum-conserving surgery in the era of chemoradiotherapy. Br J Surg 2010; 97: 1752-1764
    CrossrefPubMedSearch in Google Scholar
  • 44 Martens MH, Maas M, Heijnen LA. et al. Long-term outcomne of an organ preservation program after neoadjuvant treatment for rectal cancer. J Natl Cancer Inst 2016; 108: djw171
    CrossrefPubMedSearch in Google Scholar
  • 45 Rullier E, Rouanet P, Tuech JJ. et al. Organ preservation for rectal cancer (GRECCAR 2): a prospective, randomised, open-label, multicentre, phase 3 trial. Lancet 2017; 390: 469-479
    CrossrefPubMedSearch in Google Scholar
  • 46 Stijns RCH, de Graaf EJR, Punt CJA. et al. Long-term Oncological und Functional Outcomes of Chemoradiotherapy Followed by Organ-Sparing Transanal Endoscopic Microsurgery for Distal Rectal Cancer: The CARTS Study. JAMA Surg 2019; 154: 47-54
    CrossrefPubMedSearch in Google Scholar
  • 47 Lezoche E, Baldarelli M, Lezoche G. et al. Randomized clinical trial of endoluminal locoregional resection versus laparoscopic total mesorectal excision for T2 rectal cancer after neoadjuvant therapy. Br J Surg 2012; 99: 1211-1218
    CrossrefPubMedSearch in Google Scholar
  • 48 Bach SP, Hill J, Monson JRT. et al. A predictive model for local recurrence after transanal endoscopic microsurgery for rectal cancer. Br J Surg 2009; 96: 280-290
    CrossrefPubMedSearch in Google Scholar
  • 49 Rombouts AJM, Al-Najami I, Abbott N. et al. Can we Save the rectum by watchful waiting or Trans Anal microsurgery following (chemo) Radiotherapy versus Total mesorectal excision for early REctal Cancer (STAR-TREC study)?: protocol for a multicentre, randomised feasibility study. BMJ Open 2017 7: e019474
    CrossrefPubMed