Die Transanale Endoskopische Mikrochirurgie (TEM) ist eine chirurgische Option zur Erhaltung der Stuhlkontinenz bei ausgewählten tiefsitzenden Rektumkarzinomen

Zusammenfassung

Einleitung Trotz der Erfindung vor über 40 Jahren hat sich die TEM nicht flächendeckend durchgesetzt. Gründe sind vor allem hohe Anschaffungskosten, die anspruchsvolle Technik und alternative Therapiemöglichkeiten (radikale Resektionsverfahren), die eine größere onkologische Sicherheit bieten. Allerdings kann die Vermeidung großer Bauchoperation mit Stomaanlage und häufigeren Komplikationen das höhere Rezidivrisiko für einige Patienten aufwiegen.

Wir untersuchten die Resultate der modifizierten und in der Anschaffung kostengünstigeren V-TEM bei der Resektion von Adenomen und Karzinomen und diskutieren den heutigen Stellenwert des Verfahrens anhand der Literatur.

Methode Zwischen 2003 und 2019 wurden 154 Patienten an 170 Befunden mittels V-TEM operiert. Die Daten zu Operation und Follow-up wurden retrospektiv erhoben und ausgewertet.

Ergebnisse Das mediane Alter betrug 67 Jahre, 89 Patienten waren männlich und 65 weiblich. Die V-TEM wurde bei 79 Karzinomen, 77 Adenomen und 14 sonstigen Befunden eingesetzt. Die Komplikationsrate betrug 21,1%, eine R0-Resektion gelang in 78,8% der Fälle. Die Adenomrezidivrate betrug 7,3%, die Gesamtrezidivrate bei Karzinomen 11,9%, Lokalrezidive traten bei 6,8% auf. Das krankheitsspezifische Überleben betrug 100% nach 5 und 94,2% nach 10 Jahren.

Diskussion Der erfolgreiche Einsatz der TEM bei Adenomen und Frühkarzinomen ist unumstritten. Bei Karzinomen ab einem T1 high risk-Stadium muss jedoch mit Rezidivraten von über 10% gerechnet werden, wohingegen mit radikalen Verfahren bessere Ergebnisse erzielt werden können, weshalb diese als Therapie der Wahl in diesen Fällen gelten. Es gibt jedoch kaum Unterschiede bezüglich der Überlebensraten, zudem bietet die TEM eine bessere postoperative Lebensqualität. Insbesondere auch die Kombination neoadjuvanter Verfahren mit der TEM konnten in der Vergangenheit vielversprechende Ergebnisse bei fortgeschritteneren Stadien liefern. Weitere Studien und die geringeren Anschaffungskosten durch Modifikation zur V-TEM könnten der Methode in Zukunft größere Popularität verleihen.

Abstract

Introduction Despite its existence for more than 40 years, the TEM method has not become widespread. The main reasons are the high acquisition costs, the sophisticated technology and alternative procedures (especially radical resection procedures), which provide greater oncological safety. However, avoiding major abdominal surgery with the creation of a stoma and higher complication rates can outweigh the higher risk of recurrence for some patients. We examined the results using V-TEM with reduced acquisition costs in the resection of adenomas and carcinomas and discussed its importance by literature .

Method From 2003 to 2019, 154 patients with 170 findings were operated by V-TEM technology. Data on the operation and follow-up were collected and analyzed retrospectively.

Results The median age was 67 years, 89 patients were male and 65 female. V-TEM was performed on 79 carcinomas, 77 adenomas and 14 other findings. The complication rate was 21.2 %. R0 resection was achieved in 78.8 %. The adenoma recurrence rate was 7.3 %, the overall recurrence rate for carcinomas 11.9 %, local recurrences were observed in 6.8 %. The disease-specific survival is 100 % at 5 years and 94.2 % at ten years.

Discussion The successful use of TEM in adenomas and early carcinomas is undisputed. When treating carcinomas from a T1 high risk stage using TEM, recurrence rates higher than 10 % must be expected. Better results can be achieved with radical procedures, this is why they are considered the therapy of choice in these cases. However, there are no differences in terms of survival rates and TEM offers proven better postoperative quality of life. In particular, the combination of neoadjuvant procedures with TEM delivered promising results in more advanced stages. Further studies on TEM and the possibility of lower acquisition costs through modification to V-TEM could make the method more popular in the future.

Schlüsselwörter

Darm - Rektumkarzinom - Transanale endoskopische Mikrochirurgie - Kolorektale Chirurgie - Minimalinvasiv - Lokale Resektion

Keywords

Rectum - rectal cancer - transanal microsurgery - colorectal surgery - minimal invasive - local resection

Publication History

Received: 29 June 2023

Accepted after revision: 24 September 2023

Article published online:
10 January 2024

• Literatur

• 1 Buess G, Hutterer F, Theiss J. et al. Das System für die transanale endoskopische Rectumoperation. Der Chirurg; Zeitschrift für alle Gebiete der operativen Medizin 1984; 55: 677-680
• 2 Leitlinienprogramm Onkologie (Deutsche Krebsgesellschaft, Deutsche Krebshilfe, AWMF): S3-Leitlinie Kolorektales Karzinom, Langversion 2.1, 2019, AWMF-Registrierungsnummer: 021/007OL.
• 3 Huschitt S, Strauß P, Plaksin A. et al. Videoassistierte transanale endoskopische Mikrochirurgie von Rektumtumoren – V-TEM. Zentralblatt für Chirurgie 2014; 139: e49-54
• 4 Ganai S, Kanumuri P, Rao RS. et al. Local recurrence after transanal endoscopic microsurgery for rectal polyps and early cancers. Annals of surgical oncology 2006; 13: 547-556 DOI: 10.1245/ASO.2006.04.010. (PMID: 16514476)
• 5 Endreseth BH, Wibe A, Svinsås M. et al. Postoperative morbidity and recurrence after local excision of rectal adenomas and rectal cancer by transanal endoscopic microsurgery. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland 2005; 7: 133-137 DOI: 10.1111/j.1463-1318.2004.00724.x. (PMID: 15720349)
• 6 Allaix ME, Arezzo A, Cassoni P. et al. Recurrence after transanal endoscopic microsurgery for large rectal adenomas. Surgical endoscopy 2012; 26: 2594-2600 DOI: 10.1007/s00464-012-2238-z. (PMID: 22476837)
• 7 Guerrieri M, Baldarelli M, Sanctis A de. et al. Treatment of rectal adenomas by transanal endoscopic microsurgery: 15 years’ experience. Surgical endoscopy 2010; 24: 445-449 DOI: 10.1007/s00464-009-0585-1. (PMID: 19565297)
• 8 Tsai BM, Finne CO, Nordenstam JF. et al. Transanal endoscopic microsurgery resection of rectal tumors: outcomes and recommendations. Diseases of the colon and rectum 2010; 53: 16-23 DOI: 10.1007/DCR.0b013e3181bbd6ee. (PMID: 20010345)
• 9 Whitehouse PA, Tilney HS, Armitage JN. et al. Transanal endoscopic microsurgery: risk factors for local recurrence of benign rectal adenomas. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland 2006; 8: 795-799 DOI: 10.1111/j.1463-1318.2006.01098.x. (PMID: 17032328)
• 10 Winde G, Nottberg H, Keller R. et al. Surgical cure for early rectal carcinomas (T1). Transanal endoscopic microsurgery vs. anterior resection. Diseases of the colon and rectum 1996; 39: 969-976 DOI: 10.1007/BF02054683. (PMID: 8797643)
• 11 Moore JS, Cataldo PA, Osler T. et al. Transanal endoscopic microsurgery is more effective than traditional transanal excision for resection of rectal masses. Diseases of the colon and rectum 2008; 51: 1026-30
• 12 Bueß G F, Mentges B. Transanal endoscopic microsurgery (TEM). Minimally Invasive Therapy 1992; 1: 101-109 (PMID: 7866754)
• 13 Ondhia M, Tamvakeras P, O’Toole P. et al. Transanal endoscopic microsurgery for rectal lesions in a specialist regional early rectal cancer centre: the Mersey experience. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland 2019; 21: 1164-1174 DOI: 10.1111/codi.14730. (PMID: 31207005)
• 14 Allaix ME, Rebecchi F, Giaccone C. et al. Long-term functional results and quality of life after transanal endoscopic microsurgery. The British journal of surgery 2011; 98: 1635-1643 DOI: 10.1002/bjs.7584. (PMID: 21713758)
• 15 Heald RJ, Ryall RD. Recurrence and survival after total mesorectal excision for rectal cancer. Lancet (London, England) 1986; 1: 1479-1482
• 16 Maurer CA, Renzulli P, Kull C. et al. The impact of the introduction of total mesorectal excision on local recurrence rate and survival in rectal cancer: long-term results. Annals of surgical oncology 2011; 18: 1899-1906 DOI: 10.1245/s10434-011-1571-0. (PMID: 21298350)
• 17 Baatrup G, Breum B, Qvist N. et al. Transanal endoscopic microsurgery in 143 consecutive patients with rectal adenocarcinoma: results from a Danish multicenter study. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland 2009; 11: 270-275
• 18 Guerrieri M, Baldarelli M, Organetti L. et al. Transanal endoscopic microsurgery for the treatment of selected patients with distal rectal cancer: 15 years experience. Surgical endoscopy 2008; 22: 2030-2035
• 19 Morino M, Allaix ME, Caldart M. et al. Risk factors for recurrence after transanal endoscopic microsurgery for rectal malignant neoplasm. Surgical endoscopy 2011; 25: 3683-3690 DOI: 10.1007/s00464-011-1777-z. (PMID: 21647814)
• 20 Lee W, Lee D, Choi S. et al. Transanal endoscopic microsurgery and radical surgery for T1 and T2 rectal cancer. Surgical endoscopy 2003; 17: 1283-1287 DOI: 10.1007/s00464-002-8814-x. (PMID: 12739119)
• 21 De Graaf EJR, Doornebosch PG, Tollenaar RAEM. et al. Transanal endoscopic microsurgery versus total mesorectal excision of T1 rectal adenocarcinomas with curative intention. European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology 2009; 35: 1280-1285
• 22 Palma P, Horisberger K, Joos A. et al. Local excision of early rectal cancer: is transanal endoscopic microsurgery an alternative to radical surgery?. Revista espanola de enfermedades digestivas 2009; 101: 172-178 DOI: 10.4321/s1130-01082009000300003. (PMID: 19388797)
• 23 Ramirez JM, Aguilella V, Valencia J. et al. Transanal endoscopic microsurgery for rectal cancer. Long-term oncologic results. International journal of colorectal disease 2011; 26: 437-443 DOI: 10.1007/s00384-011-1132-9. (PMID: 21271346)
• 24 O’Neill CH, Platz J, Moore JS. et al. Transanal Endoscopic Microsurgery for Early Rectal Cancer: A Single-Center Experience. Diseases of the colon and rectum 2017; 60: 152-160 DOI: 10.1097/DCR.0000000000000764. (PMID: 28059911)
• 25 Stipa F, Burza A, Lucandri G. et al. Outcomes for early rectal cancer managed with transanal endoscopic microsurgery: a 5-year follow-up study. Surgical endoscopy 2006; 20: 541-545
• 26 Sajid MS, Farag S, Leung P. et al. Systematic review and meta-analysis of published trials comparing the effectiveness of transanal endoscopic microsurgery and radical resection in the management of early rectal cancer. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland 2014; 16: 2-14 DOI: 10.1111/codi.12474. (PMID: 24330432)
• 27 Suppiah A, Maslekar S, Alabi A. et al. Transanal endoscopic microsurgery in early rectal cancer: time for a trial?. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland 2008; 10: 314-27 DOI: 10.1111/j.1463-1318.2007.01448.x. (PMID: 18190614)
• 28 Engel J, Kerr J, Schlesinger-Raab A. et al. Quality of life in rectal cancer patients: a four-year prospective study. Annals of surgery 2003; 238: 203-213 DOI: 10.1097/01.sla.0000080823.38569.b0. (PMID: 12894013)
• 29 Sprangers MA, Taal BG, Aaronson NK. et al. Quality of life in colorectal cancer. Stoma vs. nonstoma patients. Diseases of the colon and rectum 1995; 38: 361-369 DOI: 10.1007/BF02054222. (PMID: 7720441)
• 30 Park SU, Min YW, Shin JU. et al. Endoscopic submucosal dissection or transanal endoscopic microsurgery for nonpolypoid rectal high grade dysplasia and submucosa-invading rectal cancer. Endoscopy 2012; 44: 1031-1036 DOI: 10.1055/s-0032-1310015. (PMID: 23012217)
• 31 Kawaguti FS, Nahas CSR, Marques CFS. et al. Endoscopic submucosal dissection versus transanal endoscopic microsurgery for the treatment of early rectal cancer. Surgical endoscopy 2014; 28: 1173-1179 DOI: 10.1007/s00464-013-3302-z. (PMID: 24232053)
• 32 McCarty TR, Bazarbashi AN, Hathorn KE. et al. Endoscopic submucosal dissection (ESD) versus transanal endoscopic microsurgery (TEM) for treatment of rectal tumors: a comparative systematic review and meta-analysis. Surgical endoscopy 2020; 34: 1688-1695 DOI: 10.1007/s00464-019-06945-1. (PMID: 31292744)
• 33 Oka S, Tanaka S, Saito Y. et al. Local recurrence after endoscopic resection for large colorectal neoplasia: a multicenter prospective study in Japan. The American journal of gastroenterology 2015; 110: 697-707 DOI: 10.1038/ajg.2015.96. (PMID: 25848926)
• 34 Lezoche E, Guerrieri M, Paganini AM. et al. Long-term results in patients with T2–3 N0 distal rectal cancer undergoing radiotherapy before transanal endoscopic microsurgery. The British journal of surgery 2005; 92: 1546-1552
• 35 Maas M, Beets-Tan RGH, Lambregts DMJ. et al. Wait-and-see policy for clinical complete responders after chemoradiation for rectal cancer. Journal of clinical oncology : official journal of the American Society of Clinical Oncology 2011; 29: 4633-4640 DOI: 10.1200/JCO.2011.37.7176. (PMID: 22067400)
• 36 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. The British journal of surgery 2012; 99: 1211-1218 DOI: 10.1002/bjs.8821. (PMID: 22864880)
• 37 Serra-Aracil X, Pericay C, Badia-Closa J. et al. Short-term outcomes of chemoradiotherapy and local excision versus total mesorectal excision in T2-T3ab,N0,M0 rectal cancer: a multicentre randomised, controlled, phase III trial (the TAU-TEM study). Annals of oncology : official journal of the European Society for Medical Oncology 2023; 34: 78-90 DOI: 10.1016/j.annonc.2022.09.160. (PMID: 36220461)