Transanal minimally invasive rectal resection with total mesorectal excision after endoscopic mucosal resection

Czech version

Authors: L. Kunovsky ^1,2; Z. Kala ¹; R. Svatoň ¹; M. Dastych ²; R. Kroupa ²; Jiří Dolina ²; T. Grolich ¹; V. Čan ¹; V. Procházka ¹
Authors‘ workplace: Chirurgická klinika LF MU a FN Brno ¹; Interní gastroenterologická klinika LF MU a FN Brno ²
Published in: Gastroent Hepatol 2017; 71(3): 208-214
Category: Digestive Endoscopy: Review Article
doi: https://doi.org/10.14735/amgh2017208

Overview

Rectal cancer constitutes a serious oncological problem, and treatment of this disease involves a multidisciplinary team. Nowadays, rectal cancer constitutes more than a quarter of newly diagnosed colorectal cancers in the Czech Republic. Almost 70% of colorectal cancers develop from adenomatous polyps. Benign lesions such as adenoma or hyperplastic polyps can be treated endoscopically. In addition, in non-invasive malignant lesions (which are limited to the mucosa), endoscopic resection is considered curative. If certain criteria are met, endoscopic local excision can be considered a fully curative procedure, even in invasive cancer (cut-off limit: submucosa layer SM2). In patients with an unfavourable tumour grade, with carcinoma invading the submucosal layer (SM3), the cancer cannot be treated endoscopically by endoscopic mucosal resection (EMR) or endoscopic submucosal dissection and surgery is indicated. In some cases, endoscopic treatment can be inadequate and a surgical procedure has to be performed. During 2014–2015, four patients in our department underwent EMR to treat flat mucosal lesions 4–8 cm from the anal verge; however, local excision was not oncologically radical enough, and the patients were indicated for surgical resection. In these patients, a rectal resection with coloanal anastomosis was performed by transanal minimally invasive surgery (TAMIS), a new method that combines mini-invasive surgery with radical surgery resection without a permanent stoma, while meeting oncological radicality criteria. TAMIS can be beneficially used in patients after EMR if histology is promptly evaluated. Total mesorectal excision (TME), i.e., the removal of the fat coating surrounding the rectum along with its lymphatic nodes, has already become a standard surgical treatment for rectal cancer. TAMIS can be used for rectal resection with TME without the need for a stoma, even in low rectal cancer. Adverse histological results after EMR do not necessarily need to lead to an indication for rectal resection with a permanent stoma, but there is a possibility of intersphincteric resection with total lymphadenectomy.

Key words:
rectal cancer – endoscopic mucosal resection – rectal surgery – transanal minimally invasive surgery – total mesorectal excision

The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study.

The Editorial Board declares that the manuscript met the ICMJE „uniform requirements“ for biomedical papers.

Submitted:
7. 9. 2016

Accepted:
4. 1. 2017

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