Treatment of rectal cancer by transanal endoscopic microsurgery: Experience with 425 patients

AIM:To describe our experience in treating rectal cancer by transanal endoscopic microsurgery(TEM),report morbidity and mortality and oncological outcome.METHODS:A total of 425 patients with rectal cancer(120 T1,185 T2,120 T3 lesions)were staged by digital rectal examination,rectoscopy,transanal endosonography,magnetic resonance imaging and/or computed tomography.Patients with T1-N0 lesions and favourable histological features underwent TEM immediately.Patients with preoperative stage T2-T3-N0 underwent preoperative high-dose radiotherapy;from 1997 those aged less than 70 years and in good general health also underwent preoperative chemotherapy.Patients with T2-T3-N0 lesions were restaged 30 d after radiotherapy and were then operated on 40-50 d after neoadjuvant therapy.The instrumentation designed by Buess was used for all procedures.RESULTS:There were neither perioperative mortality nor intraoperative complications.Conversion to other surgical procedures was never required.Major complications(urethral lesions,perianal or retroperitoneal phlegmon and rectovaginal fistula)occurred in six(1.4%)patients and minor complications(partial suture line dehiscence,stool incontinence and rectal haemorrhage)in 42(9.9%).Postoperative pain was minimal.Definitive histological examination of the 425 malignant lesions showed 80(18.8%)pT0,153(36%)pT1,151(35.5%)pT2,and 41(9.6%)pT3 lesions.Eighteen(4.2%)patients(ten pT2 and eight pT3)had a local recurrence and 16(3.8%)had distant metastasis.Cancer-specific survival rates at the end of follow-up were100%for pT1 patients(253 mo),93%for pT2 patients(255 mo)and 89%for pT3 patients(239 mo).CONCLUSION:TEM is a safe and effective procedure to treat rectal cancer in selected patients without evidence of nodal involvement.T2-T3 lesions require preoperative neoadjuvant therapy.