Interesting case
OD 224562963
62 yo man with irretrievable rectal TVA on screening colonoscopy, prior transanal excision
8 cm from anal verge
Pmhx: hypothyroidism, arthritis
Pshx: appendectomy, bilateral inguinal hernia repair
Meds: ASA, MVI
• Decision made to proceed with transanal minimally invasive surgery
• Lesion located between lowest and middle rectal valves
• Positioning: prone with leg splitter
• Applied Medical gelport, 90 degree scope, laparoscopic instruments
Rectal adenoma
Villous adenoma is a premalignant lesion
2/3 occur in the rectum
Equal sex distribution, peak incidence 6th and 7th decades
Difficult to detect
Harbor malignancy in 40% of cases
Biopsy often misses 40% of cancers
Patients older than 80 undergoing APR have 15% risk of perioperative death
ASA grade I patients have perioperative mortality of 0.5%
ASA grade IV patients have risk approaching 25%
Consider impact of radical surgery on QOL
Surgical options
Local excision with transanal technique
Kraske sacral operation
Radical excision (LAR or APR)
Transanal Endoscopic MicroSurgery
Transanal Minimally Invasive Surgery
What is TAMIS?
Named by Atallah et als
Described its use in 6 patients, 2 with early rectal cancers
Crossover technique using SILS equipment
Single surgeon experience using TAE vs transbdominal resections
Main outcomes were complications, recurrence and malignancy rates
• Retrospective review
• T1 and T2 rectal cancers
• Local excisions from 1997-2006
• 42 TEMS, 129 TAE patients
• Median followup 60 months for TEMS, 45 for TAE
• Only 34 patients had local recurrence
• 145 of 164 patients were disease free at last followup
• Authors conclude that TEMS resection is superior to TAE
• Indications for both may overlap
• Variables such as tumor distance from AV, T stage and adjuvant therapy may be more important predictors of outcome
Conclusions
Local excision safe for villous adenomas and early rectal cancers by multiple means (TAE, TEMS, TAMIS)
Careful patient selection
Diligent followup
Discussion with patient about radical surgery