Local Excision for the Management of Early Rectal Cancer

Abstract

Transanal endoscopic microsurgery (TEM) is a minimally invasive technique introduced in the 1980s to overcome the technical difficulties in the management of low rectal tumors. The TEM system includes a dedicated rigid rectoscope and platform with a dedicated expensive instrumentation. The transanal minimally invasive surgery (TAMIS) technique was introduced to overcome these limitations. Transanal surgery consists of three main steps: exposure of the lesion, tumor excision, and defect closure. Traditional indications are benign adenomas and selected T1 rectal cancers. However, when combined with neoadjuvant chemoradiotherapy (n-CRT), the indications may be extended to patients with selected T2-T3 rectal cancers responsive to n-CRT. Intraoperative complications may be difficult to deal with, but peritoneal entry is adequately managed by endoluminal direct closure of the defect by expert surgeons. Concerning the indications for defect closure, there is no evidence of better results to prevent complications such as bleeding; the indication for defect closure should be evaluated according to multiple variables. The management of other complications is safe and does not affect TEM’s oncological and functional outcomes. Transanal excision of rectal tumor is a safe and effective alternative to conventional resection to avoid the low anterior resection syndrome, with comparable oncological results and with the advantages of an organ-sparing strategy for better patients’ QoL.