Rare indications for transanal endoscopic microsurgery

Abstract

Aim: Transanal endoscopic microsurgery (TEM) and transanal endoscopic operation (TEO) are enabling platforms for tailored full-thickness or submucosal rectal excision. We evaluated outcomes of patients with rare rectal indications managed using these platforms.

Methods: We performed a single-centre retrospective cohort study of consecutive patients treated with TEM or TEO between 1993 and 2024 for lesions with rare final rectal histology. Inclusion criteria were local excision by TEM/TEO, rare definitive histology, and available perioperative data; standard indications (adenoma/adenocarcinoma), non-rectal lesions, and incomplete records were excluded. Data included lesion characteristics, operative details, margins, complications, hospital stay, follow-up, and recurrence.

Results: Forty-eight patients across 11 histotype groups were included. Excision was full-thickness in 45/48 cases and submucosal in 3/48. Peritoneal entry occurred in 3/48 and was managed on-platform without conversion. R0 resection was achieved in 46/48 patients. Four postoperative complications occurred overall; only one bleeding episode required transfusion and reoperation. There was no mortality. Median length of stay was 3 days [interquartile range (IQR), 2-5], and median follow-up was 36 months (IQR, 22-49). Recurrence occurred in 4/48 patients.

Conclusions: TEM/TEO provided safe, organ-preserving local excision for rare rectal lesions, with high R0 rates, limited morbidity, no mortality, and short hospital stay. These data support the use of rigid transanal endoscopic platforms for selected uncommon rectal pathologies.

Keywords

Transanal endoscopic microsurgery / transanal endoscopic operation / rare rectal lesions / local excision / organ preservation / gastrointestinal stromal tumour / neuroendocrine neoplasm

References

[1] Buess G,Hack D,Heintz A.Technique of transanal endoscopic microsurgery.Surg Endosc1988;2:71-5

[2] Winde G,Herwig R,Keller R.Benefit in therapy of superficial rectal neoplasms objectivized: transanal endoscopic microsurgery (TEM) compared to surgical standards.Minim Invasive Ther Allied Technol1997;6:315-23

[3] Moore JS,Osler T.Transanal endoscopic microsurgery is more effective than traditional transanal excision for resection of rectal masses.Dis Colon Rectum2008;51:1026-30; discussion 1030

[4] Arezzo A,Cravero F,Allaix ME.Which treatment for large rectal adenoma? Preoperative assessment and therapeutic strategy.Minim Invasive Ther Allied Technol2014;23:21-7

[5] Duek SD,Khoury W.Transanal endoscopic microsurgery: also for the treatment of retrorectal tumors.Minim Invasive Ther Allied Technol2014;23:28-31

[6] Arezzo A,Saito Y.Systematic review and meta-analysis of endoscopic submucosal dissection versus transanal endoscopic microsurgery for large noninvasive rectal lesions.Surg Endosc2014;28:427-38

[7] Middleton PF,Maddern GJ.Transanal endoscopic microsurgery: a systematic review.Dis Colon Rectum2005;48:270-84

[8] Morino M.Transanal endoscopic microsurgery: what indications in 2013?.Gastroenterol Rep2013;1:75-84 PMCID:PMC3938006

[9] Heald RJ,Ryall RD,MacFarlane JK.Rectal cancer: the Basingstoke experience of total mesorectal excision, 1978-1997.Arch Surg1998;133:894-9

[10] Nagtegaal ID, Odze RD, Klimstra D, et al.; WHO Classification of Tumours Editorial Board. The 2019 WHO classification of tumours of the digestive system.Histopathology2020;76:182-8 PMCID:PMC7003895

[11] Park SS,Lee DE.Comparison of endoscopic submucosal dissection and transanal endoscopic microsurgery for T1 rectal neuroendocrine tumors: a propensity score-matched study.Gastrointest Endosc2021;94:408-15.e2

[12] Gronchi A,Poveda Velasco A.Quality of surgery and outcome in localized gastrointestinal stromal tumors treated within an international intergroup randomized clinical trial of adjuvant imatinib.JAMA Surg2020;155:e200397 PMCID:PMC7113837

[13] Shi WK,Li YH.Long-term outcomes of transanal endoscopic microsurgery for the treatment of rectal neuroendocrine tumors.BMC Surg2022;22:43 PMCID:PMC8817465

[14] Guaglio M,Cesa Bianchi A,Battaglia L.Minimizing the surgical approach for a rare disease: transanal endoscopic microsurgery for rectal schwannoma.Tumori2019;105:NP52-6

[15] Punnen S,Raval MJ,Brown CJ.Transanal endoscopic microsurgery (TEM) for rectal GI stromal tumor.Am J Surg2021;221:183-6

[16] De Graaf EJ,Tollenaar RA.Transanal endoscopic microsurgery versus total mesorectal excision of T1 rectal adenocarcinomas with curative intention.Eur J Surg Oncol2009;35:1280-5

[17] Kethman WC,Morris AM,Kirilcuk N.Oncologic and perioperative outcomes of laparoscopic, open, and robotic approaches for rectal cancer resection: a multicenter, propensity score-weighted cohort study.Dis Colon Rectum2020;63:46-52

[18] D’Urso A,Marescaux J,Serra-Aracil X.Treatment of complete rectal prolapse using the TEO® platform (transanal endoscopic operation) - a video vignette.Colorectal Dis2024;26:820-2

[19] Hur H,Han YD.Transanal endoscopic operation for rectal tumor: short-term outcomes and learning curve analysis.Surg Laparosc Endosc Percutan Tech2016;26:236-43

[20] Boland PA,Murphy E.Local excision of rectal neoplasia: a real-world survey of current practices and perspectives.Minim Invasive Ther Allied Technol2025;34:335-43

[21] Chavda V,Chaudhri S.Management of early rectal cancer; current surgical options and future direction.World J Gastrointest Surg2021;13:655-67 PMCID:PMC8316852

[22] Kouladouros K,Kähler G.Transanal endoscopic microsurgical submucosal dissection: are there advantages over conventional ESD?.Minim Invasive Ther Allied Technol2022;31:720-7

[23] Marks JH,Salem JF.Robotic transanal surgery for rectal cancer.Clin Colon Rectal Surg2021;34:317-24 PMCID:PMC8428981

[24] Hashimoto DA,Rus D.Artificial intelligence in surgery: promises and perils.Ann Surg2018;268:70-6 PMCID:PMC5995666