K. Manncke

Functional results after transanal endoscopic microsurgery

PURPOSE: Compared with traditional operations, superior results after transanal endoscopic microsurgery (TEM) for rectal tumors have been demonstrated in terms of morbidity and mortality. However, no data were available on functional outcome after TEM. We, therefore, studied 42 patients who were undergoing TEM. METHODS: Patients were examined by anorectal manometry and participated in a standardized interview preoperatively and three months and one year after surgery. RESULTS: Anorectal function as assessed by manometry was impaired three months after surgery but improved again during the first postoperative year. In parallel, some patients complained of impaired continence or defecation disorders in the interview three months postoperatively. These functions improved during the first year after surgery, too. CONCLUSIONS: Correct comparison of our results with functional outcome after anterior rectal resection is impossible. We feel, however, that functional results after TEM are likely to be superior to those after anterior resection for rectal tumors.

Local therapy of rectal tumors

PURPOSE: The aim of the study is to outline the rising importance of local treatment of rectal tumors and a changing strategy in therapy of early rectal cancer. METHODS: As the surgical procedure, transanal endoscopic microsurgery was used. Indications for the local procedure were pT1 low-risk tumors and tumors of higher stages in patients with severe risk factors and of those who refused the operation according to oncologic guidelines. RESULTS: A total of 236 rectal adenomas and 98 carcinomas were locally excised using the transanal endoscopic microsurgery technique. Mortality rate was 0.3 percent, and rate of complications requiring surgical reintervention was 5.5 percent in adenomas and 8 percent in carcinomas. Final histology of removed carcinomas revealed 56 pT1, 27 pT2, and 15 pT3 stages. After an average follow-up time of 24 months, two recurrences were observed in the group of patients with pT1 low-risk carcinomas who only underwent local therapy. In both cases, a second intervention for cure was undertaken but for tumors in a late stage. CONCLUSIONS: In selected cases, local therapy of rectal carcinoma avoids high morbidity and mortality of the classical operation. Quality of life will be improved, especially if an artificial anus can be avoided. In case of recurrence, the chance of a secondary procedure for cure is not to be underestimated.

Functional results after laparoscopic rectopexy for rectal prolapse.

We investigated the functional results after laparoscopic rectopexy for rectal prolapse in 29 patients at least 12 months postoperatively. Twenty patients were evaluated completely pre- and postoperatively (median 22 months postoperatively, range 12 to 54 months). Six patients were interviewed by telephone, two patients were lost to follow-up, and one patient died of causes unrelated to rectal prolapse. Patients underwent a proctologic examination, anoscopy, rigid sigmoidoscopy, fluoroscopic defecography, and anorectal manometry pre- and postoperatively, and an additional standardized interview postoperatively. Anorectal manometry showed a significant increase in maximum anal resting and squeeze pressures postoperatively (resting pressure 72 ±8 vs. 95 ±13 mm Hg, pre- vs. postoperatively; P = 0.046; squeeze pressure 105 ±17 vs. 142 ±19 mm Hg, pre- vs. postoperatively; P = 0.035), and continence improved postoperatively (Wexner incontinence score 6.0 ±1.0 vs. 3.9 ± 0.8 pre- vs. postoperatively, P = 0.02). Twenty (77%) of 26 patients were satisfied with the operative result, but functional morbidity was observed in four patients, with two patients complaining of severe evacuation problems. Rectal prolapse recurred in one patient 42 months postoperatively (recurrence rate 1 [3.8%] of 26 patients). Functional results were very similar to those obtained after open rectopexy, with symptoms of prolapse and incontinence improved in the great majority of patients.

Minimal invasive surgery in the local treatment of rectal cancer.

There is growing general consent in the literature that in selected cases local treatment of rectal cancer is the therapy of choice [1]. It is argued that early rectal cancers which are well or moderately well differentiated have a low rate of regional spread and that conventional rectal resection by the abdominal approach carries a considerable risk of morbidity and mortality. This is particularly true for older patients and those at high operative risk [2]. Local excision of small rectal cancers should be performed by full thickness excision (disc excision), with a margin of clearance of at least I cm. However, there is no agreement as to which technique offers best exposure of the operative field. The lower rectum can be reached through the anus using various retractors. More proximal carcinomas can be excised by the technique of Mason [3, 4] or Kraske [5]. The poor exposure and the limited distance from the anal verge that can be achieved using retractors in transanal surgery and the invasiveness and complication rates of the Mason and Kraske procedures [6] set the stage for the development of a new surgical technique. This combined the good exposure of endoscopy with advanced instrument technology. In cooperation with the Wolf company we started this development in 1980 and the clinical application in 1983. instrument is introduced into the rectum using an obturator. A glass window is then inserted at the viewing end and the tumour is visualized using manual air insufflation as in conventional rectoscopy. Once the best view has been obtained, the rectoscope is fixed using the Martin Arm (a double-ball joint support instrument). The glass window is then removed and replaced by the working head which is attached to the rectoscope. Sealing elements prevent gas loss when the instruments are introduced.

Minimal Invasive Chirurgie: Transanale Endoskopische Mikrochirurgie (TEM)

Im Zeitraum vom 1.7.1983 bis 1.10.1990 wurden 314 Eingriffe mit dem Instrumentarium der TEM an den Universitatskliniken Koln, Mainz und Tubingen durchgefuhrt. Die hier dargestellten Ergebnisse beziehen sich auf 186 vorgenommene Operationen (137 Adenome, 49 Karzinome), fur die eine ausreichend lange Nachsorgeperiode existiert. Die hochstgelegenen Tumoren wurden aus dem unteren Sigma (bis 25 cm) entfernt. Bei einer Komplikationsrate von 6,5% wurde nach Polypektomie eine Rezidivrate von 5% beobachtet. Von 37 Patienten mit pT1-low risk-Tumoren entwickelte einer ein Rezidiv, bei drei pT1-high risk-Patienten wurden zwei Rezidive diagnostiziert. Im extraperitonealen Bereich sind Segmentresektionen mit End-zu-End-Anastomose durchfuhrbar.

695 Transanal endoscopic microsurgery in early rectal cancer

In the period from 8/89 to 1/94,355 rectal tumours were locally excised by TEM, 236 of them have been adenomas and 98 carcinomas. In the group of carcinomas, 53% preoperatively have been judged as adenomas (rectoscopy, histology, endosonography). In carcinomas, a full wall dissection or a segmental resection is always performed. The final histology showed the following tumour stages (number of reoperated patients): 54 (8) pT1, low risk and 2 (0) pT1 high risk; 25 (16) pT2, low risk and 2 (2) pT2 high risk; 13 (8) pT3 low risk and 2 (0) pT3 high risk. Patients with pT1 low risk carcinomas, resected in toto, patients treated with palliative intent, high risk patients and those who refused an open operation, were not reoperated. The more advanced tumour stages (pT1 high risk, pT2 and pT3) required another open intervention. Of the 34 reoperated, 3 showed a residual primary tumour (two in pT2 and one in pT3 carcinoma). In 15 reoperated patients, we could see lymph node metastases (only in pT2 and pT3 carcinomas). After a follow up period of 17 months, 2 of 46 patients with pT1 low risk carcinoma, 0 of 2 patients with pT1 high risk carcinema, 0 of 9 patients with only locally excised pT2 carcinomas and 1 of 7 patients with only locally excised pT3 tumour had developed a recurrence. The two patients with recurrence of pT1 low risk tumour, underwent a second procedure for cure. The zero mortality, the low morbidity rate and the oncological reliability of the TEM makes it the method of choice in the treatment of pT1 low risk rectal carcinoma.

Technik der laparoskopischen Operation des Leistenbruches mit transperitoneal oder präperitoneal eingebrachtem Prolenenetz

Bei der intraperitonealen Verschlustechnik wird laparoskopisch die Region des inneren Leistenringes dargestellt, das Peritoneum gespalten und auf eine Flache von 6 × 11 cm abprapariert. Die Samenstranggebilde werden unter exakter Sicht dargestellt und der Bruchsack reseziert. Das Prolenenetz wird eingeschnitten und eine Halfte hinter den Samenstranggebilden durchgezogen. Mit einem Hernienstapler wird der Schlitz im Netz verschlossen und das Netz an der Fascie fixiert. Abschliesend mus das Peritoneum mit Klammern sorgfaltig verschlossen werden, um ein Verkleben des Netzes mit Darmschlingen zu vermeiden. Beim praperitonealen Zugang wird uber eine kleine Incision am Nabel die Fascie gespalten und mit einem stumpfen Trokar der praperitoneale Raum sondiert. Die weitere Freipraparation erfolgt zuerst uber den Instrumentenkanal eines Laparoskopes und dann nach Einbringen von zwei weiteren Trokaren mit zusatzlichen Instrumenten. Das weitere Vorgehen entspricht weitgehend der transperitonealen Technik, auf die Resektion des Bruchsackes wird verzichtet.