Transanal endoscopic operations: A safe and effective alternative to tems

Introduction: Rectal surgery is perhaps the? easiest conduit for NOTES. Traditional TEMS was the technique of choice for small rectal lesions. More recently the transanal endoscopic operation (TEO) technique has gained a foothold as it is cheaper than TEMS, and surgeons have more refined laparoscopic skills. We report our early experience with TEO's in our unit.

Methods: TEOs carried out between January 2010 and May 2012 were identified. All cases were discussed preoperatively at our colorectal MDT meeting. Case notes were reviewed retrospectively for demographic, clinical and histological data.

Results: 14 cases were performed by 2 colorectal surgeons. There were equal numbers of men and women, with a mean age of 70 (52–80). 5 patients were ASA 3–4. The lesions were equally located anteriorly or posteriorly, at 3–15 cm from the anal margin. Pre-operative enema and post-operative antibiotics were standard protocol. All cases bar one were carried out in the lithotomy position, with a mean operative time of 67 minutes (25–110 minutes).

4 cases were adenocarcinoma, 10 were benign adenomas. All adenocarcinomas were diagnosed pre-operatively and were completely excised T1 lesions. One patient had T1 Kikuchi Sm3, and proceeded to an APER, where there was no residual tumour and no lymph nodes involvement. The other 3 patients had routine surgical and endoscopic follow-up.

The patient who had APER had a breach of the vagina during the TEO procedure. This was recognised and repaired peri-operatively.

Two patients had cardiac complications – one fast AF which settled on medical management; the other, who was ASA 4, developed complete heart block requiring pacemaker insertion. One patient died 18 months later from malignant melanoma; there was no procedure-associated mortality.

Surgeons reported frustration with defect closure owing to the confined operative space.

Conclusion: We have shown that TEOs can be used safely and effectively to treat rectal lesions, including certain early T1 adenocarcinomas, thereby avoiding the morbidity associated with conventional open and laparoscopic methods. Patients are still at risk from operative and cardio-respiratory complications, and should be selected appropriately. We welcome developments in the instrumentation to aid the frustrating elements to this emerging technique.