Transanale Tumorresektion: Indikation, Operationstechniken und Komplikationsmanagement

Zusammenfassung

Bei den transanalen Resektionsverfahren handelt es sich um spezielle Operationsmethoden der minimalinvasiven Therapie von Rektumtumoren. Neben gutartigen Tumoren eignet sich diese Operationsmethode für die Resektion von sog. Low-Risk-T1-Rektumkarzinomen, wenn diese aufgrund ihrer Größe und Lokalisation sicher im Gesunden (R0) entfernt werden können. Bei stringenter Patientenselektion werden sehr gute onkologische Ergebnisse erzielt. Derzeit wird in diversen internationalen Studien evaluiert, ob lokale Resektionsverfahren onkologisch ausreichend sind, wenn eine komplette oder fast komplette Remission nach neoadjuvanter Radio-/Chemotherapie vorliegt. Zahlreiche Untersuchungen belegen, dass insbesondere die funktionellen Resultate und die postoperative Lebensqualität nach lokalen Resektionen hervorragend sind, zumal als Alternativoperationen die tiefe Rektumresektion bzw. die abdominoperineale Exstirpation zu diskutieren sind, die bekanntermaßen sehr häufig mit funktionellen Defiziten einhergehen.

Schwere Komplikationen sind sehr selten. Typische Minorkomplikationen sind ein postoperativer Harnverhalt oder transiente Temperaturerhöhungen. Eine Nahtdehiszenz verläuft i. d. R. klinisch inapparent. Als relevante Komplikationen sind vor allem Nachblutungen und die Eröffnung des Peritoneums zu nennen. Letztere müssen intraoperativ erkannt und entsprechend versorgt werden, was meist transanal oder minimalinvasiv gelingt. Sehr selten kommt es zu Infektionen, Abszessen, rektovaginalen Fisteln oder Verletzungen von Prostata und Harnröhre.

Abstract

Transanal resection procedures are special operations for the minimally invasive treatment of rectal tumours. Apart from benign tumours, this procedure is suitable for the excision of low-risk T1 rectal carcinomas, if these can be completely removed (R0 resection). With stringent patient selection, very good oncological results are achieved. Various international trials are currently evaluating whether local resection procedures are oncologically sufficient if there is a complete or near complete response after neoadjuvant radio-/chemotherapy. Numerous studies have shown that the functional results and the postoperative quality of life after local resection are excellent, especially considering the well-known functional deficits of alternative operations, such as low anterior or abdominoperineal resection.

Severe complications are very rare. Most complications, such as urinary retention or subfebrile temperatures, are minor in nature. Suture line dehiscences are usually clinically unremarkable. Major complications comprise significant haemorrhage and the opening of the peritoneal cavity. The latter must be recognized intraoperatively and can usually be managed by primary suture. Infection, abscess formation, rectovaginal fistula, injury of the prostate or even urethra are extremely rare complications.

Schlüsselwörter

Rektumkarzinom - transanale Tumorresktion - Komplikationsmanagement - neoadjuvante Therapie

Keywords

rectal cancer - transanal surgery - management of complications - neoadjuvant treatment

Publikationsverlauf

Eingereicht: 19. Dezember 2022

Angenommen nach Revision: 25. März 2023

Artikel online veröffentlicht:
02. Juni 2023

• Literatur

• 1 Parks AG. A technique for excising extensive villous papillomatous change in the lower rectum. Proc R Soc Med 1968; 61: 441-442 (PMID: 4871777)
• 2 Bueß G, Kipfmüller K, Hack D. et al. Technique of transanal endoscopic microsurgery. Surg Endosc 1988; 2: 71-75 DOI: 10.1007/BF00704356. (PMID: 3413659)
• 3 BachSPHill J, Monson JRT. et al. A predictive model for local recurrence after transanal endoscopic microsurgery for rectal cancer. Br J Surg 2009; 96: 280-290 DOI: 10.1002/bjs.6456. (PMID: 19224520)
• 4 Christoferidis D, Hyeon-Min C, Dixon M. et al. Transanal endoscopic microsurgery versus conventional transanal excision for patients with early rectal cancer. Ann Surg 2009; 249: 776-782 DOI: 10.1097/SLA.0b013e3181a3e54b. (PMID: 19387326)
• 5 Moore JS, Cataldo PA, Osler T, Hyman NH. Transanal endoscopic microsurgery is more effective than traditional transanal excision for resection of rectal masses. Dis Colon Rectum 2008; 51: 1026-1031 DOI: 10.1007/s10350-008-9337-x. (PMID: 18481147)
• 6 Dekkers N, Dang H, van der Kraan J. et al. Risk of recurrence after local resection of T1 rectal cancer: a meta-analysis with meta-regression. Surg Endosc 2022; 36: 9156-9168 DOI: 10.1007/s00464-022-09396-3. (PMID: 35773606)
• 7 Atallah S, Albert M, Larach S. Transanal minimally invasive surgery: giant leap forward. Surg Endosc 2010; 24: 2200-2205 DOI: 10.1007/s00464-010-0927-z. (PMID: 20174935)
• 8 Van den Eynde F, Jaekers J, Fieuws S. et al. TAMIS is a valuable alternative to TEM for resection of intraluminal rectal tumors. Techniques in Coloproctology 2019; 23: 161-166 DOI: 10.1007/s10151-019-01954-7. (PMID: 30859349)
• 9 Borschitz T, Junginger T. Stellenwert der lokalen Exzision von Rektumkarzinomen. Viszeralchirurgie 2006; 41: 306-312
• 10 Kim E, Hwang JM, Garcia-Aguilar J. Local excision of rectal carcinoma. Clin Colorectal Cancer 2008; 7: 376-385 DOI: 10.3816/CCC.2008.n.050. (PMID: 19036690)
• 11 Tytherleigh MG, Warren BF, Mortensen NJ. Management of early rectal cancer. Br J Surg 2008; 95: 409-423 DOI: 10.1002/bjs.6127. (PMID: 18314929)
• 12 Matzel KE, Merkel S, Hohenberger W. Lokale Therapieprinzipien beim Rektumkarzinom. Chirurg 2003; 10: 897-904 DOI: 10.1007/s00104-003-0745-0. (PMID: 14605731)
• 13 Ramirez JM, Aguilella V, Arribas D. et al. Transanal full-thickness excision of rectal tumors: should the defect be sutured? A randomized controlled trial. Colorectal Dis 2002; 4: 51-55 DOI: 10.1046/j.1463-1318.2002.00293.x. (PMID: 12780656)
• 14 Marks JH, Frenkel JL, Greenleaf CE. et al. Transanal endoscopic microsurgery with entrance into the peritoneal cavity: Is it safe?. Dis Colon Rectum 2014; 57: 1176-1182 DOI: 10.1097/DCR.0000000000000208. (PMID: 25203373)
• 15 Baatrup G, Borschitz T, Cunningham C. et al. Perforation into the peritoneal cavity during transanal endoscopic microsurgery for rectal cancer is not associated with major complications or oncological compromise. Surg Endosc 2009; 23: 2680-2683 DOI: 10.1007/s00464-008-0281-6. (PMID: 19172355)
• 16 Hermanek P, Gall FP. Early (microinvasive) colorectal carcinoma. Pathology, diagnosis, surgical treatment. Int J Colorectal Dis 1986; 1: 79-84 DOI: 10.1007/BF01648411. (PMID: 3611938)
• 17 Kikuchi R, Takano M, Takagi K. et al. Management of early invasive colorectal cancer. Risk of recurrence and clinical guidelines. Dis Colon Rektum 1995; 38: 1286-1295 DOI: 10.1007/BF02049154. (PMID: 7497841)
• 18 Probst A, Messmann H. Kolorektale Adenome: Pro endoskopische Abtragung. Chirurg 2011; 82: 514-519 DOI: 10.1007/s00104-010-2063-7. (PMID: 21487815)
• 19 Repici A, Hassan C, De Paula Pessoa D. et al. Efficacy and safety of endoscopic submucosal dissection for colorectal neoplasia: a systematic review. Endoscopy 2012; 44: 137-150 DOI: 10.1055/s-0031-1291448. (PMID: 22271024)
• 20 Repici A, Pellicano R, Strangio G. et al. Endoscopic mucosal resection for early colorectal neoplasia: pathologic basis, procedures, and outcomes. Dis Colon Rectum 2009; 52: 1502-1515 DOI: 10.1007/DCR.0b013e3181a74d9b. (PMID: 19617768)
• 21 Barendse RM, Musters GD, de Graaf EJR. et al. Randomised controlled trial of transanal endoscopic microsurgery versus endoscopic mucosal resection for large rectal adenomas (TREND Study). Gut 2018; 67: 837-846 DOI: 10.1136/gutjnl-2016-313101. (PMID: 28659349)
• 22 Arezzo A, Passera R, Saito Y. et al. Systematic review und meta-analysis of endoscopic submucosal dissection versus transanal endoscopic microsurgery for large noninvasive rectal lesions. Surg Endosc 2014; 28: 427-438 DOI: 10.1007/s00464-013-3238-3. (PMID: 24149849)
• 23 Sagae VMT, Ribeiro IB, de Moura DTH. et al. Endoscopic submucosal dissection versus transanal endoscopic surgery for the treatment of early rectal tumor: a systematic review and meta-analysis. Surg Endosc 2020; 34: 1025-1034 DOI: 10.1007/s00464-019-07271-2. (PMID: 31754850)
• 24 Baral J. Transanal endoscopic microsurgical submucosa dissection in the treatment of rectal adenomas and T1 rectal cancer. Coloproctology 2018; 40: 364-372 DOI: 10.1007/s00053-018-0291-3. (PMID: 30416238)
• 25 Léonard D, Colin J-F, Remue C. et al. Transanal endoscopic microsurgery: long-term experience, indication expansion, and technical improvements. Surg Endosc 2012; 26: 312-322 DOI: 10.1007/s00464-011-1869-9. (PMID: 21898025)
• 26 Goertz R, Fein M, Sailer M. Impact of biopsy on the accuracy of endorectal ultrasound staging of rectal tumors. Dis Colon Rectum 2008; 51: 1125-1129 DOI: 10.1007/s10350-008-9222-7. (PMID: 18478299)
• 27 Sailer M, Leppert R, Kraemer M. et al. The value of endorectal ultrasound in the assessment of adenomas, T1 and T2 carcinomas. Int J Colorect Dis 1997; 12: 214-219 DOI: 10.1007/s003840050092. (PMID: 9272450)
• 28 Hahnloser D, Wolff BG, Larson DW. et al. Immediate radical resection after local excision of rectal cancer: an oncologic compromise?. Dis Colon Rectum 2005; 48: 429-437 DOI: 10.1007/s10350-004-0900-9. (PMID: 15747069)
• 29 Wyatt JNR, Powell SG, Altaf K. et al. Completion total mesorectal excision after transanal local excision of early rectal cancer: A systematic review and meta-analysis. Dis Colon Rectum 2022; 65: 628-640 DOI: 10.1097/DCR.0000000000002407. (PMID: 35143429)
• 30 Stipa F, Giaccaglia V, Burza A. Management and outcome of local recurrence following transanal endoscopic microsurgery for rectal cancer. Dis Colon Rectum 2012; 55: 262-269 DOI: 10.1097/DCR.0b013e318241ef22. (PMID: 22469792)
• 31 Allaix ME, Rebecci F, Giaccone C. et al. Long-term results and quality of life after transanal endoscopic microsurgery. Br J Surg 2011; 98: 1635-1643 DOI: 10.1002/bjs.7584. (PMID: 21713758)
• 32 Cataldo PA, O’Brian S, Turner O. Transanal Endoscopic Microsurgery: A prospective evaluation of functional results. Dis Colon Rectum 2005; 48: 1366-1371 DOI: 10.1007/s10350-005-0031-y. (PMID: 15933798)
• 33 Jin Z, YinL Xue L. et al. Anorectal functional results after transanal endoscopic microsurgery in benign and early malignant tumors. World J Surg 2010; 34: 1128-1132 DOI: 10.1007/s00268-010-0475-7. (PMID: 20225126)
• 34 Kreis ME, Jehle EC, Haug V. Functional results after transanal endoscopic microsurgery. Dis Colon Rectum 1996; 39: 1116-1121 DOI: 10.1007/BF02081411. (PMID: 8831526)
• 35 Brachet S, Meillat H, Chanez B. et al. Case-matched comparison of functional and quality of life outcomes of local excision and total mesorectal excision following chemoradiotherapy for rectal cancer. Dis Colon Rectum 2022; 65: 1464-1474 DOI: 10.1097/DCR.0000000000002384. (PMID: 35913830)
• 36 Hoerske C, Weber K, Goehl J. et al. Long-term outcomes and quality of life after rectal carcinoma surgery. Br J Surg 2010; 97: 1295-1303 DOI: 10.1002/bjs.7105. (PMID: 20602501)
• 37 Smits LJH, van Lieshout AS, Grüter AAJ. et al. Multidisciplinary management of early rectal cancer – The role of surgical local excision in current and future clinical practice. Surg Oncol 2022; 40: 101687 DOI: 10.1016/j.suronc.2021.101687. (PMID: 34875460)
• 38 Habr-Gama A, Perez RO, Nadalin W. et al. Operative versus nonoperative treatment for stage 0 distal rectal cancer following chemoradiation therapy; long-term results. Ann Surg 2004; 240: 711-717 DOI: 10.1097/01.sla.0000141194.27992.32. (PMID: 15383798)
• 39 Borschitz T, Wachtlin D, Möhler M. et al. Neoadjuvant chemoradiation and local excision for T2–3 rectal cancer. Ann Surg Oncol 2008; 15: 712-720 DOI: 10.1245/s10434-007-9732-x. (PMID: 18163173)
• 40 Borstlap WAA, Coeymans TJ, Tanis PJ. et al. Meta-analysis of oncological outcomes after local excision of pT1–2 rectal cancer requiring adjuvant (chemo)radiotherapy or completion surgery. Br J Surg 2016; 103: 1105-1116 DOI: 10.1002/bjs.10163. (PMID: 27302385)
• 41 Peltrini R, Sacco M, Luglio G. et al. Local excision following chemoradiotherapy in T2-T3 rectal cancer: current status and critical appraisal. Updates Surg 2020; 72: 29-37 DOI: 10.1007/s13304-019-00689-2. (PMID: 31621033)
• 42 Rouleau-Fournier F, Brown CJ. Can less be more? Organ preservation strategies in the management of rectal cancer. Curr Oncol 2019; 26 (Suppl. 01) S16-S23 DOI: 10.3747/co.26.5841. (PMID: 31819706)
• 43 Smith FM, Waldron D, Winter DC. Rectum-conserving surgery in the era of chemoradiotherapy. Br J Surg 2010; 97: 1752-1764 DOI: 10.1002/bjs.7251. (PMID: 20845400)
• 44 Martens MH, Maas M, Heijnen LA. et al. Long-term outcomne of an organ preservation program after neoadjuvant treatment for rectal cancer. J Natl Cancer Inst 2016; 108: djw171 DOI: 10.1093/jnci/djw171. (PMID: 27509881)
• 45 Rullier E, Rouanet P, Tuech JJ. et al. Organ preservation for rectal cancer (GRECCAR 2): a prospective, randomised, open-label, multicentre, phase 3 trial. Lancet 2017; 390: 469-479 DOI: 10.1016/S0140-6736(17)31056-5. (PMID: 28601342)
• 46 Stijns RCH, de Graaf EJR, Punt CJA. et al. Long-term Oncological und Functional Outcomes of Chemoradiotherapy Followed by Organ-Sparing Transanal Endoscopic Microsurgery for Distal Rectal Cancer: The CARTS Study. JAMA Surg 2019; 154: 47-54 DOI: 10.1001/jamasurg.2018.3752. (PMID: 30304338)
• 47 Lezoche E, Baldarelli M, Lezoche G. et al. Randomized clinical trial of endoluminal locoregional resection versus laparoscopic total mesorectal excision for T2 rectal cancer after neoadjuvant therapy. Br J Surg 2012; 99: 1211-1218 DOI: 10.1002/bjs.8821. (PMID: 22864880)
• 48 Bach SP, Hill J, Monson JRT. et al. A predictive model for local recurrence after transanal endoscopic microsurgery for rectal cancer. Br J Surg 2009; 96: 280-290 DOI: 10.1002/bjs.6456. (PMID: 19224520)
• 49 Rombouts AJM, Al-Najami I, Abbott N. et al. Can we Save the rectum by watchful waiting or Trans Anal microsurgery following (chemo) Radiotherapy versus Total mesorectal excision for early REctal Cancer (STAR-TREC study)?: protocol for a multicentre, randomised feasibility study. BMJ Open 2017 7: e019474 DOI: 10.1136/bmjopen-2017-019474. (PMID: 29288190)