Transanal Endoscopic Microsurgery Compared with Radical Surgery for Rectal Malignant Tumor: A Systematic Review_Chinese Journal of Evidence-Based Medicine

Authors：

GUO Xiaofan ^1,3 , XU Hainan ^1,3 ,  WANG Zhenning ^1,2

1. Department of Surgical Oncology, the First Hospital of China Medical University, Shenyang 110001, China;2. Department of General Surgery, the First Hospital of China Medical University, Shenyang 110001, China;3. Seven-Year System of China Medical University, Shenyang 110001, China;

Corresponding author：

WANG Zhenning, Email: josieon826@yahoo.com.cn

Keywords：

Transanal endoscopic microsurgery; Radical surgery; Rectal malignant tumor; Systematic review

DOI：

10.7507/1672-2531.20110013

Video：

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Objective　To evaluate the curative effectiveness and safety of transanal endoscopic microsurgery (TEM) vs. radical surgery (RS) for the patients with rectal malignant tumor, and to provide information for clinical research and practice.
Methods　Through computer searching The Cochrane Central Register of Controlled Trials, PubMed, OVID, CBM and CNKI from inception to April 2010, and hand searching relevant journals including Chinese Journal of Surgery and Chinese Journal of Evidence-Based Medicine, the randomized controlled trails (RCTs) and non-randomized controlled trails (NRCTs) comparing TEM with RS for rectal malignant tumor were collected. Data were extracted and evaluated by two reviewers independently according to the Cochrane Handbook for Systematic Reviews. Meta-analyses were conducted using the Cochrane collaboration’s software RevMan 5.0.
Results　One RCT and four NRCTs met the selection criteria, involving 929 patients. The methodological quality of all trials was low with possibility of bias. The meta-analyses showed that: a) Three studies reported local recurrence in T1 stage patients. There was a significant difference in local recurrence between the two groups (OR=12.61, 95%CI 2.59 to 61.29, P=0.002); b) Two studies reported disease-free survival in T1 stage patients. There was no significant difference between the two groups in disease-free survival (OR=1.12, 95%CI 0.31 to 4.12, P=0.86); c) Three studies reported overall survival in T1 stage patients. There was no significant difference between the two groups (OR=1.09, 95%CI 0.57 to 2.08, P=0.80); and d) Three studies reported postoperative complications in T1 stage patients. There was a significant difference between the two groups in terms of complications (OR=0.05, 95%CI 0.02 to 0.10, P lt;0.00001).
Conclusion　For T1 stage patients, TEM is associated with less injury of tissue, less operative bleeding, short duration of hospital stay, and low incidence of postoperative complications. The disease-free and overall survivals are comparable to those of RS, but the local recurrence rate is higher. The role of TEM in T2 stage patients is still under discussion. However, the trails available for this systematic review are of lower methodological quality, and bias may exist due to NRCTs. Therefore, more high quality RCTs are required.

Citation： GUO Xiaofan,XU Hainan,WANG Zhenning. Transanal Endoscopic Microsurgery Compared with Radical Surgery for Rectal Malignant Tumor: A Systematic Review. Chinese Journal of Evidence-Based Medicine, 2011, 11(1): 70-75. doi: 10.7507/1672-2531.20110013 Copy

1.	Buess G, Hutterer F, Theiss J, et al. A system for a transanal endoscopic rectum operation. Chirurg, 1984, 55(10): 677-680.
2.	Nakagoe T, Ishikawa H, Sawai T, et al. Surgical technique and outcome of gasless video endoscopic transanal rectal tumor excision. Br J Surg, 2002, 89(6): 769-774.
3.	Dafnis G, Pahlman L, Raab Y, et al. Transanal endoscopic microsurgery: clinical and functional results. Colorectal Dis, 2004, 6 (5): 336-342.
4.	刘建平. 非随机研究的系统评价方法(一). 中国循证医学, 2001, 1(4): 239-243.
5.	Lezoche G, Baldarelli M, Guerrieri M, et al. A prospective randomized study with a 5-year minimum follow-up evaluation of transanal endoscopic microsurgery versus laparoscopic total mesorectal excision after neoadjuvant therapy. Surg Endosc, 2008, 22(2): 352-358.
6.	Palma P, Horisberger K, Joos A, et al. Local excision of early rectal cancer: is transanal endoscopic microsurgery an alternative to radical surgery? Rev Esp Enferm Dig, 2009, 101(3): 172-178.
7.	Ptok H, Marusch F, Meyer F, et al. Oncological outcome of local vs radical resection of low-risk pT1 rectal cancer. Arch Surg, 2007, 142(7): 649-655.
8.	Lee W, Lee D, Choi S, et al. Transanal endoscopic microsurgery and radical surgery for T1 and T2 rectal cancer. Surg Endosc, 2003, 17(8): 1283-1287.
9.	De Graaf EJ, Doornebosch PG, Tollenaar RA, et al. Transanal endoscopic microsurgery versus total mesorectal excision of T1 rectal adenocarcinomas with curative intention. Eur J Surg Oncol, 2009, 35(12): 1280-1285.
10.	Buess G. Review: transanal endoscopic microsurgery (TEM). J R Coll Surg Edinb, 1993, 38: 239-245.
11.	Borschitz T, Heintz A, Junginger T. The influence of histopathologic criteria on the long-term prognosis of locally excised pT1 rectal carcinomas: results of local excision (transanal endoscopic microsurgery) and immediate reoperation. Dis Colon Rectum, 2006, 49: 1492-1506.
12.	Stipa F, Burza A, Lucandri G, et al. Outcomes for early rectal cancer managed with transanal endoscopic microsurgery: a 5-year follow-up study. Surg Endosc, 2006, 20: 541-545.
13.	Farmer KC, Wale R, Winnett J, et al. Transanal endoscopic microsurgery: the first 50 cases. ANZ J Surg, 2002, 72: 854-856.
14.	Mihai R, Borley N. Transanal endoscopic microsurgery – impact on the practice of a colorectal surgeon in a district general hospital. Ann R Coll Surg Engl, 2005, 87: 432-436.
15.	Platell C, Denholm E, Makin G. Efficacy of transanal endoscopic microsurgery in the management of rectal polyps. J Gastroenterol Hepatol, 2004, 19: 767-772.
16.	Maslekar S, Pillinger SH, Sharma A, et al. Cost analysis of transanal endoscopic microsurgery for rectal tumours. Colorectal Dis, 2007, 9(3): 229-234.
17.	Gavagan JA, Whiteford MH, Swanstrom LL. Full-thickness intraperitoneal excision by transanal endoscopic microsurgery does not increase short-term complications. Am J Surg, 2004, 187(5): 630-634.
18.	Guerrieri M, Feliciotti F, Baldarelli M, et al. Sphincter-saving surgery in patients with rectal cancer treated by radiotherapy and transanal endoscopic microsurgery: 10 years’ experience. Dig Liver Dis, 2003, 35(12): 876-880.
19.	Kreissler-Haag D, Schuld J, Lindemann W, et al. Complications after transanal endoscopic microsurgical resection correlate with location of rectal neoplasms. Surg Endosc, 2008, 22(3): 612-616.
20.	Lee WY, Lee WS, Yun SH, et al. Decision for salvage treatment after transanal endoscopic microsurgery. Surg Endosc, 2007, 21(6): 975-979.

1. Buess G, Hutterer F, Theiss J, et al. A system for a transanal endoscopic rectum operation. Chirurg, 1984, 55(10): 677-680.
2. Nakagoe T, Ishikawa H, Sawai T, et al. Surgical technique and outcome of gasless video endoscopic transanal rectal tumor excision. Br J Surg, 2002, 89(6): 769-774.
3. Dafnis G, Pahlman L, Raab Y, et al. Transanal endoscopic microsurgery: clinical and functional results. Colorectal Dis, 2004, 6 (5): 336-342.
4. 刘建平. 非随机研究的系统评价方法(一). 中国循证医学, 2001, 1(4): 239-243.
5. Lezoche G, Baldarelli M, Guerrieri M, et al. A prospective randomized study with a 5-year minimum follow-up evaluation of transanal endoscopic microsurgery versus laparoscopic total mesorectal excision after neoadjuvant therapy. Surg Endosc, 2008, 22(2): 352-358.
6. Palma P, Horisberger K, Joos A, et al. Local excision of early rectal cancer: is transanal endoscopic microsurgery an alternative to radical surgery? Rev Esp Enferm Dig, 2009, 101(3): 172-178.
7. Ptok H, Marusch F, Meyer F, et al. Oncological outcome of local vs radical resection of low-risk pT1 rectal cancer. Arch Surg, 2007, 142(7): 649-655.
8. Lee W, Lee D, Choi S, et al. Transanal endoscopic microsurgery and radical surgery for T1 and T2 rectal cancer. Surg Endosc, 2003, 17(8): 1283-1287.
9. De Graaf EJ, Doornebosch PG, Tollenaar RA, et al. Transanal endoscopic microsurgery versus total mesorectal excision of T1 rectal adenocarcinomas with curative intention. Eur J Surg Oncol, 2009, 35(12): 1280-1285.
10. Buess G. Review: transanal endoscopic microsurgery (TEM). J R Coll Surg Edinb, 1993, 38: 239-245.
11. Borschitz T, Heintz A, Junginger T. The influence of histopathologic criteria on the long-term prognosis of locally excised pT1 rectal carcinomas: results of local excision (transanal endoscopic microsurgery) and immediate reoperation. Dis Colon Rectum, 2006, 49: 1492-1506.
12. Stipa F, Burza A, Lucandri G, et al. Outcomes for early rectal cancer managed with transanal endoscopic microsurgery: a 5-year follow-up study. Surg Endosc, 2006, 20: 541-545.
13. Farmer KC, Wale R, Winnett J, et al. Transanal endoscopic microsurgery: the first 50 cases. ANZ J Surg, 2002, 72: 854-856.
14. Mihai R, Borley N. Transanal endoscopic microsurgery – impact on the practice of a colorectal surgeon in a district general hospital. Ann R Coll Surg Engl, 2005, 87: 432-436.
15. Platell C, Denholm E, Makin G. Efficacy of transanal endoscopic microsurgery in the management of rectal polyps. J Gastroenterol Hepatol, 2004, 19: 767-772.
16. Maslekar S, Pillinger SH, Sharma A, et al. Cost analysis of transanal endoscopic microsurgery for rectal tumours. Colorectal Dis, 2007, 9(3): 229-234.
17. Gavagan JA, Whiteford MH, Swanstrom LL. Full-thickness intraperitoneal excision by transanal endoscopic microsurgery does not increase short-term complications. Am J Surg, 2004, 187(5): 630-634.
18. Guerrieri M, Feliciotti F, Baldarelli M, et al. Sphincter-saving surgery in patients with rectal cancer treated by radiotherapy and transanal endoscopic microsurgery: 10 years’ experience. Dig Liver Dis, 2003, 35(12): 876-880.
19. Kreissler-Haag D, Schuld J, Lindemann W, et al. Complications after transanal endoscopic microsurgical resection correlate with location of rectal neoplasms. Surg Endosc, 2008, 22(3): 612-616.
20. Lee WY, Lee WS, Yun SH, et al. Decision for salvage treatment after transanal endoscopic microsurgery. Surg Endosc, 2007, 21(6): 975-979.

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