Skip to main content
SpringerLink
Log in

Hybrid-TAMIS totale mesorektale Exzision

Neue Perspektive in der Behandlung des distalen Rektumkarzinoms - Technik und Ergebnisse

Hybrid TAMIS total mesorectal excision

A new perspective in treatment of distal rectal cancer - Technique and results

  • Originalien
  • Published:
Der Chirurg Aims and scope Submit manuscript

Zusammenfassung

Hintergrund

Der transanal minimalinvasive Zugang („transanal minimally invasive surgery“, TAMIS) zur totalen mesorektalen Exzision (TME) könnte hinsichtlich Radikalität und Funktionserhalt Vorteile bieten. Zu den Ergebnissen bei Patienten mit distalen Rektumkarzinomen liegen bisher nur wenige Daten vor.

Methode

Zwischen 2/2013 und 3/2015 wurde bei 24 ausgewählten Patienten mit einem Rektumkarzinom < 6 cm ab anokutan eine laparoskopisch assistierte TAMIS TME (Hybrid-TAMIS TME) durchgeführt. Im Rahmen einer prospektiven Beobachtungsstudie wurden erste Ergebnisse zur Operationstechnik und zur Qualität der TME analysiert.

Ergebnisse

Das mediane Alter der Patienten (männlich:weiblich = 18:6) lag bei 57 Jahren (35 bis 77 Jahre). Sieben Patienten (29 %) hatten einen BMI > 30 kg/m2. Bei 19 Operationen wurde das Präparat transanal geborgen. Die TME-Qualität wurde an 22 (92 %) Präparaten mit „gut“ und an 2 mit „moderat“ bewertet. Nach neoadjuvanter Radiochemotherapie wurde in 5 Fällen eine pathohistologische Vollremission identifiziert. Der distale Sicherheitsabstand lag bei 7 mm im Median (2–30 mm), der Median des lateralen Sicherheitsabstandes lag bei 6 mm (<1 mm–30 mm). In 2 Fällen reichte der Tumor bis auf weniger als 1 mm an den zirkumferenziellen Präparatrand heran. Bei 19 (79 %) Operationen wurde ein Reservoir (Colon-J-Pouch oder lateroterminale Anastomose) angelegt. Die Morbidität des Eingriffs lag bei 29 % und schloss 1 Anastomoseninsuffizienz, 2 präsakrale Hämatome und 1 neurogene Blasenentleerungsstörung ein. Es gab keine 30-Tage-Letalität.

Zusammenfassung

Die Hybrid-TAMIS TME ist ein sicheres Verfahren zur Behandlung von Patienten mit distalen Rektumkarzinomen. In der anspruchsvollen Situation kann der minimalinvasive transanale Zugangsweg den Sphinktererhalt und eine gute TME-Qualität sichern. Studien mit längerer Nachbeobachtungszeit zur Erfassung der onkologischen und funktionellen Ergebnisse sind notwendig.

Abstract

Background

Transanal minimally invasive surgery (TAMIS) represents a promising technique for total mesorectal excision (TME) with respect to radicalness and preservation of function. There are only few publications in the literature describing results in patients with distal rectal cancer.

Methods

Between May 2013 and March 2015, 24 selected patients with a rectal carcinoma < 6 cm from the anal verge underwent a laparoscopically assisted TAMIS TME (Hybrid-TAMIS TME) procedure. This prospective observational study was conducted to examine the safety of the technique and the quality of TME surgery in distal rectal cancer and to assess the short-term postoperative outcome.

Results

The median age of patients (18 male and 6 female) at the time of surgery was 57 years (range 35–77 years) and 7 patients (29 %) had a body mass index (BMI) > 30 kg/m2. Specimen excision was carried out transanally in 19 patients. Pathological grading of TME specimens was good in 22 (92 %) and moderate in 2 cases. After neoadjuvant radiochemotherapy a complete pathological remission was identified in five patients. The median distal resection margin was 7 mm (range 2–30 mm), the median circumferential resection margin was 6 mm (range <1 mm–30 mm) and in 2 patients the tumor was ≤ 1 mm from the positive circumferential margin. A colonic reservoir was created in 19 patients (79 %) and no 30-day mortalities occurred. Morbidity was 29 %, including 1 anastomotic leak, 2 hematomas and 1 neurogenic bladder.

Conclusion

Hybrid-TAMIS TME for distal rectal cancer is safe and can provide a sphincter-preserving high-quality TME in difficult cases. Studies with long-term follow-up assessing oncological and functional results are mandatory.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1
Abb. 2

Literatur

  1. Kreis ME, Straßburg J (2015) Vorwort. In: Kreis ME, Straßburg J (Hrsg) Moderne Chirurgie des Rektumkarzinoms. Springer, Berlin, S V

    Google Scholar 

  2. Heald RJ, Husband EM, Ryall RD (1982) The mesorectum in rectal cancer surgery – the clue to pelvic recurrence? Br J Surg 69(10):613–616. (Epub 1982/10/01)

    Article  CAS  PubMed  Google Scholar 

  3. Guillou PJ, Quirke P, Thorpe H, Walker J, Jayne DG, Smith AM et al (2005) Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet 365(9472):1718–1726. (Epub 2005/05/17)

    Article  PubMed  Google Scholar 

  4. van der Pas MH, Haglind E, Cuesta MA, Furst A, Lacy AM, Hop WC et al (2013) Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol 14(3):210–218. (Epub 2013/02/12)

    Article  PubMed  Google Scholar 

  5. Arezzo A, Passera R, Salvai A, Arolfo S, Allaix ME, Schwarzer G et al (2015) Laparoscopy for rectal cancer is oncologically adequate: a systematic review and meta-analysis of the literature. Surg Endosc 29(2):334–348. (Epub 2014/07/11)

    Article  PubMed  Google Scholar 

  6. Salerno G, Daniels IR, Brown G, Norman AR, Moran BJ, Heald RJ (2007) Variations in pelvic dimensions do not predict the risk of circumferential resection margin (CRM) involvement in rectal cancer. World J Surg 31:1313–1320

    Article  CAS  PubMed  Google Scholar 

  7. Kapiteijn E, Marijnen CA, Nagtegaal ID, Putter H, Steup WH, Wiggers T et al (2001) Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med 345(9):638–646. (Epub 2001/09/08)

    Article  CAS  PubMed  Google Scholar 

  8. Kneist W, Heintz A, Wolf HK, Junginger T (2004) Darstellung autonomer Beckennerven bei partieller und totaler Mesorektumexzision. Chirurg 75:276–283

    Article  CAS  PubMed  Google Scholar 

  9. Runkel N, Reiser H (2013) Nerve-oriented mesorectal excision (NOME): autonomic nerves as landmarks for laparoscopic rectal resection. Int J Colorectal Dis 28(10):1367–1375. (Epub 2013/05/15)

    Article  PubMed  Google Scholar 

  10. Denost Q, Adam JP, Rullier A, Buscail E, Laurent C, Rullier E (2014) Perineal transanal approach: a new standard for laparoscopic sphincter-saving resection in low rectal cancer, a randomized trial. Ann Surg 260(6):993–999. (Epub 2014/06/21)

    Article  PubMed  Google Scholar 

  11. Heald RJ (2013) A new solution to some old problems: transanal TME. Tech Coloproctol 17:257–258

    Article  CAS  PubMed  Google Scholar 

  12. Atallah S (2015) Transanal total mesorectal excision: full steam ahead. Tech Coloproctol 19:57–61

    Article  CAS  PubMed  Google Scholar 

  13. Kneist W, Rink AD, Kauff DW, Konerding MA, Lang H (2015) Topography of the extrinsic internal anal sphincter nerve supply during laparoscopic-assisted TAMIS TME: five key zones of risk from the surgeons’ view. Int J Colorectal Dis 30(1):71–78. (Epub 2014/10/15)

    Article  PubMed  Google Scholar 

  14. Marks J, Nassif G, Schoonyoung H, DeNittis A, Zeger E, Mohiuddin M et al (2013) Sphinctersparing surgery for adenocarcinoma of the distal 3 cm of the true rectum: results after neoadjuvant therapy and minimally invasive radical surgery or local excision. Surg Endosc 27(12):4469–4477. (Epub 2013/09/24)

    Article  PubMed  Google Scholar 

  15. Rink AD, Kneist W, Radinski I, Guinot-Barona A, Lang H, Vestweber KH (2010) Differences in ano-neorectal physiology of ileoanal and coloanal reconstructions for restorative proctectomy. Colorectal Dis 12(4):342–350. (Epub 2009/02/12)

    Article  CAS  PubMed  Google Scholar 

  16. Aigner F, Hormann R, Fritsch H, Pratschke J, D’Hoore A, Brenner E et al (2015) Anatomical considerations for transanal minimal-invasive surgery: the caudal to cephalic approach. Colorectal Dis 17(2):O47–O53. (Epub 2014/11/25)

  17. Sylla P, Rattner DW, Delgado S, Lacy AM (2010) NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance. Surg Endosc 24(5):1205–1210. (Epub 2010/02/27)

    Article  PubMed  Google Scholar 

  18. Leroy J, Barry BD, Melani A, Mutter D, Marescaux J (2013) No-scar transanal total mesorectal excision: the last step to pure NOTES for colorectal surgery. JAMA Surg 148(3):226–230. (discussion 31) (Epub 2013/05/18)

    Article  PubMed  Google Scholar 

  19. Rouanet P, Mourregot A, Azar CC, Carrere S, Gutowski M, Quenet F et al (2013) Transanal endoscopic proctectomy: an innovative procedure for difficult resection of rectal tumors in men with narrow pelvis. Dis Colon Rectum 56(4):408–415. (Epub 2013/03/13)

    Article  PubMed  Google Scholar 

  20. Tuech JJ, Karoui M, Lelong B, De Chaisemartin C, Bridoux V, Manceau G et al (2015) A step toward NOTES total mesorectal excision for rectal cancer: endoscopic transanal proctectomy. Ann Surg 261(2):228–233. (Epub 2014/11/02)

    Article  PubMed  Google Scholar 

  21. Knol JJ, D’Hondt M, Souverijns G, Heald B, Vangertruyden G (2015) Transanal endoscopic total mesorectal excision: technical aspects of approaching the mesorectal plane from below-a preliminary report. Tech Coloproctol 19:221–229. (Epub 2015/02/22)

    Article  CAS  PubMed  Google Scholar 

  22. Chouillard E, Chahine E, Khoury G, Vinson-Bonnet B, Gumbs A, Azoulay D et al (2014) NOTES total mesorectal excision (TME) for patients with rectal neoplasia: a preliminary experience. Surg Endosc 28(11):3150–3157. (Epub 2014/06/01)

    Article  CAS  PubMed  Google Scholar 

  23. Velthuis S, Nieuwenhuis DH, Ruijter TE, Cuesta MA, Bonjer HJ, Sietses C (2014) Transanal versus traditional laparoscopic total mesorectal excision for rectal carcinoma. Surg Endosc 28(12):3494–3499. (Epub 2014/06/29)

    Article  PubMed  Google Scholar 

  24. Fernandez-Hevia M, Delgado S, Castells A, Tasende M, Momblan D, Diaz del Gobbo G et al (2015) Transanal total mesorectal excision in rectal cancer: short-term outcomes in comparison with laparoscopic surgery. Ann Surg 261(2):221–227. (Epub 2014/09/05)

    Article  PubMed  Google Scholar 

  25. Sylla P, Bordeianou LG, Berger D, Han KS, Lauwers GY, Sahani DV et al (2013) A pilot study of natural orifice transanal endoscopic total mesorectal excision with laparoscopic assistance for rectal cancer. Surg Endosc 27(9):3396–3405. (Epub 2013/04/11)

    Article  PubMed  Google Scholar 

  26. Zorron R, Phillips HN, Wynn G, Neto MP, Coelho D, Vassallo RC (2014) „Down-to-Up“ transanal NOTES Total mesorectal excision for rectal cancer: preliminary series of 9 patients. J Minim Access Surg 10(3):144–150. (Epub 2014/07/12)

    Article  PubMed  PubMed Central  Google Scholar 

  27. Atallah S, Martin-Perez B, Albert M, deBeche-Adams T, Nassif G, Hunter L et al (2014) Transanal minimally invasive surgery for total mesorectal excision (TAMIS-TME): results and experience with the first 20 patients undergoing curative-intent rectal cancer surgery at a single institution. Tech Coloproctol 18(5):473–480. (Epub 2013/11/26)

    Article  CAS  PubMed  Google Scholar 

  28. Denost Q, Adam JP, Pontallier A, Celerier B, Laurent C, Rullier E (2015) Laparoscopic total mesorectal excision with coloanal anastomosis for rectal cancer. Ann Surg 261(1):138–143. (Epub 2014/09/05)

    Article  PubMed  Google Scholar 

  29. Wolthuis AM, de Buck vanOA, D’Hoore A (2014) Dynamic article: transanal rectal excision: a pilot study. Dis Colon Rectum 57(1):105–109. (Epub 2013/12/10)

    Article  PubMed  Google Scholar 

  30. de Lacy AM, Rattner DW, Adelsdorfer C, Tasende MM, Fernandez M, Delgado S et al (2013) Transanal natural orifice transluminal endoscopic surgery (NOTES) rectal resection: „downto-up“ total mesorectal excision (TME) – short-term outcomes in the first 20 cases. Surg Endosc 27(9):3165–3172. (Epub 2013/03/23)

    Article  PubMed  Google Scholar 

  31. Velthuis S, Veltcamp Helbach M, Tuynman JB, Le TN, Bonjer HJ, Sietses C (2015) Intraabdominal bacterial contamination in TAMIS total mesorectal excision for rectal carcinoma: a prospective study. Surg Endosc doi:10.1007/s00464-015-4089-x. (Epub 2015/02/11)

  32. Jarry J, Faucheron JL (2011) Laparoscopic rectosigmoid resection with transanal colonic pullthrough and delayed coloanal anastomosis: a new approach to adult Hirschsprung disease. Dis Colon Rectum 54(10):1313–1319. (Epub 2011/09/10)

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Abteilung für Allgemein-, Viszeral- und Thoraxchirurgie, Klinikum Leverkusen, Leverkusen, Deutschland

    A.D. Rink & K.-H. Vestweber

  2. Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsmedizin der Johannes-Gutenberg Universität Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland

    D.W. Kauff, M. Paschold, H. Lang &  W. Kneist

Authors
  1. A.D. Rink
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. D.W. Kauff
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. M. Paschold
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. K.-H. Vestweber
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. H. Lang
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. W. Kneist
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to W. Kneist.

Ethics declarations

Interessenkonflikt

A.D. Rink, D.W. Kauff, M. Paschold, K.-H. Vestweber, H. Lang und W. Kneist geben an, dass kein Interessenkonflikt besteht.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Rink, A., Kauff, D., Paschold, M. et al. Hybrid-TAMIS totale mesorektale Exzision. Chirurg 87, 225–232 (2016). https://doi.org/10.1007/s00104-015-0043-7

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00104-015-0043-7

Schlüsselwörter

Keywords

Search

Navigation