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Transanal endoscopic microsurgery: Long-term experience, indication expansion, and technical improvements

机译：经肛门内窥镜显微手术：长期经验，适应症扩大和技术改进

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Background: This study aimed to review the authors' 16-year experience with transanal endoscopic microsurgery (TEM). Mortality, morbidity, recurrence rate, and functional outcome were assessed. New indications and technical improvements are presented. Methods: From November 1991 to August 2008, 123 patients (72 men and 51 women; median age, 68 years; range, 21-91 years) underwent TEM for excision of 105 adenomas with low- or high-grade dysplasia, 9 invasive adenocarcinomas (5 curative and 4 palliative resections), 2 neuroendocrine tumors, and 2 extramucosal lesions. Five additional patients had excisional biopsies, allowing staging after previous endoscopic resection. Most of the resections were full-thickness rectal resections using electrocautery or, more recently, the Harmonic scalpel. The latest mucosectomies were performed using the endoscopic submucosal dissection (ESD) technique. In addition, nontumoral indications included pelvic abscess (7 patients) and rectal strictures, which were either anastomotic or chemical. Pelvic abscesses were drained transrectally, whereas rectal stenoses were treated by strictureplasty. Foreign object retrieval and collagen plug placement for anal fistulas were performed using TEM in three patients. Results: No mortality occurred. One intraoperative rectal perforation required conversion to laparotomy. The postoperative complications included one pneumoperitoneum, which was treated medically, and one rectal perforation requiring Hartmann's procedure. In the polyp subgroup, six patients (6/91, 7%) experienced local recurrence. Pelvic abscesses were successfully treated, and stenosis did not recur after strictureplasty. Anorectal manometry showed functional alterations without significant clinical impact. Conclusions: The findings showed TEM to be a safe and effective procedure for local excision of rectal lesions with a low recurrence rate and minimal consequences in terms of anorectal function. In addition, TEM proved to be feasible and effective for pelvic abscess drainage and rectal stenosis treatment. New technologies such as the Harmonic scalpel and ESD increase the precision already offered by this approach.
机译：背景：本研究旨在回顾作者在肛门内窥镜显微手术（TEM）方面的16年经验。评估死亡率，发病率，复发率和功能结局。提出了新的适应症和技术改进。方法：自1991年11月至2008年8月，对123例患者（男72例，女51例;中位年龄68岁;范围21-91岁）行TEM切除105例低度或高度不典型增生的腺瘤，9例浸润性腺癌。 （5例治愈和4例姑息性切除），2例神经内分泌肿瘤和2例粘膜外病变。另外五名患者进行了切除活检，允许在先前的内镜切除后分期。大多数切除术是使用电烙术或最近使用谐波解剖刀进行的全层直肠切除术。最新的粘膜切除术是使用内窥镜黏膜下剥离术（ESD）技术进行的。此外，非肿瘤适应症包括盆腔脓肿（7例）和直肠狭窄，无论是吻合还是化学性。盆腔脓肿经直肠引流，而直肠狭窄则通过狭窄成形术治疗。使用TEM对3例患者进行了肛肠异物取回和胶原蛋白栓塞置入术。结果：未发生死亡。一个术中直肠穿孔需要转换为剖腹手术。术后并发症包括1例经医学治疗的气腹和1例需要Hartmann手术的直肠穿孔。在息肉亚组中，有6例患者（6 / 91，7％）经历了局部复发。盆腔脓肿治疗成功，狭窄手术后未再出现狭窄。肛门直肠测压显示功能改变，没有明显的临床影响。结论：研究结果表明，TEM是一种局部切除直肠病变的安全有效的方法，复发率低且肛门直肠功能的影响极小。另外，TEM被证明对于盆腔脓肿引流和直肠狭窄治疗是可行和有效的。谐波手术刀和ESD等新技术提高了该方法已经提供的精度。

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