1. Transanal Endoscopic Operation Indication – Technique – Results M. Sailer Department of Surgery Bethesda Hospital – Hamburg, Germany

2. Preoperative Staging Differentiated surgical therapy Control of local recurrence (Neo-) adjuvant therapy Improvement of survival Functional aspects Improvement of quality of life (QoL) TEO Stage adapted concepts in rectal surgery

3. TEO Preoperative Staging Crucial for planning of therapy Operative strategies Local resection techniques (e.g. TEO or TEM) Sphincter preserving resection Abdominoperineal resection (APR) Multivisceral resection Palliative operations (e.g. stoma, stent) Neoadjuvant therapy Radio- / chemotherapy (long course) Short course radiation (5 x 5 Gy)

4. TEO Rectal adenoma or T1 – Carcinoma EUS

5. TEO T3 – Carcinoma EUS

6. TEO T4 – Carcinoma EUS

7. TEO Operative Procedures – Rectal Cancer Transanal excision (T1-Ca) Low anterior resection (LAR) Ultralow or intersphincteric resection Abdominoperineal resection (APR) Compulsary for all resecting procedures Total Mesorectal Excision (TME)

8. TEO Indications for local excision Adenomas Carcinomas of the mucosa or submukosa Well differentiated grading (G1 / 2) No lymphangiosis carcinomatosa (L0) No vascular invasion (V0) Tumor size < 3 cm Apropriate localisation

9. TEO Small T1 - Carcinoma (G2)

10. TEO T1 – Carcinomas EUS

11. TEO Original device for TEM (Buess et al.)

12. TEO New device for TEO by Storz Co.

14. Low risk High risk (%) (%) T1 (Submucosa) 2 17 T2a (inner muscularis)10 42 T2b (outer muscularis) 20 45 T3a (< 10 mm perirectal) 23 71 T3b (> 10 mm perirectal) 30 89 TEO Incidence of loco-regional LN Mets (n = 3.241 Hermanek 2000)

15. Lokale Therapieprinzipien beim Rektumkarzinom TEO Transatlantic Dispute K. E. Matzel 1, 2, S. Merkel 1 und W. Hohenberger 1

16. TEO Outcome Sengupta, Dis Colon Rectum 2001; Nastro, Dig Surg 2005 > 10 studies und > 300 patients Local recurrence rate: 4,2 - 25 % Overall survival: 62 - 100% Inclusion criteria very variable (T1 to T3; also high-risk) Excellent results with stringent selection criteria

17. TEO Outcome Sengupta, Dis Colon Rectum 2001; Nastro, Dig Surg 2005 > 10 studies und > 300 patients Local recurrence rate: 4,2 - 25 % Overall survival: 62 - 100% Inclusion criteria very variable (T1 to T3; also high-risk) Excellent results with stringent selection criteria

18. TEO Postoperative function Cataldo et al, Dis Colon Rectum 2005 Prospective study of 39 patients Standardized scores for continence and QoL Evaluation preoperatively and 6 weeks postop. No differences preop. vs. postop. regarding: Frequency, -consistence Urgency Episodes of incontinence Quality of Life

19. Prospective evaluation of 134 patients (67 J.) TEO n = 113 Anal retractor n = 21 Preoperative staging accuracy (EUS): 93 % Complications: 4 anastomotic dehiscences, 1 stoma formation 9 haemorrhages: 3 x transfusions 3 x operative revisions 9 urinary retention (max. 6 days catheter) 7 (6,2 %) Local recurrences (5 adenomas, 2 T1-Ca) TEO Outcome – own experience

20. TEO New Aspects Lezoche et al. Surgical Endocopy 2005 Randomised controlled trial n = 40 RCHTx + TEM versus RCHTx + Laparoscop. resection Inclusion criteria: T2 N0 Rectal cancer Downstaging to T0 and / or T1 in 24 patients 1 Local recurrence and 1 distant metastasis per arm Median follow-up 56 months (44 – 67)

21. TEO Conclusion Therapeutic goal: R0 – resection Locale excision only for adenomas and well differen- tiated T1 – Ca of apropriate localisation and size Low local failure rate and excellent oncologic outcome In studies neoadjuvant radiochemotherapy (T2) Good postoperative function and Qol Patient selection crucial