Transanal Endoscopic Surgery: Does the Platform Matter?

Viewpoints from Steven Wexner, MD, PhD (Hon)

In the early 1980s, before the first laparoscopic colorectal procedure had been contemplated, the late Professor Gerhard Buess in Tübingen, Germany, created a binocular operating platform reliant upon carbon dioxide insufflation called transanal endoscopic microsurgery. Although this therapy did not gain widespread popularity until after the advent of laparoscopy, it has now become one of the requisite components of the increasingly popular transanal total mesorectal excision (taTME) operation.

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The monikers of “transanal endoscopic microsurgery (TEM),” “transanal endoscopic operating” and “transanal minimally invasive surgery (TAMIS)” are all related to proprietary transanal access platforms. The commercial implications of using these names in educational programs seemed problematic to me. Accordingly, I urged our course directors at the “hands-on courses” both during our annual Cleveland Clinic/Cleveland Clinic Florida Digestive Disease & Surgical Institute Week and the American Society of Colon and Rectal Surgeons, to instead use the generic term “transanal endoscopic surgery (TES).” I have subsequently advised that all other course directors and authors use this terminology.

As more TES platforms have been introduced to allow surgeons to employ this technology, the question has of course arisen as to whether or not there is any preference in the results obtainable based upon the platform used.

Previously, I’ve noted that both the flexible and rigid product lines have roles in TES. Most recently, Lee and colleagues performed a cohort matched analysis of 247 patients who underwent TEM with 181 patients who underwent TAMIS.

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Although the TAMIS approach was associated with a slightly shorter operative time, unfortunately, the TAMIS procedures were performed at one facility whereas the TEM procedures were performed at two other facilities. Therefore, the speed of the surgeon rather than the speed afforded by the instrumentation may potentially have accounted for this finding.

While the speed of the surgeons may have differed, the skill certainly did not as poor quality excision was similar at 8 percent versus 11 percent. Peritoneal violation was identical at 3 percent in each group, and postoperative complications were markedly similar at 11 percent and 9 percent, respectively. Very importantly, five-year disease-free survival rates were virtually identical at 80 percent for TEM and 78 percent for TAMIS. Lastly, there was a 7 percent incidence of local recurrence in patients who had undergone surgery for malignancy in each of the two groups.

Therefore, the authors concluded that within the realm of TES, TAMIS and TEM offer virtually identical outcomes. The choice of platform can safely be left to the discretion of the surgeon.