Transanal endoscopic operation (TEO) - local experience in a South African setting

• Main Author: Karjiker, Parveen
• Other Authors: Baigrie, Robert J
• Format: Dissertation
• Language: English
• Published: University of Cape Town 2018
• Subjects: Sugery
• Online Access: http://hdl.handle.net/11427/27347

Background: It is well recognised that the adenoma-carcinoma sequence is the mechanism by which most colorectal malignancies arise. Dysplastic adenomas are the precursor lesions which can progress to adenocarcinoma and premalignant sessile villous adenomas represent a particular challenge. Their early detection and removal can prevent rectal cancer. Local excision of low rectal tumors has become increasingly popular as technical advancement has rendered it easier and more effective. Local tumour excision avoids the complications of radical surgery. Transanal endoscopic operation (TEO) and Transanal endoscopic microsurgery (TEMS) are two equivalent techniques that have been widely adopted as the treatments of choice for large rectal adenomas and selected rectal cancers but has been under-employed in South Africa. The aim of this study was to evaluate TEO (the simpler and more affordable platform of the two) by describing the dimensions and anatomical parameters of specimens resected and using this to investigate whether any of these are predictive of recurrence, and to evaluate the incidence of complications of this less radical technique. Methods: In this single surgeon study, data was collected from pre-existing patient files (paper and electronic) during the first half of the time period and during the second half, was prospectively entered into a database. It includes all patients undergoing resection of benign and malignant rectal tumours by TEO at a private (Kingsbury Hospital) and public health institution (Groote Schuur Hospital) from January 2009 - May 2017. Electronic records, including operation notes, histology and radiology were reviewed. Results: Data was collected from January 2009 to May 2017. 110 patients in this study of which 87 (79.1%) were benign. There were 11 (12%) recurrences in this group. In the malignant group, there were 5 (21%) recurrences. The median tumour length was 4.5cm (IQR 2.5) and median tumour area was 16cm2 (IQR 20.11). For benign lesions, there was a significant difference in recurrence in patients presenting with incontinence (χ2 8.21, p-value<0.01, OR 16.7 (1.37-202.7)), lesions with involved surgical margins (χ2 6.29 p-value 0.01, OR 6.75 (95% CI 1.02 - 35.7)) and circumferential tumours (χ2 6.31 p-value 0.04, 6.5 (1.17-36.3)). The multinomial logistic regression model for benign lesions revealed that only incontinence and involved surgical margins were independent predictors of recurrence. Complications occurred in 21 (19.1%) patients with circumferential lesions, length of the tumour, and malignancy being predictive of complications. Conclusion: This study constitutes the only report of TEO or TEMS from a low- or middle-income country (LMIC). The results are in keeping with the published literature, demonstrating its safety and feasibility in a LMIC setting, which will reduce the need for expensive, highly morbid radical surgery for benign and malignant disease. The recommendation is for a wider introduction of TEO in South Africa and other LMIC countries with the provision of adequate training.