Treating rectal cancer using TEMS

There are different surgical options for rectal (or bowel) cancer but your colorectal surgeon will talk you through what they think is best in your case as they evaluate the size and location of your cancer. Here, one of our experts Mr Muti Abulafi explains everything that you need to know about the trans-anal endoscopic microsurgery (TEMS) procedure.
 

What is transanal endoscopic microsurgery (TEMS)?

Transanal endoscopic microsurgery (TEMS) is an operative technique pioneered in the mid-’80s, which made it possible to remove tumours of the rectum accurately by operating through the anus. Up until then with few exceptions, operations for tumours of the rectum were performed through the abdomen which involved a major operation.

The first-generation equipment provided binocular stereoscopic views with up to six times magnification, allowed the use of several instruments at the same time and unprecedented access and views of the rectum. This enabled surgeons to completely remove tumours of the rectum with a greater degree of accuracy and as result reduce the chances of leaving tumour behind which can then lead to tumour recurrence.

Early on, the equipment was expensive costing around 60k which was beyond the budget of many hospitals. However, the introduction of video-assisted surgery in the 90s enabled attaching video cameras to the telescope resulting in excellent views of the rectum but at a fraction of the cost.

This has led to a resurgent interest in local surgery for rectal tumours. Many platforms have been introduced all working on the same principle such as trans-anal endoscopic operations (TEO) and trans-anal minimally Invasive surgery (TAMIS).
 

What conditions is TEMS used for?

TEMS is used mainly to treat rectal tumours both benign (rectal polyps) and malignant (rectal cancers). However, not all rectal tumours are suitable. TEMS is: 
 

• For benign tumours or polyps, the technique is most suited for large rectal polyps or what is called as carpet polyps because they occupy a large portion of the rectal wall lining. Small polyps can still be treated by TEM, but it is much quicker to treat them endoscopically using a flexible sigmoidoscope.
• For malignant lesions or rectal cancers, the technique is most suited for small and early cancers hence the importance of diagnosing cancers early. Not only these can be treated locally by TEMS without the need for abdominal surgery but also have a better outcome in terms of cure and survival.
   

What are the benefits?

In carefully selected cases, TEMS can be as good as radical abdominal operations in terms of oncological outcome (cure from cancer). Others added advantages include:
 

• Shorter stay in hospital
• Less pain after surgery
• Rapid recovery
• Return to normal life
• Better bowel function since patients keep their rectum
• Better quality of life
• Lower complications
• Avoidance of stomas
   

How is it performed?

The operation is performed under general anaesthetic and usually requires an enema on the day of surgery instead of taking oral laxatives to clear the bowel. Patients usually attend hospital on the day of surgery and because the operation is done through the anus, there are no incisions (cuts in the skin) or scars in the body.

As a result, patients can eat a light meal and are able to get up and walk with little discomfort within a few hours after the operation. Patients can go home either the same day or the day after the surgery. They are able to go to the toilet to pass water within hours of the operation and open their bowels within a few days with minimal pain and discomfort.
 

Final thoughts

The aim of cancer surgery is to balance the risk of disease recurrence against the quality of life and non-cancer-related deaths. The introduction of TEMS has greatly increased the utility of local excision as a curative procedure. Cancer outcomes in selected tumours are comparable to radical abdominal surgery but without the associated morbidity or mortality.

TEMS is also associated with less anorectal and genitourinary dysfunction and better quality of life. In the era of minimally invasive surgery, these factors are considered by the treating surgeon and a multidisciplinary group of clinicians when deciding on optimal treatment options in select patients groups.

This includes tumours with low risk of recurrence or high-risk procedures in elderly patients who have a significant risk of dying from noncancer related disease. Radical abdominal operations risk overtreatment in these patients with minimal oncological benefit.



Mr Abulafi is a highly-skilled consultant surgeon with over 30 years’ experience in both colorectal and general surgery. You can book an appointment to see him via his Top Doctor’s profile here.