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Transanal endoscopic microsurgery under spinal anaesthesia
Yael Berger1, Rachel Gingold-Belfer2, Muhammad Khatib1, Mostafa Yassin1, Wisam Khoury3, Hemda Schmilovitz-Weiss2, Nidal Issa1
1 Department of Surgery, Rabin Medical Center, Hasharon Hospital, Petach Tikva; Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
2 Sackler School of Medicine, Tel-Aviv University, Tel Aviv; Department of Gastroenterology, Rabin Medical Center, Hasharon Hospital, Petach Tikva, Israel
3 Department of Surgery, Carmel Medical Center, Haifa, Israel
|Date of Submission||25-Jul-2020|
|Date of Decision||23-Aug-2020|
|Date of Acceptance||29-Sep-2020|
|Date of Web Publication||11-Nov-2020|
Department of Surgery, Rabin Medical Center, Hasharon Hospital, 7 Keren Kayemet Street, Petah Tikva
Source of Support: None, Conflict of Interest: None
Background: Transanal endoscopic microsurgery (TEM) is considered the procedure of choice for rectal adenomas non-amendable for endoscopic excision and for early rectal cancer. TEM may gain more importance in patients who are considered unfit for major surgery. The option of spinal anaesthesia may offer many advantages for patients undergoing TEM while maintaining the principles of complete tumour excision. The aim of this study is to report the outcome of patients undergoing TEM under spinal anaesthesia.
Methods: Demographic and clinical data pertaining patients undergoing TEM under spinal anaesthesia between 2004 and 2015 were retrospectively collected.
Results: A total of 158 TEM procedures were recorded in the study period. Twenty-three patients (15%) underwent the procedure under spinal anaesthesia and were included in the study; 13 of them were male and ten were female. The mean age of the patients was 69.1 ± 10.6 years. Seventeen (74%) rectal lesions were adenomas, two (9%) were adenocarcinoma and four (17%) had involved margins after polypectomy. The mean tumour size was 2.1 cm (range, 0.5–3). Distance from the anal verge was 7.7 ± 2.2 cm. Seventeen (74%) lesions were in the posterior wall. The operative time was 73 min (range, 46–108) No adverse anaesthesia-related events were recorded, and the post-operative pain was reduced. The median time of hospitalisation was 2 days (range, 1–4). No major complications were noted, and the minor complications were treated conservatively. The surgical margins were free of tumour in all cases.
Conclusion: TEM under spinal anaesthesia had short duration of surgery, no increase in operative and post-operative complications or hospital length of stay. Avoiding the use of general anaesthesia, in such challenging procedure, may open new opportunities for patients determined to be unfit for general anaesthesia.
Keywords: Rectal tumor, spinal anaesthesia, transanal endoscopic microsurgery
|How to cite this URL:|
Berger Y, Gingold-Belfer R, Khatib M, Yassin M, Khoury W, Schmilovitz-Weiss H, Issa N. Transanal endoscopic microsurgery under spinal anaesthesia. J Min Access Surg [Epub ahead of print] [cited 2020 Dec 5]. Available from: https://www.journalofmas.com/preprintarticle.asp?id=300599
| ¤ Introduction|| |
Transanal endoscopic microsurgery (TEM) improves the quality of local excision for rectal lesions by enabling optimal access and visualisation of the surgical field, allowing precise, full-thickness excision of rectal lesions and suture closure of the defect resulting from a broad-based polyp or cancer. In the cases of huge or broad-based polyps or submucosal tumours, TEM offers more complete resection than endoscopic resection. TEM is superior to traditional transanal excision (TAE) in terms of safety and local control for rectal adenomas.
For T1 rectal cancer, TEM provides a quick and safe method of excision, with few complications, relatively short hospital stay and good functional outcomes, when compared to that of radical rectal resection. Moreover, in selected cases, TEM appears to have comparable 5- and 10-year survival rates. TEM can also play a role in the treatment of advanced rectal cancer.
Conventionally, TEM is performed under general anaesthesia -this facilitates better patient management, as there will be a necessity of conversion to laparoscopy or laparotomy, without the need for anaesthetic alterations, in the case of protracted TEM procedures, or in the event of a complication.
The option of spinal anaesthesia may provide expeditious recovery while maintaining the principles of complete tumour excision and minimal invasiveness.
In comparison to general anaesthesia, spinal anaesthesia is a simple, reliable and affordable method. It yields good intraoperative conditions while maintaining patient airway, decreased pulmonary complications and incidence of deep-vein thrombosis and pulmonary embolism and reduction of discomfort and morbidity associated with general anaesthesia, including sore throat and airway trauma. Another advantage is the induction of preemptive regional analgesia and the rapid return of gastrointestinal function., Spinal anaesthesia may also decrease maximal resting anal pressure, causing relaxation of the anal sphincter, hence permitting easy insertion of the large TEM rectoscope.
The objective of this study is to review our experience and outcomes of patients undergoing TEM under spinal anaesthesia.
| ¤ Methods|| |
Case files of patients operated at Hasharon Hospital between 2004 and 2015 were reviewed. Patients undergoing TEM were evaluated pre-operatively according to a standard protocol that included clinical examination via digital rectal examination, colonoscopy with biopsy, rigid proctoscopy and endorectal ultrasound. For each patient, both the location of the tumour and its distance from the anal verge, as well as the tumour size, were assessed. The distance from the anal verge to the lower margin of the tumour was measured. The location of the tumour was assessed for patient positioning so that the tumour would be facing downwards during surgery.
Pre-operative patient preparation included mechanical bowel preparation (polyethylene glycol) on the day before the operation and prophylactic antibiotics (cefazolin 1 g and metronidazole 500 mg) at the time of anaesthetic induction.
The method of anaesthesia depended mainly on anaesthesiologists' judgement and patient preference. Contraindications to spinal anaesthesia included abnormal coagulation profile and previous surgery to the lumbar spine.
For spinal anaesthesia, patients were placed in the sitting position; a 25G spinal needle was introduced into the subarachnoid space through the L2–L3 intervertebral space under aseptic conditions. Once free flow of cerebrospinal fluid was achieved, hyperbaric 2-ml bupivacaine 0.5% was injected intrathecally. The patients were kept in the sitting position for 3 min and then positioned supine. After the onset of anaesthesia, a urinary catheter was placed in some patients in order to keep the bladder empty.
The TEM procedure was performed according to the standard technique described by Buess et al. using the original Richard Wolf, Knittlingen, Germany equipment. Depending on the tumour location, the patients were placed in either prone jack-knife or lithotomy position. The tumour was removed by excising the full thickness of the rectal wall with a 1-cm margin around the tumour. The underlying mesorectal fat was included with the specimen. The specimens were pinned and marked for orientation by the surgeon. The rectal defect was closed primarily in a transverse fashion with absorbable sutures.
In patients where a urinary catheter was placed at the time of surgery, it was removed the day after surgery. Post-operative pain management for all patients included oral dipyrone or paracetamol and oral narcotics (tramadol) on demand. The patients were allowed to resume oral feeding at the evening of the day of operation, and were discharged from the hospital 1–2 days after the operation. Perioperative complications were defined as unexpected and untoward events during the procedure or in the post-operative period.
The patients were evaluated 2 weeks after the surgery and re-examined at 3-month intervals for the first 2 post-operative years and every 6 months thereafter. Clinical examination and rectoscopy were performed during each of the follow-up sessions.
The full medical records of the patients were obtained and collectively reviewed and recorded. Data pertaining to patient demographics, tumour characteristics, indications for surgery, histopathology findings, post-operative outcomes and post-operative complications were collected.
The local ethics commission of Rabin Medical Center approved the study protocol.
| ¤ Results|| |
A total of 158 cases of TEM procedure were recorded during the study period. Twenty-three patients (15%) underwent the procedure under spinal anaesthesia and were included in the study; 13 of them were male and ten were female. The mean age of the patients was 69.1 ± 10.6 years. Seven (30%) patients had an American Society of Anesthesiologists (ASA) score 1, 10 (43%) patients had an ASA score 2 and 6 (26%) had ASA 3. Seventeen (74%) rectal lesions were adenomas, two (9%) lesions had carcinoma by the pre-operative biopsies and four (17%) had involved margins after endoscopic polypectomy. The mean tumour size was 2.1 cm (range, 0.5–3). The mean distance from the anal verge was 7.7 ± 2.2 cm. Seventeen (74%) lesions were located in the posterior rectal wall. [Table 1] summarises the patient and tumour characteristics.
The mean operative time was 73 min (range, 46–108 min) for the procedures. Patients who complained of abdominal discomfort during the operation received intravenous midazolam (1 mg) until complete subjective relief. Overall, three patients received intravenous midazolam.
Perioperative nausea occurred in two patients and resolved with the administration of intravenous ondansetron (4 mg). No adverse spinal anaesthesia-related events were recorded, the post-operative pain was reduced and there was a high level of patient satisfaction with spinal anaesthesia. Neither headache nor neurological sequelae were recorded. No opioids were requested during the perioperative or post-operative period.
The median time of hospitalisation was 2 days (range, 1–4). No major complications were noted. None of the cases resulted in peritoneal entry. Minor complications were noted which were treated conservatively [Table 2].
Of the 14 patients who had a urinary catheter in place during the operation, one patient required catheter re-introduction after its removal on the 1st post-operative day. Two other patients who did not have a catheter during the operation presented with urinary retention in the immediate post-operative course.
None of the patients experienced rectal bleeding, and there were no re-admissions in the post-operative period.
When examining the final pathological reports of the TEM specimens, T1 carcinoma was found in 4 patients, adenoma in 16 patients and 3 patients had no residual tumour in the final pathology. The surgical margins were free of tumour in all cases.
In the mean follow-up of 55 months (range, 20–81 months), no patient had local or distal recurrence.
| ¤ Discussion|| |
Local excision by TEM can be considered the procedure of choice for rectal adenomas non-amendable for endoscopic excision, and for low-risk (T1) rectal tumours. TEM may gain more importance in morbidly ill patients who are considered unfit for major surgeries, due to its low morbidity rate.
Spinal anaesthesia has been reserved traditionally for patients who are unfit for general anaesthesia. Its use in healthy patients may reduce complications and enhance expeditious recovery. Even though the combination of TEM and spinal anaesthesia may ameliorate the patients' outcome, there are scarce reports in the subject matter.
The present study demonstrates that TEM can be performed safely under spinal anaesthesia. TEM under spinal anaesthesia has short duration of surgery, no increase in operative and post-operative complications or hospital length of stay.
Although spinal anaesthesia is usually used in patients unfit for general anaesthesia, the selection of patients for spinal anaesthesia in our series was determined by anaesthesiologist preference and patients' choice; this may explain the fact that 70% of our patients had ASA score 1 and 2, and only 30% had ASA score 3 [Table 1].
Compared to various TEM series, TEM under spinal anaesthesia does not seem to increase operation time. In our series, tumour characteristics, such as relatively small lesion diameter and short distance from the anal verge [Table 1], may explain the relatively short operative time.
The overall complication rate for TEM for benign and malignant lesions has been reported to range from 6% to 31%, and most complications were minor.
Neither overall complications nor hospitalisation time had increased in the present study. In our series, three patients (13%) had urinary retention; this is in accordance with previously reported results. The incidence of post-operative urinary retention after anorectal surgery ranges between 1% and 52%, and urinary retention associated with regional anaesthesia owing to interruption of the micturition reflex has been reported in up to 23% of operations.
No opening of the peritoneal cavity during TEM was recorded in this cohort. A possible explanation may be the fact that patients with upper rectal or recto-sigmoid lesions had been assigned to general anaesthesia a priori, decreasing the chance of peritoneal disturbance during TEM, and adding the possibility of diagnostic laparoscopy.
Respiratory difficulty is a common problem with spinal anaesthesia in the presence of abdominal distension for which assisted masked ventilation is recommended. Nevertheless, this was not a concern here, possibly owing to the relatively short duration of surgery and/or limited bowel distension, particularly in patients who underwent surgery in prone position.
The rates of microscopic negative excision margins after TEM for adenomas and early T1 tumours are very high, and in many reports had exceeded 90%.,
The margins were free in all specimens in our series. One explanation could be the relatively small diameter of the rectal lesions in our patients, which permitted larger excision margins during the procedure. Another explanation may be the surgeon's experience.
Faecal incontinence following TEM has been reported by various series. Tsai et al. demonstrated a 4.1% rate of fecal incontinence after TEM with a nearly 82% return to baseline within 4–8 months of the operation. Guerrieri et al. reported a 1% rate of stool incontinence and their patients were treated with physiotherapy and biofeedback. Resolution of symptoms was achieved in all patients within 2 months. Post-operative sphincter injury is a possible cause of faecal incontinence following TEM due to sphincter stretching by the large rectoscope.
In our series, no faecal incontinence was reported. A possible explanation to our results may be the use of spinal anaesthesia. Spinal anaesthesia may decrease maximal resting anal pressure by approximately 30 mmHg, relaxing the anal sphincter enough to allow a safe and non-traumatic insertion of the rectoscope, without additional rectal sensation while maintaining pneumorectum. Another possible explanation is the relatively small size of the rectal lesions in our patients. The rectoscope was inserted and fixed in place for the entire duration of the procedure, without the need for further adjustments and changes in position, minimising additional stretching or trauma that may be caused to the anal sphincter.
In our opinion, combining TEM with spinal anaesthesia may further enhance the advantages of this minimally transanal technique, particularly in some patients, such as those with small rectal lesions, located at the posterior wall, and in the mid-rectal position.
Our study is limited by its retrospective nature. Furthermore, this is a non-randomised study. The procedure was performed on selected patients, was carried out at a single institution and is underpowered, subjecting the study to selection bias. Further validation of TEM technique under spinal anaesthesia mandates a randomised, multicentric, controlled study.
| ¤ Conclusion|| |
The possibility of avoiding the use of general anaesthesia, in more challenging procedures such as TEM, may open new opportunities for patients determined to be unfit for general anaesthesia.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]