title: Risk of complications and long-term functional alterations after local excision of rectal tumors with transanal endoscopic microsurgery (TEM).
abstract: BACKGROUND
  Transanal endoscopic microsurgery (TEM) is a consolidated technique for the excision of rectal tumors. However, many aspects relating to its morbidity, risk of functional alterations, and therapeutic outcomes are still unclear. The aim of this study was to assess the rate of morbidity and fecal incontinence after TEM, and to identify associated risk factors.
  
  
  METHODS
  We prospectively recorded the clinical data of 157 patients who underwent TEM from 1996 to 2013. Among these, 89 patients answered a questionnaire for the assessment of fecal continence at a median follow-up time of 40 months.
  
  
  RESULTS
  Intraoperative and postoperative TEM complication rates were 3.8 and 20.4%. The mortality rate was 0.6%. A distance from the anal verge of more than 6 cm correlated with a higher risk of perforation, while patients with cancer were more likely to have postoperative bleeding. Incontinence was reported by 32 (36%) patients, of which 7 (8%) experienced transitory symptoms only, while 25 (28%) reported persistent symptoms. We found a correlation between patients receiving preoperative radiotherapy (RT) and the development of fecal incontinence. The recurrence rate was 3% (1/32) in pT1, 80% (4/5) in pT2, and 100% (1/1) in pT3. After radiotherapy, 7% (1/9) showed a good response (pT0-1), and 18% (2/7) showed no response (pT2-3).
  
  
  CONCLUSIONS
  TEM is associated with low morbidity but the risk of developing functional alterations is not negligible and should be discussed with the patient before the operation. Good oncological outcomes are possible for early invasive cancers and for selected advanced cancers following a good response to preoperative RT.
authors: Department of Surgical Sciences, University of Cagliari, Cagliari, Italy. angelorestivo@tiscali.it.|Chirurgia Generale M - Colorectal Center, AOU Cagliari, Cagliari, Italy. angelorestivo@tiscali.it.
authors: Angelo
authors: A
authors: Restivo
authors: Department of Surgical Sciences, University of Cagliari, Cagliari, Italy.|Chirurgia Generale M - Colorectal Center, AOU Cagliari, Cagliari, Italy.
authors: Luigi
authors: L
authors: Zorcolo
authors: Chirurgia Generale M - Colorectal Center, Digestive Surgical Endoscopy section, AOU Cagliari, Cagliari, Italy.
authors: Giuseppe
authors: G
authors: D'Alia
authors: Department of Surgical Sciences, University of Cagliari, Cagliari, Italy.
authors: Francesca
authors: F
authors: Cocco
authors: Department of Surgical Sciences, University of Cagliari, Cagliari, Italy.
authors: Andrea
authors: A
authors: Cossu
authors: Department of Surgical Sciences, University of Cagliari, Cagliari, Italy.|Chirurgia Generale M - Colorectal Center, AOU Cagliari, Cagliari, Italy.
authors: Francesco
authors: F
authors: Scintu
authors: Department of Surgical Sciences, University of Cagliari, Cagliari, Italy.
authors: Giuseppe
authors: G
authors: Casula
mesh_terms: D000368:Aged; D005242:Fecal Incontinence / Q000209:etiology; D005260:Female; D006801:Humans; D007431:Intraoperative Complications; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local; D019106:Postoperative Hemorrhage / Q000209:etiology; D018714:Radiotherapy, Adjuvant / Q000009:adverse effects; D012004:Rectal Neoplasms / Q000601:surgery*; D012307:Risk Factors; D000067369:Transanal Endoscopic Microsurgery / Q000009:adverse effects*
keywords: Local excision; Rectal tumors; Transanal endoscopic microsurgery