TEMS Offers Minimally Invasive Option for Rectal Cancer

John R. T. Monson, M.D.

John R. T. Monson, M.D.

URMC’s division of Colorectal Surgery has expanded its treatments by offering Transanal Endoscopic Microsurgery (TEMS), a minimally invasive technique for the removal of rectal tumors.

TEMS enables a specially trained surgeon to remove benign polyps or cancerous growths from the rectum without removing the rectum and without an abdominal incision. TEMS instruments are designed so that the procedure can be performed through the anus and in the rectum. They allow for better exposure, magnified stereoscopic view, and greater reach into the middle and upper rectum. As a result, TEMS has a low complication rate for patients with early rectal cancer.

More than 40,000 people in the United States are diagnosed with rectal cancer each year; most of those cancers are adenocarcinomas. Despite recent advances in chemo-radiotherapy, surgery still plays an important role in the curative treatment for rectal cancers. 

The choice of surgical intervention depends on the location of the tumor, depth of rectal wall invasion, as well as clinical stage of the disease. Treatments have included radical resection such as low anterior resection, extended low anterior resection with colo-anal anastomosis, abdomino-perineal resection (APR), as well as pelvic exenteration. All are invasive procedures, with long periods of recovery for patients and many require formation of a stoma, either permanent or temporary.

TEMS was introduced in Rochester by John R. T. Monson, M.D., chief of the Division of Colorectal Surgery and vice chair of the Department of Surgery.

A pioneer in minimally invasive colorectal surgery, Monson began training in TEMS in 1993 while at the University of Hull, under the tutelage of Gerhardt Buess who developed the technique. Monson was drawn to learning the technique due to his great interest in technology and rectal surgery, and the desire to offer the best possible option for his patients.

“I like technology, and my main interest is in rectal cancer,” Monson said. “It was clear to me that this was able to do things in the best interests of patients.”

While other endoscopic procedures and instruments can be used to reach target organs, TEMS offers vastly superior capabilities.

“What TEMS is able to do with its specialized instruments is to facilitate a meticulous, precise excision of a tumor from the bowel wall, and then provide the ability to stitch up the defect like traditional surgery.

“Traditional, flexible endoscopy can reach quite far distances, but when it gets to its targeted area it is limited in what it is able to do. In essence, all you can do is snare a polyp and slice it off, and it is very much limited by the size of the lesion.”

During the TEMS procedure, an operating proctoscope is placed through the anus and positioned over the lesion. The rectum is filled with carbon dioxide gas so there is room to work. A special microscope is used to look at the area, directly and with a video camera. Long instruments are then used to grasp, cut, and suture.

Because it is less invasive than traditional procedures for removing benign polyps or cancerous rectal tumors, TEMS reduces complications and side effects associated with taking out the entire rectum. Because the procedure is performed entirely through the anus, no abdominal incision is made which means minimal pain and faster recovery time. Most patients are discharged the day after surgery, as opposed to an average of five to seven days after a more invasive radical excision. Patients are able to return to normal activities much more quickly – usually one to two weeks after surgery versus up to six weeks after abdominal surgery. The risk of complications, such as infection and hernias, is also much lower with TEMS than with abdominal surgery.

Patients who are ideal for TEMS are virtually assured of avoiding a colostomy, a common fear among those diagnosed with rectal cancer. In the U.S., 40 percent of patients treated for rectal cancer require a colostomy.

“Using TEMS, the paradigm is shifting such that many patients who may have previously undergone a more invasive procedure can now have a tumor removed without the possibility of a resulting stoma,” Monson said.

The only potential drawback to TEMS is its limited reach.

“We are limited in accessibility because the instrument can only reach 25 centimeters in length, but it has replaced the traditional transanal resection technique, which is inferior in quality and outcome,” Monson said.

TEMS may be recommended for patients with polyps that are too large to be removed with a colonoscope and for small cancers that have not yet invaded into the muscle layer of the bowel wall. Lesions up to 15 to 20 centimeters above the anal opening may often be removed with this method.

URMC colorectal surgeons Christina Cellini, M.D., and Todd Francone, M.D., are also experienced in TEMS. Francone came to Rochester from the Lahy Clinic in Boston; Cellini came from Washington University in St. Louis, following training under Steven Hunt, M.D., who was trained by Monson.

Case experience is crucial to the quality of care provided by the relatively few U.S. centers that offer TEMS. Monson, Cellini and Francone perform three to four TEMS cases each month, more than 50 percent for patients who travel to Rochester from other areas, Monson estimated.

“Treatment of rectal cancer in 2011 is rapidly changing and those patients are best served in a center that specializes in the latest techniques – both surgical and no-surgical,” he said.

Learn more about URMC’s Division of Colorectal Surgery, or e-mail colorectal@urmc.rochester.edu.

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