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Petr Vavra, Petr Andel, Anton Pelikan, Lubomir Martinek, Petra Gunkova, Igor Gunka Department of Surgery University Hospital of Ostrava, Ostrava-Poruba, 17. listopadu 1790, 708 52 Ostrava, Czech Republic E-mail: p_vavra@quick.cz Background / objective At many surgical and gastroenterological working places still persists the problem what to do with an adhered tumour in the rectum at an unfavourable distance from the anus. This paper presents the possibilities offered by contemporary coloproctology by means of TEM (transanal endoscopic microsurgery) applied to the lesions that are hardly accessible. Patients and methods At the Department of Surgery of University Hospital Ostrava, the TEM method has been used since August 2002. The technique itself was implemented by Buess in the year 1983. His working place in Tübingen, Germany serves also as a training centre for teaching TEM. In the Czech Republic, the TEM method was used for first time in 1992. In TEM methodology the advantages of mini-invasive endoscopic medical help and the advantages of surgical treatment are combined. Results At the Department of Surgery of University Hospital of Ostrava in the period between 01/2003 and 12/2003 we carried out 37 operations by means of TEM. Of this number, 15 patients were operated on for benign rectum affection, 18 for malign disease, other 4 operations were twice on periproctal fistula, one operation for rectum stenosis, one introduction of a self-expandible stent. In malign rectum lesions we performed CT and endosonography preoperatively and used TEM twice for carcinoma in situ, 6 times for T1NXM0 lesions, 3 times for T2NXM0 lesions and 4 times for T3NXM0 lesions. These patients were then operated on transabdominally on the basis of definite histological findings. For a palliative effect we used TEM twice in patients with metastatic liver affection T3NXMl and once for a patient with T4NXMl. Conclusions The TEM methodology introduced in 2002 has become an inseparable and inevitable component of coloproctological operations at our department. We think the main contribution of this method consists in a safe treatment of wide benign rectum lesions, in treatment of early rectal carcinoma stages, and last but not least, the use of TEM in palliative surgery of rectum while emphasising the quality of life preservation. Keywords: transanal endoscopic microsurgery, TEM unfavourable distance, indication, harmonic scalpel

Petr Vavra1, Marie Rydlova3, Anton Pelikan1, Lubomir Martinek1, Petra Gunkova1, Michaela Vavrova2, Igor Gunka1 1 Department of Surgery and 2 Department of Radiology, University Hospital of Ostrava, 3 Department of Pathology, Medical-Social Faculty of University of Ostrava, 17 listopadu 1790, 708 52 Ostrava Poruba, Czech Republic E-mail: p_vavra@quick.cz Background / objective Czech Republic is among the countries with the highest incidence of rectal cancer. The aim of the prospective study was to monitor the surgical treatment of patients with the diagnosis of rectal cancer. Patients and methods 188 patients (121 males and 67 females) with rectal cancer were operated on within the period of three years (2000–2002). The definitive analysis encompassed 171 patients. The following aspects were observed: the types of operations carried out, the safety distance of the lower resection line during the operation of rectal cancer mainly, the amount of lymphatic nodes spotted in the mesorectum and the possibility of their laparoscopic treatment. Results 129 patients were operated on by conventional methods and 42 patients (24.6%) by laparoscopical methods (25 anterior resections, 6 abdominoperineal amputations, 10 colostomies, 1 proctocolectomy). At a distance of 2 mm from the aboral edge of the tumour, the distal intramural spread of cancer was detected in 8 (11.8%), at 5 mm in 6 (9%), at 1 cm in 2 (2.6%), at 2 cm in 4 patients (5.8 %) and at 5 cm from the macroscopical edge no distal intramural spread was recorded. Enlarged lymphatic nodes were discovered in 128 patients. In total, there were 1383 lymphatic nodes, i.e. 10.8 lymphatic nodes per patient. 271 lymphatic nodes (19.5%) affected by a tumour process, i.e. 2.1 affected lymphatic nodes per patient were found. The number of the affected lymphatic nodes in the mesorectum was compared in connection with the usage of conventional or laparascopical operation. There was no difference in oncological radicality as far as these types of operations are concerned. Conclusions There is no evidence of the spread of well differentiated adenocarcinoma from the aboral edge of the tumour. All positive findings of distal intramural spread were found in the medium and lower differentiated adenocarcinomas. The distal intramural spread of the tumour is quite rare, but when present it signifies a very advanced and aggressive progress of the illness with a bad prognosis. It is too early to formulate the conclusions comparing the conventional and the laparoscopic approaches to rectal cancer.