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Resumen Introduccion la exeresis local del adenocarcinoma de recto T2N0M0 (ADC-T2), mediante microcirugia endoscopica transanal (TEM), se beneficia en conseguir una menor morbilidad con mejor calidad de vida. Sin embargo, la recidiva local de la exeresis local es superior al 20%, inaceptable en estos momentos. Pacientes y metodo estudio observacional de seguimiento prospectivo. Los pacientes ADC-T2 son consensuados en el comite de tumores a las actuaciones terapeuticas: escision total del mesorrecto (ETM), TEM simple, TEM con quimiorradioterapia (Qt-Rt) postoperatoria, Qt-Rt preoperatoria con posterior TEM y rescate a cirugia radical (ETM) en menos de 4 semanas. Resultados se ha intervenido a 146 pacientes mediante TEM; 75 adenocarcinomas, 59 adenomas, 6 lesiones cicatriciales, 5 carcinoides y 1 GIST. De los adenocarcinomas, 22 fueron ADC-T2. Seguimiento: mediana, 16 (intervalo, 3-32) meses. La recidiva local total ha sido del 18% (4/22). Segun la estrategia terapeutica la recidiva local fue: TEM como unico procedimiento en el 20% (2/10). Se realizo en 3 pacientes rescate a cirugia radical tras TEM, sin recidiva local ni sistemica. TEM con Qt-Rt posterior a la cirugia se realizo en 6, con una recidiva local del 33% (2/6). Se practico Qt-Rt y posteriormente TEM en 3 pacientes, sin recidiva local ni sistemica. Conclusiones el tratamiento del ADC-T2 mediante TEM simple no es razonable. La asociacion de Qt-Rt tras TEM, no consigue mejorar los resultados a la ETM. Es factible rescatar a los pacientes sin que altere la supervivencia total. La Qt-Rt preoperatoria y TEM parece ser la linea cuando se consiga una respuesta histologica y clinica, aunque es necesaria la respuesta por parte de ensayos clinicos.

Introduction The local exeresis adenocarcinoma of the rectum T2 N0 M0 (ADC-T2), using transanal endoscopic microsurgery (TEM), has the benefit of achieving lower morbidity with a better quality of life. However, local occurrence of the local exeresis is greater than 20%, which is unacceptable these days. Patients and methods Prospective, observational follow up study. The tumours committee agreed that those ADC-T2 patients could have the following treatments: total mesorectal excision (TME), simple TEM, TEM with postoperative chemo-and radiotherapy (Ct-Rt), preoperative Ct-Rt with subsequent TEM, and radical surgical rescue (TME) within at least 4 weeks. Results Of the 146 patients operated on using TEM, 75 had adenocarcinomas, 59 adenomas, 6 scarring wounds, 5 carcinoids, and 1 GIST. Of the adenocarcinomas 22 were ADC-T2. Follow up: median of 16 months (range, 3–32 months). The overall local recurrence was 18% (4/22). According to the treatment strategy the local occurrence was: TEM as the only procedure, 20% (2/10). Radical surgical rescue was performed on 3 patients after TEM, with no local or systemic recurrences. TEM with Qt-Rt after surgery was performed on 6 patients, with a local recurrence of 33% (2/6). Ct-Rt and subsequent TEM in 3 patients, with no local or systemic recurrences. Conclusions Treatment of ADC-T2 using simple TEM is not effective. The combination of Ct-Rt after TEM, does not improve the results of TME. It is possible to rescue those patients without changing the overall survival. Preoperative Ct-Rt and TEM appears to be the approach that obtains a clinical and histological response, although a response is needed by clinical trials.

Resumen Introduccion La preparacion mecanica de colon (PMC) en la cirugia colorrectal es un dogma que se ha cuestionado en los ultimos anos. El objetivo de este estudio es demostrar que la morbilidad en cirugia programada colorrectal es igual o menor sin la PMC. Material y metodo Pacientes sometidos a cirugia programada de colon izquierdo y recto con anastomosis primaria fueron aleatorizados en dos grupos. Al grupo PMC se le practico la preparacion y al grupo sin PMC, solo enemas de limpieza. Se recogieron variables demograficas, oncologicas, nutricionales y quirurgicas, modelos de prediccion de riesgo y morbimortalidad. Resultados Se incluyo a 193 pacientes, 69 con PMC y 71 sin ella; 89 pacientes con anastomosis colocolica (PMC, 38; sin PMC, 51) y 50 con anastomosis colorrectal (PMC, 31; sin PMC, 19). En el analisis general, se apreciaron diferencias estadisticamente significativas a favor de no preparar en cuanto a la morbilidad (el 43,5% en el PMC y el 27% en los sin PMC) e infeccion nosocomial (el 27,5 y el 11,4%). En la infeccion de herida, sin diferencias estadisticamente significativas, se obtuvo el 11,6% en el PMC, frente al 5,7% en el sin PMC. Las unicas muertes fueron 2/69 (2,9%) pacientes en el grupo PMC. Segun localizacion de anastomosis, en las colocolicas las diferencias fueron mas acusadas y estadisticamente significativas en las variables morbilidad, dehiscencia de anastomosis e infeccion nosocomial. en las anastomosis colorrectales no fue tan evidente el efecto de no preparar. Conclusiones Nuestros resultados indican que no existe un beneficio de la PMC en la cirugia ante anastomosis colocolicas. No preparar no tiene relacion con mas morbilidad en infeccion de herida ni dehiscencia anastomotica. En anastomosis colorrectales, las diferencias no tan evidentes hacen necesarias series mas amplias.

Resumen Introduccion y objetivo La microcirugia transanal endoscopica (TEM) es una tecnica innovadora que permite la escision local de lesiones rectales, benignas y malignas en fase inicial con mayores ventajas tecnicas y menor morbimortalidad que mediante las tecnicas habituales. Precisa de un utillaje especifico; destaca un rectoscopio de 4 cm de diametro que provoca una dilatacion anal mantenida. El objetivo de nuestro estudio es comprobar los efectos de la TEM en la funcionalidad anorrectal. Material y metodos Se incluyo a todos los pacientes intervenidos por via TEM a los que se les realizo una manometria y un cuestionario de continencia anal preoperatoria y a las 3 semanas y 4 meses postoperatorios. Se valoraron las variaciones en la presion basal (PB) y en la presion de contraccion voluntaria (PCV); tambien las variaciones en el cuestionario de continencia anal. Resultados Se intervino a 68 pacientes entre junio de 2004 y agosto de 2006. Al analizar la PB y la PCV preoperatorias (38,89; 126,28) se observo una disminucion estadisticamente significativa de ambas presiones a las 3 semanas (26,61; 104,75) que retorna a valores basales a los 4 meses (33,81; 118,9). No hubo variaciones en la prueba de continencia anal ni relacion entre la variacion de las presiones y el tiempo quirurgico. Conclusion La TEM produce una alteracion manometrica estadisticamente significativa que se normaliza a los 4 meses y que no se traduce en ninguna alteracion clinica en el postoperatorio inmediato ni en el tardio y, por tanto, es una tecnica segura que no produce alteraciones en la funcionalidad anorrectal.

Transanal endoscopic microsurgery (TEM) uses specific equipment that allows resection of large rectal adenomas and incipient malignancies in the rectal ampulla. TEM aims to provide an alternative to conventional abdominal surgery (low anterior resection or abdominoperineal amputations), which carries not inconsiderable morbidity and mortality. Application of the technique of endoanal excision is limited by the height and extension of the lesions. In this review, the authors present their own experience with this technique and that described in the literature. The protocol for selecting candidates for TEM, their preoperative preparation, equipment, characteristics of the surgical technique, postoperative complications, and follow-up are described. The collaboration of a multidisciplinary team is essential when developing this technique. TEM-associated morbidity is low and mortality is practically nil. TEM is the technique of choice in large rectal adenomas and malignant rectal tumors in stages pT1 localized in the rectal ampulla. The frequency of recurrence is similar to that in abdominal surgery. The technique does not cause complications of urinary or sexual dysfunction and fecal incontinence is minimal. In more advances stages of rectal cancer, the results of better patient selection and future studies on the possible application of neoadjuvant therapy associated with TEM are required.

Introduction Mechanical preparation of the colon (MPC) in colorectal surgery has been a dogma that has been questioned over the last few years. The objective of this study is to demonstrate that morbidity in scheduled colorectal surgery is the same or lower without MPC. Material and method Patients subjected to scheduled left colon and rectal surgery with primary anastomosis randomised into 2 groups. The “Preparation” group (MPC) received MPC and the “non-preparation” group (No-MPC) had only cleaning enemas. The variables collected were: demographic, oncological, nutritional, risk prediction models, and morbidity-mortality. Results Of the 193 patients included: 69 received MPC and 71 did not; 89 patients with colocolic anastomosis (MPC, 38; no MPC, 51) and 50 colorectal (MPC, 31; no MPC, 19). Statistically significant differences were seen in the overall analysis in favour of “no preparation” as regards morbidity (43.55% with MPC and 27% with No MPC) and nosocomial infection (27.5% and 11.4%). There was 11.6% wound infections in the MPC compared to 5.7% in the no MPC, which was not statistically significant. The only mortalities were in the MPC group 2/69 (2.9% of patients). As regards the location of the anastomosis, in the colocolics the differences were more pronounced, with statistically significant differences in the morbidity, anastomosis dehiscence, and nosocomial infection variables. The effect of no MPC was not so evident in colorectal anastomosis. Conclusions Our results suggest that there is no benefit in MPC before surgery in colocolic anastomosis. No-MPC is not associated with a higher morbidity in wound infection or anastomotic dehiscence. In colorectal anastomosis the differences are not so evident, therefore a much bigger series needs to be studied.