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postoperative histopathological analysis. In the TAE group, to surgeons, resulting in faster surgeon training to master
we had one patient each with specimen fragmentation and this technique 14, 15, 17, 18 .
positive margins. Patients with positive margins in both the
TAE and TAMIS groups had high-grade dysplasia villous ade- Despite these advantages, in certain cases, difficulties
nomas. The final histopathological findings in both groups may arise during TAMIS procedures. Firstly, in patients
mostly supported tubulovillous adenomas of low to mode- where the pathological lesion is hidden behind the rectal
rate dysplasia. In both groups, we had two cases of early T1 valves (valves of Houston), adequate identification of the
stage intramucosal carcinoma (Table 2). lesion may be challenging, making polyp excision difficult.
Secondly, TAMIS can be challenging in obese patients with
The length of hospital stay was shorter in the TAE gro- abundant adipose tissue in the gluteal region. To addre-
up compared to the TAMIS group (1.3 vs. 1.8 days). Among ss this issue, fixation sutures are placed on the GelPort in
the early postoperative complications in the TAMIS group, the perianal region to reduce the depth of the anal canal.
one patient experienced a urinary tract infection (which was Once pneumorectum is achieved, adiposity does not pose
resolved with antibiotic treatment), and one patient had po- a significant problem for the procedure. Thirdly, occasional
stoperative bleeding, which was managed with endoscopic contractions of the rectal wall may pose difficulties during
hemostasis or transrectal suturing in the TAE group. One dissection and closure of the defect thereafter .
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patient experienced urinary retention, which was resolved
by placing a urinary catheter within 24 hours postoperati- All lesions were located at a distance greater than 5 cm
vely. In patients with positive margins on the final histopat- from the anal verge. Lesions localized in the distal rectum
hological examination, we conducted follow-up endoscopic (up to 5 cm from the anal verge) were treated with conventi-
examinations at 3, 6, and 12 months postoperatively. Du- onal transanal excision. The average distance from the anal
ring this one-year follow-up period, there were no signs of verge in the TAMIS patient group was 8.1 cm, ranging from
recurrence of the underlying disease (Table 3). 5 to 14 cm. Comparing and analyzing the TAMIS and TAE
groups, we observed that polypoid lesions were smaller in
the TAE group (2.5 cm compared to 3.1 cm).
Discussion During TAMIS and TAE procedures, special attention

The aim of all local transanal techniques for the resecti- was given to achieving negative resection margins. In most
on of pathological lesions in the rectum is to achieve adequ- cases (11 patients or 91.67% in TAMIS and 14 patients or
ate negative margins for resected malignant polyps or early 93.33% in TAE), we achieved negative resection margins,
carcinomas (T1). Local transanal resections include classical with only one case each resulting in a positive margin. In
transanal excision (TAE), transanal endoscopic microsurgery both cases, the patients had a high-grade dysplastic villous
(TEMS), and transanal minimally invasive surgery (TAMIS). adenoma, and on follow-up endoscopic examinations at 3,
All these techniques are associated with lower rates of mor- 6, and 12 months postoperatively, there were no signs of
bidity and mortality compared to surgical anterior resection disease recurrence. These results are consistent with nume-
or abdominoperineal resection of the rectum (either classi- rous studies reporting negative resection margins ranging
cal or laparoscopic). These techniques are not suitable for from 47% to 100% of cases 18-21 . In patients who preopera-
addressing any type of tumor or lymphogenic metastatic tively had a high degree of dysplasia in the polyp or were
disease. All transanal resection techniques are performed diagnosed with early adenocarcinoma, we had to perform
under general endotracheal anesthesia, which entails mor- excision not only of the polypoid changes but also of the
bidity and mortality and requires appropriate preoperative entire thickness of the rectal wall, and in two cases, in ad-
preparation . dition to the entire thickness of the wall, we also removed
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a part of the mesorectal tissue. In 7 cases of TAMIS, we
Comparing the mentioned techniques, it has been conc- performed mucosectomy because the polyps had a broad
luded, based on literature data, that TAMIS has numero- and long stalk, and this degree of radicality was deemed
us advantages over TAE and TEMS. In comparison to TAE, sufficient. In patients with polyps located more than 10 cm
TAMIS allows better exposure and visualization of lesions from the anocutaneous line and on the anterior wall of the
along the entire length of the rectum. TAE can only treat rectum, we had to be very cautious to avoid intraoperati-
lesions up to 5 cm from the anorectal line. In contrast, indi- ve injury to the entire rectal wall and the development of
cations for TAMIS are expanded to include excision of high pneumoperitoneum. In some studies, the frequency of this
rectal lesions up to 15 cm from the anorectal line. Although complication during TAMIS exceeds 15%. This complication
TAMIS is slightly more challenging to perform in cases of is addressed through the TAMIS platform by placing sutures
high lesion localization, from 10 to 15 cm from the anore- across the entire rectal wall 20-22 . In cases where there was a
ctal line, the surgery is less invasive, entails lower treatment deeper defect in the wall with excision of the mesorectum
costs, and requires a shorter hospitalization period com- via the TAMIS platform, we closed the defect with 3/0 po-
pared to TAE and TEMS. In addition to these advantages, lyglactin sutures in three cases (25%). In the literature, there
there are other benefits such as easier handling of equip- is a high frequency of over 60% of cases with closure of the
ment, and use of existing laparoscopic equipment familiar defect after surgical excision using the TAMIS method. This

16 DOI: 10.5937/Galmed2409015S