It was the best of times, it was the worst of times…
This introduction to A Tale of Two Cities by Charles Dickens, written in 1859, could just as easily been written to introduce colorectal cancer. In the best of times, greater understanding and tools to manage colorectal cancer have been developed. In the worst of times, these tools are not being used to their fullest potential. According to the American Cancer Society, colorectal cancer is the third most commonly diagnosed cancer in the US. It is believed that a majority of these cancers and deaths could be prevented by a stronger adherence to screening recommendations and ensuring timely, standard treatment. Progress has been made in screening rates; however in 2010 only 59 percent of people eligible for screening reported having received colorectal cancer testing.
One of the greatest tools available for combatting colorectal cancer is early detection through screening tests, BEFORE any symptoms arise. Screening tests are more widely used for breast, cervical and prostate cancer than for colorectal cancer. The major difference among these four cancers is the precancerous stage. Cervical cancer and colorectal cancer are the only cancers that have a precancerous change that can be easily identified AND removed before malignancy. In colorectal cancer, the precancerous change is indicated by presence of adenomatous colon polyps. A polyp is a growth in the lining of the colon that, if left alone for a long enough period of time, can develop into cancer. A variety of screening tests are available for colorectal cancer, but your physician is only able to both identify AND remove the precancerous growth through a colonoscopy.
If colorectal cancer is found at an early stage, the ability to cure the patient is greater. Screening for colorectal cancer, before symptoms develop, improves the chance that a cancer will be found at a stage when it is most curable. A variety of surgical treatments are available, although some can only be used for adenomatous polyps and early stage cancers. Surgical treatment options will vary depending on if you have colon or rectal cancer. In large part, this is due to the proximity of the rectal cancer to the anus.
Below are details on different surgical techniques for colorectal cancers:
Transanal (entering the body through the anal opening) surgery has been used for many decades to remove growths within the rectum. This approach is minimally invasive, and helps patients avoid an abdominal surgery. Plus, a majority of the rectum is preserved rather than removed, so bowel function after this type of surgery is better than with other techniques. Traditionally, this technique uses an open tube with a light to provide a “naked eye view” for growth removal inside the rectum. Visibility and instrument reach is limited to only half of the rectum. Polyps that can be removed are limited to those that can fit through the opening in the operating tube; otherwise they cannot be removed in this manner.
Transanal Endoscopic Microsurgery (TEM)
Transanal endoscopic microsurgery (TEM) was developed in Germany in the 1980s. This technique has differences which provide advantages over the transanal surgery. TEM uses a closed tube system to stretch the rectum open with air to provide greater visibility and allows for larger growths to be removed. Through the use of a small camera, increased vision of the rectum lining is achieved for growth removal. The camera can be placed close to the growth, at an angle or magnified, enhancing precision and visibility through the entire length of the rectum. Adoption of this technique has been slow in the 30 years since its introduction. This, in large part, is due to the cost of the system and its complexity.
Transanal Minimally Invasive Surgery (TAMIS)
Transanal minimally invasive surgery (TAMIS) is one of the newest techniques in treating polyps and early stage rectal cancer. TAMIS is a minimally invasive procedure and a hybrid of several different techniques that have been developed over many years, first available in 2009. This hybrid approach maintains the benefits of transanal surgery (minimally invasive with rectum preservation), adds the benefits of TEM (enhanced visibility and further reach into the rectum), while using conventional laparoscopic instruments. The combination of a transanal approach (with excellent visibility) along with use of conventional instruments (ease of learning technique and reduced cost) has made this technique very popular and more widely utilized. It is also leading to additional new techniques for rectal surgery, such as transanal total mesorectal excision (taTME). Short term results are very promising. Long term results are not yet available as the technique has only been developed recently.
While transanal excision has strong benefits, it is important to know the right time to use this technique. Careful assessment and staging of a growth in the rectum is critical for your surgeon to recommend the right approach for you.
At DMG, we have a team of physicians from gastroenterology, radiology, and surgery trained in staging and treatment of rectal polyps and cancer to help design the best treatment plan for you. If you are in need of colon or rectal surgery, please contact DMG’s surgery department at 630−790−1700.