Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Transanal endoscopic surgery (TES)

Nicole Saur, MD
Joshua Bleier, MD, FACS, FASCRS
Section Editor
Martin Weiser, MD
Deputy Editor
Wenliang Chen, MD, PhD


Surgical management of rectal lesions can be technically challenging. Transanal excision of benign or premalignant lesions using conventional retractors is limited by poor visualization of the mid- to proximal rectum and a lack of exposure for en bloc excision of larger lesions.

Although total mesorectal excision (TME) is the gold standard for treating locally advanced or node-positive rectal cancers [1], TME can be associated with technical difficulties due to anatomic constraints of the bony pelvis, postoperative morbidity due to injury to pelvic nerves or blood vessels, and poor postoperative bowel function [2]. Thus, for patients with early rectal cancer, defined as lesions limited to the bowel wall with no disease extension beyond the submucosa (T1) and no evidence of lymph node metastasis (N0) (table 1), local excision is a surgical option that exerts minimal impact on bowel function and negates colostomy in those who have low-lying diseases.

Transanal endoscopic surgery (TES) is an emerging technique that offers transanal access to resecting benign, premalignant, or early malignant lesions in the mid- to proximal rectum (figure 1). For benign or premalignant lesions, TES offers improved visualization, exposure, and access over transanal excision using conventional retractors. For early rectal cancers, TES may allow oncologic cure while maintaining postoperative bowel function. TES, however, does not address locoregional lymph nodes. Thus, only patients with low-risk tumors that are unlikely to harbor nodal metastasis should be treated with local excision alone.

The indications, techniques, platforms, and outcomes of TES are discussed in this topic. The diagnosis and staging of rectal cancer as well as treatment with chemoradiation therapy and surgery (eg, TME) are discussed separately. (See "Clinical presentation, diagnosis, and staging of colorectal cancer" and "Overview of the management of rectal adenocarcinoma" and "Rectal cancer: Surgical principles" and "Rectal cancer: Surgical techniques" and "Neoadjuvant chemoradiotherapy and radiotherapy for rectal adenocarcinoma" and "Adjuvant therapy for resected rectal adenocarcinoma".)


Benign or premalignant lesions — TES can be used to treat a number of benign or premalignant rectal lesions or conditions, including [3-7]:

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Aug 08, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. van Gijn W, Marijnen CA, Nagtegaal ID, et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer: 12-year follow-up of the multicentre, randomised controlled TME trial. Lancet Oncol 2011; 12:575.
  2. Peeters KC, van de Velde CJ, Leer JW, et al. Late side effects of short-course preoperative radiotherapy combined with total mesorectal excision for rectal cancer: increased bowel dysfunction in irradiated patients--a Dutch colorectal cancer group study. J Clin Oncol 2005; 23:6199.
  3. Smith LE, Ko ST, Saclarides T, et al. Transanal endoscopic microsurgery. Initial registry results. Dis Colon Rectum 1996; 39:S79.
  4. Bochove-Overgaauw DM, Beerlage HP, Bosscha K, Gelderman WA. Transanal endoscopic microsurgery for correction of rectourethral fistulae. J Endourol 2006; 20:1087.
  5. Duek SD, Gilshtein H, Khoury W. Transanal endoscopic microsurgery: also for the treatment of retrorectal tumors. Minim Invasive Ther Allied Technol 2014; 23:28.
  6. Pigalarga R, Patel NM, Rezac C. Transanal endoscopic microsurgery-assisted rectal advancement flap is a viable option for iatrogenic rectourethral fistula repair: a case report. Tech Coloproctol 2011; 15:209.
  7. Serra-Aracil X, Mora-Lopez L, Alcantara-Moral M, et al. Atypical indications for transanal endoscopic microsurgery to avoid major surgery. Tech Coloproctol 2014; 18:157.
  8. www.nccn.org/professionals/physician_gls/f_guidelines.asp#rectal (Accessed on May 31, 2016).
  9. Arezzo A, Bianco F, Agresta F, et al. Practice parameters for early rectal cancer management: Italian Society of Colorectal Surgery (Società Italiana di Chirurgia Colo-Rettale; SICCR) guidelines. Tech Coloproctol 2015; 19:587.
  10. Morino M, Risio M, Bach S, et al. Early rectal cancer: the European Association for Endoscopic Surgery (EAES) clinical consensus conference. Surg Endosc 2015; 29:755.
  11. Maeda K, Koide Y, Katsuno H. When is local excision appropriate for "early" rectal cancer? Surg Today 2014; 44:2000.
  12. Glynne-Jones R, Wyrwicz L, Tiret E, et al. Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2017; 28:iv22.
  13. Saget A, Maggiori L, Petrucciani N, et al. Is there a limit to transanal endoscopic surgery? A comparative study between standard and technically challenging indications among 168 consecutive patients. Colorectal Dis 2015; 17:O155.
  14. Saclarides TJ, Smith L, Ko ST, et al. Transanal endoscopic microsurgery. Dis Colon Rectum 1992; 35:1183.
  15. Hur H, Bae SU, Han YD, et al. Transanal Endoscopic Operation for Rectal Tumor: Short-term Outcomes and Learning Curve Analysis. Surg Laparosc Endosc Percutan Tech 2016; 26:236.
  16. Maslekar S, Pillinger SH, Sharma A, et al. Cost analysis of transanal endoscopic microsurgery for rectal tumours. Colorectal Dis 2007; 9:229.
  17. Farmer KC, Wale R, Winnett J, et al. Transanal endoscopic microsurgery: the first 50 cases. ANZ J Surg 2002; 72:854.
  18. Heintz A, Mörschel M, Junginger T. Comparison of results after transanal endoscopic microsurgery and radical resection for T1 carcinoma of the rectum. Surg Endosc 1998; 12:1145.
  19. Maya A, Vorenberg A, Oviedo M, et al. Learning curve for transanal endoscopic microsurgery: a single-center experience. Surg Endosc 2014; 28:1407.
  20. Barendse RM, Dijkgraaf MG, Rolf UR, et al. Colorectal surgeons' learning curve of transanal endoscopic microsurgery. Surg Endosc 2013; 27:3591.
  21. Helewa RM, Rajaee AN, Raiche I, et al. The implementation of a transanal endoscopic microsurgery programme: initial experience with surgical performance. Colorectal Dis 2016; 18:1057.
  22. Atallah S, Albert M, Larach S. Transanal minimally invasive surgery: a giant leap forward. Surg Endosc 2010; 24:2200.
  23. Bislenghi G, Wolthuis AM, de Buck van Overstraeten A, D'Hoore A. AirSeal system insufflator to maintain a stable pneumorectum during TAMIS. Tech Coloproctol 2015; 19:43.
  24. Albert MR, Atallah SB, deBeche-Adams TC, et al. Transanal minimally invasive surgery (TAMIS) for local excision of benign neoplasms and early-stage rectal cancer: efficacy and outcomes in the first 50 patients. Dis Colon Rectum 2013; 56:301.
  25. Keller DS, Haas EM. Transanal Minimally Invasive Surgery: State of the Art. J Gastrointest Surg 2016; 20:463.
  26. Barendse RM, Doornebosch PG, Bemelman WA, et al. Transanal employment of single access ports is feasible for rectal surgery. Ann Surg 2012; 256:1030.
  27. Rimonda R, Arezzo A, Arolfo S, et al. TransAnal Minimally Invasive Surgery (TAMIS) with SILS™ port versus Transanal Endoscopic Microsurgery (TEM): a comparative experimental study. Surg Endosc 2013; 27:3762.
  28. Kinoshita T, Kanehira E, Omura K, et al. Transanal endoscopic microsurgery in the treatment of rectal carcinoid tumor. Surg Endosc 2007; 21:970.
  29. Chen WJ, Wu N, Zhou JL, et al. Full-thickness excision using transanal endoscopic microsurgery for treatment of rectal neuroendocrine tumors. World J Gastroenterol 2015; 21:9142.
  30. Kumar AS, Sidani SM, Kolli K, et al. Transanal endoscopic microsurgery for rectal carcinoids: the largest reported United States experience. Colorectal Dis 2012; 14:562.
  31. Christoforidis D, Cho HM, Dixon MR, et al. Transanal endoscopic microsurgery versus conventional transanal excision for patients with early rectal cancer. Ann Surg 2009; 249:776.
  32. Moore JS, Cataldo PA, Osler T, Hyman NH. Transanal endoscopic microsurgery is more effective than traditional transanal excision for resection of rectal masses. Dis Colon Rectum 2008; 51:1026.
  33. de Graaf EJ, Burger JW, van Ijsseldijk AL, et al. Transanal endoscopic microsurgery is superior to transanal excision of rectal adenomas. Colorectal Dis 2011; 13:762.
  34. Bretagnol F, Merrie A, George B, et al. Local excision of rectal tumours by transanal endoscopic microsurgery. Br J Surg 2007; 94:627.
  35. de Graaf EJ, Doornebosch PG, Tetteroo GW, et al. Transanal endoscopic microsurgery is feasible for adenomas throughout the entire rectum: a prospective study. Dis Colon Rectum 2009; 52:1107.
  36. Guerrieri M, Baldarelli M, de Sanctis A, et al. Treatment of rectal adenomas by transanal endoscopic microsurgery: 15 years' experience. Surg Endosc 2010; 24:445.
  37. Ramirez JM, Aguilella V, Gracia JA, et al. Local full-thickness excision as first line treatment for sessile rectal adenomas: long-term results. Ann Surg 2009; 249:225.
  38. Said S, Stippel D. Transanal endoscopic microsurgery in large, sessile adenomas of the rectum. A 10-year experience. Surg Endosc 1995; 9:1106.
  39. Tsai BM, Finne CO, Nordenstam JF, et al. Transanal endoscopic microsurgery resection of rectal tumors: outcomes and recommendations. Dis Colon Rectum 2010; 53:16.
  40. Winde G, Nottberg H, Keller R, et al. Surgical cure for early rectal carcinomas (T1). Transanal endoscopic microsurgery vs. anterior resection. Dis Colon Rectum 1996; 39:969.
  41. Kidane B, Chadi SA, Kanters S, et al. Local resection compared with radical resection in the treatment of T1N0M0 rectal adenocarcinoma: a systematic review and meta-analysis. Dis Colon Rectum 2015; 58:122.
  42. Lu JY, Lin GL, Qiu HZ, et al. Comparison of Transanal Endoscopic Microsurgery and Total Mesorectal Excision in the Treatment of T1 Rectal Cancer: A Meta-Analysis. PLoS One 2015; 10:e0141427.
  43. Baatrup G, Breum B, Qvist N, et al. Transanal endoscopic microsurgery in 143 consecutive patients with rectal adenocarcinoma: results from a Danish multicenter study. Colorectal Dis 2009; 11:270.
  44. Lezoche G, Guerrieri M, Baldarelli M, et al. Transanal endoscopic microsurgery for 135 patients with small nonadvanced low rectal cancer (iT1-iT2, iN0): short- and long-term results. Surg Endosc 2011; 25:1222.
  45. Lezoche G, Baldarelli M, Guerrieri M, et al. A prospective randomized study with a 5-year minimum follow-up evaluation of transanal endoscopic microsurgery versus laparoscopic total mesorectal excision after neoadjuvant therapy. Surg Endosc 2008; 22:352.
  46. Lezoche E, Guerrieri M, Paganini AM, Feliciotti F. Long-term results of patients with pT2 rectal cancer treated with radiotherapy and transanal endoscopic microsurgical excision. World J Surg 2002; 26:1170.
  47. Lezoche E, Guerrieri M, Paganini AM, et al. Transanal endoscopic versus total mesorectal laparoscopic resections of T2-N0 low rectal cancers after neoadjuvant treatment: a prospective randomized trial with a 3-years minimum follow-up period. Surg Endosc 2005; 19:751.
  48. Lezoche E, Baldarelli M, Lezoche G, et al. Randomized clinical trial of endoluminal locoregional resection versus laparoscopic total mesorectal excision for T2 rectal cancer after neoadjuvant therapy. Br J Surg 2012; 99:1211.
  49. Garcia-Aguilar J, Shi Q, Thomas CR Jr, et al. A phase II trial of neoadjuvant chemoradiation and local excision for T2N0 rectal cancer: preliminary results of the ACOSOG Z6041 trial. Ann Surg Oncol 2012; 19:384.
  50. Garcia-Aguilar J, Renfro LA, Chow OS, et al. Organ preservation for clinical T2N0 distal rectal cancer using neoadjuvant chemoradiotherapy and local excision (ACOSOG Z6041): results of an open-label, single-arm, multi-institutional, phase 2 trial. Lancet Oncol 2015; 16:1537.
  51. Verseveld M, de Graaf EJ, Verhoef C, et al. Chemoradiation therapy for rectal cancer in the distal rectum followed by organ-sparing transanal endoscopic microsurgery (CARTS study). Br J Surg 2015; 102:853.
  52. Bujko K, Richter P, Smith FM, et al. Preoperative radiotherapy and local excision of rectal cancer with immediate radical re-operation for poor responders: a prospective multicentre study. Radiother Oncol 2013; 106:198.
  53. Rullier E, Rouanet P, Tuech JJ, et al. Organ preservation for rectal cancer (GRECCAR 2): a prospective, randomised, open-label, multicentre, phase 3 trial. Lancet 2017; 390:469.
  54. Perez RO, Habr-Gama A, São Julião GP, et al. Transanal Endoscopic Microsurgery (TEM) Following Neoadjuvant Chemoradiation for Rectal Cancer: Outcomes of Salvage Resection for Local Recurrence. Ann Surg Oncol 2016; 23:1143.
  55. Hallam S, Messenger DE, Thomas MG. A Systematic Review of Local Excision After Neoadjuvant Therapy for Rectal Cancer: Are ypT0 Tumors the Limit? Dis Colon Rectum 2016; 59:984.
  56. Pucciarelli S, Giandomenico F, De Paoli A, et al. Bowel function and quality of life after local excision or total mesorectal excision following chemoradiotherapy for rectal cancer. Br J Surg 2017; 104:138.
  57. Dafnis G, Påhlman L, Raab Y, et al. Transanal endoscopic microsurgery: clinical and functional results. Colorectal Dis 2004; 6:336.
  58. Mora López L, Serra Aracil X, Hermoso Bosch J, et al. Study of anorectal function after transanal endoscopic surgery. Int J Surg 2015; 13:142.
  59. Cataldo PA, O'Brien S, Osler T. Transanal endoscopic microsurgery: a prospective evaluation of functional results. Dis Colon Rectum 2005; 48:1366.
  60. Allaix ME, Rebecchi F, Giaccone C, et al. Long-term functional results and quality of life after transanal endoscopic microsurgery. Br J Surg 2011; 98:1635.
  61. Hompes R, Ashraf SQ, Gosselink MP, et al. Evaluation of quality of life and function at 1 year after transanal endoscopic microsurgery. Colorectal Dis 2015; 17:O54.
  62. Planting A, Phang PT, Raval MJ, Brown CJ. Transanal endoscopic microsurgery: impact on fecal incontinence and quality of life. Can J Surg 2013; 56:243.
  63. Barendse RM, Oors JM, de Graaf EJ, et al. The effect of endoscopic mucosal resection and transanal endoscopic microsurgery on anorectal function. Colorectal Dis 2013; 15:e534.
  64. Karakayali FY, Tezcaner T, Moray G. Anorectal function and outcomes after transanal minimally invasive surgery for rectal tumors. J Minim Access Surg 2015; 11:257.
  65. Schiphorst AH, Langenhoff BS, Maring J, et al. Transanal minimally invasive surgery: initial experience and short-term functional results. Dis Colon Rectum 2014; 57:927.
  66. Verseveld M, Barendse RM, Gosselink MP, et al. Transanal minimally invasive surgery: impact on quality of life and functional outcome. Surg Endosc 2016; 30:1184.