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Editorial
Minimally invasive surgery
 Minimally invasive transanal excision over conventional transanal excision: pursuing the perfect removal of early rectal cancer
HyungJoo Baikorcid
Annals of Coloproctology 2025;41(2):105-106.
DOI: https://doi.org/10.3393/ac.2025.00479.0068
Published online: April 30, 2025

Division of Colorectal Surgery, Department of Surgery, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea

Correspondence to: HyungJoo Baik, MD, MS Division of Colorectal Surgery, Department of Surgery, Inje University Busan Paik Hospital, Inje University College of Medicine, 75 Bokji-ro, Busanjin-gu, Busan 47392, Korea Email: laurenbaik@gmail.com
• Received: April 15, 2025   • Accepted: April 15, 2025

© 2025 The Korean Society of Coloproctology

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Ever since Parks and Stuart [1] introduced transanal local excision (TLE), it has been utilized for the treatment of adenomas or early T1, node-negative adenocarcinoma in distal rectal cancers. The primary advantage of TLE over rectal resection and total mesorectal excision is fewer postoperative complications and greater organ preservation, thereby reducing permanent functional disorders such as low anterior syndrome or genitourinary symptoms [2]. In the 1980s, Buess et al. [3] introduced a novel surgical method called transanal endoscopic microsurgery (TEM), which employs a rigid rectoscope and rectal insufflation. More recently, transanal minimally invasive surgery (TAMIS) was developed, using a flexible platform and laparoscopic instruments after establishing pneumorectum [4]. In patients with low rectal adenomas and selected early rectal cancers, TEM has been well-established as a safe and feasible option, and TAMIS demonstrates comparable outcomes to TEM [5, 6]. However, few studies have directly compared the safety and feasibility of TAMIS with TLE, highlighting the need for additional research to support the adoption of TAMIS over TLE.
Mun et al. [7] compared the surgical and oncological outcomes of conventional transanal excision (CTA) with minimally invasive transanal excision (MTA), including TAMIS and transanal endoscopic operation (TEO), in a cohort of 133 patients. The study included adenomas, neuroendocrine tumors, and T1 node-negative adenocarcinomas without high-risk features. For the CTA group, tumor height was restricted to less than 8 cm from the anal verge, consistent with the National Comprehensive Cancer Network (NCCN) guidelines [8]. In contrast, patients in the MTA group had no height restriction as long as tumors were located within the rectosigmoid junction. Primary outcomes included comparisons of margin negativity and tumor fragmentation rates, while secondary outcomes focused on recurrence and postoperative complication rates.
Nearly 75% of patients underwent CTA. Of the 35 patients receiving MTA, only 8 underwent TEO, while the remaining received TAMIS. No significant differences were observed between groups in patient demographics or tumor size. However, the MTA group tended to have tumors located at a greater distance from the anal verge compared to the CTA group (7.57 cm vs. 4.86 cm, P<0.001). Although statistical significance was not reached, lateral margin negativity rates (100% vs. 92.9%) and deep margin negativity rates (100% vs. 96.9%) slightly favored MTA over CTA. Furthermore, specimen fragmentation was more common in the CTA group (7.1% vs. 2.9%). Only 2 patients experienced recurrence, both from the CTA group, despite initially negative resection margins. Postoperative complication rates did not differ between groups. Overall, although lacking statistical significance, surgical outcomes appeared superior in the MTA group.
Few studies have compared outcomes between TAMIS and TLE. One notable study is a meta-analysis by Dekkers et al. [9], which reported a recurrence rate of 7.7% for rectal cancer after TEM/TAMIS, compared with 10.8% following TLE. This difference resulted primarily from increased local recurrence rates, which were 4.7% for TEM/TAMIS and 7.2% for TLE. They suggested that the superior oncological outcomes of TEM/TAMIS might be due to improved tumor margin visualization facilitated by camera-assisted techniques and pneumorectum creation, potentially increasing the likelihood of complete tumor resection.
An interesting surgical approach proposed by Mun et al. [7] involved using clips as handles to facilitate tumor traction. They recommended placing the clips via colonoscopy the day before surgery, potentially enhancing accurate demarcation of tumor resection margins and leading to lower recurrence rates compared with other studies. This technique could serve as a valuable tool for surgeons performing only TLE to improve margin negativity.
No single surgical method can be universally recommended as optimal for early rectal cancer. Nonetheless, it is essential to establish consensus on patient selection criteria to determine the most beneficial surgical approach. This study reinforces the evidence that minimally invasive transanal excision is a safe and feasible alternative to conventional TLE.

Conflict of interest

HyungJoo Baik is an editorial board member of this journal, but was not involved in the peer reviewer selection, evaluation, or decision process of this article. No other potential conflict of interest relevant to this article was reported.

Funding

None.

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  • 9. Dekkers N, Dang H, van der Kraan J, le Cessie S, Oldenburg PP, Schoones JW, et al. Risk of recurrence after local resection of T1 rectal cancer: a meta- analysis with meta-regression. Surg Endosc 2022;36:9156–68. ArticlePubMedPMCPDF

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        Minimally invasive transanal excision over conventional transanal excision: pursuing the perfect removal of early rectal cancer
        Ann Coloproctol. 2025;41(2):105-106.   Published online April 30, 2025
        DOI: https://doi.org/10.3393/ac.2025.00479.0068
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