HEMICOLECTOMÍA DERECHA PUERTO UNICO SILS

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domingo, 25 de noviembre de 2012

TEM, TEO , dificultades técnicas y biológicas

La Microcirugía Transanal Endoscópica, mas conocida por sus siglas anglosajonas TEM (Transanal Endoscopic Microsurgery), es una técnica quirúrgica endoluminal, mínimamente invasiva desarrollada por Buess en la década de los 80 para la extirpación local de los tumores rectales. 

De las técnicas clásicas de cirugía local del cáncer de recto, la exéresis endoanal, procedimiento más utilizado en el tercio inferior del recto, adolece de la dificultad de controlar perfectamente los límites de resección y la hemostasia, realizar una exéresis de pared completa y hallarse limitada por la altura de la lesión respecto al margen anal. En el tercio medio del recto la técnica de exéresis local más utilizada ha sido la transesfinteriana de Mason, cada vez más en desuso por su elevada morbilidad y la incontinencia fecal resultante. 

La exéresis rectal transacra de Kraske, que permitía el acceso hasta el tercio superior, también ha sido abandonada por sus malos resultados de elevada morbimortalidad. La alternativa a estas técnicas en situaciones de grandes tumoraciones adenomatosas es la resección anterior del recto o la amputación abdominoperineal de Miles. En el cáncer de recto la técnica de elección es la escisión total del mesorrecto (ETM). Con estas técnicas, a pesar de desarrollarse en centros especializados, la mortalidad es del 1-7% y la morbilidad, como disfunciones genitourinarias y cierto grado de incontinencia fecal, del 18-34%, sin olvidar los trastornos que comporta la necesidad de practicar ostomías temporales o definitivas.La TEM permite corregir estos problemas en aquellos casos en la que está indicada

¿ Pero , en que neoplasias malignas de recto está indicada esta técnica con resultados similares a la cirugia clasica , ya sea abierta o laparoscópica ?, en 2011 Zhonghua Weichang  publica una serie de 60 pacientes llegando a la conclusión de que el TEM  es oncologicamente seguro y efectivo en tumores Tis T1 y estadios precoces menores de 3 cm de diametro . 

Sin embargo un estudio de Birger publicado en 2005 en Diseases of the colon & rectum afirma que el riesgo de recurrencia es mayor en los tumores T1 sometidos a microcirugía transanal que aquellos sometidos a cirugia tradicional.

En 2009 S. P. Bach publica en  British Journal of Surgery un articulo en el que se afirma que al técnica TEM en  ciertos pacientes  , es decir, aquellos con tumores en estadio precoz seleccionados obtienen resultados equiparables a la cirugía convencional; por otro lado,  en caso de tumores T1 y T2 sometidos a TEM en los que se comprueba una histopatología desfavorable pueden ser convertidos a cirugía radical sin que este hecho afecte a la supervivencia del paciente.

A continuación presentamos un video de una reseccion transanal realizada por el Dr. Cesar Diaz de la Unidad de Coloproctología del Hospital Universitario Reina Sofia. Si deseais conocer las dificultades técnicas de esta vía de abordaje os recomiendo la lectura de las dificultades técnicas descritas por el Dr. Cesar Diaz.

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