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Page 2 of 11 Serra-Aracil et al. Mini-invasive Surg 2019;3:37 I http://dx.doi.org/10.20517/2574-1225.2019.36

Conclusion: Clinically relevant complications after TEM are rare. For this reason, experience of these complications
is limited. Here, we propose a management protocol to ensure that these complications are neither underestimated
nor subjected to excessively aggressive or unnecessary treatment.

Keywords: Transanal endoscopic microsurgery, TEM, transanal endoscopic operation, minimally invasive surgery,
morbidity and morbidity management

INTRODUCTION
The approach to benign or initially malignant rectal lesions through local surgery posed a considerable
challenge until the advent of Transanal Endoscopic Microsurgery (TEM), introduced by Buess in the
[1]
1980s . Thanks to the creation of a pneumorectum, this technique makes it possible to perform local
resections even beyond the rectum-sigmoid junction.

[2]
Later technical variations on TEM include transanal endoscopic operation (TEO) , which uses a high
definition monitor, and TAMIS (TransAnal Minimally Invasive Surgery), a more recent development that
[3]
incorporates a single-port system. The application of strict selection criteria and careful surgical techniques
obtain good results for postoperative morbidity and mortality, function, and cure.

[4,5]
Overall postoperative morbidity after TEM ranges from 7.7% to 31.4% . However, the absence of
standardization in the recording and the description of the complications makes the results of different
[6]
studies difficult to compare. A previous study by our group reported a morbidity rate of 23.6%, grouped
[7]
according to the Clavien–Dindo classification (Cl-D) . More than half of these complications (Cl-D grade I)
required observation alone, and clinically relevant morbidity (Cl-D ≥ II) was recorded in only 5.6% of the
patients.

[6]
The most frequent complications after TEM are rectal bleeding (as in the study just mentioned) or
[8,9]
urinary morbidity, with reported rates ranging between 5.9% and 10.8% .
The management of complications after TEM has not been widely reported. Rectal bleeding, the most
frequent complication, has a Cl-D classification ranging from I to IVa/b. In the remaining postoperative
complications, such as urinary morbidity, infection, asymptomatic postoperative fever, and massive
pneumo-retroperitoneum on computed tomography (CT) or chest radiography, it is unclear what protocol
should be applied. The main aim of the present study was to describe the frequency of occurrence of
postoperative surgical complications after TEM according to their Cl-D classification. The secondary aim
was to describe the therapeutic management protocol in the most frequent complications.

METHODS
Study design
An observational, single-center study in consecutive patients undergoing TEM was carried out with
prospective data collection and retrospective analysis. Computerized data management was carried out
with the Microsoft Access 2003 software in a protected format.
®
Patients and setting
All patients were operated on by surgeons at the Parc Tauli University Hospital, Coloproctology Unit
from June 2004 to June 2019. All patients with indication of TEM underwent a preoperative study
[10]
protocol incorporating endorectal ultrasound (US) and rectal magnetic resonance imaging (MRI).
These examinations classify the patients into five groups of preoperative indication: Group I with curative