Transanal Endoscopic Microsurgery (TEMS) – PIL1053 Version 2

This leaflet tells you about Transanal Endoscopic Microsurgery (TEMS). This can also be referred to as Transanal Endoscopic Operation (TEO).

What is Transanal Endoscopic Microsurgery (TEMS)?

TEMS is an operation to remove small early cancers or benign (not cancer) polyps from the rectum (back passage) using a specially designed microscope and instruments through the anus (back passage).

You will need to stay in hospital for about 1 to 2 days. You may need to take 1 to 2 weeks off work, depending on the type of work you do. Your doctor will discuss this with you. If you need a “fit note” (sick note) please ask one of your nurses before you leave hospital.

What are the risks and possible complications?

• Bleeding – Bleeding from the operation site can happen for up to 2 days. If this bleeding continues and shows no signs of stopping you may need another operation to stop the bleeding. This can happen to 4 patients in every 100.¹

• Risks associated with general anaesthetic – Your anaesthetist (a doctor with special training in anaesthetics) will discuss this with you at your pre-assessment appointment and before your surgery.

• Deep Vein Thrombosis DVT (blood clots in the leg veins) or Pulmonary Embolism PE (blood clots in the lungs) – You will be given a leaflet ‘PIL1319 – Reducing the Risk of Blood Clots in Hospital’ which explains about this in detail.
  
  All adult patients will have their risk of developing a blood clot assessed within 12 hours of admission. Patients who are being admitted for planned surgery may have their risk assessed at a pre-assessment visit.
  
  The nurse or doctor who carries out the risk assessment will discuss your risk factors with you and advise you on any possible treatments to reduce your risk.
  
• Pelvic inflammation or infection – The area where the tumour or polyp has been removed can lead to inflammation in your rectum. This can be treated with a course of antibiotics and you may need to stay in hospital longer. This can happen to 8 patients in every 100.¹

• Incontinence – You may have some leakage of mucus or faeces after your operation which can cause staining on your underwear. This is due to the gentle stretching of the anus (opening to the back passage) during the operation. This can last for a few weeks and usually needs no treatment. You can wear pant liners to help with this. This can happen to 11 patients in every 100.¹

• Further operation – Sometimes it is not possible to complete the operation using the TEMS procedure. Your surgeon may need to complete the operation using a laparoscope (an instrument like a tiny telescope) or an open method (incision [cut] in your abdomen [tummy]). Your surgeon will discuss this with you before your operation. This can happen to 4 patients in every 100.¹

• Recurrence – If this operation is done for rectal cancer then the surgeon will explain the risk of recurrence which will increase with the size and stage of tumour. Small cancer of a very early stage can sometimes be cured by this operation.

What will happen at the pre-assessment clinic?

About 2 weeks before your operation, you will be sent an appointment to attend the pre-assessment clinic unless you have already attended after your outpatient appointment.

You will be asked about your general health. Your blood pressure, pulse and weight will be checked. Please remember to bring any requested samples with you and all tablets, medicines, inhalers and creams you are using.

Your nurse will tell you if you need to stop taking any of these before your operation. Samples of your blood will be taken and you may be sent for an X-ray and/or an ECG (a heart tracing).

What are the hospital visiting times?

Visiting varies on each ward, so please discuss this with your nurse when you are on the ward and they can let you know the arrangements.

If your family would like to make enquiries about your progress while you are in hospital, it would help if you could ask only one member of your family to contact the ward after 9.30am. They can then pass on the information to the rest of your family.

If, at any time you wish to discuss your care and treatment with a doctor or nurse, please ask a member of the nursing team to make any necessary arrangements.

Relatives will need your agreement before your doctors and nurses are able to discuss your case in detail with them.

How can I prepare for my operation?

Before any operation, it helps to try and get as fit as possible, as this will help in your recovery. If you are overweight or smoke, seek advice from your GP who will offer you support and dietary or ‘stop smoking’ advice. This will help to reduce the risk of any complications during your anaesthetic and operation.

On the morning of your operation before you come into hospital you are asked to have a shower, to make sure your skin is clean to reduce the risk of infection.

What do I need to bring with me?

The National Institute for Health and Care Excellence (NICE) recommends you keep warm before, during and after your operation because it can reduce side effects, complications and help you recover from your operation faster.²

Please make sure you bring socks and slippers, a dressing gown, a vest or other warm clothing to help you feel warm while you are in hospital. If you are being admitted as a day case patient please try and keep warm on your journey to and from the hospital.

You should also bring any medication which you are taking into hospital with you.

When will I be admitted into hospital?

You will normally be admitted to the access lounge on the day of your operation. You will be sent a letter telling you where and when you should arrive for admission to hospital. This will include instructions about when to stopping eating and drinking.

What will happen while I am in hospital?

On the day of your admission

When you arrive one of the nurses will show you to your bed. A relative or friend is welcome to stay with you until you go to theatre.

Your nurse will recheck your details, taken at the pre-admission clinic to make sure nothing has changed. If you were not seen in the pre-assessment clinic the discussions and tests described in the pre-assessment visit section of this leaflet, will be completed.

You will be seen later in the day by one of your doctors, who will answer any other questions you may have.

Before your operation one of your doctors will again explain the reasons for the operation, the operation itself, and the precautions we take to avoid any risks or complications.

When you fully understand the operation you will be asked to sign a consent form and given a copy of the form.

Before your operation

Before your operation you will be asked to remove any jewellery, except for your wedding ring. You will be asked to put on a theatre gown.

Your consultant may want you to be measured and fitted with a pair of stockings to reduce the risk of Deep Vein Thrombosis (DVT). These should be worn at all times, unless you are told otherwise. Your nurse will help you put on your stockings, if needed.

If you wear false teeth or hearing aids, these may be removed in the operating theatre.

Your rectum will need to be empty and clean. One of your nurses will give you an enema to empty your bowel before your operation.

Just before the time of your operation one of your nurses from the ward will go with you and transfer your care to a theatre nurse.

If you have any worries or concerns tell the staff, they are there to help and support you.

Your theatre nurse will again check your details with you before taking you into the anaesthetic room.

In the anaesthetic room you will meet the anaesthetist again. They will give you your anaesthetic before you are taken into the operating theatre and will stay with you throughout your operation.

A nurse will take your temperature before you are taken to the operating theatre, if it is below 36°C (96.8°F), the operation will not start until you are warm. A warm air blanket or jacket may be used to raise your temperature.

When in the operating theatre and the recovery room your nurse will take your temperature regularly, if it falls below 36°C, you will be placed under a warm air blanket or jacket.

Please tell your nurse or doctor if you feel cold during your stay in hospital.

Before and during your operation

• A cannula (fine needle) will be placed in the back of your hand or arm so we can inject drugs. Sometimes, when drugs are injected they may feel cold and sting a little.

• An intravenous drip may be attached to your cannula, but this usually takes place when you are asleep.

• You may be asked to breathe some oxygen through a face mask, before you are given the anaesthetic.

• Your blood pressure will be measured.

• Your pulse will be taken, and the amount of oxygen in your blood will be measured by attaching a special clip onto your finger. This does not hurt.

• Your heart rate will be monitored by placing sticky pads on your chest. These are attached to some leads to show a tracing of your heart monitor. This is routine practice and is nothing to worry about.

What will happen during my operation?

The surgeon will insert a specially designed microscope and instruments through the anus into your rectum.

This allows your surgeon to see inside your rectum to find any small cancers or benign polyps and remove them using small surgical instruments which are passed through the microscope.

The area where the small cancer or benign polyp is removed will be stitched (sutured) closed.

What will happen after my operation?

You may be away from the ward for several hours.

At the end of your operation you will wake up in the recovery room near the operating theatre.

Specially trained nursing staff will look after you in the recovery room until you are ready to return to your ward. Many people do not remember waking up in the recovery room or returning to their ward.

Your nurse will check your blood pressure, pulse, temperature and level of pain, regularly. You may continue to get oxygen through a face mask, for as long as you need it, to keep the oxygen levels in your body at the right level.

You will have a drip in your arm through which you will receive fluids until you are drinking again. If you feel sick please tell your nurse as you can be given medication to help.

You should be able to eat and drink soon after your operation. As soon as you are able to eat and drink, your drip will be removed.

You should move around as soon as possible after your operation. The ward staff will help you to get out of bed. This may be on the day of your operation or the following morning depending on how you feel and what time of day you have your operation.

On the morning after your operation you will have a blood test to check for early signs of infection. If this blood test is normal you should be allowed to go home.

What can I do to help myself?

It is important to avoid becoming constipated by drinking plenty of fluids and eating fibre in your diet. If you need help with this you can ask your nurse or doctor. You may wish to soften your faeces (poo) by taking lactulose; this can be bought from a pharmacy (chemist) or can be given on prescription.

After your operation your bowel habits may be changed but should settle within a few weeks.

The muscles around your anus will have been stretched during your operation and this may lead to some leakage or incontinence. As mentioned earlier in the leaflet you may wish to wear a pad or pant liner for protection until normal continence returns.

How will I feel when I go home?

When you go home, if you notice any of the following:

• Severe pain in the lower abdomen, rectum or lower back or lower back passage or lower back,
• High temperature,
• Persistent nausea or vomiting,
• Persistent bleeding from the rectum,

You must contact the specialist colorectal nurse (see contact section for numbers) or seek medical help immediately.

When can I have sex again?

You may have sex as soon as you feel comfortable to do so.

Contact numbers

If you have any worries or concerns you should contact:

University Hospital of North Tees/Hartlepool

Specialist Colorectal Nurses
Telephone: 01642 624399
Monday to Friday, 9.00am to 4.30pm
Non-urgent messages can be left on the answering machine.

For urgent advice within 2 weeks of discharge, outside of these hours, please contact the:

Surgical Decision Unit
Telephone: 01642 624566

If you have any worries or concerns after 2 weeks you should contact your GP during normal surgery hours. Outside surgery hours you should contact your GP’s surgery for the Out of Hours Service number or contact NHS 111.

Further information is available from:

Transanal Endoscopic Microsurgery (TEMS) for Rectal Cancer: University Hospital of North Tees Experience. Indian Journal of Surgery (Dec 2015)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4775597/pdf/12262_2014_Article_1067.pdf

References

1. Tsai B.M. et al, 2010, Transanal Endoscopic Microsurgery Resection of rectal tumors: Outcomes and recommendations, Diseases of the colon and rectum, Vol 53 (1).

2. National Institute for Health and Care Excellence (NICE), 2008, Inadvertent perioperative hypothermia, Clinical guideline 65.

Comments, concerns, compliments or complaints

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Telephone: 01642 624719
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