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Comparison of transanal total mesorectal excision and robotic total mesorectal excision for low rectal cancer after neoadjuvant chemoradiotherapy. Surg Endosc 2021; 35:6998-7004. [PMID: 33523275 DOI: 10.1007/s00464-020-08213-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 12/02/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND To improve the quality of surgery for rectal cancer, both transanal total mesorectal excision (taTME) and robotic total mesorectal excision (R-TME) can be performed. However, few studies have compared outcomes of taTME and R-TME, especially for patients with low rectal cancer after undergoing neoadjuvant chemoradiation (nCRT). Thus, the objective of this study was to compare outcomes of taTME and R-TME for patients with low rectal cancer after undergoing nCRT. METHODS A total of 306 consecutive patients with low rectal cancer who underwent taTME or R-TME after nCRT between 2008 and 2018 were analyzed retrospectively. Patients were classified into two groups: 1) taTME surgery group (n = 94); and 2) R-TME surgery group (n = 212). RESULTS Clinicopathologic variables were comparable between the two groups. There was no significant difference in circumference margin involvement (1.1% in taTME vs. 2.8% in R-TME, p = 0.680) or distal resection margin (2.3 cm in taTME vs. 2.4 cm in R-TME, p = 0.629). Total operation time (239 min in taTME vs. 243 min in R-TME, p = 0.675) and major complications (including anastomosis site leakage, surgical site infection, and voiding difficulty) showed no significant difference between the two groups either. CONCLUSIONS Transanal and robotic TMEs have similar short-term outcomes for patients with rectal cancer after undergoing nCRT. High quality TME can be equally achieved with both transanal and robotic approaches.
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Caycedo-Marulanda A, Lee L, Chadi SA, Verschoor CP, Crosina J, Ashamalla S, Brown CJ. Association of Transanal Total Mesorectal Excision With Local Recurrence of Rectal Cancer. JAMA Netw Open 2021; 4:e2036330. [PMID: 33533932 PMCID: PMC7859847 DOI: 10.1001/jamanetworkopen.2020.36330] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Proponents of novel transanal total mesorectal excision (TME) suggest the procedure overcomes the technical and oncologic challenges of conventional approaches for treating rectal cancer. Recently, however, there has been controversy regarding the oncologic safety of the procedure. OBJECTIVE To assess the association of transanal TME with the incidence of local recurrence (LR) of cancer and the probability of remaining free of LR during follow-up. DESIGN, SETTING, AND PARTICIPANTS This multicenter cohort study used data from 8 high-volume rectal cancer academic institutions from across Canada on all consecutive patients with primary rectal cancer treated by transanal TME at the participating centers. The study was conducted between January 2014 and December 2018, and data were analyzed from April 1, 2020, to September 15, 2020. EXPOSURE Transanal TME. MAIN OUTCOMES AND MEASURES The incidence of LR was reported as a direct measure of quality of resection. The cumulative probability of LR- and systemic recurrence (SR)-free survival at 36 months was estimated. Local recurrence and SR were defined as radiologic or endoscopic evidence of 1 or more new lesions in or outside the pelvis, respectively, documented during surveillance after the removal of the primary tumor. RESULTS Of 608 total patients included in the analysis, 423 (69.6%) were male; the median age was 63 years (interquartile range [IQR], 54-70 years). Local recurrence was identified in 22 patients (3.6%) after a median follow-up of 27 months (IQR, 18-38 months). The median time to LR was 13 months (IQR, 9-19 months). Sixteen of the 22 patients with LR (72.7%) were male, 14 (63.6%) received neoadjuvant chemoradiation, and 12 (54.5%) had American Joint Committee on Cancer stage III disease. Of those with LR, 16 (72.7%) had a negative circumferential radial margin and 20 (90.9%) had a negative distal resection margin, 2 (9.1%) experienced conversion to open surgery, and 15 (68.2%) also developed SR. The probability of LR-free survival at 36 months was 96% (95% CI, 94%-98%). According to the Cox proportional hazards regression model, the hazard ratio of LR was estimated to be 4.2 (95% CI, 2.9-6.2) times higher among patients with a positive circumferential radial margin than among those with a negative circumferential radial margin. CONCLUSIONS AND RELEVANCE In this cohort study, transanal TME performed by experienced surgeons was associated with an incidence of LR and SR that is in line with the published literature on open and laparoscopic TME, suggesting that transanal TME may be an acceptable approach for management of rectal cancer.
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Affiliation(s)
- Antonio Caycedo-Marulanda
- Department of Surgery, Kingston Health Sciences Centre, Queen’s University, Kingston, Ontario, Canada
- Health Sciences North Research Institute, Sudbury, Ontario, Canada
| | - Lawrence Lee
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Sami A. Chadi
- Division of Surgical Oncology and General Surgery, University Health Network and Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Jordan Crosina
- Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | - Shady Ashamalla
- Department of Surgery Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Carl J. Brown
- Department of Surgery, St Paul’s Hospital, The University of British Columbia, Vancouver, British Columbia, Canada
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Chen J, Sun Y, Chi P, Sun B. MRI pelvimetry-based evaluation of surgical difficulty in laparoscopic total mesorectal excision after neoadjuvant chemoradiation for male rectal cancer. Surg Today 2021; 51:1144-1151. [PMID: 33420827 PMCID: PMC8215037 DOI: 10.1007/s00595-020-02211-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 11/10/2020] [Indexed: 12/16/2022]
Abstract
Purpose Laparoscopic total mesorectal excision (LaTME) is technically demanding in rectal cancer after neoadjuvant chemoradiotherapy (NCRT). This study aimed to predict the surgical difficulty of LaTME after NCRT based on pelvimetric parameters. Methods This study enrolled 147 patients who underwent LaTME after NCRT. The surgical difficulty was graded as high or low according to the operative time, estimated blood loss, conversion to open surgery, postoperative hospital stay, and postoperative complications. Pelvimetry parameters were collected based on preoperative MRI. A logistic regression analysis was performed to identify predictors of high surgical difficulty, and a nomogram was developed. Results Totally, 18 (12.2%) patients were graded as high surgical difficulty. High surgical difficulty was correlated with a shorter interspinous distance (P = 0.014), a small angle α and γ (P = 0.008, P = 0.008, respectively), and a larger mesorectal area and mesorectal fat area (P = 0.041, P = 0.046, respectively). Tumor distance from the anal verge (OR = 0.619, P = 0.024), tumor diameter (OR = 3.747, P = 0.004), interspinous distance (OR = 0.127, P = 0.007), and angle α (OR = 0.821, P = 0.039) were independent predictors of high surgical difficulty. A predictive nomogram was developed with a C-index of 0.867. Conclusion A shorter tumor distance from the anal verge, larger tumor diameter, shorter interspinous distance, and smaller angle α could help to predict high surgical difficulty of LaTME in male LARC patients after NCRT. Supplementary Information The online version contains supplementary material available at 10.1007/s00595-020-02211-3.
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Affiliation(s)
- Jianhua Chen
- Department of Radiology, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, 350001, Fujian, People's Republic of China
| | - Yanwu Sun
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, People's Republic of China
| | - Pan Chi
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, People's Republic of China
| | - Bin Sun
- Department of Radiology, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, 350001, Fujian, People's Republic of China.
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Gardner IH, Kelley KA, Abdelmoaty WF, Sharata A, Hayman AV, Whiteford MH. Transanal total mesorectal excision outcomes for advanced rectal cancer in a complex surgical population. Surg Endosc 2021; 36:167-175. [PMID: 33416990 DOI: 10.1007/s00464-020-08251-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 12/16/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND Total mesorectal excision (TME) is the gold standard for oncologic resection in low and mid rectal cancers. However, abdominal approaches to TME can be hampered by poor visibility, inadequate retraction, and distal margin delineation. Transanal TME (taTME) is a promising hybrid technique that was developed to mitigate the difficulties of operating in the low pelvis and to optimize the circumferential resection and distal margins. METHODS The objective of this study was to characterize our experience implementing taTME at our institution in a technically challenging patient population. We performed a retrospective review of consecutive patients who underwent taTMEs between November 2013 and May 2019 for rectal cancer at a tertiary community cancer center. Outcome measures included pathologic grading of TME specimen, post-operative complications, and oncologic outcomes. RESULTS Forty-four patients with mid and low rectal cancer underwent low anterior resection via taTME. The most common staging modality was rectal MRI which demonstrated T3 or T4 tumors in 89% of our patients prior to neoadjuvant. Eighty-six percent of patients underwent neoadjuvant chemoradiation. The initial cases were performed sequentially as a single team, but we later transitioned to a synchronous, two-team approach. Ninety-one percent of TME grades were complete or near complete. Only one patient (2.3%) had a positive circumferential margin. Six patients developed anastomotic leaks with an overall anastomotic complication rate of 18.2%. Two patients (4.5%) with primary rectal cancer developed local recurrence, one of which developed multifocal local recurrence. CONCLUSIONS Using the taTME approach on selected locally advanced low rectal cancers, especially in technically complex irradiated and obese male patients, has yielded comparably safe and effective outcomes to laparoscopic proctectomy.
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Affiliation(s)
- Ivy H Gardner
- Department of Surgery, Oregon Health and Science University, Portland, USA
| | | | - Walaa F Abdelmoaty
- Department of Surgery, Oregon Health and Science University, Portland, USA
| | - Ahmed Sharata
- Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, Providence Cancer Institute, 4805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA
| | - Amanda V Hayman
- Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, Providence Cancer Institute, 4805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA
| | - Mark H Whiteford
- Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, Providence Cancer Institute, 4805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA.
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Transanal total mesorectal excision for stage II or III rectal cancer: pattern of local recurrence in a tertiary referral center. Surg Endosc 2021; 35:7191-7199. [PMID: 33398553 DOI: 10.1007/s00464-020-08200-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 11/19/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND For mid and low rectal cancer, transanal total mesorectal excision (TaTME) has been established as an alternative approach to laparoscopic surgery. However, there are concerns about an unexpected pattern of local recurrence. This study aimed to analyze the pattern of local recurrence for patients treated with TaTME in a tertiary referral center. METHODS A retrospective single-center analysis was performed. Since 2011, all patients with rectal cancer undergoing TaTME with curative intent were prospectively included in a standardized database. Patients with tumors within 12 cm, clinical stage II or III were included. The primary endpoint of the study was the overall local recurrence rate, together with a critical analysis of the patterns of local failures. RESULTS Two hundred and five patients were included in this analysis. At the time of surgery, patients had a mean age of 67.1 years (SD 12.3), and 66.8% were male. Neoadjuvant therapy was administered in 73.7%. Mesorectal specimen quality was complete or near-complete in 98.5%, while circumferential resection margin was ≤ 1 mm (including T4 tumors) in 11.8%. After a median follow-up of 34.3 months (95% CI 30.1-38.5), 3.4% (n = 7) presented with local recurrent disease. Six out of the seven patients were also diagnosed with hematogenous metastases. Of the seven patients, three presented with at least one of the following risk factors: T4 tumor, N2 disease, incomplete mesorectal specimen, or positive CRM. Local failure was noted posteriorly (n = 3), laterally (n = 2), anteriorly (n = 1), and in the axial compartment (n = 1). Median time to relapse was 31.5 months (10.3-40.9). The median follow-up after local recurrence was 7.9 (95% CI 6.7-9.1) months, with an overall survival of 85.7%. CONCLUSIONS TaTME provided satisfactory local recurrence outcomes, and the most common patterns of failure were in the central pelvis.
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Guevara Jabiles A, Berrospi Espinoza F, Chávez Passiuri IK, Payet Meza E, Luque-Vásquez CE, Ruiz Figueroa E. TransAnal Total Mesorectal Excision (TaTME) in Peru: Case series. Int J Surg Case Rep 2020; 76:425-430. [PMID: 33099247 PMCID: PMC7585049 DOI: 10.1016/j.ijscr.2020.09.204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 09/22/2020] [Accepted: 09/30/2020] [Indexed: 11/25/2022] Open
Abstract
Transanal total mesorectum excision is feasible for mid and low rectal cancer. Good quality of the mesorectum specimen is obtain after TaTME surgery. TaTME with intersphincteric resection is a feasible option for selected cases of very low rectal cancer. Surgical complication rates after intersphincteric TaTME with hand-sewn coloanal anastomosis could be higher.
Introduction Describe and demonstrate the feasibility and safety of TaTME in short term outcomes in the Instituto Nacional de Enfermedades Neoplásicas (INEN) in Peru. Materials and methods Case series with retrospective and prospective data collection of patients with middle and inferior rectal cancer who underwent TaTME between January 2015 and March 2020. Patients and tumor characteristics, operative details, postoperative complications and pathological results were analyzed. Results Nineteen patients were included. The median age was 56 years old (range 40–69). Ten were female. The median distance from the anal verge was 4 cm (range 3–6) and 17 cases were located in the inferior rectum. Eleven patients with clinical stage III. Thirteen (68.4%) patients received neoadjuvant treatment. There was no conversion to open surgery reported. Ten (52.6%) cases had intersphincteric resection and 18 (94.7%) had primary coloanal anastomosis, 13 (72.2%) of them with hand-sewn. All patients had a diversion with ileostomy. The median operative time was 330 min (range 270–480). Median postoperative hospital stay of 5 days (range 3–18). The overall rate of postoperative complication was 21.1%, two cases (10.5%) had anastomotic leakage and mortality was present in one (5.3%) patient. 94.5% had an optimal TME specimen, only one case (5.3%) had positive circumferential resection margin and positive distal margin. The median tumor size in the specimen was 4 cm (range 2–11) and nine (47.4%) patients had ypT3 on pathology. Conclusion TaTME is a safe and feasible technique with good pathological results.
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Affiliation(s)
- Andrés Guevara Jabiles
- Department of Abdominal Surgery, INEN, Angamos Este 2520 Ave, Surquillo, 15038 Lima, Peru.
| | | | | | - Eduardo Payet Meza
- Department of Abdominal Surgery, INEN, Angamos Este 2520 Ave, Surquillo, 15038 Lima, Peru
| | | | - Eloy Ruiz Figueroa
- Department of Abdominal Surgery, INEN, Angamos Este 2520 Ave, Surquillo, 15038 Lima, Peru
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A comparative cost analysis of transanal and laparoscopic total mesorectal excision for rectal cancer. Updates Surg 2020; 73:85-91. [PMID: 32929690 DOI: 10.1007/s13304-020-00879-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 08/30/2020] [Indexed: 02/07/2023]
Abstract
Despite proven clinical benefits in the short term, technical difficulties limit utilization of laparoscopy in rectal cancer surgery (RCS). Transanal Total Mesorectal Excision (taTME) overcomes many technical limitations of laparoscopic RCS. However, the costs of this procedure have not been addressed yet. Our goal was to perform a comparative cost analysis of taTME and laparoscopic TME (lapTME). Consecutive patients undergoing curative TME between 1 February 2014 and 31 October 2018 were selected from a prospectively maintained database and stratified, according to the type of procedure, into taTME and lapTME groups. Patient demographics, tumour characteristics, operative parameters, and short-term outcomes were analyzed. The main outcome measure was intraoperative costs of the two procedures. Secondary outcomes were short-term outcome and the utilization of hospital resources to manage the postoperative course. Hundred and fifty-two patients with rectal cancer (66 lapTME, 86 taTME) were included in the study. Surgical supplies required for taTME procedure exceeded the cost of lapTME of 754,54 €. The duration of surgery was not significantly different between the two approaches (266 ± 92.85 vs 271 ± 83.63, p = 0.50). Short-term outcomes were comparable including postoperative complication rate (17 vs 20%, p = 0.68), reintervention rate, and length of stay. There was no difference in hospital resources utilization to manage postoperative course including blood test, diagnostics, consultations, and medications. TaTME has higher intraoperative costs in terms of supplies with respect to lapTME. Short-term outcomes and hospital resources to manage postoperative course are comparable.
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Nonaka T, Tominaga T, Akazawa Y, Sawai T, Nagayasu T. Feasibility of laparoscopic-assisted transanal pelvic exenteration in locally advanced rectal cancer with anterior invasion. Tech Coloproctol 2020; 25:69-74. [PMID: 32815047 DOI: 10.1007/s10151-020-02324-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 08/04/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Transanal (Ta) pelvic exenteration is a promising, minimally invasive method for treating locally advanced colorectal cancer. However, since it is technically difficult to perform, Ta pelvic exenteration is rarely reported in locally advanced T4 rectal cancer cases. The aim of this study was to evaluate the feasibility of transabdominal laparoscopy-assisted Ta pelvic exenteration. METHODS Six patients (4 males and 2 females) had laparoscopy-assisted Ta total or posterior pelvic exenteration for locally advanced or recurrent colorectal cancer cases at the Nagasaki University Hospital between September 2018 and August 2019. Clinical and pathological outcomes were measured and analyzed. RESULTS The median operation time and intraoperative blood loss were 481 (range 456-709) minutes and 352.5 (range 257-1660) ml, respectively. R0 resection was achieved in all cases, and no patient required open surgery. Two patients had grade 3 complications (Clavien-Dindo) or higher. There was no mortality, and no reoperation was required. CONCLUSIONS The results suggest that laparoscopic-assisted Ta pelvic exenteration is an acceptable procedure, may help overcome the current technical difficulties, and may improve outcomes in patients with locally advanced rectal cancer.
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Affiliation(s)
- T Nonaka
- Department of Surgical Oncology, Nagasaki University Graduate School of Biological Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.
| | - T Tominaga
- Department of Surgical Oncology, Nagasaki University Graduate School of Biological Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Y Akazawa
- Department of Pathology, Nagasaki University Graduate School of Biological Sciences, Nagasaki, Japan.,Department of Tumor and Diagnostic Pathology, Atomic Bomb Disease Institute, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - T Sawai
- Department of Surgical Oncology, Nagasaki University Graduate School of Biological Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Takeshi Nagayasu
- Department of Surgical Oncology, Nagasaki University Graduate School of Biological Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
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Ryan OK, Ryan ÉJ, Creavin B, Rausa E, Kelly ME, Petrelli F, Bonitta G, Kennelly R, Hanly A, Martin ST, Winter DC. Surgical approach for rectal cancer: A network meta-analysis comparing open, laparoscopic, robotic and transanal TME approaches. Eur J Surg Oncol 2020; 47:285-295. [PMID: 33280950 DOI: 10.1016/j.ejso.2020.06.037] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 06/19/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The optimal approach for total mesorectal excision (TME) of rectal cancer remains controversial. AIM To compare short- and long-term outcomes after open (OpTME), laparoscopic (LapTME), robotic (RoTME) and transanal TME (TaTME). METHODS A systematic search of electronic databases was performed up to January 1, 2020 for randomized controlled trials (RCTs) comparing at least 2 TME strategies. A Bayesian arm-based random effect network meta-analysis (NMA) was performed, specifically, a mixed treatment comparison (MTC). RESULTS 30 RCTs (and six updates) of 5586 patients with rectal cancer were included. No significant differences were identified in recurrence rates or survival rates. Operating time was shorter with OpTME (surface under the cumulative ranking curve [SUCRA] 0.96) compared to LapTME, RoTME and TaTME. Although OpTME was associated with the most blood loss (SUCRA 0.90) and had a slower recovery with increased length of stay (SUCRA 0.90) compared to the minimally invasive techniques, there was no difference in postoperative morbidity. OpTME was associated with a more complete TME specimen compared to LapTME (Risk Ratio [RR] 1.05, 95% Credible Interval [CrI] 1.01, 1.11), and TaTME had less involved CRMs (RR 0.173, 95% CrI 0.02, 0.76) versus LapTME. There were no differences between the modalities in terms of deep TME defects, DRM distance, or lymph node yield. CONCLUSIONS While OpTME was the most effective TME modality for short term histopathological resection quality, there was no difference in long-term oncologic outcomes. Minimally invasive approaches enhance postoperative recovery, at the cost of longer operating times. Technique selection should be based on individual tumour characteristics and patient expectations, as well as surgeon and institutional expertise.
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Affiliation(s)
- Odhrán K Ryan
- School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland.
| | - Éanna J Ryan
- Department of Surgery, Surgical Professorial Unit, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Ben Creavin
- Department of Surgery, Surgical Professorial Unit, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Emanuele Rausa
- Division of Surgical Oncology, ASST-Bergamo Ovest, Treviglio, Italy
| | - Michael E Kelly
- Department of Surgery, Surgical Professorial Unit, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Fausto Petrelli
- Division of Surgical Oncology, ASST-Bergamo Ovest, Treviglio, Italy
| | - Gianluca Bonitta
- Division of Surgical Oncology, ASST-Bergamo Ovest, Treviglio, Italy
| | - Rory Kennelly
- Department of Surgery, Surgical Professorial Unit, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland.
| | - Ann Hanly
- Department of Surgery, Surgical Professorial Unit, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Seán T Martin
- Department of Surgery, Surgical Professorial Unit, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Des C Winter
- School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland; Department of Surgery, Surgical Professorial Unit, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
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de Lacy FB, Roodbeen SX, Ríos J, van Laarhoven J, Otero-Piñeiro A, Bravo R, Visser T, van Poppel R, Valverde S, Hompes R, Sietses C, Castells A, Bemelman WA, Tanis PJ, Lacy AM. Three-year outcome after transanal versus laparoscopic total mesorectal excision in locally advanced rectal cancer: a multicenter comparative analysis. BMC Cancer 2020; 20:677. [PMID: 32689968 PMCID: PMC7372845 DOI: 10.1186/s12885-020-07171-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 07/12/2020] [Indexed: 12/16/2022] Open
Abstract
Background For patients with mid and distal rectal cancer, robust evidence on long-term outcome and causal treatment effects of transanal total mesorectal excision (TaTME) is lacking. This multicentre retrospective cohort study aimed to assess whether TaTME reduces locoregional recurrence rate compared to laparoscopic total mesorectal excision (LapTME). Methods Consecutive patients with rectal cancer within 12 cm from the anal verge and clinical stage II-III were selected from three institutional databases. Outcome after TaTME (Nov 2011 - Feb 2018) was compared to a historical cohort of patients treated with LapTME (Jan 2000 - Feb 2018) using the inverse probability of treatment weights method. The primary endpoint was three-year locoregional recurrence. Results A total of 710 patients were analysed, 344 in the TaTME group and 366 in the LapTME group. At 3 years, cumulative locoregional recurrence rates were 3.6% (95% CI, 1.1–6.1) in the TaTME group and 9.6% (95% CI, 6.5–12.7) in the LapTME group (HR = 0.4; 95% CI, 0.23–0.69; p = 0.001). Three-year cumulative disease-free survival rates were 74.3% (95% CI, 68.8–79.8) and 68.6% (95% CI, 63.7–73.5) (HR = 0.82; 95% CI, 0.65–1.02; p = 0.078) and three-year overall survival 87.2% (95% CI, 82.7–91.7) and 82.2% (95% CI, 78.0–86.2) (HR = 0.74; 95% CI, 0.53–1.03; p = 0.077), respectively. In patients who underwent sphincter preservation procedures, TaTME was associated with a significantly better disease-free survival (HR = 0.78; 95% CI, 0.62–0.98; p = 0.033). Conclusions These findings suggest that TaTME may improve locoregional recurrence and disease-free survival rates among patients with mid and distal locally advanced rectal cancer.
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Affiliation(s)
- F B de Lacy
- Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clinic, IDIBAPS, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBERehd), University of Barcelona, Centro Esther Koplowitz, and Cellex Biomedical Research Center, Barcelona, Catalonia, Spain.
| | - S X Roodbeen
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - J Ríos
- Medical Statistics Core Facility, August Pi and Sunyer Biomedical Research Institute (IDIBAPS); Biostatistics Unit, Faculty of Medicine, Universitat Autònoma de Barcelona, Villarroel 170, 08036, Barcelona, Catalonia, Spain
| | - J van Laarhoven
- Department of General Surgery, Jeroen Bosch Ziekenhuis, 's Hertogenbosch, The Netherlands
| | - A Otero-Piñeiro
- Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clinic, IDIBAPS, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBERehd), University of Barcelona, Centro Esther Koplowitz, and Cellex Biomedical Research Center, Barcelona, Catalonia, Spain
| | - R Bravo
- Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clinic, IDIBAPS, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBERehd), University of Barcelona, Centro Esther Koplowitz, and Cellex Biomedical Research Center, Barcelona, Catalonia, Spain
| | - T Visser
- Department of Surgery, Gelderse Vallei Hospital, Ede, The Netherlands
| | - R van Poppel
- Department of Surgery, Gelderse Vallei Hospital, Ede, The Netherlands
| | - S Valverde
- Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clinic, IDIBAPS, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBERehd), University of Barcelona, Centro Esther Koplowitz, and Cellex Biomedical Research Center, Barcelona, Catalonia, Spain
| | - R Hompes
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - C Sietses
- Department of Surgery, Gelderse Vallei Hospital, Ede, The Netherlands
| | - A Castells
- Department of Gastroenterology, Institute of Digestive and Metabolic Diseases, Hospital Clinic, IDIBAPS, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBERehd), University of Barcelona, Barcelona, Catalonia, Spain
| | - W A Bemelman
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - P J Tanis
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - A M Lacy
- Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clinic, IDIBAPS, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBERehd), University of Barcelona, Centro Esther Koplowitz, and Cellex Biomedical Research Center, Barcelona, Catalonia, Spain
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Keller DS, Berho M, Perez RO, Wexner SD, Chand M. The multidisciplinary management of rectal cancer. Nat Rev Gastroenterol Hepatol 2020; 17:414-429. [PMID: 32203400 DOI: 10.1038/s41575-020-0275-y] [Citation(s) in RCA: 151] [Impact Index Per Article: 37.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/07/2020] [Indexed: 02/07/2023]
Abstract
Rectal cancer treatment has evolved during the past 40 years with the use of a standardized surgical technique for tumour resection: total mesorectal excision. A dramatic reduction in local recurrence rates and improved survival outcomes have been achieved as consequences of a better understanding of the surgical oncology of rectal cancer, and the advent of adjuvant and neoadjuvant treatments to compliment surgery have paved the way for a multidisciplinary approach to disease management. Further improvements in imaging techniques and the ability to identify prognostic factors such as tumour regression, extramural venous invasion and threatened margins have introduced the concept of decision-making based on preoperative staging information. Modern treatment strategies are underpinned by accurate high-resolution imaging guiding both neoadjuvant therapy and precision surgery, followed by meticulous pathological scrutiny identifying the important prognostic factors for adjuvant chemotherapy. Included in these strategies are organ-sparing approaches and watch-and-wait strategies in selected patients. These pathways rely on the close working of interlinked disciplines within a multidisciplinary team. Such multidisciplinary forums are becoming standard in the treatment of rectal cancer across the UK, Europe and, more recently, the USA. This Review examines the essential components of modern-day management of rectal cancer through a multidisciplinary team approach, providing information that is essential for any practising colorectal surgeon to guide the best patient care.
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Affiliation(s)
- Deborah S Keller
- Department of Surgery, New York-Presbyterian, Columbia University Medical Centre, New York, NY, USA
| | - Mariana Berho
- Department of Pathology and Laboratory Medicine, Cleveland Clinic Florida, Weston, Florida, USA
| | | | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - Manish Chand
- Wellcome EPSRC Centre for Interventional and Surgical Sciences (WEISS); University College London, London, UK.
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Tey HTV, Foo SMJ, Fong SS, Chong CS. Short Term Postoperative and Oncological Outcomes of Two-Dimensional Versus Three-Dimensional Laparoscopic Transanal Total Mesorectal Excision of Rectal Cancer. J Laparoendosc Adv Surg Tech A 2020; 30:1350-1353. [PMID: 32522084 DOI: 10.1089/lap.2020.0093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Transanal total mesorectal excision (TaTME) carried out synchronously with laparoscopy is a useful surgical technique in rectal cancer patients who are overweight or who have a narrow pelvis. This retrospective study aims to compare the safety and efficacy of two-dimensional (2D) and three-dimensional (3D) laparoscopic TaTME of rectal cancer based on the short-term postoperative and oncological outcomes of 40 patients in Singapore who underwent laparoscopic TaTME. Materials and Methods: Forty patients underwent laparoscopic TaTME for rectal cancer in one of three centers in Singapore from October 2015 to August 2018. Out of these patients, 23 underwent 3D laparoscopic TaTME with the Olympus Flexible Tip™ 10 mm scope. Data on patient demographics, operative details, and postoperative and oncological outcomes were collected retrospectively by going through soft copy patient records, analyzed and compared. Results: The operative time for 3D group was significantly shorter (340 versus 419 minutes, P = .04). Complete TME grade and R0 resection was achieved in a higher percentage of patients in the 3D group although this was not statistically significant. There were no other significant differences between the two groups in terms of oncological outcomes and other short-term postoperative outcomes. Discussion and Conclusion: TaTME is overall a safe technique. Three-dimensional TaTME for rectal cancers is as safe and feasible as 2D TaTME, with the advantage of a shorter operative time.
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Affiliation(s)
- Hwee Ting Vanessa Tey
- Division of Colorectal Surgery, University Surgical Cluster, National University Health System, National University Hospital, Singapore, Singapore
| | - Shuo Min Jonathan Foo
- Division of General Surgery, National University Health System, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Sau Shung Fong
- Division of Colorectal Surgery, National Healthcare Group, Tan Tock Seng Hospital, Singapore, Singapore
| | - Choon Seng Chong
- Division of Colorectal Surgery, University Surgical Cluster, National University Health System, National University Hospital, Singapore, Singapore
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Cooper M, Kim J, Shin BNH, Ng SK, Lu C, Nolan G, Von Papen M. Transanal total mesorectal excision the Gold Coast experience: learning curve and comparison to traditional technique. ANZ J Surg 2020; 90:1316-1320. [PMID: 32406584 DOI: 10.1111/ans.15968] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 04/24/2020] [Accepted: 04/25/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Laparoscopic and open techniques in rectal cancer are well-published, however, technical challenges remain for mid to low rectal cancer resections in the narrow pelvis. Transanal total mesorectal excision (taTME) has been pioneered to potentially circumvent these challenges. The aims of this study were to evaluate the learning curve associated with our first cases of taTME as well as compare outcomes to that of conventionally performed rectal resections. METHODS This was a single-centre retrospective study with data collated from all elective resections by the colorectal unit from 2015 to 2017. Primary outcome was completeness of total mesorectal excision and secondary outcomes were intra- and post-operative morbidity and mortality. RESULTS A total of 43 patients were identified. Of which, 20 underwent taTME. Mesorectal completeness was obtained in only 47.4% in the taTME group compared to 78.3% in the anterior resection group (p = 0.115). 5.9% of patients in our taTME group had positive circumferential resection margin compared to nil in the anterior resection. Conversion rates were greater in the taTME group (15% versus 0%; 0.028). Operative time, length of stay and clavien IV and V complications were greater in the taTME group. CONCLUSION This study highlights the difficulty in introducing a novel technique given the learning curve. Our results would expect to improve with increased caseload.
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Affiliation(s)
- Michelle Cooper
- General Surgery DepartmentGold Cost University Hospital Gold Cost Queensland Australia
- Griffith University Brisbane Queensland Australia
| | - Jason Kim
- General Surgery DepartmentGold Cost University Hospital Gold Cost Queensland Australia
| | - Brian Ng Hung Shin
- General Surgery DepartmentGold Cost University Hospital Gold Cost Queensland Australia
| | - Shu Kay Ng
- Griffith University Brisbane Queensland Australia
| | - Cu‐Tai Lu
- General Surgery DepartmentGold Cost University Hospital Gold Cost Queensland Australia
- Griffith University Brisbane Queensland Australia
| | - Gregory Nolan
- General Surgery DepartmentGold Cost University Hospital Gold Cost Queensland Australia
| | - Michael Von Papen
- General Surgery DepartmentGold Cost University Hospital Gold Cost Queensland Australia
- Griffith University Brisbane Queensland Australia
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Zuhdy M, Elmore U, Shams N, Hegazy MAF, Roshdy S, Eldamshety O, Metwally IH, Rosati R. Transanal Versus Laparoscopic Total Mesorectal Excision: A Comparative Prospective Clinical Trial from Two Centers. J Laparoendosc Adv Surg Tech A 2020; 30:769-776. [PMID: 32240035 DOI: 10.1089/lap.2019.0828] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Purpose: Laparoscopic total mesorectal excision (LapTME) faced many obstacles in obese male with narrow pelvis and bulky mesorectum with increased risk of incomplete mesorectal excision and positive circumferential resection margin (CRM) and distal resection margin (DRM). Transanal total mesorectal excision (TaTME) is reported to result in a better quality total mesorectal excision (TME) specimen, lower incidence of CRM and DRM involvement, and higher rates of sphincter preservation. To date, there is still a debate about the feasibility and efficacy of transanal versus the laparoscopic approach for TME in middle and low rectal cancer. Materials and Methods: This is a prospective controlled clinical trial where 38 patients of middle or low rectal cancer from two tertiary centers were nonrandomly assigned to either TaTME or LapTME. Results: Eighteen patients were operated by TaTME versus 20 patients by LapTME. Mean body mass index was significantly higher in the TaTME group (30.74 ± 7.79) than in the LapTME group (25.99 ± 4.68) (P = .03). TaTME was associated with more transanal specimen extraction (55.5% versus 20%, P = .06). No significant differences were detected in CRM, DRM, peri- or postoperative complications, or conversion rates with more reported Clavien-Dindo grade III complications in the TaTME group (P = .29). Conclusions: TaTME facilitated rectal cancer surgery in obese patients and increased the chance of transanal specimen extraction with equivalent oncological outcomes to conventional LapTME. Further studies are recommended to build better evidence.
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Affiliation(s)
- Mohammad Zuhdy
- Surgical Oncology Unit, Oncology Center Mansoura University (OCMU), Mansoura, Egypt
| | - Ugo Elmore
- Department of Gastrointestinal Surgery, IRCCS San Raffaele, University Vita e Salute, Milan, Italy
| | - Nazem Shams
- Surgical Oncology Unit, Oncology Center Mansoura University (OCMU), Mansoura, Egypt
| | - Mohamed A F Hegazy
- Surgical Oncology Unit, Oncology Center Mansoura University (OCMU), Mansoura, Egypt
| | - Sameh Roshdy
- Surgical Oncology Unit, Oncology Center Mansoura University (OCMU), Mansoura, Egypt
| | - Osama Eldamshety
- Surgical Oncology Unit, Oncology Center Mansoura University (OCMU), Mansoura, Egypt
| | - Islam H Metwally
- Surgical Oncology Unit, Oncology Center Mansoura University (OCMU), Mansoura, Egypt
| | - Riccardo Rosati
- Department of Gastrointestinal Surgery, IRCCS San Raffaele, University Vita e Salute, Milan, Italy
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Tokunaga T, Higashijima J, Yoshikawa K, Nishi M, Kashihara H, Takasu C, Shimada M. The usefulness of intraoperative X-ray fluoroscopy in avoiding urethral injury during transanal total mesorectal excision. Asian J Endosc Surg 2020; 13:242-245. [PMID: 31215751 DOI: 10.1111/ases.12717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 02/15/2019] [Accepted: 04/22/2019] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Urethral injury is one of the most important complications that can occur during transanal total mesorectal excision in male patients with rectal cancer. This report shows the usefulness of intraoperative X-ray fluoroscopy to avoid urethral injury associated with transanal total mesorectal excision. MATERIALS AND SURGICAL TECHNIQUE Real-time navigation using fluoroscopy was performed to check the distance between the urethra and the dissection line at the level of the exposed rectourethral muscle, the middle level of the divided rectourethral muscle, and the level at which the prostate was identified. DISCUSSION The dissection was completed transanally up to the level of peritoneal reflection on the anterior side without urethral injury. Pathological examination confirmed that the circumferential resection margin was tumor free. This novel technique using intraoperative X-ray fluoroscopy is an easy-to-use approach that helps prevent urethral injury in male patient who undergo transanal total mesorectal excision for rectal cancer.
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Affiliation(s)
- Takuya Tokunaga
- Department of Surgery, Tokushima University, Tokushima, Japan
| | - Jun Higashijima
- Department of Surgery, Tokushima University, Tokushima, Japan
| | - Kozo Yoshikawa
- Department of Surgery, Tokushima University, Tokushima, Japan
| | - Masaaki Nishi
- Department of Surgery, Tokushima University, Tokushima, Japan
| | | | - Chie Takasu
- Department of Surgery, Tokushima University, Tokushima, Japan
| | - Mitsuo Shimada
- Department of Surgery, Tokushima University, Tokushima, Japan
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66
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A Multicenter Matched Comparison of Transanal and Robotic Total Mesorectal Excision for Mid and Low-rectal Adenocarcinoma. Ann Surg 2020; 270:1110-1116. [PMID: 29916871 DOI: 10.1097/sla.0000000000002862] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To compare the quality of surgical resection of transanal total mesorectal excision (TA-TME) and robotic total mesorectal excision (R-TME). BACKGROUND Both TA-TME and R-TME have been advocated to improve the quality of surgery for rectal cancer below 10 cm from the anal verge, but there are little data comparing TA-TME and R-TME. METHODS Data of patients undergoing TA-TME or R-TME for rectal cancer below 10 cm from the anal verge and a sphincter-saving procedure from 5 high-volume rectal cancer referral centers between 2011 and 2017 were obtained. Coarsened exact matching was used to create balanced cohorts of TA-TME and R-TME. The main outcome was the incidence of poor-quality surgical resection, defined as a composite measure including incomplete quality of TME, or positive circumferential resection margin (CRM) or distal resection margin (DRM). RESULTS Out of a total of 730 patients (277 TA-TME, 453 R-TME), matched groups of 226 TA-TME and 370 R-TME patients were created. These groups were well-balanced. The mean tumor height from the anal verge was 5.6 cm (SD 2.5), and 70% received preoperative radiotherapy. The incidence of poor-quality resection was similar in both groups (TA-TME 6.9% vs R-TME 6.8%; P = 0.954). There were no differences in TME specimen quality (complete or near-complete TA-TME 99.1% vs R-TME 99.2%; P = 0.923) and CRM (5.6% vs 6.0%; P = 0.839). DRM involvement may be higher after TA-TME (1.8% vs 0.3%; P = 0.051). CONCLUSIONS High-quality TME for patients with rectal adenocarcinoma of the mid and low rectum can be equally achieved by transanal or robotic approaches in skilled hands, but attention should be paid to the distal margin.
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Abstract
The role of robotics in colon and rectal surgery has been established as an important and effective tool for the surgeon. Its inherent technologies have provided for increased visualization and ease of dissection in the minimally invasive approach to surgery. The value of the robot is apparent in the more challenging aspects of colon and rectal procedures, including the intracorporeal anastomosis for right colectomies and the low pelvic dissection for benign and malignant diseases.
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Perdawood SK, Kroeigaard J, Eriksen M, Mortensen P. Transanal total mesorectal excision: the Slagelse experience 2013-2019. Surg Endosc 2020; 35:826-836. [PMID: 32072292 DOI: 10.1007/s00464-020-07454-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 02/11/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To describe outcomes after transanal total mesorectal excision (TaTME) 5 years from implementation at a large-volume colorectal unit, including local recurrence, distant metastasis, and survival. BACKGROUND Transanal total mesorectal excision (TaTME) is a relatively new procedure for mid- and low-rectal cancer, with well-documented safety and feasibility. However, data on long-term results are limited. METHODS This study was based on a prospective data collection via a maintained database in a large colorectal unit. The database included patients who underwent TaTME from December 2013 through July 2019. We have updated the database through a review of patient charts, including radiology and pathology reports. Data collection included operative details, intraoperative findings, postoperative complications, pathologic results, and oncologic results. RESULTS During the study period, two hundred patients underwent TaTME in the study period (men = 147). The mean BMI was 26.7%, and the mean tumor height from the anal verge was 7.86 cm. Neoadjuvant treatment was given to 22% of patients. Anastomotic leakage occurred in 9.3% of patients, and the overall rate of postoperative complications was 24.5%. The TME specimen was incomplete in 11% of patients, and the CRM was positive in 5.5% of patients. Local recurrence (LR) occurred in seven patients with a follow-up of at least 2 years (4.7%). Distant metastasis (DM) occurred in 12% of patients. The overall survival was 90% and disease-free survival was 81%. The operating time was reduced in the later period of our experience. CONCLUSIONS This study showed that TaTME is feasible, safe, and had acceptable short-term outcomes and an acceptable rate of LR. The study included, however, one group that was non-randomized, and the follow-up was not long enough for most patients. Studies with longer follow-up data are awaited.
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Affiliation(s)
- Sharaf Karim Perdawood
- Department of Gastrointestinal Surgery, Slagelse Hospital, Faelledvej 11, 4200, Slagelse, Denmark.
| | - Jens Kroeigaard
- Department of Gastrointestinal Surgery, Slagelse Hospital, Faelledvej 11, 4200, Slagelse, Denmark
| | - Marianne Eriksen
- Department of Gastrointestinal Surgery, Slagelse Hospital, Faelledvej 11, 4200, Slagelse, Denmark
| | - Pauli Mortensen
- Department of Gastrointestinal Surgery, Slagelse Hospital, Faelledvej 11, 4200, Slagelse, Denmark
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Otero-Piñeiro AM, de Lacy FB, Van Laarhoven JJ, Martín-Perez B, Valverde S, Bravo R, Lacy AM. The impact of fluorescence angiography on anastomotic leak rate following transanal total mesorectal excision for rectal cancer: a comparative study. Surg Endosc 2020; 35:754-762. [DOI: 10.1007/s00464-020-07442-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 02/10/2020] [Indexed: 02/07/2023]
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Kang L, Sylla P, Atallah S, Ito M, Wexner SD, Wang JP. taTME: boom or bust? Gastroenterol Rep (Oxf) 2020; 8:1-4. [PMID: 32104580 PMCID: PMC7034229 DOI: 10.1093/gastro/goaa001] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 01/09/2020] [Accepted: 01/09/2020] [Indexed: 01/04/2023] Open
Affiliation(s)
- Liang Kang
- Department of Colorectal Surgery, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
| | - Patricia Sylla
- Division of Colon and Rectal Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sam Atallah
- The College of Medicine, Endo-Surgical Center of Florida, Department of Colorectal Surgery, Florida Hospital, Orlando, FL, USA
| | - Massaki Ito
- Colorectal and Pelvic Surgery Division, Department of Surgical Oncology, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Jian-Ping Wang
- Department of Colorectal Surgery, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, P. R. China
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Simillis C, Lal N, Thoukididou SN, Kontovounisios C, Smith JJ, Hompes R, Adamina M, Tekkis PP. Open Versus Laparoscopic Versus Robotic Versus Transanal Mesorectal Excision for Rectal Cancer: A Systematic Review and Network Meta-analysis. Ann Surg 2020; 270:59-68. [PMID: 30720507 DOI: 10.1097/sla.0000000000003227] [Citation(s) in RCA: 100] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To compare techniques for rectal cancer resection. SUMMARY BACKGROUND DATA Different surgical approaches exist for mesorectal excision. METHODS Systematic literature review and Bayesian network meta-analysis performed. RESULTS Twenty-nine randomized controlled trials included, reporting on 6237 participants, comparing: open versus laparoscopic versus robotic versus transanal mesorectal excision. No significant differences identified between treatments in intraoperative morbidity, conversion rate, grade III/IV morbidity, reoperation, anastomotic leak, nodes retrieved, involved distal margin, 5-year overall survival, and locoregional recurrence. Operative blood loss was less with laparoscopic surgery compared with open, and with robotic surgery compared with open and laparoscopic. Robotic operative time was longer compared with open, laparoscopic, and transanal. Laparoscopic operative time was longer compared with open. Laparoscopic surgery resulted in lower overall postoperative morbidity and fewer wound infections compared with open. Robotic surgery had fewer wound infections compared with open. Time to defecation was longer with open surgery compared with laparoscopic and robotic. Hospital stay was longer after open surgery compared with laparoscopic and robotic, and after laparoscopic surgery compared with robotic. Laparoscopic surgery resulted in more incomplete or nearly complete mesorectal excisions compared with open, and in more involved circumferential resection margins compared with transanal. Robotic surgery resulted in longer distal resection margins compared with open, laparoscopic, and transanal. CONCLUSIONS The different techniques result in comparable perioperative morbidity and long-term survival. The laparoscopic and robotic approaches may improve postoperative recovery, and the open and transanal approaches may improve oncological resection. Technique selection should be based on expected benefits by individual patient.
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Affiliation(s)
- Constantinos Simillis
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - Nikhil Lal
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Sarah N Thoukididou
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Christos Kontovounisios
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - Jason J Smith
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - Roel Hompes
- Academic Medical Center, Amsterdam, The Netherlands
| | - Michel Adamina
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Paris P Tekkis
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK
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72
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Larsen SG, Pfeffer F, Kørner H. Norwegian moratorium on transanal total mesorectal excision. Br J Surg 2020; 106:1120-1121. [PMID: 31304578 DOI: 10.1002/bjs.11287] [Citation(s) in RCA: 142] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 05/27/2019] [Indexed: 01/06/2023]
Abstract
A national decision
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Affiliation(s)
- S G Larsen
- Department of Gastroenterological Surgery, Oslo University Hospital, N-0424 Oslo, Norway.,Norwegian Colorectal Cancer Group, Norway
| | - F Pfeffer
- Department of Gastroenterological Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Norwegian Colorectal Cancer Group, Norway
| | - H Kørner
- Department of Gastroenterological Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway.,Norwegian Colorectal Cancer Group, Norway
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Clinical and oncological outcomes of single-incision vs. conventional laparoscopic surgery for rectal cancer. Surg Endosc 2019; 34:5294-5303. [PMID: 31858246 DOI: 10.1007/s00464-019-07317-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 12/03/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND To evaluate the clinical and oncological outcomes of single-incision laparoscopic surgery (SILS) vs. conventional laparoscopic surgery (CLS) for patients with rectal cancer (RC) who underwent total mesorectal excision (TME) surgery. METHODS This was a retrospective case-control study of patients with RC operated between 12/2013 and 12/2017 in Ruijin Hospital North, Shanghai Jiaotong University School of Medicine. In total, 177 patients who underwent CLS and 51 who underwent SILS met the inclusion and exclusion criteria and were matched 1:1 using propensity score matching method (PSM). RESULTS Compared with the CLS group, the SILS group showed shorter operation time [105 (40) vs. 125 (55) min, P = 0.045], shorter total incision length [4 (1) vs. 6.5 (1.5) cm, P < 0.001], lower VAS score on POD2 [1 (1) vs. 2 (1), P < 0.001], shorter time to soft diet [7 (1) vs. 8 (2) days, P = 0.048], and shorter length of hospital stay [9 (2) vs. 11 (3) days, P < 0.001]. The postoperative complications were similar between two groups [1(2%) vs. 5 (9.8%), P = 0.205]. No readmissions or mortality in either group occurred within 30 days of surgery. All 102 specimens met the requirements of TME. No significant differences were observed in the pathologic outcomes between the two groups. The median follow-up period was 32.6 months in the SILS group and 36.8 months in the CLS group (P = 0.053). The 3-year disease-free survival rates and overall survival rates of the SILS and CLS groups were 89.8% vs. 96.0% (P = 0.224) and 90.9% vs. 96.9% (P = 0.146), respectively. CONCLUSIONS Compared with CLS, TME surgery for rectal cancer can be performed safely and effectively using the SILS technique with better cosmetic results, less postoperative pain, faster postoperative recovery, and acceptable clinical and oncological outcomes.
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74
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Wasmuth HH, Færden AE, Myklebust TÅ, Pfeffer F, Norderval S, Riis R, Olsen OC, Lambrecht JR, Kørner H, Larsen SG, Forsmo HM, Bækkelund O, Lavik S, Knapp JC, Sjo O, Rashid G. Transanal total mesorectal excision for rectal cancer has been suspended in Norway. Br J Surg 2019; 107:121-130. [DOI: 10.1002/bjs.11459] [Citation(s) in RCA: 129] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 11/06/2019] [Accepted: 11/12/2019] [Indexed: 12/21/2022]
Abstract
Abstract
Background
Transanal total mesorectal excision (TaTME) for rectal cancer has emerged as an alternative to the traditional abdominal approach. However, concerns have been raised about local recurrence. The aim of this study was to evaluate local recurrence after TaTME. Secondary aims included postoperative mortality, anastomotic leak and stoma rates.
Methods
Data on all patients who underwent TaTME were recorded and compared with those from national cohorts in the Norwegian Colorectal Cancer Registry (NCCR) and the Norwegian Registry for Gastrointestinal Surgery (NoRGast). Kaplan–Meier estimates were used to compare local recurrence.
Results
In Norway, 157 patients underwent TaTME for rectal cancer between October 2014 and October 2018. Three of seven hospitals abandoned TaTME after a total of five procedures. The local recurrence rate was 12 of 157 (7·6 per cent); eight local recurrences were multifocal or extensive. The estimated local recurrence rate at 2·4 years was 11·6 (95 per cent c.i. 6·6 to 19·9) per cent after TaTME compared with 2·4 (1·4 to 4·3) per cent in the NCCR (P < 0·001). The adjusted hazard ratio was 6·71 (95 per cent c.i. 2·94 to 15·32). Anastomotic leaks resulting in reoperation occurred in 8·4 per cent of patients in the TaTME cohort compared with 4·5 per cent in NoRGast (P = 0·047). Fifty-six patients (35·7 per cent) had a stoma at latest follow-up; 39 (24·8 per cent) were permanent.
Conclusion
Anastomotic leak rates after TaTME were higher than national rates; local recurrence rates and growth patterns were unfavourable.
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Affiliation(s)
- H H Wasmuth
- Department of Gastrointestinal Surgery, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - A E Færden
- Department of Gastrointestinal Surgery, Akershus University Hospital, Lørenskog, Norway
| | - T Å Myklebust
- Department of Registration, Cancer Registry Norway, Oslo, Norway
- Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway
| | - F Pfeffer
- Department of Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - S Norderval
- Department of Gastrointestinal Surgery, Tromsø University Hospital, University of Northern Norway, Tromsø, Norway
| | - R Riis
- Department of Gastrointestinal Surgery, Akershus University Hospital, Lørenskog, Norway
| | - O C Olsen
- Department of Gastrointestinal Surgery, Drammen Hospital, Vestre Viken Hospital Trust, Drammen, Norway
| | - J R Lambrecht
- Department of Surgery, Gjøvik Hospital, Innlandet Hospital Trust, Gjøvik, Norway
| | - H Kørner
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - S G Larsen
- Department of Gastrointestinal Surgery, Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
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75
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Chen CC, Lai YL, Cheng AYM, Chu CH, Huang IP, Yang SH. Transanal total mesorectal excision for rectal cancer: hype or new hope? J Gastrointest Oncol 2019; 10:1193-1199. [PMID: 31949939 DOI: 10.21037/jgo.2019.01.13] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Rectal cancer has always posed surgical challenges to the colorectal surgeon. The quality of the total mesorectal excision (TME) performed is key in determining local disease control. Unlike the great success in adoption of laparoscopic surgery in colon cancer treatment, studies comparing laparoscopy to open rectal surgery all revealed noninferiority was not achieved. Transanal TME (taTME) is the latest advanced technique pioneered to tackle difficult pelvic dissections. The evolution of taTME surgery in recent years was explored in this review. The outcomes to date on the latest literatures are reviewed, included complications, functional outcomes, oncological results and future clinical researches. taTME, while definitely still in its early stages of development, has steadily accumulated safety and feasibility data. It not only provides a better solution to an old problem that colorectal surgeons have been attempting to tackle for quite some time, but also appears to be quite promising in terms of outcomes on numerous fronts. With structured training models, and proctored clinical application, alongside design and implementation of international-scale large multicenter randomized clinical trials, one can only hope that taTME and its innovations will not only open a new era for colorectal surgery, but also for even more surgical disease pathologies.
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Affiliation(s)
- Chien-Chih Chen
- Department of Surgery, Koo Foundation, Sun Yat-Sen Cancer Center, Taipei.,College of Medicine, National Yang-Ming University, Taipei
| | - Yi-Ling Lai
- Department of Surgery, Koo Foundation, Sun Yat-Sen Cancer Center, Taipei.,College of Medicine, National Yang-Ming University, Taipei
| | - Andy Yi-Ming Cheng
- Department of Medicine, Division of Hospital Medicine, University of Pittsburgh Medical Center Shadyside Hospital, Pittsburgh, Pennsylvania, USA
| | - Chun-Ho Chu
- Department of Surgery, Koo Foundation, Sun Yat-Sen Cancer Center, Taipei.,College of Medicine, National Yang-Ming University, Taipei
| | - I-Ping Huang
- Department of Surgery, Koo Foundation, Sun Yat-Sen Cancer Center, Taipei
| | - Shung-Haur Yang
- College of Medicine, National Yang-Ming University, Taipei.,Division of Colorectal Surgery, Taipei Veterans General Hospital, Taipei.,Department of Surgery, National Yang-Ming University Hospital, Yilan
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76
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Transanal Minimally Invasive Surgical Management of Persisting Pelvic Sepsis or Chronic Sinus After Low Anterior Resection. Dis Colon Rectum 2019; 62:1458-1466. [PMID: 31567923 DOI: 10.1097/dcr.0000000000001483] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Redo surgery of persisting pelvic sepsis or chronic presacral sinus after low anterior resection for rectal cancer is challenging. Transanal minimally invasive surgery improves visibility and accessibility of the deep pelvis. OBJECTIVE The aim of this study was to compare the conventional approach with transanal minimally invasive surgery for redo pelvic surgery with or without anastomotic reconstruction. DESIGN This is a retrospective cohort study. SETTINGS This study was conducted in a tertiary referral center. PATIENTS All consecutive patients undergoing redo pelvic surgery after low anterior resection for rectal cancer between January 2005 and March 2018 were included. INTERVENTIONS Redo surgery was divided into redo anastomosis and intersphincteric completion proctectomy. Transanal minimally invasive surgery procedures since November 2014 were compared with the conventional approach. MAIN OUTCOME MEASURES Primary end points were procedural characteristics and 90-day major complications. RESULTS In total, 104 patients underwent redo surgery; 47 received a redo anastomosis (18 conventional and 29 transanal minimally invasive surgery) and 57 underwent intersphincteric completion proctectomy (35 conventional and 22 transanal minimally invasive surgery). The transabdominal part of the transanal minimally invasive surgery procedures was performed laparoscopically in 72% and 59% of redo anastomosis and intersphincteric completion proctectomy, compared with 6% and 34% in the conventional group (p < 0.001 and p = 0.100). The 90-day major complication rate was 33% and 45% after redo anastomosis (p=0.546) and 29% and 41% after intersphincteric completion proctectomy (p=0.349) in conventional surgery and transanal minimally invasive surgery. LIMITATIONS A limitation of this study is the relatively small sample size. CONCLUSIONS This study suggests that transanal minimally invasive surgery is a valid alternative to conventional top-down redo pelvic surgery for persisting pelvic sepsis or chronic sinus, with more often a laparoscopic approach for the abdominal part. See Video Abstract at http://links.lww.com/DCR/B87. MANEJO QUIRÚRGICO TRANSANAL MÍNIMAMENTE INVASIVO DE LA SEPSIS PÉLVICA PERSISTENTE O DE UN SENO CRÓNICO DESPUÉS DE RESECCIÓN ANTERIOR BAJA: La cirugía de reoperación por sepsis pélvica persistente o un seno presacro crónico después de una resección anterior baja por cáncer de recto es un desafío. La cirugía transanal mínimamente invasiva mejora la visibilidad y la accesibilidad a la región profunda de la pelvis.El objetivo de este estudio fue comparar el abordaje convencional con la cirugía transanal mínimamente invasiva para cirugía pélvica de reoperación con o sin reconstrucción anastomótica.Este es un estudio de cohorte retrospectiva.Este estudio se realizó en un centro de referencia terciario.Se incluyeron todos los pacientes consecutivos que se sometieron a una cirugía pélvica de reoperación después de una resección anterior baja por cáncer de recto entre enero de 2005 y marzo de 2018.La cirugía de reoperación se dividió en reconstrucción de anastomosis y proctectomía interesfintérica. Los procedimientos de cirugía transanal mínimamente invasiva desde noviembre de 2014 se compararon con el abordaje convencional.Los puntos primarios fueron las características del procedimiento y las complicaciones mayores a 90 días.En total, 104 pacientes fueron sometidos a cirugía de reoperación; 47 recibieron una reconstrucción de anastomosis (18 abordaje convencional y 29 cirugía transanal mínimamente invasiva) y 57 se sometieron a una proctectomía interesfintérica (35 abordaje convencional y 22 cirugía transanal mínimamente invasiva). La parte transabdominal de los procedimientos de cirugía transanal mínimamente invasiva se realizó por vía laparoscópica en el 72% y el 59% de las reconstrucciones de anastomosis y las proctectomías interesfintéricas, respectivamente, en comparación con el 6% y el 34%, respectivamente, en el grupo convencional (p <0.001 y p = 0.100). La tasa de complicaciones mayores a los 90 días fue del 33% y del 45% después de la anastomosis de reconstrucción (p = 0.546) y del 29% y 41% después de la proctectomía interesfintérica (p = 0.349) en cirugía convencional y cirugía transanal mínimamente invasiva, respectivamente.La limitación de este estudio es el tamaño relativamente pequeño de la muestra.Este estudio sugiere que la cirugía transanal mínimamente invasiva es una alternativa válida para la cirugía pélvica de reoperación convencional en sepsis pélvica persistente o seno crónico, con un abordaje laparoscópico utilizado más frecuentemente para la parte abdominal. Vea el Abstract del video en http://links.lww.com/DCR/B87.
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77
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Predictive Factors and Risk Model for Positive Circumferential Resection Margin Rate After Transanal Total Mesorectal Excision in 2653 Patients With Rectal Cancer. Ann Surg 2019; 270:884-891. [DOI: 10.1097/sla.0000000000003516] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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78
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Dekker E, Tanis PJ, Vleugels JLA, Kasi PM, Wallace MB. Colorectal cancer. Lancet 2019; 394:1467-1480. [PMID: 31631858 DOI: 10.1016/s0140-6736(19)32319-0] [Citation(s) in RCA: 2387] [Impact Index Per Article: 477.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 07/19/2019] [Accepted: 08/15/2019] [Indexed: 02/07/2023]
Abstract
Several decades ago, colorectal cancer was infrequently diagnosed. Nowadays, it is the world's fourth most deadly cancer with almost 900 000 deaths annually. Besides an ageing population and dietary habits of high-income countries, unfavourable risk factors such as obesity, lack of physical exercise, and smoking increase the risk of colorectal cancer. Advancements in pathophysiological understanding have increased the array of treatment options for local and advanced disease leading to individual treatment plans. Treatments include endoscopic and surgical local excision, downstaging preoperative radiotherapy and systemic therapy, extensive surgery for locoregional and metastatic disease, local ablative therapies for metastases, and palliative chemotherapy, targeted therapy, and immunotherapy. Although these new treatment options have doubled overall survival for advanced disease to 3 years, survival is still best for those with non-metastasised disease. As the disease only becomes symptomatic at an advanced stage, worldwide organised screening programmes are being implemented, which aim to increase early detection and reduce morbidity and mortality from colorectal cancer.
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Affiliation(s)
- Evelien Dekker
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, Netherlands.
| | - Pieter J Tanis
- Department of Surgery, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, Netherlands
| | - Jasper L A Vleugels
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, Netherlands; Department of Internal Medicine, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, Netherlands
| | - Pashtoon M Kasi
- Department of Medical Oncology, University of Iowa, Iowa City, IA, USA
| | - Michael B Wallace
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
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79
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Nikolic A, Waters PS, Peacock O, Choi CCM, Rajkomar A, Heriot AG, Smart P, Warrier S. Hybrid abdominal robotic approach with conventional transanal total mesorectal excision (TaTME) for rectal cancer: feasibility and outcomes from a single institution. J Robot Surg 2019; 14:633-641. [PMID: 31625075 DOI: 10.1007/s11701-019-01032-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 09/05/2019] [Indexed: 12/11/2022]
Abstract
Total mesorectal excision (TME) is currently recognised as the standard of care for patients with rectal cancer. Complete TME is known to be associated with lower rates of recurrence. Robotic and endoscopic TaTME approaches are reported to offer excellent proximal and distal rectal dissection into the TME plane, however, combining both approaches in a hybrid procedure could potentially optimise visualisation of the dissection plane and confer improved circumferential and distal margin rates. The aim of this study was to analyse the feasibility of a hybrid robotic abdominal approach with conventional TaTME for rectal cancer. Furthermore, pathological and patient outcomes were assessed. A review of prospectively maintained databases was undertaken to assess all patients undergoing robotic TME surgery for rectal tumours from August 2016 to October 2017. Patient demographics, tumour characteristics and outcomes were collated from patient charts and hospital databases. All patients underwent a modified Cecil approach after multidisciplinary team discussion. Eight patients (7 male, 1 female) underwent a combined hybrid approach with a median age of 60 years (range 47-73) and BMI of 29.5 (range 20-39.1) kg/m2. Median distance from the anorectal junction (ARJ) was 7.5 (range 4-13) cm. Six patients underwent neoadjuvant treatment with chemoradiotherapy. Patients had a median length of stay (LOS) of 9 (range 4-33) days. There were no intra-operative complications encountered and no patients required a conversion to an open procedure. Complications included one anastomotic leak and one presacral collection. All patients had a complete TME with RO resection with a median number of lymph nodes harvested was 22 (range 6-37) lymph nodes. This hybrid technique is a feasible, practical and operatively favourable approach to rectal cancer surgery with initial pathological outcomes and complication profile equivalent to other approaches.
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Affiliation(s)
- Amanda Nikolic
- General Surgery and Gastroenterology Clinical Institute, Epworth Healthcare, Richmond, Australia.,Department of Surgery, The Surgery Centre, Austin Health, 145 Studley Road, Heidelberg, Melbourne, VIC, 3084, Australia
| | - Peadar S Waters
- General Surgery and Gastroenterology Clinical Institute, Epworth Healthcare, Richmond, Australia.,Colorectal Surgery Unit, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC, 3000, Australia
| | - Oliver Peacock
- General Surgery and Gastroenterology Clinical Institute, Epworth Healthcare, Richmond, Australia.,Colorectal Surgery Unit, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC, 3000, Australia
| | - Colin Chan-Min Choi
- General Surgery and Gastroenterology Clinical Institute, Epworth Healthcare, Richmond, Australia
| | - Amrish Rajkomar
- General Surgery and Gastroenterology Clinical Institute, Epworth Healthcare, Richmond, Australia
| | - Alexander G Heriot
- General Surgery and Gastroenterology Clinical Institute, Epworth Healthcare, Richmond, Australia.,Colorectal Surgery Unit, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC, 3000, Australia.,The Alfred Hospital, 55 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Philip Smart
- General Surgery and Gastroenterology Clinical Institute, Epworth Healthcare, Richmond, Australia.,Department of Surgery, The Surgery Centre, Austin Health, 145 Studley Road, Heidelberg, Melbourne, VIC, 3084, Australia.,Department of Surgery, Eastern Health, 5 Arnold Street, Box Hill, Melbourne, VIC, 3128, Australia
| | - Satish Warrier
- General Surgery and Gastroenterology Clinical Institute, Epworth Healthcare, Richmond, Australia. .,Colorectal Surgery Unit, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC, 3000, Australia. .,The Alfred Hospital, 55 Commercial Road, Melbourne, VIC, 3004, Australia.
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80
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Aubert M, Mege D, Panis Y. Total mesorectal excision for low and middle rectal cancer: laparoscopic versus transanal approach-a meta-analysis. Surg Endosc 2019; 34:3908-3919. [PMID: 31617090 DOI: 10.1007/s00464-019-07160-8] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 09/24/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Transanal total mesorectal excision (TaTME) appeared to be a challenging alternative to Laparoscopic Total Mesorectal Excision (LaTME) for low and middle rectal cancer. However, evidence remains low on the possible benefits of TaTME. The aim of this study was to perform a meta-analysis of comparative studies between TaTME and LaTME. METHODS A systematic review and meta-analysis based on Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) guidelines was conducted on Medline, Embase, and Cochrane database. The following outcomes were assessed: conversion, operative time, morbidity, length of stay, readmission rate, and pathological and oncological results. RESULTS After review of 756 identified records, 14 studies were included (case-matched control n = 10, prospective cohort n = 3, retrospective study n = 1) comparing 495 TaTME and 547 LaTME. No randomized trial was available. Following criteria were significantly improved after TaTME vs. LaTME: readmission's rate (9% after TaTME vs. 18% after LaTME, OR 0.44, 95%CI 0.26-0.74, p = 0.002), length of stay (OR - 2.17, 95%CI - 3.68 to - 0.66, p = 0.005), overall morbidity (34 vs. 41%, OR 0.65, 95%CI 0.46-0.91, p = 0.001), major morbidity (8.7 vs. 14%, OR 0.53, 95%CI 0.34-0.83, p = 0.005), anastomotic leak (6.4 vs. 11.6%, OR 0.53, 95%CI 0.31-0.93, p = 0.03), and circumferential resection margin (CRM) involvement (4 vs. 8.8%, OR 0.48, 95%CI 0.27-0.86, p = 0.01). No significant differences were observed between TaTME and LaTME regarding conversion's rate (3.2 vs. 8.8%, p = 0.09), operative time (OR - 10.73, p = 0.26), intraoperative complications (8.1 vs. 6.3%, p = 0.48), minor morbidity (27.9 vs. 29.6%, p = 0.27), positive distal resection margin (1.4 vs. 1.4%, p = 0.93), complete TME (75 vs. 75%, p = 0.74), harvested lymph nodes (OR 0.38, p = 0.44), and local recurrence rate (3.5 vs. 2.2%, p = 0.64). CONCLUSION This meta-analysis based on nonrandomized studies suggests that TaTME seems better than LaTME in terms of overall and major morbidities, anastomotic leak, readmission rate, CRM involvement, and length of stay. These results need to be confirmed by randomized controlled trial.
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Affiliation(s)
- Mathilde Aubert
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris VII, Clichy, France
| | - Diane Mege
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris VII, Clichy, France
| | - Yves Panis
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris VII, Clichy, France. .,Département de Chirurgie Colorectale, Hôpital Beaujon, 100 Boulevard du Général Leclerc, 92110, Clichy, France.
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81
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Peltrini R, Luglio G, Cassese G, Amendola A, Caruso E, Sacco M, Pagano G, Sollazzo V, Tufano A, Giglio MC, Bucci L, Palma GDD. Oncological Outcomes and Quality of Life After Rectal Cancer Surgery. Open Med (Wars) 2019; 14:653-662. [PMID: 31565674 PMCID: PMC6744610 DOI: 10.1515/med-2019-0075] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/16/2019] [Indexed: 12/16/2022] Open
Abstract
Surgery for rectal cancer has been completely revolutionized thanks to the adoption of new technologies and up-to-date surgical procedures that have been applied to the traditional milestone represented by Total Mesorectal Excision (TME). The multimodal and multidisciplinary approach, with new technologies increased the patients’ life expectancies; nevertheless, they have placed the surgeon in front of newer issues, represented by both oncological outcomes and the patients’ need of a less destructive surgery and improved quality of life. In this review we will go through laparoscopic, robotic and transanal TME surgery, to show how the correct choice of the most appropriate technique, together with a deep knowledge of oncological principles and pelvic anatomy, is crucial to pursue an optimal cancer treatment. Novel technologies might also help to decrease the patients’ fear of surgery and address important issues such as cosmesis and improved preservation of postoperative functionality.
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Affiliation(s)
- Roberto Peltrini
- Department of Clinical Medicine and Surgery. University of Naples "Federico II", 80131 Naples, Via Pansini 5, Italy
| | - Gaetano Luglio
- Department of Public Health. University of Naples "Federico II", Naples, Italy
| | - Gianluca Cassese
- Department of Clinical Medicine and Surgery. University of Naples "Federico II", 80131 Naples, Via Pansini 5, Italy
| | - Alfonso Amendola
- Department of Clinical Medicine and Surgery. University of Naples "Federico II", 80131 Naples, Via Pansini 5, Italy
| | - Emanuele Caruso
- Department of Clinical Medicine and Surgery. University of Naples "Federico II", 80131 Naples, Via Pansini 5, Italy
| | - Michele Sacco
- Department of Clinical Medicine and Surgery. University of Naples "Federico II", 80131 Naples, Via Pansini 5, Italy
| | - Gianluca Pagano
- Department of Clinical Medicine and Surgery. University of Naples "Federico II", 80131 Naples, Via Pansini 5, Italy
| | - Viviana Sollazzo
- Department of Clinical Medicine and Surgery. University of Naples "Federico II", 80131 Naples, Via Pansini 5, Italy
| | - Antonio Tufano
- Department of Urology, University of Rome "La Sapienza", 00161 Roma RM Italy
| | - Mariano Cesare Giglio
- Department of Clinical Medicine and Surgery. University of Naples "Federico II", 80131 Naples, Via Pansini 5, Italy
| | - Luigi Bucci
- Department of Public Health. University of Naples "Federico II", Naples, Italy
| | - Giovanni Domenico De Palma
- Department of Clinical Medicine and Surgery. University of Naples "Federico II", 80131 Naples, Via Pansini 5, Italy.,Center of Excellence for Technical Innovation in Surgery (CEITC). University of Naples Federico II, 80131 Naples, Italy
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82
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Holmer C, Benz S, Fichtner-Feigl S, Jehle EC, Kienle P, Post S, Schiedeck T, Weitz J, Kreis ME. [Transanal total mesorectal excision-a critical appraisal]. Chirurg 2019; 90:478-486. [PMID: 30911795 DOI: 10.1007/s00104-019-0945-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Total mesorectal excision (TME) is the international standard for rectal cancer surgery. In addition to laparoscopic TME (lapTME), transanal TME (taTME) was developed in recent years to reduce the rate of incomplete TME, conversion to open surgery and postoperative functional impairment. Despite limited evidence, this technique is becoming increasingly more popular and is already routinely used by many hospitals for rectal cancer in varying tumor level locations. The aim of this review was to evaluate the taTME compared to anterior rectal resection with lapTME as the standard of care in rectal cancer surgery based on currently available evidence. METHOD The databases PubMed and Medline were systematically searched for publications on transanal total mesorectal excision (taTME) and transanal minimally invasive surgery (TAMIS). Relevant studies were selected and further research based on the reference lists was undertaken. RESULTS A total of 16 studies analyzing 3782 patients were identified. The taTME does not lead to a higher rate of complete TME-resected specimens compared to the standard procedure. So far, superiority could not be demonstrated for complication rates or for functional or oncological results. Serious complications secondary to dissection in incorrect planes were observed. The anastomotic level generally seems to be closer to the sphincter after taTME versus anterior lapTME. CONCLUSION Considering current evidence, taTME failed to show superiority compared to conventional anterior lapTME. Although taTME has some potential advantages, it carries substantial risks. If performed outside of clinical trials, it should therefore only be used in carefully selected patients with a high possibility of conversion, following adequate patient informed consent and after intense and systematic training of the surgeon.
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Affiliation(s)
- C Holmer
- Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Hindenburgdamm 30, 12200, Berlin, Deutschland
| | - S Benz
- Klinikum Sindelfingen-Böblingen, Klinik für Allgemein‑, Viszeral- und Kinderchirurgie, Klinikverbund Südwest, Böblingen, Deutschland
| | - S Fichtner-Feigl
- Klinik für Allgemein- und Viszeralchirurgie, Department Chirurgie, Universitätsklinikum Freiburg, Freiburg, Deutschland
| | - E C Jehle
- Klinik für Allgemein- und Viszeralchirurgie, St. Elisabethen-Klinikum, Ravensburg, Deutschland
| | - P Kienle
- Klinik für Allgemein- und Viszeralchirurgie, Theresienkrankenhaus, Mannheim, Deutschland
| | - S Post
- Chirurgische Klinik, Universitätsklinikum Mannheim, Mannheim, Deutschland
| | - T Schiedeck
- Klinik für Allgemein- und Viszeralchirurgie, Klinikum Ludwigsburg, Ludwigsburg, Deutschland
| | - J Weitz
- Klinik und Poliklinik für Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus der TU Dresden, Dresden, Deutschland
| | - M E Kreis
- Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Hindenburgdamm 30, 12200, Berlin, Deutschland.
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83
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Bell SW, Heriot AG, Warrier SK, Farmer CK, Stevenson ARL, Bissett I, Kong JC, Solomon M. Surgical techniques in the management of rectal cancer: a modified Delphi method by colorectal surgeons in Australia and New Zealand. Tech Coloproctol 2019; 23:743-749. [PMID: 31440953 DOI: 10.1007/s10151-019-02052-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 07/24/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Technological developments have allowed advances in minimally invasive techniques for total mesorectal excision such as laparoscopy, robotics, and transanal surgery. There remains an ongoing debate about the safety, benefits, and appropriate clinical scenarios for which each technique is employed. The aim of this study was to provide a panel of expert opinion on the role of each surgical technique currently available in the management of rectal cancer using a modified Delphi method. METHODS Surveys were designed to explore the key patient- and tumor-related factors including clinical scenarios for determining a surgeon's choice of surgical technique. RESULTS Open surgery was favoured in obese patients with an extra-peritoneal tumor and a positive circumferential resection margin (CRM) or T4 tumor when a restorative resection was planned. Laparoscopy was favoured in non-obese males and females, in both intra- and extra-peritoneal tumors with a clear CRM. Robotic surgery was most commonly offered to obese patients when the CRM was clear and if an abdominoperineal resection was planned. Transanal total mesorectal excision (taTME) was preferred in male patients with a mid or low rectal cancer, particularly when obese. Transanal endoscopic microsurgery/transanal minimally invasive surgery local excision was only offered to frail patients with small, early stage tumors. CONCLUSIONS All surgical techniques for rectal cancer dissection have a role and may be considered appropriate. Some techniques have advantages over others in certain clinical situations, and the best outcomes may be achieved by considering all options before applying an individualised approach to each clinical situation.
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Affiliation(s)
- S W Bell
- Department of Colorectal Surgery, Monash University, Melbourne, VIC, Australia.
- Alfred Hospital, Monash University, Melbourne, VIC, Australia.
| | - A G Heriot
- Division of Cancer Research, University of Melbourne, Melbourne, VIC, Australia
- Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, VIC, Australia
| | - S K Warrier
- Department of Colorectal Surgery, Monash University, Melbourne, VIC, Australia
- Alfred Hospital, Monash University, Melbourne, VIC, Australia
- Division of Cancer Research, University of Melbourne, Melbourne, VIC, Australia
| | - C K Farmer
- Department of Colorectal Surgery, Monash University, Melbourne, VIC, Australia
- Alfred Hospital, Monash University, Melbourne, VIC, Australia
| | - A R L Stevenson
- Faculty of Medicine and Biomedical Sciences, University of Queensland, Brisbane, Australia
- Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - I Bissett
- Department of Surgery, University of Auckland, Auckland, 1010, New Zealand
| | - J C Kong
- Division of Cancer Research, University of Melbourne, Melbourne, VIC, Australia
- Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, VIC, Australia
| | - M Solomon
- Institute of Academic Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia
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84
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Hardon SF, van Kasteren RJ, Dankelman J, Bonjer HJ, Tuynman JB, Horeman T. The value of force and torque measurements in transanal total mesorectal excision (TaTME). Tech Coloproctol 2019; 23:843-852. [PMID: 31432333 PMCID: PMC6791959 DOI: 10.1007/s10151-019-02057-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 07/31/2019] [Indexed: 12/16/2022]
Abstract
Background Transanal total mesorectal excision (TaTME) is associated with a relatively long learning curve. Force, motion, and time parameters are increasingly used for objective assessment of skills to enhance laparoscopic training efficacy. The aim of this study was to identify relevant metrics for accurate skill assessment in more complex transanal purse-string suturing. Methods A box trainer was designed for TaTME and equipped with two custom made multi-DOF force/torque sensors. These sensors measured the applied forces in the axial direction of the instruments (Fz), instrument load orientation expressed in torque (Mx and My) on the entrance port, and the full tissue interaction force (Fft) at the intestine fixation point. In a construct validity study, novices for TaTME performed a purse-string suture to investigate which parameters can be used best to identify meaningful events during tissue manipulation and instrument handling. Results Significant differences exist between pre- and post-training assessment for the mean axial force at the entrance port Fz (p = 0.01), mean torque in the entrance port Mx (p = 0.03) and mean force on the intestine during suturing Fft (p = 0.05). Furthermore, force levels during suturing exceed safety threshold values, potentially leading to dangerous complications such as rupture of the rectum. Conclusions Forces and torque measured at the entrance port, and the tissue interaction force signatures provide detailed insight into instrument handling, instrument loading, and tissue handling during purse-string suturing in a TaTME training setup. This newly developed training setup for single-port laparoscopy that enables objective feedback has the potential to enhance surgical training in TaTME.
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Affiliation(s)
- S F Hardon
- Department of Surgery, Amsterdam UMC-VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands.
- Department of BioMechanical Engineering, Delft University of Technology, Delft, The Netherlands.
| | - R J van Kasteren
- Department of BioMechanical Engineering, Delft University of Technology, Delft, The Netherlands
| | - J Dankelman
- Department of BioMechanical Engineering, Delft University of Technology, Delft, The Netherlands
| | - H J Bonjer
- Department of Surgery, Amsterdam UMC-VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - J B Tuynman
- Department of Surgery, Amsterdam UMC-VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - T Horeman
- Department of BioMechanical Engineering, Delft University of Technology, Delft, The Netherlands
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Lawson EH, Melvin JC, Geltzeiler CB, Heise CP, Foley EF, King RS, Harms BA, Carchman EH. Advances in the management of rectal cancer. Curr Probl Surg 2019; 56:100648. [PMID: 31779779 DOI: 10.1016/j.cpsurg.2019.100648] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 07/01/2019] [Indexed: 01/05/2023]
Affiliation(s)
| | | | - Cristina B Geltzeiler
- University of Wisconsin-Madison, Madison, WI; University of Wisconsin-Madison, William S. Middleton Memorial Veterans Hospital, Madison, WI
| | | | | | - Ray S King
- University of Wisconsin-Madison, Madison, WI
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Comment on “Distal Resection Margin Status in Transanal Total Mesorectal Excision (TA-TME)”. Ann Surg 2019; 270:e34-e35. [DOI: 10.1097/sla.0000000000003069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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87
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Hu JM, Chu CH, Jiang JK, Lai YL, Huang IP, Cheng AYM, Yang SH, Chen CC. Robotic transanal total mesorectal excision assisted by laparoscopic transabdominal approach: A preliminary twenty-case series report. Asian J Surg 2019; 43:330-338. [PMID: 31320234 DOI: 10.1016/j.asjsur.2019.06.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 06/13/2019] [Accepted: 06/18/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Laparoscopy-assisted robotic transanal total mesorectal excision is a novel surgical technique for rectal cancer resection. Compared to prior DaVinci Si system case series, this case series is the first to report robotic taTME assisted by laparoscopy (r-taTME) in which the "transanal team" operates via the DaVinci Xi system. As a result, we aim to delineate and discuss preliminary findings from our robotic taTME experiences. METHODS A total of twenty patients (twelve males) who underwent robotic taTME assisted by laparoscopy (r-taTME) between January 2016 and November 2016 at a single institution were documented. Surgical outcomes, including complications, pathological outcomes, and short-term results, were then retrospectively analyzed. RESULTS All patients underwent r-taTME via a two-team approach. The "abdominal team" operated via a single port method (ileostomy site), while the "transanal team" operated via the DaVinci Xi system. The mean patient age was 56.7 ± 14.3 years (range 31-79), and the mean distance from tumor to anal verge was 6.0 ± 2.7 cm (range 2-10). The mean estimated intraoperative blood loss was 88 ± 107 ml (range 30-500), and circular stapling was utilized to restore continuity in 80% of study patients. The overall postoperative complication rate was 35%, and the mean distal margin length was 3.1 ± 1.3 cm. There were three patients who had a circumferential margin (CRM) involved by cancer cells (≤1 mm). CONCLUSION Our preliminary series report demonstrates that utilization of r-taTME assisted by laparoscopy is safe and feasible. Development of a novel transanal approach that allows single-port access alongside a multi-arm robotic system may increase the convenience and efficiency of future operation.
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Affiliation(s)
- Je-Ming Hu
- Division of Colorectal Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Chun-Ho Chu
- Department of Surgery, Koo Foundation, Sun Yat-Sen Cancer Center, Taipei, Taiwan; College of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Jeng-Kae Jiang
- College of Medicine, National Yang-Ming University, Taipei, Taiwan; Division of Colorectal Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yi-Ling Lai
- Department of Surgery, Koo Foundation, Sun Yat-Sen Cancer Center, Taipei, Taiwan
| | - I-Ping Huang
- Department of Surgery, Koo Foundation, Sun Yat-Sen Cancer Center, Taipei, Taiwan
| | - Andy Yi-Ming Cheng
- Department of Medicine, Division of Hospital Medicine, University of Pittsburgh Medical Center Shadyside Hospital, United States of America
| | - Shung-Haur Yang
- College of Medicine, National Yang-Ming University, Taipei, Taiwan; Division of Colorectal Surgery, Taipei Veterans General Hospital, Taipei, Taiwan; National Yang-Ming University Hospital, Yilan, Taiwan
| | - Chien-Chih Chen
- Department of Surgery, Koo Foundation, Sun Yat-Sen Cancer Center, Taipei, Taiwan; College of Medicine, National Yang-Ming University, Taipei, Taiwan.
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Sparreboom CL, Komen N, Rizopoulos D, van Westreenen HL, Doornebosch PG, Dekker JWT, Menon AG, Tuynman JB, Daams F, Lips D, van Grevenstein WMU, Karsten TM, Lange JF, D'Hoore A, Wolthuis AM. Transanal total mesorectal excision: how are we doing so far? Colorectal Dis 2019; 21:767-774. [PMID: 30844130 PMCID: PMC6850385 DOI: 10.1111/codi.14601] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 02/25/2019] [Indexed: 12/11/2022]
Abstract
AIM This subgroup analysis of a prospective multicentre cohort study aims to compare postoperative morbidity between transanal total mesorectal excision (TaTME) and laparoscopic total mesorectal excision (LaTME). METHOD The study was designed as a subgroup analysis of a prospective multicentre cohort study. Patients undergoing TaTME or LaTME for rectal cancer were selected. All patients were followed up until the first visit to the outpatient clinic after hospital discharge. Postoperative complications were classified according to the Clavien-Dindo classification and the comprehensive complication index (CCI). Propensity score matching was performed. RESULTS In total, 220 patients were selected from the overall prospective multicentre cohort study. After propensity score matching, 48 patients from each group were compared. The median tumour height for TaTME was 10.0 cm (6.0-10.8) and for LaTME was 9.5 cm (7.0-12.0) (P = 0.459). The duration of surgery and anaesthesia were both significantly longer for TaTME (221 vs 180 min, P < 0.001, and 264 vs 217 min, P < 0.001). TaTME was not converted to laparotomy whilst surgery in five patients undergoing LaTME was converted to laparotomy (0.0% vs 10.4%, P = 0.056). No statistically significant differences were observed for Clavien-Dindo classification, CCI, readmissions, reoperations and mortality. CONCLUSION The study showed that TaTME is a safe and feasible approach for rectal cancer resection. This new technique obtained similar postoperative morbidity to LaTME.
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Affiliation(s)
- C. L. Sparreboom
- Department of SurgeryErasmus University Medical CenterRotterdamThe Netherlands
| | - N. Komen
- Department of SurgeryUniversity Hospital AntwerpEdegemBelgium
| | - D. Rizopoulos
- Department of BiostatisticsErasmus University Medical CenterRotterdamThe Netherlands
| | | | - P. G. Doornebosch
- Department of SurgeryIJsselland ZiekenhuisCapelle aan den IJsselThe Netherlands
| | - J. W. T. Dekker
- Department of SurgeryReinier de Graaf GasthuisDelftThe Netherlands
| | - A. G. Menon
- Department of SurgeryIJsselland ZiekenhuisCapelle aan den IJsselThe Netherlands
| | - J. B. Tuynman
- Department of SurgeryVU University Medical CenterAmsterdamThe Netherlands
| | - F. Daams
- Department of SurgeryVU University Medical CenterAmsterdamThe Netherlands
| | - D. Lips
- Department of SurgeryJeroen Bosch ZiekenhuisHertogenboschThe Netherlands
| | | | - T. M. Karsten
- Department of SurgeryOnze Lieve Vrouwe GasthuisAmsterdamThe Netherlands
| | - J. F. Lange
- Department of SurgeryErasmus University Medical CenterRotterdamThe Netherlands
| | - A. D'Hoore
- Departmenf of Abdominal SurgeryUniversity Hospital LeuvenLeuvenBelgium
| | - A. M. Wolthuis
- Departmenf of Abdominal SurgeryUniversity Hospital LeuvenLeuvenBelgium
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Gustafsson UO, Scott MJ, Hubner M, Nygren J, Demartines N, Francis N, Rockall TA, Young-Fadok TM, Hill AG, Soop M, de Boer HD, Urman RD, Chang GJ, Fichera A, Kessler H, Grass F, Whang EE, Fawcett WJ, Carli F, Lobo DN, Rollins KE, Balfour A, Baldini G, Riedel B, Ljungqvist O. Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS ®) Society Recommendations: 2018. World J Surg 2019; 43:659-695. [PMID: 30426190 DOI: 10.1007/s00268-018-4844-y] [Citation(s) in RCA: 1044] [Impact Index Per Article: 208.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol. METHODS A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. RESULTS All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly. CONCLUSIONS The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.
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Affiliation(s)
- U O Gustafsson
- Department of Surgery, Danderyd Hospital and Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
| | - M J Scott
- Department of Anesthesia, Virginia Commonwealth University Hospital, Richmond, VA, USA
- Department of Anesthesiology, University of Pennsylvania, Philadelphia, USA
| | - M Hubner
- Department of Visceral Surgery, CHUV, Lausanne, Switzerland
| | - J Nygren
- Department of Surgery, Ersta Hospital and Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - N Demartines
- Department of Visceral Surgery, CHUV, Lausanne, Switzerland
| | - N Francis
- Colorectal Unit, Yeovil District Hospital, Higher Kingston, Yeovil, BA21 4AT, UK
- University of Bath, Wessex House Bath, BA2 7JU, UK
| | - T A Rockall
- Department of Surgery, Royal Surrey County Hospital NHS Trust, and Minimal Access Therapy Training Unit (MATTU), Guildford, UK
| | - T M Young-Fadok
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - A G Hill
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland Middlemore Hospital, Auckland, New Zealand
| | - M Soop
- Irving National Intestinal Failure Unit, The University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - H D de Boer
- Department of Anesthesiology, Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital, Groningen, The Netherlands
| | - R D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - G J Chang
- Department of Surgical Oncology and Department of Health Services Research, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - A Fichera
- Division of Gastrointestinal Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - H Kessler
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Ohio, USA
| | - F Grass
- Department of Visceral Surgery, CHUV, Lausanne, Switzerland
| | - E E Whang
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - W J Fawcett
- Department of Anaesthesia, Royal Surrey County Hospital NHS Foundation Trust and University of Surrey, Guildford, UK
| | - F Carli
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, QC, Canada
| | - D N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - K E Rollins
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - A Balfour
- Department of Colorectal Surgery, Surgical Services, Western General Hospital, NHS Lothian, Edinburgh, UK
| | - G Baldini
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, QC, Canada
| | - B Riedel
- Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Australia
| | - O Ljungqvist
- Department of Surgery, Örebro University and University Hospital, Örebro & Institute of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Vignali A, Elmore U, Milone M, Rosati R. Transanal total mesorectal excision (TaTME): current status and future perspectives. Updates Surg 2019; 71:29-37. [PMID: 30734896 DOI: 10.1007/s13304-019-00630-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 02/02/2019] [Indexed: 12/14/2022]
Abstract
Total mesorectal excision (TME) is the gold standard surgical treatment for mid- and low rectal cancer; however, it is associated with specific technical hurdles. Transanal TME (TaTME) is a new procedure developed to overcome these difficulties, through an enhanced visualization of the dissection plane. This potentially could result in a more accurate distal dissection with a lower rate of positive circumferential resection margins, increasing the rate of sphincter-saving procedures. The indications for TaTME are currently expanding, despite not being yet standardized, and structured training programs are ongoing to help overcome the steep learning curve related to the technique. The procedure is feasible and safe with similar intraoperative complications and readmission rates when compared with conventional open or laparoscopic TME. Favorable short-term oncologic results have been reported: in particular, TaTME is associated with mesorectal specimen of a better quality and a longer distal resection margin that is established at the beginning of the procedure under direct view. Robotics, when available, will probably overcome the steep learning curve related to the complexity of TaTME. Long-term follow-up and ongoing RCT trials data are awaited regarding functional results, local recurrence and survival, and to facilitate the comparison with standard laparoscopic or robotic rectal resections. The present review is focused on critically analyzing the theoretical benefits and risks of the procedure, its indications, short- and long-term results and future direction in the application of TaTME.
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Affiliation(s)
- Andrea Vignali
- Department of Surgery, San Raffaele Hospital and San Raffaele Vita-Salute University, Via Olgettina 60, 20123, Milan, Italy.
| | - Ugo Elmore
- Department of Surgery, San Raffaele Hospital and San Raffaele Vita-Salute University, Via Olgettina 60, 20123, Milan, Italy
| | - Marco Milone
- Department of Surgical Specialties, Nephrology University "Federico II" of Naples, Naples, Italy
| | - Riccardo Rosati
- Department of Surgery, San Raffaele Hospital and San Raffaele Vita-Salute University, Via Olgettina 60, 20123, Milan, Italy
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Transanal versus laparoscopic total mesorectal excision for mid and low rectal cancer: a meta-analysis of short-term outcomes. Wideochir Inne Tech Maloinwazyjne 2019; 14:353-365. [PMID: 31534564 PMCID: PMC6748052 DOI: 10.5114/wiitm.2019.82798] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 01/12/2019] [Indexed: 02/07/2023] Open
Abstract
Introduction The benefit of transanal total mesorectal excision (TaTME) for mid and low rectal cancer is conflicting. Aim To assess and compare the short-term outcomes of TaTME with conventional laparoscopic total mesorectal excision (LaTME) for middle and low rectal cancer. Material and methods We searched PubMed, Embase and Cochrane Library databases for studies addressing TaTME versus conventional LaTME for rectal cancer between 2008 and December 2018. Randomized controlled trials (RCTs) and retrospective studies which compared TaTME with LaTME were included. Results Twelve retrospective case-control studies were identified, including a total of 899 patients. We did not find significant differences in overall intraoperative complications, blood loss, conversion rate, operative time, overall postoperative complication, anastomotic leakage, ileus, or urinary morbidity. Also no significant differences in oncological outcomes including circumferential resection margin (CRM), positive CRM, distal margin distance (DRM), positive DRM, quality of mesorectum, number of harvested lymph nodes, temporary stoma or local recurrence were found. Although the TaTME group had better postoperative outcomes (readmission, reoperation, length of hospital stay) on average, the difference did not reach statistical significance. Conclusions Transanal total mesorectal excision offers a safe and feasible alternative to LaTME although the clinicopathological features were not superior to LaTME in this study. Currently, with the lack of evidence on benefits of TaTME, further evaluation of TaTME requires large randomized control trials to be conducted.
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Gys B, Fransis K, Hubens G, Van den Broeck S, Op de Beeck B, Komen N. Simultaneous laparoscopic proctocolectomy (TaTME) and robot-assisted radical prostatectomy for synchronous rectal and prostate cancer. Acta Chir Belg 2019; 119:47-51. [PMID: 29198168 DOI: 10.1080/00015458.2017.1411550] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE We would like to present a patient with a history of ulcerative colitis suffering from a synchronous rectal and prostate cancer treated with a laparoscopic total proctocolectomy (with TaTME) and Retzius sparing RARP simultaneously. METHODS Retzius sparing RARP with bilateral lymph node harvesting was performed first. Afterwards, TaTME was commenced with the placement of a Lonestar® retractor and GelPort®. Anterior dissection was troubled unexpectedly by outspoken fibrosis. For that reason, it was completed laparoscopically. We then continued with the laparoscopic total proctocolectomy. Last, a transanal circular stapled ileoanal anastomosis was created and a derivating ileostomy was installed. RESULTS Postoperative proctoscopy showed a patent ileoanal anastomosis. After removal of the Foley catheter on day 21, the patient was immediately continent. Prostate specimen revealed a pT2cN1M0 transmural invasive adenocarcinoma with a Gleason score of 7 (3 + 4). Pathology analysis of the rectum revealed a stage IIIc transmural invasive moderately differentiated rectal adenocarcinoma (pT3N2bM0) with free margins. He was referred for adjuvant chemotherapy. CONCLUSIONS In this case, the combination of TaTME and Retzius sparing RARP for synchronous rectal and prostate cancer was feasible and safe. We suggest performing the anterior TaTME dissection last, due to disturbing blood flow into the operating field after prostatectomy.
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Affiliation(s)
- Ben Gys
- Dienst Abdominale, Kinder-en Reconstructieve Heelkunde, UZA, Antwerpen, Belgium
| | | | - Guy Hubens
- Dienst Abdominale, Kinder-en Reconstructieve Heelkunde, UZA, Antwerpen, Belgium
| | | | | | - Niels Komen
- Dienst Abdominale, Kinder-en Reconstructieve Heelkunde, UZA, Antwerpen, Belgium
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Caycedo-Marulanda A, Jiang HY, Kohtakangas EL. Outcomes of a Single Surgeon-Based Transanal-Total Mesorectal Excision (TATME) for Rectal Cancer. J Gastrointest Cancer 2019; 49:455-462. [PMID: 28702861 DOI: 10.1007/s12029-017-9989-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Several studies have shown the transanal total mesorectal excision (TATME) is emerging as a safe and effective technique for proctectomy. The majority of these studies to date, however, is based on procedures done in centers with teams of two surgeons working simultaneously. Few were performed by single-surgeon teams with sizeable case load. The objective of our study was to identify the feasibility and safety of a single-surgeon TATME. METHODS Chart review of prospectively collected data on 27 patients who underwent TATME at our institution from June 2015 to September 2016 were included in this study. Indications for TATME included mid and low rectal cancers. Only patients who underwent surgery for neoplastic lesions were included in the study. Outcomes assessed included mesorectal integrity, margin status, operative time, complications, morbidity, LOS, and 30-day readmission. RESULTS A total of 27 cases were available for inclusion. A single surgeon performed all procedures. The average BMI was 27.2 ± 1.3 kg/m2. The average tumor distance from anal verge was 6.8 ± 0.6 cm. The median operative time was 283 min. No intraoperative complications, including injuries and conversions, occurred. Circumferential resection margin (CRM) and distal resection margin (DRM) were R0 in 96 and 100% of patients, respectively. Mesorectal integrity was "Complete" in 67% and "Near complete" in 33% of patients. There were no incomplete specimens. The total lymph node (LN) harvest was 26 ± 2. The average LOS was 4 days for 75% of all patients. There were no mortalities. The overall morbidity was 33% (9/27). There were 4/27 anastomotic leaks, one required a laparoscopic ileostomy, one had laparoscopic drainage of an abscess, and the other two were endoscopically washed and trans-rectal drains inserted. CONCLUSION TATME performed by a one-surgeon team is oncologically adequate, and it is safe and feasible. Morbidities are comparable with existing literature data from two-surgeon teams. In addition, resection margins, mesorectal integrity, and LN harvests are also comparable or superior to some of the existing studies.
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Affiliation(s)
- Antonio Caycedo-Marulanda
- Department of Surgery, Health Sciences North, Sudbury, ON, Canada.
- Faculty of Medicine, Northern Ontario School of Medicine, 410-65 Larch Street, Sudbury, ON, P3E1B8, Canada.
| | - Henry Y Jiang
- Department of Surgery, Health Sciences North, Sudbury, ON, Canada
- Faculty of Medicine, Northern Ontario School of Medicine, 410-65 Larch Street, Sudbury, ON, P3E1B8, Canada
| | - Erica L Kohtakangas
- Department of Surgery, Health Sciences North, Sudbury, ON, Canada
- Faculty of Medicine, Northern Ontario School of Medicine, 410-65 Larch Street, Sudbury, ON, P3E1B8, Canada
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The current state of the transanal approach to the ileal pouch-anal anastomosis. Surg Endosc 2019; 33:1368-1375. [PMID: 30675660 DOI: 10.1007/s00464-019-06674-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 01/17/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND The transanal approach to pelvic dissection has gained considerable traction and utilization continues to expand, fueled by the transanal total mesorectal excision (TaTME) for rectal cancer. The same principles and benefits of transanal pelvic dissection may apply to the transanal restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA)-the TaPouch procedure. Our goal was to review the literature to date on the development and current state of the TaPouch. MATERIALS AND METHODS We performed a PubMed database search for original articles on transanal pelvic dissections, IPAA, and the TaPouch procedure, with a manual search from relevant citations in the reference list. The main outcomes were the technical aspects of the TaPouch, clinical and functional outcomes, and potential advantages, drawbacks, and future direction for the procedure. RESULTS The conduct of the procedure has been defined, with the safety and feasibility demonstrated in small series. The reported rates of conversion and anastomotic leakage are low. There are no randomized trials or large-scale comparative studies available for comparative effectiveness compared to the traditional IPAA. CONCLUSIONS The transanal approach to ileal pouch-anal anastomosis is an exciting adaption of the transanal total mesorectal excision for refining the technical steps of a complex operation. Additional experience is needed for comparative outcomes and defining the ideal training and implementation pathways.
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CO2 embolism can complicate transanal total mesorectal excision. Tech Coloproctol 2018; 22:881-885. [DOI: 10.1007/s10151-018-1897-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 11/22/2018] [Indexed: 01/11/2023]
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Lei P, Ruan Y, Yang X, Fang J, Chen T. Trans-anal or trans-abdominal total mesorectal excision? A systematic review and meta-analysis of recent comparative studies on perioperative outcomes and pathological result. Int J Surg 2018; 60:113-119. [DOI: 10.1016/j.ijsu.2018.11.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 10/18/2018] [Accepted: 11/01/2018] [Indexed: 02/07/2023]
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Comparison of Short-Term Clinical and Pathological Outcomes after Transanal versus Laparoscopic Total Mesorectal Excision for Low Anterior Rectal Resection Due to Rectal Cancer: A Systematic Review with Meta-Analysis. J Clin Med 2018; 7:jcm7110448. [PMID: 30463197 PMCID: PMC6262322 DOI: 10.3390/jcm7110448] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 11/14/2018] [Accepted: 11/15/2018] [Indexed: 12/18/2022] Open
Abstract
Background: Transanal total mesorectal excision (TaTME) is a new technique that is designed to overcome the limits of the open and laparoscopic approach for rectal resections. Objective: This study is designed to compare TaTME with standard laparoscopic TME (LaTME). Methods: We searched Medline, Embase, and Scopus databases covering a up to October 2018. Inclusion criteria for study enrolment: (1) study comparing laparoscopic resection of rectal cancer vs. TaTME for rectal malignancy, (2) reporting of overall morbidity, operative time, or major complications. Results: Eleven non-randomized studies were eligible with a total of 778 patients. We found statistical significant differences in regard to major complications in favour of TaTME (RR = 0.55; 95% CI 0.31–0.97; p = 0.04). We did not found significant differences regarding overall complications intraoperative adverse effects, operative time, anastomotic leakage, intra-abdominal abscess occurrence, Surgical Site Infection, reoperations, Length of stay, completeness of mesorectal excision, R0 resection rate, number of harvested lymph nodes, circumferential resection margin, and distal resection margin. Conclusions: This meta-analysis shows benefits of TaTME technique regarding major postoperative complications. Regarding clinicopathological features transanal approach is not superior to LaTME. Currently, the quality of the evidence on benefits of TaTME is low due to lack of randomized controlled trials, which needs to be taken into consideration in further evaluation of the technique. Further evaluation of TaTME require conducting large randomized control trials.
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Mizrahi I, de Lacy FB, Abu-Gazala M, Fernandez LM, Otero A, Sands DR, Lacy AM, Wexner SD. Transanal total mesorectal excision for rectal cancer with indocyanine green fluorescence angiography. Tech Coloproctol 2018; 22:785-791. [PMID: 30430309 DOI: 10.1007/s10151-018-1869-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Accepted: 10/15/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the impact of fluorescence angiography (FA) on any change in proximal resection margin and/or anastomotic leak (AL) following transanal total mesorectal excision (TaTME) for rectal cancer (RC). METHODS This retrospective cohort study was conducted at two centers by three senior surgeons. Both institutions' prospectively maintained Institutional Review Board-approved databases were retrospectively queried for all consecutive patients between July 2015 and May 2017 who had laparoscopic hybrid trans-abdominal total mesorectal excision (TME) and TaTME for RC with colorectal or coloanal anastomosis < 10 cm from the anal verge. All patients had intraoperative FA to assess colonic perfusion of the planned proximal resection margin before bowel transection and after construction of the anastomosis. Primary outcomes measured any changes in proximal resection margins and AL rates. RESULTS Fifty-four patients (31 males; mean age 63 ± 12 years) were included; 30 (55%) of whom received neoadjuvant chemoradiation. The average anastomotic height was 3.6 cm from the anal verge and 8 (14.5%) patients required intersphincteric dissection. Forty-six patients (85%) had loop ileostomy. FA led to a change in the proximal resection margin in 10 patients (18.5%), one of whom had AL on postoperative day 3 requiring diagnostic laparoscopy and loop ileostomy. A second patient, without a change in the proximal resection margin, also had an AL. The overall AL rate was 3.7%. CONCLUSIONS FA changed the planned proximal resection margin in 18.5% of patients, possibly accounting for the relatively low AL rate. FA is imperfect, and subjective but does have the potential to improve outcomes.
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Affiliation(s)
- I Mizrahi
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - F B de Lacy
- Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clinic, IDIBAPS, Barcelona, Spain
| | - M Abu-Gazala
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - L M Fernandez
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - A Otero
- Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clinic, IDIBAPS, Barcelona, Spain
| | - D R Sands
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - A M Lacy
- Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clinic, IDIBAPS, Barcelona, Spain
| | - S D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA.
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Transanal total mesorectal excision (TaTME): single-centre early experience in a selected population. Updates Surg 2018; 71:157-163. [PMID: 30406934 DOI: 10.1007/s13304-018-0602-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Accepted: 10/30/2018] [Indexed: 01/13/2023]
Abstract
Total mesorectal excision (TME) represents the key principle in the surgical treatment of rectal cancer. Transanal mesorectal excision was introduced as a complement to conventional surgery to overcome its technical difficulties. The aim of this study was to evaluate the early surgical results following the introduction of this novel technique at our Unit. Between January and May 2016, 12 patients diagnosed with mid-low rectal adenocarcinoma were enrolled into this study and evaluated with regards demography, histopathology, peri-operative data and postoperative complications. The tumor was located in the middle rectum in 6 patients (50%), in the lower rectum in 6 patients (50%). Mean operative time was 356.5 ± 76.2 min (range 240-494). Eleven out 12 patients (91.6%) had less than 200 mL of intraoperative blood loss. Mean hospital stay was 10.9 ± 4.6 days (range 5-19). No mortality was recorded. Intraoperative complications were recorded in 1, while early post-operative complications (< 30 days) were observed in 5 patients (41.6%). Histopathology showed in all cases an intact mesorectum. Mean number of lymphnodes harvested was 13.6 ± 6.6 (range 4-29). Distal and circumferential margin was, respectively, of 20.8 ± 14.2 mm (range 2-45 mm) and 16.1 ± 7.6 mm (range 3-30 mm). The comparative analysis showed significant differences concerning mean operative time (p = 0.0473) and estimated blood loss (p = 0.0367). This study confirms this technique is safe and feasible, but more evidence to support its use over conventional laparoscopic surgery is needed.
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