Clinical results of transanal endoscopic microsurgery

Treatment Options for Distal Rectal Cancer in the Era of Organ Preservation

OPINION STATEMENT

The introduction of total mesorectal excision into the radical surgery of rectal cancer has significantly improved the oncological outcome with longer survival and lower local recurrence. Traditional treatment modalities of distal rectal cancer, relying on radical surgery, while effective, take their own set of risks, including surgical complications, potential damage to the anus, and surrounding structure owing to the pursuit of thorough resection. The progress of operating methods as well as the integration of systemic therapies and radiotherapy into the peri-operative period, particularly the exciting clinical complete response of patients after neoadjuvant treatment, have paved the way for organ preservation strategy. The non-inferiority oncological outcome of "watch and wait" compared with radical surgery underscores the potential of organ preservation not only to control local recurrence but also to reduce the need for treatments followed by structure destruction, hopefully improving the long-term quality of life. Radical radiotherapy provides another treatment option for patients unwilling or unable to undergo surgery. Organ preservation points out the direction of treatment for distal rectal cancer, while additional researches are needed to answer remaining questions about its optimal use.

Brazilian society of surgical oncology: Guidelines for the surgical treatment of mid-low rectal cancer

BACKGROUND

Colorectal cancer (CRC) is the third leading cause of cancer in North America, Western Europe, and Brazil, and represents an important public health problem. It is estimated that approximately 30% of all the CRC cases correspond to tumors located in the rectum, requiring complex multidisciplinary treatment. In an effort to provide surgeons who treat rectal cancer with the most current information based on the best evidence in the literature, the Brazilian Society of Surgical Oncology (SBCO) has produced the present guidelines for rectal cancer treatment that is focused on the main topics related to daily clinical practice.

OBJECTIVES

The SBCO developed the present guidelines to provide recommendations on the main topics related to the treatment of mid-low rectal cancer based on current scientific evidence.

METHODS

Between May and June 2021, 11 experts in CRC surgery met to develop the guidelines for the treatment of mid-low rectal cancer. A total of 22 relevant topics were disseminated among the participants. The methodological quality of a final list with 221 sources was evaluated, all the evidence was examined and revised, and the treatment guideline was formulated by the 11-expert committee. To reach a final consensus, all the topics were reviewed via a videoconference meeting that was attended by all 11 of the experts.

RESULTS

The prepared guidelines contained 22 topics considered to be highly relevant in the treatment of mid-low rectal cancer, covering subjects related to the tests required for staging, surgical technique-related aspects, recommended measures to reduce surgical complications, neoadjuvant strategies, and nonoperative treatments. In addition, a checklist was proposed to summarize the important information and offer an updated tool to assist surgeons who treat rectal cancer provide the best care to their patients.

CONCLUSION

These guidelines summarize concisely the recommendations based on the most current scientific evidence on the most relevant aspects of the treatment of mid-low rectal cancer and are a practical guide that can help surgeons who treat rectal cancer make the best therapeutic decision.

Current Challenges for Education and Training in Transanal Surgery

Transanal endoscopic microsurgery (TEM) is a technique that was introduced in the 1980s for improved exposure to upper rectal polyps. This technique, though initially difficult to master due to new skill acquisition for surgeons, has spared many patients proctectomy. There are many benign indications for transanal endoscopic surgery which has led to in vivo operating room training with fewer undesirable effects to the patient. With the explosion of laparoscopic technology this transanal technique is no longer limited to intraluminal pathology, but is now being used to remove the entire rectum. In transanal total mesorectal excision (taTME), benign indications are less common, translating to potentially more severe oncologic patient consequences during the early phase of adoption. For this reason, strict training criteria consensus guidelines have been developed by the experts in taTME. The current consensus statements agree that training surgeons should have performed a minimum of 10 laparoscopic TME procedures and should have some experience with transanal surgery. Surgeons need to attend a formal training course and should start clinically on benign or early malignant pathology without threated circumferential resection margins. Surgeons also need to have their first cases proctored until deemed proficient by the proctor and monitor their morbidity, oncologic, and functional outcomes prospectively.

Robotic transanal minimally invasive surgery: a case series

INTRODUCTION

This study describes the experience with robot-assisted transanal minimally invasive surgery (rTAMIS) at a single institution. TAMIS has become a popular minimally invasive technique for local excision of well-selected rectal lesions. rTAMIS has been proposed as another option as it improves the ergonomics of conventional laparoscopic techniques.

METHODS

Retrospective case series of patients with rectal lesions who underwent rTAMIS. Patient demographics, final pathology, surgical and admission details, and clinical outcomes were recorded. Successful procedures were defined as having negative margins on final pathology.

RESULTS

A total of 16 patients underwent rTAMIS by a single surgeon between April 2018 and December 2019. Mean age of patients was 63 years. Final pathologies were negative for tumor (n = 4), tubulovillous adenoma (n = 4), tubulovillous adenoma with high-grade dysplasia (n = 4), and invasive rectal adenocarcinoma (n = 4). 43% were located in the middle rectum and 56% were located in the distal rectum. Mean maximum diameter was 4.1 cm (IQR 2-3.1 cm). Negative margins were seen in 100% of the excision cases, and 100% were intact. Mean operative time was 87 min (IQR 54.8-97.3 min), and median length of stay was 0 days (IQR 0-1 days). Postoperative complications included incontinence (n = 1) and abscess formation (n = 2). rTAMIS provided curative treatment for 12/16 patients, and the remaining 4 patients received the appropriate standard of care for their respective pathologies.

CONCLUSIONS

Robot-assisted TAMIS is a safe alternative to laparoscopic TAMIS for resection of appropriate rectal polyps and early rectal cancers. rTAMIS may provide a modality for resecting larger or more proximal rectal lesions due to the wristed instruments and superior visualization with the robotic camera. Future studies should focus on comparing outcomes between robotic and laparoscopic TAMIS, and whether rTAMIS allows for the removal of larger, more complex lesions, which may save patients from a more morbid radical proctectomy.

How can we utilize local excision to help, not harm, geriatric patients with rectal cancer?

A majority of the morbidity and mortality burden of rectal cancer is distributed within the geriatric age group. Current surgical and medical treatment modalities pose significant challenges in treating complications specifically in the already pre-disposed senior population with baseline dysfunction. This chapter reviews the work-up, management, current data and oncologic outcomes of treating rectal cancer in the senior adult.

Transanal endoscopic microsurgery for rectal villous tumours: Can we rely solely on preoperative biopsies and the surgeon’s experience?

Background

Transanal endoscopic microsurgery has become the standard of treatment for rectal villous adenomas. However, the role of preoperative imaging for these lesions is not clear. The aim of this study was to compare the value of preoperative imaging and surgeon clinical staging in the preoperative evaluation of patients with rectal villous adenomas having transanal endoscopic microsurgery resection.

Methods

We conducted a single-centre comparative retrospective cohort study of patients who underwent transanal endoscopic microsurgery surgery for rectal villous adenomas from 2011 to 2013. The intervention was preoperative imaging versus surgeon clinical staging. The primary outcome was the accuracy of clinical staging by preoperative imaging and surgeon clinical staging according to the histopathologic staging.

Results

A total of 146 patients underwent transanal endoscopic microsurgery surgery for rectal villous adenomas. One hundred and twelve (76.7%) of those patients had no preoperative imaging while 34 patients (23.3%) had either endorectal ultrasound (22 patients) or magnetic resonance imaging (12 patients). Surgeon staging was accurate in 89.3% of cases whereas staging by endorectal ultrasound was accurate in 40.9% cases and magnetic resonance imaging was accurate in 0% of cases. In the imaging group, inaccurate staging would have led to unnecessary radical surgery in 44.0% of patients.

Conclusion

This study was subject to selection bias because of its retrospective nature and the limited number of patients with imaging. Patients with rectal villous tumours without invasive carcinoma on biopsies and without malignant characteristics on appearance in the judgment of an experienced colorectal surgeon might not benefit from preoperative imaging before undergoing transanal endoscopic microsurgery procedures.

Transanal Surgery: A History of taTME Ancestry

Transanal total mesorectal excision (taTME) is the culmination of major developments in rectal cancer management and minimally invasive surgery. This surgical breakthrough holds great promise and excitement for the care of the rectal cancer patient. We would be remiss in discussing taTME to not acknowledge the role of transanal abdominal transanal proctosigmoidectomy, transanal endoluminal microsurgery, laparoscopy, and natural orifice transluminal endoscopic surgery that got us to this modern day explosion of the taTME approach. In this article, we detail and explain the convergence of these disparate experiences, how they culminated in the development of the taTME, and explore future directions in this field.

Transcolonic Perirectal NOTES Access (PNA): A feasibility study with survival in swine model

Transrectal access still has some unsolved issues such as spatial orientation, infection, access and site closure. This study presents a simple technique to perform transcolonic access with survival in a swine model series. A new technique for NOTES perirectal access to perform retroperitoneoscopy, peritoneoscopy, liver and lymphnode biopsies was performed in 6 pigs, using Totally NOTES technique. The specimens were extracted transanally. The flexible endoscope was inserted through a posterior transmural incision and the retrorectal space. Cultures of bacteria were documented for the retroperitoneal space and intra abdominal cavity after 14 days. Rectal site was closed using non-absorbable sutures. There was no bowel cleansing, nor preoperative fasting. The procedures were performed in 6 pigs through transcolonic natural orifice access using available endoscopic flexible instruments. All animals survived 14 days without complications, and cultures were negative. Histopathologic examination of the rectal closure site showed adequate healing of suture line and no micro abscesses. The results of feasibility and safety of experimental Transcolonic NOTES potentially brings new frontiers and future wider applications for minimally invasive surgery. The treatment of colorectal, abdominal and retroperitoneal diseases through a flexible Perirectal NOTES Access (PNA) is a promising new approach.

A case of local recurrence of T1 rectal cancer 10 years after transanal excision

We report a case of a patient with T1 rectal cancer, which recurred locally after 10 years from the primary operation. A 78-year-old woman was diagnosed with rectal cancer. Transanal excision (TAE) was performed in December 2006. The pathological findings revealed stage I rectal cancer [tub2>muc, pSM (2,510 µm), ly0, v0, pHM0, pVM0]. Because she did not opt for additional treatment, she received follow-up examination. After approximately 10 years from the primary operation, she presented to her physician, complaining of melena, and she was referred to our hospital again in November 2016. She was diagnosed with recurrent rectal cancer. Laparoscopic abdominoperineal resection was performed in December 2016. Pathological findings revealed stage IIIB rectal cancer (tub2>muc, pA, pN1). The reported postoperative local recurrence rate for T1 rectal cancer after TAE is high, but local recurrence after years from the primary operation is rare. In high-risk cases, local recurrence may be observed even after 10 years from the primary operation. Long-term and close postoperative follow-up is important to detect local recurrence early.

Transanal Minimally Invasive Surgery

Transanal endoscopic surgery (TES) techniques encompass a variety of approaches, including transanal endoscopic microsurgery and transanal minimally invasive surgery. These allow a surgeon to perform local excision of rectal lesions with minimal morbidity and the potential to spare the need for proctectomy. As understanding of the long-term outcomes from these procedures has evolved, so have the indications for TES. In this study, we review the development of TES, its early results, and the evolution of new surgical techniques. In addition, we evaluate the most recent research on indications and outcomes in rectal cancer.

Transanal TATA/TME: a case-matched study of taTME versus laparoscopic TME surgery for rectal cancer

BACKGROUND

Natural orifice translumenal endoscopic surgery (NOTES) has always made more sense in the colorectal field where the target organ for entry houses the pathology. To address the question whether an adequate total mesorectal excision (TME) for rectal cancer can be performed from a transanal bottoms-up approach, we performed a case-matched study.

METHODS

Starting in 2009, transanal TME (taTME) surgery was selectively used for rectal cancer after neoadjuvant therapy and prospectively entered into a database. Between March 2012 and February 2014, 17 consecutive taTME rectal cancer patients were identified and case-matched to multiport laparoscopic TME (MP TME) based on age, body mass index, uT stage, radiation dose, level in the rectum, and procedure. Perioperative outcomes, morbidity, mortality, local recurrence, completeness of TME, and radial and distal margins were analyzed. Statistically significant differences were identified using Student's t test.

RESULTS

There were 12 transanal abdominal transanal (TATA)/5 abdominoperineal resection procedures in each group. Data regarding overall/taTME/MP TME are as follows: % positive-circumferential margin: 2.9/0/5.9 % (p = 0.32). Distal margin: 0/0/0 %. Complete or near-complete TME: 97.1/100/94.1 % (p = 0.32). Incomplete TME 2.9/0/5.9 % (p = 0.32). Local recurrence: 2.9/5.9/0 % (p = 0.32). There were no perioperative mortalities. Morbidity in each group: 26.4/23.5/29.4 % (p = 0.79). There were no differences in perioperative or postoperative outcomes except days to clear liquids (1/2 days, p = 0.03) and largest incision length (1.3/2.6 cm, p = 0.05).

CONCLUSIONS

We demonstrated no differences in perioperative/postoperative outcomes or pathologic TME outcomes of transanal or bottoms-up TME compared to standard laparoscopic TME. TaTME is a promising progressive approach to NOTES and deserves additional evaluation.

Multicentre study of short-course radiotherapy and transanal endoscopic microsurgery for early rectal cancer

Background

Organ-preserving treatment for early-stage rectal cancer may avoid the substantial perioperative morbidity and functional sequelae associated with total mesorectal excision (TME). The initial results of an organ-preserving approach using preoperative short-course radiotherapy (SCRT) and transanal endoscopic microsurgery (TEMS) are presented.

Methods

Patients with cT1–2N0 rectal cancers staged using high-quality MRI and endorectal ultrasonography received SCRT, with TEMS 8–10 weeks later, at four regional referral centres between 2007 and 2013. Patients were generally considered high risk for TME surgery (a small number refused TME).

Results

Following SCRT and TEMS, 60 (97 per cent) of 62 patients had an R0 resection. Histopathological staging identified 20 ypT0 tumours, 23 ypT1, 18 ypT2 and one ypT3. Preoperative uT category was significantly associated with a complete pathological response, which was achieved in 13 of 27 patients with uT0/uT1 disease and in five of 29 with uT2 (P = 0·010). Acute complications affected 19 patients, the majority following TEMS. No fistulas occurred and no stomas were formed. Surveillance detected four intraluminal local recurrences at a median follow-up of 13 months, all in patients with tumours staged as ypT2. Salvage TME achieved R0 resection in three patients and a stent was placed in one patient owing to co-morbidities.

Conclusion

SCRT with TEMS was effective in the majority of patients considered high risk for (or who refused) TME surgery.

Endoscopic submucosal dissection versus local excision for early rectal cancer: a systematic review and meta-analysis

Endoscopic submucosal dissection (ESD) and local excision (LE) are minimally invasive procedures that can be used to treat early rectal cancer. There are no current guidelines or consensus on the optimal treatment strategy for these lesions. A systematic review was conducted to compare the efficacy and safety of ESD and LE. A meta-analysis was conducted following all aspects of the Cochrane Handbook for systematic reviews and preferred reporting items for systematic reviews and meta-analysis (PRISMA) statement. To perform the statistical analysis, the odds ratio (OR) was used for categorical variables and the weighted mean difference (WMD) for continuous variables. Four studies, involving a total of 307 patients, were identified. The length of hospital stay was longer in the group of patients undergoing LE [weighted mean difference (WMD) -1.94; 95% CI -2.85 to -1.02; p < 0.0001]. The combined results of the individual studies showed no significant differences as regards en-bloc resection rate (OR 0.82; 95% CI 0.25-2.70; p = 0.74), R0 resection rate (OR 1.53; 95% CI 0.62-3.73; p = 0.35), overall complication rate (OR 0.67; 95% CI 0.26-1.69; p = 0.40), and tumor size (WMD 0.57; 95% CI -3.64 to 4.78; p = 0.79) between ESD and LE. When adopting the fixed effect model which takes into account the study size, ESD was associated with a lower recurrence rate than LE (OR 0.15; 95% CI 0.03-0.87; p = 0.03), while with the random-effect model the difference was not significant (OR 0.18; 95% CI 0.02-2.04; p = 0.17). Over the last decade improvements in technology have improved the technical feasibility of rectal ESD. In specialized centers with highly experienced endoscopists, ESD can provide high-quality en-bloc excision of rectal neoplasms equivalent to traditional local excision.

Comparison of Transanal Endoscopic Microsurgery and Total Mesorectal Excision in the Treatment of T1 Rectal Cancer: A Meta-Analysis

Background

Transanal endoscopic microsurgery (TEM) for the treatment of early-stage rectal cancer has attracted attention due to its advantages of reduced surgical trauma, fewer complications, low operative mortality, rapid postoperative recovery and short hospital stay. However, there are still significant controversies regarding TEM for the treatment of rectal cancer, mainly related to the prognosis associated with this method.

Objective

This study sought to compare the efficacy of transanal endoscopic microsurgery (TEM) and total mesorectal excision (TME) for the treatment of T1 rectal cancer.

Methods

We searched the Cochrane Library, PubMed, Embase and CNKI databases. Based on the Cochrane Handbook for Systematic Reviews, we screened the trials, evaluated the quality and extracted the data.

Results

One randomized controlled trial (RCT) and six non-randomized controlled clinical trials (CCTs) were included in the meta-analysis (a total of 860 rectal cancer patients were included; 303 patients were treated with TEM, and 557 patients were treated with TME). Analysis revealed that all seven studies reported local recurrence rates, and there was a significant difference between the TEM and TME groups [odds ratio (OR) = 4.62, 95% confidence interval (CI) (2.03, 10.53), P = 0.0003]. A total of five studies reported distant metastasis rates, and there was no significant difference between the TEM and TME groups [OR = 0.74, 95%CI (0.32, 1.72), P = 0.49]. A total of six studies reported postoperative overall survival of the patients, and there was no significant difference between the TEM and TME groups [OR = 0.87, 95%CI(0.55, 1.38), P = 0.55]. In addition, two studies reported the postoperative disease-free survival rates of patients, and there was no significant difference between the TEM and TME groups [OR = 1.12, 95%CI (0.31, 4.12), P = 0.86].

Conclusions

For patients with T1 rectal cancer, the distant metastasis, overall survival and disease-free survival rates did not differ between the TEM and TME groups, although the local recurrence rate after TEM was higher than that after TME.

Transanal Endoscopic Microsurgery

Transanal endoscopic microsurgery (TEM) was developed by Professor Gerhard Buess 30 years ago at the dawn of minimally invasive surgery. TEM utilizes a closed proctoscopic system whereby endoluminal surgery is accomplished with high-definition magnification, constant CO2 insufflation, and long-shafted instruments. The end result is a more precise excision and closure compared to conventional instrumentation. Virtually any benign lesion can be addressed with this technology; however, proper patient selection is paramount when using it for cancer.

The impact of a dedicated multidisciplinary team on the management of early rectal cancer

AIM

Local excision of early rectal cancer (ERCa) offers comparable survival and reduced operative morbidity compared with radical surgery, yet it risks an adverse oncological outcome if performed in the wrong setting. This retrospective review considers the impact of the introduction of a specialist early rectal cancer multidisciplinary team (ERCa MDT) on the investigation and management of ERCa.

METHOD

A retrospective comparative cohort study was undertaken. Patients with a final diagnosis of pT1 rectal cancer at our unit were identified for two 12-month periods before and after the introduction of the specialist ERCa MDT. Data on investigations and therapeutic interventions were compared.

RESULTS

Nineteen patients from 2006 and 24 from 2011 were included. In 2006, 12 patients underwent MRI and four transrectal ultrasound (TRUS) examination, while in 2011, 18 and 20, respectively, received MRI and TRUS. In 2006 four patients underwent incidental ERCa polypectomy, with all having a positive resection margin leading to anterior resection. In 2011 only one case with a positive margin following extended endoscopic mucosal resection was identified. Definitive local excision without subsequent resection occurred in two patients in 2006 and in 16 in 2011.

CONCLUSION

The study demonstrates an improvement in preoperative ERCa staging, a reduction in margin positivity and an increase in the use of local excision following the implementation of a specialist ERCa MDT. The increased detection of rectal neoplasms through screening and surveillance programmes requires further investigation and management. A specialist ERCa MDT will improve management and should be available to all practitioners involved with patients with ERCa.

Pitfalls of transanal endoscopic microsurgery for rectal cancer following neoadjuvant chemoradiation therapy

Transanal endoscopic microsurgery has become a very useful surgical tool for the management of selected cases of rectal cancer. However, the considerably high local recurrence rates led to the introduction of neoadjuvant therapies including radiation with or without chemotherapy. This treatment strategy may result in significant rates of tumor regression allowing the procedure to be offered to a significant proportion of cases. On the other hand, neoadjuvant chemoradiation (CRT) may also determine wound-healing difficulties with significant postoperative pain. In addition, salvage total mesorectal excision in the case of local recurrence may also be a challenging task. Finally, accurate selection criteria for this minimally invasive approach are still lacking and may be influenced by baseline staging, post-treatment staging and final pathology information. Ultimately, selection of patients for this treatment modality remains a significant challenge for the colorectal surgeon who should be aware of the pitfalls of this procedure in the setting of neoadjuvant CRT.

"Down-to-Up" transanal NOTES Total mesorectal excision for rectal cancer: Preliminary series of 9 patients

BACKGROUND:

Applications for natural orifice translumenal endoscopic surgery (NOTES) to access the abdominal cavity have increased in recent years. Despite potential advantages of transanal and transcolonic NOTES for colorectal pathology, it has not been widely applied in the clinical setting. This study describes a series of nine patients for whom we performed transanal retrograde (“Down-to-Up”) total mesorectal excision for rectal cancer.

MATERIALS AND METHODS:

Under IRB approval, informed consent was obtained from each patient with rectal adenocarcinoma. Rectosigmoidectomy with total mesorectal excision was performed using low rectal translumenal access to the mesorectal fascia and subsequent dissection in a retrograde fashion. This was achieved using either a single port device or flexible colonoscope with endoscopic instrumentation and laparoscopic assistance. This was followed by transanal extraction of the specimen and hand-sewn anastomosis.

RESULTS:

Mean operative time was 311 min. Mean hospital stay was 7.56 days. Complications occurred in two patients, and consisted of one anastomotic leakage with reoperation and one intraoperative conversion to open surgery because of impossibility to dissect the specimen. TME specimen integrity was adequate in six patients.

CONCLUSION:

This series suggests that a retrograde mesorectal dissection via a NOTES technique is feasible in patients with rectal adenocarcinoma. This technique may act as a complimentary part of operative treatment for rectal cancer alongside other minimally invasive strategies. Long-term follow up will be needed to assess oncological results.

"Down-to-Up" transanal NOTES Total mesorectal excision for rectal cancer: Preliminary series of 9 patients

BACKGROUND

Applications for natural orifice translumenal endoscopic surgery (NOTES) to access the abdominal cavity have increased in recent years. Despite potential advantages of transanal and transcolonic NOTES for colorectal pathology, it has not been widely applied in the clinical setting. This study describes a series of nine patients for whom we performed transanal retrograde ("Down-to-Up") total mesorectal excision for rectal cancer.

MATERIALS AND METHODS

Under IRB approval, informed consent was obtained from each patient with rectal adenocarcinoma. Rectosigmoidectomy with total mesorectal excision was performed using low rectal translumenal access to the mesorectal fascia and subsequent dissection in a retrograde fashion. This was achieved using either a single port device or flexible colonoscope with endoscopic instrumentation and laparoscopic assistance. This was followed by transanal extraction of the specimen and hand-sewn anastomosis.

RESULTS

Mean operative time was 311 min. Mean hospital stay was 7.56 days. Complications occurred in two patients, and consisted of one anastomotic leakage with reoperation and one intraoperative conversion to open surgery because of impossibility to dissect the specimen. TME specimen integrity was adequate in six patients.

CONCLUSION

This series suggests that a retrograde mesorectal dissection via a NOTES technique is feasible in patients with rectal adenocarcinoma. This technique may act as a complimentary part of operative treatment for rectal cancer alongside other minimally invasive strategies. Long-term follow up will be needed to assess oncological results.

Endoscopic resection yields reliable outcomes for small rectal neuroendocrine tumors

BACKGROUND AND AIM

We analyzed the characteristics of gastrointestinal neuroendocrine tumors and examined the outcomes and safety of modalities in rectal neuroendocrine tumors.

METHODS

Between 2007 and 2011, a total of 91 patients with gastrointestinal neuroendocrine tumors were retrospectively reviewed in terms of the characteristics of tumors.

RESULTS

Sixty-six patients had rectal neuroendocrine tumors and underwent endoscopic mucosal resection (EMR, n = 29), endoscopic submucosal dissection (ESD, n = 23), or transanal endoscopic microsurgery (TEM, n = 14). The complete resection rate was higher in the ESD group (82.7%) and in the TEM group (100%) compared to the EMR group (65.5%) (P < 0.046). The complication rate was higher in the ESD group (47.8%) than in the EMR group (18.5%) (P = 0.003). No local tumor recurrence was observed in all patients, regardless of the procedure, during the median follow-up period of 21.5 ± 13.5 months.

CONCLUSIONS

ESD achieved a higher complete resection rate than EMR and comparable to TEM. Tumor recurrence was not observed in the endoscopic resection and TEM groups, regardless of the completeness of resection. Small neuroendocrine tumors of the gastrointestinal tract can be managed reliably with both endoscopic resection and TEM.

Transanal minimal invasive surgery with the Endorec(TM) trocar: a low cost but effective technique

PURPOSE

Transanal endoscopic microsurgery (TEM) is a well-established surgical approach for local excision of benign adenomas and early-stage rectal cancer. This technique is expensive and associated with a long learning curve. To avoid these obstacles, we have developed an alternative approach using the Endorec(TM) trocar (Aspide, France), which combines the advantages of local transanal excision and single-port access. The aim of this study was to evaluate the feasibility of this technique.

PATIENTS AND METHODS

Fourteen consecutive patients underwent transanal resection using Endorec trocar and standard laparoscopic instruments. A retrospective evaluation of the outcome of this technique was performed.

RESULTS

Fourteen patients were successfully operated. Rectal lesions included adenoma in ten patients, T1 adenocarcinoma in three and one T2 adenocarcinoma not amenable for abdominal surgery. The average distal margin from the anal verge was 10 cm (range 5-17 cm), and the mean diameter was 3.5 cm (range 1-5 cm). Negative margins were obtained in 13 patients (92,8 %). Median operating time was 60 min (range 20-100). The excisional area was sutured in nine patients. Median postoperative stay was 4 days (range 1-13). Postoperative complications (21 %) included postoperative fever in one patient and two patients were readmitted with rectal blood loss 6 and 15 days postoperatively and were treated with conservative measures.

CONCLUSIONS

Our current data show that transanal surgery using Endorec trocar is feasible and safe. Although long-term outcomes and definite indications should be yet evaluated, we believe that this new technique offers a promising alternative to TEM.

Transanal colorectal resection using natural orifice translumenal endoscopic surgery (NOTES)

The surgical management of rectal cancer has evolved over the past century, with total mesorectal excision (TME) emerging as standard of care. As a result of the morbidity associated with open TME, minimally invasive techniques have become popular. Natural orifice translumenal endoscopic surgery (NOTES) has been held as the next revolution in surgical techniques, offering the possibility of 'incisionless' TME. Early clinical series of transanal TME with laparoscopic assistance (n = 72) are promising, with overall intraoperative and postoperative complication rates of 8.3% and 27.8%, respectively, similar to laparoscopic TME. The mesorectal specimen was intact in all patients, and 94.4% had negative margins. There was no oncological recurrence in average-risk patients at short-term follow up, and 2-year survival rates in high-risk patients were comparable to that after laparoscopic TME. These preliminary studies demonstrate transanal NOTES TME with laparoscopic assistance to be clinically feasible and safe given careful patient selection, surgical expertise, and appropriate procedural training. We are hopeful that with optimization of transanal instruments and surgical techniques, pure transanal NOTES TME will become a viable alternative to open and laparoscopic TME in the future.

Learning curve for transanal endoscopic microsurgery: a single-center experience

INTRODUCTION

Transanal endoscopic microsurgery (TEM) was first published by the late Professor Buess in 1983. The procedure initially had a slow acceptance due to its perceived difficulty, the cost of the equipment, and limited indications. However, the widespread adoption of laparoscopic colorectal surgery provided an impetus to increase the penetration of the platform. The purpose of this study was to evaluate the TEM learning curve (LC).

METHODS

After institutional review board approval, all patients who underwent TEM, from November 2005 to October 2008 were identified from a prospective database. The operations were performed by a single, board-certified colorectal surgeon (DRS), after learning the technique from Professor Buess. Patient, operative, and postoperative variables were obtained by retrospective chart review. Rates of excision in minutes per cm(2) of tissue were calculated. The CUSUM method was used to plot the LC. Variables were compared using χ (2) and Student's t test. A p < 0.05 was considered significant.

RESULTS

Twenty-three patients underwent TEM (median age 61 years, 69.5 % male). Mean operative time was 130.5 (range 39-254) min, and the mean specimen size was 16.6 (7.4-42) cm(2). Average rate of excision (ARE) was 8.9 min/cm(2). A stabilization of the LC was observed after the first four cases, showing an ARE of 13.8 min/cm(2) for the first four cases versus 7.9 min/cm(2) for the last 19 cases (p = 0.001). An additional rising and leveling of the LC was observed after the first 10 cases, when an increasing number of lesions located cephalad to 8 cm from the dentate line were being resected (lesions above 8 cm in the first 10 cases: 20 % vs. last 13 cases: 61 %; p = 0.04).

CONCLUSIONS

The ARE significantly declined after the first four cases. The LC for TEM is associated with a significant decrease in operative time after four cases.

Complications of transanal endoscopic microsurgery are rare and minor: a single institution's analysis and comparison to existing data

BACKGROUND

Transanal endoscopic microsurgery, a minimally invasive procedure for treatment of early-stage rectal cancer, carcinoid tumors, and adenomas, is shown to be a safe procedure with very low perioperative morbidity.

OBJECTIVE

We aimed to compare the outcomes of transanal endoscopic microsurgery at a large volume tertiary care center with the existing literature.

DESIGN

We retrospectively reviewed a prospectively collected database of 325 transanal endoscopic microsurgery procedures and looked for risk factors associated with complications. Indications for transanal endoscopic microsurgery included rectal adenocarcinomas, adenomas, and carcinoids.

SETTING

Procedures were performed by a single surgeon at a large-volume tertiary care center.

PATIENTS

Patients were enrolled over a 20-year period, and data were collected on demographics, perioperative details, tumor characteristics, and complications.

INTERVENTIONS

Transanal endoscopic microsurgery was performed on all 325 patients.

MAIN OUTCOME MEASURES

Main outcome measures were urinary retention, late bleeding requiring intervention, dehiscence, peritoneal cavity entry, conversion to abdominal approach, fecal soiling, and rectovaginal fistula.

RESULTS

Intraoperative bleeding was associated with larger tumor size, whereas postoperative bleeding requiring intervention was not associated with any factors studied. Peritoneal cavity entry and urinary retention were more likely if the tumor was in either the anterior or lateral position in the rectum. The peritoneal cavity was entered in 9 patients, and conversion to abdominal approach occurred in 1 patient. Intraoperative bleeding, by surgeon's choice, and urinary retention, by patient's choice, were associated with a greater likelihood of admission to the inpatient ward. Fecal soiling was not reported by patients and not recorded.

LIMITATIONS

This study was limited because it was a retrospective analysis

CONCLUSIONS

Transanal endoscopic microsurgery is an extremely safe procedure, offering very low perioperative morbidity. The overall morbidity found in our study was 10.5%, on par with published data for large series of 21%, 7.7%, and 14.9%. In contrast, complications from radical resection are reported at 18% to 55%.

Transanal minimally invasive surgery (TAMIS) for local excision of benign neoplasms and early-stage rectal cancer: efficacy and outcomes in the first 50 patients

BACKGROUND

Since its inception in 2009, transanal minimally invasive surgery has been used increasingly in the United States and internationally as an alternative to local excision and transanal endoscopic microsurgery for local excision of neoplasms in the distal and mid rectum. Despite its increasing acceptance, the clinical benefits of transanal minimally invasive surgery have not yet been validated.

OBJECTIVE

The aim of this study is to assess the adequacy of transanal minimally invasive surgery for the local excision of benign and malignant lesions of the rectum.

DESIGN

This is a retrospective analysis of consecutive patients who underwent transanal minimally invasive surgery for local excision of neoplasms at a single institution.

SETTINGS

The study was conducted by a single group of colorectal surgeons at a tertiary referral center.

PATIENTS

Eligible patients with early-stage rectal cancer and benign neoplasms were offered transanal minimally invasive surgery as a means for local excision. Data from these patients were collected prospectively in a registry.

MAIN OUTCOME MEASURES

The primary outcome measures included the feasibility of transanal minimally invasive surgery for local excision, resection quality, and short-term clinical results.

RESULTS

: Fifty patients underwent transanal minimally invasive surgery between July 2009 and December 2011. Twenty-five benign neoplasms, 23 malignant lesions, and 2 neuroendocrine tumors were excised. All lesions were excised using transanal minimally invasive surgery without conversion to an alternate transanal platform. The average length of stay was 0.6 days (range, 0-6), and 68% of patients were discharged on the day of surgery. The average distance from the anal verge was 8.1 cm (range, 3-14 cm). All lesions were excised completely with only 2 fragmented specimens (4%). All specimens were removed with grossly negative margins, although 3 (6%) were found to have microscopically positive margins on final pathology. There were 2 recurrences (4%) at 6- and 18-month follow-up. Early complications occurred in 3 patients (6%). No long-term complications were observed at a median follow-up of 20 months.

LIMITATIONS

The study was limited by its retrospective nature and midterm follow-up.

CONCLUSIONS

Transanal minimally invasive surgery is an advanced transanal platform that provides a safe and effective method for resecting benign neoplasms, as well as carefully selected, early-stage malignancies of the mid and distal rectum.

A computer-aided algorithm to quantitatively predict lymph node status on MRI in rectal cancer

OBJECTIVE

The aim of this study was to demonstrate the principle of supporting radiologists by using a computer algorithm to quantitatively analyse MRI morphological features used by radiologists to predict the presence or absence of metastatic disease in local lymph nodes in rectal cancer.

METHODS

A computer algorithm was developed to extract and quantify the following morphological features from MR images: chemical shift artefact; relative mean signal intensity; signal heterogeneity; and nodal size (volume or maximum diameter). Computed predictions on nodal involvement were generated using quantified features in isolation or in combinations. Accuracies of the predictions were assessed against a set of 43 lymph nodes, determined by radiologists as benign (20 nodes) or malignant (23 nodes).

RESULTS

Predictions using combinations of quantified features were more accurate than predictions using individual features (0.67-0.86 vs 0.58-0.77, respectively). The algorithm was more accurate when three-dimensional images were used (0.58-0.86) than when only middle image slices (two-dimensional) were used (0.47-0.72). Maximum node diameter was more accurate than node volume in representing the nodal size feature; combinations including maximum node diameter gave accuracies up to 0.91.

CONCLUSION

We have developed a computer algorithm that can support radiologists by quantitatively analysing morphological features of lymph nodes on MRI in the context of rectal cancer nodal staging. We have shown that this algorithm can combine these quantitative indices to generate computed predictions of nodal status which closely match radiological assessment. This study provides support for the feasibility of computer-assisted reading in nodal staging, but requires further refinement and validation with larger data sets.

Anorectal functional outcome after repeated transanal endoscopic microsurgery

AIM: To evaluate the status of anorectal function after repeated transanal endoscopic microsurgery (TEM).

METHODS: Twenty-one patients undergoing subtotal colectomy with ileorectal anastomosis were included. There were more than 5 large (> 1 cm) polyps in the remaining rectum (range: 6-20 cm from the anal edge). All patients, 19 with villous adenomas and 2 with low-grade adenocarcinomas, underwent TEM with submucosal endoscopic excision at least twice between 2005 and 2011. Anorectal manometry and a questionnaire about incontinence were carried out at week 1 before operation, and at weeks 2 and 3 and 6 mo after the last operation. Anal resting pressure, maximum squeeze pressure, maximum tolerable volume (MTV) and rectoanal inhibitory reflexes (RAIR) were recorded. The integrity and thickness of the internal anal sphincter (IAS) and external anal sphincter (EAS) were also evaluated by endoanal ultrasonography. We determined the physical and mental health status with SF-36 score to assess the effect of multiple TEM on patient quality of life (QoL).

RESULTS: All patients answered the questionnaire. Apart from negative RAIR in 4 patients, all of the anorectal manometric values in the 21 patients were normal before operation. Mean anal resting pressure decreased from 38 ± 5 mmHg to 19 ± 3 mmHg (38 ± 5 mmHg vs 19 ± 3 mmHg, P = 0.000) and MTV from 165 ± 19 mL to 60 ± 11 mL (165 ± 19 mL vs 60 ± 11 mL, P = 0.000) at month 3 after surgery. Anal resting pressure and MTV were 37 ± 5 mmHg (38 ± 5 mmHg vs 37 ± 5 mmHg, P = 0.057) and 159 ± 19 mL (165 ± 19 mL vs 159 ± 19 mL, P = 0.071), respectively, at month 6 after TEM. Maximal squeeze pressure decreased from 171 ± 19 mmHg to 62 ± 12 mmHg (171 ± 19 mmHg vs 62 ± 12 mmHg, P = 0.000) at week 2 after operation, and returned to normal values by postoperative month 3 (171 ± 19 vs 166 ± 18, P = 0.051). RAIR were absent in 4 patients preoperatively and in 12 (χ² = 4.947, P = 0.026) patients at month 3 after surgery. RAIR was absent only in 5 patients at postoperative month 6 (χ² = 0.141, P = 0.707). Endosonography demonstrated that IAS disruption occurred in 8 patients, and 6 patients had temporary incontinence to flatus that was normalized by postoperative month 3. IAS thickness decreased from 1.9 ± 0.6 mm preoperatively to 1.3 ± 0.4 mm (1.9 ± 0.6 mm vs 1.3 ± 0.4 mm, P = 0.000) at postoperative month 3 and increased to 1.8 ± 0.5 mm (1.9 ± 0.6 mm vs 1.8 ± 0.5 mm, P = 0.239) at postoperative month 6. EAS thickness decreased from 3.7 ± 0.6 mm preoperatively to 3.5 ± 0.3 mm (3.7 ± 0.6 mm vs 3.5 ± 0.3 mm, P = 0.510) at month 3 and then increased to 3.6 ± 0.4 mm (3.7 ± 0.6 mm vs 3.6 ± 0.4 mm, P = 0.123) at month 6 after operation. Most patients had frequent stools per day and relatively high Wexner scores in a short time period. While actual fecal incontinence was exceptional, episodes of soiling were reported by 3 patients. With regard to the QoL, the physical and mental health status scores (SF-36) were 56.1 and 46.2 (50 in the general population), respectively.

CONCLUSION: The anorectal function after repeated TEM is preserved. Multiple TEM procedures are useful for resection of multi-polyps in the remaining rectum.

Shifting concepts in rectal cancer management: a review of contemporary primary rectal cancer treatment strategies

The management of rectal cancer has transformed over the last 3 decades and continues to evolve. Some of these changes parallel progress made with other cancers: refinement of surgical technique to improve organ preservation, selective use of neoadjuvant (and adjuvant) therapy, and emergence of criteria suggesting a role for individually tailored therapy. Other changes are driven by fairly unique issues including functional considerations, rectal anatomic features, and surgical technical issues. Further complexity is due to the variety of staging modalities (each with its own limitations), neoadjuvant treatment alternatives, and competing strategies for sequencing multimodal treatment even for nonmetastatic disease. Importantly, observations of tumor response made in the era of neoadjuvant therapy are reshaping some traditionally held concepts about tumor behavior. Frameworks for prioritizing and integrating complex data can help to formulate treatment plans for patients.

Transanal endoscopic microsurgery for rectal carcinoids: the largest reported United States experience

AIM

Rectal carcinoids are often inadequately resected by snare excision during colonoscopy. Transanal endoscopic microsurgery is a minimally invasive procedure with low morbidity that offers full-thickness excision with a low rate of negative margins. It presents an excellent alternative to radical surgery for mid and proximally located lesions. We report the largest United States (US) experience in the use of transanal endoscopic microsurgery for rectal carcinoids.

METHOD

Data of patients who had undergone transanal endoscopic microsurgery for rectal carcinoids were prospectively collected and retrospectively analyzed. Patient and tumour characteristics, operative and perioperative details, as well as oncological outcomes were reviewed.

RESULTS

Over a 12-year period, 24 patients underwent transanal endoscopic microsurgery for rectal carcinoids. Of these, six (25%) were primary surgical resections and 18 (75%) were performed after incomplete snare excisions during colonoscopy. Three (17%) patients who underwent full-thickness resection after snare excision had residual tumour on histopathological examination. Negative margins were obtained in all cases. No recurrences were noted.

CONCLUSION

Transanal endoscopic microsurgery is effective and safe for the surgical resection of rectal carcinoids<2 cm in diameter, with typical features and located more than 5 cm from the anal verge. Transanal endoscopic microsurgery can be used for primary resection or for resection after incomplete colonoscopic snare excision.

Transanal endoscopic microsurgery-based transanal access for colorectal surgery: experience on human cadavers

Transanal endoscopic microsurgery (TEM) was described in 1983 for local excision of rectal tumors. In the context of natural orifice translumenal endoscopic surgery, we have modified the original TEM system and developed a new set of instruments. These are more curved and, in addition, steerable. After extensive studies in an ex-vivo model, we developed a novel technique for transanal rectosigmoid resection and colorectal anastomosis. The technique comprises closure of the rectal lumen by purse-string suture, transection of the rectal wall distal to the closure, circumferential mobilization of rectum and mesorectal tissue in the anatomical plane from below upward, control of the inferior mesenteric vessel, removal of mobilized colorectum through the anus, and, finally, the colorectal anastomosis by either stapled or hand-sutured technique. This procedure was performed on three alcohol-glycerol preserved well-built human cadavers (M:F=2:1). The average operating time was 190 minutes. The average length of the resected specimen was 23 cm. There was no fecal contamination or injury to the resected specimen. Postprocedure laparotomy revealed adequate mesorectal resection and no inadvertent injury to other viscera. During dissection in the pelvis, as the resected rectum was pushed upward, an unobstructed "empty pelvis" situation was developed in the operating site, thus facilitating the mesorectal resection. Transanal access for colorectal surgery seems feasible. It provides a precise definition of the distal safety margin, good view of the pelvis for meticulous mesorectal resection, and reduces the abdominal wall trauma. These may enhance the outcome of colorectal resection. However, further clinical studies can only substantiate these findings.

Perirectal NOTES access: "down-to-up" total mesorectal excision for rectal cancer

OBJECTIVES

Clinical natural orifice surgery has been applied for abdominal surgery in recent years, mostly by vaginal and oral access. The study describes preliminary successful human applications of transcolonic natural orifice transluminal endoscopic surgery (NOTES), using a new transrectal total mesorectal excision procedure for rectal cancer.

METHODS

Institutional review board approval was obtained for the study. In 2 patients with rectal adenocarcinoma, total mesorectal resection and rectosigmoidectomy with lymphadenectomy was performed using a low NOTES transcolonic access. "Down-to-up" mesorectal dissection was achieved either using a flexible scope or a transrectal single port device. The specimens were extracted transanally, and transorificial low anastomosis was performed.

RESULTS

Operative time was 350 and 360 minutes, respectively; no complications occurred and patients were discharged after 6 days.

CONCLUSION

Successful human reports on transcolonic NOTES suggest potential applications. The treatment of colorectal diseases through transorificial single port or flexible perirectal NOTES access are promising new approaches besides current methods to improve patient care.

A novel single-port technique for transanal rectosigmoid resection and colorectal anastomosis on an ex vivo experimental model

BACKGROUND

In the context of natural orifice translumenal endoscopic surgery (NOTES), we developed a new set of rigid instruments according to the principles of transanal endoscopic microsurgery (TEM).These instruments are long, curved, and steerable by rotating two wheels near its handle. Our success in transvaginal cholecystectomy in human with these instruments motivated us to explore the feasibility of rectosigmoid resection through the anus.

METHODS

The young bovine large bowel with attached organs is collected en bloc and reintegrated into an anatomically designed trainer to reproduce the human anatomy. The technique comprises the following: (1) closure of the rectal lumen by an endolumenal pursestring suture; (2) transection of the rectal wall 1 cm distal to the pursestring suture and continuation of the dissection toward the fascia and upward excising the mesorectal tissue; (3) inferior mesenteric artery is divided near its origin; (4) the colon is mobilized up to the splenic flexure; (5) the mobilized colon is brought down to the pelvis, ligated twice at the intended proximal resection site, and divided between the ligatures; (6) specimen is delivered transanally; and (7) intestinal continuity is restored by stapled or hand-sutured anastomosis.

RESULTS

Twelve rectosigmoid resections, 20 stapled, and 27 hand-sutured anastomoses were performed in two experimental setups. Mean operation time for the resection part was 78.6 min (standard deviation (SD)=9.9). The average specimen length was 37.2 cm. During dissection in the pelvis, as the specimen was pushed upward and toward abdomen, an "empty pelvis" view of the working field was achieved, facilitating dissection. The mean operation time for hand-sutured and stapled anastomoses were 47.7 (SD=6.9) and 43.3 (SD=7.1) min, respectively. Both groups had one anastomotic leak.

CONCLUSIONS

Transanal rectosigmoid resection is feasible with TEM technology. The unobstructed "empty pelvis" view is likely to enhance the quality of mesorectal dissection.

International multicenter trial on clinical natural orifice surgery--NOTES IMTN study: preliminary results of 362 patients

OBJECTIVES

Natural orifice translumenal endoscopic surgery (NOTES) is evolving as a promising alternative for abdominal surgery. IMTN Registry was designed to prospectively document early results of natural orifice surgery among a large group of clinical cases.

METHODS

Sixteen centers from 9 countries were approved to participate in the study, based on study protocol requirements and local institutional review board approval. Transgastric and transvaginal endoscopic natural orifice surgery was clinically applied in 362 patients. Intraoperative and postoperative parameters were prospectively documented.

RESULTS

Mean operative time for transvaginal cholecystectomy was 96 minutes, compared with 111 minute for transgastric cholecystectomy. A general complication rate of 8.84% was recorded (grade I-II representing 5.8%, grade III-IV representing 3.04%). No requirement for any analgesia was found in one fourth of cholecystectomy and appendectomy patients.

CONCLUSIONS

Results of clinical applications of NOTES in the IMTN Study showed the feasibility of different methods of this new minimally invasive alternative for laparoscopic and open surgery.

Anorectal functional results after transanal endoscopic microsurgery in benign and early malignant tumors

BACKGROUND

Transanal endoscopic microsurgery (TEM) has been suggested as a minimally invasive procedure of low morbidity for rectal villous adenomas and early anorectal adenocarcinomas. It has been used clinically in many areas outside of China for more than 20 years, but it began in mainland China only about 2 years ago. Some articles have reported excellent results with regard to morbidity and relapse rate with TEM, but there are no studies addressing its functional results in China until now. The aim of the present study was to analyze the effect of TEM on the manometric results.

METHODS

Thirty-seven patients (16 females, 21 males) underwent TEM and were followed for more than 6 months. Anorectal manometry and an incontinence questionnaire were administered 1 week preoperatively, 2 weeks postoperatively, 3 and 6 months postoperatively.

RESULTS

Of the 37 patients, 24 had villous adenomas and 13 had adenocarcinomas (11 uT1 and 2 uT2). Anorectal manometric values showed the mean anal resting pressure (ARP) decrease from 45 +/- 6 mmHg to 29 +/- 4 mmHg (p < 0.05) and the maximum tolerable volume (MTV) decrease from 175 +/- 21 ml to 90 +/- 15 ml (p < 0.05) at the third month after TEM. Maximal squeeze pressure (MSP) decreased from 181 +/- 20 mmHg to 92 +/- 14 mmHg (p < 0.05) at second week after operation and returned to normal value by the third postoperative month. The ARP and MTV were 45 +/- 5 mmHg and 177 +/- 21 ml, respectively, at 6 months after TEM, near the normal value (p > 0.05). Rectoanal inhibitory reflex (RAIR) was absent preoperatively in two patients; it was also absent in 10 patients 3 months postoperatively and in three patients 6 months postoperatively. Endosonography demonstrated internal anal sphincter (IAS) rupture in five patients, and full integrity of the external anal sphincter (EAS) in all patients. Of the five patients with IAS rupture, four had temporary incontinence to flatus normalized up to three postoperative months. Most patients had more times of stools per day and relative higher Wexner scores in a short period after TEM. All these patients were followed for 6-20 months with no incidence of relapse.

CONCLUSIONS

Anorectal function was preserved well after TEM, although some anorectal manometric parameters changed over time. Thus TEM is safe, in terms of anorectal function, for the cure of benign and early malignant tumors of the rectum.

Modified stapled transanal rectal resection (Starr) for full thickness excision of rectal tumour

INTRODUCTION

Traditionally, adenomatous rectal lesions and unexpected malignant polyps that could not be removed endoscopically are referred to surgery. Local excision is the treatment of choice, and several techniques have been proposed. The choice of the approach requires that the tumour is excised intact, with a low recurrence rate and limited morbidity. Local excision can be a straight forward or conversely a demanding procedure due to the restricted space in which the surgeon must work and the difficulty of achieving a satisfactory exposure.

METHODS

We describe a modified stapled transanal rectal resection for the excision of flat lesions with a diameter up to 2 cm and located between 5 and 12 cm from the anal verge.

DISCUSSION AND CONCLUSION

In our experience, it is quick, simple, and easy to teach but it has not previously been reported. It provides full thickness resection with adequate lateral margins. It overcomes some of the limits of the incomplete surgical field exposure and difficult manipulation, since after the confectioning of double half purse-string suture, the suture and sectioning is made by the stapler device.

Cirurgia por orifícios naturais transcolônica: acesso NOTES peri-retal (PNA) para excisão mesoretal total

OBJETIVOS: Cirurgia por orifícios naturais tem sido recentemente aplicada em series clínicas para cirurgia abdominal. Apesar de potenciais vantagens do acesso NOTES transcolônico para doenças colorretais, este ainda não havia sido utilizado clinicamente. O presente trabalho descreve a primeira aplicação bem-sucedida de NOTES transcolônico da literatura, em uma nova abordagem de excisão mesoretal total (TME) para cancer de reto. MÉTODOS: Foi obtida aprovação de Comitê de Ética em Pesquisa para cirurgias por orifícios naturais, e o paciente assinou termo de consentimento informado. Em um paciente de 54 anos portador de adenocarcinoma de reto, o procedimento de retossigmoidectomia e linfadenectomia, com excisão mesoretal total foi realizada utilizando um acesso posterior transcolônico pouco acima da borda anal. A dissecção mesorretal foi conseguida utilizando um colonoscópio flexível e instrumentos endoscópicos, com assistência laparoscópica. O espécime foi retirado via transanal, e anastomose foi transorificial, com estoma proximal de proteção. RESULTADOS: O tempo operatório foi de 350 min, não ocorrendo complicações operatórias. A evolução pós-operatória foi favorável, e o paciente recebeu alta no sexto dia de pós-operatório com dieta plena. CONCLUSÃO: Este primeiro relato bem sucedido de cirurgia NOTES transcolônica traz potencialmente novas fronteiras de aplicações clínicas na cirurgia minimamente invasiva. O tratamento de doenças colorretais utilizando o novo acesso flexível PNA (Perirectal NOTES Access) é uma promissora nova abordagem, paralelamente à laparoscopia e cirurgia aberta, para melhoria do tratamento dos pacientes.

Natural orifice surgery applied for colorectal diseases

Clinical natural orifice surgery has been applied to abdominal surgery in recent years, mostly using transvaginal and transgastric access. Rectal and transcolonic natural orifice transluminal endoscopic surgery (NOTES) were tested in animal and cadaver models by a few research groups. Despite the potential advantages of transcolonic NOTES for colorectal diseases, it has not yet been clinically applied. The first successful series of human applications of transcolonic NOTES in the literature from the NOTES Research Group in Brazil provide new possibilities in the field in new transrectal procedures for rectal cancer and benign disease. Successful first human reports on Transcolonic NOTES potentially brings new frontiers and applications for minimally invasive surgery. The treatment of colorectal diseases through flexible Perirectal NOTES Access is a promising new approach alongside existing laparoscopic and open surgery to improve patient care.

Rectal cancer

Surgery is the cornerstone of rectal cancer treatment. Oncological cure and overall survival continue to be the main goals, but sparing of the anal sphincter mechanism and functional results are also important. The modern management of rectal cancer is a multidisciplinary approach, and pre-operative staging is of crucial importance when planning treatment in these patients. Pre-operative staging is used to determine the indication for neoadjuvant therapy prior to surgical resection or to determine whether local excision is an option in carefully selected patients with early rectal cancer. Surgery in the form of total mesorectal excision (TME) has become the standard of care for mid and distal rectal cancers. Early rectal cancers do not require neoadjuvant therapy. For locally advanced cancers of the lower two-thirds of the rectum, the combination of surgical resection with chemoradiotherapy decreases local recurrence rates and probably improves overall survival. Whereas in the past local excision was only contemplated in patients who were unfit for radical surgery or for local palliation in cases of metastatic disease, over the last number of years there has been increasing interest in local treatment with curative intent in early rectal cancer.

Long-term results of local excision for T1 rectal carcinoma: the experience of two colorectal units

BACKGROUND

Local excision for early rectal cancer has low morbidity and good functional results. Its use is limited by the inability to assess regional lymph nodes and by the uncertainty of oncologic outcome.

METHODS

We conducted a retrospective chart review of all patients who underwent local excision of early rectal cancer in two colorectal units between 1995 and 2007. The retrieved and analyzed data were patient age and gender, tumor size, tumor distance from the anal verge, tumor differentiation, and additional treatment.

RESULTS

There were 42 patients with T1 rectal cancer: 24 underwent transanal endoscopic microsurgery and 18 had a transanal excision. The surgical margins were free of tumor in 39 patients (93%), they were involved by tumor in one (2%) and margin status was unclear in two (5%). Seven patients (16%) had postoperative complications. There was no postoperative mortality. The mean hospital stay was 67 h. Thirty-nine patients (93%) were followed up for 57 months (mean). Two patients had local recurrence, at 7 and 41 months post-surgery. They had a tumor that invaded into the lower third of the submucosa, sm3. Both received chemoradiotherapy, and underwent an abdominoperineal resection and a low anterior resection. One of them died of metastatic disease 13 months later and the other is alive with no evidence of disease. Another two patients had salvage low anterior resection, one for suspected local recurrence and one for lymphovascular invasion: the specimens were tumor free. Six patients died of unrelated causes.

CONCLUSIONS

Local excision of early rectal cancer is a feasible and acceptable alternative to radical resection. It has low complication and recurrence rates and a short postoperative hospital stay.