Combining ultrasonic dissection and the Storz operation rectoscope

Transanal hybrid colon resection: techniques and outcomes for benign colorectal diseases

BACKGROUND

Transanal hybrid rectal and colon resection have been introduced in recent years at dedicated surgical centers. The anus is used as a natural orifice for large size access. The use of transanal hybrid colectomy techniques is still in its infancy with outcomes and unique complications being identified. The purpose of this work is the evaluation of outcomes for transanal hybrid colon resections (ta-CR), including intra operative and postoperative complications, results, and advantages.

METHODS

A prospectively maintained database was analyzed. Inclusion criteria were any patient who underwent ta-CR for rectal prolapse, slow transit, obstructive defaecation, and chronic sigmoid diverticulitis. Patients were excluded from ta-CR if BMI > 30, major previous abdominal surgery, or presence of a large inflammatory mass in diverticulitis. Transanal access was used for all operative steps requiring access of more than 5 mm, such as staplers, large graspers, and specimen retrieval. Data acquisition and analysis was performed for operative time, complications, and postoperative quality of life.

RESULTS

From 2012 to 2017, 82 patients underwent ta-CR [33 males, 49 females, median age 58 (24-80)]. Transanal-subtotal colectomy and ta-CR for constipation was performed in 12 patients; ta-CR and rectopexy in 31, and ta-CR for diverticulitis was performed in 39 patients. Conversion to traditional approach was required in 3 cases (3.6%). Intraoperative complication included 1 rectal tear requiring intervention. Post-op complications included 3 leaks requiring laparoscopic and 1 open revision, the latter developed wound infection and an incisional hernia. Gastrointestinal Quality of Life Index (GIQLI) improved significantly from preoperative 89 to postoperative 119 (p < 0.001). No patients with ta-CR without open revision developed a hernia post-op with median 18 months follow-up.

CONCLUSIONS

ta-CR is a safe and effective NOTES Hybrid technique for colorectal procedures in selected patients with benign colon disorders. GIQLI shows improvement and this technique can have the potential in preventing wound and hernia complications.

Transanal endoscopic microsurgery with 3-D (TEM) or high-definition 2-D transanal endoscopic operation (TEO) for rectal tumors. A prospective, randomized clinical trial

PURPOSE

Transanal endoscopic microsurgery (TEM) is a three-dimensional viewing endoscopic system procedure which provides access to rectal tumors through a rectoscope. Two-dimensional transanal endoscopic operation (TEO), with the introduction of high-definition vision, achieves results that are comparable to those of the classical TEM. The main aim of the study was to compare the effectiveness of TEO and TEM systems in a prospective, randomized clinical trial.

STUDY POPULATION

patients meeting inclusion criteria for diagnosis of rectal tumors with curative intent. Sample size, 36 patients. Patients were randomized to receive one of the two procedures. Study variables recorded were the following: preoperative data (time taken to assemble equipment, surgical time, quality of pneumorectum), postoperative morbidity and mortality, pathology study of the tumors, and economic analysis.

RESULTS

Thirty-six patients were analyzed according to intention to treat. Two patients were excluded. The final per-protocol analysis was 34 patients. There were no significant differences in the preoperative or operative variables, quality of pneumorectum, postoperative variables, or pathology results. A trend toward benefit was observed in favor of TEO in time required for assembly, surgical suture time, and total surgical time though the differences were not statistically significant. Statistically significant differences were found in terms of the total cost of the procedure, with mean costs of 2,031 <euro> ± 440 for TEO and 2,603 <euro> ± 507 for TEM (95% CI 218.15-926.486 <euro>, p = 0.003).

CONCLUSION

No technical or clinical differences were observed between the results obtained with the two systems except lower cost with TEO.

Transanal endoscopic microsurgery

Transanal endoscopic microsurgery (TEMS) is a well established method of accurate resection of specimens from the rectum under binocular vision. This review examines its role in the treatment of benign conditions of the rectum and the evidence to support its use and compliment existing endoscopic treatments. The evolution of TEMS in early rectal cancer and the concepts and outcomes of how it has been utilised to treat patients so far are presented. The bespoke nature of early rectal cancer treatment is changing the standard algorithms of rectal cancer care. The future of TEMS in the organ preserving treatment of early rectal cancer is discussed and how as clinicians we are able to select the correct patients for neoadjuvant or radical treatments accurately. The role of radiotherapy and outcomes from combination treatment using TEMS are presented with suggestions for areas of future research.

A single surgeon's experience with transanal endoscopic microsurgery over 20 years with 153 early cancer cases

BACKGROUND

The first author performed transanal endoscopic surgery (TEM) in 302 patients in Japan for the last 20 years, 153 of which were early rectal cancer cases. The short- and long-term outcomes of the early rectal cancer cases are herein reported.

MATERIAL AND METHODS

The original technique of TEM developed by Gerhard Buess was performed in all cases. The hospital records were reviewed to assess the clinical outcomes. A questionnaire was sent to the patients to analyze the long-term outcomes.

RESULTS

One-hundred and fifty-three early cancer cases included 115 T0 and 38 T1 lesions. Full-thickness resection was performed in 36 patients, while 117 underwent submucosal dissection. Conversion to laparoscopic low anterior resection occurred in one case. Mortality was nil. Major operative complication was noted in only one patient, who developed stenosis. Seven patients underwent immediate salvage surgery. Six patients died of recurrence of rectal cancer. Disease-free survival rate at year 5 was 93.7%.

CONCLUSIONS

Our study, one of the largest series in the world, confirms that TEM is a preferable option in the surgical treatment of T0 and T1a rectal carcinoma. As long as early cancer cases are treated, submucosal resection seems to be sufficient. When risk of recurrence is found by pathological examination, immediate salvage operation is mandatory to improve the prognosis.

Transanal employment of single access ports is feasible for rectal surgery

OBJECTIVE

To evaluate the feasibility of transanal single port surgery in 15 consecutive patients.

BACKGROUND

The current method of choice for local resection of rectal tumors is transanal endoscopic microsurgery (TEM), a complex and expensive technique. Single access surgery is easy, relatively cheap, and more broadly applied in laparoscopy. Evidence regarding transanal use of single access ports is scarce.

METHODS

Consecutive patients with a rectal lesion otherwise eligible for TEM were operated using the Single Site Laparoscopic Access System (SSL) and standard laparoscopic instrumentation. Patient, lesion and procedure characteristics, hospitalization length, and peroperative and postoperative complications were recorded.

RESULTS

Fifteen patients were planned for single port transanal surgery. In 2 patients (13.3%), intrarectal retractor expansion failed, and conversion to conventional TEM was necessary. The remaining 13 patients were successfully operated. Rectal lesions (mean diameter 36 mm, standard deviation ±25 mm, mean distance from the dentate line 6 cm [±4.5]) included adenoma in 7 patients, T1 adenocarcinoma in 1, T2 adenocarcinoma in 3, carcinoid in 1, and fibrosis only in 1 (after prior polypectomy). All patients were operated in lithotomy position. Resections were en bloc, full thickness, and had complete margins. Resection specimens measured 65 (±35) × 52 (±24) mm. Twelve rectal defects were sutured. One peroperative pneumoscrotum occurred. Mean operating time was 57 (±39) minutes. One patient presented with postoperative hemorrhage, treated conservatively (postoperative morbidity rate 7.7%). Mean hospitalization lasted 2.5 days (±2.7).

CONCLUSIONS

Transanal single port surgery via the SSL is feasible and safe and may become a promising alternative to TEM.

Endoscopic mucosal resection vs transanal endoscopic microsurgery for the treatment of large rectal adenomas

AIM

Large (> 2 cm) rectal adenomas are currently treated by transanal endoscopic microsurgery (TEM) or piecemeal endoscopic mucosal resection (EMR). The potential lower morbidity of EMR becomes irrelevant if it is less effective. We aimed to compare the safety and effectiveness of EMR and TEM for large rectal adenomas.

METHOD

Data from patients undergoing TEM or EMR for a rectal adenoma > 2 cm in eight hospitals were retrospectively collected. Patient- and procedure-related characteristics, complications and recurrences were recorded. As EMR may require several attempts to achieve complete resection, early (after a single intervention) and late (permitting re-treatment for residual adenoma within 6 months) recurrence rates were determined.

RESULTS

Two hundred and ninety-two (292) patients (49% male; mean age 67 years) were included; 219 were treated by TEM and 73 by EMR. Adenomas treated by EMR were smaller (median 30 vs 40 mm; P = 0.007). Perioperative complication rates were 2% for TEM and 6% for EMR (P = 0.171). Postoperative complications occurred in 24% of TEM patients and in 13% of EMR patients (P = 0.038). Median hospitalization after TEM was 3 days vs 0 days after EMR (P < 0.001). Median follow-up was 12.6 months (0-47 months); Early recurrence rates were 10.2% in TEM patients and 31.0% in EMR patients (P < 0.001); late recurrence rates were 9.6% and 13.8%, respectively (P = 0.386).

CONCLUSION

After a single intervention, EMR of large rectal adenomas seems less effective, but safer than TEM. When allowing re-treatment of residual adenoma within 6 months, EMR and TEM seem equally effective. A prospective randomized comparison seems to be necessary.

Efficiency and outcomes of harmonic device in transanal endoscopic microsurgery compared with monopolar scalpel

INTRODUCTION

An important fact when facing new technologies is their cost for the Health Publishes. The purpose of this paper is to compare the costs of performing TEM with harmonic scalpel and classic monopolar scalpel and to analyze complications.

METHODS

Operation time, blood loss, and hospital stay were recorded to determine the cost of the TEM procedure. We also recorded early and late complications. Patients were divided in two groups: harmonic scalpel group (UC) and monopolar scalpel group (MS).

RESULTS

TEM for curative intention was used in 330 rectal tumors from January 1997 to January 2010. A total of 229 patients met the criteria for this study: UC group (n = 87) and MS group (n = 142). Patients from the UC group developed fewer complications (16%) than patients from the MS group (23%). The difference of mean stay between groups was 1.5 days (95% confidence interval, 0.7; 2.2 days; P < 0.001) in favor of the UC group.

CONCLUSIONS

Harmonic scalpel provides a safer, easier, and more precise surgical section through clean, bloodless, and better visualized operative field. The additional cost of UC was compensated with the decrease in the health resources (mainly hospital stay).

Transanal single port microsurgery (TSPM) as a modified technique of transanal endoscopic microsurgery (TEM)

BACKGROUND

Single port access (SPA) surgery is a new procedure for minimal invasive surgery using one multichannel port. The authors adapted this technique for transanal surgery as an improvement of the transanal endoscopic microsurgery (TEM).

METHODS

A total of 3 patients underwent SPA modified TEM using the SILS port (Covidien) under CO(2) insufflation. This port allows insertion of 2 laparoscopic instruments and a telescope.

RESULTS

The operation was completed successfully in all cases. The transanal placement of the SILS port was easy to perform; a prior dilatation of the anal sphincter was not necessary. There were no perioperative or postoperative complications as verified by postoperative observation, rectoscopy, and anal ultrasound.

CONCLUSIONS

Transanal single port microsurgery is a feasible and new technique for less invasive and more gentle transanal surgery. By using this new multichannel device TEM surgery was changed in a modified way while preserving the anal sphincter.

Harmonic long shears further reduce operation time in transanal endoscopic microsurgery

BACKGROUND

Previous research indicates that application of 5-mm harmonic shears rather than diathermia significantly reduces operation time in transanal endoscopic microsurgery (TEM). Frequently, however, additional instruments were required to complete resection. We investigated whether the new 5-mm harmonic long shears (H-LS) are better equipped for TEM compared with regular harmonic shears (HS).

METHODS

Between 2001 and 2006, 162 tumors (117 adenomas, 42 carcinomas, and 3 other tumors; mean distance 6.6 cm, mean area 40 cm(2)) were excised in 161 patients (82 men, 79 women; mean age 66 years).

RESULTS

Eighty-eight resections were performed with HS and 74 with H-LS. Tumor and patient characteristics were similar except for specimen area. Tumors resected by H-LS were on average smaller than those resected by HS (34.4 versus 44.1 cm(2); Mann-Whitney U-test: p = 0.027). Mean operation time was 48 min and proportional to area in both groups (univariate analysis of variance p < 0.001). Mean operation time was 54 min using HS and 41 min using H-LS (t-test: p < 0.001). After correction for area, operation time for H-LS was reduced by 14% compared with HS (t-test: p < 0.001). H-LS is singly capable of completing resection in 88% compared with 26% for HS (Mann-Whitney U-test: p < 0.001). Mean blood loss was 16 cc for HS and 3 cc for H-LS (p < 0.001). Morbidity (11%) and mortality (0.6%) were not different between the two groups (Fisher's exact test).

CONCLUSION

Performing transanal endoscopic microsurgery with 5-mm harmonic long shears reduces operation time compared with regular shears, and completing resection seldom requires other instruments.

Transanal endoscopic operation for rectal lesions using two-dimensional visualization and standard endoscopic instruments: a prospective cohort study and comparison with the literature

BACKGROUND

The transanal endoscopic operation (TEO) has proved to be an effective alternative to conventional surgery for the treatment of rectal lesions. The TEO procedure offers reduced morbidity, faster recovery and equivalent oncologic outcome. Currently, two instrument sets are available: one with three-dimensional (Wolf) and one with two-dimensional (Storz) optic capacities. The three-dimensional (3D) instrument set is considered the golden standard. Although the advantages of TEO are imposing, the procedure with the 3D armamentarium has certain technical and financial drawbacks. This study therefore aimed to compare results for the TEO 2D alternative with recently published results for 3D TEO.

METHODS

All consecutive patients with benign or malignant pT1 or pT2 rectal lesions undergoing TEO were prospectively followed. All procedures were performed with the 2D armamentarium using standard endoscopic instruments, a rectoscope (diameter, 4 cm; working length, 7.5-15 cm), and 5-mm Ligasure and Ultracision. Operating times, complications, hospital stay, and oncologic outcome were gathered and compared with published data.

RESULTS

Between 2004 and 2006, 31 patients with a median age of 75 years (range, 33-87 years) underwent 31 TEOs for a total of 36 rectal lesions (29 tubulovillous adenomas and 7 adenocarcinomas). The median distance of the lesion from the anal verge was 7.5 cm (range, 5-15 cm). The median lesion diameter was 2.3 cm (range, 0.5-5.0 cm). The locations of the lesions were as follows: 18 on the dorsal, 5 on the ventral, and 5 on the lateral rectal wall. The median operating time was 55 min (range, 25-165 min), compared with 105 min reported in the literature. All the lesions except one could be radically excised. No intraoperative complications occurred. Postoperative complications occurred for three patients, all due to hemorrhage. The median hospital stay was 3 days (range, 1-21 days). During a median follow-up period of 15 months (range, 1-35 months), two recurrences took place.

CONCLUSION

The study findings showed that for rectal tumors located up to 15 cm from the anal verge with a maximal diameter of 5 cm, TEO using standard laparoscopic instruments with a 2D view is feasible and provides results comparable with those associated with a 3D view and dedicated instruments. Furthermore, the 2D procedure can be performed with improved ergonomics due to movable monitors and is considerably less expensive.

Contemporary Applications of Transanal Endoscopic Microsurgery: Technical Innovations and Limitations

PURPOSE

Transanal endoscopic microsurgery (TEM) is a minimally invasive procedure used to transanally excise select benign and malignant tumors of the rectum. In properly selected patients, TEM can provide for decreased postoperative morbidity without compromising oncologic outcome. This report summarizes the recent literature concerning TEM, comprehensively analyzes the authors' experience with TEM, and describes recent technical innovations and indications.

PATIENTS AND METHODS

Thirty-two consecutive patients scheduled for TEM were identified from our prospectively maintained colorectal service database. Clinicopathologic factors, postoperative complications, and oncologic outcomes were analyzed for all patients. In addition, a PubMed literature search was performed with use of the key words "transanal endoscopic microsurgery," "TEM," "rectal tumor," and "rectal cancer."

RESULTS

Transanal endoscopic microsurgery was performed for rectal adenocarcinoma (n = 17; 53%), adenoma (n = 12; 38%), and carcinoid tumors (n = 3; 9%). Median tumor location was 9 cm from the anal verge (range, 3-15 cm). Of the 32 attempted TEM procedures, 27 (84%) were completed. Reasons for inability to complete TEM included narrow rectal lumen or contour of bony pelvis prohibiting passage of the operating proctoscope into the upper rectum and inability to maintain the proctoscope in the rectal lumen with carbon dioxide insufflation because of the distal location of the tumor. Innovations used in the excision of rectal tumors via TEM included the use of the harmonic scalpel, closure of the rectal defect with an extracorporeal slip knot, and a hybrid approach incorporating TEM and traditional transanal techniques.

CONCLUSION

Transanal endoscopic microsurgery provides for low morbidity and does not appear to impair oncologic outcome in properly selected patients.

Ultracision Harmonic Scalpel and multifunctional tem400 instrument complement in transanal endoscopic microsurgery: a prospective study

BACKGROUND

For transanal endoscopic microsurgery, the ultracision Harmonic Scalpel (UC) and the multifunctional TEM400 instrument (T400) seem advantageous. This study investigated their clinical use.

METHODS

Prospective analysis of tumor, patient, and operation characteristics was performed for 196 tumor resections per instrument intended for application.

RESULTS

The T400 instrument was applied in 162 operations, and the UC in 34 operations. Tumor and patient characteristics were similar except for tumor area (respectively, 7.5 and 17 cm(2); p = 0.003). Operative time was proportionate to the tumor area (p < 0.001) and inversely proportionate to its distance from the dentate line to the lower margin of the tumor of the UC (p = 0.002). Application reduced operative time by 26% (p = 0.02, corrected for area). Whereas, T400 was always singly sufficient for excision, the UC required T400 application in 50% of operations, especially for larger tumors (p = 0.026), with the result that more rectal wall circumference was captured (p = 0.043). Both groups had similar safety parameters.

CONCLUSIONS

The UC substantially reduced operative time compared with the T400, but frequently required the T400 for procedure completion. The T400 is always singly sufficient.