1
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Xie Y, Li J, Ding L, Zhang H. Analysis of Bacterial Culture of Fluid in the Surgical Area in Transanal Total Mesorectal Excision and Laparoscopic Total Mesorectal Excision. J Laparoendosc Adv Surg Tech A 2024; 34:576-580. [PMID: 38634816 DOI: 10.1089/lap.2024.0104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024] Open
Abstract
Purpose: To investigate the clinical value of the bacterial culture of fluid in the surgical area in laparoscopic transanal total mesorectal excision (Lap-taTME) and laparoscopic total mesorectal excision (Lap-TME). Methods: Clinical data of 106 patients with rectal cancer who had undergone surgery were retrospectively collected, including 56 patients in the Lap-taTME group and 50 patients in the Lap-TME group. In the Lap-taTME group, the initial pelvic fluid, the rectal cavity fluid after purse-string suture, and the pelvic cavity fluid after anastomosis were collected and recorded as culture No. 1, No. 2, and No. 3, respectively. In the Lap-TME group, culture No. 1 and No. 3 were collected as done in the Lap-taTME group. The culture results and postoperative complications were statistically analyzed. Results: The positive rate of culture No. 1 was zero in both groups, and there were 6 cases (10.7%) with positive culture No. 2 in the Lap-taTME group. However, the number of patients with positive culture No. 3 (7, 12.5%) and cumulative positive culture cases (11, 19.6%) in the Lap-taTME group were significantly higher than those in the Lap-TME group (0) (all P < .05). Pelvic infection occurred in 4 (7.1%) of the 11 cases (19.6%) with positive culture in the Lap-taTME group, accounting for 36.4% (4/11). There were no significant intergroup differences in anastomotic leakage and pelvic infection (all P > .05). Conclusion: Positive bacterial culture of fluid during Lap-taTME indicates an increased risk of pelvic infection after operation. Lap-taTME is more prone to intraoperative contamination than Lap-TME but does not significantly increase the risk of postoperative pelvic infection.
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Affiliation(s)
- Yang Xie
- Department of General Surgery, Chongqing General Hospital, Chongqing University, Chongqing, China
| | - Jie Li
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Liping Ding
- Department of Pediatrics, West China Second Hospital, Sichuan University, Chengdu, China
| | - Hongyu Zhang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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2
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You K, Hwang JA, Sohn DK, Lee DW, Park SS, Han KS, Hong CW, Kim B, Kim BC, Park SC, Oh JH. Exfoliate cancer cell analysis in rectal cancer surgery: comparison of laparoscopic and transanal total mesorectal excision, a pilot study. Ann Coloproctol 2023; 39:502-512. [PMID: 38145898 PMCID: PMC10781597 DOI: 10.3393/ac.2023.00479.0068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 09/26/2023] [Accepted: 11/05/2023] [Indexed: 12/27/2023] Open
Abstract
PURPOSE Minimally invasive surgery (MIS) is currently the standard treatment for rectal cancer. However, its limitations include complications and incomplete total mesorectal resection (TME) due to anatomical features and technical difficulties. Transanal TME (TaTME) has been practiced since 2010 to improve this, but there is a risk of local recurrence and intra-abdominal contamination. We aimed to analyze samples obtained through lavage to compare laparoscopic TME (LapTME) and TaTME. METHODS From June 2020 to January 2021, 20 patients with rectal cancer undergoing MIS were consecutively and prospectively recruited. Samples were collected at the start of surgery, immediately after TME, and after irrigation. The samples were analyzed for carcinoembryonic antigen (CEA) and cytokeratin 20 (CK20) through a quantitative real-time polymerase chain reaction. The primary outcome was to compare the detected amounts of CEA and CK20 immediately after TME between the surgical methods. RESULTS Among the 20 patients, 13 underwent LapTME and 7 underwent TaTME. Tumor location was lower in TaTME (7.3 cm vs. 4.6 cm, P=0.012), and negative mesorectal fascia (MRF) was more in LapTME (76.9% vs. 28.6%, P=0.044). CEA and CK20 levels were high in 3 patients (42.9%) only in TaTME. There was 1 case of T4 with incomplete purse-string suture and 1 case of positive MRF with dissection failure. All patients were followed up for an average of 32.5 months without local recurrence. CONCLUSION CEA and CK20 levels were high only in TaTME and were related to tumor factors or intraoperative events. However, whether the detection amount is clinically related to local recurrence remains unclear.
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Affiliation(s)
- Kiho You
- Center for Colorectal Cancer, National Cancer Center, Goyang, Korea
| | - Jung-Ah Hwang
- Genomics Core Facility, Research Core Center, National Cancer Center, Goyang, Korea
| | - Dae Kyung Sohn
- Center for Colorectal Cancer, National Cancer Center, Goyang, Korea
| | - Dong Woon Lee
- Center for Colorectal Cancer, National Cancer Center, Goyang, Korea
| | - Sung Sil Park
- Center for Colorectal Cancer, National Cancer Center, Goyang, Korea
| | - Kyung Su Han
- Center for Colorectal Cancer, National Cancer Center, Goyang, Korea
| | - Chang Won Hong
- Center for Colorectal Cancer, National Cancer Center, Goyang, Korea
| | - Bun Kim
- Center for Colorectal Cancer, National Cancer Center, Goyang, Korea
| | - Byung Chang Kim
- Center for Colorectal Cancer, National Cancer Center, Goyang, Korea
| | - Sung Chan Park
- Center for Colorectal Cancer, National Cancer Center, Goyang, Korea
| | - Jae Hwan Oh
- Center for Colorectal Cancer, National Cancer Center, Goyang, Korea
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3
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Harsløf S, Pachler FR, Thaysen HV, Drejer M, Brandsborg S, Nørager CB, Tøttrup A. Functional outcome and quality of life after transanal minimal invasive pouch surgery. Int J Colorectal Dis 2022; 37:1141-1150. [PMID: 35467122 DOI: 10.1007/s00384-022-04158-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/17/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE To investigate functional outcomes and quality of life (QoL) after restorative proctocolectomy (RPC) using transanal minimal invasive surgery (TAMIS). METHOD The study consists of two sub-studies. A cohort study comprised 98 consecutive patients, who underwent TAMIS RPC. These patients were the first at our department to undergo TAMIS RPC. We collected information about surgery, complications, postoperative morbidity and mortality ≤ 30 days, and pouch problems. Patients were also invited to participate in a case-control study in which the patients would respond to three different questionnaires, the Inflammatory Bowel Disease Questionnaire (IBDQ), the Short Form-36 General Health Questionnaire (SF-36), and questions from the Pouch Dysfunction Score. We compared the responding TAMIS RPC patients to a Danish national cohort (0-10 years from RPC, n = 514) of patients having RPC between 1980 and 2010. We compared functional outcomes and QoL. RESULTS Four (4%) of the TAMIS patients had an anastomotic leak; none of these required re-operation with removal of the pouch. Anastomotic leak was treated with antibiotics and drain. Out of the four leaks, only one ended up with a permanent stoma; all others had their stoma reversed successfully. The TAMIS patients had the same number of bowel movements as the patients in the Danish national cohort study. The same was seen with regard to incontinence. We had no conversions in our series of TAMIS procedures. CONCLUSION The TAMIS technique shows acceptable outcomes, both in regard to postoperative complications and also functional outcome and QoL.
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Affiliation(s)
- Sanne Harsløf
- Surgical Department, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark.
| | - Frederik Rønne Pachler
- Surgical Department, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Henriette Vind Thaysen
- Surgical Department, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Marie Drejer
- Surgical Department, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Søren Brandsborg
- Surgical Department, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Charlotte Buchard Nørager
- Surgical Department, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Anders Tøttrup
- Surgical Department, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark
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4
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Takai M, Kawase K, Kato D, Iinuma K, Nakane K, Koie T. Totally intracorporeal urinary diversion under robot‐assisted surgery may not increase the incidence and risk factors of surgical site infection. Int J Urol 2022; 29:474-476. [DOI: 10.1111/iju.14810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 01/06/2022] [Accepted: 01/17/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Manabu Takai
- Department of Urology Gifu University Graduate School of Medicine Gifu Japan
| | - Kota Kawase
- Department of Urology Gifu University Graduate School of Medicine Gifu Japan
| | - Daiki Kato
- Department of Urology Gifu University Graduate School of Medicine Gifu Japan
| | - Koji Iinuma
- Department of Urology Gifu University Graduate School of Medicine Gifu Japan
| | - Keita Nakane
- Department of Urology Gifu University Graduate School of Medicine Gifu Japan
| | - Takuya Koie
- Department of Urology Gifu University Graduate School of Medicine Gifu Japan
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5
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Nguyen TX, Ho HT, Phan HT, Vu HA, Pham NH. The effectiveness of double team for transanal total mesorectal excision in treatment of mid-low rectal cancer. INTERNATIONAL JOURNAL OF SURGERY OPEN 2021. [DOI: 10.1016/j.ijso.2021.100359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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6
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Park L, Zaghiyan KN, Fleshner PR. Transanal Ileal Pouch: Is It Better? J Laparoendosc Adv Surg Tech A 2021; 31:898-904. [PMID: 34129407 DOI: 10.1089/lap.2021.0115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background: Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the procedure of choice for patients with ulcerative colitis and select patients with Crohn's disease. Minimally invasive techniques have been increasingly adopted including the transanal approach. However there remains a dearth of comparative data assessing the technical advantages and outcomes of a transanal approach to the IPAA against other minimally invasive techniques. Methods: In this review, we describe our learned approach with the transanal IPAA (ta-IPAA) and highlight key technical steps for a successful surgery in addition to evaluating the current literature on surgical and functional outcomes of this relatively novel procedure. Results: The ta-IPAA affords better visualization and access during a pelvic dissection translating to lower conversion rates. Lower odds of postoperative morbidity have been reported, but there was no difference in severity of complications when present. Though this technique has the advantages of a more accurate rectal transection obviating the need for multiple staple firings, the risk of anastomotic leak was similar between the two groups. Functional outcomes were found to be overall similar, though data is limited. Conclusions: The technical aspects of the IPAA have continued to evolve to mitigate the challenges posed by a deep pelvic dissection. While the ta-IPAA has been shown to be a safe and feasible procedure, the true advantages and functional benefits of this technique have yet to be elucidated with large-scale, quality data.
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Affiliation(s)
- Lisa Park
- Department of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Karen N Zaghiyan
- Department of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Phillip R Fleshner
- Department of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
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7
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Cordewener C, Zürcher M, Müller PC, Müller-Stich BP, Zerz A, Linke GR, Steinemann DC. Randomized clinical trial on the use of a colon-occlusion device to assist rectal washout. Surg Endosc 2020; 35:5078-5087. [PMID: 32968914 PMCID: PMC8346441 DOI: 10.1007/s00464-020-07992-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 09/14/2020] [Indexed: 12/29/2022]
Abstract
Background Transrectal Natural Orifice Transluminal Endoscopic Surgery is currently limited by the inherent risk of surgical site infection due to peritoneal contamination after rectotomy. Coloshield has been developed as a temporary colon occlusion device to facilitate rectal washout. However, effectiveness and safety has not been evaluated in humans. Methods Twenty-two patients have been randomly assigned to undergo proctological intervention with a rectal washout with and without the use of Coloshield. Patients and assessors were blinded. Boston Bowel Preparation Scale (BBPS) has been determined 30 min as well as immediately after rectal washout. Feasibility, pain, intra- and postoperative morbidity as well as bowel function and continence 6 weeks after surgery were assessed. Results BBPS 30 min after rectal washout with and without Coloshield was in mean 2.42 ± 1.02 and 2.12 ± 0.89 (p = 0.042). Mean BBPS immediately after rectal washout was 2.39 ± 1.02 and 2.24 ± 0.66 (p = 0.269). Mean BBPS immediately after rectal washout and 30 min thereafter did not differ (p = 0.711). Coloshield application was feasible without any complications. The median (interquartile range) numeric rating scale for pain 4 h after surgery was 1 (0–1) and 3 (0–4) (p = 0.212). Six weeks after surgery 0/11 and 1/11 patients suffered from evacuation difficulties (p = 1.0) and the median Vaizey–Wexner score was 1 (0–3) and 1 (0–2) (p = 0.360). Conclusions Coloshield application in humans is feasible and safe. Slight benefits in rectal preparation by washout are found when Coloshield is used. Colon occlusion by Coloshield for transrectal NOTES should be evaluated within clinical studies. Trial registration Clinicaltrials.gov NCT02579330
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Affiliation(s)
- Carolin Cordewener
- Pelvic Floor Unit, Clarunis, University Center for Gastrointestinal and Liver Diseases, 4002, Basel, Switzerland
| | - Manuel Zürcher
- Department of Surgery, Spital Thun STS AG, Krankenhausstrasse 12, 3600, Thun, Switzerland
| | - Philip C Müller
- Department of Visceral and Transplantation Surgery, University Hospital Zürich, Rämistrasse 100, 8032, Zurich, Switzerland
| | - Beat P Müller-Stich
- Department of Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Andreas Zerz
- eSwiss Medical and Surgical Center, Klinik Stephanshorn, Brauerstrasse 97, 9016, St. Gallen, Switzerland
| | - Georg R Linke
- Department of Surgery, Spital Thun STS AG, Krankenhausstrasse 12, 3600, Thun, Switzerland
| | - Daniel C Steinemann
- Pelvic Floor Unit, Clarunis, University Center for Gastrointestinal and Liver Diseases, 4002, Basel, Switzerland. .,Medical Faculty, University Basel, Klingelbergstrasse 61, 4056, Basel, Switzerland.
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8
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Atallah S. Anatomical Considerations and Procedure-Specific Aspects Important in Preventing Operative Morbidity during Transanal Total Mesorectal Excision. Clin Colon Rectal Surg 2020; 33:157-167. [PMID: 32351339 DOI: 10.1055/s-0040-1701604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
As transanal total mesorectal excision (taTME) becomes increasingly utilized, its technical challenges and potential pitfalls have become more clearly appreciated. This chapter explores the differences in how anatomy presents itself from the taTME vantage point as compared with traditional approaches to taTME, and how special problems unique to taTME pose a new set of operative challenges. Morbidity related, specifically, to the technique of taTME is also delineated with particular focus on male urethral injury.
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Affiliation(s)
- Sam Atallah
- Department of Colorectal Surgery, Florida Hospital, Orlando, Florida
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9
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van Oostendorp SE, Belgers HJ, Bootsma BT, Hol JC, Belt EJTH, Bleeker W, Den Boer FC, Demirkiran A, Dunker MS, Fabry HFJ, Graaf EJR, Knol JJ, Oosterling SJ, Slooter GD, Sonneveld DJA, Talsma AK, Van Westreenen HL, Kusters M, Hompes R, Bonjer HJ, Sietses C, Tuynman JB. Locoregional recurrences after transanal total mesorectal excision of rectal cancer during implementation. Br J Surg 2020; 107:1211-1220. [PMID: 32246472 PMCID: PMC7496604 DOI: 10.1002/bjs.11525] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 12/19/2019] [Accepted: 01/13/2020] [Indexed: 12/21/2022]
Abstract
Background Transanal total mesorectal excision (TaTME) has been proposed as an approach in patients with mid and low rectal cancer. The TaTME procedure has been introduced in the Netherlands in a structured training pathway, including proctoring. This study evaluated the local recurrence rate during the implementation phase of TaTME. Methods Oncological outcomes of the first ten TaTME procedures in each of 12 participating centres were collected as part of an external audit of procedure implementation. Data collected from a cohort of patients treated over a prolonged period in four centres were also collected to analyse learning curve effects. The primary outcome was the presence of locoregional recurrence. Results The implementation cohort of 120 patients had a median follow up of 21·9 months. Short‐term outcomes included a positive circumferential resection margin rate of 5·0 per cent and anastomotic leakage rate of 17 per cent. The overall local recurrence rate in the implementation cohort was 10·0 per cent (12 of 120), with a mean(s.d.) interval to recurrence of 15·2(7·0) months. Multifocal local recurrence was present in eight of 12 patients. In the prolonged cohort (266 patients), the overall recurrence rate was 5·6 per cent (4·0 per cent after excluding the first 10 procedures at each centre). Conclusion TaTME was associated with a multifocal local recurrence rate that may be related to suboptimal execution rather than the technique itself. Prolonged proctoring, optimization of the technique to avoid spillage, and quality control is recommended.
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Affiliation(s)
- S E van Oostendorp
- Department of Surgery, Amsterdam UMC, Location VUmc, Amsterdam, the Netherlands
| | - H J Belgers
- Zuyderland Medical Centre, Sittard-Geleen and Heerlen, Dordrecht, the Netherlands
| | - B T Bootsma
- Department of Surgery, Amsterdam UMC, Location VUmc, Amsterdam, the Netherlands
| | - J C Hol
- Department of Surgery, Amsterdam UMC, Location VUmc, Amsterdam, the Netherlands.,Gelderse Vallei Hospital, Ede, the Netherlands
| | - E J T H Belt
- Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - W Bleeker
- Wilhelmina Hospital, Assen, the Netherlands
| | | | | | - M S Dunker
- Noord West Hospital, Alkmaar, the Netherlands
| | - H F J Fabry
- Bravis Hospital, Roosendaal, the Netherlands
| | - E J R Graaf
- IJsselland Hospital, Cappelle aan den Ijssel, the Netherlands
| | - J J Knol
- Department of Abdominal Surgery, Jessa Hospital, Hasselt, Belgium
| | | | - G D Slooter
- Maxima Medical Centre, Veldhoven, the Netherlands
| | | | - A K Talsma
- Deventer Hospital, Deventer, the Netherlands
| | | | - M Kusters
- Department of Surgery, Amsterdam UMC, Location VUmc, Amsterdam, the Netherlands
| | - R Hompes
- Department of Surgery, Amsterdam UMC, Location AMC, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - H J Bonjer
- Department of Surgery, Amsterdam UMC, Location VUmc, Amsterdam, the Netherlands
| | - C Sietses
- Gelderse Vallei Hospital, Ede, the Netherlands
| | - J B Tuynman
- Department of Surgery, Amsterdam UMC, Location VUmc, Amsterdam, the Netherlands
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10
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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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11
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Thien HH, Hiep PN, Thanh PH, Xuan NT, Trung TN, Vy PT, Dong PX, Hieu MT, Son NH. Transanal total mesorectal excision for locally advanced middle-low rectal cancers. BJS Open 2019; 4:268-273. [PMID: 32207572 PMCID: PMC7093787 DOI: 10.1002/bjs5.50234] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 09/22/2019] [Accepted: 09/30/2019] [Indexed: 12/13/2022] Open
Abstract
Background This study investigated the results of transanal total mesorectal excision (TaTME) combined with laparoscopy for locally advanced mid–low rectal cancer. Methods Patients with mid–low locally advanced rectal cancer (T3 category or above and/or N+) who underwent rectal resection with TaTME technique were enrolled prospectively. Patients who had distant metastasis, multiple malignancies, intestinal obstruction or perforation, or a clinical complete response to chemoradiotherapy were excluded. Postoperative results, including morbidity, circumferential resection margin (CRM) assessment, short‐term survival and functional outcomes, were analysed. Results Thirty‐eight patients, with 25 mid and 13 low rectal tumours, who had elective resection by TaTME from March 2015 to September 2018 were included. There were 25 men and 13 women. Mean(s.d.) age was 58·2(16·4) years and mean(s.d.) BMI was 24·2(2·5) kg/m2. Tumours were 3–9 cm from the anal verge. Mean(s.d.) duration of surgery was 210(42) min. All patients had hand‐sewn anastomoses and protective ileostomies. There were no conversions, abdominal perineal resections or postoperative deaths. Four patients had a complication, including three presacral abscesses, all managed by transanastomotic drainage. At 3 months after ileostomy closure, all patients had perfect continence. Apart from a greater tumour diameter in patients with low rectal cancers (6·0 cm versus 4·6 cm in those with mid rectal tumours; P = 0·035), clinical features were similar in the two groups. CRM positivity was greater for low than for mid rectal tumours (3 of 13 versus 0 of 25 respectively; P = 0·034), and more patients with a low tumour had TME grade 2 (4 of 13 versus 1 of 25; P = 0·038). There was no difference in oncological outcomes at 17 months. Conclusion Although this study cohort was small, special attention should be paid to bulky low rectal tumours to reduce the rate of CRM positivity.
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Affiliation(s)
- H. H. Thien
- Department of Paediatric and Abdominal Emergency SurgeryHue Central HospitalHue CityVietnam
| | - P. N. Hiep
- Department of Paediatric and Abdominal Emergency SurgeryHue Central HospitalHue CityVietnam
| | - P. H. Thanh
- Department of Paediatric and Abdominal Emergency SurgeryHue Central HospitalHue CityVietnam
| | - N. T. Xuan
- Department of Paediatric and Abdominal Emergency SurgeryHue Central HospitalHue CityVietnam
| | - T. N. Trung
- Department of Paediatric and Abdominal Emergency SurgeryHue Central HospitalHue CityVietnam
| | - P. T. Vy
- Department of Paediatric and Abdominal Emergency SurgeryHue Central HospitalHue CityVietnam
| | - P. X. Dong
- Department of Paediatric and Abdominal Emergency SurgeryHue Central HospitalHue CityVietnam
| | - M. T. Hieu
- Department of Paediatric and Abdominal Emergency SurgeryHue Central HospitalHue CityVietnam
| | - N. H. Son
- Paediatric CentreHue Central HospitalHue CityVietnam
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12
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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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13
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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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14
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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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15
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Kneist W. [Transanal total mesorectal excision (TaTME) for primary rectal cancer : Video article]. Chirurg 2019; 88:863-866. [PMID: 28695225 DOI: 10.1007/s00104-017-0467-3] [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: 01/03/2023]
Abstract
Transanal total mesorectal excision (TaTME) is a new surgical technique in the treatment of selected patients with rectal cancer. This manuscript and the accompanying video report with commentary, which is available online, outlines various equipment requirements and step by step aspects of the surgical technique. With respect to the implementation of TaTME particular attention should be paid to the topography and surgical education.
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Affiliation(s)
- W Kneist
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland.
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16
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Veltcamp Helbach M, van Oostendorp SE, Koedam TWA, Knol JJ, Stockmann HBAC, Oosterling SJ, Vuylsteke RCLM, de Graaf EJR, Doornebosch PG, Hompes R, Bonjer HJ, Sietses C, Tuynman JB. Structured training pathway and proctoring; multicenter results of the implementation of transanal total mesorectal excision (TaTME) in the Netherlands. Surg Endosc 2019; 34:192-201. [PMID: 30888498 PMCID: PMC6946716 DOI: 10.1007/s00464-019-06750-w] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 03/06/2019] [Indexed: 12/17/2022]
Abstract
Background Transanal total mesorectal excision (TaTME) is a new complex technique with potential to improve the quality of surgical mesorectal excision for patients with mid and low rectal cancer. The procedure is technically challenging and has shown to be associated with a relative long learning curve which might hamper widespread adoption. Therefore, a national structured training pathway for TaTME has been set up in the Netherlands to allow safe implementation. The aim of this study was to monitor safety and efficacy of the training program with 12 centers. Methods Short-term outcomes of the first ten TaTME procedures were evaluated in 12 participating centers in the Netherlands within the national structured training pathway. Consecutive patients operated during and after the proctoring program for rectal carcinoma with curative intent were included. Primary outcome was the incidence of intraoperative complications, secondary outcomes included postoperative complications and pathological outcomes. Results In October 2018, 12 hospitals completed the training program and from each center the first 10 patients were included for evaluation. Intraoperative complications occurred in 4.9% of the cases. The clinicopathological outcome reported 100% for complete or nearly complete specimen, 100% negative distal resection margin, and the circumferential resection margin was positive in 5.0% of patients. Overall postoperative complication rate was 45.0%, with 19.2% Clavien–Dindo ≥ III and an anastomotic leak rate of 17.3%. Conclusions This study shows that the nationwide structured training program for TaTME delivers safe implementation of TaTME in terms of intraoperative and pathology outcomes within the first ten consecutive cases in each center. However, postoperative morbidity is substantial even within a structured training pathway and surgeons should be aware of the learning curve of this new technique.
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Affiliation(s)
- M Veltcamp Helbach
- Department of Surgery, Amsterdam UMC, Location VUmc, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
| | - S E van Oostendorp
- Department of Surgery, Amsterdam UMC, Location VUmc, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - T W A Koedam
- Department of Surgery, Amsterdam UMC, Location VUmc, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - J J Knol
- Department of Surgery, Jessa Hospital, Hasselt and Herk-de-Stad, Belgium
| | - H B A C Stockmann
- Department of Surgery, Spaarne Gasthuis, Haarlem and Hoofddorp, The Netherlands
| | - S J Oosterling
- Department of Surgery, Spaarne Gasthuis, Haarlem and Hoofddorp, The Netherlands
| | - R C L M Vuylsteke
- Department of Surgery, Spaarne Gasthuis, Haarlem and Hoofddorp, The Netherlands
| | - E J R de Graaf
- Department of Surgery, IJsselland Hospital, Cappelle a/d Ijssel, The Netherlands
| | - P G Doornebosch
- Department of Surgery, IJsselland Hospital, Cappelle a/d Ijssel, The Netherlands
| | - R Hompes
- Department of Surgery, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - H J Bonjer
- Department of Surgery, Amsterdam UMC, Location VUmc, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - C Sietses
- Department of Surgery, Gelderse Vallei Hospital, Ede, The Netherlands
| | - J B Tuynman
- Department of Surgery, Amsterdam UMC, Location VUmc, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
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17
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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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18
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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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19
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Wu Z, Zhou W, Chen F, Wang W, Feng Y. Short-term Outcomes of Transanal versus Laparoscopic Total Mesorectal Excision: A Systematic Review and Meta-Analysis of Cohort Studies. J Cancer 2019; 10:341-354. [PMID: 30719128 PMCID: PMC6360303 DOI: 10.7150/jca.27830] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 10/01/2018] [Indexed: 12/14/2022] Open
Abstract
Introduction: The TaTME surgery has been developed to overcome the difficulties encountered in the practice of laparoscopic surgery for rectal cancer, especially in male, obese patients with a narrow pelvis and mid and low rectal tumours. Although the TaTME shows some promising results regarding oncological and operative outcomes, some pitfalls have been indicated. Thus, the real benefits of this novel technique over the laparoscopic surgery remain unknown. The aim of the present study was to perform a systematic review and meta-analysis of the currently available literature on the outcomes of TaTME in comparison with laparoscopic procedure. Methods: A systematic literature search was conducted using the web-based databases MEDLINE, EMBASE, and Cochrane CENTRAL, followed by a manual search of the references of the initially identified articles. The study information, patient characteristics, oncological outcomes, perioperative outcomes, as well as short- and long-term postoperative outcomes were collected and critically evaluated. Results: Nine retrospective cohort studies were identified, comprising 751 patients (348 with TaTME, 403 with LaTME). The positive circumferential resection margin (P = 0.01) was better in patients treated with TaTME; whereas the quality of mesorectum, circumferential resection margin, distal resection margin, and harvested lymph nodes were comparable. The TaTME was associated with shorter operative time (P = 0.05; P = 0.0006 in subgroup analysis), less blood loss (P = 0.02), less conversion (P = 0.007), and shorter hospital stay (P = 0.06; P = 0.003 in subgroup analysis). The intraoperative complications were similar. As for the postoperative outcomes, the overall postoperative complications (P = 0.02) and the readmission (P = 0.003) were found less in patients treated with TaTME; however, the individual postoperative complications were found comparable. Conclusion: The present systematic review and meta-analysis suggested some advantages of TaTME, in terms of circumferential resection margin involvement, operative time, blood loss, conversion, hospital stay, overall postoperative complications, and readmission. It appears that the TaTME procedure achieved a better resection quality and smoother recovery in selected patients, without compromising the short-term safety. Nevertheless, it is too early to draw any conclusion, since results of high quality clinical evidence from randomized controlled trials have to be awaited. As it is technically demanding, the procedure needs to be taught and learned systematically to ensure safe implementation.
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Affiliation(s)
- Zhiyuan Wu
- Department of Colorectal and Hernia Minimally Invasive Surgery, Shengjing Hospital of China Medical University, Shenyang, China
| | - Wenlong Zhou
- Department of General Surgery, Shenyang 242 Hospital, Shenyang, China
| | - Fu Chen
- Department of General Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Wentao Wang
- Department of Gastrosurgery, Liaoning Cancer Hospital and Institute, Shenyang, China
| | - Yong Feng
- Department of Colorectal and Hernia Minimally Invasive Surgery, Shengjing Hospital of China Medical University, Shenyang, China
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20
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Müller PC, Dube A, Steinemann DC, Senft JD, Gehrig T, Benner L, Nickel F, Müller-Stich BP, Linke GR. Contamination After Disinfectant Rectal Washout in Left Colectomy as a Model for Transrectal NOTES: A Randomized Controlled Trial. J Surg Res 2018; 232:635-642. [PMID: 30463785 DOI: 10.1016/j.jss.2018.07.066] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 07/16/2018] [Accepted: 07/19/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND In natural orifice transluminal endoscopic surgery (NOTES) with transrectal (TR) access the intraoperative opening of the rectal wall poses a risk of intraperitoneal contamination and subsequent infectious complications. A rectal washout with a disinfectant may reduce this risk. The aim of the study was to assess the intraoperative contamination on the circular stapler pin when a rectal washout with povidone-iodine (RW-PI) or Ringer solution was performed in patients undergoing left-sided colectomy. Furthermore, the additional effect of an irrigation instrument on the contamination was evaluated. METHODS In a patient and assessor blinded randomized controlled trial, patients undergoing left-sided colectomy were assigned to rectal washout with PI with an irrigation instrument (RW-PI; n = 23), rectal washout with Ringer solution with an irrigation instrument (RW-R; n = 21) or rectal washout with Ringer solution without an irrigation instrument (RW; n = 25). An end-to-end anastomosis with a circular stapler was performed. The contamination on the pin of the circular stapler was chosen as primary endpoint in order to simulate the intraabdominal contamination risk during TR NOTES. Secondary endpoints were contamination of the rectal mucosa, peritoneal contamination and postoperative morbidity. RESULTS The contamination rate of the pin of the circular stapler did not differ (RW-PI 39.1%, RW-R 33.3%, RW 52.0%; P = 0.421), but contamination of the rectal mucosa was reduced (47.8% versus 95.2% versus 100%; P < 0.001) and peritoneal contamination tended to be reduced (39.1% versus 71.4% versus 60.0%; P = 0.09) when a rectal washout with PI was performed. The rates of infectious complications (17.4% versus 9.5% versus 12.0%; P = 0.821) and of overall complications (30.4% versus 28.6% versus 44.0%; P = 0.476) did not differ. CONCLUSIONS Despite an intense rectal washout with PI, contamination of the stapler pin did not differ. Intraabdominal bacterial translocation was frequently encountered even after disinfectant rectal washout with PI. Further studies might focus on the clinical impact of intraabdominal contamination in TR NOTES.
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Affiliation(s)
- Philip C Müller
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Anand Dube
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Daniel C Steinemann
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Jonas D Senft
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Tobias Gehrig
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Laura Benner
- Institute for Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Felix Nickel
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Beat P Müller-Stich
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Georg R Linke
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany; Department of Surgery, Hospital STS Thun AG, Thun, Switzerland.
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21
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Westwood DA, Cuda TJ, Hamilton AER, Clark D, Stevenson ARL. Transanal total mesorectal excision for rectal cancer: state of the art. Tech Coloproctol 2018; 22:649-655. [PMID: 30255213 DOI: 10.1007/s10151-018-1844-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 09/01/2018] [Indexed: 12/13/2022]
Abstract
Achieving a high-quality total mesorectal excision (TME) resection specimen is a central tenet of curative rectal cancer management. However, operating at the caudal extremity of the pelvis is inherently challenging and a number of patient- and tumour-related factors may increase the risk of obtaining a poor TME specimen and positive resection margins. Transanal TME (TaTME) is an advanced surgical technique developed to overcome the limitations in pelvic exposure and instrumentation of transabdominal surgery. This up-to-date narrative review describes the evolution of TME surgery, the indications for TaTME, current published outcomes, its limitations and future developments.
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Affiliation(s)
- David A Westwood
- Colorectal Unit, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Brisbane, QLD, Australia.
| | - Tahleesa J Cuda
- Colorectal Unit, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Brisbane, QLD, Australia
| | - A E Ricardo Hamilton
- Colorectal Unit, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Brisbane, QLD, Australia
| | - David Clark
- Colorectal Unit, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Brisbane, QLD, Australia.,Holy Spirit Northside Private Hospital, Brisbane, QLD, Australia
| | - Andrew R L Stevenson
- Colorectal Unit, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Brisbane, QLD, Australia.,Holy Spirit Northside Private Hospital, Brisbane, QLD, Australia
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22
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Iordache F, Prodan A, Beuran M, Gachabayov M, Bergamaschi R. Pilot study on bacterial contamination of the pelvis in proctectomy for cancer. Colorectal Dis 2018; 20:823-825. [PMID: 29927515 DOI: 10.1111/codi.14315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 05/14/2018] [Indexed: 02/08/2023]
Affiliation(s)
- F Iordache
- Department of Surgery, Bucharest Emergency Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - A Prodan
- Department of Surgery, Bucharest Emergency Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - M Beuran
- Department of Surgery, Bucharest Emergency Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - M Gachabayov
- Department of Surgery, Bucharest Emergency Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - R Bergamaschi
- Department of Surgery, Bucharest Emergency Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
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23
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Atallah S, Hodges A, Larach SW. Direct target NOTES: prospective applications for next generation robotic platforms. Tech Coloproctol 2018; 22:363-371. [PMID: 29855814 DOI: 10.1007/s10151-018-1788-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 05/04/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND A new era in surgical robotics has centered on alternative access to anatomic targets and next generation designs include flexible, single-port systems which follow circuitous rather than straight pathways. Such systems maintain a small footprint and could be utilized for specialized operations based on direct organ target natural orifice transluminal endoscopic surgery (NOTES), of which transanal total mesorectal excision (taTME) is an important derivative. METHODS During two sessions, four direct target NOTES operations were conducted on a cadaveric model using a flexible robotic system to demonstrate proof-of-concept of the application of a next generation robotic system to specific types of NOTES operations, all of which required removal of a direct target organ through natural orifice access. These four operations were (a) robotic taTME, (b) robotic transvaginal hysterectomy in conjunction with (c) robotic transvaginal salpingo-oophorectomy, and in an ex vivo model, (d) trans-cecal appendectomy. RESULTS Feasibility was demonstrated in all cases using the Flex® Robotic System with Colorectal Drive. During taTME, the platform excursion was 17 cm along a non-linear path; operative time was 57 min for the transanal portion of the dissection. Robotic transvaginal hysterectomy was successfully completed in 78 min with transvaginal extraction of the uterus, although laparoscopic assistance was required. Robotic transvaginal unilateral salpingo-oophorectomy with transvaginal extraction of the ovary and fallopian tube was performed without laparoscopic assistance in 13.5 min. In an ex vivo model, a robotic trans-cecal appendectomy was also successfully performed for the purpose of demonstrating proof-of-concept only; this was completed in 24 min. CONCLUSIONS A flexible robotic system has the potential to access anatomy along circuitous paths, making it a suitable platform for direct target NOTES. The conceptual operations posed could be considered suitable for next generation robotics once the technology is optimized, and after further preclinical validation.
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Affiliation(s)
- S Atallah
- Endo-Surgical Center of Florida, Department of Colorectal Surgery, Florida Hospital, Orlando, FL, USA.
| | - A Hodges
- Nova Southeastern University, Davie, FL, USA
| | - S W Larach
- Endo-Surgical Center of Florida, Department of Colorectal Surgery, Florida Hospital, Orlando, FL, USA
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24
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Chang TC, Kiu KT. Transanal Total Mesorectal Excision in Lower Rectal Cancer: Comparison of Short-Term Outcomes with Conventional Laparoscopic Total Mesorectal Excision. J Laparoendosc Adv Surg Tech A 2018; 28:365-369. [DOI: 10.1089/lap.2017.0520] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Tung-Cheng Chang
- Division of Colorectal Surgery, Department of Surgery, Taipei Medical University Shuang-Ho Hospital, New Taipei City, Taiwan
- Graduate Institute of Clinical Medicine, Taipei Medical University, Taipei City, Taiwan
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, Taiwan
| | - Kee-Thai Kiu
- Division of Colorectal Surgery, Department of Surgery, Taipei Medical University Shuang-Ho Hospital, New Taipei City, Taiwan
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25
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Emile SH, de Lacy FB, Keller DS, Martin-Perez B, Alrawi S, Lacy AM, Chand M. Evolution of transanal total mesorectal excision for rectal cancer: From top to bottom. World J Gastrointest Surg 2018; 10:28-39. [PMID: 29588809 PMCID: PMC5867456 DOI: 10.4240/wjgs.v10.i3.28] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 01/07/2018] [Accepted: 02/09/2018] [Indexed: 02/06/2023] Open
Abstract
The gold standard for curative treatment of locally advanced rectal cancer involves radical resection with a total mesorectal excision (TME). TME is the most effective treatment strategy to reduce local recurrence and improve survival outcomes regardless of the surgical platform used. However, there are associated morbidities, functional consequences, and quality of life (QoL) issues associated with TME; these risks must be considered during the modern-day multidisciplinary treatment for rectal cancer. This has led to the development of new surgical techniques to improve patient, oncologic, and QoL outcomes. In this work, we review the evolution of TME to the transanal total mesorectal excision (TaTME) through more traditional minimally invasive platforms. The review the development, safety and feasibility, proposed benefits and risks of the procedure, implementation and education models, and future direction for research and implementation of the TaTME in colorectal surgery. While satisfactory short-term results have been reported, the procedure is in its infancy, and long term outcomes and definitive results from controlled trials are pending. As evidence for safety and feasibility accumulates, structured training programs to standardize teaching, training, and safe expansion will aid the safe spread of the TaTME.
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Affiliation(s)
- Sameh Hany Emile
- Department of General Surgery, Mansoura Faculty of Medicine, Mansoura City 35516, Egypt
| | - F Borja de Lacy
- Department of Surgery, Hospital Clinic, University of Barcelona, Barcelona 08036, Spain
| | - Deborah Susan Keller
- GENIE Centre, University College London, London NW1 2BU, United Kingdom
- Department of Surgery and Interventional Sciences, University College London Hospitals, NHS Trusts, London NW1 2BU, United Kingdom
| | - Beatriz Martin-Perez
- Department of Surgery, Hospital Clinic, University of Barcelona, Barcelona 08036, Spain
| | - Sadir Alrawi
- Department of Surgical Oncology, Alzahra Cancer Center, Al Zahra Hospital, Dubai 3499, United Arab Emirates
| | - Antonio M Lacy
- Department of Surgery, Hospital Clinic, University of Barcelona, Barcelona 08036, Spain
| | - Manish Chand
- GENIE Centre, University College London, London NW1 2BU, United Kingdom
- Department of Surgery and Interventional Sciences, University College London Hospitals, NHS Trusts, London NW1 2BU, United Kingdom
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Müller PC, Senft JD, Gath P, Steinemann DC, Nickel F, Billeter AT, Müller-Stich BP, Linke GR. Transrectal rigid-hybrid NOTES cholecystectomy can be performed without peritoneal contamination: a controlled porcine survival study. Surg Endosc 2018; 32:478-484. [PMID: 28799061 DOI: 10.1007/s00464-017-5804-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 07/29/2017] [Indexed: 01/02/2023]
Abstract
BACKGROUND AND STUDY AIMS The risk of infectious complications due to peritoneal contamination is a major concern and inhibits the widespread use of transrectal NOTES. A standardized rectal washout with a reversible colon occlusion device in situ has previously shown potential in reducing peritoneal contamination. The aim of this study was to compare the peritoneal contamination rate and inflammatory reaction for transrectal cholecystectomy after ideal rectal preparation (trCCE) and standard laparoscopic cholecystectomy (lapCCE) in a porcine survival experiment. METHODS Twenty pigs were randomized to trCCE (n = 10) or lapCCE (n = 10). Before trCCE, rectal washout was performed with saline solution. A colon occlusion device was then inserted and a second washout with povidone-iodine was performed. The perioperative course and the inflammatory reaction (leukocytes, C-reactive protein) were compared. At necropsy, 14 days after surgery the abdominal cavity was screened for infectious complications and peritoneal swabs were obtained for comparison of peritoneal contamination. RESULTS Peritoneal contamination was lower after trCCE than after lapCCE (0/10 vs. 6/10; p = 0.003). No infectious complications were found at necropsy in either group and postoperative complications did not differ (p = 1.0). Immediately after the procedure, leukocytes were higher after lapCCE (17.0 ± 2.7 vs. 14.6 ± 2.3; p = 0.047). Leukocytes and C-reactive protein showed no difference in the further postoperative course. Intraoperative complications and total operation time (trCCE 114 ± 32 vs. 111 ± 27 min; p = 0.921) did not differ, but wound closure took longer for trCCE (31.5 ± 19 vs. 13 ± 5 min; p = 0.002). CONCLUSIONS After standardized rectal washout with a colon occlusion device in situ, trCCE was associated without peritoneal contamination and without access-related infectious complications. Based on the findings of this study, a randomized controlled clinical study comparing clinical outcomes of trCCE with lapCCE should be conducted.
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Affiliation(s)
- Philip C Müller
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
| | - Jonas D Senft
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Philip Gath
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Daniel C Steinemann
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Felix Nickel
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Adrian T Billeter
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Beat P Müller-Stich
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Georg R Linke
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
- Department of Surgery, Hospital STS Thun AG, Krankenhausstrasse 12, 3600, Thun, Switzerland
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Adamina M, Buchs NC, Penna M, Hompes R. St.Gallen consensus on safe implementation of transanal total mesorectal excision. Surg Endosc 2017; 32:1091-1103. [PMID: 29234940 PMCID: PMC5807525 DOI: 10.1007/s00464-017-5990-2] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 10/23/2017] [Indexed: 02/06/2023]
Abstract
Background The management of rectal cancer has evolved over the years, including the recent rise of Transanal Total Mesorectal Excision (TaTME). TaTME addresses the limitations created by the bony confines of the pelvis, bulky tumours, and fatty mesorectum, particularly for low rectal cancers. However, guidance is required to ensure safe implementation and to avoid the pitfalls and potential major morbidity encountered by the early adopters of TaTME. We report a broad international consensus statement, which provides a basis for optimal clinical practice. Methods Forty international experts were invited to participate based on clinical and academic achievements. The consensus statements were developed using Delphi methodology incorporating three successive rounds. Consensus was defined as agreement by 80% or more of the experts. Results A total of 37 colorectal surgeons from 20 countries and 5 continents (Europe, Asia, North and South America, Australasia) contributed to the consensus. Participation to the iterative Delphi rounds was 100%. An expert radiologist, pathologist, and medical oncologist provided recommendations to maximize relevance to current practice. Consensus was obtained on all seven different chapters: patient selection and surgical indication, perioperative management, patient positioning and operating room set up, surgical technique, devices and instruments, pelvic anatomy, TaTME training, and outcomes analysis. Conclusions This multidisciplinary consensus statement achieved more than 80% approval and can thus be graded as strong recommendation, yet acknowledging the current lack of high level evidence. It provides the best possible guidance for safe implementation and practice of Transanal Total Mesorectal Excision.
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Affiliation(s)
- Michel Adamina
- Department of Surgery, Cantonal Hospital Winterthur, Brauerstrasse 15, Postfach 834, 8401, Winterthur, Switzerland.
- University of Basel, Basel, Switzerland.
| | - Nicolas C Buchs
- Department of Surgery, University Hospital Geneva, Geneva, Switzerland
| | - Marta Penna
- Department of Colorectal Surgery, University Hospitals of Oxford, Oxford, UK
| | - Roel Hompes
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
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Operative vectors, anatomic distortion, fluid dynamics and the inherent effects of pneumatic insufflation encountered during transanal total mesorectal excision. Tech Coloproctol 2017; 21:783-794. [PMID: 28993914 DOI: 10.1007/s10151-017-1693-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 09/06/2017] [Indexed: 01/14/2023]
Abstract
BACKGROUND Transanal total mesorectal excision (taTME) is an altogether different approach to rectal cancer surgery, and the effects of carbon dioxide (CO2) on this dissection remain poorly described. METHODS This article critically examines the effect of carbon dioxide insufflation and the workspace it creates during the process of taTME. The unique aspects of insulation with this approach are governed by the laws of physics, especially the principles of fluid dynamics, an area that remains poorly described for laparoscopy and not at all described for taTME. RESULTS A summary of established factors which affect the operative field of the taTME surgeon is delineated and further explored. In addition, new concepts regarding gas delivery, such as insufflation vectors, anatomic distortion, hyper-dissection, and workspace volume rate of change as a function of taTME dissection time, are addressed. Collectively, these factors pose important challenges which increase case complexity and are thus essential for taTME trainers and trainees alike to understand. CONCLUSIONS Although an invisible gas, CO2 insufflation with taTME produces markedly visible effects which are imposed upon the operative field. This can result in anatomic distortion and misperception of operative planes. Thus, practicing taTME surgeons should be cognizant of these effects.
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Uptake of Transanal Total Mesorectal Excision in North America: Initial Assessment of a Structured Training Program and the Experience of Delegate Surgeons. Dis Colon Rectum 2017; 60:1023-1031. [PMID: 28891845 DOI: 10.1097/dcr.0000000000000823] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Transanal total mesorectal excision is a new approach to curative-intent rectal cancer surgery. Training and surgeon experience with this approach has not been assessed previously in America. OBJECTIVE The purpose of this study was to characterize a structured training program and to determine the experience of delegate surgeons. DESIGN Data were assimilated from an anonymous, online survey delivered to attendees on course completion. Data on surgeon performance during hands-on cadaveric dissection were collected prospectively. SETTINGS This study was conducted at a single tertiary colorectal surgery referral center, and cadaveric hands-on training was conducted at a specialized surgeon education center. MAIN OUTCOME MEASURES The main outcome measurement was the use of the course and surgeon experience posttraining. RESULTS During a 12-month period, eight 2-day transanal total mesorectal excision courses were conducted. Eighty-one colorectal surgeons successfully completed the course. During cadaveric dissection, 71% achieved a complete (Quirke 3) specimen; 26% were near complete (Quirke 2), and 3% were incomplete (Quirke 1). A total of 9.1% demonstrated dissection in the incorrect plane, whereas 4.5% created major injury to the rectum or surrounding structures, excluding the prostate. Thirty eight (46.9%) of 81 surgeon delegates responded to an online survey. Of survey respondents, 94.6% believed training should be required before performing transanal total mesorectal excision. Posttraining, 94.3% of surgeon delegates planned to use transanal total mesorectal excision for distal-third rectal cancers, 74.3% for middle-third cancers, and 8.6% for proximal-third cancers. The most significant complication reported was urethral injury; 5 were reported by the subset of survey respondents who had performed this operation postcourse. LIMITATIONS The study was limited by inherent reporting bias, including observer and recall biases. CONCLUSIONS Although this structured training program for transanal total mesorectal excision was found to be useful by the majority of respondents, the risk of iatrogenic injury after training remains high, suggesting that this training pedagogy alone is insufficient. See Video Abstract at http://links.lww.com/DCR/A335.
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Transanal Total Mesorectal Excision: Pneumodissection of Retroperitoneal Structures Eases Laparoscopic Rectal Resection. Dis Colon Rectum 2017; 60:1109-1112. [PMID: 28891856 DOI: 10.1097/dcr.0000000000000893] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Laparoscopic total mesorectal excision is effective and safe but often technically challenging because of inadequate exposure. Transanal total mesorectal excision was introduced to mitigate this limitation and improve the quality of mesorectal dissection in even the most challenging cases. Currently, the technique for transanal total mesorectal excision dissection is not standardized. TECHNIQUE The sequential approach to transanal total mesorectal excision mirrors the principles of the transanal abdominal transanal procedure. It begins with the transanal step, followed by the laparoscopic step, and then the transanal total mesorectal excision. The perirectal space is entered via a full-thickness dissection of the anterior rectal wall. Carbon dioxide is left flowing, widening the embryonic planes between the mesorectal and pelvic fascias, then moving upward through the retroperitoneal space. The surgeon switches to the abdominal field and begins laparoscopic dissection, consisting of inferior mesenteric artery dissection and division, inferior mesenteric vein dissection and division, and possible splenic flexure dissection. Pneumodissection facilitates this procedure by distancing the inferior mesenteric artery from the hypogastric nerves and opening the embryonic fusion plane between the Toldt and Gerota fascias to allow faster division of the left colon lateral attachments. The operation continues with a switch to the perineal field and mesorectal excision. RESULTS A total of 102 patients underwent transanal total mesorectal excision as described. Mean operative time was 185.0 + 87.5 minutes (range, 60-480 min), and there was no conversion to open surgery. Postoperative morbidity was 33.3%. Mortality rate at 30 days was 1.96% (2 cases). Quality of mesorectal excision according to Quirke was assessed in all of the specimens and found to be complete in 99 cases (97.1%) and nearly complete in 2.9% of cases. CONCLUSIONS Transanal total mesorectal excision may benefit from pneumodissection, expedites the laparoscopic step, and the sequential approach facilitates the visualization of the correct dissection planes. The safety and cost-effectiveness of the procedure still warrant consideration. See Video at http://links.lww.com/DCR/A418.
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Plummer JM, Leake PA, Albert MR. Recent advances in the management of rectal cancer: No surgery, minimal surgery or minimally invasive surgery. World J Gastrointest Surg 2017; 9:139-148. [PMID: 28690773 PMCID: PMC5483413 DOI: 10.4240/wjgs.v9.i6.139] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 03/06/2017] [Accepted: 04/10/2017] [Indexed: 02/06/2023] Open
Abstract
Over the last decade, with the acceptance of the need for improvements in the outcome of patients affected with rectal cancer, there has been a significant increase in the literature regarding treatment options available to patients affected by this disease. That treatment related decisions should be made at a high volume multidisciplinary tumor board, after pre-operative rectal magnetic resonance imaging and the importance of total mesorectal excision (TME) are accepted standard of care. More controversial is the emerging role for watchful waiting rather than radical surgery in complete pathologic responders, which may be appropriate in 20% of patients. Patients with early T1 rectal cancers and favorable pathologic features can be cured with local excision only, with transanal minimal invasive surgery (TAMIS) because of its versatility and almost universal availability of the necessary equipment and skillset in the average laparoscopic surgeon, emerging as the leading option. Recent trials have raised concerns about the oncologic outcomes of the standard “top-down” TME hence transanal TME (TaTME “bottom-up”) approach has gained popularity as an alternative. The challenges are many, with a dearth of evidence of the oncologic superiority in the long-term for any given option. However, this review highlights recent advances in the role of chemoradiation only for complete pathologic responders, TAMIS for highly selected early rectal cancer patients and TaTME as options to improve cure rates whilst maintaining quality of life in these patients, while we await the results of further definitive trials being currently conducted.
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Abstract
Since the introduction of transanal endoscopic microsurgery (TEM) in the 1980 s, the minimally invasive transanal approach has been a treatment option for selected patients with colorectal diseases. Recently, transanal minimally invasive surgery (TAMIS) was introduced as an alternative technique. TAMIS is a hybrid between TEM and single-port laparoscopy and was followed by introduction of transanal total mesorectal excision (TaTME). Although the TaTME experience remains preliminary, it appears to be an attractive minimally invasive procedure for carefully selected patients with resectable rectal cancer. The objective of this review is to describe the latest technologies which enhanced progress of minimally invasive transanal approaches for endo- and extraluminal surgery in this area of colorectal surgery.
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Affiliation(s)
- W Kneist
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsmedizin Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland.
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Lelong B, de Chaisemartin C, Meillat H, Cournier S, Boher JM, Genre D, Karoui M, Tuech JJ, Delpero JR. A multicentre randomised controlled trial to evaluate the efficacy, morbidity and functional outcome of endoscopic transanal proctectomy versus laparoscopic proctectomy for low-lying rectal cancer (ETAP-GRECCAR 11 TRIAL): rationale and design. BMC Cancer 2017; 17:253. [PMID: 28399840 PMCID: PMC5387204 DOI: 10.1186/s12885-017-3200-1] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 03/16/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Total mesorectal excision is the standard surgical treatment for mid- and low-rectal cancer. Laparoscopy represents a clear leap forward in the management of rectal cancer patients, offering significant improvements in post-operative measures such as pain, first bowel movement, and hospital length of stay. However, there are still some limits to its applications, especially in difficult cases. Such cases may entail either conversion to an open procedure or positive resection margins. Transanal endoscopic proctectomy (ETAP) was recently described and could address the difficulties of approaching the lower third of the rectum. Early series and case-control studies have shown favourable short-term results, such as a low conversion rate, reduced hospital length of stay and oncological outcomes comparable to laparoscopic surgery. The aim of the proposed study is to compare the rate of positive resection margins (R1 resection) with ETAP versus laparoscopic proctectomy (LAP), with patients randomly assigned to each arm. METHODS/DESIGN The proposed study is a multicentre randomised trial using two parallel groups to compare ETAP and LAP. Patients with T3 lower-third rectal adenocarcinomas for whom conservative surgery with manual coloanal anastomosis is planned will be recruited. Randomisation will be performed immediately prior to surgery after ensuring that the patient meets the inclusion criteria and completing the baseline functional and quality of life tests. The study is designed as a non-inferiority trial with a main criterion of R0/R1 resection. Secondary endpoints will include the conversion rate, the minimal invasiveness of the abdominal approach, postoperative morbidity, the length of hospital stay, mesorectal macroscopic assessment, functional urologic and sexual results, faecal continence, global quality of life, stoma-free survival, and disease-free survival at 3 years. The inclusion period will be 3 years, and every patient will be followed for 3 years. The number of patients needed is 226. DISCUSSION There is a strong need for optimal evaluation of the ETAP because of substancial changes in the operative technique. Assessment of oncological safety and septic risk, as well as digestive and urological functional results, is particularily mandatory. Moreover, benefits of the ETAP technique could be demonstrated in post-operative outcome. TRIAL REGISTRATION ClinicalTrial.gov: NCT02584985 . Date and version identifier: Version n°2 - 2015 July 6.
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Affiliation(s)
- Bernard Lelong
- Department of Digestive Surgical Oncology, Department of Mini Invasive Interventions (DIMI), Paoli Calmettes Institute, Comprehensive Cancer Centre, Marseille, France.
| | - Cécile de Chaisemartin
- Department of Digestive Surgical Oncology, Department of Mini Invasive Interventions (DIMI), Paoli Calmettes Institute, Comprehensive Cancer Centre, Marseille, France
| | - Helene Meillat
- Department of Digestive Surgical Oncology, Department of Mini Invasive Interventions (DIMI), Paoli Calmettes Institute, Comprehensive Cancer Centre, Marseille, France
| | - Sandra Cournier
- Department of Clinical Research and Innovation (DRCI), Paoli Calmettes Institute, Comprehensive Cancer Centre, Marseille, France
| | - Jean Marie Boher
- Department of Biostatistics and Methodology, Paoli Calmettes Institute, Comprehensive Cancer Centre, Marseille, France
| | - Dominique Genre
- Department of Clinical Research and Innovation (DRCI), Paoli Calmettes Institute, Comprehensive Cancer Centre, Marseille, France
| | - Mehdi Karoui
- Department of Digestive Surgery, CHU Pitié-Salpetriere, Paris, France
| | | | - Jean Robert Delpero
- Department of Digestive Surgical Oncology, Department of Mini Invasive Interventions (DIMI), Paoli Calmettes Institute, Comprehensive Cancer Centre, Marseille, France
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[Hybrid TAMIS total mesorectal excision. A new perspective in treatment of distal rectal cancer - Technique and results]. Chirurg 2017; 87:225-32. [PMID: 26187139 DOI: 10.1007/s00104-015-0043-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Transanal minimally invasive surgery (TAMIS) represents a promising technique for total mesorectal excision (TME) with respect to radicalness and preservation of function. There are only few publications in the literature describing results in patients with distal rectal cancer. METHODS Between May 2013 and March 2015, 24 selected patients with a rectal carcinoma < 6 cm from the anal verge underwent a laparoscopically assisted TAMIS TME (Hybrid-TAMIS TME) procedure. This prospective observational study was conducted to examine the safety of the technique and the quality of TME surgery in distal rectal cancer and to assess the short-term postoperative outcome. RESULTS The median age of patients (18 male and 6 female) at the time of surgery was 57 years (range 35-77 years) and 7 patients (29 %) had a body mass index (BMI) > 30 kg/m(2). Specimen excision was carried out transanally in 19 patients. Pathological grading of TME specimens was good in 22 (92 %) and moderate in 2 cases. After neoadjuvant radiochemotherapy a complete pathological remission was identified in five patients. The median distal resection margin was 7 mm (range 2-30 mm), the median circumferential resection margin was 6 mm (range <1 mm-30 mm) and in 2 patients the tumor was ≤ 1 mm from the positive circumferential margin. A colonic reservoir was created in 19 patients (79 %) and no 30-day mortalities occurred. Morbidity was 29 %, including 1 anastomotic leak, 2 hematomas and 1 neurogenic bladder. CONCLUSION Hybrid-TAMIS TME for distal rectal cancer is safe and can provide a sphincter-preserving high-quality TME in difficult cases. Studies with long-term follow-up assessing oncological and functional results are mandatory.
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Lelong B, Meillat H, Zemmour C, Poizat F, Ewald J, Mege D, Lelong JC, Delpero JR, de Chaisemartin C. Short- and Mid-Term Outcomes after Endoscopic Transanal or Laparoscopic Transabdominal Total Mesorectal Excision for Low Rectal Cancer: A Single Institutional Case-Control Study. J Am Coll Surg 2016; 224:917-925. [PMID: 28024946 DOI: 10.1016/j.jamcollsurg.2016.12.019] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Revised: 12/12/2016] [Accepted: 12/13/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Transabdominal laparoscopic proctectomy (LAP) for rectal cancer was associated with postoperative recovery improvement. Early studies showed favorable short-term results of endoscopic transanal proctectomy (ETAP), with low conversion rates to open procedures. We aimed to compare efficacy, morbidity, and functional outcomes of ETAP to standard LAP for low rectal cancer. STUDY DESIGN From 2008 to 2013, 72 consecutive patients received proctectomy and coloanal manual anastomosis for low rectal adenocarcinoma. Thirty-four patients had transanal endoscopic proctectomy, and 38 patients underwent the standard laparoscopic procedure. RESULTS When compared with the LAP group, the ETAP group demonstrated a lower conversion rate to open procedures (23.7% vs 2.9%, respectively; p = 0.015), shorter in-hospital stays (9 vs 8 days, respectively; p = 0.04), and a lower readmission rate (13.2% vs 0%; p = 0.03). Overall postoperative morbidity rates for the LAP and the ETAP groups (36.8% vs 32.4%, respectively; p = 0.69) and functional results (Kirwan score 1/2, 73.7% vs 73.5%, respectively; p = 0.85) were comparable; additionally, we found similar oncologic quality criteria (R1 resection 10.5% vs 5.9%, respectively; p = 0.68; grade 3 mesorectal integrity 52.6% vs 55.9%, respectively; p = 0.66). Disease-free survival of 24 months (Kaplan-Meier estimation) was comparable in the 2 groups: 86% in the ETAP group vs 88% in the LAP group; p = 0.91. At the date of last follow-up, 91.2% of ETAP patients and 92.1% of LAP patients were free of stoma. CONCLUSIONS The endoscopic transanal approach could facilitate mesorectal excision and improve short-term outcomes without impairing the oncologic quality of the resection or mid-term functional and oncologic results.
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Affiliation(s)
- Bernard Lelong
- Department of Digestive Surgical Oncology, Paoli Calmettes Institute, Marseille, France.
| | - Hélène Meillat
- Department of Digestive Surgical Oncology, Paoli Calmettes Institute, Marseille, France
| | - Christophe Zemmour
- Department of Clinical Research and Innovation, Biostatistics and Methodology Unit, Paoli Calmettes Institute, Marseille, France
| | - Flora Poizat
- Department of Biopathology, Paoli Calmettes Institute, Marseille, France
| | - Jacques Ewald
- Department of Digestive Surgical Oncology, Paoli Calmettes Institute, Marseille, France
| | - Diane Mege
- Department of Digestive Surgical Oncology, Paoli Calmettes Institute, Marseille, France
| | | | - Jean Robert Delpero
- Department of Digestive Surgical Oncology, Paoli Calmettes Institute, Marseille, France
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Clinical outcomes and case volume effect of transanal total mesorectal excision for rectal cancer: a systematic review. Tech Coloproctol 2016; 20:811-824. [PMID: 27853973 PMCID: PMC5156667 DOI: 10.1007/s10151-016-1545-0] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 10/03/2016] [Indexed: 12/30/2022]
Abstract
Transanal total mesorectal excision (TaTME) has been developed to improve quality of TME for patients with mid and low rectal cancer. However, despite enthusiastic uptake and teaching facilities, concern exists for safe introduction. TaTME is a complex procedure and potentially a learning curve will hamper clinical outcome. With this systematic review, we aim to provide data regarding morbidity and safety of TaTME. A systematic literature search was performed in MEDLINE (PubMed), EMBASE (Ovid) and Cochrane Library. Case reports, cohort series and comparative series on TaTME for rectal cancer were included. To evaluate a potential effect of case volume, low-volume centres (n ≤ 30 total volume) were compared with high-volume centres (n > 30 total volume). Thirty-three studies were identified (three case reports, 25 case series, five comparative studies), including 794 patients. Conversion was performed in 3.0% of the procedures. The complication rate was 40.3, and 11.5% were major complications. The quality of the mesorectum was “complete” in 87.6%, and the circumferential resection margin (CRM) was involved in 4.7%. In low- versus high-volume centres, the conversion rate was 4.3 versus 2.7%, and major complication rates were 12.2 versus 10.5%, respectively. TME quality was “complete” in 80.5 versus 89.7%, and CRM involvement was 4.8 and 4.5% in low- versus high-volume centres, respectively. TaTME for mid and low rectal cancer is a promising technique; however, it is associated with considerable morbidity. Safe implementation of the TaTME should include proctoring and quality assurance preferably within a trial setting.
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Xu W, Xu Z, Cheng H, Ying J, Cheng F, Xu W, Cao J, Luo J. Comparison of short-term clinical outcomes between transanal and laparoscopic total mesorectal excision for the treatment of mid and low rectal cancer: A meta-analysis. Eur J Surg Oncol 2016; 42:1841-1850. [PMID: 27697315 DOI: 10.1016/j.ejso.2016.09.002] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 09/05/2016] [Indexed: 02/07/2023] Open
Abstract
AIM The objective of this meta-analysis was to evaluate the feasibility, safety, and short-term clinical outcomes of transanal total mesorectal excision (TaTME) comparing with laparoscopy total mesorectal excision (LapTME) for mid and low rectal cancer. METHODS Relevant studies were searched from the databases of Pubmed, Embase, and the Cochrane Library. The qualities of all of the included studies were evaluated using Newcastle-Ottawa Scale (NOS). The synthesized outcomes were pooled using fixed-effects models or random-effects models, which weighted the odds ratio (OR) or mean difference (MD) with 95% confidence intervals (95% CI). A funnel plot was used to evaluate the publication bias. RESULTS Seven original studies including 209 TaTME patients and 257 LapTME patients with rectal cancer met the inclusion criteria in this meta-analysis. Compared with LapTME, TaTME showed a longer CRM, lower rate of positive CRM, complete TME rate, and less operative time. There were no significant differences in the outcomes of the harvested lymph nodes, distal margin distance, hospital stay, intraoperative complications, anastomotic leakage, postoperative complications, reoperation, readmission, or conversion between the TaTME group and the LapTME group. CONCLUSIONS Compared with LapTME, TaTME is a feasible and safe approach for patients with mid and low rectal cancer. In addition, TaTME showed a better short-term clinical outcomes, such as a longer CRM, lower risk of positive CRM, higher complete quality of TME rate, and shorter operative duration. Further prospective studies with long-term follow-up are required.
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Affiliation(s)
- W Xu
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, 330006, Nanchang, Jiangxi, China
| | - Z Xu
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, 330006, Nanchang, Jiangxi, China
| | - H Cheng
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, 330006, Nanchang, Jiangxi, China
| | - J Ying
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, 330006, Nanchang, Jiangxi, China
| | - F Cheng
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, 330006, Nanchang, Jiangxi, China
| | - W Xu
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, 330006, Nanchang, Jiangxi, China
| | - J Cao
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, 330006, Nanchang, Jiangxi, China
| | - J Luo
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, 330006, Nanchang, Jiangxi, China.
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Does Intraoperative Systematic Bacterial Sampling During Complete Cytoreductive Surgery (CRS) with Hyperthermic Intraoperative Peritoneal Chemotherapy (HIPEC) Influence Postoperative Treatment? A New Predictive Factor for Postoperative Abdominal Infectious Complications. World J Surg 2016; 40:3035-3043. [DOI: 10.1007/s00268-016-3635-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Hüscher CGS, Tierno SM, Romeo V, Lirici MM. Technologies, technical steps, and early postoperative results of transanal TME. MINIM INVASIV THER 2016; 25:247-56. [PMID: 27387893 DOI: 10.1080/13645706.2016.1206024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION First described in 1982, TME overcomes most of the concerns regarding adequate local control after anterior rectal resection. TME requires close sharp dissection along the so-called Heald's plane down to the levators, with distal dissection often cumbersome. In recent years, Transanal TME was introduced with the aim to improve distal rectal dissection and quality of mesorectal excision. MATERIAL AND METHODS A prospective, non-randomized study, started in 2013, is currently ongoing in two Italian Centers. Study objectives were assessing the safety of TaTME and TME quality. TaTME technique and technologies as performed in these centers and cumulative results at ≤30 postoperative days of the first 102 patients are reported. RESULTS Early postoperative morbidity and mortality rates were 33.3% (34 pts, 16 Clavien-Dindo I + II and 18 Clavien-Dindo III + IV + V), and 1.96% (two deaths), respectively. The quality of mesorectal excision according to Quirke was: complete in 97.1% and nearly complete in 2.9% of the cases. CONCLUSIONS The results confirm the effectiveness of TaTME, especially regarding the quality of the mesorectal dissection. Open questions regarding standardization, anatomical landmarks, indications, morbidity (with special regard to local infection and sepsis), learning curve and oncological outcomes require further answers from larger studies and RCTs before definitive validation of this procedure. .
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Affiliation(s)
| | | | - Valentina Romeo
- b Department of Surgery San Giovanni Hospital , Rome , Italy
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Atallah S, Albert M, Monson JRT. Critical concepts and important anatomic landmarks encountered during transanal total mesorectal excision (taTME): toward the mastery of a new operation for rectal cancer surgery. Tech Coloproctol 2016; 20:483-94. [PMID: 27189442 DOI: 10.1007/s10151-016-1475-x] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 04/27/2016] [Indexed: 12/15/2022]
Abstract
Over the past 3 years, colorectal surgeons have begun to adapt the technique of transanal total mesorectal excision. As international experience has been quickly forged, an improved recognition of the pitfalls and the practical details of this disruptive technique have been realized. The purpose of this technical note was to express the various nuances of transanal total mesorectal excision as learned during the course of its clinical application and international teaching, so as to rapidly communicate and share important insights with other surgeons who are in the early adoption phase of this approach. The technical points specific to transanal total mesorectal excision are addressed herein. When correctly applied, these will likely improve the quality of surgery and decrease morbidity attributable to inexperience with the transanal approach to total mesorectal excision.
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Affiliation(s)
- S Atallah
- Florida Hospital, Winter Park, FL, USA.
| | - M Albert
- Florida Hospital, Winter Park, FL, USA
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Chen CC, Lai YL, Jiang JK, Chu CH, Huang IP, Chen WS, Cheng AYM, Yang SH. Transanal Total Mesorectal Excision Versus Laparoscopic Surgery for Rectal Cancer Receiving Neoadjuvant Chemoradiation: A Matched Case-Control Study. Ann Surg Oncol 2015; 23:1169-76. [PMID: 26597369 DOI: 10.1245/s10434-015-4997-y] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Indexed: 01/01/2023]
Abstract
BACKGROUND Neoadjuvant chemoradiation therapy (nCRT) has been indicated for locally advanced rectal cancer. While utilization of laparoscopy in rectal cancer surgery has been popular in recent years, tumors receiving nCRT is still a surgical challenge. Transanal total mesorectal excision (TaTME) has emerged as a focused area of laparoscopic surgery that is becoming an increasingly acceptable approach in the field of rectal surgery. METHODS Between December 2013 and April 2015, a total of 50 patients (38 males) with post-nCRT middle or lower rectal cancer who then underwent TaTME at two separate institutions were prospectively documented. Overall, 100 matched control cohorts who received conventional laparoscopic rectal surgery (LapTME) were simultaneously retrieved from a prospectively registered database. Four parameters of sex, age, clinical stage, and American Society of Anesthesiologists (ASA) score were matched for surgical outcomes, and short-term oncological results, including complications and pathological outcomes, were analyzed. RESULTS Both the TaTME and LapTME groups received 5-fluorouracil-based chemotherapy and 5 weeks of long-course radiation therapy. Mean operative time for the TaTME group was 182.1 ± 55.4 min (156.6 ± 37.8 min in two-team-approach cases) and 178.7 ± 34.8 min for the LapTME group. The TaTME group yielded longer distal margin lengths. No significant differences were observed in blood loss, intraoperative complication rate, conversion rate, anastomosis type, and free circumferential margin rate. CONCLUSION This matched case-control study demonstrated that TaTME is safe and feasible. Compared with LapTME, TaTME not only achieves identical circumferential margin status without compromising other operative and quality parameters but also benefits patients by achieving a longer distal margin. Thus, TaTME has the potential to become an option in managing irradiated rectal cancer.
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Affiliation(s)
- Chien-Chih Chen
- Department of Surgery, Koo Foundation, Sun Yat-Sen Cancer Center, Taipei, Taiwan.,College of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yi-Ling Lai
- Department of Surgery, Koo Foundation, Sun Yat-Sen Cancer Center, Taipei, Taiwan
| | - Jeng-Kae Jiang
- College of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Colorectal Surgery, Taipei Veterans General Hospital, 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
| | - I-Ping Huang
- Department of Surgery, Koo Foundation, Sun Yat-Sen Cancer Center, Taipei, Taiwan
| | - Wei-Shone Chen
- College of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Colorectal Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | | | - Shung-Haur Yang
- College of Medicine, National Yang-Ming University, Taipei, Taiwan. .,Division of Colorectal Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.
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Buchs NC, Nicholson GA, Ris F, Mortensen NJ, Hompes R. Transanal total mesorectal excision: A valid option for rectal cancer? World J Gastroenterol 2015; 21:11700-11708. [PMID: 26556997 PMCID: PMC4631971 DOI: 10.3748/wjg.v21.i41.11700] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 07/21/2015] [Accepted: 09/14/2015] [Indexed: 02/06/2023] Open
Abstract
Low anterior resection can be a challenging operation, especially in obese male patients and in particular after radiotherapy. Transanal total mesorectal excision (TaTME) might offer technical advantages over laparoscopic or open approaches particularly for tumors in the distal third of the rectum. The aim of this article is to review the current experience with TaTME. The limits and future developments are also explored. Although the experience with TaTME is still limited, it might be a promising alternative to laparoscopic TME, especially for difficult cases where laparoscopy is too demanding. The preliminary data on complications and short-term oncological outcomes are good, but also emphasize the importance of careful patient selection. Finally, there is a need for large-scale trials focusing on long-term outcomes and oncological safety before widespread adoption can be recommended.
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Transanal Hartmann reversal: a new technique. Surg Endosc 2015; 30:2628-31. [PMID: 26423412 DOI: 10.1007/s00464-015-4504-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 08/03/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Hartmann procedure consists in a sigmoidectomy followed by a terminal colostomy. However, the stoma is associated with complications and suboptimal quality of life, so the restoration of colonic continuity should be, at least, considered in any case. Open restoration has been associated with significant morbidity and mortality; therefore, many authors have described the advantages of laparoscopic Hartmann reversal. We want to go a step further showing our experience using a combined laparoscopic and transanal approach in an attempt to improve the surgical technique. METHODS Patients with an end colostomy due to an emergency Hartmann procedure are selected for this intervention. This approach is performed simultaneously laparoscopically and transanally, with single-port devices, through the colostomy wound in the first case and trough anal canal in the second one. The previous stapler line is resected transanally and the proximal rectum and mesorectum are dissected until the peritoneal reflexion, where both teams work together to complete the adhesiolysis. Finally an end-to-end anastomosis is performed under laparoscopic control. RESULTS As in patients with rectal cancer, dissection of the stump in Hartmann reversal procedure may be better and associated with shorter operative time. CONCLUSIONS As with any new surgical procedure, it is probably too early to draw conclusions, but nowadays transanal combined with laparoscopic approach seems to be a safe and feasible technique to perform a Hartmann reversal.
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