Transanal single-port laparoscopic total mesorectal excision in the treatment of rectal cancer

Clinical Status and Future Prospects of Transanal Total Mesorectal Excision

Low rectal cancer has always posed surgical challenges to gastrointestinal surgeons. Transanal total mesorectal excision (taTME) is a novel approach to radical resection for low rectal cancer. Compared with conventional laparoscopic TME (laTME), taTME is relevant to the benefits of better vision of the mesorectal plane, feasibility of operating in a narrow pelvis, and exact definition of distal resection margin, which may lead to a higher possibility of free circumferential resection margin, better quality of TME specimen, and lower conversion rate. Although there are concerns about its long-term oncological outcomes and complex learning curve, taTME is a promising alternative for rectal cancer. In this review, we discuss the application status and prospects of taTME.

Locally Advanced Rectal Cancer: What We Learned in the Last Two Decades and the Future Perspectives

The advancement in surgical techniques, optimization of systemic chemoradiotherapy, and development of refined diagnostic and imaging modalities have brought a phenomenal shift in the treatment of the locally advanced rectal cancer. Although each therapeutic option has shown substantial progress in their field, it is finding their ideal amalgamation which has baffled the clinician and researchers alike. In the effort to identifying the perfect salutary treatment plan, we have even shifted our attention from the trimodal approach to non-operative "watchful waiting" to more recent individualized care. In this article, we acknowledge the scientific progress in the management of locally advanced rectal cancer and compare the opportunities as well as the obstacles while implementing them clinically. We also explore the current challenges and controversies surrounding the multidisciplinary approach and highlight the new trends and recent advances with an ultimate goal to improve the patients' quality of life.

Total Transperineal Laparoscopic Proctectomy for the Treatment of Crohn's Proctitis

INTRODUCTION

Completion proctectomy is traditionally performed using a combination of abdominal and perineal approaches. Access to and exposure of the pelvis through the abdominal cavity can be limited in patients with prior surgery or inflammatory conditions. We describe a novel technique for a total transperineal approach for proctectomy for Crohn's proctitis, avoiding technical challenges, risks, and recovery associated with abdominal surgery.

TECHNIQUE

We utilized the skills and expertise acquired from our experience with transanal total mesorectal excision to perform a total transperineal laparoscopic proctectomy in a male patient with medically refractory proctitis. He previously underwent an anterior resection, drainage of a chronic presacral abscess, omental pedicle flap transposition to the pelvis, and end colostomy for severe Crohn's colitis. The total transperineal laparoscopic proctectomy approach avoids the need for abdominal access, including the risks associated with abdominal entry, adhesiolysis, pelvic access and visualization, and wound-related issues. Following an initial intersphincteric perineal dissection, the GelPOINT Path minimal access platform is utilized to perform a total transperineal proctectomy.

RESULTS

The patient recovered uneventfully and was discharged to home 2 days after surgery. At 1-month postoperative follow-up, the patient is recovering well with complete healing of the perineal wound.

CONCLUSION

We demonstrate the feasibility, safety, and technical steps of a minimally invasive completion proctectomy for fistulizing Crohn's proctitis by using a total transperineal approach. This approach allowed us to utilize direct, inline, high-definition visualization to access and safely operate in the distal aspects of a narrow, scarred, and fibrotic pelvis while avoiding the need for any abdominal access. Advanced experience with redo pelvic and minimally invasive transanal surgery is critical. See Video at http://links.lww.com/DCR/B664.

Transanal Total Mesorectal Excision: Short-term Outcomes of 1283 Cases from a Nationwide Registry in China

BACKGROUND

Transanal total mesorectal excision is a promising surgical procedure for mid to low rectal cancer.

OBJECTIVE

This study aimed to determine the short-term outcomes of Chinese patients treated with transanal total mesorectal excision.

DESIGN

This was an observational study using data from an online registry system.

SETTING

Study participants were recruited from 40 different centers across 15 provinces in China.

PATIENTS

Patients with either benign or malignant rectal disease who underwent transanal total mesorectal excision procedure and were registered in the Chinese Transanal Total Mesorectal Excision Registry Collaborative from May 2010 to November 2019 were included.

INTERVENTION

Patients underwent transanal total mesorectal excision.

MAIN OUTCOME MEASURES

The primary outcomes measured were the postoperative complications and pathological outcomes.

RESULTS

In total, 1283 patients, comprising 888 men (69.2%) and 395 women (39.8%) with a median age of 61 (22-92) years and a median BMI of 23.6 (14.5-46.3) kg/m2, were analyzed. Among 40 participating centers, the average number of registered cases was 32.1±34.7, and 12 centers (30%) registered >40 cases in the registry. Among 849 patients with rectal cancer who underwent laparoscopic-assisted transanal total mesorectal excision, the conversion rate was 0.5% in the abdominal phase and 1.9% in the perineal phase. Three patients reported urethral injury (0.5%). The postoperative complication rate and the anastomotic leakage incidence were 18.4% and 5.8%. The quality of the total mesorectum excision specimens was found to be complete in 81.9% of patients. In addition, the positive circumferential resection margin rate was 2.8%.

LIMITATIONS

The primary limitation of this registry study was the high percentage of missing data (10.8% overall), and, for some of the analyzed variables, up to 35% of the data was missing. Postoperative complications were not monitored after discharge, resulting in a lower morbidity rate than the 30-day morbidity rate reported in other studies.

CONCLUSIONS

The short-term outcomes of patients who underwent transanal total mesorectal excision procedures in China were acceptable. See Video Abstract at http://links.lww.com/DCR/B414.

EXCISIN TOTAL DEL MESORRECTO POR VA TRANSANAL RESULTADOS A CORTO PLAZO DE CASOS DE UN REGISTRO NACIONAL EN CHINA

ANTECEDENTES:La excisión total del mesorrecto por vía transanal es un procedimiento quirúrgico prometedor para el cáncer de recto medio y bajo.OBJETIVO:Determinar los resultados a corto plazo de los pacientes chinos tratados con escisión mesorrectal total transanal.DISEÑO:Estudio observacional con datos de un sistema de registro en línea.AJUSTE:Los participantes del estudio fueron reclutados en 40 centros diferentes en 15 provincias de China.PACIENTES:Se incluyeron pacientes con enfermedad rectal benigna o maligna que se sometieron a una cirugía de excisión total del mesorrecto por vía transanal y que se registraron en el Registro Colaborativo de Excisión Total del Mesorrecto por vía Transanal en China desde mayo de 2010 hasta noviembre de 2019.INTERVENCIÓN:Excisión total delmesorrecto por vía transanal.PRINCIPALES MEDIDAS DE RESULTADO:Complicaciones postoperatorias y resultados patológicos.RESULTADOS:Fueron analizados un total de 1.283 pacientes, que comprendían 888 hombres (69,2%) y 395 mujeres (39,8%) con una mediana de edad de 61 (22-92) años y una mediana de índice de masa corporal de 23,6 (14,5-46,3) kg / m2. Entre los 40 centros participantes, el promedio de casos registrados fue de 32,1 ± 34,7, y 12 centros (30%) inscribieron > 40 casos en el registro. Entre 849 pacientes con cáncer de recto que se sometieron a excisión total del mesorrecto pééor vía transanal asistida por laparoscopia, la tasa de conversión fue del 0,5% en la fase abdominal y del 1,9% en la fase perineal. Tres pacientes refirieron una lesión uretral (0,5%). La tasa de complicaciones posoperatorias y la incidencia de fuga anastomótica fueron del 18,4% y el 5,8%, respectivamente. La calidad de las muestras de excisión total del mesorrecto se evaluó como completa en el 81,9% de los pacientes. Además, la tasa de margen de resección circunferencial positiva fue del 2,8%.LIMITACIONES:La principal limitación del presente estudio de registros fue el alto porcentaje de datos faltantes (10,8% en general), y para algunas de las variables analizadas, faltaba hasta el 35% de los datos. Las complicaciones postoperatorias no fueron verificadas después del alta, lo que resultó en una tasa de morbilidad más baja que la tasa de morbilidad a 30 días informada en otros estudios.CONCLUSIONES:Los resultados a corto plazo de los pacientes que se sometieron al procedimiento de excisión total del mesorrecto por vía transanal en China fueron aceptables. Consulte Video Resumen en http://links.lww.com/DCR/B414. (Traducción-Dr. Xavier Delgadillo).

Pure transanal endoscopic colectomy for ascending colon cancer

BACKGROUND

Previous studies have demonstrated that pure transanal endoscopic surgery is safe and feasible in the treatment of rectal cancer. However, the role of pure transanal endoscopic colectomy in ascending colon cancer (ACC) treatment has not been evaluated. We report a case of transanal endoscopic surgery for ACC.

METHODS

A 35-year-old woman was treated for ACC, using a transanal endoscopic surgery device as the operation platform, and pure transanal endoscopic right hemicolectomy without transabdominal assistance was safely performed. An instrument suture, side-to-side, ileocolic anastomosis was performed. Operative time was 245 min and intraoperative blood loss was 60 ml.

RESULTS

The patient recovered well from the surgery. Compared with the traditional approach, this approach was less invasive and resulted in satisfactory outcomes and cosmesis (no scar).

CONCLUSIONS

Application of pure transanal endoscopic colectomy without abdominal assistance to ACC appears to be feasible and safe.

Comparison of short-term efficacy of transanal total mesorectal excision and laparoscopic total mesorectal excision in low rectal cancer

BACKGROUND/OBJECTIVE

The transanal total mesorectal excision(TaTME) of rectal malignancies is largely referred to as treatment of mid to low, especially low rectal cancer. This study was to compare the short-term efficacy of TaTME and laparoscopic total mesorectal excision (LaTME) for low rectal cancer.

METHODS

A prospective study of patients with low rectal cancer who underwent laparoscopic radical surgery at the General Surgery of Guangzhou Red Cross Hospital from January 2017 to December 2019 was performed. The general information, perioperative results and pathological results of the two groups were compared.

RESULTS

A total of 64 patients were included in the study, 32 in the TaTME group and 32 in the LaTME group. The clinical characteristics of the two groups was comparable (P > 0.05). The operation time in the TaTME group was longer than that in the LaTME group (212.59 ± 28.71min vs 187.66 ± 27.15min, P = 0.001), no significant differences were seen in the conversion rate, intraoperative complications, morbidity, serious morbidity, anastomotic leak, unplanned reoperation and hospital stay(P > 0.05). The circumferential resection margin (CRM) distance in the TaTME group was longer than that in the LaTME group (6.81 ± 2.99 mm vs 5.21 ± 3.06 mm, P = 0.039). The inter-group difference in terms of harvested lymph nodes, mesorectum integrity, CRM involvement, DRM distance, R1 resection, complete remission, pathological T stage, pathological N stage and pathological TNM stage was not significant (P > 0.05).

CONCLUSIONS

TaTME is a promising surgical technique and maybe offers a safe and feasible alternative to LaTME in managing low rectal cancer.

Transanal total mesorectal excision (TaTME) using flexible endoscope with laparoscopic assistance: a pilot study in porcine models

BACKGROUND

Transanal total mesorectal excision (TaTME) is routinely performed to excise low rectal tumors. TaTME often relies on transanal endoscopic microsurgery (TEM) or transanal minimally invasive surgery (TAMIS) platform, all using rigid endoscopes. Our study reported a novel approach to TaTME which was completed using flexible endoscope, and we named it F-TaTME.

METHODS

The feasibility of rectum resection using F-TaTME was evaluated in five pigs. Firstly, the superior rectal artery and vein were managed under the assistance of laparoscopy. Secondly, the flexible endoscope was used to complete the full-thickness rectotomy and rectal mobilization. Finally, the specimen was removed and the manual colon-rectal anastomosis was performed under direct vision.

RESULTS

F-TaTME was accomplished in all 5 pigs. The mean procedure time was 136.6 min (97-162 min). The mean length from the lower edge of the lesion to circumferential dissection line was 1.4 cm (1.0-1.8 cm) and mean length of exteriorized rectum was 12.6 cm (11-14 cm). No injury to colorectal wall, adjacent pelvic or abdominal organs was found.

CONCLUSIONS

Our preliminary data suggested that F-TaTME may be a feasible method for TaTME.

Learning Transanal Total Mesorectal Excision

A dynamic evolution is occurring in transanal surgery. Transanal techniques began with intraluminal surgical removal of rectal masses and have progressed to transanal total mesorectal excision (taTME) for rectal cancer. TaTME was first performed in 2009 by Sylla, Rattner, Delgado, and Lacy. This article documents the training pathway followed by pioneers in the taTME technique as well as consensus reports outlining the process of learning the taTME technique. A literature search was performed for taTME training, learning, and technique. Key elements in learning the taTME technique include appropriate indications, cadaver training, and outcomes reporting such as participating in a taTME registry. Consensus reports also agree on the following facets associated with improved outcomes: (1) appropriate case selection of mid and low rectal cancers, (2) prerequisite completion of an accredited training program in laparoscopic colorectal surgery and prior experience in transanal endoscopic surgery, (3) a two-team taTME approach from above and below is ideal, and (4) higher rectal cancer volume surgical practice. The unifying international recommendation for surgeons interested in learning the taTME technique conveys the following message: taTME is an advanced and complex technique that requires dedicated training and experience in TME surgery.

Transanal Surgery: A History of taTME Ancestry

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

Transanal total mesorectal excision for rectal cancer: hype or new hope?

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.

Pure transanal total mesorectal excision for rectal cancer: experience with 55 cases

Background

Although the anatomic difficulties of laparoscopic surgery for rectal cancer have been resolved by hybrid transanal total mesorectal excision (h-taTME), a completely incisionless surgical procedure has not yet been developed. This study was performed to explore the efficacy of pure taTME (p-taTME) without laparoscopic assistance as a completely non-invasive surgical procedure for rectal cancer.

Methods

We retrospectively evaluated all patients with rectal cancer who underwent p-taTME between December 2015 and April 2018. Relevant patient characteristics and clinical information including the surgical procedure, specimens, pathological characteristics, and patients’ post-operative state were analysed and the feasibility of p-taTME in patients with rectal cancer was assessed.

Results

Fifty-five patients who had undergone p-taTME were included in this study. They comprised 32 (58.2%) men and 23 (41.8%) women with a mean age of 65.6 ± 10.6 years and mean body mass index of 23.4 ± 3.3 kg/m². The median surgical time was 180.0 (range, 130–360) min and estimated blood loss was 25.0 (range, 15–80) mL. The commonest post-operative complication was varying degrees of faecal incontinence (56.4%). However, such incontinence greatly improved after pelvic-floor-function-rehabilitation exercises and did not seriously affect the patients’ quality of life.

Conclusions

p-taTME is a relatively safe and incisionless procedure for patients with middle and low rectal cancer, especially in those with obesity or a narrow pelvis. However, further studies of the indications and long-term efficacy are needed to verify the suitability of this procedure.

Transanal total mesorectal excision for locally advanced middle-low rectal cancers

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.

Transanal total mesorectal excision for rectal cancer: a multicentric cohort study

Background

Transanal total mesorectal excision (taTME) has recently emerged as a promising novel surgical procedure for rectal cancer. It is believed to hold the potential advantage of providing better access to mobilize the distal rectum and achieving better pathologic results. This study aimed to evaluate the feasibility of taTME for rectal cancer and summarize the preliminary experience in 10 Chinese hospitals.

Methods

A total of 211 patients were enrolled in this study. Variables for evaluation of safety, feasibility, and oncologic outcomes were retrospectively collected and analysed.

Results

The median distance between the tumor and the anal verge was 5.9 cm (range, 1.5–12 cm). The median operating time was 280 min (range, 70–600 min) and the median estimated intra-operative blood loss was 50 mL (range, 10–1,500 mL). The overall rate of complication was 27.9%. Among the 211 patients, 175 (82.9%) had complete TME and 33 (15.6%) had near complete TME. The circumferential resection margin was negative in 97.7% of patients. The patients were followed for a median of 35 months (range, 2–86 months). There was 7.6% (16) mortality, 6.2% (13) had local recurrence, and 12.8% (27) had systemic recurrence. Kaplan–Meier survival analysis showed that 1-, 2-, and 3-year disease-free survival rates were 94.8%, 89.3%, and 80.2%, respectively, and 1-, 2-, and 3-year OS rates were 97.4%, 95.7%, and 92.9%, respectively.

Conclusions

Although limited by its retrospective nature, taTME was safe and feasible in selected patients. Future work with rigorous data recording is warranted.

Novel box trainer for taTME - prospective evaluation among medical students

Background

Transanal total mesorectal excision (taTME) has been subject to extensive research and increasing clinical application. It allows further reduction of trauma by accessing via a natural orifice. Manifold platforms and instruments have been introduced and heterogeneity in surgical techniques exists. Because of the technique’s complexity there is a persistent need for dedicated training devices and concepts.

Materials and methods

The key steps of taTME were analyzed and a box trainer with three modules resembling these steps was designed and manufactured. Twenty-one surgically inexperienced medical students performed five repetitions of the three tasks with the new box trainer. Time and error count were analyzed for assessment of a learning curve.

Results

A significant reduction of processing time could be demonstrated for tasks 1–3 (p < 0.001; p < 0.001; p = 0.001). The effect size was high for comparison of repetition 1 and 5 and decreased over the course (task 1: r = 0.88 vs. r = 0.21; task 2: r = 0.86 vs. r = 0.23; task 3: r = 0.74 vs. r = 0.44). Also, a significant reduction of errors was demonstrated for tasks 1 and 2. The decrease of effect size was analogously demonstrated.

Conclusions

The trainer might help to reduce the use of animal models for testing of platforms and instruments as well as gaining first-hand experience in transanal rectal resection.

Transanal Total Proctocolectomy with Ileal Pouch-Anal Anastomosis for Synchronous Triple Colorectal Cancer

Introduction: Transanal total mesorectal excision (TME) has been utilized as a minimally invasive surgery for colorectal cancer.¹ Sylla et al. first reported the use of transanal TME and since then, various platforms have been applied for this procedure.² The most widely used procedure is laparoscope-assisted transanal TME using a hybrid technique. de Lacy et al. introduced the Cecil procedure, which utilizes two teams (transabdominal and transanal).³ With regard to rectal cancer, a small group of authors attempted pure natural orifice transluminal endoscopic surgery (NOTES) transanal TME.^4,5 The aim of this case report is to show that a transanal laparoscopic technique can be utilized for total colectomy. Except for rectal cancer, there are few reports regarding colon resection using NOTES. In this video, we perform a transanal total proctocolectomy with ileal pouch-anal anastomosis in a patient with synchronous triple colorectal cancer (ascending colon, rectosigmoid colon, and rectum). Methods: We performed transanal total proctocolectomy with ileal pouch-anal anastomosis in a patient with synchronous triple colorectal cancer (ascending colon, rectosigmoid colon, and rectum). On preoperative MRI, there was no pelvic lateral lymph node, so we did not need to perform chemoradiation therapy. After transanal dissection of the mesorectum, rectum was flipped into the intraperitoneal space for further dissection. In our setting, we used conventional laparoscopic instruments for most procedures and long-shafted instruments helped during mobilization of the splenic and hepatic flexures. The entire specimen was extracted transanally. The ileal pouch was constructed intracorporeally and ileal pouch-anal anastomosis was performed using a circular stapler. We did not create a defunctioning stoma. Results: The operating time was 328 minutes and blood loss was <50 mL. We harvested 61 lymph nodes, and 1 regional lymph node metastasis was found. The patient experienced temporary paralytic ileus and was discharged on postoperative day 10 and had no major complications. The patient had medications for loose stool but had no incontinence. The patient refused adjuvant chemotherapy. During the 24 months follow-up period, there were no recurrences or metastases in three colonoscopies and three CT scans. This operation was performed in February 2017 and transanal total colectomy has not been reported so far. Conclusion: This transanal laparoscopic technique is feasible for total colectomy and may be adapted to achieve colonic resection through a natural orifice in the future. No competing financial interests exist. Runtime of video: 9 mins 55 secs This subject was previously presented at the International Society of University Colon and Rectal Surgeons (ISUCRS), August 29-September 1, 2018, in London, United Kingdom.

Safety and Feasibility of Transanal Endoscopic Surgery for Diffuse Cavernous Hemangioma of the Rectum

Purpose

To evaluate the safety and feasibility of transanal endoscopic surgery for diffuse cavernous hemangioma of the rectum (DCHR).

Methods

All DCHR patients who underwent transanal endoscopic surgery in our hospital between January 2014 and June 2018 were reviewed.

Results

A total of 7 patients with a diagnosis of DCHR underwent transanal endoscopic surgery during the study period. Four patients (57.1%) were male, with a mean age at surgery of 34.5 ± 7.7 years, and three patients (42.9%) were female, with a mean age at surgery of 29.9 ± 3.8 years. Recurrent painless rectal bleeding was the main symptom in all patients. The mean age was 32 years old (range 21-54 years). The median duration of symptoms was 10 years (range 1 month-50 years). The level of hemoglobin at admission ranged from 59.0 to 148.0 g/l (mean 106.6 g/l), and the level of mean corpuscular volume (MCV) ranged from 75.1 fl to 93.5 fl (mean 83.7 fl). Colonoscopy, computed tomography (CT), and magnetic resonance imaging (MRI) were important in the diagnosis of DCHR because of their high positive rates and accurate features. All of the lesions are between the anal canal and the descending colon. Two patients could be found with some enlarged serpentine vessels in the cervix, vagina, or corpus cavernosum by MRI. After admission, all the patients underwent transanal endoscopic surgery and four patients had simultaneous loop ileostomy. The mean operative time was 278 min (range 168-400 min). The median amount of intraoperative blood loss was 50 ml (range 10-300 ml). The mean distance from anal verge to anastomosis was 2.2 ± 0.2 cm. The anastomosis was fashioned with a stapler in two patients (28.6%). There were no intraoperative and postoperative complications. All the patients continued to recover well from the surgery, and nobody needed postoperative blood transfusions.

Conclusions

The specific diagnosis rate of DCHR is low. Preoperative MRI and CT examination can make a definitive diagnosis and determine the extent of the lesions. DCHR is mostly restricted to the rectum, sigmoid colon, anal wall, and mesorectum. The best treatment for DCHR is complete lesion resection. It is safe and feasible to treat DCHR using transanal endoscopic surgery. Moreover, transanal endoscopic surgery might have a huge potential when used to treat other rectal diseases.

Transanal versus laparoscopic total mesorectal excision for mid and low rectal cancer: a meta-analysis of short-term outcomes

Introduction

The benefit of transanal total mesorectal excision (TaTME) for mid and low rectal cancer is conflicting.

Aim

To assess and compare the short-term outcomes of TaTME with conventional laparoscopic total mesorectal excision (LaTME) for middle and low rectal cancer.

Material and methods

We searched PubMed, Embase and Cochrane Library databases for studies addressing TaTME versus conventional LaTME for rectal cancer between 2008 and December 2018. Randomized controlled trials (RCTs) and retrospective studies which compared TaTME with LaTME were included.

Results

Twelve retrospective case-control studies were identified, including a total of 899 patients. We did not find significant differences in overall intraoperative complications, blood loss, conversion rate, operative time, overall postoperative complication, anastomotic leakage, ileus, or urinary morbidity. Also no significant differences in oncological outcomes including circumferential resection margin (CRM), positive CRM, distal margin distance (DRM), positive DRM, quality of mesorectum, number of harvested lymph nodes, temporary stoma or local recurrence were found. Although the TaTME group had better postoperative outcomes (readmission, reoperation, length of hospital stay) on average, the difference did not reach statistical significance.

Conclusions

Transanal total mesorectal excision offers a safe and feasible alternative to LaTME although the clinicopathological features were not superior to LaTME in this study. Currently, with the lack of evidence on benefits of TaTME, further evaluation of TaTME requires large randomized control trials to be conducted.

Evaluation of anatomical landmarks for transanal total mesorectal excision based on MRI

BACKGROUND

Transanal total mesorectal excision (taTME) is a novel sphincter-preserving procedure for low rectal cancer. This "bottom to up" approach is unfamiliar to colorectal surgeons and the crucial anatomical landmarks also remain unclear.

METHODS

Two hundred and five cases of pelvic magnetic resonance imaging (MRI) from 2015 to 2016 were reviewed. Curvature of posterior mesorectal fascia, distal mesorectal angle, length of posterior mesorectal fascia, main structures around the mesorectum were measured and analyzed. The landmarks identified on MRI were verified in taTME procedures of five rectal cancer patients.

RESULTS

The most of acute angles of posterior mesorectal fascia located at the joint of anococcygeal ligament-coccyx. Degree of distal mesorectal angle was independently correlated with gender and degree of angle of anococcygeal ligament-coccyx. Candidate landmarks evaluated by MRI with verification during taTME procedures included: anterior: seminal vesicle for male while cervix for female. And peritoneal reflection was a substitute landmark when cervix was hardly confirmed in operation; posterior: the joint of anococcygeal ligament-coccyx. The area between the joint of anococcygeal ligament-coccyx and S3S4 was a "transitional zone", the level of S3S4 could be the as the terminal landmark of transanal posterior dissection during taTME.

CONCLUSIONS

Preoperative MRI geometrical measurement of mesorectum might play an important role in evaluating the difficulty of taTME procedure before operation, as well as standardizing landmarks during taTME procedure.

Pure natural orifice transluminal endoscopic surgery for rectal cancer: Ta-TME and CME without abdominal assistance

AIM

To report our institution's experiences with pure transanal total mesorectal excision (TME) of rectal cancer using single-port equipment and to discuss the feasibility and safety of the technique.

METHODS

Between February and December 2017, 12 patients who were selected underwent NOTES TME in our institution. The preoperative assessment included blood analyses with carcinoembryonic antigen serum concentration, full colonoscopy, pelvic magnetic resonance imaging (MRI), and computed tomography (CT) of the abdomen and chest.

RESULTS

Ten patients (male:female, 6:4) treated with transanal TME with colorectal anastomosis in our institution were reviewed. Pure TME was performed without laparoscopic assistance in 6 of 10 patients. The mean operative time was 303.5 min. The median distal margin was 2.1 (0.2-4.2) cm. The median number of harvested lymph nodes is 17.5. Except one patient with anastomotic leak, most patients started dietary intake on postoperative day (POD) 3 and were discharged on POD 7. Anastomotic leak was the only postoperative complication.

CONCLUSION

This study showed that pure natural orifice transluminal endoscopic surgery (NOTES) TME with coloanal anastomosis for rectal cancer is safe and feasible in selected cases.

Transanal Total Mesorectal Excision (taTME) for Rectal Cancer: A Case Series Report of a Natural Orifice Surgical Technique

In the treatment of colorectal cancer, total mesorectal excision (TME) has risen as the gold standard in the surgical treatment of this disease in order to obtain negative distal and circumferential radial margins. Since introduction in 2010, transanal TME has aimed to decrease the rate of positive margins and improve the quality of the dissection while decreasing the complications associated with a transabdominal low pelvic dissection. We retrospectively reviewed 25 cases of transanal TME completed between December 2014 and August 2017. Most of the patients in our case series were male (60%) with an average age of 57.1 years, BMI of 28.4 kg/m2, and with an American Society of Anesthesiologists score of II. The average tumor was midrectal (about 5.9 cm from the anal verge), clinically T3-T4 (92%), and had undergone neoadjuvant therapy (96%). The average operation was about six hours and 44 minutes with ileostomy placed most of the time (92%). In all the cases where the TME quality was graded, the specimens were reported to have been complete (grade I). There were no positive distal, radial, or proximal margins. The average hospital stay was about 5.9 days. The rate of minor complications was about 48 per cent and major complications occurred about 16 per cent of the time.

Laparoscopic sphincter-saving surgery for low rectal cancer through marker meeting approach

Laparoscopic low anterior resection (LAR) with sphincter preservation for ultra-low rectal cancer is always a challenging operation in colorectal surgery. To achieve negative margins, reducing the difficulty and risks of the procedure are major goals for us. The marker meeting approach we reported can help to accomplish this goal. The key technique for the marker meeting approach is to ensure a clear distal margin in a low resection of the rectum by transanal dissection. This procedure allows access to the space around the distal rectum and mesorectum and to pack the gauzes in the distal part of the space as a landmark. Routine laparoscopic LAR was performed to dissect the space until reaching the gauzes packed above and achieve complete mobilization of the rectum and mesorectum. This surgical procedure is simpler and reduces the difficulty of the operation. Therefore, it is expected to reduce the risk of surgery-related complications and positive margins and is suitable to be widely applied and extended in clinical practice. The short-term and long-term clinical outcomes of the marker meeting approach need more research in large samples.

Natural orifice transluminal endoscopic surgery for colorectal cancer

Background

Natural orifice transluminal endoscopic surgery (NOTES) has theoretical advantages over other approaches.

Methods

This was a prospective cohort study of colorectal cancers operated on by NOTES (transanally for rectal tumours, transvaginally for sigmoid tumours) between December 2013 and December 2015, with a minimum follow‐up of 1 year. Eligibility criteria included ASA fitness grade I–III, BMI below 25 kg/m² and TNM stage T3 N0 M0. Exclusion criteria included pregnancy or distant metastasis. The anastomosis was either handsewn or performed mechanically.

Results

Sixteen patients were operated on by a transanal and four by a transvaginal approach. There were ten men and ten women, with a mean(s.d.) age of 55·6(12·1) years. Mean BMI was 22·4(2·6) kg/m². Four anterior, 11 low anterior and five intersphincteric resections were performed for 16 rectal and four low sigmoid tumours. The mean duration of surgery was 258(11) min. No conversion to laparotomy was needed, and there were no deaths. Five patients required additional ports, for intraoperative bleeding (1), suture of an intraoperative urethral injury with covering ileostomy (1) and difficulty in dissection (3). One patient had an anastomotic leak requiring transanal closure and ileostomy on day 7. Both ileostomies were closed after 2 months. The mean hospital stay was 6·4(1·8) days. All resections were R0.

Conclusion

In carefully selected patients NOTES for colorectal cancer resection was feasible and effective.

Direct target NOTES: prospective applications for next generation robotic platforms

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.

Study protocol for a multicenter prospective controlled and randomized trial of transanal total mesorectal excision versus laparoscopic low anterior resection in rectal cancer

PURPOSE

Compared with the open approach, laparoscopic total mesorectal excision (TME) achieves faster patient recovery, reduces morbidity rates, and shortens hospital stay. However, in laparoscopic low anterior resection (L-LAR), conversion to open surgery is required in almost 20% of cases. Transanal TME (Ta-TME) combined with laparoscopy, also called hybrid natural orifice transluminal endoscopic surgery (NOTES), is a less invasive procedure that can overcome some of the limitations of laparoscopic rectal surgery. In this study, we aim to determine whether Ta-TME has a lower rate of conversion to open surgery than L-LAR, and thus achieves faster patient recovery without altering the pathological, functional, or oncological results. The main objective is to compare the results for conversion to open surgery between Ta-TME and L-LAR.

METHODS

Multicenter, prospective randomized controlled study of patients diagnosed with rectal adenocarcinoma who will be randomly allocated to Ta-TME or L-LAR groups after the application of inclusion and exclusion criteria. The main endpoint is conversion to open surgery and the secondary endpoints are general morbidity and mortality and hospital stay. Demographic, surgical, and pathological variables will also be studied, along with quality of life and survival. A sample size of 53 patients per group is calculated. With an estimated loss of 10%, the final sample required will be 116 patients.

CONCLUSIONS

Ta-TME achieves a lower conversion rate to open surgery than L-LAR, thus improving patient recovery and reducing overall morbidity.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02550769. Registration no. Ethical and Clinical Research Committee, Parc Taulí University Hospital: ID 2014/064.

Pathological outcomes of transanal versus laparoscopic total mesorectal excision for rectal cancer: a systematic review with meta-analysis

BACKGROUND

Since 2010, comparative studies on transanal and laparoscopic total mesorectal excision (TME) have been published and it remains unclear about the oncological benefit from transanal total mesorectal excision (taTME).

METHODS

We have searched English databases to identify all taTME studies published between January 2010 and August 2017. Pathological outcomes included circumferential resection margin (CRM), positive CRM (< 1 M), length of distal resection margin (DRM), positive DRM, quality of mesorectum (complete mesorectum), harvested lymph node, and length of the specimen. Odds ratios (ORs) were calculated for dichotomous outcomes and weighted mean differences (WMDs) for continuous outcomes.

RESULTS

We have included ten studies comprising of 762 patients. Compared with laparoscopic TME, taTME had a longer CRM (WMD, 0.833; 95% CI 0.366-1.299; P < 0.001), a lower positive rate of CRM (OR, 0.505; 95% CI 0.258-0.991; P = 0.047), and a longer DRM (WMD, 6.261; 95% CI 1.049-11.472; P = 0.019). There were no significant differences in other pathological outcomes. Both cumulative meta-analysis and sensitivity analysis were unable to detect potential sources of the heterogeneity in DRM. There was no evidence of publication bias.

CONCLUSIONS

This meta-analysis revealed that taTME had more advantages on positive CRM, CRM, and DRM compared with laparoscopic TME. Compared with laparoscopic TME, more benefits of taTME on pathological outcomes remained undetected. The current findings are all based on observational studies, RCTs with adequate power are required.

Rationale and limitations of transanal total mesorectal excision for rectal tumors

Transanal total mesorectal excision (taTME), belonging to natural-orifice transluminal endoscopic surgery, has been a hot topic in minimally invasive surgery for colorectal cancer in recent years. For low rectal tumors, taTME can offer more advantages than open or laparoscopic surgery, especially for obese patients and male patients with narrow pelvis. This technique may be possible to reduce positive circumferential resection margin rate and locoregional recurrence. However, surgeons may encounter some difficulties including being unfamiliar with the operation pathway, limited pelvic operation space, and being uneasy to ligate mesenteric vessels. Since taTME has not been applied for a very long time, there have been no sufficient number of cases available. Therefore, more cases and long-term follow-up are needed to improve this surgical technique.

Application of gluteus maximus fasciocutaneous V-Y advancement flap combined with resection in sacrococcygeal pressure ulcers: A CONSORT-compliant article

BACKGROUND

Traditional gluteus maximus myocutaneous flaps have generally been used to fill tissue defects after resection of sacrococcygeal pressure ulcers. However, postoperative complications were gradually revealed as increasing operations were performed. This study aimed to introduce the innovative application of gluteus maximus fasciocutaneous V-Y advancement flaps for repairing tissue defects and to comparatively analyze the differences between the innovative and traditional flaps.

METHODS

A total of 32 cases were included in this study. All the PU lesions were removed by resection. Sixteen cases used the gluteus maximus myocutaneous flaps, and the remaining 16 cases used gluteus maximus fasciocutaneous V-Y advancement flaps to fill the tissue defects after surgery. Comparative analysis between the gluteus maximus myocutaneous flaps and gluteus maximus fasciocutaneous V-Y advancement flaps was used to evaluate the 2 flaps based on the mean operating time, postoperative infection, paresthesia, appearance of flaps, and recurrence.

RESULTS

The gluteus maximus fasciocutaneous V-Y advancement flaps required a reduced operating time and a more simple operation compared with the gluteus maximus myocutaneous flaps. Although the infectious risk of the gluteus maximus fasciocutaneous V-Y advancement flaps was reduced compared with the gluteus maximus myocutaneous flaps, the gluteus maximus myocutaneous flaps have a better appearance compared with the gluteus maximus fasciocutaneous V-Y advancement flaps. Most importantly, no flap necrosis was noted, and the recurrence rate during follow-up was reduced in cases using the gluteus maximus fasciocutaneous V-Y advancement flaps.

CONCLUSION

The combined application of gluteus maximus fasciocutaneous V-Y advancement flaps with surgical resection can reduce the postoperative complications and aid in the treatment of sacrococcygeal pressure ulcers.

Simple instruments facilitating achievement of transanal total mesorectal excision in male patients

AIM

To assess the efficacy of a modified approach with transanal total mesorectal excision (taTME) using simple customized instruments in male patients with low rectal cancer.

METHODS

A total of 115 male patients with low rectal cancer from December 2006 to August 2015 were retrospectively studied. All patients had a bulky tumor (tumor diameter ≥ 40 mm). Forty-one patients (group A) underwent a classical approach of transabdominal total mesorectal excision (TME) and transanal intersphincteric resection (ISR), and the other 74 patients (group B) underwent a modified approach with transabdominal TME, transanal ISR, and taTME. Some simple instruments including modified retractors and an anal dilator with a papilionaceous fixture were used to perform taTME. The operative time, quality of mesorectal excision, circumferential resection margin, local recurrence, and postoperative survival were evaluated.

RESULTS

All 115 patients had successful sphincter preservation. The operative time in group B (240 min, range: 160-330 min) was significantly shorter than that in group A (280 min, range: 200-360 min; P = 0.000). Compared with group A, more complete distal mesorectum and total mesorectum were achieved in group B (100% vs 75.6%, P = 0.000; 90.5% vs 70.7%, P = 0.008, respectively). After 46.1 ± 25.6 mo follow-up, group B had a lower local recurrence rate and higher disease-free survival rate compared with group A, but these differences were not statistically significant (5.4% vs 14.6%, P = 0.093; 79.5% vs 65.1%, P = 0.130).

CONCLUSION

Retrograde taTME with simple customized instruments can achieve high-quality TME, and it might be an effective and economical alternative for male patients with bulky tumors.

Transanal total mesorectal excision as a surgical procedure for diffuse cavernous hemangioma of the rectum: A case report

•

DCHR is a rare benign vascular tumor, with the most common symptom being rectal bleeding.

•

The main challenge in the surgical management of DCHR lies in the precise resection of distal rectum.

•

TaTME appears to be a safe and feasible procedure for patients with DCHR in experienced hands.

•

DCHR is a rare benign vascular tumor, with the most common symptom being rectal bleeding.

•

The main challenge in the surgical management of DCHR lies in the precise resection of distal rectum.

•

TaTME appears to be a safe and feasible procedure for patients with DCHR in experienced hands.

Background

The safety and feasibility of transanal total mesorectal excision (TaTME) were demonstrated in the management of rectal cancer. However, its role in the management of patients with diffuse cavernous hemangioma of the rectum (DCHR) has not been evaluated.

Methods

A female patient with DCHR was admitted to our hospital. Colonoscopy, magnetic resonance imaging (MRI), abdominal computed tomography (CT) and arteriography were performed. Lesions were detected in mesorectum and rectal wall extending from the dentate line to 5 cm proximally. TaTME with a protecting loop ileostomy were performed. The research work has been reported in line with the SCARE criteria Agha et al., 2016 [1].

Results

TaTME and a protecting loop ileostomy were safely performed, with an intact mesorectal specimen being harvested. The entire procedure took 348 min. The estimated blood loss was 100 ml. The patient recovered uneventfully. Her symptom of painless rectal bleeding was resolved satisfactorily following the surgery. The histopathological evaluation confirmed the diagnosis of DCHR.

Conclusions

TaTME appears to be a safe and feasible procedure for patients with DCHR in experienced hands.

Transanal Total Mesorectal Excision: A Novel Approach to Rectal Surgery

Less invasive approaches continue to be explored and refined for diseases of the colon and rectum. The current gold standard for the surgical treatment of rectal cancer, total mesorectal excision (TME), is a technically precise yet demanding procedure with outcomes measured by both oncologic and functional outcomes (including bowel, urinary, and sexual). To date, the minimally invasive approach to rectal cancer has not yet been perfected, leaving ample opportunity for rectal surgeons to innovate. Transanal TME has recently emerged as a safe and effective technique for both benign and malignant diseases of the rectum. While widespread acceptance of this surgical approach remains tempered at this time due to lack of long-term oncologic outcome data, short-term outcomes are promising and there is great excitement surrounding the promise of this technique.

Combined robotic transanal total mesorectal excision (R-taTME) and single-site plus one-port (R-SSPO) technique for ultra-low rectal surgery-initial experience with a new operation approach

OBJECTIVE

Robot-assisted rectal surgery is gaining popularity, and robotic single-site surgery is also being explored clinically. We report our initial experience with robotic transanal total mesorectal excision (R-taTME) and radical proctectomy using the robotic single-site plus one-port (R-SSPO) technique for low rectal surgery.

METHODS

Between July 2015 and March 2016, 15 consecutive patients with ultra-low rectal lesions underwent R-taTME followed by radical proctectomy using the R-SSPO technique by a single surgeon. The clinical and pathological results were retrospectively analyzed.

RESULTS

The median operative time was 473 (range, 335-569) min, and the estimated blood loss was 33 (range, 30-50) mL. The median number of lymph nodes harvested was 12 (range, 8-18). The median distal resection margin was 1.4 (range, 0.4-3.5) cm, and all patients had clear circumferential resection margins. We encountered a left ureteric transection intraoperatively in one patient, and another patient required reoperation for postoperative adhesive intestinal obstruction. There was no 30-day mortality.

CONCLUSION

R-taTME followed by radical proctectomy using the R-SSPO technique for patients with low rectal lesions is technically feasible and safe without compromising oncologic outcomes. However, there were considerable limitations and a steep learning curve using current robotic technology.

Clinical outcomes and case volume effect of transanal total mesorectal excision for rectal cancer: a systematic review

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.

Pure Natural Orifice Transluminal Endoscopic Surgery (NOTES) with a new elongated, curved Transanal Endoscopic Operation (TEO) device for rectosigmoid resection: a survival study in a porcine model

BACKGROUND

Natural orifice transluminal endoscopic surgery (NOTES) has seen considerable new developments in its evolution to a platform for rectal and sigmoid resection, but to date no true single NOTES procedure has been convincing. This study investigates the safety and feasibility of a further developed transanal NOTES platform for single-access NOTES rectosigmoid resection.

METHODS

Ten large female pigs, mean weight 99.3 kg [standard deviation (SD) 7 kg, range 85.1-112.6 kg], underwent transanal rectosigmoid resection. Five animals were included in an acute study group with immediate postoperative euthanization. A second group included five animals in a survival study. Transanal rectosigmoid resections were performed with an elongated and curved transanal endoscopic operation (TEO) device. Coloanal anastomosis was performed using the transanal circular stapler technique. Survival follow-up was at 7 and 28 days via colonoscopy under sedation.

RESULTS

Single-access NOTES transanal rectosigmoid resection with coloanal anastomosis was performed in nine out of ten female pigs. Mean length of rectosigmoid specimens exteriorized was 18.7 cm (SD 2.9 cm, range 14-23 cm). Mean operating time was 124 min (SD 35.7 min, range 70-166 min). Within the survival group, no complications occurred during the monitoring phase. In one case, there was ascites and colitis at necropsy as well as fibrosis at the anastomosis site.

CONCLUSIONS

Pure transanal rectosigmoid resection is a feasible procedure. The approach via a single transanal access is demanding but viable with the elongated and curved TEO device. The newly developed scope offers an excellent view of the area cephalad to the promontory.

Is transanal total mesorectal excision a reproducible and oncologically adequate technique? A pilot study in a single center

PURPOSE

An oncologically effective total mesorectal excision (TME) still represents a technical challenge, especially in the presence of a low rectal cancer and anatomical restraints such as obesity or narrow pelvis. Recently, few reports have shown that transanal TME was feasible and associated with good outcomes. Nevertheless, a widespread employment of the technique has yet to happen due to the doubts about the reproducibility of the results outside a tertiary specialized center.

METHODS

Between February 2014 and June 2015, patients with low rectal cancer underwent a transanal TME with laparoscopic assistance. The end points included the oncologic adequacy of the mesorectal excision and the perioperative outcomes.

RESULTS

Eleven patients (9 male, median age 70.5 years) with proven low rectal cancer were enrolled in the study. The median distance of the tumor from the anal verge was 5 cm (2-7). Four patients (36.4 %) received preoperative chemoradiation. The median operative time was 360 min (275-445). Postoperative morbidity (36.4 %) included one (9.1 %) anastomotic leak requiring a reoperation. The median length of hospital stay was 8 days (3-28). The median distance from the circumferential and distal resection margins were, respectively, 5 (1-20) and 10 (5-20) mm, and the mean number of harvested lymph nodes was 21.7 (11-50). All cases had a complete or nearly complete mesorectal plane of surgery.

CONCLUSIONS

Although technically challenging, the initial results suggest that transanal TME could be a feasible, oncologically safe, and reproducible operation. However, more robust studies are required to assess the short- and long-term outcomes.

A systematic review of transanal total mesorectal excision: is this the future of rectal cancer surgery?

AIM

The surgical technique used for transanal total mesorectal excision (TaTME) was reviewed including the oncological quality of resection and the peri-operative outcome.

METHOD

A literature search of MEDLINE, Embase, Science Citation Index Expanded and Cochrane was performed in order to identify studies reporting on TaTME.

RESULTS

Thirty-six studies (eight case reports, 24 case series and four comparative studies) were identified, reporting 510 patients who underwent TaTME. The mean age ranged from 43 to 80 years and the mean body mass index from 21.7 to 31.8 kg/m(2) . The mean distance of the tumour from the anal verge ranged from 4 to 9.7 cm. The mean operation time ranged from 143 to 450 min and mean operative blood loss from 22 to 225 ml. The ratio of hand-sewn coloanal to stapled anastomoses performed was 2:1. One death was reported and the peri-operative morbidity rate was 35%. The anastomotic leakage rate was 6.1% and the reoperation rate was 3.7%. The mean hospital stay ranged from 4.3 to 16.6 days. The mesorectal excision was described as complete in 88% cases, nearly complete in 6% and incomplete in 6%. The circumferential resection margin was negative in 95% of cases and the distal resection margin was negative in 99.7%.

CONCLUSION

TaTME is a feasible and reproducible technique, with good quality of oncological resection. Standardization of the technique is required with formal training. Clear indications for this procedure need to be defined and its safety further assessed in future trials.

Transanal total mesorectal excision (taTME) for rectal cancer: a training pathway

BACKGROUND

With increasing interest in natural orifice surgery, there has been a dramatic evolution of transanal and endoluminal surgical techniques. These techniques began with transanal endoluminal surgical removal of rectal masses and have progressed to transanal radical proctectomy for rectal cancer. The first transanal total mesorectal excision (taTME) was performed in 2009 by Sylla, Rattner, Delgado, and Lacy. The improved visibility and working space associated with the taTME technique is intriguing. This video manuscript outlines the training pathway followed by pioneers in the taTME technique, the process of implementation into clinical practice, and initial case report.

METHODS

A double board-certified colorectal surgeon with expertise in rectal cancer, minimally invasive total mesorectal excision, transanal endoscopic surgery (TES), and intersphincteric dissection, underwent taTME training in male cadaver models. Institutional review board (IRB) approval for a phase I clinical trial was achieved. The entire operative team including surgeons, nurses, and operative staff underwent taTME cadaver training the day prior to the first clinical case. The case was proctored by an expert in taTME.

RESULTS

A 66-year-old male with uT3N1M0 rectal cancer located in the posterior distal rectum, underwent taTME with laparoscopic abdominal assistance, hand sewn coloanal anastomosis, and diverting loop ileostomy. The majority of the TME was performed transanally with laparoscopic assistance for exposure, splenic flexure mobilization, and high ligation of the vascular pedicles. Operative time was 359 min. There were no intraoperative complications. Pathology revealed a ypT2N1 moderately differentiated invasive adenocarcinoma, grade I TME, 1 cm circumferential radial margin, and 2/13 positive lymph nodes.

CONCLUSION

Implementation of taTME into practice can be achieved by surgeons with expertise in minimally invasive TME, TES, pre-clinical taTME training in cadavers, case observation, proctoring, and ongoing mentorship. IRB peer review process and participation in a clinical registry are additional measures that should be employed.

Single-incision laparoscopic surgery for rectal cancer: early results and medium-term oncological outcome

AIM

Conventional laparoscopic surgery for rectal cancer management is now widely accepted as an alternative to open surgery, bestowing specific advantages without causing detriment to oncological outcome. Evolving from this, single-incision laparoscopic surgery (SILS) has been successfully utilized for the removal of colonic tumours, but the literature lacks data analysing the suitability of SILS for rectal cancer resection, particularly on oncological outcome. We report the medium-term oncological outcome from a prospective observational study of SILS for rectal cancer, including high and low anterior resections.

METHOD

A prospective electronic database was collated of all patients undergoing SILS rectal cancer resection in our institution, between 2009 and 2014. In addition to patient, tumour and operative data, histopathological and medium-term oncological end-points were recorded. Kaplan-Meier curves were used to analyse survival.

RESULTS

Sixty-one patients underwent SILS for rectal cancer by high anterior resection (n = 34), low anterior resection with total mesorectal excision (TME) (n = 24) and low anterior resection with TME and hand-sewn colo-anal anastomosis (n = 3). The median operation time was 105 (37-280) min and 92% of cases were completed by SILS. The mean interval to resuming oral feeding was 11 h and the median length of stay was 2 (1-8) days. The median number of lymph nodes found by the histopathologist in the resected specimen was 18 (6-44) and all operations completely removed the tumour (R0 resection). At a median follow-up of 46 (16-64) months, eight (13%) patients developed metastatic disease, of whom three had local recurrence. Overall, three patients have died, of whom all had metastatic disease.

CONCLUSION

Anterior resection with TME for rectal cancer can be safely performed using the SILS technique, with acceptable histopathological results and good oncological outcome.

Transanal total mesorectal excision: A valid option for rectal cancer?

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.

Shifting Paradigms in Minimally Invasive Surgery: Applications of Transanal Natural Orifice Transluminal Endoscopic Surgery in Colorectal Surgery

Since the advent of laparoscopy, minimally invasive techniques such as single port laparoscopy, robotics, endoscopically assisted laparoscopy, and transanal endoscopic surgery continue to revolutionize the field of colorectal surgery. Transanal natural orifice transluminal endoscopic surgery (NOTES) represents a further paradigm shift by combining the advantages of these earlier techniques to reduce the size and number of abdominal incisions and potentially optimize rectal dissection, especially with respect to performance of an oncologically adequate total mesorectal excision (TME) for rectal cancer. Since the first experimental report of transanal rectosigmoid resection in 2007, the potential impact of transanal NOTES in colorectal surgery has been extensively investigated in experimental models and recently transitioned to clinical application. There have been 14 clinical trials of transanal TME (taTME) for rectal cancer that have demonstrated the feasibility and preliminary oncologic safety of this approach in carefully selected patients, with results comparable to outcomes after laparoscopic and open TME, including cumulative intraoperative and postoperative complication rates of 5.5 and 35.5%, respectively, 97.3% rate of complete or near-complete specimens, and 93.6% rate of negative margins. Transanal NOTES has also been safely applied to proctectomy and colectomy for benign indications. The consensus among published series suggests that taTME is most safely performed with transabdominal assistance by surgeons experienced with laparoscopic TME, transanal endoscopic surgery, and sphincter-preserving techniques including intersphincteric resection. Future applications of transanal NOTES may include evolution to a pure endoscopic transanal approach for TME, colectomy, and sentinel lymph node biopsy for rectal cancer, with a potential role for robotic assistance.

Transanal total mesorectal excision (TATME) - preliminary findings

Fifteen years ago, laparoscopic surgery of rectal cancer was considered as radical in terms of oncology as open surgery. A trend to reduce surgical injury may be observed in surgery in recent years. In this paper the first experience in the new minimally invasive method of anterior rectal resection is described - through the transanal way. The procedure duration was 130 min. The use of transanal access in rectal cancer surgery is undoubtedly an alternative method to standard laparoscopic surgery. In patients with a large tumour in the lower rectum, the technique allows a longer rectal stump to be left below the resection border.

Transanal total mesorectal excision for rectal cancer: a preliminary report

BACKGROUND

Currently, the majority cases of the novel down-to-up transanal total mesorectal excision (TaTME) were performed in a hybrid approach with conventional laparoscopic assistance because of less operative difficulty. However, although cases are limited, the successes of TaTME in a pure approach (without laparoscopic assistance) indicate that the costly and less mini-invasive hybrid TaTME could be potentially avoided.

METHODS

In the present single institutional, prospective study, we attempted to demonstrate the safety and feasibility of this approach in rectal cancer by evaluating the short-term results of our first 20 TaTME cases. For the majority of cases, we adopted a strategy that laparoscopic assistance was not introduced unless it was required during the planned pure TaTME procedure.

RESULTS

A total of 20 patients (12 males and 8 females) were analyzed in this study, including 11 cases (55 %) of pure TaTME and 9 cases (45 %) of hybrid TaTME. Overall, the median operative time was 200 min (range 70-420), along with a median estimated blood loss of 50 ml (range 20-800). Morbidity rate was 20 % (one urethral injury, two urinary retentions, one anastomotic hemorrhage and one mild anastomotic leak). The median number of harvested lymph nodes was 12 (range 1-20). All specimens were intact in mesorectum without positive distal and circumferential resection margins. Among the 15 patients who were preoperatively scheduled to undertake pure TaTME, four patients (26.7 %) required converting to laparoscopic assistance. Moreover, among these 15 patients, the results of the comparative analysis between female and male subgroups favor the former, suggesting easier operation in them.

CONCLUSION

This preliminary study demonstrates that TaTME in rectal cancer is safe and feasible. The strategy of not introducing laparoscopic assistance unless it is required while performing the planned pTaTME should be cautiously explored. Further studies with larger sample size and longer follow-up are warranted.

Transanal total mesorectal excision assisted by single-port laparoscopic surgery for low rectal cancer

INTRODUCTION

We have combined the minimally invasive single-port laparoscopic surgery and the transanal total mesorectal excision (TaTME) for rectal cancer with the goal to standardize the approach and improve the quality of rectal cancer resection.

METHODS

By using two single-port platforms, selected patients were first operated by TaTME, and then a single-port laparoscopic surgery was introduced to assist and complete the abdominal portion. Short-term outcomes including perioperative outcome and pathologic results of these patients were evaluated.

RESULTS

Between July 2014 and March 2015, six patients with low rectal cancer (five males and one female) at a median age of 68 years were successfully operated in a median time of 360 min (range 310-420). The median estimated blood loss was 150 ml (range 50-800). In one patient, the spleen was removed because of a lesion identified preoperatively. Their postoperative recovery was uneventful except one acute myocardial infarction on postoperative day 3. Pathologic specimens showed negative margins and a complete excision of the mesorectum in all cases. The median number of harvested lymph nodes was 11.5 (range 4-12). At a median follow-up of 4 months (range 3-9), after ileostomy closure, none of the patients suffered from fecal incontinence.

CONCLUSION

TaTME assisted by abdominal single-port may be safely achieved in selected rectal cancer patients.

Transanal total mesorectal excision: a pure NOTES approach for selected patients

BACKGROUND

The concept of natural orifice transluminal endoscopic surgery (NOTES) has stimulated the development of various "incisionless" procedures. One of the most popular is the transanal approach for rectal lesions. The aims of this study were to report how we standardized NOTES technique for transanal mesorectal excision without abdominal assistance, discuss the difficulties and surgical outcomes of this technique and report its feasibility in a small group of selected patients.

METHODS

Three consecutive female patients underwent transanal NOTES rectal resection without transabdominal laparoscopic assistance for rectal lesions. Functional results were assessed with the Fecal Incontinence Quality of Life scale and the Wexner score.

RESULTS

The technical steps are described in details and complemented with a video. All procedures were completed without transabdominal laparoscopic help. The mesorectal plane was entirely dissected without any disruption, and distal and circumferential margins were tumor-free. No major complications were observed. Functional results show a significant impairment after surgery with improvement at 6 months to levels near those of the preoperative period.

CONCLUSIONS

The performance and publication of NOTES procedures are subject to much discussion. Despite the small number of patients, this procedure appears feasible and can be accomplished maintaining fecal continence and respecting oncologic principles.

Low rectal cancer: Sphincter preserving techniques-selection of patients, techniques and outcomes

Low rectal cancer is traditionally treated by abdominoperineal resection. In recent years, several new techniques for the treatment of very low rectal cancer patients aiming to preserve the gastrointestinal continuity and to improve both the oncological as well as the functional outcomes, have been emerged. Literature suggest that when the intersphincteric resection is applied in T1-3 tumors located within 30-35 mm from the anal verge, is technically feasible, safe, with equal oncological outcomes compared to conventional surgery and acceptable quality of life. The Anterior Perineal PlanE for Ultra-low Anterior Resection technique, is not disrupting the sphincters, but carries a high complication rate, while the reports on the oncological and functional outcomes are limited. Transanal Endoscopic MicroSurgery (TEM) and TransAnal Minimally Invasive Surgery (TAMIS) should represent the treatment of choice for T1 rectal tumors, with specific criteria according to the NCCN guidelines and favorable pathologic features. Alternatively to the standard conventional surgery, neoadjuvant chemo-radiotherapy followed by TEM or TAMIS seems promising for tumors of a local stage T1sm2-3 or T2. Transanal Total Mesorectal Excision should be performed only when a board approved protocol is available by colorectal surgeons with extensive experience in minimally invasive and transanal endoscopic surgery.