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Abstract
BACKGROUND Restorative proctocolectomy with IPAA is the standard procedure in ulcerative colitis patients with medical refractory disease or dysplasia and select patients with IBD unclassified or Crohn's disease. A variety of minimally invasive techniques have become increasingly utilized, including the transanal IPAA. Unfortunately, despite its growing popularity, there is a lack of high-quality data for the transanal approach. OBJECTIVE The aim of this study was to investigate clinical outcomes, including complication rates, during our initial experience with the transanal approach. DESIGN The study design was a single-center prospective case series. SETTINGS The study was conducted at a tertiary referral center. PATIENTS The study included patients with ulcerative colitis, IBD unclassified, and Crohn's disease undergoing 2- or 3-stage restorative proctocolectomy with IPAA. INTERVENTIONS Consecutive patients after November 2016 undergoing restorative proctocolectomy with transanal approach were compared with a historic cohort of patients who underwent an open approach before October 2016. MAIN OUTCOME MEASURES The primary outcome measure was early and late anastomotic leak rates during our learning curve. Secondary outcomes included postoperative clinical measures. RESULTS The study group consisted of 100 open and 65 transanal approach patients. Median (interquartile range) estimated blood loss was lower with the transanal approach (100 [50-150] vs 150 [100-250] mL; p = 0.007), and hospital stay was lower in the transanal group by 2 days ( p < 0.001). There was a significantly higher rate of anastomotic leaks with the transanal approach compared with the open approach (n = 7 [11%] vs n = 2 [2%] respectively; p = 0.03). There were fewer, but statistically insignificant, anastomotic complications in the third tertile, which was later in our learning curve. LIMITATIONS The study was nonrandomized with consecutive assignment, introducing possible selection and chronology biases. CONCLUSION Restorative proctocolectomy with the transanal approach was associated with lower blood loss and shorter hospital stay but a significantly higher anastomotic leak rate. The transanal minimally invasive approach for pouch surgery offers some advantages but carries a steep learning curve. See Video Abstract at http://links.lww.com/DCR/B842 . EXPERIENCIA DE UN SOLO CENTRO DE PROCTECTOMA TRANSANAL CON ANASTOMOSIS ILEOANAL CON RESERVORIO ILEAL PARA ENFERMEDAD INFLAMATORIA INTESTINAL ANTECEDENTES:La proctocolectomía restaurativa con anastomosis ileoanal con reservorio ileal es el procedimiento estándar en pacientes con colitis ulcerativa con enfermedad médica refractaria o displasia y pacientes seleccionados con enfermedad inflamatoria intestinal no clasificada o enfermedad de Crohn. Se ha utilizado cada vez más una variedad de técnicas mínimamente invasivas, incluido el enfoque de anastomosis ileoanal con reservorio ileal transanal. Desafortunadamente, a pesar de su creciente popularidad, hay falta de datos de alta calidad para el enfoque transanal.OBJETIVO:Investigar los resultados clínicos, incluidas las tasas de complicaciones, durante nuestra experiencia inicial con el enfoque transanal.DISEÑO:Serie de casos prospectivos de un solo centro.AJUSTES:Centro de referencia terciario.PACIENTES:Pacientes con ulcerativa, enfermedad inflamatoria intestinal no clasificada y enfermedad de Crohn sometidos a proctocolectomía restaurativa de 2 o 3 etapas con anastomosis ileoanal con reservorio ileal.INTERVENCIONES:Pacientes consecutivos después de noviembre del 2016 sometidos a proctocolectomía restaurativa con abordaje transanal fueron comparados con una cohorte histórica que se sometieron a un abordaje abierto antes de octubre del 2016.PRINCIPALES MEDIDAS DE RESULTADO:La principal medida de resultado fueron las tasas de fuga anastomótica temprana y tardía durante nuestra curva de aprendizaje. Los resultados secundarios incluyeron medidas clínicas postoperatorias.RESULTADOS:El grupo de estudio estuvo formado por 100 pacientes con abordaje abierto y 65 por vía transanal. La media de pérdida sanguínea estimada fue menor con el abordaje transanal (100 [50-150] vs 150 [100-250] mL; p = 0.007) y la estancia hospitalaria fue menor en el grupo transanal por 2 días ( p < 0.001). Hubo una tasa significativamente mayor de fugas anastomóticas con el abordaje transanal en comparación con el abordaje abierto (n = 7 [11%] vs n = 2 [2%] respectivamente, p = 0.03). Hubo menos complicaciones anastomóticas, pero estadísticamente insignificantes, en el tercer tercil, posterior en nuestra curva de aprendizaje.LIMITACIONES:Estudio no randomizado con asignación consecutiva que presenta posibles sesgos de selección y cronología.CONCLUSIÓNES:La proctocolectomía restaurativa con abordaje transanal se asoció a una menor pérdida sanguínea y estancia hospitalaria más corta, pero con una tasa de fuga anastomótica significativamente mayor. El abordaje transanal mínimamente invasivo para cirugía de reservorio ofrece algunas ventajas, pero conlleva a una curva de aprendizaje pronunciada. Consulte Video Resumen en http://links.lww.com/DCR/B842 . (Traducción- Dr. Francisco M. Abarca-Rendon ).
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Li L, Wang T, Hu D, Wu D, Bi L, Luo Y, Guo Y, Yang X. Pathologic outcomes of transanal versus laparoscopic total mesorectal excision for rectal cancer: a meta-analysis of 26 studies. Int J Colorectal Dis 2022; 37:1063-1071. [PMID: 35411470 DOI: 10.1007/s00384-022-04147-1] [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] [Accepted: 04/04/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Transanal total mesorectal excision (TaTME) has the potential advantages for patients with low rectal cancer. The objective of this meta-analysis was to identify the pathologic outcomes between the TaTME and laparoscopic total mesorectal excision (LaTME) in rectal cancer. METHODS The literature searches were conducted in PubMed, Cochrane Library, and EMBASE with English language restriction. The primary endpoint was circumferential margin (CRM), and the secondary endpoints were distal resection margin (DRM), mesorectal excision quality, and harvested lymph nodes. RESULTS Our research identified 1090 articles, and 26 studies met the inclusion criteria for the meta-analysis. The positive CRM was lower in the TaTME than the LaTME (OR = 0.72; 95% CI = 0.53, 0.98; P = 0.04). There was no significant difference in the positive CRM between the TaTME and LaTME published after 2016 (OR = 0.80; 95% CI = 0.57, 1.12; P = 0.19), prospective study (OR = 2.70; 95% CI = 0.51, 14.24; P = 0.24), respective study (OR = 0.76; 95% CI = 0.55, 1.04; P = 0.09), BMI > 26 (OR = 1.00; 95% CI = 0.63, 1.58; P = 0.98), or sample size > 100 (OR = 0.84; 95% CI = 0.57, 1.23; P = 0.38). In addition, there was no significant difference observed between the TaTME and LaTME in terms of DRM, mesorectum incompleteness, and harvested lymph nodes. CONCLUSIONS The TaTME is associated with lower positive CRM compared to the LaTME and similar pathologic outcomes including DRM, harvested lymph node, and mesorectal excision quality.
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Affiliation(s)
- Laiyuan Li
- Department of Anorectal Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Tao Wang
- Department of Anorectal Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Dongping Hu
- Department of Anorectal Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Dewang Wu
- Department of Anorectal Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Liang Bi
- Department of Anorectal Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Yang Luo
- Department of Neurology, The First Hospital of Lanzhou University, Lanzhou, China
| | - Yinyin Guo
- Department of Pharmacy, Lanzhou University Second Hospital, Lanzhou, China
| | - Xiongfei Yang
- Department of Anorectal Surgery, Gansu Provincial Hospital, Lanzhou, China.
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Total mesorectal excision laparoscopic versus transanal approach for rectal cancer: A systematic review and meta-analysis. Ann Med Surg (Lond) 2022; 74:103260. [PMID: 35145658 PMCID: PMC8802044 DOI: 10.1016/j.amsu.2022.103260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 01/12/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction Total mesorectal excision (TME) performed for the first time by Held through an open approach, it has become the standard technique for the surgical treatment of rectal cancer. The aim the of this meta-analysis is to compare the outcomes provided by TaTME than LaTME. Material and methods In this meta-analysis, we included all comparative studies, prospective and retrospective, which addressed in low and middle rectal cancer, a comparison between TaTME and LaTME. A search was performed through MEDLINE and Cochrane Database. 846 records were identified. Results Eight relevant studies have been included in this meta-analysis. The studies were from France, Russia, USA, Netherlands, Taiwan, Egypt. The eight studies including 471 patients with middle or low rectal cancer. Conclusion The meta-analysis confirmed safety of TaTME for low and middle rectal cancer. TaTME can lead to a high quality of rectal cancer resection specimen. The aim the of this meta-analysis is to compare the outcomes provided by TaTME than LaTME. We included all comparative studies, which addressed in low and middle rectal cancer. Eight relevant studies have been included. The meta-analysis confirmed safety of TaTME for rectal cancer.
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Ullah S, Ali FS, Liu BR. Advancing flexible endoscopy to natural orifice transluminal endoscopic surgery. Curr Opin Gastroenterol 2021; 37:470-477. [PMID: 34091533 DOI: 10.1097/mog.0000000000000753] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW This review is an update on the recent advancements and clinical applications of flexible endoscopy in the context of natural orifice translumenal endoscopic surgery (NOTES). We focus on recent developments in gastrointestinal luminal and transluminal NOTES. RECENT FINDINGS NOTES has evolved from a hybrid approach utilizing a laparoscopic assistant to pure NOTES without laparoscopic assistance. Current experimental and clinical studies focus on the implementation of new minimally invasive approaches as well as on the training in the use of these procedures. In recent years, flexible endoscopic-NOTES and endoluminal surgery have increasingly reported favorable results in preclinical and experimental settings using flexible endoscopic cholecystectomy, cholecystolithotomy, and appendectomy. Additionally, flexible endoscopic lymphadenectomy and thyroidectomy are among the new interventions that are opening new frontiers for endoscopists to explore. SUMMARY Flexible endoscopy has paved way to new frontiers for endoscopists and surgeons. As the armamentarium of interventional endoscopy increases and the ability of endoscopists to perform advanced interventions safely fosters an inevitable step forward that will involve the integration of new technology with innovative thinking.
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Affiliation(s)
- Saif Ullah
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Faisal S Ali
- Department of Internal Medicine, Saint Joseph Hospital, Chicago, Illinois, USA
| | - Bing-Rong Liu
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- State Key Laboratory of Esophageal Cancer Prevention and Treatment, Zhengzhou University, Zhengzhou, China
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Wang X, Zheng Z, Yu Q, Ghareeb WM, Lu X, Huang Y, Huang S, Lin S, Chi P. Impact of Surgical Approach on Surgical Resection Quality in Mid- and Low Rectal Cancer, A Bayesian Network Meta-Analysis. Front Oncol 2021; 11:699200. [PMID: 34458142 PMCID: PMC8385749 DOI: 10.3389/fonc.2021.699200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 07/15/2021] [Indexed: 02/01/2023] Open
Abstract
Aim To evaluate the evidence concerning the quality of surgical resection in laparoscopic (LapTME), robotic (RobTME) and transanal (TaTME) total mesorectal excision for mid-/low rectal cancer. Methods A systematic literature search of the PubMed, EMBASE and Cochrane Central Register of Controlled Trials databases was performed. A Bayesian network meta-analysis was utilized to compare surgical resection involved in these 3 surgical techniques by using ADDIS software. Rates of positive circumferential resection margins (CRMs) were the primary endpoint. Results A total of 34 articles, 2 randomized clinical trials (RCTs) and 32 non-RCTs, were included in this meta-analysis. Pooled data showed CRM positivity in 114 of 1763 LapTME procedures (6.5%), 54 of 1051 RobTME procedures (5.1%) and 60 of 1276 TaTME procedures (4.7%). There was no statistically significant difference among these 3 surgical approaches in terms of CRM involvement rates and all other surgical resection quality outcomes. The incomplete mesorectal excision rates were 9.6% (69/720) in the LapTME group, 1.9% (11/584) in the RobTME group and 5.6% (45/797) in the TaTME group. Pooled network analysis observed a higher but not statistically significant risk of incomplete mesorectum when comparing both LapTME with RobTME (OR = 1.99; 95% CI = 0.48-11.17) and LapTME with TaTME (OR = 1.90; 95% CI = 0.99-5.25). By comparison, RobTME was most likely to be ranked the best or second best in terms of CRM involvement, complete mesorectal excision, rate of distal resection margin (DRM) involvement and length of DRMs. In addition, RobTME achieved a greater mean tumor distance to the CRM than TaTME. It is worth noting that TaTME was most likely to be ranked the worst in terms of CRM involvement for intersphincteric resection of low rectal cancer. Conclusion Overall, RobTME was most likely to be ranked the best in terms of the quality of surgical resection for the treatment of mid-/low rectal cancer. TaTME should be performed with caution in the treatment of low rectal cancer.
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Affiliation(s)
- Xiaojie Wang
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Zhifang Zheng
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Qian Yu
- Department of Pathology, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Waleed M Ghareeb
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Xingrong Lu
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Ying Huang
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Shenghui Huang
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Shuangming Lin
- Department of Gastrointestinal and Anal Surgery, Longyan First Hospital, Affiliated to Fujian Medical University, Longyan, China
| | - Pan Chi
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
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Bochkarev V. Two-Year Follow-Up of the First Transanal Total Mesorectal Excision (TaTME) Case Performed in Community Hospital in Hawai'i: A Case Report and Literature Review. HAWAI'I JOURNAL OF HEALTH & SOCIAL WELFARE 2021; 80:159-164. [PMID: 34278323 PMCID: PMC8280358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Surgical management of rectal cancer has evolved with the advent of total mesorectal excision (TME) and neo-adjuvant treatment allowing for more sphincter-preserving proctectomies. The laparoscopic approach to TME has numerous advantages over the open approach, including faster recovery, fewer wound complications, and overall reduced morbidity. However, laparoscopic dissection around the distal portion of the rectum is particularly difficult, and thus makes achieving TME completeness and negative resection margins for low rectal tumors a challenge. Transanal TME (TaTME) is designed to overcome these difficulties. It is performed in addition to laparoscopic operation as a bottom-up approach facilitating dissection around the distal rectum. More importantly, TaTME has been shown to have the potential to improve oncological outcomes of minimally-invasive sphincter-preserving proctectomy by providing better TME specimen quality and resection margins. Although interest in TaTME has been growing worldwide, the technique is still relatively new, and adoption into routine practice may be challenging. Potential criteria for successful adoption of the TaTME technique include experience in laparoscopic rectal resection and transanal minimally-invasive surgery (TAMIS), cadaveric TaTME training, and a multidisciplinary approach to selection and management of patients with rectal cancer. Once these criteria are met, gradual and careful implementation of TaTME could be feasible. This report describes the 2-year follow-up of the first TaTME case in Hawai'i managed by a multidisciplinary oncological team in a community hospital setting.
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Affiliation(s)
- Victor Bochkarev
- General Surgery, Hilo Medical Center, Hawai‘i Health Systems Corporation, Hilo, HI
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Alimova I, Chernyshov S, Nagudov M, Rybakov E. Comparison of oncological and functional outcomes and quality of life after transanal or laparoscopic total mesorectal excision for rectal cancer: a systematic review and meta-analysis. Tech Coloproctol 2021; 25:901-913. [PMID: 34002288 DOI: 10.1007/s10151-021-02420-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 01/29/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND The aim of this study was to compare long-term oncological, functional outcomes and quality of life (QoL) after transanal total mesorectal excision (TaTME) and laparoscopic total mesorectal excision (LaTME) for rectal cancer. METHODS A systematic review and meta-analysis based on Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were conducted on PubMed and Cochrane database. Non-randomized controlled trials (NRCTs) which compared TaTME with LaTME were included. RESULTS Ten non-randomized studies were identified, including a total of 638 patients (323 TaTME and 315 LaTME). Age, sex, body mass index, neoadjuvant treatment and American Society of Anesthesiologists (ASA) staging of patients in the two groups were comparable in all included studies. The follow-up period was significantly shorter in the TaTME group than in the LaTME group. No significant differences in local (p = 0.71) and distant (p = 0.23) recurrence rate, 2-year disease-free (p = 0.86) and overall (p = 0.25) survival was found. Also, no significant differences in function outcomes and QoL, including the Wexner score (p = 0.48) or the International Prostate Syndrome Score (IPSS) (p = 0.64) were found. However, the low anterior resection syndrome (LARS) score was significantly higher in the TaTME group (p = 0.04). CONCLUSIONS TaTME and LaTME have similar long-term oncological and functional outcomes as well as QoL. The only exception is higher LARS scores after TaTME. The current data are based mainly on observational studies and further randomized controlled trials are required.
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Affiliation(s)
- I Alimova
- Ryzhikh National Medical Research Center of Coloproctology, Saliama Adila street, 2, Moscow, 123423, Russian Federation.
| | - S Chernyshov
- Ryzhikh National Medical Research Center of Coloproctology, Saliama Adila street, 2, Moscow, 123423, Russian Federation
| | - M Nagudov
- Ryzhikh National Medical Research Center of Coloproctology, Saliama Adila street, 2, Moscow, 123423, Russian Federation
| | - E Rybakov
- Ryzhikh National Medical Research Center of Coloproctology, Saliama Adila street, 2, Moscow, 123423, Russian Federation
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A prospective study of health related quality of life, bowel and sexual function after TaTME and conventional laparoscopic TME for mid and low rectal cancer. Tech Coloproctol 2021; 25:449-459. [PMID: 33646454 DOI: 10.1007/s10151-020-02397-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 12/27/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND The aim of our study was to evaluate short -term (3 months) and medium-term (12 months) postoperative effects on health related quality of life (HRQoL), bowel and sexual function after transanal total mesorectal excision (TaTME) in comparison with conventional laparoscopic total mesorectal excision (TME). METHODS A prospective study was conducted on consecutive patients who had conventional laparoscopic TME and TaTME at our institution from November 2014 to December 2018.We evaluated HRQoL and bowel function using validated scales including the European Organization for Research and Treatment of Cancer Quality of Life of colorectal cancer specific module (EORTC-QLQ-CR29), International Index of Erectile Function (IIEF-5), Female Sexual Function Index (FSFI), low anterior resection syndrome (LARS) score and Wexner score. Patients were matched one-to-one through propensity score matching. Outcomes of the questionnaires at 3 and 12 months were compared. RESULTS Sixty patients were enrolled in the study. There were 30 in the conventional laparoscopic group (13 males; median age 69.3 years [range 35-80 years]) and 30 in the TaTME group (14 males; median age 75.6 years [range 42-83 years]). Three months after ileostmy closure, patients in the TaTME group had significantly more buttock pain (p = 0.030), bloating (p = 0.023), stool frequency (p = 0.013), flatulence (p < 0.001) and fecal incontinence (p = 0.044), although none of these differences persisted at 12 months. Patients in the TaTME group had a higher median overall LARS score at 3 months (p = 0.032) but there was no difference at 12 months. At 12 months after TaTME female patients had better women's sexual interest (p = 0.039) and dyspareunia scores (p < 0.001), while male patients had better erectile function (p = 0.038). Other scales did not reveal a significant difference at either 3 of 12 months between groups. CONCLUSIONS Compared with patients with mid and low rectal cancer treated with conventional laparoscopic TME, those treated with TaTME have worse HRQoL and bowel function for a short period after primary resection, but seem to have better sexual function in the long term.
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Bokey L, Zhang M, Fingerhut A, Dent OF, Chapuis PH. Trans-anal total mesorectal excision - reflections on the introduction of a new procedure. Colorectal Dis 2020; 22:739-744. [PMID: 32533809 DOI: 10.1111/codi.15190] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 04/24/2020] [Indexed: 02/08/2023]
Affiliation(s)
- L Bokey
- Department of Colorectal Surgery and Department of Surgery, Liverpool Hospital, Liverpool, New South Wales, Australia.,School of Medicine, Western Sydney University, Penrith, New South Wales, Australia
| | - M Zhang
- Department of Anatomy, University of Otago, Otago, New Zealand
| | - A Fingerhut
- Department of Surgery, Medical University of Graz, Graz, Austria.,Department of General Surgery, Shanghai Minimally Invasive Surgery Centre, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - O F Dent
- School of Medicine, Western Sydney University, Penrith, New South Wales, Australia
| | - P H Chapuis
- School of Medicine, Western Sydney University, Penrith, New South Wales, Australia
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Sun T, Cao Z, Zhang Y, Li B, Huang Y, Zou G, Yin X, Yuan X, Zhang C, Ning S. Transanal total mesorectal excision (TaTME) using flexible endoscope with laparoscopic assistance: a pilot study in porcine models. Updates Surg 2020; 72:845-850. [PMID: 32399596 DOI: 10.1007/s13304-020-00768-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 04/11/2020] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Tao Sun
- Department of Gastroenterology, Air Force Medical Center PLA, Fucheng Road 30, Beijing, 100142, China
| | - Zhen Cao
- Department of General Surgery, The 6th Medical Center, Chinese PLA General Hospital, Fucheng Road 6, Beijing, 100048, China
| | - Yan Zhang
- Department of General Surgery, The 6th Medical Center, Chinese PLA General Hospital, Fucheng Road 6, Beijing, 100048, China
| | - Bairong Li
- Department of Gastroenterology, Air Force Medical Center PLA, Fucheng Road 30, Beijing, 100142, China
| | - Yun Huang
- Department of General Surgery, The 6th Medical Center, Chinese PLA General Hospital, Fucheng Road 6, Beijing, 100048, China
| | - Guijun Zou
- Department of General Surgery, The 6th Medical Center, Chinese PLA General Hospital, Fucheng Road 6, Beijing, 100048, China
| | - Xin Yin
- Department of Gastroenterology, Air Force Medical Center PLA, Fucheng Road 30, Beijing, 100142, China
| | - Xinpu Yuan
- Department of General Surgery, The 6th Medical Center, Chinese PLA General Hospital, Fucheng Road 6, Beijing, 100048, China
| | - Chaojun Zhang
- Department of General Surgery, The 6th Medical Center, Chinese PLA General Hospital, Fucheng Road 6, Beijing, 100048, China.
| | - Shoubin Ning
- Department of Gastroenterology, Air Force Medical Center PLA, Fucheng Road 30, Beijing, 100142, China.
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Hajibandeh S, Hajibandeh S, Eltair M, George AT, Thumbe V, Torrance AW, Budhoo M, Joy H, Peravali R. Meta-analysis of transanal total mesorectal excision versus laparoscopic total mesorectal excision in management of rectal cancer. Int J Colorectal Dis 2020; 35:575-593. [PMID: 32124047 DOI: 10.1007/s00384-020-03545-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/18/2020] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To evaluate comparative outcomes of transanal total mesorectal excision (TaTME) and laparoscopic TME (LaTME) in patients with rectal cancer. METHODS We systematically searched multiple databases and bibliographic reference lists. A combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators, and limits were applied. Overall intraoperative complications, overall postoperative complications, anastomotic leak, surgical site infections (SSIs), completeness of mesorectal excision, R0 resection, distal (DRM) and circumferential resection margin (CRM), number of harvested lymph nodes, and procedure time were the evaluated outcome parameters. RESULTS We identified 18 comparative studies reporting a total of 2048 patients evaluating outcomes of TaTME (n = 1000) and LaTME (n = 1048) in patients with rectal cancer. TaTME was associated with significantly higher number of R0 resection (OR 1.67, P = 0.01) and harvested lymph nodes (MD 1.08, P = 0.01), and lower rate of positive CRM (OR 0.67, P = 0.04) and conversion to an open procedure (OR 0.17, P < 0.00001) compared with LaTME. However, there was no significant difference in intraoperative complications (OR 1.18, P = 0.54), postoperative complications (OR 0.89, P = 0.24), anastomotic leak (OR 0.88, P = 0.42), SSIs (OR 0.64, P = 0.26), completeness of mesorectal excision (OR 1.43, P = 0.19), DRM (MD 1.87, P = 0.16), CRM (MD 0.36, P = 0.58), and procedure time (MD - 10.87, P = 0.18) between TaTME and LaTME. Moreover, for low rectal tumours, TaTME was associated with significantly lower rate of anastomotic leak and higher number of lymph nodes (MD 2.06, P = 0.002). CONCLUSIONS Although the meta-analysis of best available evidence (level 2) demonstrated that TaTME may be associated with better short-term oncological outcomes and similar clinical outcomes compared with LaTME, the differences between the two groups were small questioning their clinical relevance. No solid conclusions can be made due to lack of high quality randomised studies.
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Affiliation(s)
- Shahin Hajibandeh
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK.
| | - Shahab Hajibandeh
- Department of General Surgery, Glan Clwyd Hospital, Rhyl, Denbighshire, UK
| | - Mokhtar Eltair
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Anil T George
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Vijay Thumbe
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Andrew W Torrance
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Misra Budhoo
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Howard Joy
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Rajeev Peravali
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
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12
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Khilkov YS, Ponomarenko AA, Rybakov EG, Shelygin YA. OPEN, LAPAROSCOPIC AND TRANSANAL TOTAL MESORECTAL EXCISION: A SYSTEMATIC LITERATURE REVIEW AND NETWORK META ANALYSIS. ACTA ACUST UNITED AC 2019. [DOI: 10.33878/2073-7556-2019-18-4-37-85] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
AIM: to compare the effectiveness of different methods of total mesorectumectomy (TME).MATERIALS AND METHODS: the systematic review performed in accordance with PRISMA practice and recommendations.RESULTS: Forty-one papers were included in the analysis. Fourteen studies were for transanal total mesorectumectomy (TA TME) (n=480) compared with laparoscopic (LA TME), 26 – for LA TME vs open (n=6820), 1 – for open vs TA TME. There was no significant difference between open TME, LA TME and TA TME in grade 3 quality of mesorectumectomy by Quirke. The positive circular resection margin (CRM) is less often in TA TME group, then LA TME (OR=2.58, CI 1.34-4.97, p=0.005). There was significantly lower positive CRM rate in LA TME then open TME (OR=0.73, CI 0.63-0.85, p<0.0001). There were no significant differences in postoperative complications rates between LA TME and TA TME (p=0.72). Network meta-analysis showed less postoperative complications followed LA TME than open TME (OR=0.75, CI 0.65-0.84).CONCLUSION: TA TME is comparable with laparoscopic and open TME in short term results. Rates of positive CRM, the quality of Grade 1 mesorectal excision, the conversion rate, the postoperative urinary dysfunction, may have better results in TA TME.
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Affiliation(s)
- Yu. S. Khilkov
- State Scientific Centre of Coloproctology of the Ministry of Healthcare of Russia
| | - A. A. Ponomarenko
- State Scientific Centre of Coloproctology of the Ministry of Healthcare of Russia
| | - E. G. Rybakov
- State Scientific Centre of Coloproctology of the Ministry of Healthcare of Russia
| | - Yu. A. Shelygin
- State Scientific Centre of Coloproctology of the Ministry of Healthcare of Russia
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13
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Aubert M, Mege D, Panis Y. Total mesorectal excision for low and middle rectal cancer: laparoscopic versus transanal approach-a meta-analysis. Surg Endosc 2019; 34:3908-3919. [PMID: 31617090 DOI: 10.1007/s00464-019-07160-8] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 09/24/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Transanal total mesorectal excision (TaTME) appeared to be a challenging alternative to Laparoscopic Total Mesorectal Excision (LaTME) for low and middle rectal cancer. However, evidence remains low on the possible benefits of TaTME. The aim of this study was to perform a meta-analysis of comparative studies between TaTME and LaTME. METHODS A systematic review and meta-analysis based on Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) guidelines was conducted on Medline, Embase, and Cochrane database. The following outcomes were assessed: conversion, operative time, morbidity, length of stay, readmission rate, and pathological and oncological results. RESULTS After review of 756 identified records, 14 studies were included (case-matched control n = 10, prospective cohort n = 3, retrospective study n = 1) comparing 495 TaTME and 547 LaTME. No randomized trial was available. Following criteria were significantly improved after TaTME vs. LaTME: readmission's rate (9% after TaTME vs. 18% after LaTME, OR 0.44, 95%CI 0.26-0.74, p = 0.002), length of stay (OR - 2.17, 95%CI - 3.68 to - 0.66, p = 0.005), overall morbidity (34 vs. 41%, OR 0.65, 95%CI 0.46-0.91, p = 0.001), major morbidity (8.7 vs. 14%, OR 0.53, 95%CI 0.34-0.83, p = 0.005), anastomotic leak (6.4 vs. 11.6%, OR 0.53, 95%CI 0.31-0.93, p = 0.03), and circumferential resection margin (CRM) involvement (4 vs. 8.8%, OR 0.48, 95%CI 0.27-0.86, p = 0.01). No significant differences were observed between TaTME and LaTME regarding conversion's rate (3.2 vs. 8.8%, p = 0.09), operative time (OR - 10.73, p = 0.26), intraoperative complications (8.1 vs. 6.3%, p = 0.48), minor morbidity (27.9 vs. 29.6%, p = 0.27), positive distal resection margin (1.4 vs. 1.4%, p = 0.93), complete TME (75 vs. 75%, p = 0.74), harvested lymph nodes (OR 0.38, p = 0.44), and local recurrence rate (3.5 vs. 2.2%, p = 0.64). CONCLUSION This meta-analysis based on nonrandomized studies suggests that TaTME seems better than LaTME in terms of overall and major morbidities, anastomotic leak, readmission rate, CRM involvement, and length of stay. These results need to be confirmed by randomized controlled trial.
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Affiliation(s)
- Mathilde Aubert
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris VII, Clichy, France
| | - Diane Mege
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris VII, Clichy, France
| | - Yves Panis
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris VII, Clichy, France. .,Département de Chirurgie Colorectale, Hôpital Beaujon, 100 Boulevard du Général Leclerc, 92110, Clichy, France.
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14
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Hasegawa H, Okabayashi K, Tsuruta M, Ishida T, Asahara F, Coleman MG. Evolution of surgery for rectal cancer: Transanal total mesorectal excision~new standard or fad?~. JOURNAL OF THE ANUS RECTUM AND COLON 2019; 2:115-121. [PMID: 31559353 PMCID: PMC6752134 DOI: 10.23922/jarc.2018-029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 09/27/2018] [Indexed: 12/20/2022]
Abstract
Transanal Total Mesorectal Excision (TaTME) has recently been developed to overcome the difficulties associated with conventional laparoscopic or robotic TME. TaTME has gained popularity and becomes the center of attention among colorectal surgeons globally. The present review aims to update the literature, clarify the current status and perspectives of TaTME. Complete TaTME specimens were obtained in 85-97.1% of the case; the reported circumferential resection margin (CRM) ranged from 1.5% to 8.1%, whereas and distal resection margin (DRM) positive rates ranged from 0% to 3.2%. The conversion rate of TaTME occurred from 0 to 15%, and there was no difference between TaTME and laparoscopic or robotic TME. Intraoperative complications occurred in 5-6% of the case, which compared favorably to laparoscopic TME. The most serious intraoperative complication with this approach was urethral injury, although only small numbers were reported, which was possibly due to under-reporting. Clavien-Dindo I or II postoperative complications occurred in 22-24% of the case, and III or IV in 10-11% of the case, which did not differ between TaTME and laparoscopic or robotic TME. TaTME may be technically easier and more beneficial than laparoscopic, robotic or open TME in male patients with a narrow pelvis; in obese patients with a bulky tumor. At present two randomized controlled trials, COLOR III and GRECCAR, and comparing TaTME with laparoscopic TME are being conducted and their outcomes are awaited. TaTME is a complex procedure, but proved to be feasible, oncologically safe, and effective in difficult cases. Before this new technique is adopted, proper training with Proctor/mentorship is strongly advised. Careful case selection and audit of data are mandatory.
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Affiliation(s)
- Hirotoshi Hasegawa
- Department of Surgery, Tokyo Dental College, Ichikawa General Hospital, Ichikawa City, Japan
| | - Koji Okabayashi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Masashi Tsuruta
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Takashi Ishida
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Fumitaka Asahara
- Department of Surgery, Tokyo Dental College, Ichikawa General Hospital, Ichikawa City, Japan
| | - Mark G Coleman
- University Hospitals NHS Trust, Derriford Hospitals NHS Trust, Plymouth, UK
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15
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Monsellato I, Morello A, Prati M, Argenio G, Piscioneri D, Lenti LM, Priora F. Robotic transanal total mesorectal excision: A new perspective for low rectal cancer treatment. A case series. Int J Surg Case Rep 2019; 61:86-90. [PMID: 31352319 PMCID: PMC6664155 DOI: 10.1016/j.ijscr.2019.07.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 07/03/2019] [Accepted: 07/09/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Rectal cancer treatment is still a challenging frontier in general surgery, as there is no general agreement on which surgical approach is best for its management. Total mesorectal excision (TME), influenced the practical approach to rectal cancer, and brought a significant improvement on tumor recurrence and patients survival. Robotic transanal surgery is a newer approach to rectal dissection whose purpose is to overcome the limits of the traditional transabdominal approach, improving accuracy of distal dissection and preservation of hypogastric innervation. An increasing interest on this new technique has raised, thanks to the excellent pathological and acceptable short-term clinical outcomes reported. MATERIALS AND METHODS Three consecutive cases of robotic transanal TME were prospectically performed between May 2017 and October 2017. RESULTS TME quality was Quirke 3 grade in all cases. Mean operative time was 530 min. None of the patients had intra-operatively or post-operatively complications. CONCLUSIONS Robotic transanal TME is a very recent procedure. Acclaimed greatest advantage of robotic transanal TME is the facilitation of dissection with an in-line view, which translates in an improved surgical field exposure and visualization. Further investigations are needed to assure the actual value of robotic transanal approach.
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Affiliation(s)
- Igor Monsellato
- Division of General Surgery, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy.
| | - Alessia Morello
- Division of General Surgery, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Marta Prati
- Division of General Surgery, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Giulio Argenio
- Division of General Surgery, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Domenico Piscioneri
- Division of General Surgery, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Luca Matteo Lenti
- Division of General Surgery, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Fabio Priora
- Division of General Surgery, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
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16
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Sparreboom CL, Komen N, Rizopoulos D, van Westreenen HL, Doornebosch PG, Dekker JWT, Menon AG, Tuynman JB, Daams F, Lips D, van Grevenstein WMU, Karsten TM, Lange JF, D'Hoore A, Wolthuis AM. Transanal total mesorectal excision: how are we doing so far? Colorectal Dis 2019; 21:767-774. [PMID: 30844130 PMCID: PMC6850385 DOI: 10.1111/codi.14601] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 02/25/2019] [Indexed: 12/11/2022]
Abstract
AIM This subgroup analysis of a prospective multicentre cohort study aims to compare postoperative morbidity between transanal total mesorectal excision (TaTME) and laparoscopic total mesorectal excision (LaTME). METHOD The study was designed as a subgroup analysis of a prospective multicentre cohort study. Patients undergoing TaTME or LaTME for rectal cancer were selected. All patients were followed up until the first visit to the outpatient clinic after hospital discharge. Postoperative complications were classified according to the Clavien-Dindo classification and the comprehensive complication index (CCI). Propensity score matching was performed. RESULTS In total, 220 patients were selected from the overall prospective multicentre cohort study. After propensity score matching, 48 patients from each group were compared. The median tumour height for TaTME was 10.0 cm (6.0-10.8) and for LaTME was 9.5 cm (7.0-12.0) (P = 0.459). The duration of surgery and anaesthesia were both significantly longer for TaTME (221 vs 180 min, P < 0.001, and 264 vs 217 min, P < 0.001). TaTME was not converted to laparotomy whilst surgery in five patients undergoing LaTME was converted to laparotomy (0.0% vs 10.4%, P = 0.056). No statistically significant differences were observed for Clavien-Dindo classification, CCI, readmissions, reoperations and mortality. CONCLUSION The study showed that TaTME is a safe and feasible approach for rectal cancer resection. This new technique obtained similar postoperative morbidity to LaTME.
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Affiliation(s)
- C. L. Sparreboom
- Department of SurgeryErasmus University Medical CenterRotterdamThe Netherlands
| | - N. Komen
- Department of SurgeryUniversity Hospital AntwerpEdegemBelgium
| | - D. Rizopoulos
- Department of BiostatisticsErasmus University Medical CenterRotterdamThe Netherlands
| | | | - P. G. Doornebosch
- Department of SurgeryIJsselland ZiekenhuisCapelle aan den IJsselThe Netherlands
| | - J. W. T. Dekker
- Department of SurgeryReinier de Graaf GasthuisDelftThe Netherlands
| | - A. G. Menon
- Department of SurgeryIJsselland ZiekenhuisCapelle aan den IJsselThe Netherlands
| | - J. B. Tuynman
- Department of SurgeryVU University Medical CenterAmsterdamThe Netherlands
| | - F. Daams
- Department of SurgeryVU University Medical CenterAmsterdamThe Netherlands
| | - D. Lips
- Department of SurgeryJeroen Bosch ZiekenhuisHertogenboschThe Netherlands
| | | | - T. M. Karsten
- Department of SurgeryOnze Lieve Vrouwe GasthuisAmsterdamThe Netherlands
| | - J. F. Lange
- Department of SurgeryErasmus University Medical CenterRotterdamThe Netherlands
| | - A. D'Hoore
- Departmenf of Abdominal SurgeryUniversity Hospital LeuvenLeuvenBelgium
| | - A. M. Wolthuis
- Departmenf of Abdominal SurgeryUniversity Hospital LeuvenLeuvenBelgium
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17
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Leão P, Santos C, Goulart A, Caetano AC, Sousa M, Hogemann G, Parvaiz A, Figueiredo N. TaTME: analysis of the evacuatory outcomes and EUS anal sphincter. MINIM INVASIV THER 2019; 28:332-337. [PMID: 30888248 DOI: 10.1080/13645706.2019.1567555] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction: Some patients undergoing transanal total mesorectal excision (TaTME) may experience post-surgical complications, such as impaired bowel function and urogenital and sexual dysfunction. The present work aims to evaluate the one-year impact of TaTME surgery on bowel function, quality of life, and outcomes.Material and methods: Twenty patients undergoing TaTME with cancer in the mid and lower rectum were assessed prospectively by endoscopic transanal ultrasound (EUS) and three physiological function degrees, along with different clinical outcome questionnaires.Results: EUS sphincter evaluation revealed no structural impact in follow-up. For evacuatory evaluation, differences in the scores of the first postoperative month of Wexner questionnaires were shown when compared to a 12-month period. At least 10% of patients remain with major low anterior resection syndrome (LARS) after one year. The (Fecal incontinence Quality of Life) FiQoL questionnaire revealed that the cases in which values were worse in the first month posteriorly recovered to baseline preoperative values.Conclusions: TaTME does not seem to impact sphincter structure and evacuatory function, with a good recovery rate one year post-surgery, but does not seem to interfere with patients' evacuatory function quality of life.
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Affiliation(s)
- Pedro Leão
- General Surgery, Hospital de Braga, Braga, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal.,ICVS/3B's - PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | | | - André Goulart
- General Surgery, Hospital de Braga, Braga, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal.,ICVS/3B's - PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | | | - Maria Sousa
- General Surgery, Hospital de Braga, Braga, Portugal
| | - Gerrit Hogemann
- Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal.,ICVS/3B's - PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Amjad Parvaiz
- Colorectal Surgery, Champalimaud Foundation, Lisboa, Portugal
| | - Nuno Figueiredo
- Colorectal Surgery, Champalimaud Foundation, Lisboa, Portugal
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18
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Mikalauskas S, Uselis S, Jurkeviciutė D, Poskus T, Poskus E, Strupas K. Transanal Total Mesorectal Excision: Is There a Real Advantage? The Baltic View. Visc Med 2019; 35:145-150. [PMID: 31367610 DOI: 10.1159/000495309] [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: 12/14/2022] Open
Abstract
Background The novel surgical procedure transanal total mesorectal excision (taTME) has rapidly become an interest of research in order to overcome the shortcomings of laparoscopic surgery in the treatment of middle and low rectal cancer. taTME is a new natural orifice transluminal endoscopic surgery modality combining three rectal surgery techniques. Methods A retrospective clinical study was conducted in a single centre for a period of 3 years, and herein we report on our first 25 taTME procedures in patients with middle and lower third rectal adenocarcinoma. Results The main demographics were evaluated. The mean age of patients was 64 ± 12 years. There were predominantly males (72%) and 7 female patients (28%) with an average body mass index of 29 ± 4.8 kg/m<sup>2</sup>. High blood pressure, obesity, chronic heart insufficiency, chronic atrial fibrillation, and diabetes mellitus were commonly diagnosed in all patients. A circumferential resection margin >1 mm was achieved in 16% (n = 4), >2 mm in 40% (n = 10), and >3 mm in 44% (n = 11) of operated patients. The average CRM was 1.8 ± 0.9 cm. In 24% of cases, the distance of a tumour from the mesorectal fascia (MRF) was <1 mm; meanwhile, for 76% of patients, the tumour margin was >1 mm from the MRF. Recovery to flatus was 3 ± 1 days. The average length of hospital stay was 11 ± 3 days. The overall postoperative morbidity was 8%, i.e. one (4%) complication classified as Clavien-Dindo degree I and one (4%) major (IIIb) complication. Subsequently, all patients successfully recovered and were discharged from hospital. During the follow-up period no cancer recurrence was observed. Conclusion Our results nicely demonstrate that taTME can be safely performed with acceptable perioperative complications in patients with middle or lower third rectal cancer. In addition, the perioperative morbidity is also acceptable. However, taTME remains a technically highly demanding operation but is feasible and safe after the appropriate experience is gained. Nevertheless, larger multi-centre prospective randomised studies are ongoing to confirm the safety and to verify oncological results when compared to laparoscopic rectal surgery.
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Affiliation(s)
- Saulius Mikalauskas
- Center of Abdominal Surgery, Vilnius University.,Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | | | | | - Tomas Poskus
- Center of Abdominal Surgery, Vilnius University.,Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Eligijus Poskus
- Center of Abdominal Surgery, Vilnius University.,Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Kestutis Strupas
- Center of Abdominal Surgery, Vilnius University.,Faculty of Medicine, Vilnius University, Vilnius, Lithuania
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19
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Transanal versus laparoscopic total mesorectal excision for mid and low rectal cancer: a meta-analysis of short-term outcomes. Wideochir Inne Tech Maloinwazyjne 2019; 14:353-365. [PMID: 31534564 PMCID: PMC6748052 DOI: 10.5114/wiitm.2019.82798] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 01/12/2019] [Indexed: 02/07/2023] Open
Abstract
Introduction The benefit of transanal total mesorectal excision (TaTME) for mid and low rectal cancer is conflicting. Aim To assess and compare the short-term outcomes of TaTME with conventional laparoscopic total mesorectal excision (LaTME) for middle and low rectal cancer. Material and methods We searched PubMed, Embase and Cochrane Library databases for studies addressing TaTME versus conventional LaTME for rectal cancer between 2008 and December 2018. Randomized controlled trials (RCTs) and retrospective studies which compared TaTME with LaTME were included. Results Twelve retrospective case-control studies were identified, including a total of 899 patients. We did not find significant differences in overall intraoperative complications, blood loss, conversion rate, operative time, overall postoperative complication, anastomotic leakage, ileus, or urinary morbidity. Also no significant differences in oncological outcomes including circumferential resection margin (CRM), positive CRM, distal margin distance (DRM), positive DRM, quality of mesorectum, number of harvested lymph nodes, temporary stoma or local recurrence were found. Although the TaTME group had better postoperative outcomes (readmission, reoperation, length of hospital stay) on average, the difference did not reach statistical significance. Conclusions Transanal total mesorectal excision offers a safe and feasible alternative to LaTME although the clinicopathological features were not superior to LaTME in this study. Currently, with the lack of evidence on benefits of TaTME, further evaluation of TaTME requires large randomized control trials to be conducted.
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20
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Yang SX, Sun ZQ, Zhou QB, Xu JZ, Chang Y, Xia KK, Wang GX, Li Z, Song JM, Zhang ZY, Yuan WT, Liu JB. Security and Radical Assessment in Open, Laparoscopic, Robotic Colorectal Cancer Surgery: A Comparative Study. Technol Cancer Res Treat 2018; 17:1533033818794160. [PMID: 30198395 PMCID: PMC6131308 DOI: 10.1177/1533033818794160] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Purpose: This retrospective study was designed to assess the safety and effectiveness of open,
laparoscopic, robotic colorectal cancer surgery. Methods: Three hundred patients with colorectal cancer who underwent curative resection in the
First Affiliated Hospital of Zhengzhou University between February 2014 and May 2016
were included. Patients were classified into open surgery group, laparoscopic surgery
group, and robot-assisted group. Results: The blood loss in laparoscopic surgery group was less than that in open surgery group,
and the blood loss in robot-assisted group less was than the open surgery group. The
number of lymph node dissection in robot-assisted group was significantly larger than
that in the open group (P < .05). The distance between the lower
edge of the tumor group and the distal margin in robotic group was longer than that of
the laparoscopic surgery group and the open group (P < .05). Three
(2.8%) cases of urinary retention occurred in the open surgery group, 4 (3.92%) cases in
the laparoscopic surgery group, and 1 (1.1%) case in the robot-assisted group, while 2
(1.87%) cases of sexual dysfunction occurred in the open surgery group, 2 (1.96%) cases
in the laparoscopic surgery group, and 1 (1.1%) case in the robot-assisted group. The
urinary retention and sexual dysfunction rate did not differ between the 3 groups
(P > .05), but the minimally invasive group showed a certain
advantage over the open group. Conclusion: Compared to the traditional open surgery, minimally invasive surgery (especially in
robot-assisted group) has advantages such as less intraoperative bleeding, rapid
postoperative recovery, and radical cure; open group, laparoscopic surgery group, and
robot-assisted group have a similar incidence of postoperative complications, but
reduction in the incidence of anastomotic leakage and intestinal obstruction.
Robot-assisted group has the potential advantage for pelvic autonomic nerve
protection.
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Affiliation(s)
- Shuai-Xi Yang
- 1 Department of colorectal Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhen-Qiang Sun
- 1 Department of colorectal Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Quan-Bo Zhou
- 1 Department of colorectal Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ji-Zhong Xu
- 1 Department of colorectal Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuan Chang
- 1 Department of colorectal Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Kun-Kun Xia
- 1 Department of colorectal Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Gui-Xian Wang
- 1 Department of colorectal Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhen Li
- 1 Department of colorectal Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jun-Min Song
- 1 Department of colorectal Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhi-Yong Zhang
- 1 Department of colorectal Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Wei-Tang Yuan
- 1 Department of colorectal Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jin-Bo Liu
- 1 Department of colorectal Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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21
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Zaghiyan K, Warusavitarne J, Spinelli A, Chandrasinghe P, Di Candido F, Fleshner P. Technical variations and feasibility of transanal ileal pouch-anal anastomosis for ulcerative colitis and inflammatory bowel disease unclassified across continents. Tech Coloproctol 2018; 22:867-873. [DOI: 10.1007/s10151-018-1889-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 11/19/2018] [Indexed: 02/06/2023]
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22
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Comparison of Short-Term Clinical and Pathological Outcomes after Transanal versus Laparoscopic Total Mesorectal Excision for Low Anterior Rectal Resection Due to Rectal Cancer: A Systematic Review with Meta-Analysis. J Clin Med 2018; 7:jcm7110448. [PMID: 30463197 PMCID: PMC6262322 DOI: 10.3390/jcm7110448] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 11/14/2018] [Accepted: 11/15/2018] [Indexed: 12/18/2022] Open
Abstract
Background: Transanal total mesorectal excision (TaTME) is a new technique that is designed to overcome the limits of the open and laparoscopic approach for rectal resections. Objective: This study is designed to compare TaTME with standard laparoscopic TME (LaTME). Methods: We searched Medline, Embase, and Scopus databases covering a up to October 2018. Inclusion criteria for study enrolment: (1) study comparing laparoscopic resection of rectal cancer vs. TaTME for rectal malignancy, (2) reporting of overall morbidity, operative time, or major complications. Results: Eleven non-randomized studies were eligible with a total of 778 patients. We found statistical significant differences in regard to major complications in favour of TaTME (RR = 0.55; 95% CI 0.31–0.97; p = 0.04). We did not found significant differences regarding overall complications intraoperative adverse effects, operative time, anastomotic leakage, intra-abdominal abscess occurrence, Surgical Site Infection, reoperations, Length of stay, completeness of mesorectal excision, R0 resection rate, number of harvested lymph nodes, circumferential resection margin, and distal resection margin. Conclusions: This meta-analysis shows benefits of TaTME technique regarding major postoperative complications. Regarding clinicopathological features transanal approach is not superior to LaTME. Currently, the quality of the evidence on benefits of TaTME is low due to lack of randomized controlled trials, which needs to be taken into consideration in further evaluation of the technique. Further evaluation of TaTME require conducting large randomized control trials.
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Short- and long-term outcomes of transanal versus laparoscopic total mesorectal excision for mid-to-low rectal cancer: a meta-analysis. Surg Endosc 2018; 33:972-985. [PMID: 30374790 DOI: 10.1007/s00464-018-6527-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Accepted: 10/11/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Transanal total mesorectal excision (TaTME) is positioned at the cutting edge of minimally invasive approach to mid- and low rectal cancer. This meta-analysis was to compare the short- and long-term outcomes of TaTME versus laparoscopic total mesorectal excision (LTME) and to evaluate the safety, efficacy, and possible superiority of TaTME. METHODS A comprehensive search was conducted for randomized controlled trials (RCTs) and non-RCTs (NRCTs) comparing TaTME with LTME. Inter-group differences were evaluated via standardized mean differences and relative risks (RRs). All outcomes were analyzed using fixed effects or random effects models according to the heterogeneity. Statistical analysis was performed using Stata/SE 12.0 software. RESULTS Eleven studies (1 RCT and 10 NRCTs) with involving 757 patients were included. Among which, 361 patients underwent TaTME and 396 patients underwent LTME. Comparing the surgical and oncological quality of resection of TaTME with that of LTME, reports of TaTME indicated favorable outcomes considering mesorectal resection quality, circumferential resection margin involvement, intraoperative blood loss, conversions, and postoperative complications, while the differences between the two groups had no statistical significance in terms of distal resection margin, harvested lymph node, operation time, hospital stay, recurrence, 2-year overall survival (OS), and 2-year disease-free survival. CONCLUSION TaTME is a promising surgical technique and is fully a safe, efficacious, and diffusible alternative to LTME in managing mid- and distal rectal cancer. Larger scale, national, multicentric RCTs are warranted to further verify these results and the possible superiority of TaTME.
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Roodbeen SX, Penna M, Mackenzie H, Kusters M, Slater A, Jones OM, Lindsey I, Guy RJ, Cunningham C, Hompes R. Transanal total mesorectal excision (TaTME) versus laparoscopic TME for MRI-defined low rectal cancer: a propensity score-matched analysis of oncological outcomes. Surg Endosc 2018; 33:2459-2467. [PMID: 30350103 PMCID: PMC6647375 DOI: 10.1007/s00464-018-6530-4] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 10/11/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND While a shift to minimally invasive techniques in rectal cancer surgery has occurred, non-inferiority of laparoscopy in terms of oncological outcomes has not been definitely demonstrated. Transanal total mesorectal excision (TaTME) has been pioneered to potentially overcome difficulties experienced when operating with a pure abdominal approach deep down in the pelvis. This study aimed to compare short-term oncological results of TaTME versus laparoscopic TME (lapTME), based on a strict anatomical definition for low rectal cancer on MRI. METHODS From June 2013, all consecutive TaTME cases were included and compared to lapTME in a single institution. Propensity score-matching was performed for nine relevant factors. Primary outcome was resection margin involvement (R1), secondary outcomes included intra- and post-operative outcomes. RESULTS After matching, forty-one patients were included in each group; no significant differences were observed in patient and tumor characteristics. The resection margin was involved in 5 cases (12.2%) in the laparoscopic group, versus 2 (4.9%) TaTME cases (P = 0.432). The TME specimen quality was complete in 84.0% of the laparoscopic cases and in 92.7% of the TaTME cases (P = 0.266). Median distance to the circumferential resection margin (CRM) was 5 mm in lapTME and 10 mm in TaTME (P = 0.065). Significantly more conversions took place in the laparoscopic group, 9 (22.0%) compared to none in the TaTME group (P < 0.001). Other clinical outcomes did not show any significant differences between the two groups. CONCLUSION This is the first study to compare results of TaTME with lapTME in a highly selected patient group with MRI-defined low rectal tumors. A significant decrease in R1 rate could not be demonstrated, although conversion rate was significantly lower in this TaTME cohort.
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Affiliation(s)
- Sapho Xenia Roodbeen
- Department Surgery, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Marta Penna
- Department of Colorectal Surgery, Churchill Hospital, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Hugh Mackenzie
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Miranda Kusters
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Andrew Slater
- Department of Radiology, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Oliver M Jones
- Department of Colorectal Surgery, Churchill Hospital, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Ian Lindsey
- Department of Colorectal Surgery, Churchill Hospital, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Richard J Guy
- Department of Colorectal Surgery, Churchill Hospital, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Chris Cunningham
- Department of Colorectal Surgery, Churchill Hospital, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Roel Hompes
- Department Surgery, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Jeong WJ, Choi BJ, Lee SC. Pure natural orifice transluminal endoscopic surgery for rectal cancer: Ta-TME and CME without abdominal assistance. Asian J Surg 2018; 42:450-457. [PMID: 30309707 DOI: 10.1016/j.asjsur.2018.08.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 08/08/2018] [Accepted: 08/27/2018] [Indexed: 12/11/2022] Open
Abstract
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.
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Affiliation(s)
- Won Jun Jeong
- Department of Surgery, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, South Korea
| | - Byung Jo Choi
- Department of Surgery, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, South Korea
| | - Sang Chul Lee
- Department of Surgery, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, South Korea.
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Hu D, Jin P, Hu L, Liu W, Zhang W, Guo T, Yang X. The application of transanal total mesorectal excision for patients with middle and low rectal cancer: A systematic review and meta-analysis. Medicine (Baltimore) 2018; 97:e11410. [PMID: 29995787 PMCID: PMC6076192 DOI: 10.1097/md.0000000000011410] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 06/13/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Recently, in order to overcome the shortcomings of laparoscopic surgery in the treatment of low rectal cancer, a new kind of surgical procedure, transanal total mesorectal excision (TaTME), has rapidly become a research hotspot in the field of rectal cancer surgery study. Our study aimed to evaluate the efficacy and safety of transanal total mesorectal excision (TaTME) for the patients with rectal cancer. METHODS Relevant studies were searched from the databases of the Cochrane Library, PubMed, Embase, Web of science. All relevant studies were collected to evaluate the efficacy and safety of TaTME for patients with rectal cancer. The quality of the included studies was assessed by the Newcastle-Ottawa Quality Assessment Scale (NOS) and Cochrane Library Handbook 5.1.0. Data analysis was conducted using the Review Manager 5.3 software. RESULTS Thirteen studies including 859 patients were included in our analysis. In terms of efficacy, compared with laparoscopic total mesorectal excision (LaTME), meta-analysis showed that the rate of complete tumor resection increased and the risk of positive circumferential margins decreased in the TaTME group. For complete tumor resection and positive circumferential margins in the TaTME group, the odds ratios (ORs) and 95% confidence intervals (CIs) were 1.93 and 1.09 to 3.42 (P = .02) and 0.43 and 0.22 to 0.82 (P = .01), respectively. Concerning safety, results showed that the rates of postoperative complications were similar in the 2 groups, and differences in the risk of ileus and anastomotic leakage were not statistically significant (OR = 0.75, 95%CI = 0.51-1.09, P = .13; OR = 0.91, 95%CI = 0.46-1.78, P = .78; OR = 0.79, 95%CI = 0.45-1.38, P = .40). CONCLUSIONS The results of this meta-analysis show that TaTME is associated with a reduced positive circumferential resection margin (CRM) rate, and could achieve complete tumor resection and improved the long-term survival in patients with mid- and low-rectal cancer.
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Affiliation(s)
| | - Penghui Jin
- Gansu Provincial Hospital
- Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, Gansu, China
| | - Lidong Hu
- Gansu Provincial Hospital
- Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, Gansu, China
| | - Wenhan Liu
- Gansu Provincial Hospital
- Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, Gansu, China
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Mege D, Hain E, Lakkis Z, Maggiori L, Prost À la Denise J, Panis Y. Is trans-anal total mesorectal excision really safe and better than laparoscopic total mesorectal excision with a perineal approach first in patients with low rectal cancer? A learning curve with case-matched study in 68 patients. Colorectal Dis 2018; 20:O143-O151. [PMID: 29693307 DOI: 10.1111/codi.14238] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 04/11/2018] [Indexed: 02/08/2023]
Abstract
AIM To compare the learning curve for trans-anal total mesorectal excision (TATME) with laparoscopic TME started by a perineal approach (LTME). METHOD The first 34 consecutive patients who underwent TATME for low rectal cancer were matched with LTME (performed by the same surgeon) for gender, body mass index and chemoradiation. RESULTS Thirty-four patients undergoing TATME (23 men; 58 ± 14 years) were matched with 34 undergoing LTME (23 men; 59 ± 13 years). Intra-operative complications occurred more frequently during TATME (21%) than LTME (6%), but this difference was not significant (P = 0.07). The complications of TATME included rectal (n = 4), bladder (n = 1) and vaginal (n = 1) injury and bleeding (n = 1). Length of stay and postoperative overall and major morbidities were similar between groups. Early symptomatic anastomotic leakage (AL) occurred in 1/34 TATME and 5/34 LTME (15%; P = 0.02) procedures. Asymptomatic AL occurred in four TATME (12%) and four LTME (12%, P = 1). Thus, the overall rate of AL was 5/34 (15%) for TATME vs 9/34 (26%) for LTME (P = 0.4). No significant difference between the two groups was noted with regard to tumour, number of harvested and positive lymph nodes, R1 resection rate or completeness of the mesorectum. Metastatic recurrence was similar between groups (15% vs 18%, P = 0.7), but follow-up was shorter after TATME (13 ± 6 months) than after LTME (25 ± 14 months; P < 0.0001). CONCLUSION The TATME learning curve seems to be associated with a significant rate of intra-operative complications. Because no significant benefit has been reported to date, more evidence is needed before TATME can be considered as a better approach than laparoscopic TME with a perineal approach first in patients with low rectal cancer.
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Affiliation(s)
- D Mege
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris VII, Clichy, France
| | - E Hain
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris VII, Clichy, France
| | - Z Lakkis
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris VII, Clichy, France
| | - L Maggiori
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris VII, Clichy, France
| | - J Prost À la Denise
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris VII, Clichy, France
| | - Y Panis
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris VII, Clichy, France
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d'Alessandro A, Kari N, Alameh A, Pasquier N, Tarhini A, Vinson Bonnet B, Noun R, Chouillard E. Preliminary experience with umbilical stoma in transumbilical single-port colorectal surgery. Tech Coloproctol 2018; 22:301-304. [PMID: 29512046 DOI: 10.1007/s10151-018-1767-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Accepted: 01/09/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND The umbilicus, an embryological natural orifice, is increasingly used as the only access route during single-incision laparoscopic surgery (SILS) for colorectal disease. As a part of some of these procedures, a temporary, diverting ostomy could be exteriorized through the umbilicus itself. Theoretical advantages include better preservation of the abdominal wall and potentially superior cosmetic results. The aim of the present study was to evaluate our preliminary experience in SILS colorectal resection with umbilical stoma (u-stoma). METHODS We retrospectively reviewed all colorectal patients operated using SILS for benign or malignant disease at Paris Poissy Medical Center. Patients were selected for consideration of u-stoma with our stoma therapists. RESULTS Between January 2010 and December 2016, 234 patients underwent colorectal SILS procedures. In 74 patients (31.6%), an ileostomy (n = 41) or a colostomy (n = 33) was fashioned. Of these, 20 (27% of all ostomies) were umbilical stomas. The 20 u-stoma patients, 10 men and 10 women, received either a loop ileostomy (n = 14) or an end (n = 4) or loop (n = 2) colostomy. The mean age was 52 years (range 29-81 years). There was no mortality. Operative stoma-related morbidity occurred in only 5% of patients (n = 1: ileal torsion volvulus). Median follow-up after stoma formation was 30 months (range 12-59 months). Adjustment to the stoma and quality of life were satisfactory as estimated by both the patient and the stoma therapist. All stomas were reversed. At a median follow-up of 27.5 months (range 7-55 months) after stoma reversal, two patients had reoperation for incisional hernia. CONCLUSION This preliminary experience showed that u-stoma is a feasible and safe alternative to more conventional ostomy after SILS.
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Affiliation(s)
- A d'Alessandro
- Unit of Colorectal Surgery, Department of Digestive and Minimally Invasive Surgery, Paris Poissy Medical Center, Saint-Germain-En-Laye, 10 rue du Champ, Gaillard, 78300, Poissy, France
| | - N Kari
- Department of General and Minimally Invasive Surgery, Hotel-Dieu de France, Université Saint-Joseph, Beirut, Lebanon
| | - A Alameh
- Department of General and Minimally Invasive Surgery, Hotel-Dieu de France, Université Saint-Joseph, Beirut, Lebanon
| | - N Pasquier
- Unit of Colorectal Surgery, Department of Digestive and Minimally Invasive Surgery, Paris Poissy Medical Center, Saint-Germain-En-Laye, 10 rue du Champ, Gaillard, 78300, Poissy, France
| | - A Tarhini
- Department of General and Minimally Invasive Surgery, Hotel-Dieu de France, Université Saint-Joseph, Beirut, Lebanon
| | - B Vinson Bonnet
- Unit of Colorectal Surgery, Department of Digestive and Minimally Invasive Surgery, Paris Poissy Medical Center, Saint-Germain-En-Laye, 10 rue du Champ, Gaillard, 78300, Poissy, France
| | - R Noun
- Department of General and Minimally Invasive Surgery, Hotel-Dieu de France, Université Saint-Joseph, Beirut, Lebanon
| | - E Chouillard
- Unit of Colorectal Surgery, Department of Digestive and Minimally Invasive Surgery, Paris Poissy Medical Center, Saint-Germain-En-Laye, 10 rue du Champ, Gaillard, 78300, Poissy, France.
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Lee KY, Shin JK, Park YA, Yun SH, Huh JW, Cho YB, Kim HC, Lee WY. Transanal Endoscopic and Transabdominal Robotic Total Mesorectal Excision for Mid-to-Low Rectal Cancer: Comparison of Short-term Postoperative and Oncologic Outcomes by Using a Case-Matched Analysis. Ann Coloproctol 2018. [PMID: 29535985 PMCID: PMC5847400 DOI: 10.3393/ac.2018.34.1.29] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Purpose This study aimed to compare short-term postoperative and oncologic outcomes of a transanal endoscopic total mesorectal excision (TME) to those of a transabdominal robotic TME. Methods A total of 62 patients with rectal cancer underwent transanal (n = 26) or robotic (n = 36) TME between June 2013 and December 2014. After case-matching by tumor location and TNM stage, 45 patients were included for analysis. The median follow-up period was 21.3 months. Operative, histopathologic and postoperative outcomes and recurrences were analyzed. Results Patients younger than 60 years of age were more frequently observed in the robotic TME group (75.0% vs. 47.6%, P = 0.059), but tumor location, cT and cN category, and preoperative chemoradiotherapy were not different between the 2 groups. Estimated blood loss was greater in the transanal group (283 mL vs. 155 mL, P = 0.061); however, the operation time and the rate of a diverting ileostomy and subsequent ileostomy repair were not different between the groups. The proximal resection margin was longer in the transanal TME group (20.8 cm ± 16.0 cm, P = 0.030), but the distal resection margins, involvements of the circumferential resection margin, TME quality, numbers of retrieved lymph nodes, postoperative complications, including anastomotic leak and voiding difficulty, and recurrence rates for the 2 groups were not statistically different. Conclusion Transanal endoscopic and transabdominal robotic TME showed similar histopathologic and postoperative outcomes with the exception of the estimated blood loss and the proximal resection margin for a select group of patients.
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Affiliation(s)
- Ki Young Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Kyoung Shin
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoon Ah Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seong Hyeon Yun
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Wook Huh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Beom Cho
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Cheol Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Woo Yong Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Pathological outcomes of transanal versus laparoscopic total mesorectal excision for rectal cancer: a systematic review with meta-analysis. Surg Endosc 2018; 32:2632-2642. [PMID: 29464401 DOI: 10.1007/s00464-018-6103-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 02/07/2018] [Indexed: 12/21/2022]
Abstract
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.
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Silva PA, Goulart A, Sousa M, Rios H, Atallah S, Leão P. Transanal total mesorectal excision with triangle rules: a road map to prevent injuries. Tech Coloproctol 2017; 21:819-820. [DOI: 10.1007/s10151-017-1698-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 09/19/2017] [Indexed: 11/30/2022]
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Abstract
PURPOSE OF REVIEW The recent developments and clinical applications of natural orifice translumenal endoscopic surgery (NOTES)-procedures and technologies are going to be presented. RECENT FINDINGS In experimental as well as clinical settings, NOTES-procedures are predominantly performed in hybrid technique. Current experimental studies focus on the implementation of new surgical approaches as well as on the training of procedures. One emphasis in the clinical application is transrectal and transanal interventions. Transanal total mesorectal excision is equivalent to laparoscopic procedures but with the benefit of an even less invasive access. Transvaginal cholecystectomy can achieve results that are comparable to surgeries that are performed with laparoscopic techniques alone. An analysis of the German NOTES-Register concerning appendectomies as well as the national performance of NOTES-interventions in Switzerland is presented. Apart from intraabdominal approaches, several centers proclaim transoral thyroidectomies and transoral mediastinoscopies. SUMMARY NOTES-procedures are performed in animal experiments as well as in clinical setting although with less frequency. At this time, hybrid techniques using rigid instruments are mainly applied.
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Martínez-Pérez A, de'Angelis N, Brunetti F. A meta-analysis comparing transanal vs. laparoscopic total mesorectal excision for rectal cancer. Eur J Surg Oncol 2016; 43:847-848. [PMID: 27955834 DOI: 10.1016/j.ejso.2016.10.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 10/19/2016] [Indexed: 10/20/2022] Open
Affiliation(s)
- A Martínez-Pérez
- Department of Digestive, Hepatobiliary Surgery and Liver Transplantation, Henri Mondor University Hospital, AP-HP, Université Paris Est - UPEC, 51 avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France; Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Avenida Gaspar Aguilar 90, 46017 Valencia, Spain.
| | - N de'Angelis
- Department of Digestive, Hepatobiliary Surgery and Liver Transplantation, Henri Mondor University Hospital, AP-HP, Université Paris Est - UPEC, 51 avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
| | - F Brunetti
- Department of Digestive, Hepatobiliary Surgery and Liver Transplantation, Henri Mondor University Hospital, AP-HP, Université Paris Est - UPEC, 51 avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
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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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Aigner F, Biebl M, Fürst A, Jöns T, Pratschke J, Kneist W. Trainingskurs transanale totale mesorektale Exzision (TaTME). Chirurg 2016; 88:147-154. [DOI: 10.1007/s00104-016-0295-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Araujo SEA, Perez RO, Seid VE, Bertoncini AB, Klajner S. Laparo-endoscopic Transanal Total Mesorectal Excision (TATME): evidence of a novel technique. MINIM INVASIV THER 2016; 25:278-87. [DOI: 10.1080/13645706.2016.1199435] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Kneist W, Hanke L, Kauff DW, Lang H. Surgeons' assessment of internal anal sphincter nerve supply during TaTME - inbetween expectations and reality. MINIM INVASIV THER 2016; 25:241-6. [PMID: 27333465 PMCID: PMC5044775 DOI: 10.1080/13645706.2016.1197269] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background: Intraoperative identification of nerve fibers heading from the inferior rectal plexus (IRP) to the internal anal sphincter (IAS) is challenging. The transanal total mesorectal excision (TaTME) is said to better preserve pelvic autonomic nerves. The aim of this study was to investigate the nerve identification rates during TaTME by transanal visual and electrophysiological assessment. Material and methods: A total of 52 patients underwent TaTME for malignant conditions. The IRP with its posterior branches to the IAS and the pelvic splanchnic nerves (PSN) were visually assessed in 20 patients (v-TaTME). Electrophysiological nerve identification was performed in 32 patients using electric stimulation under processed electromyography of IAS (e-TaTME). Results: The indication profile for TaTME was comparable between the v-TaTME and the e-TaTME group. The identification of IRP was more meaningful under electrophysiological assessment than under visual assessment for the left pelvic side (81% vs. 45%, p = 0.008) as well as the right pelvic side (78% vs. 45%, p = 0.016). The identification rates for PSN did not significantly differ between both groups, respectively (81% vs. 75%, p = 0.420 and 84% vs. 70%, p = 0.187). Conclusions: The transanal approach facilitated visual identification of IAS nerve supply. In combination with electrophysiological nerve assessment the identification rate almost doubled. For further insights functional data are needed.
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Affiliation(s)
- Werner Kneist
- a Department of General, Visceral and Transplant Surgery , University Medical Center, Johannes Gutenberg-University Mainz , Mainz , Germany
| | - Laura Hanke
- a Department of General, Visceral and Transplant Surgery , University Medical Center, Johannes Gutenberg-University Mainz , Mainz , Germany
| | - Daniel W Kauff
- a Department of General, Visceral and Transplant Surgery , University Medical Center, Johannes Gutenberg-University Mainz , Mainz , Germany
| | - Hauke Lang
- a Department of General, Visceral and Transplant Surgery , University Medical Center, Johannes Gutenberg-University Mainz , Mainz , Germany
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