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Arndt K, Vigna C, Kaul S, Fabrizio A, Cataldo T, Smith M, Messaris E. Magnetic resonance imaging accuracy in staging early and locally advanced rectal cancer. Surg Oncol 2023; 50:101987. [PMID: 37717374 DOI: 10.1016/j.suronc.2023.101987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 08/21/2023] [Accepted: 09/07/2023] [Indexed: 09/19/2023]
Abstract
INTRODUCTION Magnetic Resonance Imaging (MRI) is the standard pretreatment staging in patients with rectal cancer. Accurate tumor staging is paramount to determining the appropriate treatment course for patients diagnosed with rectal cancer. The current study aims to re-evaluate the accuracy of pre-operative MRI in staging of both early and locally advanced rectal cancer following completion of neoadjuvant therapy (NAT) compared to the pathologic stage. METHODS A retrospective review of patients treated for rectal cancer between 2015 and 2020 at a single academic institution. All patients underwent rectal cancer protocol MRIs before surgical resection. Analysis was carried out in two groups: early rectal cancer: T1/2 N0 tumors with upfront surgical resection (N = 40); and locally advanced disease: T3 or greater or N+ disease receiving NAT, with restaging MRI following NAT (n = 63). RESULTS 103 patients were included in analysis. MRI accuracy in early tumors was 35% ICC = 0.52 (95% CI 0.25-0.71) T stage and 66% ICC = 0 (95% CI -0.24, 0.29) for 29 patients with nodal data for N stage. There was 28% understaging of T2 tumors and 34% understaging of N0 stage by MRI. Post NAT MRI had 44% accuracy ICC = 0.57 (95% CI -0.15-0.20) T stage and 60% accuracy ICC = 0.32 (95% CI 0.08-0.52) N stage. Tumor invasion was overstaged on MRI: 40% T2, 29% T3, 90% T4. Nodal inaccuracy was due to overstaging, 61% N1, 90% N2. CONCLUSIONS In locally advanced rectal cancer MRI overstaged tumors, this could be due to the continued effect of NAT from MRI to resection. This overstaging is of little clinical significance as it doesn't alter the treatment plan, except in cases of complete clinical response. In early rectal cancer, MRI had limited accuracy compared to pathology, understaging a quarter of patients who would benefit from NAT before surgery. Other adjunct imaging modalities should be considered to improve accuracy in staging early rectal cancer and consideration of complete response and enrollment in watch and wait protocols.
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Affiliation(s)
- Kevin Arndt
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | - Carolina Vigna
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sumedh Kaul
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Anne Fabrizio
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Thomas Cataldo
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Martin Smith
- Department of Diagnostic Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Evangelos Messaris
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Robotic Transanal Minimally Invasive Surgery for Benign and Malignant Rectal Lesions: a Single-Institution Experience. J Gastrointest Surg 2022; 27:601-603. [PMID: 36253505 DOI: 10.1007/s11605-022-05475-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 09/20/2022] [Indexed: 01/31/2023]
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Kim MJ, Lee TG. Transanal minimally invasive surgery using laparoscopic instruments of the rectum: A review. World J Gastrointest Surg 2021; 13:1149-1165. [PMID: 34754384 PMCID: PMC8554714 DOI: 10.4240/wjgs.v13.i10.1149] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 07/18/2021] [Accepted: 09/16/2021] [Indexed: 02/06/2023] Open
Abstract
Transanal minimally invasive surgery (TAMIS) was first described in 2010 as an alternative to transanal endoscopic microsurgery (TEM). The TAMIS technique can be access to the proximal and mid-rectum for resection of benign and early-stage malignant rectal lesions and also used for noncurative intent surgery of more advanced lesions in patients who are not candidates for radical surgery. TAMIS has a shorter learning curve, reduced device setup time, flexibility in instrument use, and versatility in application than TEM. Also, TAMIS shows similar results in a view of the operation time, conversion rate, reoperation rate, and complication to TEM. For these reasons, TAMIS is an easily accessible, technically feasible, and cost-effective alternative to TEM. Overall, TAMIS has enabled the performance of high-quality local excision of rectal lesions by many colorectal surgeons. As TAMIS becomes more broadly utilized such as pelvic abscess drainage, rectal stenosis, and treatment of anastomotic dehiscence, the acquisition of appropriate training must be ensured, and the continued assessment and assurance of outcome must be maintained.
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Affiliation(s)
- Myung Jo Kim
- Department of Surgery, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju 28644, South Korea
| | - Taek-Gu Lee
- Department of Surgery, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju 28644, South Korea
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Mendes CRS, Ferreira LSDM, Sapucaia RA, Lima MA, Araujo SEA. Transanal minimally-invasive surgery (TAMIS): Technique and results from an initial experience. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1016/j.jcol.2013.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
AbstractTransanal endoscopic microsurgery is a minimally-invasive approach for rectal lesions. Superior exposure and access to the entire rectum result in lesser risk of compromised margins and lower recurrence rates, when compared to conventional transanal excision. The aim of this study was to describe a single institution's initial experience with transanal minimally invasive surgery (TAMIS). This was a prospective review of our database. Eleven procedures from January 2012 to June 2013 were analyzed.
Results eleven operations were completed. Five men were evaluated. Mean age was 62.9 (40-86). Mean follow-up was 9.3 (2-17) months. Average tumor size was 3.8 (1.8-8) cm. Mean distance from anal verge was 6.3 (3-12) cm. Mean operating time was 53.73 (28-118) min. Postoperative complication rate was 9.1%. There were no readmissions. Mortality was null. Operative pathology disclosed the presence of adenoma in four patients, invasive adenocarcinoma in two, neuroendocrine carcinoma in three, and no residual lesion in one case. TAMIS is a minimallyinvasive procedure with low postoperative morbidity at the initial experience. TAMIS is a curative procedure for benign lesions and for selected early cancers. It is useful after neoadjuvant therapy for strictly selected cancers, pending the results of multi-institutional trials.
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Affiliation(s)
- Carlos Ramon Silveira Mendes
- Service of Coloproctology, Hospital Santa Izabel, Salvador, BA, Brazil
- Sociedade Brasileira de Coloproctologia, Rio de Janeiro, RJ, Brazil
- Department of Gastroenterology, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, SP, Brazil
| | | | - Ricardo Aguiar Sapucaia
- Service of Coloproctology, Hospital Santa Izabel, Salvador, BA, Brazil
- Sociedade Brasileira de Coloproctologia, Rio de Janeiro, RJ, Brazil
| | - Meyline Andrade Lima
- Service of Coloproctology, Hospital Santa Izabel, Salvador, BA, Brazil
- Sociedade Brasileira de Coloproctologia, Rio de Janeiro, RJ, Brazil
| | - Sergio Eduardo Alonso Araujo
- Service of Colon and Rectal Surgery, Hospital Geral Roberto Santos, Salvador, BA, Brazil
- Service of Colon and Rectal Surgery, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, SP, Brazil
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Punnen S, Karimuddin AA, Raval MJ, Phang PT, Brown CJ. Transanal Endoscopic Microsurgery (TEM) for rectal GI stromal tumor. Am J Surg 2020; 221:183-186. [PMID: 32782081 DOI: 10.1016/j.amjsurg.2020.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 07/06/2020] [Accepted: 07/15/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Transanal endoscopic microsurgery (TEM) is effective in treating adenomas and select early rectal cancers. Our objective is to evaluate TEM in treating early rectal GISTs. METHODS Patients were identified in a prospective database with pathology confirmed rectal GIST prior to TEM over 10 years. Demographic, pathologic, operative and follow-up data was analysed and presented with descriptive statistics. RESULTS 7 cases of rectal GIST were treated with TEM with a follow-up time of 31 months (0-71). Median tumor distance from the anal verge was 4 cm (2.5-6) and median tumor size was 3 cm (2-5.7). Negative margins were achieved in 4/7 patients. Those with positive margins were treated with repeat TEM or imatinib. 1 patient had local recurrence successfully treated by TEM. CONCLUSIONS Overall, TEM is safe for locally excising GISTs. As rectal GISTs are rare, a multicenter registry may better elucidate outcomes with this treatment.
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Affiliation(s)
- S Punnen
- University of British Columbia, 2329 West Mall, Vancouver, BC, v6t1z4, Canada
| | - A A Karimuddin
- University of British Columbia, 2329 West Mall, Vancouver, BC, v6t1z4, Canada; St. Paul's Hospital, 1081 Burrard Street, Vancouver, BC, v6z1y6, Canada
| | - M J Raval
- University of British Columbia, 2329 West Mall, Vancouver, BC, v6t1z4, Canada; St. Paul's Hospital, 1081 Burrard Street, Vancouver, BC, v6z1y6, Canada
| | - P T Phang
- University of British Columbia, 2329 West Mall, Vancouver, BC, v6t1z4, Canada; St. Paul's Hospital, 1081 Burrard Street, Vancouver, BC, v6z1y6, Canada
| | - C J Brown
- University of British Columbia, 2329 West Mall, Vancouver, BC, v6t1z4, Canada; St. Paul's Hospital, 1081 Burrard Street, Vancouver, BC, v6z1y6, Canada.
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Ding L, Ji G, Xu X, Xie Y, Hu D, Zhang H. Evaluation of Transanal Minimally Invasive Surgery for Rectal Benign Lesions. J Laparoendosc Adv Surg Tech A 2020; 30:1160-1164. [PMID: 32251610 DOI: 10.1089/lap.2020.0087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objective: To evaluate the clinical efficacy and safety of transanal minimally invasive surgery (TAMIS) for the treatment of benign rectal lesions so that patients can be provided with better surgical alternatives. Materials and Methods: A retrospective analysis was conducted on patients with rectal benign lesions who underwent TAMIS in the Department of Gastrointestinal Surgery, the First Affiliated Hospital of Chongqing Medical University from January 2018 to June 2019. The patients' clinical data were thoroughly recorded, such as surgical-related information, postoperative pathology, and so on. At the same time, the patients were followed up regularly and carefully after the surgery. Results: A total of 16 eligible patients were enrolled in the study. All patients underwent colonoscopy before surgery and the biopsy results showed that all the removed specimens were rectal benign tumors. All the lesions were resected with TAMIS. The average operation time was 111.94 ± 46.13 minutes. Among the 16 cases, 1 of the patients was found to have undergone peritoneal entry during operation 1 and this showed that the peritoneal cavity was penetrated during the operation. The average postoperative hospital stay was 4.56 ± 1.79 days. The final pathology of the TAMIS specimens revealed a malignant neoplasm in 10 patients, including 9 cases of rectal adenocarcinoma, 1 case of nerve endocrine tumor, and 6 cases of rectal adenoma. No long-term complications were observed during the mean follow-up time of 10.19 ± 5.14 months. Conclusions: TAMIS is a safe and effective minimally invasive surgical procedure for the treatment of rectal adenomas, which can minimize the adverse effect on anal function.
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Affiliation(s)
- Liping Ding
- Chongqing Medical University, Chongqing, China
| | - Guangyan Ji
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiang Xu
- Department of General Surgery, Ninth People's Hospital of Chongqing City, Chongqing, China
| | - Yang Xie
- Chongqing Medical University, Chongqing, China
| | - Denghua Hu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hongyu Zhang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Abstract
PUPRPOSE Benign polyps that are technically challenging and unsafe to remove via polypectomy are known as complex polyps. Concerns regarding safety and completeness of resection dictate they undergo advanced endoscopic techniques, such as endoscopic mucosal resection or surgery. We provide a comprehensive overview of complex polyps and current treatment options. METHODS A review of the English literature was conducted to identifyarticles describing the management of complex polyps of the colon and rectum. RESULTS Endoscopic mucosal resection is the standard of care for the majority of complex polyps. Only polyps that fail endoscopic mucosal resection or are highly suspicious of invasive cancer but which cannot be removed endoscopically warrant surgery. CONCLUSION Several factors influence the treatment of a complex polyp; therefore, there cannot be a "one-size-fitsall" approach. Treatment should be tailored to the lesion's characteristics, the risk of adverse events, and the resources available to the treating physician.
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Gómez Ruiz M, Cagigas Fernández C, Alonso Martín J, Cristobal Poch L, Manuel Palazuelos C, Barredo Cañibano FJ, Gómez Fleitas M, Castillo Diego J. Robotic Assisted Transanal Polypectomies: Is There Any Indication? Cir Esp 2017; 95:601-609. [PMID: 29146073 DOI: 10.1016/j.ciresp.2017.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 09/04/2017] [Accepted: 09/11/2017] [Indexed: 01/06/2023]
Abstract
OBJECTIVES Robotic assisted transanal polipectomy may have advantages compared with the conventional transanal minimally invasive surgery technique. We evaluate the safety, feasibility and advantages of this technique. METHODS Between February 2014 and October 2015, 9patients underwent robotic transanal polypectomy. We performed a retrospective study in which we analyse prospectively collected data regarding patient and tumor characteristics, perioperative outcomes, pathological report, morbidity and mortality. RESULTS A total of 5 male and 4 female patients underwent robotic TAMIS. Lesions were 6,22cm from the anal verge. Mean size was 15,8cm2. All procedures were performed in the lithotomy position. Closure of the defect was performed in all cases. Mean blood loss was 39,8ml. Mean operative time was 71,9min. No severe postoperative complications or readmissions occured. Median hospital stay was 2,5 days. CONCLUSIONS Robotic TAMIS is useful to treat complex rectal lesions. Our transanal platform allowed a wider range of movements of the robotic arms and to perform all procedures in the lithotomy position.
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Affiliation(s)
- Marcos Gómez Ruiz
- Cirugía Colorrectal, Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario Marqués de Valdecilla, Santander, España.
| | - Carmen Cagigas Fernández
- Cirugía Colorrectal, Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - Joaquín Alonso Martín
- Cirugía Colorrectal, Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - Lidia Cristobal Poch
- Cirugía Colorrectal, Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - Carlos Manuel Palazuelos
- Cirugía Colorrectal, Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - Francisco Javier Barredo Cañibano
- Anestesiología en Cirugía General, Servicio de Anestesiología, Reanimación y Unidad del Dolor, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - Manuel Gómez Fleitas
- Departamento de Innovación y Cirugía Robótica, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - Julio Castillo Diego
- Cirugía Colorrectal, Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario Marqués de Valdecilla, Santander, España
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deBeche-Adams T, Hassan I, Haggerty S, Stefanidis D. Transanal Minimally Invasive Surgery (TAMIS): a clinical spotlight review. Surg Endosc 2017; 31:3791-3800. [DOI: 10.1007/s00464-017-5636-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 06/03/2017] [Indexed: 02/07/2023]
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Current Controversies in Transanal Surgery for Rectal Cancer. Surg Laparosc Endosc Percutan Tech 2016; 26:431-438. [DOI: 10.1097/sle.0000000000000357] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Abstract
Transanal minimally invasive surgery (TAMIS) was first described in 2010 as a crossover between single-incision laparoscopic surgery and transanal endoscopic microsurgery (TEM) to allow access to the proximal and mid-rectum for resection of benign and early-stage malignant rectal lesions. The TAMIS technique can also be used for noncurative intent surgery of more advanced lesions in patients who are not candidates for radical surgery. Proper workup and staging should be done before surgical decision-making. In addition to the TAMIS port, instrumentation and set up include readily available equipment found in most operating suites. TAMIS has proven its usefulness in a wide range of applications outside of local excision, including repair of rectourethral fistula, removal of rectal foreign body, control of rectal hemorrhage, and as an adjunct in total mesorectal excision for rectal cancer. TAMIS is an easily accessible, technically feasible, and cost-effective alternative to TEM.
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Affiliation(s)
| | - George Nassif
- Center for Colon and Rectal Surgery, Florida Hospital, Orlando, Florida
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Abstract
BACKGROUND The concept of natural orifice transluminal endoscopic surgery (NOTES) has stimulated the development of various "incisionless" procedures. One of the most popular is the transanal approach for rectal lesions. The aims of this study were to report how we standardized NOTES technique for transanal mesorectal excision without abdominal assistance, discuss the difficulties and surgical outcomes of this technique and report its feasibility in a small group of selected patients. METHODS Three consecutive female patients underwent transanal NOTES rectal resection without transabdominal laparoscopic assistance for rectal lesions. Functional results were assessed with the Fecal Incontinence Quality of Life scale and the Wexner score. RESULTS The technical steps are described in details and complemented with a video. All procedures were completed without transabdominal laparoscopic help. The mesorectal plane was entirely dissected without any disruption, and distal and circumferential margins were tumor-free. No major complications were observed. Functional results show a significant impairment after surgery with improvement at 6 months to levels near those of the preoperative period. CONCLUSIONS The performance and publication of NOTES procedures are subject to much discussion. Despite the small number of patients, this procedure appears feasible and can be accomplished maintaining fecal continence and respecting oncologic principles.
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Dimitriou N, Michail O, Moris D, Griniatsos J. Low rectal cancer: Sphincter preserving techniques-selection of patients, techniques and outcomes. World J Gastrointest Oncol 2015; 7:55-70. [PMID: 26191350 PMCID: PMC4501926 DOI: 10.4251/wjgo.v7.i7.55] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 03/28/2015] [Accepted: 05/27/2015] [Indexed: 02/05/2023] Open
Abstract
Low rectal cancer is traditionally treated by abdominoperineal resection. In recent years, several new techniques for the treatment of very low rectal cancer patients aiming to preserve the gastrointestinal continuity and to improve both the oncological as well as the functional outcomes, have been emerged. Literature suggest that when the intersphincteric resection is applied in T1-3 tumors located within 30-35 mm from the anal verge, is technically feasible, safe, with equal oncological outcomes compared to conventional surgery and acceptable quality of life. The Anterior Perineal PlanE for Ultra-low Anterior Resection technique, is not disrupting the sphincters, but carries a high complication rate, while the reports on the oncological and functional outcomes are limited. Transanal Endoscopic MicroSurgery (TEM) and TransAnal Minimally Invasive Surgery (TAMIS) should represent the treatment of choice for T1 rectal tumors, with specific criteria according to the NCCN guidelines and favorable pathologic features. Alternatively to the standard conventional surgery, neoadjuvant chemo-radiotherapy followed by TEM or TAMIS seems promising for tumors of a local stage T1sm2-3 or T2. Transanal Total Mesorectal Excision should be performed only when a board approved protocol is available by colorectal surgeons with extensive experience in minimally invasive and transanal endoscopic surgery.
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Sirohi B, Shrikhande SV, Perakath B, Raghunandharao D, Julka PK, Lele V, Chaturvedi A, Nandakumar A, Ramadwar M, Bhatia V, Mittal R, Kaur T, Shukla DK, Rath GK. Indian Council of Medical Research consensus document for the management of colorectal cancer. Indian J Med Paediatr Oncol 2014; 35:192-6. [PMID: 25336788 PMCID: PMC4202613 DOI: 10.4103/0971-5851.142031] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Affiliation(s)
- Bhawna Sirohi
- Department of Medical Oncology, Kiran Mazumdar Shaw Cancer Centre, Bangalore, Karnataka, India
| | - Shailesh V Shrikhande
- Department of Surgical Oncology, Pathology, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Benjamin Perakath
- Department of Colorectal Surgery, Christian Medical College, Vellore, Tamilnadu, India
| | - Digumarti Raghunandharao
- Homi Bhabha Cancer Hospital and Research Centre, Visakhapatnam, Andhra Pradesh, Maharashtra, India
| | - Pramod Kumar Julka
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Vikram Lele
- Department of Nuclear Medicine, Jaslok Hospital, Mumbai, Maharashtra, India
| | - Arvind Chaturvedi
- Department of Radiodiagnosis, Rajiv Gandhi Cancer Institute, New Delhi, India
| | | | - M Ramadwar
- Department of Surgical Oncology, Pathology, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Vikram Bhatia
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rohin Mittal
- Department of Colorectal Surgery, Christian Medical College, Vellore, Tamilnadu, India
| | - Tanvir Kaur
- Indian Council of Medical Research, New Delhi, India
| | | | - Goura Kishor Rath
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India
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Piccoli M, Agresta F, Trapani V, Nigro C, Pende V, Campanile FC, Vettoretto N, Belluco E, Bianchi PP, Cavaliere D, Ferulano G, La Torre F, Lirici MM, Rea R, Ricco G, Orsenigo E, Barlera S, Lettieri E, Romano GM, Ferulano G, Giuseppe F, La Torre F, Filippo LT, Lirici MM, Maria LM, Rea R, Roberto R, Ricco G, Gianni R, Orsenigo E, Elena O, Barlera S, Simona B, Lettieri E, Emanuele L, Romano GM, Maria RG. Clinical competence in the surgery of rectal cancer: the Italian Consensus Conference. Int J Colorectal Dis 2014; 29:863-75. [PMID: 24820678 DOI: 10.1007/s00384-014-1887-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/23/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIM The literature continues to emphasize the advantages of treating patients in "high volume" units by "expert" surgeons, but there is no agreed definition of what is meant by either term. In September 2012, a Consensus Conference on Clinical Competence was organized in Rome as part of the meeting of the National Congress of Italian Surgery (I Congresso Nazionale della Chirurgia Italiana: Unità e valore della chirurgia italiana). The aims were to provide a definition of "expert surgeon" and "high-volume facility" in rectal cancer surgery and to assess their influence on patient outcome. METHOD An Organizing Committee (OC), a Scientific Committee (SC), a Group of Experts (E) and a Panel/Jury (P) were set up for the conduct of the Consensus Conference. Review of the literature focused on three main questions including training, "measuring" of quality and to what extent hospital and surgeon volume affects sphincter-preserving procedures, local recurrence, 30-day morbidity and mortality, survival, function, choice of laparoscopic approach and the choice of transanal endoscopic microsurgery (TEM). RESULTS AND CONCLUSION The difficulties encountered in defining competence in rectal surgery arise from the great heterogeneity of the parameters described in the literature to quantify it. Acquisition of data is difficult as many articles were published many years ago. Even with a focus on surgeon and hospital volume, it is difficult to define their role owing to the variability and the quality of the relevant studies.
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Gavilanes Calvo C, Manuel Palazuelos JC, Alonso Martín J, Castillo Diego J, Martín Parra I, Gómez Ruiz M, Gómez Fleitas M. [Transanal endoscopic operations for rectal tumours]. Cir Esp 2013; 92:38-43. [PMID: 24169437 DOI: 10.1016/j.ciresp.2013.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Revised: 02/04/2013] [Accepted: 02/05/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND Transanal endoscopic operation (TEO) may be the technique of choice for the treatment of rectal lesions, both benign and selected malignant lesions, with similar survival rates to conventional surgery but with lower morbidity. METHODS In this article we present a series of 70 patients operated on with this procedure (TEO) in our center. The indications were benign rectal lesions and malignant lesions at early stages (T1) 86%. The surgical procedure was performed with the the transanal endoscopic operation platform (TEO; Karl Storz, Tüttlingen, Germany) and ultrasonic scalpel (Harmonic scalpel, Ethicon Endo-surgery,…). RESULTS The indication in 43 patients was a benign lesion (adenoma), in the other 27 the diagnosis was adenocarcinoma. After the resection, 61% of the series had a malignant lesion in the pathology report: 13 patients of the 43 with a benign lesion initially had a malignant lesion in the pathology report. Postoperative morbidity was 36%, Clavien III (5,7%). 3 patients (4%) needed emergency surgery. All of the benign lesions were completely excised, but 7 malignant lesions had resection margin involvement The median follow-up time was 26,4 months (range, 1-71 months), the overall recurrence for benign tumors was 9%, 8% for malignant pT1 and 12,5% for malignant pT2. Early salvage surgery was performed on 8 patients. CONCLUSIONS TEO allows us to excise benign rectal lesions that could not be excised with a conventional approach (endoscopic or transanal resection) with a low morbidity rate. TEO can be used for malignant rectal tumors in early stages (pT1) with pathological confirmation.
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Affiliation(s)
- Carlos Gavilanes Calvo
- Servicio de Cirugía General, Hospital Universitario Marqués de Valdecilla, Santander, España
| | | | - Joaquín Alonso Martín
- Unidad Colorrectal, Servicio de Cirugía General, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - Julio Castillo Diego
- Unidad Colorrectal, Servicio de Cirugía General, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - Ignacio Martín Parra
- Unidad Colorrectal, Servicio de Cirugía General, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - Marcos Gómez Ruiz
- Unidad Colorrectal, Servicio de Cirugía General, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - Manuel Gómez Fleitas
- Unidad Colorrectal, Servicio de Cirugía General, Hospital Universitario Marqués de Valdecilla, Santander, España; Cátedra de Cirugía General, Universidad de Cantabria, Santander, España
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Evans MD, Thomas R, Williams GL, Beynon J, Smith JJ, Stamatakis JD, Stephenson BM. A comparative study of colorectal surgical outcome in a national audit separated by 15 years. Colorectal Dis 2013; 15:608-12. [PMID: 23078669 DOI: 10.1111/codi.12065] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Accepted: 08/11/2012] [Indexed: 02/08/2023]
Abstract
AIM The Wales-Trent Bowel Cancer Audit (WTBA) was carried out in 1993, and since 2001 Welsh Bowel Cancer Audits (WBCA) have taken place annually. Screening for bowel cancer in Wales was introduced in 2008. This study compared patient variables, the role of surgery and operative mortality rates over the 15-year interval between the WTBA and the last WBCA before the introduction of population screening. METHOD Data from the WTBA in 1993 were compared with those of the WBCA including patients diagnosed between April 2007 and March 2008. RESULTS In 1993, 1536 patients were diagnosed with colorectal cancer (CRC) compared with 1793 in 2007-2008. Patient demographics and American Society of Anesthesiology (ASA) score did not change during these periods. Surgical treatment for CRC decreased (93% in 1993 vs 80% in 2007-2008; P < 0.001) particularly in the use of resectional surgery (84% in 1993 vs 71% in 2007-2008; P < 0.001). The 30-day postoperative mortality rate fell from 7.4% in 1993 to 5.9% in 2007-2008 (P = 0.097). Advanced disease at operation was more prevalent in the WTBA (25% of all operated patients were Stage IV in 1993 vs 13% in 2007-2008; P < 0.001). The use of surgery in patients with metastatic disease also declined over this period. CONCLUSION Surgery is used less frequently in the management of CRC compared with 15 years previously, and is a factor in the reduction of the interpreted 30-day operative mortality.
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Affiliation(s)
- M D Evans
- All Wales Higher Surgical Training Scheme, UK.
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Albert M, Atallah S, Larach S, deBeche-Adams T. Minimally Invasive Anorectal Surgery: From Parks Local Excision to Transanal Endoscopic Microsurgery to Transanal Minimally Invasive Surgery. SEMINARS IN COLON AND RECTAL SURGERY 2013. [DOI: 10.1053/j.scrs.2012.10.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Transanal minimally invasive surgery (TAMIS) for local excision of benign neoplasms and early-stage rectal cancer: efficacy and outcomes in the first 50 patients. Dis Colon Rectum 2013; 56:301-7. [PMID: 23392143 DOI: 10.1097/dcr.0b013e31827ca313] [Citation(s) in RCA: 190] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Since its inception in 2009, transanal minimally invasive surgery has been used increasingly in the United States and internationally as an alternative to local excision and transanal endoscopic microsurgery for local excision of neoplasms in the distal and mid rectum. Despite its increasing acceptance, the clinical benefits of transanal minimally invasive surgery have not yet been validated. OBJECTIVE The aim of this study is to assess the adequacy of transanal minimally invasive surgery for the local excision of benign and malignant lesions of the rectum. DESIGN This is a retrospective analysis of consecutive patients who underwent transanal minimally invasive surgery for local excision of neoplasms at a single institution. SETTINGS The study was conducted by a single group of colorectal surgeons at a tertiary referral center. PATIENTS Eligible patients with early-stage rectal cancer and benign neoplasms were offered transanal minimally invasive surgery as a means for local excision. Data from these patients were collected prospectively in a registry. MAIN OUTCOME MEASURES The primary outcome measures included the feasibility of transanal minimally invasive surgery for local excision, resection quality, and short-term clinical results. RESULTS : Fifty patients underwent transanal minimally invasive surgery between July 2009 and December 2011. Twenty-five benign neoplasms, 23 malignant lesions, and 2 neuroendocrine tumors were excised. All lesions were excised using transanal minimally invasive surgery without conversion to an alternate transanal platform. The average length of stay was 0.6 days (range, 0-6), and 68% of patients were discharged on the day of surgery. The average distance from the anal verge was 8.1 cm (range, 3-14 cm). All lesions were excised completely with only 2 fragmented specimens (4%). All specimens were removed with grossly negative margins, although 3 (6%) were found to have microscopically positive margins on final pathology. There were 2 recurrences (4%) at 6- and 18-month follow-up. Early complications occurred in 3 patients (6%). No long-term complications were observed at a median follow-up of 20 months. LIMITATIONS The study was limited by its retrospective nature and midterm follow-up. CONCLUSIONS Transanal minimally invasive surgery is an advanced transanal platform that provides a safe and effective method for resecting benign neoplasms, as well as carefully selected, early-stage malignancies of the mid and distal rectum.
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Dash I, Walter CJ, Wheeler JMD, Borley NR. Does the incidence of unexpected malignancy in 'benign' rectal neoplasms undergoing trans-anal endoscopic microsurgery vary according to lesion morphology? Colorectal Dis 2013; 15:183-6. [PMID: 22686137 DOI: 10.1111/j.1463-1318.2012.03126.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Mucosectomy by trans-anal endoscopic microsurgery (TEMS) allows safe and effective excision of benign rectal lesions. Preoperative endoscopic, clinical and ultrasonographic assessment aims to select benign lesions whilst avoiding inappropriate mucosectomy in lesions with malignancy. This study examines the relationship between lesion morphology and accurate benign preoperative classification of rectal lesions undergoing TEMS. METHOD Primary lesions preoperatively assessed as benign were identified from a prospective TEMS database. Operative specimen morphology was independently classified by two blinded investigators, using photographs, into flat-sessile, exophytic or mixed morphology. The accuracy of the preoperative assessment by rectal ultrasonography was compared with the results of histological examination of the excised specimen (χ(2) and Fisher's exact tests). RESULTS Of 167 lesions with adequate data, the morphological classification showed 60 flat-sessile, 56 mixed morphology and 51 exophytic tumours, of which 5, 7 and 9, respectively, contained unexpected malignancy (P=0.48). Accurate preoperative assessment of a lesion as benign occurred in 89% of flat-sessile and mixed morphology (n=55 and 49, respectively) and in 70% of exophytic lesions (n=36) (P=0.01). Only the exophytic group contained patients in whom preoperative endoscopic and ultrasonographic staging could not be confidently made (uTx). Histology demonstrated six of the seven uTx cases to be benign. CONCLUSION In this study exophytic polyps were less likely to be accurately classified as benign using preoperative ultrasonography/endoscopy when compared with flat-sessile or mixed morphology polyps.
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Affiliation(s)
- I Dash
- Cheltenham General Hospital GHNHSFT, Cheltenham, UK.
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Smink M, Hermans RH, Schoot DBC, Luyer M, Pijnenborg JMA. First report of transvaginal endoscopic microsurgery in a patient with squamous cell carcinoma of the vagina. J Laparoendosc Adv Surg Tech A 2013; 23:154-7. [PMID: 23327348 DOI: 10.1089/lap.2012.0458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Transanal endoscopic microsurgery has been used by surgeons since 1983. All these years of experience and research have shown that this is a safe and successful approach for rectal neoplasms, both benign and malignant. The advantage of this procedure is the excellent view and hence precise surgical margins in an operative field that is otherwise difficult to reach. Furthermore, selected patients who used to require major rectal surgery now may be treated using this minimally invasive technique. These advantages may also be favorable for the gynecological field, especially in intravaginal surgery. Our case report describes the first successfully performed transvaginal endoscopic microsurgery in a woman with residual disease after treatment with chemoradiation for squamous cell carcinoma of the vagina. Despite the difficulty of operating in tissue with post-radiation effect, the rest of the tumor was excised with clear surgical margins without damage to the rectum. The patient was discharged from the hospital 2 days after the procedure and recovered without complications.
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Affiliation(s)
- Marieke Smink
- Department of Obstetrics and Gynecology, Catharina Hospital, Eindhoven, The Netherlands
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[Transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS)]. Cir Esp 2012; 90:418-20. [PMID: 22809543 DOI: 10.1016/j.ciresp.2012.04.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Revised: 03/23/2012] [Accepted: 04/08/2012] [Indexed: 11/20/2022]
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Affiliation(s)
- S Halligan
- University College London, Centre for Medical Imaging, University College Hospital, London, UK.
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