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Lauricella S, Brucchi F, Carrano FM, Cassini D, Cirocchi R, Sylla P. Quality of life and functional outcomes after laparoscopic total mesorectal excision (LaTME) and transanal total mesorectal excision (taTME) for rectal cancer. an updated meta-analysis. Int J Colorectal Dis 2024; 39:129. [PMID: 39120642 PMCID: PMC11315702 DOI: 10.1007/s00384-024-04703-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/02/2024] [Indexed: 08/10/2024]
Abstract
PURPOSE Concerns exist regarding the potential for transanal total mesorectal excision (TaTME) to yield poorer functional outcomes compared to laparoscopic TME (LaTME). The aim of this study is to assess the functional outcomes following taTME and LaTME, focusing on bowel, anorectal, and urogenital disorders and their impact on the patient's QoL. METHODS A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and A Measurement Tool to Assess systematic Reviews (AMSTAR) guidelines. A comprehensive search was conducted in Medline, Embase, Scopus, and Cochrane Library databases. The variables considered are: Low Anterior Resection Syndrome (LARS), International Prostate Symptom Score (IPSS) and Jorge-Wexner scales; European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C29 and QLQ-C30 scales. RESULTS Eleven studies involving 1020 patients (497-taTME group/ 523-LaTME group) were included. There was no significant difference between the treatments in terms of anorectal function: LARS (MD: 2.81, 95% CI: - 2.45-8.08, p = 0.3; I2 = 97%); Jorge-Wexner scale (MD: -1.3, 95% CI: -3.22-0.62, p = 0.19). EORTC QLQ C30/29 scores were similar between the groups. No significant differences were reported in terms of urogenital function: IPSS (MD: 0.0, 95% CI: - 1.49-1.49, p = 0.99; I2 = 72%). CONCLUSIONS This review supports previous findings indicating that functional outcomes and QoL are similar for rectal cancer patients who underwent taTME or LaTME. Further research is needed to confirm these findings and understand the long-term impact of the functional sequelae of these surgical approaches.
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Affiliation(s)
- Sara Lauricella
- Colorectal Surgery Division, Department of Surgery, Fondazione IRCCS Istituto Nazionale Dei Tumori, 20133, Milan, Italy
| | | | - Francesco Maria Carrano
- Department of Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology, St Andrea Hospital, Sapienza University, Rome, Italy
| | - Diletta Cassini
- ASST Nord Milano-Department of General Surgery, Sesto San Giovanni Hospital, Sesto San Giovanni, MI, Italy
| | - Roberto Cirocchi
- Digestive and Emergency Surgery Unit, S.Maria Hospital Trust, 05100, Terni, Italy
| | - Patricia Sylla
- Division of Colon and Rectal Surgery, Mount Sinai Health System, New York, NY, USA
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Development of a performance rubric for transanal endoscopic rectal purse-string sutures. Tech Coloproctol 2021; 26:109-115. [PMID: 34761314 DOI: 10.1007/s10151-021-02545-1] [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] [Received: 02/25/2021] [Accepted: 10/28/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Placing a transanal endoscopic rectal purse-string suture (taEPS) is the crucial first component of transanal total mesorectal excision (taTME). However, no structured training is available to improve the procedure-specific skills for taEPS. The aim of this study was to create a performance rubric to improve taEPS skills and provide preliminary evidence for its validity. METHODS A performance rubric was created based on technical considerations for taEPS, identified by consulting with taTME surgical and performance assessment experts. Ten independent, blinded raters assessed 10 videotaped taEPS procedures of consecutive taTME cases, at National Cancer Center Hospital East (NCCHE), Chiba, Japan, in January 2018-March 2019 using the rubric and the Global Operative Assessment of Laparoscopic Skills (GOALS). Internal consistency and inter-rater reliabilities were calculated. Videotaped taEPS procedures were timed and assessed by the rubric. Correlation between rubric scores and suturing times were analyzed. RESULTS The rubric consists of four items: loading the needle (LN), atraumatic needle passage (AP), planned suture path (PS), and overall performance (OA). Videotaped performances were graded on a 3-point Likert scale; scores were calculated as sums of the points. Cronbach's α for internal consistency was 0.713. Inter-rater reliabilities were LN: 0.73, AP: 0.76, PS: 0.71, and OA: 0.70. Rubric and GOALS scores were strongly correlated (r = 0.964, p < 0.001). In 112 consecutive taEPS performances, rubric scores were strongly correlated with suturing time (r = - 0.69, p < 0.001). Surgeons' experience with taTME was associated with rubric scores and suturing time. CONCLUSIONS This study provides preliminary validation for the taEPS skill performance rubric. The rubric's structured training may facilitate skill acquisition by providing trainees with critical clinical considerations.
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Teste B, Rullier E. Intraoperative complications during laparoscopic total mesorectal excision. Minerva Surg 2021; 76:332-342. [PMID: 33944516 DOI: 10.23736/s2724-5691.21.08691-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Intraoperative complication during laparoscopic mesorectal excision for rectal cancer is a common complication occurring in 11% to 15% of the cases. They are probably underestimated because not systematically reported. The most frequent intraoperative complications are haemorrhage (3-7%), tumour perforation (1-4%), bowel injury (1-3%), ureter injury (1%), urogenital injury (2%), other organ injury (<1%), and anastomotic complications (1%). The mechanisms, management and prevention of vascular port injury, inferior mesenteric artery bleeding, small bowel and colon perforation, ureteral and urethral injury, pelvic nerve damage, tumour perforation and anastomotic failure are described. This review underlines the necessity to prevent intraoperative complication to avoid operative death and severe side-effects.
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Affiliation(s)
- Blanche Teste
- Department of Colorectal Surgery, Haut-Levèque Hospital, University of Bordeaux, Pessac, France
| | - Eric Rullier
- Department of Colorectal Surgery, Haut-Levèque Hospital, University of Bordeaux, Pessac, France -
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López-Sánchez A, Morandeira-Rivas A, Moreno-Sanz C, Cortina-Oliva FJ, Manzanera-Díaz M, Gonzales-Aguilar JD. Long-Term Anorectal Manometry Outcomes After Laparoscopic and Transanal Total Mesorectal Excision. J Laparoendosc Adv Surg Tech A 2021; 31:395-401. [PMID: 33617729 DOI: 10.1089/lap.2020.1005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: During transanal total mesorectal excision (TaTME), sustained dilation of the anal canal occurs, which can cause anatomical and functional damage to the sphincter complex. This study aimed to analyze the impact of laparoscopic total mesorectal excision (LaTME) and TaTME in anorectal sphincter function. Materials and Methods: An observational study was conducted comparing two cohorts of patients who underwent LaTME or TaTME for rectal cancer. The two groups were paired for comparison based on age, gender, and distance of the neoplasm to the anal margin. The anorectal function was assessed by manometry before surgery and at least 6 months after primary intervention or stoma closure. The intestinal function was assessed using the low anterior resection syndrome (LARS) score. Results: Twenty-two patients were included. There were no significant differences in baseline characteristics between groups except for the time between surgery and testing. A decrease in the mean resting and squeeze pressures between pre- and postoperative manometry was observed in both the treatment groups, the difference being only significant in the squeeze pressure values (TaTME P = .003; LaTME P = .004). After surgery, squeeze pressure reduction correlated with a worsening of the LARS point count (rho 0.587; P = .004). The time elapsed since surgery was negatively correlated with the LARS point count (rho -0.696; P = .001) and the difference between pre- and postoperative mean squeeze pressures (rho -0.499; P = .018). Conclusion: Manometric findings after TME are comparable between the laparoscopic and the transanal approach. Deterioration of both anal sphincter function and LARS improves with time after surgery.
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Affiliation(s)
- Ana López-Sánchez
- Department of Surgery, La Mancha Centro General Hospital, Alcázar de San Juan, Spain
| | | | - Carlos Moreno-Sanz
- Department of Surgery, La Mancha Centro General Hospital, Alcázar de San Juan, Spain
| | | | - Marina Manzanera-Díaz
- Department of Surgery, La Mancha Centro General Hospital, Alcázar de San Juan, Spain
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Caycedo-Marulanda A, Nadeau K, Verschoor CP, Sands D, Spinelli A, Ashamalla S, Patel SV, Di Candido F, Mujukian A, Zaghiyan K, Stevenson G, Wolthuis A, Clark DA, D'Hoore A, Stevenson A, Wexner SD. Exploring the perioperative outcomes of a sample of successful adopters of transanal total mesorectal excision (taTME) during the learning phase. Surgery 2020; 169:774-781. [PMID: 33243484 DOI: 10.1016/j.surg.2020.10.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 10/06/2020] [Accepted: 10/19/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Transanal total mesorectal excision can be a technically challenging operation to master. While many early adopters have reported adequate outcomes, others have failed to reproduce these results. There are contradicting data on oncologic outcomes during the learning phase of this technique. Thus, our objective was to perform a multicentered assessment of oncological outcomes in patients undergoing transanal total mesorectal excision during the learning phase in a sample of successful adopting centers. METHODS Surgeons from 8 centers with experience in the management of rectal cancer were invited to participate. The initial 51 consecutive benign and malignant cases of the participating units were retrospectively reviewed, but only 366 cancer cases were included in the analysis. Procedures were divided into implementation (ie, the first 10 cases) and postimplementation (ie, case 11 on onwards) groups, and the main outcome was the incidence of local recurrence. RESULTS The overall prevalence of local recurrence was 4.1% at a median follow-up of 35 months (interquartile range 20.3-44.2); among implementation and postimplementation groups local recurrence was 7.5% and 3.1%, respectively, and the rate of local recurrence was observed to be nearly 60% lower in the postimplementation group (hazard ratio [95% confidence interval] = 0.43 [0.26-0.72]) Total mesorectal excision specimens were complete or nearly complete in 87.7% of cases, and the circumferential and distal margins were clear in 93.2% and 92.6%, respectively CONCLUSION: Local recurrence rate was low during the learning phase of the transanal total mesorectal excision in a sample of rectal cancer surgeons with acceptable surgical and oncologic outcomes. Both the prevalence and rate of local recurrence were markedly lower in the postimplementation phase, indicating improvement as experience accumulated.
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Affiliation(s)
- Antonio Caycedo-Marulanda
- Department of Surgery, Queen's University, Kingston, Canada; Health Sciences North Research Institute, Sudbury, Canada.
| | - Kara Nadeau
- Department of Surgery, Northern Ontario School of Medicine, Health Sciences North, Sudbury, Canada
| | | | - Dana Sands
- Department of Surgery, Cleveland Clinic, Weston, FL
| | - Antonino Spinelli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, IRCCS, Rozzano-Milano, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milano, Italy
| | - Shady Ashamalla
- Department of Surgery, University Health Network, Toronto, Canada
| | - Sunil V Patel
- Department of Surgery, Queen's University, Kingston, Canada
| | - Francesca Di Candido
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, IRCCS, Rozzano-Milano, Italy
| | - Angela Mujukian
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Karen Zaghiyan
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Grant Stevenson
- School of Public Health, Faculty of Medicine, University of Queensland, Brisbane, Australia; Department of Surgery, University of Queensland, Brisbane, Australia
| | | | - David A Clark
- Department of Surgery, University of Queensland, Brisbane, Australia; Department of Surgery, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Andre D'Hoore
- Department of Surgery, University Hospital Leuven, Belgium
| | - Andrew Stevenson
- Department of Surgery, University of Queensland, Brisbane, Australia; Department of Surgery, Royal Brisbane and Women's Hospital, Brisbane, Australia
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Caycedo-Marulanda A, Patel SV, Verschoor CP, Uscategui JP, Chadi SA, Moeslein G, Chand M, Maeda Y, Monson JRT, Wexner SD, Mayol J. A Snapshot of the International Views of the Treatment of Rectal Cancer Patients, a Multi-regional Survey: International Tendencies in Rectal Cancer. World J Surg 2020; 45:302-312. [PMID: 33033856 DOI: 10.1007/s00268-020-05795-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Management of rectal cancer has a number of potentially appropriate alternatives for each patient. Despite acceptance of standards, practices may vary among regions. There is significant paucity of data in this area. The objective was to create a snapshot of the regional differences. DESIGN This online survey included 10 questions. Enquiries focused on controversial topics, on surgeon and hospital volume, surgical margins, appropriateness of surgical approaches and techniques, watch-and-wait strategies, and total neoadjuvant therapy. Major colorectal surgery societies around the world were asked to invite their members to complete the survey. OUTCOME MEASURES Frequency of responses across regions within each question was compared by Fisher's exact test. RESULTS Seven hundred and fifty-three participants from 60 countries responded. Eight regions were identified, and four had sufficient representation for comparisons. Similarities and differences in the therapies among these regions were identified. Robotic surgery penetrance is higher in North America, and watch and wait is more accepted in South America. Patients in Oceania are more likely to be diverted; Europe has more usage of taTME. DISCUSSION This online survey was practical as a mean to provide a rapid assessment of the international picture on consistency and variability of rectal cancer patients' care, and to potentially identify opportunities to standardized care to patients. Medical surveys have inherent limitations; pertinence to our study is selection bias. CONCLUSIONS The management of rectal cancer varies among different regions. Identification of differences is important when considering global efforts to improve management and interpret data.
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Affiliation(s)
- Antonio Caycedo-Marulanda
- Department of Surgery, Queens University, Kingston, Canada. .,Health Sciences North Research Institute, Sudbury, Canada. .,Kingston General Hospital, Kingston, Canada.
| | - Sunil V Patel
- Department of Surgery, Queens University, Kingston, Canada
| | | | | | - Sami A Chadi
- Department of Surgery University Health Network (UHN), Toronto, Canada
| | - Gabriela Moeslein
- Department of Surgery, University of Witten/Herdecke, Witten, Germany
| | - Manish Chand
- Department of Surgery, University College London, London, UK
| | - Yasuko Maeda
- Department of Colorectal Surgery, Western General Hospital, Edinburgh, Scotland, UK
| | - John R T Monson
- Center for Colon and Rectal Surgery, Digestive Health and Surgery Institute, AdventHealth Orlando, Orlando, USA
| | - Steven D Wexner
- Department of Surgery, Cleveland Clinic Florida, Weston, USA
| | - Julio Mayol
- Department of Surgery, Hospital Clinico San Carlos, Madrid, Spain
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Canadian taTME expert collaboration (CaTaCO) position statement. Surg Endosc 2020; 34:3748-3753. [PMID: 32504263 PMCID: PMC7395021 DOI: 10.1007/s00464-020-07680-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/27/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Transanal total mesorectal excision (taTME) is a novel approach to surgery for rectal cancer. The technique has gained significant popularity in the surgical community due to the promising ability to overcome technical difficulties related to the access of the distal pelvis. Recently, Norwegian surgeons issued a local moratorium related to potential issues with the safety of the procedure. Early adopters of taTME in Canada have recognized the need to create guidelines for its adoption and supervision. The objective of the statement is to provide expert opinion based on the best available evidence and authors' experience. METHODS The procedure has been performed in Canada since 2014 at different institutions. In 2016, the first Canadian taTME congress was held in the city of Toronto, organized by two of the authors. In early 2019, a multicentric collaborative was established [The Canadian taTME expert Collaboration] which aimed at ensuring safe performance and adoption of taTME in Canada. Recently surgeons from 8 major Canadian rectal cancer centers met in the city of Toronto on December 7 of 2019, to discuss and develop a position statement. There in person, meeting was followed by 4 rounds of Delphi methodology. RESULTS The generated document focused on the need to ensure a unified approach among rectal cancer surgeons across the country considering its technical complexity and potential morbidity. The position statement addressed four domains: surgical setting, surgeons' requirements, patient selection, and quality assurance. CONCLUSIONS Authors agree transanal total mesorectal excision is technically demanding and has a significant risk for morbidity. As of now, there is uncertainty for some of the outcomes. We consider it is possible to safely adopt this operation and obtain adequate results, however for this purpose it is necessary to meet specific requirements in different domains.
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Caycedo-Marulanda A, Verschoor CP. Experience beyond the learning curve of transanal total mesorectal excision (taTME) and its effect on the incidence of anastomotic leak. Tech Coloproctol 2020; 24:309-316. [PMID: 32112245 PMCID: PMC7082408 DOI: 10.1007/s10151-020-02160-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 02/05/2020] [Indexed: 02/06/2023]
Abstract
Background The most important advancement in the surgical management of rectal cancer has been the introduction of total mesorectal excision (TME). Technical limitations to approaching mid and distal lesions remain. The recently described transanal TME makes it possible to minimize some of the difficulties by improving access. Anastomotic leak is a persistent concern after colorectal surgery no matter what technique is used. The objective of this study was to explore the impact of experience on the incidence of anastomotic leak after transanal TME. Secondary endpoints were local recurrence and margin status. Methods A retrospective cohort study was conducted over a period of 3 years at a tertiary care center in Northern Ontario with high volume of rectal cancer patients. The initial 100 consecutive patients with rectal neoplasia who had transanal TME surgery were included. All cases were performed by a single team. The main outcome assessed was the incidence of anastomotic leak beyond a pre-determined learning curve, as previously established in the literature. For statistical analysis, associations between patient characteristics and outcomes were estimated using ordinary least squares and logistic regression. Results Six cases of anastomotic leak occurred over the course of the study, the last of which occurred in the 37th patient. Relative to a baseline anastomotic leak rate of 7.8%, cumulative sum (CUSUM) analysis indicated that a 50% improvement in risk occurred at trial 50 of 85 patients that had an anastomosis performed. Two patients developed local recurrence during the study period. No correlation between learning curve and oncologic outcomes was identified. Conclusions Proficiency is likely to have a positive effect on the 30-day occurrence of anastomotic leak. Larger studies are required to explore the impact of experience on local recurrence.
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Affiliation(s)
- A Caycedo-Marulanda
- Department of Surgery, Health Sciences North, 65 Larch St, Sudbury, ON, P3E 1B8, Canada. .,Health Sciences North Research Institute, Sudbury, ON, Canada. .,Department of Surgery, Northern Ontario School of Medicine, Sudbury, ON, Canada.
| | - C P Verschoor
- Health Sciences North Research Institute, Sudbury, ON, Canada.,Department of Surgery, Northern Ontario School of Medicine, Sudbury, ON, Canada
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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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Lee L, Kelly J, Nassif GJ, deBeche-Adams TC, Albert MR, Monson JRT. Defining the learning curve for transanal total mesorectal excision for rectal adenocarcinoma. Surg Endosc 2018; 34:1534-1542. [PMID: 29998391 DOI: 10.1007/s00464-018-6360-4] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 07/06/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Early observational data suggest that this approach is safe and feasible, but it is technically challenging and the learning curve has not yet been determined. The objective of this study was to determine the number of cases required achieve proficiency in transanal total mesorectal excision (TA-TME) for rectal adenocarcinoma. METHODS All TA-TME cases performed from 03/2012-01/2017 at a single high-volume tertiary care institution for rectal adenocarcinoma were included. A cumulative summation (CUSUM) analysis was performed to determine the number of cases required to reach proficiency, defined as high-quality TME (complete or near-complete mesorectal envelope, negative distal (DRM), and circumferential resection (> 1 mm; CRM) margin). The acceptable and unacceptable rates of good quality TME were defined based on the incidence of high-quality TME in laparoscopic (unacceptable rate = 81.7%) and open (acceptable rate = 86.9%) arms of the ACOSOG Z6051 trial. RESULTS A total of 87 consecutive cases were included with mean tumor height 4.8 cm (SD 2.7) and 80% (70/87) received neoadjuvant chemoradiation. Post-operative morbidity occurred in 44% (38/87) of cases, including 21% (18/87) readmissions. Median length of stay was 4 days [IQR 3-8]. A good quality TME was performed in 95% (83/87) of cases including 98% (85/87) negative CRM, 99% (86/87) negative DRM, and 99% (86/87) complete or near-complete mesorectal envelope. CUSUM analysis reported that the good quality TME rate reaches an acceptable rate after 51 cases overall, and 45 cases if abdominoperineal resections are excluded. CONCLUSION TA-TME is a complex technique that requires a minimum of 45-51 cases to reach an acceptable incidence of high-quality TME and lower operative duration.
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Affiliation(s)
- Lawrence Lee
- Center for Colon and Rectal Surgery, Florida Hospital, 2415 N Orange Ave, suite 102, Orlando, FL, 32804, USA.
| | - Justin Kelly
- Center for Colon and Rectal Surgery, Florida Hospital, 2415 N Orange Ave, suite 102, Orlando, FL, 32804, USA
| | - George J Nassif
- Center for Colon and Rectal Surgery, Florida Hospital, 2415 N Orange Ave, suite 102, Orlando, FL, 32804, USA
| | - Teresa C deBeche-Adams
- Center for Colon and Rectal Surgery, Florida Hospital, 2415 N Orange Ave, suite 102, Orlando, FL, 32804, USA
| | - Matthew R Albert
- Center for Colon and Rectal Surgery, Florida Hospital, 2415 N Orange Ave, suite 102, Orlando, FL, 32804, USA
| | - John R T Monson
- Center for Colon and Rectal Surgery, Florida Hospital, 2415 N Orange Ave, suite 102, Orlando, FL, 32804, USA
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Purse-string rupture: pitfalls of transanal total mesorectal excision (Cecil approach). Tech Coloproctol 2018; 22:393-394. [PMID: 29796756 DOI: 10.1007/s10151-018-1797-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 05/04/2018] [Indexed: 01/28/2023]
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Crawford A, Firtell J, Caycedo-Marulanda A. How Is Rectal Cancer Managed: a Survey Exploring Current Practice Patterns in Canada. J Gastrointest Cancer 2018; 50:260-268. [DOI: 10.1007/s12029-018-0064-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Gilshtein H, Neymark M, Manassa E, Khoury W, Duek D. Transanal Endoscopic Microsurgery Implementation in Ultra-Low Anterior Resection. J Laparoendosc Adv Surg Tech A 2017; 28:186-188. [PMID: 29064311 DOI: 10.1089/lap.2017.0474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Distal rectal cancer resection is an ongoing challenge for the colorectal surgeon. In recent years new technical approaches, especially with implementation of transanal platforms were developed to help in the visualization and resection of these tumors. Nevertheless, the use of these platforms is demanding with significant complications during the onset phase. METHODS Patients with very low rectal cancer were operated on in a single tertiary center with a combined abdominal and transanal endoscopic microsurgery (TEM) approach. Demographic, pathological, and surgical data were collected retrospectively with an emphasis on distal margin involvement. RESULTS Nineteen patients were operated on during the study period. All patients had negative distal resection margins with a low complication rate. The distant metastasis and local recurrence rates were low with a mean follow-up of 2 years. CONCLUSIONS TEM provides an appealing and viable option for the resection of low rectal cancer in a combined transabdominal and transanal approach in patients with a good response after neoadjuvant treatment. This is one of the available platforms a colorectal surgeon might benefit from having in his armamentarium. It has a very low complication rate with maintenance of oncological principles, enabling a clear visualization of the distal rectum, and thus ensures free distal resection margins.
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Affiliation(s)
- Hayim Gilshtein
- 1 Department of General Surgery, Rambam Health Care Campus , Haifa, Israel .,2 Colorectal Surgery Unit, Rambam Health Care Campus , Haifa, Israel
| | - Mariya Neymark
- 1 Department of General Surgery, Rambam Health Care Campus , Haifa, Israel
| | - Elias Manassa
- 1 Department of General Surgery, Rambam Health Care Campus , Haifa, Israel
| | - Wisam Khoury
- 1 Department of General Surgery, Rambam Health Care Campus , Haifa, Israel .,2 Colorectal Surgery Unit, Rambam Health Care Campus , Haifa, Israel
| | - Daniel Duek
- 1 Department of General Surgery, Rambam Health Care Campus , Haifa, Israel .,2 Colorectal Surgery Unit, Rambam Health Care Campus , Haifa, Israel
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