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Stipa F, Tierno SM, Russo G, Burza A. Trans-anal minimally invasive surgery (TAMIS) versus trans-anal endoscopic microsurgery (TEM): a comparative case-control matched-pairs analysis. Surg Endosc 2021; 36:2081-2086. [PMID: 33844090 DOI: 10.1007/s00464-021-08494-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 03/28/2021] [Indexed: 11/24/2022]
Abstract
AIM Since its introduction, transanal endoscopic microsurgery (TEM) has become the treatment of choice for rectal benign lesions not amenable to flexible endoscopic excision and for early rectal cancer. Disposable soft devices as the Trans-anal Minimally Invasive Surgery (TAMIS) are a valid alternative to non-disposable rigid trans-anal endoscopic microsurgery (TEM) platforms. The aim of the present study is to compare TEM and TAMIS in terms of incidence of R1 resection and lesion fragmentation which were combined in a composite outcome called quality resection. Perioperative complication and operative time were also investigated. METHODS A total of 132 patients were eligible for this study of whom 63 (47.7%) underwent TAMIS and 69 (52.3%) underwent TEM. Patients were extracted for from a prospective maintained database and groups resulted homogenous after matching using propensity score in terms of size of the lesion, height from the anal verge, position within the rectal lumen, preoperative histology, neoadjuvant treatment. A multivariate logistic and linear regression analysis was carried out using those variables that have significant independent relationship with the quality of surgical resection and operative time. RESULTS The incidence of R0 resection and lesion fragmentation was similar between groups. No differences were found in terms of perioperative complication. TAMIS was associated with less setup time and less operative time compared with TEM. Variables influencing quality resection at the multivariate analysis were larger lesion (> 5 cm) and ≥ T2 stage. Variables influencing operative time were surgical procedure (TEM vs TAMIS), height from the anal verge and size of the lesion. CONCLUSION The present study shows that TEM and TAMIS are equally effective in terms of quality of local excision and perioperative complication. TAMIS resulted less operative time consuming compared to TEM.
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Affiliation(s)
- Francesco Stipa
- Department of Surgery, Madre Giuseppina Vannini Hospital, Istituto Figlie Di San Camillo, Via di Acqua Bullicante 4, 00177, Rome, Italy.
| | - Simone Maria Tierno
- Department of Surgery, Madre Giuseppina Vannini Hospital, Istituto Figlie Di San Camillo, Via di Acqua Bullicante 4, 00177, Rome, Italy
| | - Giulia Russo
- Department of Surgery, Madre Giuseppina Vannini Hospital, Istituto Figlie Di San Camillo, Via di Acqua Bullicante 4, 00177, Rome, Italy
| | - Antonio Burza
- Department of Surgery, Madre Giuseppina Vannini Hospital, Istituto Figlie Di San Camillo, Via di Acqua Bullicante 4, 00177, Rome, Italy
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D’Amico F, Wexner SD, Vaizey CJ, Gouynou C, Danese S, Peyrin-Biroulet L. Tools for fecal incontinence assessment: lessons for inflammatory bowel disease trials based on a systematic review. United European Gastroenterol J 2020; 8:886-922. [PMID: 32677555 PMCID: PMC7707876 DOI: 10.1177/2050640620943699] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 06/09/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Fecal incontinence is a disabling condition affecting up to 20% of women. OBJECTIVE We investigated fecal incontinence assessment in both inflammatory bowel disease and non-inflammatory bowel disease patients to propose a diagnostic approach for inflammatory bowel disease trials. METHODS We searched on Pubmed, Embase and Cochrane Library for all studies on adult inflammatory bowel disease and non-inflammatory bowel disease patients reporting data on fecal incontinence assessment from January 2009 to December 2019. RESULTS In total, 328 studies were included; 306 studies enrolled non-inflammatory bowel disease patients and 22 studies enrolled inflammatory bowel disease patients. In non-inflammatory bowel disease trials the most used tools were the Wexner score, fecal incontinence quality of life questionnaire, Vaizey score and fecal incontinence severity index (in 187, 91, 62 and 33 studies). Anal manometry was adopted in 41.2% and endoanal ultrasonography in 34.0% of the studies. In 142 studies (46.4%) fecal incontinence evaluation was performed with a single instrument, while in 64 (20.9%) and 100 (32.7%) studies two or more instruments were used. In inflammatory bowel disease studies the Wexner score, Vaizey score and inflammatory bowel disease quality of life questionnaire were the most commonly adopted tools (in five (22.7%), five (22.7%) and four (18.2%) studies). Anal manometry and endoanal ultrasonography were performed in 45.4% and 18.2% of the studies. CONCLUSION Based on prior validation and experience, we propose to use the Wexner score as the first step for fecal incontinence assessment in inflammatory bowel disease trials. Anal manometry and/or endoanal ultrasonography should be taken into account in the case of positive questionnaires.
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Affiliation(s)
- Ferdinando D’Amico
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston USA
| | | | - Célia Gouynou
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Silvio Danese
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IBD Center, Department of Gastroenterology, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
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Marinello FG, Curell A, Tapiolas I, Pellino G, Vallribera F, Espin E. Systematic review of functional outcomes and quality of life after transanal endoscopic microsurgery and transanal minimally invasive surgery: a word of caution. Int J Colorectal Dis 2020; 35:51-67. [PMID: 31761962 DOI: 10.1007/s00384-019-03439-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE The introduction of transanal endoscopic or minimally invasive surgery has allowed organ preservation for rectal tumors with good oncological results. Data on functional and quality-of-life (QoL) outcomes are scarce and controversial. This systematic review sought to synthesize fecal continence, QoL, and manometric outcomes after transanal endoscopic microsurgery (TEM) or transanal minimally invasive surgery (TAMIS). METHODS A systematic review of the literature including Medline, Embase, and the Cochrane Library databases was conducted searching for articles reporting on functional outcomes after TEM or TAMIS between January 1995 and June 2018. The evaluated outcome parameters were pre- and postoperative fecal continence (primary endpoint), QoL, and manometric results. Data were extracted using the same scales and measurement units as from the original study. RESULTS A total of 29 studies comprising 1297 patients were included. Fecal continence outcomes were evaluated in 23 (79%) studies with a wide variety of assessment tools and divergent results. Ten studies (34%) analyzed QoL changes, and manometric variables were assessed in 15 studies (51%). Most studies reported some deterioration in manometric scores without major QoL impairment. Due to the heterogeneity of the data, it was not possible to perform any pooled analysis or meta-analysis. CONCLUSIONS These techniques do not seem to affect continence by themselves except in minor cases. The possibility of worsened function after TEM and TAMIS should not be underestimated. There is a need to homogenize or standardize functional and manometric outcomes assessment after TEM or TAMIS.
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Affiliation(s)
- Franco G Marinello
- Colorectal Unit - Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Anna Curell
- Colorectal Unit - Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ingrid Tapiolas
- Colorectal Unit - Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Gianluca Pellino
- Colorectal Unit - Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Francesc Vallribera
- Colorectal Unit - Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Eloy Espin
- Colorectal Unit - Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
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Ramkumar J, Letarte F, Karimuddin AA, Phang PT, Raval MJ, Brown CJ. Assessing the safety and outcomes of repeat transanal endoscopic microsurgery. Surg Endosc 2019; 33:1976-1980. [PMID: 30746573 DOI: 10.1007/s00464-018-6501-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 10/11/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Transanal endoscopic microsurgery (TEM) is the treatment of choice for benign rectal tumors and select early rectal cancers. This surgical approach has become ubiquitous and surgeons are seeing recurrent lesions after TEM resection. This study aims to outline the safety and outcomes of repeat TEM when compared to primary TEM procedures. METHODS At St. Paul's Hospital, demographic, surgical, pathologic, and follow-up data for patients treated by TEM are maintained in a prospectively populated database. Two groups were established for comparison: patients undergoing first TEM procedure (TEM-P) and patients undergoing repeat TEM procedure (TEM-R). RESULTS Between 2007 and 2017, 669 patients had their first TEM procedure. Over this time frame, 57 of these patients required repeat TEM procedures, including 15 of these patients treated by 3 or more TEMs. Indications for repeat TEM included recurrence (78%), positive margins (15%), and metachronous lesions (7%). There were no differences between the groups in patient age, gender, or tumor histology. Compared to TEM-P, TEM-R had shorter operative times (38 vs. 52 min, p < 0.001), more distal lesions (5 vs. 7 cm, p < 0.004), and smaller lesions (3 vs. 4 cm, p < 0.0003). The TEM-R group had similar length of hospital stay (0.45 vs. 0.56 days, p = 0.65), rates of clear margins on pathology (81% vs. 88%, p = 0.09), and 30-day readmission rates (7% vs. 4%, p = 0.27) when compared to TEM-P group. TEM-R was more likely to be managed without suturing the surgical defect (72% vs. 32%, p < 0.0001). Repeat TEM was associated with similar post-operative complications as primary TEM graded on the Clavien-Dindo classification scale (Grade 1: 5% vs. 5%, Grade 2: 5% vs. 4%, Grade 3: 5% vs. 1%, p = 0.53). No 30-day mortality occurred in either group. CONCLUSIONS The St. Paul's Hospital TEM experience suggests repeat TEM is a safe and feasible procedure with similar outcomes as patients undergoing first TEM.
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Affiliation(s)
- Jonathan Ramkumar
- Division of General Surgery, Vancouver General Hospital, 950 West 10th Avenue, Vancouver, Canada
| | - Francois Letarte
- Department of Surgery, St. Paul's Hospital, Vancouver, BC, Canada
| | - Ahmer A Karimuddin
- Department of Surgery, St. Paul's Hospital, Vancouver, BC, Canada.,Section of Colorectal Surgery, St. Paul's Hospital, Room C310 - 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - P Terry Phang
- Department of Surgery, St. Paul's Hospital, Vancouver, BC, Canada.,Section of Colorectal Surgery, St. Paul's Hospital, Room C310 - 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Manoj J Raval
- Department of Surgery, St. Paul's Hospital, Vancouver, BC, Canada.,Section of Colorectal Surgery, St. Paul's Hospital, Room C310 - 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Carl J Brown
- Department of Surgery, St. Paul's Hospital, Vancouver, BC, Canada. .,Section of Colorectal Surgery, St. Paul's Hospital, Room C310 - 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
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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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D'Hondt M, Yoshihara E, Dedrye L, Vindevoghel K, Nuytens F, Pottel H. Transanal Endoscopic Operation for Benign Rectal Lesions and T1 Carcinoma. JSLS 2017; 21:JSLS.2016.00093. [PMID: 28144126 PMCID: PMC5266515 DOI: 10.4293/jsls.2016.00093] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background and Objectives: Transanal endoscopic operation (TEO) is a minimally invasive technique used for local excision of benign and selected malignant rectal lesions. The purpose of this study was to investigate the feasibility, safety, and oncological outcomes of the procedure and to report the experience in 3 centers. Methods: Retrospective review of a prospectively collected database was performed of all patients with benign lesions or ≤cT1N0 rectal cancer who underwent TEO with curative intent at 3 Belgian centers (2012 through 2014). Results: Eighty-three patients underwent 84 TEOs for 89 rectal lesions (37 adenomas, 43 adenocarcinomas, 1 gastrointestinal stromal tumor, 1 lipoma, 2 neuroendocrine tumors, and 5 scar tissues). Operative time was associated with lesion size (P < .001). Postoperative complications occurred in 13 patients: 7 hemorrhages, 1 urinary tract infection, 1 urinary retention, 2 abscesses, 1 anastomotic stenosis, and 1 entrance into the peritoneal cavity. Median hospital stay was 3 days (range, 1–8). During a median follow-up of 13 months (range, 2–27), there was 1 recurrence. Conclusion: Although longer follow-up is still necessary, TEO appears to be an effective method of excising benign tumors and low-risk T1 carcinomas of the rectum. However, TEO should be considered as part of the diagnostic work-up. Furthermore, the resected specimen of a TEO procedure allows adequate local staging in contrast to an endoscopic piecemeal excision. Nevertheless, definitive histology must be appreciated, and in case of unfavorable histology, radical salvage resection still has to be performed.
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Affiliation(s)
- Mathieu D'Hondt
- Department of General and Digestive Surgery, Groeninge Hospital, Kortrijk, Belgium
| | - Emi Yoshihara
- Department of General and Digestive Surgery, Groeninge Hospital, Kortrijk, Belgium
| | - Lieven Dedrye
- Department of General and Digestive Surgery, Jan Yperman Hospital, Ieper, Belgium
| | - Koen Vindevoghel
- Department of General and Digestive Surgery, OLV van Lourdes Hospital, Waregem, Belgium
| | - Frederiek Nuytens
- Department of General and Digestive Surgery, Groeninge Hospital, Kortrijk, Belgium
| | - Hans Pottel
- Interdisciplinary Research Center, Catholic University Leuven, Kortrijk, Belgium
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Leong KJ, Evans J, Davies MM, Scott A, Lidder P. Transanal endoscopic surgery: past, present and future. Br J Hosp Med (Lond) 2016; 77:394-402. [PMID: 27388378 DOI: 10.12968/hmed.2016.77.7.394] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Transanal endoscopic surgery is a safe, established technique to remove lesions in the rectum via the anus. This article reviews its evolution, approaches, indications and evidence for its role in treating benign rectal polyps. The future of transanal endoscopic surgery in rectal cancer and inflammatory bowel disease is also explored.
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Affiliation(s)
- Kai J Leong
- Specialty Registrar in the Department of Colorectal Surgery, University Hospitals of Coventry and Warwickshire NHS Trust, Coventry CV2 2DX
| | - John Evans
- Consultant Colorectal Surgeon in the Department of Colorectal Surgery, Northampton General Hospital NHS Trust, Northampton
| | - Michael M Davies
- Consultant Colorectal Surgeon in the Department of Colorectal Surgery, University Hospital of Wales, Cardiff
| | - Adam Scott
- Consultant Colorectal Surgeon in the Department of Colorectal Surgery, Leicester General Hospital, University Hospitals of Leicester NHS Trust, Leicester
| | - Paul Lidder
- Consultant Colorectal Surgeon in the Department of Surgery, Royal Cornwall Hospitals NHS Trust, Cornwall
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Transanal Endoscopic Microsurgery: Current and Future Perspectives. Surg Laparosc Endosc Percutan Tech 2016; 26:e46-9. [DOI: 10.1097/sle.0000000000000273] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Transanal endoscopic microsurgery for large benign rectal tumors; where are the limits? Int J Surg 2016; 29:128-31. [DOI: 10.1016/j.ijsu.2016.03.041] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 02/19/2016] [Accepted: 03/10/2016] [Indexed: 11/20/2022]
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Smart CJ, Cunningham C, Bach SP. Transanal endoscopic microsurgery. Best Pract Res Clin Gastroenterol 2014; 28:143-57. [PMID: 24485262 DOI: 10.1016/j.bpg.2013.11.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Revised: 09/14/2013] [Accepted: 11/23/2013] [Indexed: 02/07/2023]
Abstract
Transanal endoscopic microsurgery (TEMS) is a well established method of accurate resection of specimens from the rectum under binocular vision. This review examines its role in the treatment of benign conditions of the rectum and the evidence to support its use and compliment existing endoscopic treatments. The evolution of TEMS in early rectal cancer and the concepts and outcomes of how it has been utilised to treat patients so far are presented. The bespoke nature of early rectal cancer treatment is changing the standard algorithms of rectal cancer care. The future of TEMS in the organ preserving treatment of early rectal cancer is discussed and how as clinicians we are able to select the correct patients for neoadjuvant or radical treatments accurately. The role of radiotherapy and outcomes from combination treatment using TEMS are presented with suggestions for areas of future research.
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Affiliation(s)
- Christopher J Smart
- School of Cancer Studies, Academic Department of Surgery, Room 28, 4th Floor,Queen Elizabeth Hospital Edgbaston, Birmingham B15 2TH, UK.
| | - Chris Cunningham
- Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Headley Way, Headington, England OX3 9DU, UK.
| | - Simon P Bach
- School of Cancer Studies, Academic Department of Surgery, Room 28, 4th Floor,Queen Elizabeth Hospital Edgbaston, Birmingham B15 2TH, UK.
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