Why the Conventional Parks Transanal Excision for Early Stage Rectal Cancer Should Be Abandoned

Rectal Cancer following Local Excision of Rectal Adenomas with Low-Grade Dysplasia-A Multicenter Study

Purpose: Rectal polyps with low-grade dysplasia (LGD) can be removed by local excision surgery (LE). It is unclear whether these lesions pose a higher risk for recurrence and cancer development and might warrant an early repeat rectal endoscopy. This study aims to assess the rectal cancer rate following local excision of LGD rectal lesions. Methods: A retrospective multicenter study including all patients that underwent LE for rectal polyps over a period of 11 years was conducted. Demographic, clinical, and surgical data of patients with LGD werecollected and analyzed. Results: Out of 274 patients that underwent LE of rectal lesions, 81 (30%) had a pathology of LGD. The mean patient age was 65 ± 11 years, and 52 (64%) were male. The mean distance from the anal verge was 7.2 ± 4.3 cm, and the average lesion was 3.2 ± 1.8 cm. Full thickness resection was achieved in 68 patients (84%), and four (5%) had involved margins for LGD. Nine patients (11%) had local recurrence and developed rectal cancer in an average time interval of 19.3 ± 14.5 months, with seven of them (78%) diagnosed less than two years after the initial LE. Seven of the nine patients were treated with another local excision, whilst one had a low anterior resection, and one was treated with radiation. The mean follow-up time was 25.3 ± 22.4 months. Conclusions: Locally resected rectal polyps with LGD may carry a significant risk of recurring and developing cancer within two years. This data suggests patients should have a closer surveillance protocol in place.

Transanal Endoscopic Platforms: TAMIS versus Rigid Platforms: Pros and Cons

Transanal endoscopic surgery encompasses the minimally invasive surgical techniques used to operate in the rectum under magnification while maintaining pneumorectum via a resectoscope or port. The view, magnification, and surgical precision afforded by these advanced transanal techniques have resulted in excellent specimen quality and low recurrence rates, especially compared with traditional transanal surgery. For rigid platforms, the surgeon operates through a rigid 4-cm diameter steel proctoscope of varying lengths that is clamped to the operating table with an articulating arm. Transanal minimally invasive surgery (TAMIS) is a newer flexible platform using a disposable port which "hooks" into the anorectal ring to remain in place. The cost-effectiveness and versatility of the TAMIS platform have resulted in its popularity and use in more advanced applications such as transanal total mesorectal excision. Ultimately, the choice of operating platform should be based on surgeon preference, patient characteristics, availability, and cost. The pros and cons of each platform will be discussed in this article.

Transanal Minimally Invasive Surgery for Local Excision of Benign and Malignant Rectal Neoplasia: Outcomes From 200 Consecutive Cases With Midterm Follow Up

OBJECTIVE

This study describes the outcomes for 200 consecutive transanal minimally invasive surgery (TAMIS) local excision (LE) for rectal neoplasia.

BACKGROUND

TAMIS is an advanced transanal platform that can result in high quality LE of rectal neoplasia.

METHODS

Consecutive patients from July 1, 2009 to December 31, 2015 from a prospective institutional registry were analyzed. Indication for TAMIS LE was endoscopically unresectable benign lesions or histologically favorable early rectal cancers. The primary endpoints were resection quality, neoplasia recurrence, and oncologic outcomes. Kaplan-Meier survival analyses were used to describe disease-free survival (DFS) for patients with rectal adenocarcinoma that did not receive immediate salvage radical surgery.

RESULTS

There were 200 elective TAMIS LE procedures performed in 196 patients for 90 benign and 110 malignant lesions. Overall, a 7% margin positivity and 5% fragmentation rate was observed. The mean operative time for TAMIS was 69.5 minutes (SD 37.9). Postoperative morbidity was recorded in 11% of patients, with hemorrhage (9%), urinary retention (4%), and scrotal or subcutaneous emphysema (3%) being the most common. The mean follow up was 14.4 months (SD 17.4). Local recurrence occurred in 6%, and distant organ metastasis was noted in 2%. Mean time to local recurrence for malignancy was 16.9 months (SD 13.2). Cumulative DFS for patients with rectal adenocarcinoma was 96%, 93%, and 84% at 1-, 2-, and 3-years.

CONCLUSIONS

For carefully selected patients, TAMIS for local excision of rectal neoplasia is a valid option with low morbidity that maintains the advantages of organ preservation.

Transanal endoscopic microsurgery as day surgery - a single-centre experience with 500 patients

AIM

Transanal endoscopic microsurgery (TEM) is the current treatment of choice for rectal adenomas and early rectal cancer. Postoperative admission to hospital is common but possibly unnecessary. Our objective was to analyse predictors and outcomes of TEM patients having same day discharge (TEM-D) compared with those who were admitted to hospital (TEM-A).

METHOD

At St Paul's Hospital (SPH), demographic, surgical, pathological and follow-up data have been collected prospectively since TEM was started in 2007. Trends in admission and readmission rates were analysed using the Cochran-Armitage trend test, and predictors of admission were analysed using univariate and multivariate logistic regressions.

RESULTS

Between 2007 and 2016, 500 patients were treated by TEM at SPH. The overall admission rate was 29% (145/500), but this decreased to 19% in the last 3 years of the study (P < 0.001). The readmission rate was 5.2% (n = 26/500) and did not change significantly over the study period (P = 0.30). Reasons for admission included the following: surgeon discretion/monitoring (35%), urinary retention (26%), haemorrhage (10%), breach of peritoneal cavity (7%), infection (7%) and other (15%). The most common reasons for readmission were haemorrhage (54%, n = 14), pain (19%, n = 5) and infection (12%, n = 3). Factors associated with admission were as follows: tumour height (OR 1.09, 1.02-1.17), prolonged operative time (OR 1.25, 1.14-1.37), unsutured surgical defect (OR 1.99, 1.22-3.25) and surgeon experience (OR 4.62, 2.75-7.77).

CONCLUSION

Outpatient TEM is safe and carries a low risk of readmission. In centres with an outpatient TEM strategy, predictors of hospital admission include proximal tumours, prolonged surgical time and open management of the surgical defect.

Local excision for rectal cancer: a minimally invasive option

Transanal excision (TAE) with conventional retractors and transanal endoscopic microsurgery (TEM) are two well established minimally invasive surgical options for the treatment of selected rectal cancers. TEM is nowadays considered the standard of care for the transanal excision of rectal tumors, since it is associated with significantly better quality of excision and lower rates of recurrence than TAE. When compared with rectal resection and total mesorectal excision, TEM has lower postoperative morbidity and better functional outcomes, with similar long-term survival rates in selected early rectal cancers. More recently, transanal minimally invasive surgery (TAMIS) has been developed as an alternative to TEM. Possible benefits of TAMIS are under evaluation.

Evolution of transanal total mesorectal excision for rectal cancer: From top to bottom

The gold standard for curative treatment of locally advanced rectal cancer involves radical resection with a total mesorectal excision (TME). TME is the most effective treatment strategy to reduce local recurrence and improve survival outcomes regardless of the surgical platform used. However, there are associated morbidities, functional consequences, and quality of life (QoL) issues associated with TME; these risks must be considered during the modern-day multidisciplinary treatment for rectal cancer. This has led to the development of new surgical techniques to improve patient, oncologic, and QoL outcomes. In this work, we review the evolution of TME to the transanal total mesorectal excision (TaTME) through more traditional minimally invasive platforms. The review the development, safety and feasibility, proposed benefits and risks of the procedure, implementation and education models, and future direction for research and implementation of the TaTME in colorectal surgery. While satisfactory short-term results have been reported, the procedure is in its infancy, and long term outcomes and definitive results from controlled trials are pending. As evidence for safety and feasibility accumulates, structured training programs to standardize teaching, training, and safe expansion will aid the safe spread of the TaTME.

Robotic Assisted Transanal Polypectomies: Is There Any Indication?

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.

Quality of Local Excision for Rectal Neoplasms Using Transanal Endoscopic Microsurgery Versus Transanal Minimally Invasive Surgery: A Multi-institutional Matched Analysis

BACKGROUND

There are no data comparing the quality of local excision of rectal neoplasms using transanal endoscopic microsurgery and transanal minimally invasive surgery.

OBJECTIVE

The purpose of this study was to compare the incidence of tumor fragmentation and positive margins for patients undergoing local excision of benign and malignant rectal neoplasms using transanal endoscopic microsurgery versus transanal minimally invasive surgery.

DESIGN

This was a multi-institutional cohort study using coarsened exact matching.

SETTINGS

The study was conducted at high-volume tertiary institutions with specialist colorectal surgeons.

PATIENTS

Patients undergoing full-thickness local excision for benign and malignant rectal neoplasms were included.

INTERVENTIONS

Transanal endoscopic microsurgery and transanal minimally invasive surgery were the included interventions.

MAIN OUTCOME MEASURES

The incidence of poor quality excision (composite measure including tumor fragmentation and/or positive resection margin) was measured.

RESULTS

The matched cohort consisted of 428 patients (247 with transanal endoscopic microsurgery and 181 with transanal minimally invasive surgery). Transanal minimally invasive surgery was associated with shorter operative time and length of stay. Poor quality excision was similar (8% vs 11%; p = 0.233). There were also no differences in peritoneal violation (3% vs 3%; p = 0.965) and postoperative complications (11% vs 9%; p = 0.477). Cumulative 5-year disease-free survival for patients undergoing transanal endoscopic microsurgery was 80% compared with 78% for patients undergoing transanal minimally invasive surgery (log rank p = 0.824). The incidence of local recurrence for patients with malignancy who did not undergo immediate salvage surgery was 7% (8/117) for transanal endoscopic microsurgery and 7% (7/94) for transanal minimally invasive surgery (p = 0.864).

LIMITATIONS

All of the procedures were also performed at high-volume referral centers by specialist colorectal surgeons with slightly differing perioperative practices and different time periods.

CONCLUSIONS

High-quality local excision for benign and rectal neoplasms can be equally achieved using transanal endoscopic microsurgery or transanal minimally invasive surgery. The choice of operating platform for local excisions of rectal neoplasms should be based on surgeon preference, availability, and cost. See Video Abstract at http://links.lww.com/DCR/A382.

Establishing the learning curve of transanal minimally invasive surgery for local excision of rectal neoplasms

INTRODUCTION

Transanal minimally invasive surgery (TAMIS) is an endoscopic operating platform for local excision of rectal neoplasms. However, it may be technically demanding, and its learning curve has yet to be adequately defined. The objective of this study was to determine the number of TAMIS procedures for the local excision of rectal neoplasm required to reach proficiency.

METHODS AND PROCEDURES

All TAMIS cases performed from 07/2009 to 12/2016 at a single high-volume tertiary care institution for local excision of benign and malignant rectal neoplasia were identified from a prospective database. A cumulative summation (CUSUM) analysis was performed to determine the number of cases required to reach proficiency. The main proficiency outcome was rate of margin positivity (R1 resection). The acceptable and unacceptable R1 rates were defined as the R1 rate of transanal endoscopic microsurgery (TEM-10%) and traditional transanal excision (TAE-26%), which was obtained from previously published meta-analyses. Comparisons of patient, tumor, and operative characteristics before and after TAMIS proficiency were performed.

RESULTS

A total of 254 TAMIS procedures were included in this study. The overall R1 resection rate was 7%. The indication for TAMIS was malignancy in 57%. CUSUM analysis reported that TAMIS reached an acceptable R1 rate between 14 and 24 cases. Moving average plots also showed that the mean operative times stabilized by proficiency gain. The mean lesion size was larger after proficiency gain (3.0 cm (SD 1.5) vs. 2.3 cm (SD 1.3), p = 0.008). All other patient, tumor, and operative characteristics were similar before and after proficiency gain.

CONCLUSIONS

TAMIS for local excision of rectal neoplasms is a complex procedure that requires a minimum of 14-24 cases to reach an acceptable R1 resection rate and lower operative duration.