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Yang WF, Chen W, He Z, Wu Z, Liu H, Li G, Li WL. Simple transanal total mesorectal resection versus laparoscopic transabdominal total mesorectal resection for the treatment of low rectal cancer: a single-center retrospective case-control study. Front Surg 2023; 10:1171382. [PMID: 37576920 PMCID: PMC10413134 DOI: 10.3389/fsurg.2023.1171382] [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: 02/28/2023] [Accepted: 07/10/2023] [Indexed: 08/15/2023] Open
Abstract
Aim To evaluate the efficacy and safety of simple TaTNE in the treatment of low rectal cancer compared with laparoscopic transabdominal TME. Methods We collected patients with low rectal cancer admitted to our hospital between January 2019 and November 2021 who received simple TaTME or laparoscopic transabdominal TME. The main outcome was the integrity of the TME specimen. Secondary outcomes were the number of lymph nodes dissected, intraoperative blood loss, operative time, surgical conversion rate, Specimen resection length, circumferential margin (CRM), and distal resection margin (DRM), complication rate. In addition, the Wexner score and LARS score of fecal incontinence were performed in postoperative follow-up. Results Pathological tissues were successfully resected in all patients. all circumferential margins of the specimen were negative. Specimen resection length was not statistically significant (9.94 ± 2.85 vs. 8.90 ± 2.49, P > 0.05). The incidence of postoperative complications in group A (n = 0) was significantly lower than that in group B (n = 3) (P > 0.05). There was no significant difference in operation time between group A and group B (296 ± 60.36 vs. 305 ± 58.28, P > 0.05). Among the patients with follow-up time less than 1 year, there was no significant difference in Wexner score and LARS score between group A and group B (P > 0.05). However, in patients who were followed up for more than 1 year, the Wexner score in group A (9.25 ± 2.73) was significantly lower than that in group B (17.36 ± 10.95) and was statistically significant (P < 0.05). Conclusion For radical resection of low rectal cancer, Simple TaTME resection may be as safe and effective as laparoscopic transabdominal TME, and the long-term prognosis may be better.
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Affiliation(s)
| | | | | | | | | | | | - Wang-Lin Li
- School of Medicine, South China University of Technology, Guangzhou, China
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El-Ahmar M, Koch F, Ristig M, Lehmann K, Ritz JP. Reconstruction, oversewing, or taking the anastomosis down - which surgical intervention is most potent in the treatment of anastomotic leaks following colorectal resections? Langenbecks Arch Surg 2023; 408:266. [PMID: 37405509 DOI: 10.1007/s00423-023-02986-2] [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: 06/17/2022] [Accepted: 06/14/2023] [Indexed: 07/06/2023]
Abstract
PURPOSE Anastomotic leak (AL) following colorectal resections can be treated interventionally. However, most cases require surgical intervention. Thus, several surgical techniques are available, which intend to affect the further course positively. The aim of this retrospective analysis is to determine which surgical technique proves to have the biggest potential in reducing the morbidity and mortality as well as to minimize the need of re-interventions after AL. METHODS All patients with a history of AL following colorectal resection between 2008 and 2020 were analyzed. Patient's outcomes following surgical treatment of AL, including morbidity and mortality, clinical and para-clinical (laboratory examinations, ultrasound, and CT-scan) detection of AL recurrence, re-intervention rate, and the length of hospital stay were documented and correlated with the surgical technique used (e.g. simply over-sewing the AL, over-sewing the AL with the construction of a protective ileostomy, resection and reconstruction of the anastomosis, peritoneal lavage and transanal drainage, or taking the anastomosis down and constructing an end stoma). RESULTS A total of 2,724 colorectal resections were documented. Grade C AL occurred in 92 (4.4% AL occurrence-rate) and 31 (7.2% AL occurrence-rate) cases following colon and rectal resections, respectively. The anastomosis was not preservable in 52 and 17 cases following colon and rectal resections, respectively. Therefore, the anastomosis had been taken down and an end-stoma had been constructed. Over-sewing the AL with the construction of a protective ileostomy had the highest anastomosis preservation rate (14 of 18 cases) and lowest re-intervention rate (mean value of 1.5 re-interventions) following colon and rectal resections (7 of 9 cases; mean value, 1.5 re-interventions). CONCLUSION In cases where an AL is preservable, over-sewing the anastomosis and constructing a protective ileostomy has the greatest potential for positive short-term outcomes following colorectal resections.
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Affiliation(s)
- M El-Ahmar
- Department of General and Visceral Surgery, Helios Kliniken Schwerin, Wismarsche Straße 393 - 397, 19055, Schwerin, Germany.
- Department of General and Visceral Surgery, Charité Universitätsmedizin Berlin Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany.
| | - F Koch
- Department of General and Visceral Surgery, Helios Kliniken Schwerin, Wismarsche Straße 393 - 397, 19055, Schwerin, Germany
| | - M Ristig
- Department of General and Visceral Surgery, Helios Kliniken Schwerin, Wismarsche Straße 393 - 397, 19055, Schwerin, Germany
| | - K Lehmann
- Department of General and Visceral Surgery, Charité Universitätsmedizin Berlin Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - J P Ritz
- Department of General and Visceral Surgery, Helios Kliniken Schwerin, Wismarsche Straße 393 - 397, 19055, Schwerin, Germany
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Seow W, Dudi-Venkata NN, Bedrikovetski S, Kroon HM, Sammour T. Outcomes of open vs laparoscopic vs robotic vs transanal total mesorectal excision (TME) for rectal cancer: a network meta-analysis. Tech Coloproctol 2022; 27:345-360. [PMID: 36508067 DOI: 10.1007/s10151-022-02739-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 11/29/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Total mesorectal excision (TME) for rectal cancer can be achieved using open (OpTME), laparoscopic (LapTME), robotic (RoTME), or transanal techniques (TaTME). However, the optimal approach for access remains controversial. The aim of this network meta-analysis was to assess operative and oncological outcomes of all four surgical techniques. METHODS Ovid MEDLINE, EMBASE, and PubMed databases were searched systematically from inception to September 2020, for randomised controlled trials (RCTs) comparing any two TME surgical techniques. A network meta-analysis using a Bayesian random-effects framework and mixed treatment comparison was performed. Primary outcomes were the rate of clear circumferential resection margin (CRM), defined as > 1 mm from the closest tumour to the cut edge of the tissue, and completeness of mesorectal excision. Secondary outcomes included radial and distal resection margin distance, postoperative complications, locoregional recurrence, disease-free survival, and overall survival. Surface under cumulative ranking (SUCRA) was used to rank the relative effectiveness of each intervention for each outcome. The higher the SUCRA value, the higher the likelihood that the intervention is in the top rank or one of the top ranks. RESULTS Thirty-two RCTs with a total of 6151 patients were included. Compared with OpTME, there was no difference in the rates of clear CRM: LapTME RR = 0.99 (95% (Credible interval) CrI 0.97-1.0); RoTME RR = 1.0 (95% CrI 0.96-1.1); TaTME RR = 1.0 (95% CrI 0.96-1.1). There was no difference in the rates of complete mesorectal excision: LapTME RR = 0.98 (95% CrI 0.98-1.1); RoTME RR = 1.1 (95% CrI 0.98-1.4); TaTME RR = 1.0 (95% CrI 0.91-1.2). RoTME was associated with improved distal resection margin distance compared to other techniques (SUCRA 99%). LapTME had a higher rate of conversion to open surgery when compared with RoTME: RoTME RR = 0.23 (95% CrI 0.034-0.70). Length of stay was shortest in RoTME compared to other surgical approaches: OpTME mean difference in days (MD) 3.3 (95% CrI 0.12-6.0); LapTME MD 1.7 (95% CrI - 1.1-4.4); TaTME MD 1.3 (95% CrI - 5.2-7.4). There were no differences in 5-year overall survival (LapTME HR 1.1, 95% CrI 0.74, 1.4; TaTME HR 1.7, 95% CrI 0.79, 3.4), disease-free survival rates (LapTME HR 1.1, 95% CrI 0.76, 1.4; TaTME HR 1.1, 95% CrI 0.52, 2.4), or anastomotic leakage (LapTME RR = 0.92 (95% CrI 0.63, 1.1); RoTME RR = 1.0 (95% CrI 0.48, 1.8); TaTME RR = 0.53 (95% CrI 0.19, 1.2). The overall quality of evidence as per Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessments across all outcomes including primary and secondary outcomes was deemed low. CONCLUSIONS In selected patients eligible for a RCT, RoTME achieved improved distal resection margin distance and a shorter length of hospital stay. No other differences were observed in oncological or recovery parameters between (OpTME), laparoscopic (LapTME), robotic (RoTME), or trans-anal TME (TaTME). However, the overall quality of evidence across all outcomes was deemed low.
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Affiliation(s)
- Warren Seow
- Discipline of Surgery, Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, 4 North Terrace, Adelaide, South Australia, 5000, Australia
| | - Nagendra N Dudi-Venkata
- Discipline of Surgery, Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, 4 North Terrace, Adelaide, South Australia, 5000, Australia.
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
| | - Sergei Bedrikovetski
- Discipline of Surgery, Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, 4 North Terrace, Adelaide, South Australia, 5000, Australia
| | - Hidde M Kroon
- Discipline of Surgery, Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, 4 North Terrace, Adelaide, South Australia, 5000, Australia
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Tarik Sammour
- Discipline of Surgery, Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, 4 North Terrace, Adelaide, South Australia, 5000, Australia
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Madbouly KM, Hany Emile S, Gamal AA. Transanal total mesorectal excision (TaTME) with delayed coloanal anastomosis versus TaTME with immediate coloanal anastomosis and temporary diversion in middle and low rectal cancer. J Surg Oncol 2022; 125:865-871. [PMID: 35032329 DOI: 10.1002/jso.26795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 12/20/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Transanal total mesorectal excision (TaTME) avoids the difficulty of laparoscopic dissection of the lower part of the rectum. The need for stoma is associated with many stoma-related complications. The objective was to compare TaTME with immediate coloanal anastomosis and protective ileostomy (TaTME-IA) versus Turnbull-Cutait delayed coloanal anastomosis (TaTME-TC). METHODS A retrospective cohort study included patients with low rectal cancer at least 1 cm above the top of the anal sphincter. Patients had either TaTME-IA or TaTME-TC. Primary outcome measures were anastomotic and stoma-related complications. Secondary outcomes included rate of permanent stomas, local recurrence, continence, and quality of life (QOL). RESULTS TaTME-IA was done in 25 patients versus 20 who had TaTME-TC. TaTME-IA had significantly longer mean operative time (p = 0.04) and shorter length of stay (LOS) (4.5 vs. 11.4 days; p = 0.0001) compared to TaTME-TC. Anastomotic leak was reported in two patients of TaTME-IA versus one patient of TaTME-TC (p = 0.77). Anastomotic stenosis was reported in one patient in each group. No significant difference between groups as regard continence, local recurrence, and QOL. CONCLUSION TaTME-TC is a safe option that can be offered for patients with low rectal cancer who refuse or are not amenable to a temporary stoma. Anastomotic complications were similar in both groups. LOS was much longer in TaTME-TC, however, it avoids stoma complications. Both groups had similar functional oncologic outcomes and QOL.
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Affiliation(s)
- Khaled M Madbouly
- Department of Surgery, Section of Colon & Rectal Surgery, University of Alexandria, Alexandria, Egypt
| | - Sameh Hany Emile
- Department of Surgery, Colorectal Surgery Unit, Mansoura University, Mansoura, Egypt
| | - Abd Allah Gamal
- Department of Surgery, Section of Colon & Rectal Surgery, University of Alexandria, Alexandria, Egypt
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5
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Lask A, Biebl M, Dittrich L, Fischer A, Adler A, Tacke F, Aigner F, Schmuck R, Chopra S, Knoop M, Pratschke J, Gül-Klein S. Safety of transanal ileal pouch-anal anastomosis for ulcerative colitis: a retrospective observational cohort study. Patient Saf Surg 2021; 15:31. [PMID: 34537080 PMCID: PMC8449900 DOI: 10.1186/s13037-021-00306-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 08/23/2021] [Indexed: 12/12/2022] Open
Abstract
Background Colectomy with transanal ileal pouch-anal anastomosis (taIPAA) is a surgical technique that can be used to treat benign colorectal disease. Ulcerative colitis is the most frequent inflammatory bowel disease (IBD) and although pharmacological therapy has improved, colectomy rates reach up to 15%. The objective of this study was to determine anastomotic leakage rates and treatment after taIPAA as well as short- and long-term pouch function. Methods We conducted a retrospective analysis of a prospective database of all patients undergoing taIPAA at an academic tertiary referral center in Germany, between 01/03/2015 and 31/08/2019. Patients with indications other than ulcerative colitis or with adjuvant chemotherapy following colectomy for colorectal carcinoma were excluded for short- and long-term follow up due to diverging postoperative care yet considered for evaluation of anastomotic leakage. Results A total of 22 patients undergoing taIPAA during the study time-window were included in analysis. Median age at the time of surgery was 32 ± 12.5 (14–54) years. Two patients developed an anastomotic leakage at 11 days (early anastomotic leakage) and 9 months (late anastomotic leakage) after surgery, respectively. In both patients, pouches could be preserved with a multimodal approach. Twenty patients out of 22 met the inclusion criteria for short and long term follow-up. Data on short-term pouch function could be obtained in 14 patients and showed satisfactory pouch function with only four patients reporting intermittent incontinence at a median stool frequency of 9–10 times per day. In the long-term we observed an inflammation or “pouchitis” in 11 patients and a pouch failure in one patient. Conclusion Postoperative complication rates in patients with benign colorectal disease remain an area of concern for surgical patient safety. In this pilot study on 22 selected patients, taIPAA was associated with two patients developing anastomotic leakage. Future large-scale validation studies are required to determine the safety and feasibility of taIPAA in patients with ulcerative colitis.
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Affiliation(s)
- Aina Lask
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Matthias Biebl
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Luca Dittrich
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Andreas Fischer
- Department of Hepatology and Gastroenterology, Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt Universität zu Berlin , Berlin, Germany
| | - Andreas Adler
- Department of Hepatology and Gastroenterology, Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt Universität zu Berlin , Berlin, Germany
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Charité - Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt Universität zu Berlin , Berlin, Germany
| | - Felix Aigner
- Department of Surgery, Barmherzige Brüder Krankenhaus Graz, Graz, Austria
| | - Rosa Schmuck
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Sascha Chopra
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Michael Knoop
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Safak Gül-Klein
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
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6
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Ferko A, Váňa J, Adámik M, Švec A, Žáček M, Demeter M, Grendár M. Mucosa plication reinforced colorectal anastomosis and trans-anal vacuum drainage: a pilot study with preliminary results. Updates Surg 2021; 73:2145-2154. [PMID: 34089500 PMCID: PMC8606370 DOI: 10.1007/s13304-021-01105-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 05/25/2021] [Indexed: 12/13/2022]
Abstract
Dehiscence of colorectal anastomosis is a serious complication that is associated with increased mortality, impaired functional and oncological outcomes. The hypothesis was that anastomosis reinforcement and vacuum trans-anal drainage could eliminate some risk factors, such as mechanically stapled anastomosis instability and local infection. Patients with rectal cancer within 10 cm of the anal verge and low anterior resection with double-stapled technique were included consecutively. A stapler anastomosis was supplemented by trans-anal reinforcement and vacuum drainage using a povidone-iodine-soaked sponge. Modified reinforcement using a circular mucosa plication was developed and used. Patients were followed up by postoperative endoscopy and outcomes were acute leak rate, morbidity, and diversion rate. The procedure was successfully completed in 52 from 54 patients during time period January 2019–October 2020. The mean age of patients was 61 years (lower–upper quartiles 54–69 years). There were 38/52 (73%) males and 14/52 (27%) females; the neoadjuvant radiotherapy was indicated in a group of patients in 24/52 (46%). The mean level of anastomosis was 3.8 cm (lower–upper quartiles 3.00–4.88 cm). The overall morbidity was 32.6% (17/52) and Clavien–Dindo complications ≥ 3 grade appeared in 3/52 (5.7%) patients. No loss of anastomosis was recorded and no patient died postoperatively. The symptomatic anastomotic leak was recorded in 2 (3.8%) patients and asymptomatic blind fistula was recorded in one patient 1/52 (1.9%). Diversion ileostomy was created in 1/52 patient (1.9%). Reinforcement of double-stapled anastomosis using a circular mucosa plication with combination of vacuum povidone-iodine-soaked sponge drainage led to a low acute leak and diversion rate. This pilot study requires further investigation. Registered at ClinicalTrials.gov.: Trial registration number is NCT04735107, date of registration February 2, 2021, registered retrospectively.
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Affiliation(s)
- Alexander Ferko
- Department of Surgery and Transplant Centre, Jessenius Medical Faculty in Martin, Comenius University in Bratislava, University Hospital Martin, Martin, Slovak Republic. .,, Františka Komárka 865/6, 503 11, Hradec Králové, Czech Republic.
| | - Juraj Váňa
- Department of Surgery, Faculty Hospital Žilina, Žilina, Slovak Republic
| | - Marek Adámik
- Department of Surgery and Transplant Centre, Jessenius Medical Faculty in Martin, Comenius University in Bratislava, University Hospital Martin, Martin, Slovak Republic
| | - Adam Švec
- Department of Surgery and Transplant Centre, Jessenius Medical Faculty in Martin, Comenius University in Bratislava, University Hospital Martin, Martin, Slovak Republic
| | - Michal Žáček
- Department of Surgery, Faculty Hospital Žilina, Žilina, Slovak Republic
| | - Michal Demeter
- Department of Gastroenterology, Jessenius Medical Faculty in Martin, Comenius University in Bratislava, University Hospital Martin, Martin, Slovak Republic
| | - Marián Grendár
- Laboratory of Bioinformatics and Biostatistics, Jessenius Medical Faculty in Martin, Biomedical Center Martin, Comenius University in Bratislava, Martin, Slovak Republic
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Patient Acceptance of Routine Serial Postoperative Endoscopy Following Low Anterior Resection (LAR) and Its Ability to Detect Biomarkers in Anastomotic Lavage Fluid. World J Surg 2021; 45:2227-2234. [PMID: 33742231 DOI: 10.1007/s00268-021-06062-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Various reports have now established that postoperative endoscopy to examine and intervene in the process of anastomotic healing is both feasible and safe. Here we present our preliminary experience with serial postoperative endoscopy to determine its feasibility, patient acceptance and the ability to obtain and the utility of perianastomotic material for molecular analysis. METHODS Patients undergoing LAR with ileostomy for rectal cancer were recruited for study to undergo routine serial endoscopic surveillance (SES) at three time points during the course of LAR: intraoperatively, before discharge (postoperative day 3-7) and at follow-up (postoperative day 10-28). At each endoscopy, images were captured, anastomotic tissues were lavaged and lavage fluid was retrieved. Fluid samples were analyzed using proteomics, zymography, ELISA and bacteria via 16S rRNA gene amplicon sequencing and culture of collagenolytic strains. RESULTS SES is feasible and acceptable to this limited set of patients following LAR. Biologic analysis of perianastomotic fluids was able to detect the presence of proteins, microbiota and inflammatory mediators previously identified at anastomotic sites in animals with pathologic healing. CONCLUSION SES can be implemented in patients undergoing LAR with a high degree of patient compliance and capture of biologic information and imaging. Application of this approach has the potential to uncover, for the first time, the natural history of normal versus pathologic anastomotic healing in patients undergoing anastomotic surgery.
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8
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Jiang TY, Ma JJ, Zheng MH. Controversies and consensus in transanal total mesorectal excision (taTME): Is it a valid choice for rectal cancer? J Surg Oncol 2021; 123 Suppl 1:S59-S64. [PMID: 33650698 DOI: 10.1002/jso.26340] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 11/27/2020] [Accepted: 11/28/2020] [Indexed: 02/06/2023]
Abstract
Transanal total mesorectal excision (taTME) is a novel approach to radical surgery for low rectal cancer. taTME is associated with the benefits of a higher rate of free distal resection margins (DRM) under direct visualization, better visualization of the mesorectal plane, and the feasibility of overcoming the restriction of the distal pelvis. Thus, it is increasingly used globally. In this review, we investigated whether taTME yields better short- and long-term outcomes than laparoscopic TME.
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Affiliation(s)
- Tian-Yu Jiang
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Minimally Invasive Surgery Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Jun-Jun Ma
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Minimally Invasive Surgery Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Min-Hua Zheng
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Minimally Invasive Surgery Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
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9
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Colorectal anastomosis dehiscence: a call for more detailed morphological classification. Wideochir Inne Tech Maloinwazyjne 2020; 16:98-109. [PMID: 33786122 PMCID: PMC7991942 DOI: 10.5114/wiitm.2020.97367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 06/04/2020] [Indexed: 02/06/2023] Open
Abstract
Introduction A proactive approach is recommended in colorectal anastomosis leak treatment, and early diagnosis is very important. Early postoperative endoscopy would allow rapid diagnosis of anastomotic pathologies and consequent prompt intervention according to anastomotic disruption morphology. Aim To evaluate the effectiveness of close endoscopic follow-up of all patients (including asymptomatic ones) in improving diagnosis of acute leak (AL) and reducing its complications. Material and methods This study included 124 patients who had undergone rectum resection for rectal cancer with stapled anastomosis. Endoscopy was performed between the 7th and 10th postoperative day and 1 month postoperatively. For defect morphology assessment, a classification system was created based on four levels of severity. Photographic findings were evaluated by an independent, experienced gastroenterologist. Results Postoperative endoscopy revealed 28 (22.6%) patients with acute leakage. Initial endoscopy confirmed AL in 18 patients. Six (31.6%) patients were asymptomatic and 13 (68.4%) were symptomatic. The second endoscopy revealed another 9 (32.1%) leaks (4 (44.5%) asymptomatic and 5 (55.5%) symptomatic). Sixteen (57.1%) patients had grade A leakages, 7 (25.0%) had grade B leakages, and 5 (17.9%) had grade C leakages. Furthermore, 22 of 27 (81%) defects were located posterior and posterior-laterally. Fifteen (55.5%) defects were smaller than 1/3 the circumference, 7 (25.9%) affected 1/3–1/2 of the circumference, and 5 (18.5%) affected more than 1/2 of the circumference. Conclusions Incorporation of early endoscopy in postoperative management allows rapid diagnosis of AL and allows faster intervention, even in leaks that are clinically silent.
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10
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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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