Transanal colorectal resection using natural orifice translumenal endoscopic surgery (NOTES)

State of the Art: Pouch Surgery in the 21st Century

BACKGROUND

An ileoanal pouch with IPAA is the preferred method to restore intestinal continuity in patients who require a total proctocolectomy. Pouch surgery has evolved during the past decades thanks to increased experience and research, changes in the medical management of patients who require an ileal pouch, and technological innovations.

OBJECTIVE

To review the main changes in pouch surgery over the past 2 decades, with a focus on staging, minimally invasive and transanal approaches, pouch design, and anastomotic configuration.

RESULTS

The decision on the staging approach depends on the patient's conditions, their indication for surgery, and the risk of anastomotic leak. A minimally invasive approach should be performed whenever feasible, but open surgery still has a role in this technically demanding operation. Transanal IPAA may be performed in experienced centers and may reduce conversion to open surgery in the hostile pelvis. The J-pouch is the easiest, fastest, and most commonly performed design, but other designs may be used when a J-pouch is not feasible. A stapled anastomosis without mucosectomy can be safely performed in the majority of cases, with a low incidence of rectal cuff neoplasia and better functional outcomes than handsewn. Finally, Crohn's disease is not an absolute contraindication to an ileoanal pouch, but pouch failure may be higher compared to other indications.

CONCLUSIONS

Many technical nuances contribute to the success of an ileoanal pouch. The current standard of care is a laparoscopic J-pouch with double-stapled anastomosis, but this should not be seen as a dogma, and the optimal approach and design should be tailored to each patient. See video from symposium.

Locally Advanced Rectal Cancer: What We Learned in the Last Two Decades and the Future Perspectives

The advancement in surgical techniques, optimization of systemic chemoradiotherapy, and development of refined diagnostic and imaging modalities have brought a phenomenal shift in the treatment of the locally advanced rectal cancer. Although each therapeutic option has shown substantial progress in their field, it is finding their ideal amalgamation which has baffled the clinician and researchers alike. In the effort to identifying the perfect salutary treatment plan, we have even shifted our attention from the trimodal approach to non-operative "watchful waiting" to more recent individualized care. In this article, we acknowledge the scientific progress in the management of locally advanced rectal cancer and compare the opportunities as well as the obstacles while implementing them clinically. We also explore the current challenges and controversies surrounding the multidisciplinary approach and highlight the new trends and recent advances with an ultimate goal to improve the patients' quality of life.

Transanal Total Mesorectal Excision for Malignant Rectal Lesion: A Prospective Cohort Study

AIMS: The main outcome of this study was to use the transanal total mesorectal excision (TaTME) technique for rectal cancer resection and to assess as a primary endpoint the short-term oncological outcome; in terms of circumferential resection margin, longitudinal resection margins (proximally and distally), and lymph nodes (LN) retrieval, while secondary endpoints were operative time, estimated blood loss, length of hospital stay, cost per case, and overall complication rate. METHODS: This was a prospective cohort study. Forty patients were included and subjected to TaTME from May 2018 to January 2020 and patients were followed up for a period of 6 months. RESULTS: Primary endpoint: Depending on the post-operative specimen pathological assessment; circumferential resection margin (CRM) was free in all patients, proximal resection margins had a mean 14.37 2.87 cm, distal resection margins had a mean 2.08 ± 0.4 cm and LNs retrieval had a mean 13.27 ± 5.9, and number of positive LNs had a mean 2.40 ± 3.77. Secondary endpoints: Mean total operative time (from induction of anesthesia till skin closure) was 179.10, estimated blood loss (using gauze visual analog plus what was obtained in the OR suction device) was 133.67 66.59 ml, the length of hospital stay (admission till discharge) was 5.27 ± 1.08 days, cost per case had a mean (in 1000 USD) 2.95 ± 0.12, and overall complication rate was 10%. CONCLUSION: TaTME represents a promising complementary technique to laparoscopic TME in the step of low rectal dissection.

Early Experience With Transanal Total Mesorectal Excision Compared With Laparoscopic Total Mesorectal Excision for Rectal Cancer: A Propensity Score-Matched Analysis

BACKGROUND

Laparoscopic total mesorectal excision is widely used for rectal cancers; however, it is sometimes challenging, especially in obese patients with low tumors, particularly after chemoradiotherapy. Transanal total mesorectal excision was developed to overcome these limitations in terms of visualization, dissection, and stapling.

OBJECTIVE

The purpose of this study was to compare the pathologic and early oncologic outcomes of the laparoscopic and transanal approaches.

DESIGN

This was a retrospective comparative study using propensity score-matched analysis.

SETTING

The study was conducted at a tertiary hospital specializing in oncology.

PATIENTS

In total, 722 inpatients who underwent total mesorectal excision for rectal cancer from January 2014 to December 2017 were included.

INTERVENTIONS

Laparoscopic (N = 514) and transanal (N = 208) total mesorectal excision were performed.

MAIN OUTCOME MEASURES

The primary outcome was pathologic outcome including circumferential and distal resection margin involvement. The secondary outcomes were intraoperative and postoperative complications and overall survival, recurrence-free survival, and local recurrence rates.

RESULTS

The 2 groups of the cohort had several differences; thus, we performed propensity score matching. The circumferential resection margin was involved in 13.4% and 12.9% of the laparoscopic and transanal groups (p = 0.88). The distal resection margin was involved in 1% and 3% of the laparoscopic and transanal groups (p = 0.28). Complete or nearly complete total mesorectal excision was 98.0% and 96.5% in the laparoscopic and transanal groups (p = 0.41). Postoperative complications with Clavien-Dindo grade III or higher did not differ significantly between groups (p = 0.54) but were significantly higher in patients with tumors <5 cm from the anal verge who underwent laparoscopy (laparoscopic group = 11.9%; transanal group = 1.7%; p = 0.04). There were no statistical differences in the 3-year overall survival, recurrence-free survival, or local recurrence rates between groups.

LIMITATIONS

This was a retrospective study design with a short follow-up period.

CONCLUSIONS

Early experience with the transanal approach showed similar pathologic outcomes as those of conventional laparoscopy; hence, it should be considered as a surgical option for lower rectal cancer. See Video Abstract at http://links.lww.com/DCR/B352. EXPERIENCIA TEMPRANA CON LA ESCISIÓN MESORRECTAL TOTAL TRANSANAL EN COMPARACIÓN CON LA ESCISIÓN MESORRECTAL TOTAL LAPAROSCÓPICA PARA EL CÁNCER DE RECTO: UN ANÁLISIS DE PUNTUACIÓN DE PROPENSIÓN: La escisión mesorrectal total laparoscópica se usa ampliamente para los cánceres rectales; Sin embargo, a veces es un desafío, especialmente en pacientes obesos con tumores bajos, particularmente después de la quimiorradioterapia. La escisión mesorrectal total transanal se desarrolló para superar estas limitaciones en términos de visualización, disección y grapado.Comparar los resultados patológicos y oncológicos precoces de los enfoques laparoscópico y transanal.estudio comparativo retrospectivo con puntaje de propensión-análisis emparejadoHospital terciario especializado en oncología.En total, se incluyeron 722 pacientes hospitalizados que se sometieron a una escisión mesorrectal total por cáncer rectal desde Enero de 2014 hasta Diciembre de 2017.Se realizó escisión mesorrectal total laparoscópica (n = 514) y transanal (n = 208).El resultado primario fue el resultado patológico, incluyendo el involucramiento del margen de resección circunferencial y distal. Los resultados secundarios fueron complicaciones intraoperatorias, postoperatorias y supervivencia general, supervivencia libre de recurrencia y tasas de recurrencia local.Los dos grupos de la cohorte tuvieron varias diferencias; así, realizamos un emparejamiento de puntuación de propensión. El margen de resección circunferencial estuvo involucrado en 13.4% y 12.9% de los grupos laparoscópico y transanal, respectivamente (p = 0.88). El margen de resección distal estuvo involucrado en 1% y 3% de los grupos laparoscópico y transanal, respectivamente (p = 0.28). La escisión mesorrectal total completa o casi completa fue de 98.0% y 96.5% en los grupos laparoscópico y transanal, respectivamente (p = 0.41). Las complicaciones postoperatorias con Clavien-Dindo grado ≥ III no difirieron significativamente entre los grupos (p = 0,54), pero fueron significativamente mayores en pacientes con tumores de < 5 cm del borde anal que se sometieron a laparoscopia (grupo laparoscópico, 11,9%; grupo transanal, 1,7%; p = 0,04). No hubo diferencias estadísticas en la supervivencia general a 3 años, la supervivencia libre de recurrencia y las tasas de recurrencia local entre los grupos.Diseño de estudio retrospectivo, corto período de seguimiento.La experiencia temprana con el enfoque transanal mostró resultados patológicos similares a los de la laparoscopia convencional; por lo tanto, debe considerarse como una opción quirúrgica para el cáncer rectal mas bajo. Consulte Video Resumen en http://links.lww.com/DCR/B352. (Traducción-Dr Yesenia Rojas-Khalil).

Feasibility of laparoscopic-assisted transanal pelvic exenteration in locally advanced rectal cancer with anterior invasion

BACKGROUND

Transanal (Ta) pelvic exenteration is a promising, minimally invasive method for treating locally advanced colorectal cancer. However, since it is technically difficult to perform, Ta pelvic exenteration is rarely reported in locally advanced T4 rectal cancer cases. The aim of this study was to evaluate the feasibility of transabdominal laparoscopy-assisted Ta pelvic exenteration.

METHODS

Six patients (4 males and 2 females) had laparoscopy-assisted Ta total or posterior pelvic exenteration for locally advanced or recurrent colorectal cancer cases at the Nagasaki University Hospital between September 2018 and August 2019. Clinical and pathological outcomes were measured and analyzed.

RESULTS

The median operation time and intraoperative blood loss were 481 (range 456-709) minutes and 352.5 (range 257-1660) ml, respectively. R0 resection was achieved in all cases, and no patient required open surgery. Two patients had grade 3 complications (Clavien-Dindo) or higher. There was no mortality, and no reoperation was required.

CONCLUSIONS

The results suggest that laparoscopic-assisted Ta pelvic exenteration is an acceptable procedure, may help overcome the current technical difficulties, and may improve outcomes in patients with locally advanced rectal cancer.

Transanal total mesorectal excision (TaTME) using flexible endoscope with laparoscopic assistance: a pilot study in porcine models

BACKGROUND

Transanal total mesorectal excision (TaTME) is routinely performed to excise low rectal tumors. TaTME often relies on transanal endoscopic microsurgery (TEM) or transanal minimally invasive surgery (TAMIS) platform, all using rigid endoscopes. Our study reported a novel approach to TaTME which was completed using flexible endoscope, and we named it F-TaTME.

METHODS

The feasibility of rectum resection using F-TaTME was evaluated in five pigs. Firstly, the superior rectal artery and vein were managed under the assistance of laparoscopy. Secondly, the flexible endoscope was used to complete the full-thickness rectotomy and rectal mobilization. Finally, the specimen was removed and the manual colon-rectal anastomosis was performed under direct vision.

RESULTS

F-TaTME was accomplished in all 5 pigs. The mean procedure time was 136.6 min (97-162 min). The mean length from the lower edge of the lesion to circumferential dissection line was 1.4 cm (1.0-1.8 cm) and mean length of exteriorized rectum was 12.6 cm (11-14 cm). No injury to colorectal wall, adjacent pelvic or abdominal organs was found.

CONCLUSIONS

Our preliminary data suggested that F-TaTME may be a feasible method for TaTME.

Laparoscopy-Assisted Natural Orifice Specimen Extraction to Treat Tumors of the Sigmoid Colon and Rectum: The Short- and Long-Term Outcomes of a Retrospective Study

Background: Few studies have assessed the short- and long-term outcomes of laparoscopically assisted natural orifice specimen extraction (NOSE) in patients with sigmoid colon and rectal tumors. We investigated the short- and long-term outcomes of patients undergoing laparoscopic-assisted NOSE for tumors of the sigmoid colon and rectum. Methods: Ninety-eight patients with sigmoid colon and rectal tumors undergoing laparoscopic-assisted NOSE were included. The tumor was classified according to its distance from the anal verge: Group 1 (15-30 cm), Group 2 (5-15 cm), and Group 3 (≤5 cm). In Group 1 patients, a laparoscopic surgical specimen collection bag was used as a special transrectal device. In Group 2 patients, transanal endoscopic microsurgery device and specimen collection bag were used. In Group 3 patients, a Lone-Star retractor was used. The demographic characteristics and intra- and postoperative outcomes were measured. Results: In Group 1, 1 patient had respiratory disease and 1 had enterocolitis as short-term postoperative complications. One patient showed intestinal obstruction as a long-term postoperative complication. In Group 2, 2 patients had an ileus, 1 had an anastomotic leak, 2 had urinary retention, and 1 had respiratory disease as short-term complications. Only one patient had a long-term complication: anastomotic stenosis. In Group 3, short-term complications were present in 3 patients: 1 had hemorrhage, 1 had urinary retention, and 1 had respiratory disease. Long-term complications included one case of anastomotic stenosis and one of intestinal obstruction. Conclusions: NOSE is safe and cosmetically and theoretically superior to conventional laparoscopy when different devices are used according to the tumor's location.

Transluminal Cancer Surgery

Transluminal surgery, also known as natural orifices endoluminal surgery, can be considered the most minimally invasive approach of gaining access to an organ. Although some approaches, such as transgastric or transvaginal cholecystectomy, have remained experimental, peroral endoscopic myotomy to treat achalasia and transanal total mesorectal excision to treat low rectal cancer have become accepted, safe, and feasible approaches by trained surgeons for selected patients. This article recapitulates the development of transluminal surgery from its experimental beginnings to the validated procedure it has become today.

Transanal total mesorectal excision for rectal cancer: state of the art

Achieving a high-quality total mesorectal excision (TME) resection specimen is a central tenet of curative rectal cancer management. However, operating at the caudal extremity of the pelvis is inherently challenging and a number of patient- and tumour-related factors may increase the risk of obtaining a poor TME specimen and positive resection margins. Transanal TME (TaTME) is an advanced surgical technique developed to overcome the limitations in pelvic exposure and instrumentation of transabdominal surgery. This up-to-date narrative review describes the evolution of TME surgery, the indications for TaTME, current published outcomes, its limitations and future developments.

Natural orifice transluminal endoscopic surgery for colorectal cancer

Background

Natural orifice transluminal endoscopic surgery (NOTES) has theoretical advantages over other approaches.

Methods

This was a prospective cohort study of colorectal cancers operated on by NOTES (transanally for rectal tumours, transvaginally for sigmoid tumours) between December 2013 and December 2015, with a minimum follow‐up of 1 year. Eligibility criteria included ASA fitness grade I–III, BMI below 25 kg/m² and TNM stage T3 N0 M0. Exclusion criteria included pregnancy or distant metastasis. The anastomosis was either handsewn or performed mechanically.

Results

Sixteen patients were operated on by a transanal and four by a transvaginal approach. There were ten men and ten women, with a mean(s.d.) age of 55·6(12·1) years. Mean BMI was 22·4(2·6) kg/m². Four anterior, 11 low anterior and five intersphincteric resections were performed for 16 rectal and four low sigmoid tumours. The mean duration of surgery was 258(11) min. No conversion to laparotomy was needed, and there were no deaths. Five patients required additional ports, for intraoperative bleeding (1), suture of an intraoperative urethral injury with covering ileostomy (1) and difficulty in dissection (3). One patient had an anastomotic leak requiring transanal closure and ileostomy on day 7. Both ileostomies were closed after 2 months. The mean hospital stay was 6·4(1·8) days. All resections were R0.

Conclusion

In carefully selected patients NOTES for colorectal cancer resection was feasible and effective.

Needlescopic versus conventional laparoscopic surgery for colorectal cancer ~a comparative study~

Objectives: This study set out to determine whether Needlescopic surgery (NS) produces comparable surgical outcomes for patients with colorectal cancer (CRC) compared to conventional multi-port laparoscopic surgery (MPS). Methods: We used the five-port method with a 3.5 cm umbilical incision for extraction and reconstruction during MPS for CRC. One or two 5 mm ports were exchanged for needle forceps and all surgical procedures were as for previous MPS since July 2012. We investigated the short-term outcomes of 138 consecutive patients who underwent curative resection of CRC by NS (July 2012-August 2014) and 130 consecutive patients with CRC treated with MPS during a previous period (January 2010-June 2012). Results: Operative time in the NS group was comparable to that of MPS (p=0.467); the NS group had significantly less estimated blood loss (p=0.002) and a shorter postoperative hospital stay (p<0.001). The mean number of dissected lymph nodes was 27 in both groups (p=0.730). No mortality occurred in either group, and similar morbidity rates were observed (p=0.454). Conclusions: NS using Endo Relief needle forceps is a safe and feasible option compared to conventional MPS for CRC.

Feasibility of transanal total mesorectal excision in cases with challenging patient and tumor characteristics

Purpose

To assess the feasibility of transanal total mesorectal excision in difficult cases including obese patients or patients with bulky tumors or threatened mesorectal fascias.

Methods

We performed laparoscopy-assisted transanal total mesorectal excision in patients with biopsy-proven rectal adenocarcinoma located 3–12 cm from the anal verge as part of a prospective, single arm, pilot trial. The primary endpoint was resection quality and circumferential resection margin involvement. Secondary endpoints included the number of harvested lymph nodes and 30-day postoperative complications.

Results

A total of 12 patients (9 men and 3 women) were enrolled: one obese patient, 7 with large tumors and 8 with threatened mesorectal fascias (4 patients had multiple indications). Tumors were located a median of 5.5 cm from the anal verge, and all patients received preoperative chemoradiotherapy. Median operating time was 191 minutes, and there were no intraoperative complications. One patient needed conversion to open surgery for ureterocystostomy after en bloc resection. Complete or near-complete excision and negative circumferential resection margins were achieved in all cases. The median number of harvested lymph nodes was 15.5. There was no postoperative mortality and 3 cases of postoperative morbidity (1 postoperative ileus, 1 wound problem near the stoma site, and 1 anastomotic dehiscence).

Conclusion

This pilot study showed that transanal total mesorectal excision is also feasible in difficult laparoscopic cases such as in obese patients or those with bulky tumors or tumors threatening the mesorectal fascia. Additional larger studies are needed.

Clinical outcomes and case volume effect of transanal total mesorectal excision for rectal cancer: a systematic review

Transanal total mesorectal excision (TaTME) has been developed to improve quality of TME for patients with mid and low rectal cancer. However, despite enthusiastic uptake and teaching facilities, concern exists for safe introduction. TaTME is a complex procedure and potentially a learning curve will hamper clinical outcome. With this systematic review, we aim to provide data regarding morbidity and safety of TaTME. A systematic literature search was performed in MEDLINE (PubMed), EMBASE (Ovid) and Cochrane Library. Case reports, cohort series and comparative series on TaTME for rectal cancer were included. To evaluate a potential effect of case volume, low-volume centres (n ≤ 30 total volume) were compared with high-volume centres (n > 30 total volume). Thirty-three studies were identified (three case reports, 25 case series, five comparative studies), including 794 patients. Conversion was performed in 3.0% of the procedures. The complication rate was 40.3, and 11.5% were major complications. The quality of the mesorectum was “complete” in 87.6%, and the circumferential resection margin (CRM) was involved in 4.7%. In low- versus high-volume centres, the conversion rate was 4.3 versus 2.7%, and major complication rates were 12.2 versus 10.5%, respectively. TME quality was “complete” in 80.5 versus 89.7%, and CRM involvement was 4.8 and 4.5% in low- versus high-volume centres, respectively. TaTME for mid and low rectal cancer is a promising technique; however, it is associated with considerable morbidity. Safe implementation of the TaTME should include proctoring and quality assurance preferably within a trial setting.

Feasibility of transanal endoscopic total mesorectal excision for rectal cancer: results of a pilot study

Purpose

To evaluate the feasibility of transanal total mesorectal excision (TME) in patients with rectal cancer.

Methods

This study enrolled 12 patients with clinically node negative rectal cancer located 4–12 cm from the anal verge who underwent transanal endoscopic TME with the assistance of single port laparoscopic surgery between September 2013 and August 2014. The primary endpoint was TME quality; secondary endpoints included number of harvested lymph nodes and postoperative complications within 30 days (NCT01938027).

Results

The 12 patients included 7 males and 5 females, of median age 59 years and median body mass index 24.2 kg/m². Tumors were located on average 6.7 cm from the anal verge. Four patients (33.3%) received preoperative chemoradiotherapy. Median operating time was 195 minutes and median blood loss was 50 mL. There were no intraoperative complications and no conversions to open surgery. TME was complete or nearly complete in 11 patients (91.7%). Median distal resection and circumferential resection margins were 18.5 mm and 10 mm, respectively. Median number of harvested lymph nodes was 15. Median length of hospital stay was 9 days. There were no postoperative deaths. Six patients experienced minor postoperative complications, including urinary dysfunction in 2, transient ileus in 3, and wound abscess in 1.

Conclusion

This pilot study showed that high-quality TME was possible in most patients without serious complications. Transanal TME for patients with rectal cancer may be feasible and safe, but further investigations are necessary to evaluate its long-term functional and oncologic outcomes and to clarify its indications.

Comparison of short-term clinical outcomes between transanal and laparoscopic total mesorectal excision for the treatment of mid and low rectal cancer: A meta-analysis

AIM

The objective of this meta-analysis was to evaluate the feasibility, safety, and short-term clinical outcomes of transanal total mesorectal excision (TaTME) comparing with laparoscopy total mesorectal excision (LapTME) for mid and low rectal cancer.

METHODS

Relevant studies were searched from the databases of Pubmed, Embase, and the Cochrane Library. The qualities of all of the included studies were evaluated using Newcastle-Ottawa Scale (NOS). The synthesized outcomes were pooled using fixed-effects models or random-effects models, which weighted the odds ratio (OR) or mean difference (MD) with 95% confidence intervals (95% CI). A funnel plot was used to evaluate the publication bias.

RESULTS

Seven original studies including 209 TaTME patients and 257 LapTME patients with rectal cancer met the inclusion criteria in this meta-analysis. Compared with LapTME, TaTME showed a longer CRM, lower rate of positive CRM, complete TME rate, and less operative time. There were no significant differences in the outcomes of the harvested lymph nodes, distal margin distance, hospital stay, intraoperative complications, anastomotic leakage, postoperative complications, reoperation, readmission, or conversion between the TaTME group and the LapTME group.

CONCLUSIONS

Compared with LapTME, TaTME is a feasible and safe approach for patients with mid and low rectal cancer. In addition, TaTME showed a better short-term clinical outcomes, such as a longer CRM, lower risk of positive CRM, higher complete quality of TME rate, and shorter operative duration. Further prospective studies with long-term follow-up are required.

A Systematic Review of Outcomes After Transanal Mesorectal Resection for Rectal Cancer

BACKGROUND

Transanal mesorectal resection has been developed to facilitate minimally invasive proctectomy for rectal cancer.

OBJECTIVE

The purpose of this study was to evaluate the evidence regarding technical parameters, oncological outcomes, morbidity, and mortality after transanal mesorectal resection.

DATA SOURCES

The Cochrane Library, PubMed, and MEDLINE databases were reviewed.

STUDY SELECTION

Systematic review of the literature from January 2005 to September 2015 was used for study selection.

INTERVENTION

Intervention included transanal mesorectal resection for rectal cancer.

MAIN OUTCOME MEASURES

Technical parameters, histological outcomes, morbidity, and mortality were the outcomes measured.

RESULTS

Fifteen predominately retrospective studies involving 449 patients were included (mean age, 64.3 years; 64.1% men). Different platforms were used. The operative mortality rate was 0.4% and the cumulative morbidity rate 35.5%. Circumferential resection margins were clear in 98%, and the resected mesorectum was grade III in 87% of patients. Median follow-up was 14.7 months. There were 4 local recurrences (1.5%) and 12 patients (5.6%) with metastatic disease. No study followed patients long enough to report on 5-year overall and disease-free survival rates. Functional outcome was only reported in 3 studies.

LIMITATIONS

A low number of procedures were performed by expert early adopters. There are no comparative or randomized data included in this study and inconsistent reporting of outcome variables.

CONCLUSIONS

Transanal mesorectal resection for rectal cancer may enhance negative circumferential margin rates with a reasonable safety profile. Contemporary randomized, controlled studies are required before there can be universal recommendation.

Pure Natural Orifice Transluminal Endoscopic Surgery (NOTES) with a new elongated, curved Transanal Endoscopic Operation (TEO) device for rectosigmoid resection: a survival study in a porcine model

BACKGROUND

Natural orifice transluminal endoscopic surgery (NOTES) has seen considerable new developments in its evolution to a platform for rectal and sigmoid resection, but to date no true single NOTES procedure has been convincing. This study investigates the safety and feasibility of a further developed transanal NOTES platform for single-access NOTES rectosigmoid resection.

METHODS

Ten large female pigs, mean weight 99.3 kg [standard deviation (SD) 7 kg, range 85.1-112.6 kg], underwent transanal rectosigmoid resection. Five animals were included in an acute study group with immediate postoperative euthanization. A second group included five animals in a survival study. Transanal rectosigmoid resections were performed with an elongated and curved transanal endoscopic operation (TEO) device. Coloanal anastomosis was performed using the transanal circular stapler technique. Survival follow-up was at 7 and 28 days via colonoscopy under sedation.

RESULTS

Single-access NOTES transanal rectosigmoid resection with coloanal anastomosis was performed in nine out of ten female pigs. Mean length of rectosigmoid specimens exteriorized was 18.7 cm (SD 2.9 cm, range 14-23 cm). Mean operating time was 124 min (SD 35.7 min, range 70-166 min). Within the survival group, no complications occurred during the monitoring phase. In one case, there was ascites and colitis at necropsy as well as fibrosis at the anastomosis site.

CONCLUSIONS

Pure transanal rectosigmoid resection is a feasible procedure. The approach via a single transanal access is demanding but viable with the elongated and curved TEO device. The newly developed scope offers an excellent view of the area cephalad to the promontory.

Transanal Minimally Invasive Surgery: State of the Art

The treatment for rectal cancer and benign rectal lesions continues to progress in the arena of minimally invasive surgery. While surgical excision of the primary mass remains essential for eradication of disease, there has been a paradigm shift towards less invasive resection methods. Local excision is increasing in popularity for its low morbidity and excellent functional results in select patients. Transanal minimally invasive surgery (TAMIS) is a new technology developed to elevate the practice of local excision to state-of-the-art resection. The goal of this article is to evaluate the history, short-term outcomes, and evolution of the TAMIS technique for excision of benign and malignant rectal neoplasia.

Laparoscopic colorectal surgery: Current status and implementation of the latest technological innovations

The introduction of laparoscopy is an example of surgical innovation with a rapid implementation in many areas of surgery. A large number of controlled studies and meta-analyses have shown that laparoscopic colorectal surgery is associated with the same benefits than other minimally invasive procedures, including lesser pain, earlier recovery of bowel transit and shorter hospital stay. On the other hand, despite initial concerns about oncological safety, well-designed prospective randomized multicentre trials have demonstrated that oncological outcomes of laparoscopy and open surgery are similar. Although the use of laparoscopy in colorectal surgery has increased in recent years, the percentages of patients treated with surgery using minimally invasive techniques are still reduced and there are also substantial differences among centres. It has been argued that the limiting factor for the use of laparoscopic procedures is the number of surgeons with adequate skills to perform a laparoscopic colectomy rather than the tumour of patients’ characteristics. In this regard, future efforts to increase the use of laparoscopic techniques in colorectal surgery will necessarily require more efforts in teaching surgeons. We here present a review of recent controversies of the use of laparoscopy in colorectal surgery, such as in rectal cancer operations, the possibility of reproducing complete mesocolon excision, and the benefits of intra-corporeal anastomosis after right hemicolectomy. We also describe the results of latest innovations such as single incision laparoscopic surgery, robotic surgery and natural orifice transluminal endoscopic surgery for colon and rectal diseases.

Current status of trans-anal total mesorectal excision (TaTME) following the Second International Consensus Conference

This article documents the consensus of an expert group of surgeons from the Second International Trans-anal Total Mesorectal Excision (TaTME) Conference held in Paris in July 2014. It outlines three facets of the TaTME procedure: (i) the technique and its indications, (ii) training and adoption, and (iii) data collection and the TaTME registry.

A systematic review of transanal total mesorectal excision: is this the future of rectal cancer surgery?

AIM

The surgical technique used for transanal total mesorectal excision (TaTME) was reviewed including the oncological quality of resection and the peri-operative outcome.

METHOD

A literature search of MEDLINE, Embase, Science Citation Index Expanded and Cochrane was performed in order to identify studies reporting on TaTME.

RESULTS

Thirty-six studies (eight case reports, 24 case series and four comparative studies) were identified, reporting 510 patients who underwent TaTME. The mean age ranged from 43 to 80 years and the mean body mass index from 21.7 to 31.8 kg/m(2) . The mean distance of the tumour from the anal verge ranged from 4 to 9.7 cm. The mean operation time ranged from 143 to 450 min and mean operative blood loss from 22 to 225 ml. The ratio of hand-sewn coloanal to stapled anastomoses performed was 2:1. One death was reported and the peri-operative morbidity rate was 35%. The anastomotic leakage rate was 6.1% and the reoperation rate was 3.7%. The mean hospital stay ranged from 4.3 to 16.6 days. The mesorectal excision was described as complete in 88% cases, nearly complete in 6% and incomplete in 6%. The circumferential resection margin was negative in 95% of cases and the distal resection margin was negative in 99.7%.

CONCLUSION

TaTME is a feasible and reproducible technique, with good quality of oncological resection. Standardization of the technique is required with formal training. Clear indications for this procedure need to be defined and its safety further assessed in future trials.

Transanal total mesorectal excision: A valid option for rectal cancer?

Low anterior resection can be a challenging operation, especially in obese male patients and in particular after radiotherapy. Transanal total mesorectal excision (TaTME) might offer technical advantages over laparoscopic or open approaches particularly for tumors in the distal third of the rectum. The aim of this article is to review the current experience with TaTME. The limits and future developments are also explored. Although the experience with TaTME is still limited, it might be a promising alternative to laparoscopic TME, especially for difficult cases where laparoscopy is too demanding. The preliminary data on complications and short-term oncological outcomes are good, but also emphasize the importance of careful patient selection. Finally, there is a need for large-scale trials focusing on long-term outcomes and oncological safety before widespread adoption can be recommended.

Shifting Paradigms in Minimally Invasive Surgery: Applications of Transanal Natural Orifice Transluminal Endoscopic Surgery in Colorectal Surgery

Since the advent of laparoscopy, minimally invasive techniques such as single port laparoscopy, robotics, endoscopically assisted laparoscopy, and transanal endoscopic surgery continue to revolutionize the field of colorectal surgery. Transanal natural orifice transluminal endoscopic surgery (NOTES) represents a further paradigm shift by combining the advantages of these earlier techniques to reduce the size and number of abdominal incisions and potentially optimize rectal dissection, especially with respect to performance of an oncologically adequate total mesorectal excision (TME) for rectal cancer. Since the first experimental report of transanal rectosigmoid resection in 2007, the potential impact of transanal NOTES in colorectal surgery has been extensively investigated in experimental models and recently transitioned to clinical application. There have been 14 clinical trials of transanal TME (taTME) for rectal cancer that have demonstrated the feasibility and preliminary oncologic safety of this approach in carefully selected patients, with results comparable to outcomes after laparoscopic and open TME, including cumulative intraoperative and postoperative complication rates of 5.5 and 35.5%, respectively, 97.3% rate of complete or near-complete specimens, and 93.6% rate of negative margins. Transanal NOTES has also been safely applied to proctectomy and colectomy for benign indications. The consensus among published series suggests that taTME is most safely performed with transabdominal assistance by surgeons experienced with laparoscopic TME, transanal endoscopic surgery, and sphincter-preserving techniques including intersphincteric resection. Future applications of transanal NOTES may include evolution to a pure endoscopic transanal approach for TME, colectomy, and sentinel lymph node biopsy for rectal cancer, with a potential role for robotic assistance.

Transanal total mesorectal excision for rectal cancer: a preliminary report

BACKGROUND

Currently, the majority cases of the novel down-to-up transanal total mesorectal excision (TaTME) were performed in a hybrid approach with conventional laparoscopic assistance because of less operative difficulty. However, although cases are limited, the successes of TaTME in a pure approach (without laparoscopic assistance) indicate that the costly and less mini-invasive hybrid TaTME could be potentially avoided.

METHODS

In the present single institutional, prospective study, we attempted to demonstrate the safety and feasibility of this approach in rectal cancer by evaluating the short-term results of our first 20 TaTME cases. For the majority of cases, we adopted a strategy that laparoscopic assistance was not introduced unless it was required during the planned pure TaTME procedure.

RESULTS

A total of 20 patients (12 males and 8 females) were analyzed in this study, including 11 cases (55 %) of pure TaTME and 9 cases (45 %) of hybrid TaTME. Overall, the median operative time was 200 min (range 70-420), along with a median estimated blood loss of 50 ml (range 20-800). Morbidity rate was 20 % (one urethral injury, two urinary retentions, one anastomotic hemorrhage and one mild anastomotic leak). The median number of harvested lymph nodes was 12 (range 1-20). All specimens were intact in mesorectum without positive distal and circumferential resection margins. Among the 15 patients who were preoperatively scheduled to undertake pure TaTME, four patients (26.7 %) required converting to laparoscopic assistance. Moreover, among these 15 patients, the results of the comparative analysis between female and male subgroups favor the former, suggesting easier operation in them.

CONCLUSION

This preliminary study demonstrates that TaTME in rectal cancer is safe and feasible. The strategy of not introducing laparoscopic assistance unless it is required while performing the planned pTaTME should be cautiously explored. Further studies with larger sample size and longer follow-up are warranted.

Transrectal Rigid-Hybrid Natural Orifice Translumenal Endoscopic Sigmoidectomy for Diverticular Disease: A Prospective Cohort Study

BACKGROUND

Our goal was to evaluate the feasibility of transrectal rigid hybrid natural orifice translumenal endoscopic surgery (NOTES) sigmoidectomy (trNS) in a series of consecutive prospective patients with diverticular disease. The NOTES for left colectomy offers patients reduced pain and easier recovery. Limited data are available for trNS, which is considered safe for various indications. However, the technique is not standardized, and patients in the reported series are highly selected.

STUDY DESIGN

Patients scheduled for trNS were entered into a prospective registry on an intention-to-treat basis. The primary endpoint was trNS feasibility, and secondary endpoints were morbidity, pain, length of stay, and inflammatory response. A medial-to-lateral dissection with full mobilization of the splenic flexure and total intracorporeal anastomosis was performed. The rectum was covered with a wound protector for transrectal extraction.

RESULTS

Of 95 elective sigmoidectomies, 81% (n = 77) were enrolled for either transvaginal NOTES resection (n = 37) or trNS (n = 40). There was no difference in body mass index or indication between patients undergoing laparoscopic-assisted sigmoidectomy (LAS), transvaginal resection, or trNS, although trNS patients were younger. Mainly because of a mismatch of bulky specimen and narrow pelvis, 17.5% of trNS were converted to LAS. Major morbidity was 10%, including 2 septic complications. During the study, the anastomosis technique was changed from double stapled end-to-end to side-to-end anastomosis.

CONCLUSIONS

Transrectal rigid hybrid natural orifice translumenal endoscopic sigmoidectomy is feasible and safe in a high proportion of unselected consecutive patients with diverticular disease undergoing elective treatment. Intracorporeal side-to-end anastomosis is the preferred technique, and trNS should be offered for elective sigmoidectomy presupposing advanced laparoscopic experience.

The new approach to the rectal cancer: 'down-to-up' double endolaparoscopic pelvic access. Preliminary evaluation of outcomes

Laparoscopic access in low anterior rectal resection is widely adopted, performing an 'up-to-down' dissection. The aim of this study is to present and analyze the outcomes of a novel surgical 'down-to-up' total mesorectal excision technique that could obviate to the well-known issues of the standard treatment. 18 suitable patients underwent double endolaparoscopic pelvic access (DEPA) 'down-to-up' technique. DEPA TME was completed in all patients, with intact mesorectum. Mean operative time was 365 min (range 280-510 min). The morbidity rate was 22%, including three radiologically detected leakage (grade A) and one pelvic abscess, requiring only a conservative management. Mortality rate at 30 and 90 days was 0%. Resection margins were negative in all patients. A median of 11 nodes (range 5-19) was retrieved per specimen. Mean length of hospital stay was 9 days (range 7-19 days). Patients were followed for an average of 14 months (range 0-42 months), with no recurrence. Despite exiguous patient's sample in this pilot study, transanal endoscopic TME with laparoscopic assistance seems to be feasible and safe, and is a promising alternative to open and laparoscopic TME. However, a conspicuous functional and oncologic long-term evaluation is required, before the widespread adoption could be recommended.

Transanal total mesorectal excision for rectal carcinoma: short-term outcomes and experience after 80 cases

BACKGROUND

Low anterior resection for distal and mid-rectal cancer is associated with high positive resection margins. Transanal total mesorectal excision (TaTME) is a new treatment in which the rectum is dissected transanally according to TME principles. The short-term results and oncological follow-up of the first 80 patients were described.

METHODS

Between June 2012 and September 2014, all patients in the Gelderse Vallei Hospital and the VU University Medical Center with histologically proven distal or mid-rectal carcinomas without evidence of distant metastases underwent TaTME. Patients with T4 tumors were excluded. Transanal mobilization was performed with the aid of a single port and endoscopic instruments according to TME criteria.

RESULTS

Eighty patients were operated in a period of 2 years. Laparotomy was recommended and performed in four patients. Postoperative morbidity was 39%. Ten (12%) complications were graded as severe (Clavien-Dindo grade 3, 4 and 5) and needed re-intervention. Median operative time was 204 min (range 91-447). Median hospital stay was 8 days (range 3-41). Specimens were graded as complete in 88% of the patients, nearly complete in 9% and incomplete in 3%. A positive circumferential resection margin (<2 mm) was observed in two patients. During the two and half years study period, a local recurrence was observed in two patients.

CONCLUSION

TaTME is a safe alternative to standard laparoscopic TME in selected low-risk patients with rectal carcinoma when treated by an experienced colorectal team. In the future, randomized trials are necessary to prove its oncological safety.

Laparoscopic anterior resection with transanal total mesorectal excision for rectal cancer: preliminary experience and impact on postoperative bowel function

AIM

Transanal total mesorectal excision (TME) and the "down-to-up" mobilization concept might be possible alternatives to the standard TME, particularly in cases of narrow pelvis or bulky tumors in obese patients. Our aim was to test the feasibility and safety of transanal TME and to evaluate its impact on short-term functional outcome.

SUBJECTS AND METHODS

Six consecutive patients with histologically proven low/middle rectal adenocarcinoma were prospectively enrolled. All patients underwent laparoscopic anterior resection with transanal TME. Intraoperative complications, postoperative morbidity, and oncologic adequacy of the surgical specimen were evaluated in all patients. A bowel function questionnaire using information from the Wexner's score continence grading scale was administered to all patients 1 week before surgery and 6 months following operation.

RESULTS

Laparoscopically assisted transanal TME was successful in all patients. Mean operative time was 236 minutes (range, 200-270 minutes). There were no intraoperative complications. The anastomotic leak rate was 16.6%. Clear distal and circumferential margins and proper lymphadenectomy were obtained in all surgical specimens (mean number of nodes harvested, 32; range, 19-68). In no patients was a major incontinence observed; the median (range) Wexner score at 6 months after surgery was 3 (1-7).

CONCLUSIONS

Transanal TME is safe and feasible. Preliminary outcomes meet oncologic criteria. Moreover, the transanal approach does not have an adverse impact on functional outcome. Further long-term evaluation of results and clinical trials should be performed.

Transanal Total Mesorectal Excision for Rectal Cancer: Outcomes after 140 Patients

BACKGROUND

The anatomic difficulties that we have to deal with in open surgery for rectal cancer have not been overcome with the laparoscopic approach. In the search for a solution, a change of concept arose: approaching the rectum from below. The main objectives of this study were to show the potential advantages of the hybrid transabdominal-transanal total mesorectal excision (taTME). This approach may improve quality of the mesorectal specimens. Second, proctectomy can be technically easier and more safely performed "down to up," which would result in shorter surgical times, lower conversion rates, and less morbidity.

STUDY DESIGN

A prospective series of hybrid taTME was conducted from October 2011 to November 2014.

RESULTS

During the study period, 140 procedures were performed. Mean operative time was 166 minutes. There were no conversions or intraoperative complications. Macroscopic quality assessment of the resected specimen was complete in 97.1% and nearly complete in 2.1%. Thirty-day morbidity was minor (Clavien-Dindo I + II) in 24.2% and major (Clavien-Dindo III + IV) in 10 %. No patient died within the first 30 days postsurgery (Clavien-Dindo V). The mean follow-up was 15 months, with a 2.3% local recurrence rate and a 7.6% rate of systemic recurrence.

CONCLUSIONS

Pathologic analysis showed a very good macroscopic quality of TME specimens, which is the most important prognostic factor in rectal cancer. Intraoperative outcomes regarding conversion, surgical times, and intraoperative complications are very satisfactory. Short-term morbidity and oncologic outcomes are as good as in other laparoscopic TME series.

Impact of technology on indications and limitations for transanal surgical removal of rectal neoplasms

Transanal surgery has and continues to be well accepted for local excision of benign rectal disease not amenable to endoscopic resection. More recently, there has been increasing interest in applying transanal surgery to local resection of early malignant disease. In addition, some groups have started utilizing a transanal route in order to accomplish total mesorectal excision (TME) for more advanced rectal malignancies. We aim to review the role of various transanal and endoscopic techniques in the local resection of benign and malignant rectal disease based on published trial data. Preliminary data on the use of transanal platforms to accomplish TME will also be highlighted. For endoscopically unresectable rectal adenomas, transanal surgery remains a widely accepted method with minimal morbidity that avoids the downsides of a major abdomino-pelvic operation. Transanal endoscopic microsurgery and transanal minimally invasive surgery offer improved visualization and magnification, allowing for finer and more precise dissection of more proximal and larger rectal lesions without compromising patient outcome. Some studies have demonstrated efficacy in utilizing transanal platforms in the surgical management of early rectal malignancies in selected patients. There is an overall higher recurrence rate with transanal surgery with the concern that neither chemoradiation nor salvage surgery may compensate for previous approach and correct the inferior outcome. Application of transanal platforms to accomplish transanal TME in a natural orifice fashion are still in their infancy and currently should be considered experimental. The current data demonstrate that transanal surgery remains an excellent option in the surgical management of benign rectal disease. However, care should be used when selecting patients with malignant disease. The application of transanal platforms continues to evolve. While the new uses of transanal platforms in TME for more advanced rectal malignancy are exciting, it is important to remain cognizant and not sacrifice long term survival for short term decrease in morbidity and improved cosmesis.

Topography of the extrinsic internal anal sphincter nerve supply during laparoscopic-assisted TAMIS TME: five key zones of risk from the surgeons' view

PURPOSE

Sparing the extrinsic autonomic innervation of the internal anal sphincter during total mesorectal excision is important for the preservation of anal sphincter function. This study electrophysiologically confirmed the topography of the internal anal sphincter nerve supply during laparoscopic-assisted transanal minimally invasive surgery for total mesorectal excision.

METHODS

This prospective study was conducted at two large multispecialty referral centers. Six patients (five males and one female) aged between 45 and 65 years with low rectal cancer (≤5 cm from the anal verge) were enrolled. Surgery was performed under electric stimulation of the pelvic autonomic nerves with observation of the electromyographic signals of the internal anal sphincter.

RESULTS

The minimally invasive transanal surgical approach enabled advantageous visualization of the pelvic autonomic nerves in all patients. In particular, extrinsic innervation to the internal anal sphincter near the levator muscle was consciously spared under electrophysiological confirmation. The evoked absolute electromyographic amplitudes of the internal anal sphincter during transanal minimally invasive surgery were significantly lower than the initial results of the laparoscopic approach [3.7 μV (interquartile range 2.4; 5.7) vs. 4.3 μV (interquartile range 3.1; 8.6); p = 0.002]. Five key zones of risk for pelvic autonomic nerve damage were identified. No complications occurred.

CONCLUSIONS

The electromyographic results of this preliminary study indicate advantages for sparing the internal anal sphincter innervation during transanal minimally invasive mesorectal dissection considering the specific in situ neuroanatomical topography.

Improving outcomes and cost-effectiveness of colorectal surgery

In order to truly make an impact on improving the cost effectiveness, and most importantly, the outcomes of patients undergoing colorectal surgery, all aspects of care need to be scrutinized, re-evaluated, and refined. To accomplish this, everything from the way we train surgeons to the adoption of a minimally invasive approach for colorectal disease, along with the use of adjunct intraoperative measures to decrease morbidity and mortality, may all need to be incorporated within an ERAS program. Only then will this approach lead the provider to a patient-centric care plan which can successfully reduce metrics such as morbidity, mortality, and length of stay (even with the obligatory readmission rate) and provide it all at a lower cost of care.

The evolving practice of hybrid natural orifice transluminal endoscopic surgery (NOTES) for rectal cancer

BACKGROUND

Natural orifice transluminal endoscopic surgery (NOTES) has emerged as the area of focus in laparoscopic surgery. Hybrid NOTES (hNOTES) has some potential advantages for treating rectal cancer.

METHODS

Between May 2013 and November 2013, a total of 20 patients (11 males) who received hNOTES at two institutes participating in the study were documented and reviewed. Surgical outcomes, including complications and pathological outcomes, were analyzed.

RESULTS

The mean age of patients was 57.8 ± 10.1 years (range 34-78). Eleven patients received preoperative neoadjuvant chemoradiotherapy, with the mean distance between tumor and anal verge being 5.9 ± 1.7 cm (mean 2-8). The mean estimated intraoperative blood loss was 68 ± 106 ml (range 30-500), with one case converted to open procedure due to uncontrolled bleeding. Eight cases underwent simultaneous two-team approach. The mean operative time was 200.8 ± 47.7 min (range 110-285). Circular stapling was performed for 14 cases (70 %) as the anastomosis, and protective stoma performed for 17 cases (85 %). The overall postoperative complication rate was 25 %. Two cases (10 %) develop pelvic abscess due to leakage, which were controlled by medical treatments. The distal and circumferential margins were all free of tumor cells, and the mean distal margin length was 2.4 ± 0.98 cm (range 0.5-4).

CONCLUSIONS

Hybrid NOTES for rectal cancer is safe and feasible. Rapid experience-building accelerates its evolution, as reflected here by the high stapling rate and the idea of a two-team approach. It has the potential to become an option of treating rectal cancers.

Future directions in surgery for colorectal cancer: the evolving role of transanal endoscopic surgery

SUMMARY 

The morbidity associated with radical surgery for rectal cancer has launched a revolution in increasingly less-invasive methods of resection, including a recent resurgence in transanal endoscopic surgical approaches. The next evolution in transanal surgery for rectal cancer is natural orifice translumenal endoscopic surgery (NOTES). To date, 14 series of transanal NOTES total mesorectal excision (TME) for rectal cancer have been published (n = 76). Overall, the intraoperative and postoperative complication rates of 8 and 28%, respectively, compare favorably to those expected from laparoscopic and open TME. Short-term follow-up after NOTES TME has yielded no cancer recurrence in average-risk patients. High-risk patients have cancer recurrence rates similar to those after laparoscopic TME. Overall, these early data support transanal NOTES TME as a safe and viable alternative to conventional TME. Advances in instrumentation, surgical expertise and neoadjuvant treatment may expand current indications for NOTES even further.

Clinical Robotic Surgery Association Fifth Worldwide Congress, Washington DC, 3-5 October 2013: Robotic Colorectal Surgery

The colorectal session was one of the most successful and well attended sessions at the Fifth Worldwide Clinical Robotic Surgery Association Congress because of the increasing interest and diffusion of robotic techniques in this specific field. This session was structured as follows: two technical focuses, one on rectal resection and the other on right colectomies; a journal club with two hot topic papers presented by the authors; a face-to-face on single-port laparoscopic versus robotic surgery; an update on the transanal approach; and three lectures, on the oncologic safety of robotic total mesorectal excision, on the use of fluorescence in colorectal surgery, and finally an update on the ongoing ROLARR trial (laparoscopic versus robotic rectal resection).

Sphincter-sparing surgery in patients with low-lying rectal cancer: techniques, oncologic outcomes, and functional results

BACKGROUND

Rectal cancer management has evolved into a complex multimodality approach with survival, local recurrence, and quality of life parameters being the relevant endpoints. Surgical treatment for low rectal cancer has changed dramatically over the past 100 years.

DISCUSSION

Abdominoperineal resection, once the standard of care for all rectal cancers, has become much less frequently utilized as surgeons devise and test new techniques for preserving the sphincters, maintaining continuity, and performing oncologically sound ultra-low anterior or local resections. Progress in rectal cancer surgery has been driven by improved understanding of the anatomy and pathophysiology of the disease, innovative surgical technique, improved technology, multimodality approaches, and increased appreciation of the patient's quality of life. The patient with a low rectal cancer, once almost universally destined for impotence and a colostomy, now has the real potential for improved survival, avoidance of a permanent stoma, and preservation of the normal route of defecation.

Transanal minimally invasive surgery for total mesorectal excision (TAMIS-TME): results and experience with the first 20 patients undergoing curative-intent rectal cancer surgery at a single institution

BACKGROUND

Transanal TME is a new approach to performing minimally invasive rectal resection. It is particularly well suited for patients with locally advanced distal rectal cancer and obesity, where the abdominal approach is challenging. Transanal TME can be performed with either TAMIS or TEM. Here, we report our initial experience with transanal TME using TAMIS (TAMIS-TME).

METHODS

Patients were selected to undergo transanal TME using the TAMIS platform (TAMIS-TME) primarily for malignant disease, but also for select cases of benign disease. Transanal TME defines a "bottom-up" approach to en bloc rectal cancer resection. Transanal TME requires abdominal access for proximal colonic mobilization and is often done in conjunction with a laparoscopic approach.

RESULTS

During a 32-month period, 20 patients underwent TAMIS-TME with curative intent. The primary indication for transanal TME was distal, locally advanced rectal cancer. The median age of rectal cancer patients at the time of surgery was 57 years (range 36-73 years) with 30% (6) female and 70% (14) male. The median body mass index (BMI) measured was 24 kg/m(2) (range 18-41 kg/m(2)); this included six patients (30%) with obesity (BMI ≥ 30 kg/m(2)). Mean operating time was 243 min (range 140-495 min) with blood loss averaging 153 ml. Postoperative length of stay averaged 4.5 days (range 3-24 days). There was no 30-day postoperative mortality. Surgical complications included wound infection (n = 2), pelvic abscess (n = 4), and prolonged ileus (n = 4). The anastomotic leak rate was 6.7% (1/15). Of the 20 patients who underwent resection, 90% (18/20) had negative margins. Pathologic grading of the TME specimen revealed that 85% (17/20) of transanal TME specimens were found to have "completely" or "near-completely" intact mesorectal envelopes. Data collected during the 6-month median follow-up period revealed that only one patient had developed distant metastasis. There was no locoregional recurrence in any of the patients.

CONCLUSIONS

Transanal TME is a feasible method for oncologic resection of locally advanced mid- and distal-rectal cancer with curative intent. It has special application for patients with obesity and anatomic constraints such as a narrow male pelvis.