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Serracant A, Consola B, Ballesteros E, Sola M, Novell F, Montes N, Serra-Aracil X. How to Study the Location and Size of Rectal Tumors That Are Candidates for Local Surgery: Rigid Rectoscopy, Magnetic Resonance, Endorectal Ultrasound or Colonoscopy? An Interobservational Study. Diagnostics (Basel) 2024; 14:315. [PMID: 38337831 PMCID: PMC10855339 DOI: 10.3390/diagnostics14030315] [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: 12/25/2023] [Revised: 01/22/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024] Open
Abstract
1. BACKGROUND Preoperative staging of rectal lesions for transanal endoscopic surgery (TES) comprises digital rectal examination, intraoperative rigid rectoscopy (IRR), endorectal ultrasound (EUS), colonoscopy and rectal magnetic resonance imaging (rMRI). The gold standard for topographic features is IRR. Are the results of the other tests sufficiently reliable to eliminate the need for IRR? rMRI is a key test in advanced rectal cancer and is not operator-dependent. Description of anatomical landmarks is variable. Can we rely on the information regarding topographic features provided by all radiologists? 2. MATERIALS AND METHODS This is a concordance interobservational study involving four diagnostic tests of anatomical characteristics of rectal lesions (colonoscopy, EUS, rectal MRI and IRR), performed by four expert radiologists, regarding topographic rectal features with rMRI. 3. RESULTS Fifty-five rectal tumors were operated on by using TES. The distance of the tumor from the anal verge, location by quadrants, size by quadrants and size of tumor were assessed (IRR as gold standard). For most of the tumors, the correlation between IRR and colonoscopy or EUS was very good (ICC > 0.75); the correlation between rMRI and IRR in respect of the size by quadrants (ICC = 0.092) and location by quadrants (ICC = 0.292) was weak. Topographic landmarks studied by the expert radiologists had an excellent correlation, except for distance from the peritoneal reflection to the anal verge (ICC = 0.606). 4. CONCLUSIONS Anatomical description of rectal lesions by IRR, EUS, colonoscopy and rMRI is reliable. Topographic data obtained by EUS and colonoscopy can serve as a reference to avoid IRR. Determination of these topographic data by rMRI is less reliable. As performed by the expert radiologists, the anatomical study by rMRI is accurate and reproducible.
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Affiliation(s)
- Anna Serracant
- Coloproctology Unit, General and Digestive Surgery Department, Institut d’Investigació i Innovació Parc Tauli I3PT-CERCA, Parc Tauli Hospital Universitari, Universitat Autònoma de Barcelona, Parc Tauli s/n, 08208 Sabadell, Spain; (A.S.); (N.M.)
| | - Beatriz Consola
- Diagnostic Radiology Department, Institut d’Investigació i Innovació Parc Tauli I3PT-CERCA, Parc Tauli Hospital Universitari, Universitat Autònoma de Barcelona, Parc Tauli s/n, 08208 Sabadell, Spain; (B.C.); (E.B.); (M.S.); (F.N.)
| | - Eva Ballesteros
- Diagnostic Radiology Department, Institut d’Investigació i Innovació Parc Tauli I3PT-CERCA, Parc Tauli Hospital Universitari, Universitat Autònoma de Barcelona, Parc Tauli s/n, 08208 Sabadell, Spain; (B.C.); (E.B.); (M.S.); (F.N.)
| | - Marta Sola
- Diagnostic Radiology Department, Institut d’Investigació i Innovació Parc Tauli I3PT-CERCA, Parc Tauli Hospital Universitari, Universitat Autònoma de Barcelona, Parc Tauli s/n, 08208 Sabadell, Spain; (B.C.); (E.B.); (M.S.); (F.N.)
| | - Francesc Novell
- Diagnostic Radiology Department, Institut d’Investigació i Innovació Parc Tauli I3PT-CERCA, Parc Tauli Hospital Universitari, Universitat Autònoma de Barcelona, Parc Tauli s/n, 08208 Sabadell, Spain; (B.C.); (E.B.); (M.S.); (F.N.)
| | - Noemi Montes
- Coloproctology Unit, General and Digestive Surgery Department, Institut d’Investigació i Innovació Parc Tauli I3PT-CERCA, Parc Tauli Hospital Universitari, Universitat Autònoma de Barcelona, Parc Tauli s/n, 08208 Sabadell, Spain; (A.S.); (N.M.)
| | - Xavier Serra-Aracil
- Coloproctology Unit, General and Digestive Surgery Department, Institut d’Investigació i Innovació Parc Tauli I3PT-CERCA, Parc Tauli Hospital Universitari, Universitat Autònoma de Barcelona, Parc Tauli s/n, 08208 Sabadell, Spain; (A.S.); (N.M.)
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Tips and tricks in transanal suture lines, knots and purse strings with TEO. Tech Coloproctol 2022; 26:999-1001. [PMID: 35731332 DOI: 10.1007/s10151-022-02649-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 05/26/2022] [Indexed: 10/17/2022]
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Serra-Aracil X, Lucas-Guerrero V, Mora-López L. Complex Procedures in Transanal Endoscopic Microsurgery: Intraperitoneal Entry, Ultra Large Rectal Tumors, High Lesions, and Resection in the Anal Canal. Clin Colon Rectal Surg 2022; 35:129-134. [PMID: 35237108 PMCID: PMC8885161 DOI: 10.1055/s-0041-1742113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Transanal endoscopic microsurgery (TEM) allows the local excision of rectal tumors and achieves lower morbidity and mortality rates than total mesorectal excision. TEM can treat lesions up to 18 to 20 cm from the anal verge, obtaining good oncological results in T1 stage cancers and preserving sphincter function. TEM is technically demanding. Large lesions (>5 cm), those with high risk of perforation into the peritoneal cavity, those in the upper rectum or the rectosigmoid junction, and those in the anal canal are specially challenging. Primary suture after peritoneal perforation during TEM is safe and it does not necessarily require the creation of a protective stoma. We recommend closing the wall defect in all cases to avoid the risk of inadvertent perforation. It is important to identify these complex lesions promptly to transfer them to reference centers. This article summarizes complex procedures in TEM.
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Affiliation(s)
- Xavier Serra-Aracil
- Division of Colorectal Surgery, Department of General and Digestive Surgery, Parc Taulí University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain,Address for correspondence Xavier Serra-Aracil, MD, PhD Coloproctology Unit, Department of General and Digestive Surgery, Parc Tauli University Hospital, Universitat Autònoma de BarcelonaParc Tauli s/n., 08208 Sabadell, BarcelonaSpain
| | - Victoria Lucas-Guerrero
- Division of Colorectal Surgery, Department of General and Digestive Surgery, Parc Taulí University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Laura Mora-López
- Division of Colorectal Surgery, Department of General and Digestive Surgery, Parc Taulí University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
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Casalots A, Serra-Aracil X, Mora-Lopez L, Garcia-Nalda A, Pericay C, Ferreres JC, Navarro-Soto S. T1 Rectal Adenocarcinoma: a Different Way to Measure Tumoral Invasion Based on the Healthy Residual Submucosa with Its Prognosis and Therapeutic Implications. J Gastrointest Surg 2021; 25:2660-2667. [PMID: 33629231 DOI: 10.1007/s11605-021-04948-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 01/24/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Surgical treatment of early rectal cancer T1 is either local excision or total mesorectal excision. The choice of surgery is based on the risk of metastatic lymph node involvement. The most important factor to consider is the degree of submucosal invasion. We present a different way to measure tumoral invasion derived from the measurement of the healthy residual submucosa with its prognosis and therapeutic implications METHODS: Observational study of tumor submucosal invasion in patients undergoing transanal endoscopic microsurgery was conducted. Parameters evaluated are submucosal invasion, measuring the healthy residual submucosa at the point of maximum invasion; macroscopic morphology of the tumor; presence of muscularis mucosa, muscularis propria, and measurement of submucosa in the tumor area and the healthy area. The classification proposed is compared with the ones previously published. RESULTS Eighty consecutive patients diagnosed with T1 rectal cancer underwent transanal endoscopic microsurgery. Seventeen tumors (21.3%) were polypoid. En bloc resection was achieved in 77 (96.3%). The muscularis mucosa was present in 28 (35%), and the muscularis propria in 77 (96.3%) (p < 0.001). The healthy residual submucosa in the tumor area measured 2,343 ± 1,869 μm. Agreement was moderate with the Kikuchi classification (kappa 0.58) and very good with the Kudo classification (kappa 0.87). CONCLUSIONS We describe a method for measuring submucosal invasion in T1 rectal cancer which does not depend on the morphology of the lesion or on the presence of the muscularis mucosa. It can be applied to all T1 classifications of the digestive tract in which the muscularis propria is present.
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Affiliation(s)
- Alex Casalots
- Pathology Department, Parc Tauli University Hospital, Sabadell, Sabadell, Barcelona, Spain
| | - Xavier Serra-Aracil
- Coloproctology Unit, General and Digestive Surgery Department, Parc Tauli University Hospital, Sabadell, Parc Tauli s/n, 08208, Sabadell, Barcelona, Spain.
| | - Laura Mora-Lopez
- Coloproctology Unit, General and Digestive Surgery Department, Parc Tauli University Hospital, Sabadell, Parc Tauli s/n, 08208, Sabadell, Barcelona, Spain
| | - Albert Garcia-Nalda
- Coloproctology Unit, General and Digestive Surgery Department, Parc Tauli University Hospital, Sabadell, Parc Tauli s/n, 08208, Sabadell, Barcelona, Spain
| | - Carles Pericay
- Medical Oncology Department, Parc Tauli Hospital Universitari. Institut d'Investigació i Innovació Parc Tauli I3PT., Sabadell, Barcelona, Spain.,Universitat Autonoma de Barcelona, Parc Tauli s/n, 08208, Sabadell, Barcelona, Spain
| | - Joan Carles Ferreres
- Pathology Department, Parc Tauli University Hospital, Sabadell, Sabadell, Barcelona, Spain
| | - Salvador Navarro-Soto
- Coloproctology Unit, General and Digestive Surgery Department, Parc Tauli University Hospital, Sabadell, Parc Tauli s/n, 08208, Sabadell, Barcelona, Spain
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Serra-Aracil X, Montes N, Mora-Lopez L, Serracant A, Pericay C, Rebasa P, Navarro-Soto S. Preoperative Diagnostic Uncertainty in T2-T3 Rectal Adenomas and T1-T2 Adenocarcinomas and a Therapeutic Dilemma: Transanal Endoscopic Surgery, or Total Mesorectal Excision? Cancers (Basel) 2021; 13:cancers13153685. [PMID: 34359589 PMCID: PMC8345169 DOI: 10.3390/cancers13153685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 07/13/2021] [Accepted: 07/19/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Endorectal ultrasound and rectal magnetic resonance are sometimes unable to differentiate between stages T2 and T3 in rectal adenomas that are possible adenocarcinomas, or between stages T1 and T2 in rectal adenocarcinomas. These cases of diagnostic uncertainty raise a therapeutic dilemma: transanal endoscopic surgery (TES) or total mesorectal excision (TME)? METHODS An observational study of a cohort of 803 patients who underwent TES from 2004 to 2021. Patients operated on for adenoma (group I) and low-grade T1 adenocarcinoma (group II) were included. The variables related to uncertain diagnosis, and to the definitive pathological diagnosis of adenocarcinoma stage higher than T1, were analyzed. RESULTS A total of 638 patients were included. Group I comprised 529 patients, 113 (21.4%) with uncertain diagnosis. Seventeen (15%) eventually had a pathological diagnosis of adenocarcinoma higher than T1. However, the variable diagnostic uncertainty was a risk factor for adenocarcinoma above T1 (OR 2.3, 95% CI 1.1-4.7). Group II included 109 patients, eight with uncertain diagnosis (7.3%). Two patients presented a definitive pathological diagnosis of adenocarcinoma above T1. CONCLUSIONS On the strength of these data, we recommend TES as the initial indication in cases of diagnostic uncertainty. Multicenter studies with larger samples for both groups should now be performed to further assess this strategy of initiating treatment with TES.
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Affiliation(s)
- Xavier Serra-Aracil
- Servicio de Cirugía General y del Ap. Digestivo, Departament de Cirurgia, Institut d’Investigació i Innovació Parc Tauli I3PT, Parc Tauli Hospital Universitari, Universitat Autònoma de Barcelona, 08208 Sabadell, Spain; (N.M.); (L.M.-L.); (A.S.); (P.R.); (S.N.-S.)
- Correspondence:
| | - Noemi Montes
- Servicio de Cirugía General y del Ap. Digestivo, Departament de Cirurgia, Institut d’Investigació i Innovació Parc Tauli I3PT, Parc Tauli Hospital Universitari, Universitat Autònoma de Barcelona, 08208 Sabadell, Spain; (N.M.); (L.M.-L.); (A.S.); (P.R.); (S.N.-S.)
| | - Laura Mora-Lopez
- Servicio de Cirugía General y del Ap. Digestivo, Departament de Cirurgia, Institut d’Investigació i Innovació Parc Tauli I3PT, Parc Tauli Hospital Universitari, Universitat Autònoma de Barcelona, 08208 Sabadell, Spain; (N.M.); (L.M.-L.); (A.S.); (P.R.); (S.N.-S.)
| | - Anna Serracant
- Servicio de Cirugía General y del Ap. Digestivo, Departament de Cirurgia, Institut d’Investigació i Innovació Parc Tauli I3PT, Parc Tauli Hospital Universitari, Universitat Autònoma de Barcelona, 08208 Sabadell, Spain; (N.M.); (L.M.-L.); (A.S.); (P.R.); (S.N.-S.)
| | - Carles Pericay
- Medical Oncology Department, Institut d’Investigació i Innovació Parc Tauli I3PT, Parc Tauli Hospital Universitari, Universitat Autònoma de Barcelona, 08208 Sabadell, Spain;
| | - Pere Rebasa
- Servicio de Cirugía General y del Ap. Digestivo, Departament de Cirurgia, Institut d’Investigació i Innovació Parc Tauli I3PT, Parc Tauli Hospital Universitari, Universitat Autònoma de Barcelona, 08208 Sabadell, Spain; (N.M.); (L.M.-L.); (A.S.); (P.R.); (S.N.-S.)
| | - Salvador Navarro-Soto
- Servicio de Cirugía General y del Ap. Digestivo, Departament de Cirurgia, Institut d’Investigació i Innovació Parc Tauli I3PT, Parc Tauli Hospital Universitari, Universitat Autònoma de Barcelona, 08208 Sabadell, Spain; (N.M.); (L.M.-L.); (A.S.); (P.R.); (S.N.-S.)
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Serra-Aracil X, Gracia-Roman R, Badía-Closa J, Mora-Lopez L, Pallisera-Lloveras A, Serra-Pla S, Garcia-Nalda A, Navarro-Soto S. How to Learn a Complex Endoscopic Procedure: Knots in Transanal Endoscopic Surgery: Different Skill Among Surgeons. Surg Laparosc Endosc Percutan Tech 2021; 31:669-673. [PMID: 34238868 DOI: 10.1097/sle.0000000000000969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/14/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE The intrarectal suture is considered a high technically complex procedure. The study's objectives were to assess the feasibility of making an intrarectal knot, through an in vitro study and assessing whether the video tutorial facilitates learning. MATERIALS AND METHODS A detailed description of the technique. A comparative observational cross-sectional study in surgeons with no previous experience in intrarectal knots. RESULTS Twenty-one of these 32 participants passed the intrarectal knot test without video tutorial (T1) (65.6%), and 26 (81.2%) after the video tutorial (T2) (P=0.26). The mean time taken to tie the knot fell from 74 seconds (SD=46) in T1 to 41 seconds (SD=41) in T2 (P<0.001). At T1, 26 participants (81.3%) described the technique as difficult, but only 7 (21.9%) at T2 (P<0.001). CONCLUSIONS Performing the intrarectal knot suture is feasible. Despite the technical difficulty, the video tutorial is sufficient for surgeons to learn the technique.
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Affiliation(s)
- Xavier Serra-Aracil
- Department of Colorectal Surgery and General Digestive Surgery, Parc Tauli University Hospital, Institut d'investigaciò i Innovaciò Parc Tauli I3PT, Universitat Autonoma de Barcelona (UAB), Sabadell (Barcelona), Spain
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Transanal minimally invasive surgery (TAMIS) for local excision of selected rectal neoplasms: efficacy and outcomes in the first 11 patients. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1016/j.jcol.2014.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AbstractDisposable single-port surgery devices have been used for transanal minimally invasive surgery (TAMIS) with benefits, when compared to local resection and transanal endoscopic microsurgery (TEM).
Objective To show outcomes and details of the technique.
Method A series of patients with indication for local resection of rectal tumors were submitted to surgery using the TAMIS platform.
Results Eleven patients have been submitted to TAMIS. Distance from anal verge was from 1.5 to 8 cm and maximum tumor diameter was 6 cm. Initial diagnosis of adenoma was the most frequent indication for resection. One partial dehiscence was the only complication seen. Minimal setup time, low cost and the possibility of using regular laparoscopic instruments make TAMIS a good option for transanal resection. The results of this technique are encouraging, concerning the feasibility, maneuverability, upfront cost, setup time, resectability and complication rate. Because of its simplicity and similarity with conventional laparoscopic surgery, it can be learned easily. Although at the present time the appropriate use of local excision is still under debate, TAMIS is a technique that still expects a lot of growing and much remains to be learned.
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Completion Surgery in Unfavorable Rectal Cancer after Transanal Endoscopic Microsurgery: Does It Achieve Satisfactory Sphincter Preservation, Quality of Total Mesorectal Excision Specimen, and Long-term Oncological Outcomes? Dis Colon Rectum 2021; 64:200-208. [PMID: 33315715 DOI: 10.1097/dcr.0000000000001730] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Unfavorable adenocarcinoma after transanal endoscopic microsurgery requires "completion surgery" with total mesorectal excision. The literature on this procedure is very limited. OBJECTIVE This study aims to assess the percentage of transanal endoscopic microsurgery that will require completion surgery. DESIGN This is an observational study with prospective data collection and retrospective analysis from patients who were operated on consecutively. SETTINGS The study was conducted at a single academic institution. PATIENTS Patients undergoing transanal endoscopic microsurgery from June 2004 to December 2018 who later required total mesorectal excision were included. MAIN OUTCOME MEASURES All the patients followed the same protocol: preoperative study, indication of transanal endoscopic microsurgery with curative intent, performance of transanal endoscopic microsurgery, and completion surgery indication 3 to 4 weeks after transanal endoscopic microsurgery. RESULTS Seven hundred seventy-four patients underwent transanal endoscopic microsurgery, 622 with curative intent (group I: adenoma, 517; group II: adenocarcinoma, 105). Completion surgery was indicated in 64 of 622 (10.3%) patients: group I, 40 of 517 (7.7%) and group II, 24 of 105 (22.9%). After applying exclusion criteria, completion surgery was performed in 55 patients (8.8%). Abdominoperineal resection was performed in 23 (45.1%); the initial lesion was within 6 cm of the anal verge in 19 of these 23 (82.6%). The clinical morbidity rate (Clavien Dindo> II) was 3 of 51 (5.9%). Total mesorectal excision was graded as complete in 42 of 49 (85.7%). The circumferential resection margin was tumor-free in 47 of 50 (94%). Median follow-up was 58 months. Local recurrence was recorded in 2 of 51 (3.9%) and systemic recurrence was recorded in 7 of 51 (13.7%); 5-year disease-free survival was 86%. LIMITATIONS The limitations are defined by the study's observational design and the retrospective analysis. CONCLUSION The indication of completion surgery after transanal endoscopic microsurgery is low, but is higher in the indication of adenocarcinoma. Compared with initial total mesorectal excision, completion surgery requires a higher rate of abdominoperineal resection, but has similar postoperative morbidity, total mesorectal excision quality, and oncological results. See Video Abstract at http://links.lww.com/DCR/B423. CIRUGA COMPLEMENTARIA EN CNCER DE RECTO DESFAVORABLE DESPUS DE UNA TEM SE OBTIENE SATISFACTORIAMENTE PRESERVACIN DEL ESFNTER, CALIDAD DE MUESTRA DE ETM Y RESULTADOS ONCOLGICOS A LARGO PLAZO ANTECEDENTES:El adenocarcinoma con evolución desfavorable luego de una de microcirugía endoscópica transanal (TEM) requiere "cirugía de finalización" con la excisión total del mesorecto. La literatura sobre este procedimiento es muy limitada.OBJETIVO:Evaluar el porcentaje de microcirugía endoscópica transanal que requerió cirugía completa.DISEÑO:Estudio observacional con recolección prospectiva de datos y análisis retrospectivo de pacientes operados consecutivamente.AJUSTES:El estudio se realizó en una sola institución académica.PACIENTES:Aquellos pacientes sometidos a microcirugía endoscópica transanal desde junio de 2004 hasta diciembre de 2018 que luego requirieron excisón toztal del mesorecto.PRINCIPALES MEDIDAS DE RESULTADO:Todos los pacientes siguieron el mismo protocolo: estudio preoperatorio, indicación de microcirugía endoscópica transanal con intención curativa, realización de microcirugía endoscópica transanal e indicación de cirugía complementaria 3-4 semanas después de la microcirugía endoscópica transanal.RESULTADOS:Setecientos setenta y cuatro pacientes fueron sometidos a microcirugía endoscópica transanal, 622 con intención curativa (grupo I, adenoma: 517, grupo II, adenocarcinoma: 105). la cirugía complementaria fué indicada en 64/622 (10.3%), grupo I: 40/517 (7.7%) y grupo II 24/105 (22.9%). Después de aplicar los criterios de exclusión, la cirugía complementaria se realizó en 55 pacientes (8,8%). La resección abdominoperineal fué realizada en 23 (45,1%); en 19 de estos casos 23 (82,6%) la lesión inicial se encontraba dentro los 6 cm del margen anal. La tasa de morbilidad clínica (Clavien-Dindo > II) fue de 3/51 (5,9%). La excisión total del mesorecto se calificó como completa en 42/49 (85,7%). El margen de resección circunferencial se encontraba libre de tumor en 47/50 (94%). La mediana de seguimiento fue de 58 meses. La recurrencia local se registró en 2/51 (3.9%) y la recurrencia sistémica en 7/51 (13.7%); La supervivencia libre de enfermedad a 5 años fue del 86%.LIMITACIONES:Todas definidas por el diseño observacional y el análisis retrospectivo del mismo.CONCLUSIÓN:La indicación de completar la cirugía después de una TEM es baja, pero es más alta cuando la indicación es por adenocarcinoma. En comparación con la excisión total del mesorecto inicial, la cirugía complementaria requiere una tasa más alta de resección abdominoperineal, pero tiene una morbilidad postoperatoria, una calidad de excisión total del mesorecto y resultados oncológicos similares. ConsulteVideo Resumen en http://links.lww.com/DCR/B423. (Traducción-Dr. Xavier Delgadillo).
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Serra-Aracil X, Badia-Closa J, Pallisera-Lloveras A, Mora-López L, Serra-Pla S, Garcia-Nalda A, Navarro-Soto S. Management of intra- and postoperative complications during TEM/TAMIS procedures: a systematic review. Minerva Surg 2021; 76:343-349. [PMID: 33433070 DOI: 10.23736/s2724-5691.20.08405-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Transanal endoscopic microsurgery (TEM) is a safe procedure and the rates of intra- and postoperative complications are low. The information in the literature on the management of these complications is limited, and so their importance may be either under- or overestimated (which may in turn lead to under- or overtreatment). The present article reviews the most relevant series of TEM procedures and their complications and describes various approaches to their management. EVIDENCE ACQUISITION A systematic review of the literature, including TEM series of more than 150 cases each. We analyzed the population characteristics, surgical variables and intraoperative and postoperative complications. EVIDENCE SYNTHESIS A total of 1043 records were found. After review, 1031 were excluded. The review therefore includes 12 independent cohorts of TEM procedures with a total of 4395 patients. The rate of perforation into the peritoneal cavity was 5.1%, and conversion to abdominal approach was required in 0.8% of cases. The most frequent complications were acute urinary retention (AUR, 4.9%) and rectal bleeding (2.2%). Less common complications included abscesses (0.99%) and rectovaginal fistula (0.62%). Mortality rates were low, with a mean value of 0.29%. CONCLUSIONS Awareness and knowledge of TEM complications and their management can play an important role in their treatment and patient safety. Here, we present a review of the most important TEM series and their complication rates and describe various approaches to their management.
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Affiliation(s)
- Xavier Serra-Aracil
- Colorectal Unit, Department of General and Digestive Surgery, Parc Taulí University Hospital, Universitat Autònoma de Barcelona (UAB), Sabadell, Barcelona, Spain -
| | - Jesus Badia-Closa
- Colorectal Unit, Department of General and Digestive Surgery, Parc Taulí University Hospital, Universitat Autònoma de Barcelona (UAB), Sabadell, Barcelona, Spain
| | - Anna Pallisera-Lloveras
- Colorectal Unit, Department of General and Digestive Surgery, Parc Taulí University Hospital, Universitat Autònoma de Barcelona (UAB), Sabadell, Barcelona, Spain
| | - Laura Mora-López
- Colorectal Unit, Department of General and Digestive Surgery, Parc Taulí University Hospital, Universitat Autònoma de Barcelona (UAB), Sabadell, Barcelona, Spain
| | - Sheila Serra-Pla
- Colorectal Unit, Department of General and Digestive Surgery, Parc Taulí University Hospital, Universitat Autònoma de Barcelona (UAB), Sabadell, Barcelona, Spain
| | - Albert Garcia-Nalda
- Colorectal Unit, Department of General and Digestive Surgery, Parc Taulí University Hospital, Universitat Autònoma de Barcelona (UAB), Sabadell, Barcelona, Spain
| | - Salvador Navarro-Soto
- Colorectal Unit, Department of General and Digestive Surgery, Parc Taulí University Hospital, Universitat Autònoma de Barcelona (UAB), Sabadell, Barcelona, Spain
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de Lima RDAL, Parra RS, Feitosa MR, Feres O, da Rocha JJR. Surgical and postoperative evaluations of rectal adenomas excised with a rigid proctoscope. Acta Cir Bras 2020; 35:e202000807. [PMID: 32965304 PMCID: PMC7518222 DOI: 10.1590/s0102-865020200080000007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 06/05/2020] [Accepted: 07/07/2020] [Indexed: 11/21/2022] Open
Abstract
PURPOSE This study presents the surgical and postoperative results achieved with a rigid proctoscope using the transanal endoscopic technique to excise rectal adenomas. The results are compared to the results obtained with other currently employed transanal techniques. METHODS We investigated the medical records of patients who underwent transanal endoscopic operations from April 2000 to June 2018 at two tertiary referral centers for colorectal cancer. RESULTS This study included 99 patients. The mean age was 65.3 ± 13.3 years. The average size of the adenomas was 4.6 ± 2.3 cm, and their average distance to the anal border was 5.6 ± 3.3 cm. The average operative time was 65.3 ± 41.7 min. In 48.5% of the operations, the specimen was fragmented, and in 59.6% of the cases, the microscopic margins were free. The rates of postoperative complications and relapse were 5% and 19%, respectively. The mean follow-up was 80 ± 61.5 months. CONCLUSIONS The described proctoscope proved to be a viable technique with results similar to other techniques, with the advantage that it allowed greater accessibility for surgeons. Therefore, its use could be implemented and become widespread in surgical practice.
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Affiliation(s)
- Roberta Denise Alkmin Lopes de Lima
- Fellow PhD degree, Postgraduate Program in Surgical Clinic, Division of Coloproctology, Department of Anatomy and Surgery, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (FMRP-USP), Ribeirao Preto-SP, Brazil. Substantive scientific and intellectual contributions; conception and design of the study; acquisition, analysis and interpretation of data; manuscript preparation, final approval
| | - Rogério Serafim Parra
- PhD, Division of Coloproctology, Department of Anatomy and Surgery, FMRP-USP, Ribeirao Preto-SP, Brazil. Substantive scientific and intellectual contributions, manuscript writing, critical revision, final approval
| | - Marley Ribeiro Feitosa
- PhD, Division of Coloproctology, Department of Anatomy and Surgery, FMRP-USP, Ribeirao Preto-SP, Brazil. Substantive scientific and intellectual contributions, analysis and interpretation of data, statistics analysis, final approval
| | - Omar Feres
- PhD, Associated Professor, Division of Coloproctology, Department of Anatomy and Surgery, FMRP-USP, Ribeirao Preto-SP, Brazil. Substantive scientific and intellectual contributions, analysis and interpretation of data, critical revision, final approval
| | - José Joaquim Ribeiro da Rocha
- PhD, Associated Professor, Head, Division of Coloproctology, Department of Anatomy and Surgery, FMRP-USP, Ribeirao Preto-SP, Brazil. Substantive scientific and intellectual contributions; conception and design of the study; acquisition, analysis and interpretation of data; critical revision, final approval
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11
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Serra-Aracil X, Gil-Barrionuevo E, Lobato-Gil R, Gonzalez-Costa A, Mora-López L, Pallisera-Lloveras A, Serra-Pla S, Navarro-Soto S. Is obesity a factor of surgical difficulty in transanal endoscopic surgery? Am J Surg 2020; 220:687-692. [PMID: 31983409 DOI: 10.1016/j.amjsurg.2020.01.027] [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: 11/20/2019] [Revised: 01/15/2020] [Accepted: 01/17/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The aim of this study is to assess the feasibility of transanal endoscopic surgery (TES) in obese patients. METHODS Observational descriptive study evaluating the feasibility of TES in obese rectal tumors between June 2004 and January 2019. Patients were assigned to two groups: body mass index (BMI) < 30 kg/m2 and BMI ≥30 kg/m2, the latter defined as obese. RESULTS From 775 patients, 681 were enrolled in the study, 145 (21.3%) of them obese. No statistically significant differences between groups were found with respect to overall morbidity (27, 18.6%).The obese patients presented trends towards shorter mean surgical time (65 min, IQR 48 min), less perforation in the peritoneal cavity (eight, 5.5%), and 133 (91.7%) presented a lower rate of lesion fragmentation. CONCLUSION There were no significant differences in postoperative outcomes in obese patients (BMI ≥30 kg/m2). TES in those obese patients does not represent a factor of surgical difficulty.
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Affiliation(s)
- Xavier Serra-Aracil
- Department of Colorectal Surgery, Department of General and Digestive Surgery, Parc Taulí University Hospital, Universidad Autonoma de Barcelona (UAB), Parc Taulí S/n, 08208, Sabadell, Barcelona, Spain.
| | - Esther Gil-Barrionuevo
- Department of Colorectal Surgery, Department of General and Digestive Surgery, Parc Taulí University Hospital, Universidad Autonoma de Barcelona (UAB), Parc Taulí S/n, 08208, Sabadell, Barcelona, Spain
| | - Raquel Lobato-Gil
- Department of Colorectal Surgery, Department of General and Digestive Surgery, Parc Taulí University Hospital, Universidad Autonoma de Barcelona (UAB), Parc Taulí S/n, 08208, Sabadell, Barcelona, Spain
| | - Anna Gonzalez-Costa
- Department of Colorectal Surgery, Department of General and Digestive Surgery, Parc Taulí University Hospital, Universidad Autonoma de Barcelona (UAB), Parc Taulí S/n, 08208, Sabadell, Barcelona, Spain
| | - Laura Mora-López
- Department of Colorectal Surgery, Department of General and Digestive Surgery, Parc Taulí University Hospital, Universidad Autonoma de Barcelona (UAB), Parc Taulí S/n, 08208, Sabadell, Barcelona, Spain
| | - Anna Pallisera-Lloveras
- Department of Colorectal Surgery, Department of General and Digestive Surgery, Parc Taulí University Hospital, Universidad Autonoma de Barcelona (UAB), Parc Taulí S/n, 08208, Sabadell, Barcelona, Spain
| | - Sheila Serra-Pla
- Department of Colorectal Surgery, Department of General and Digestive Surgery, Parc Taulí University Hospital, Universidad Autonoma de Barcelona (UAB), Parc Taulí S/n, 08208, Sabadell, Barcelona, Spain
| | - Salvador Navarro-Soto
- Department of Colorectal Surgery, Department of General and Digestive Surgery, Parc Taulí University Hospital, Universidad Autonoma de Barcelona (UAB), Parc Taulí S/n, 08208, Sabadell, Barcelona, Spain
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12
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A scoring system to predict complex transanal endoscopic surgery. Surg Endosc 2019; 34:4828-4836. [PMID: 31741162 DOI: 10.1007/s00464-019-07259-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 11/11/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Since the introduction of screening for colorectal cancer, the use of transanal endoscopic surgery (TEM) has become increasingly popular. However, the technical difficulty of this surgery varies widely. The few studies of learning curve in TEM have produced very disparate results. The aim of this study is to distinguish between straightforward and complex procedures, in order to refer more difficult cases to centers with greater experience. METHOD Observational study with prospective data collection and retrospective analysis was carried out between June 2004 and January 2019. All TEMs performed on rectal tumors were included. The complexity of the procedure was defined according to the weighted mean surgical time for each surgeon. A predictive model of complexity was established, with a score higher than 5 indicating a complex lesion. RESULTS During the study period, 773 TEMs were performed, 708 of which met the study's inclusion criteria. One hundred and three tumors were defined as complex. Predictors of complexity were as follows: male sex (OR: 1.78, 95% CI 1.1-2.9, score: 1), tumor size > 5 cm (OR: 5.1, 95% CI 3.2-8.2, score: 4), TEM for recurrence (OR: 6.3, 95% CI 2.3-16.7, score: 5), and distance from the upper margin of the tumor to the anal verge > 15 cm (OR: 1.6, 95% CI 0.96-2.7, score: 1). CONCLUSIONS Rather than establishing the learning curve merely in terms of the number of TEM procedures performed, it is important to consider the surgical difficulty of the interventions. To this end, it is essential to differentiate simple TEMs from the complex ones.
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Abstract
BACKGROUND An important drawback of local surgery for lesions in the anal canal is the difficulty of achieving en bloc full-thickness resections. The aim of this study is to evaluate TEM/TEO in lesions of this type from the point of view of morbidity, mortality and the quality of the pathology specimen. METHODS This is an observational study with prospective data collection from June 2004 to July 2018. Two groups are defined: group A (rectal tumors with proximal margin between 0 and ≤4 cm from anal verge) and group B (distal margin > 4 cm from anal verge). A technical description is provided; resections and postoperative complications in both groups are compared. RESULTS During the study period, 757 patients underwent TEM/TEO. Finally, 692 patients were included, 192 patients in group A and 500 patients in group B. An en bloc surgical specimen was obtained in 176/192 patients (91.7%), although the defect was completely sutured in 132 (68.8%). In the comparative analysis, group A did not present significantly greater fragmentation of the resected piece [16/192 (8.3%) vs. 36/500 (7.2%), p = 0.630], although group A was associated with greater involvement of the surgical margin [28/192 (14.6%), 32/500 (6.4%), p = 0.001] and clinically relevant morbidity [16/192 (8.3%), 20/500 (4%), p = 0.034]. There was no mortality. CONCLUSIONS The use of TEM/TEO to remove lesions originating in the anal canal is feasible. But we have to take into account that there is an increase in complications, technical difficulties and affected margins resection.
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Importance of Resection Margins in the Treatment of Rectal Adenomas by Transanal Endoscopic Surgery. J Gastrointest Surg 2019; 23:1874-1883. [PMID: 30306452 DOI: 10.1007/s11605-018-3980-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 09/17/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Polypectomy is the gold standard for treating colorectal adenomas up to 2 cm in size. For larger lesions, various procedures ranging from endoscopy to transanal surgery can be performed and achieve varying results for en bloc resection and recurrence. There are no clear guidelines for dealing with involved resection margins. We assess the recurrence of rectal adenomas operated using TEM with full-thickness wall excision with or without free resection margins and define optimal endoscopic follow-up. METHOD Observational study with prospective data collection, including patients undergoing TEM between 6/2004 and 11/2017, with definitive diagnosis of rectal adenoma. Data on epidemiological, preoperative, surgical, postoperative, pathological, and follow-up variables were recorded. Univariate analysis, follow-up risk function, and multivariate logistic regression analysis were performed to detect risk factors for recurrence. RESULTS TEM was indicated in 736 patients; 481 adenomas were identified in the preoperative biopsy, of which 95 were infiltrating adenocarcinomas (19.8%) in the definitive pathology study. With a minimum follow-up of 1 year, 372 patients were included. Pathology study showed free margins in 324 (87%). Recurrences were recorded in 15 patients (4%), up to 18 months in the free margins group and up to 24 months in the involved margins group. Thirteen patients with recurrence (86.6%) were treated with TEM. No predictors of recurrence were found in the multivariate analysis. CONCLUSION TEM is the technique of choice for treating rectal adenomas and recurrences, achieving a low relapse rate. Follow-up must be adapted to resection margins and should be extended to 24 months.
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Serra-Aracil X, Flores-Clotet R, Mora-López L, Pallisera-Lloveras A, Serra-Pla S, Navarro-Soto S. Transanal endoscopic microsurgery in very large and ultra large rectal neoplasia. Tech Coloproctol 2019; 23:869-876. [DOI: 10.1007/s10151-019-02071-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 08/20/2019] [Indexed: 02/07/2023]
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Transanal Minimally Invasive Surgery for Local Excision of Benign and Malignant Rectal Neoplasia: Outcomes From 200 Consecutive Cases With Midterm Follow Up. Ann Surg 2019; 267:910-916. [PMID: 28252517 DOI: 10.1097/sla.0000000000002190] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE This study describes the outcomes for 200 consecutive transanal minimally invasive surgery (TAMIS) local excision (LE) for rectal neoplasia. BACKGROUND TAMIS is an advanced transanal platform that can result in high quality LE of rectal neoplasia. METHODS Consecutive patients from July 1, 2009 to December 31, 2015 from a prospective institutional registry were analyzed. Indication for TAMIS LE was endoscopically unresectable benign lesions or histologically favorable early rectal cancers. The primary endpoints were resection quality, neoplasia recurrence, and oncologic outcomes. Kaplan-Meier survival analyses were used to describe disease-free survival (DFS) for patients with rectal adenocarcinoma that did not receive immediate salvage radical surgery. RESULTS There were 200 elective TAMIS LE procedures performed in 196 patients for 90 benign and 110 malignant lesions. Overall, a 7% margin positivity and 5% fragmentation rate was observed. The mean operative time for TAMIS was 69.5 minutes (SD 37.9). Postoperative morbidity was recorded in 11% of patients, with hemorrhage (9%), urinary retention (4%), and scrotal or subcutaneous emphysema (3%) being the most common. The mean follow up was 14.4 months (SD 17.4). Local recurrence occurred in 6%, and distant organ metastasis was noted in 2%. Mean time to local recurrence for malignancy was 16.9 months (SD 13.2). Cumulative DFS for patients with rectal adenocarcinoma was 96%, 93%, and 84% at 1-, 2-, and 3-years. CONCLUSIONS For carefully selected patients, TAMIS for local excision of rectal neoplasia is a valid option with low morbidity that maintains the advantages of organ preservation.
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Transanal endoscopic micro-surgery in elderly and very elderly patients: a safe option? Observational study with prospective data collection. Surg Endosc 2019; 33:184-191. [PMID: 29934869 DOI: 10.1007/s00464-018-6292-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 06/18/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND Although the incidence of colorectal cancer increases with the patient's age, the elderly continue to be less likely to be scheduled for surgery. Transanal endoscopic micro-surgery (TEM) is a surgical alternative to total mesorectal excision (TME) in early stage rectal cancer and/or in selected patients that could decrease morbidity and mortality rates in this group of patients. Our main objective is to assess the safety and feasibility of TEM in elderly (75-84 years) and very elderly (≥ 85 years) patients. METHODS Observational study was conducted with prospective data collection of all consecutive patients who underwent TEM between April 2004 and January 2017. Patients were assigned to groups according to age. Descriptive and comparative analyses between groups were performed. RESULTS We analyzed 693 patients, 429 patients < 75 years (61.9%), 220 patients between the ages of 75 and 84 (31.7%), and 44 patients ≥ 85 years old (6.3%). The tendency in our series is to increase comorbidities with age. Palliative or consensus intent was more frequently performed in elderly (10.5%, 34/220), and very elderly (45.4%, 20/44), compared with the youngest (6.3%, 27/429), (p < 0.001). Global morbidity presented an increasing trend related to age from 20.3% in < 75 years, to 25.9% in elderly and 34.1% in very elderly. Surgical complications were recorded in 18.5% (128/693) of patients with no significant differences between groups. The most common one was rectal bleeding 16.1% (111/693). Significant differences were found in non-surgical complications, recorded in 7.3% (16/220) in the elderly, and 15.9% (7/44) in the group above 84 years (p = 0.013). CONCLUSIONS TEM presents acceptable morbidity rates mainly due to non-surgical-related adverse effects in elderly and very elderly patients and may be a feasible and safe alternative in this population in both curative and non-curative indications.
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Serra-Aracil X, Pallisera-Lloveras A, Mora-Lopez L, Rebasa P, Serra-Pla S, Navarro S. Perforation in the peritoneal cavity during transanal endoscopic microsurgery for rectal tumors: a real surgical complication with a challenging prognosis? Surg Endosc 2018; 33:1870-1879. [DOI: 10.1007/s00464-018-6466-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 09/18/2018] [Indexed: 01/20/2023]
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Morbidity after transanal endoscopic microsurgery: risk factors for postoperative complications and the design of a 1-day surgery program. Surg Endosc 2018; 33:1508-1517. [PMID: 30203205 DOI: 10.1007/s00464-018-6432-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 09/05/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Transanal endoscopic microsurgery (TEM) is a minimally invasive procedure with low morbidity. The definition of risk factors for postoperative complications would help to identify the patients likely to require more care and surveillance in an ambulatory or 1-day surgery (A-OdS) program. The main endpoints are overall 30-day morbidity and relevant morbidity. The secondary objectives are to detect risk factors for complications, rehospitalization, and the time of occurrence of the postoperative complications, and to describe the adverse effects following hospitalization that the A-OdS program would avoid. METHODS This is an observational study of consecutive patients undergoing TEM between June 2004 and December 2016. Overall and relevant morbidity based on the Clavien-Dindo (Cl-D) classification were recorded, as were demographic, preoperative, surgical, and pathology variables. Univariate and multivariate analyses of the risk factors were carried out. RESULTS Six hundred and ninety patients underwent surgery, of whom 639 were included in the study. Overall morbidity rate was 151/639 patients (23.6%); the clinically relevant morbidity rate was 36/639 (Cl-D > II) (5.6%) and mortality 2/639 (0.3%). The most frequent complication was rectal bleeding, recorded in 16.9% (108/639 patients) and grade I in 86/108 patients (78. 9%). The period with the greatest risk of complications was the first 2 days. The rehospitalization rate after 48 h was 7%. The risk factors for complications were as follows: tumor size > 6 cm (OR 3.2, 95% CI 1.3-7.8), anti-platelet medication (OR 2.3, 95% CI 1.1-5.1), and surgeon's experience < 150 procedures (OR 2.0, 95% CI 1-4.1). CONCLUSIONS TEM is a safe procedure. The low rates of morbidity, re-hospitalization, and postoperative complications in the first 2 days after surgery make the procedure suitable for A-OdS.
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Serra-Aracil X, Pallisera-Lloveras A, Mora-Lopez L, Serra-Pla S, Puig-Diví V, Casalots À, Martínez-Bauer E, Navarro-Soto S. Transanal endoscopic surgery is effective and safe after endoscopic polypectomy of potentially malignant rectal polyps with questionable margins. Colorectal Dis 2018; 20:789-796. [PMID: 29577555 DOI: 10.1111/codi.14108] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 03/06/2018] [Indexed: 02/08/2023]
Abstract
AIM To determine the percentage of residual lesion observed in the pathology study of transanal endoscopic surgery (TEM) specimens after endoscopic polypectomy of malignant rectal polyps with questionable margins, and the need for further surgery. Secondary aims: to determine the morbidity and mortality associated with this procedure and to identify the percentage of recurrence after excision by TEM. METHODS Observational study with prospective data collection of all patients undergoing TEM after endoscopic polypectomy for malignant rectal polyps or non-invasive high-grade neoplasia, from January 2004 to December 2016. An en bloc full-thickness wall excision of the scar was performed. Variables recorded: histology of TEM specimen, 30-day morbidity and mortality according to the Clavien-Dindo classification, need for salvage surgery and recurrence. RESULTS Fifty out of 690 patients undergoing TEM during the study period (36 adenocarcinomas, five non-invasive high-grade neoplasias and 9 neuroendocrine tumors) were included. Post-surgery histology showed residual lesion in 21 (42%) patients: 7 neuroendocrine tumors, 10 adenomas and 4 adenocarcinomas (two pT1, one pT2 and one pT3). The pT2 and pT3 patients (4%) underwent salvage surgery. No recurrence was observed, and mean follow-up was 29.1Â ± 21.6 months. The 30-day morbidity rate was 14%, but 4/7 with Clavien-Dindo grade I. CONCLUSIONS After endoscopic polypectomy of malignant rectal polyps with questionable margins, the presence of residual lesion in the pathology study of transanal resection specimens is high. TEM with full-thickness resection of these lesions is an appropriate treatment, allowing disease control and achieving minimal morbidity.
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Affiliation(s)
- X Serra-Aracil
- Coloproctology Unit, General and Digestive Surgery Department, Parc Taulí University Hospital, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - A Pallisera-Lloveras
- Coloproctology Unit, General and Digestive Surgery Department, Parc Taulí University Hospital, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - L Mora-Lopez
- Coloproctology Unit, General and Digestive Surgery Department, Parc Taulí University Hospital, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - S Serra-Pla
- Coloproctology Unit, General and Digestive Surgery Department, Parc Taulí University Hospital, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - V Puig-Diví
- Digestive Department, Parc Taulí University Hospital, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - À Casalots
- Pathology Department, Parc Taulí University Hospital, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - E Martínez-Bauer
- Digestive Department, Parc Taulí University Hospital, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - S Navarro-Soto
- Coloproctology Unit, General and Digestive Surgery Department, Parc Taulí University Hospital, Universitat Autònoma de Barcelona, Sabadell, Spain
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Serra-Aracil X, Gràcia R, Mora-López L, Serra-Pla S, Pallisera-Lloveras A, Labró M, Navarro-Soto S. How to deal with rectal lesions more than 15 cm from the anal verge through transanal endoscopic microsurgery. Am J Surg 2018; 217:53-58. [PMID: 29709273 DOI: 10.1016/j.amjsurg.2018.04.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 04/12/2018] [Accepted: 04/17/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND The aim of this study is to assess postoperative morbidity and mortality in tumors with a proximal margin 15 cm or more from the anal verge operated with transanal endoscopic microsurgery (TEM). METHODS This observational study of consecutive rectal tumor patients undergoing TEM was carried out from July 2004 to June 2017. We compared the results of rectal tumors at distances of ≥15 cm (group A) and <15 cm (group B) from the anal verge. RESULTS During the study period 667 patients were included: 118 in group A and 549 in group B. In the comparative analysis there were no significant differences in morbidity (p = 0.23), mortality (p = 0.32) or free margin involvement (p = 0.545). Differences were observed in terms of lesion size (p < 0.001), surgical time (p < 0.001) and peritoneal cavity perforation, which were all increased in group A. CONCLUSION TEM for lesions in the rectosigmoid junction is feasible and is not associated with higher morbidity or mortality.
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Affiliation(s)
- Xavier Serra-Aracil
- Coloproctology Unit. General and Digestive Surgery Service, Parc Tauli University Hospital, Sabadell, Universitat Autonoma de Barcelona, Parc Tauli s/n, 08208, Sabadell (Barcelona), Spain.
| | - Raquel Gràcia
- Coloproctology Unit. General and Digestive Surgery Service, Parc Tauli University Hospital, Sabadell, Universitat Autonoma de Barcelona, Parc Tauli s/n, 08208, Sabadell (Barcelona), Spain
| | - Laura Mora-López
- Coloproctology Unit. General and Digestive Surgery Service, Parc Tauli University Hospital, Sabadell, Universitat Autonoma de Barcelona, Parc Tauli s/n, 08208, Sabadell (Barcelona), Spain
| | - Sheila Serra-Pla
- Coloproctology Unit. General and Digestive Surgery Service, Parc Tauli University Hospital, Sabadell, Universitat Autonoma de Barcelona, Parc Tauli s/n, 08208, Sabadell (Barcelona), Spain
| | - Anna Pallisera-Lloveras
- Coloproctology Unit. General and Digestive Surgery Service, Parc Tauli University Hospital, Sabadell, Universitat Autonoma de Barcelona, Parc Tauli s/n, 08208, Sabadell (Barcelona), Spain
| | - Maritxell Labró
- Coloproctology Unit. General and Digestive Surgery Service, Parc Tauli University Hospital, Sabadell, Universitat Autonoma de Barcelona, Parc Tauli s/n, 08208, Sabadell (Barcelona), Spain
| | - Salvador Navarro-Soto
- Coloproctology Unit. General and Digestive Surgery Service, Parc Tauli University Hospital, Sabadell, Universitat Autonoma de Barcelona, Parc Tauli s/n, 08208, Sabadell (Barcelona), Spain
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Serra-Aracil X, Pericay C, Golda T, Mora L, Targarona E, Delgado S, Reina A, Vallribera F, Enriquez-Navascues JM, Serra-Pla S, Garcia-Pacheco JC. Non-inferiority multicenter prospective randomized controlled study of rectal cancer T 2-T 3s (superficial) N 0, M 0 undergoing neoadjuvant treatment and local excision (TEM) vs total mesorectal excision (TME). Int J Colorectal Dis 2018; 33:241-249. [PMID: 29234923 DOI: 10.1007/s00384-017-2942-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/28/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE The standard treatment of rectal adenocarcinoma is total mesorectal excision (TME), in many cases requires a temporary or permanent stoma. TME is associated with high morbidity and genitourinary alterations. Transanal endoscopic microsurgery (TEM) allows access to tumors up to 20 cm from the anal verge, achieves minimal postoperative morbidity and mortality rates, and does not require an ostomy. The treatment of T2, N0, and M0 cancers remains controversial. Preoperative chemoradiotherapy (CRT) in association with TEM reduces local recurrence and increases survival. The TAU-TEM study aims to demonstrate the non-inferiority of the oncological outcomes and the improvement in morbidity and quality of life achieved with TEM compared with TME. METHODS Prospective, multicenter, randomized controlled non-inferiority trial includes patients with rectal adenocarcinoma less than 10 cm from the anal verge and up to 4 cm in size, staged as T2 or T3-superficial N0-M0. Patients will be randomized to two areas: CRT plus TEM or radical surgery (TME). Postoperative morbidity and mortality will be recorded and patients will complete the quality of life questionnaires before the start of treatment, after CRT in the CRT/TEM arm, and 6 months after surgery in both arms. The estimated sample size for the study is 173 patients. Patients will attend follow-up controls for local and systemic relapse. CONCLUSIONS This study aims to demonstrate the preservation of the rectum after preoperative CRT and TEM in rectal cancer stages T2-3s, N0, M0 and to determine the ability of this strategy to avoid the need for radical surgery (TME). TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01308190. Número de registro del Comité de Etica e Investigación Clínica (CEIC) del Hospital universitario Parc Taulí: TAU-TEM-2009-01.
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Affiliation(s)
- X Serra-Aracil
- Coloproctology Unit, General and Digestive Surgery Department, Parc Tauli University Hospital, Universitat Autònoma de Barcelona, Parc Tauli s/n. 08208, Sabadell, Spain.
| | - C Pericay
- Medical Oncology Department, Parc Tauli University Hospital, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - T Golda
- Coloproctology Unit, General and Digestive Surgery Department, Bellvitge University Hospital, Barcelona, Spain
| | - L Mora
- Coloproctology Unit, General and Digestive Surgery Department, Parc Tauli University Hospital, Universitat Autònoma de Barcelona, Parc Tauli s/n. 08208, Sabadell, Spain
| | - E Targarona
- General and Digestive Surgery Department, Santa Creu and Sant Pau University Hospital, Barcelona, Spain
| | - S Delgado
- General and Digestive Surgery Department, Clinic University Hospital, Barcelona, Spain
| | - A Reina
- Coloproctology Unit, General and Digestive Surgery Department, Torrecardenas University Hospital, Almeria, Spain
| | - F Vallribera
- Coloproctology Unit, General and Digestive Surgery Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - S Serra-Pla
- Coloproctology Unit, General and Digestive Surgery Department, Parc Tauli University Hospital, Universitat Autònoma de Barcelona, Parc Tauli s/n. 08208, Sabadell, Spain
| | - J C Garcia-Pacheco
- Coloproctology Unit, General and Digestive Surgery Department, Parc Tauli University Hospital, Universitat Autònoma de Barcelona, Parc Tauli s/n. 08208, Sabadell, Spain
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Sevá-Pereira G, Trombeta VL, Capochim Romagnolo LG. Transanal minimally invasive surgery (TAMIS) using a new disposable device: our initial experience. Tech Coloproctol 2013; 18:393-7. [PMID: 23740029 DOI: 10.1007/s10151-013-1036-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2013] [Accepted: 05/19/2013] [Indexed: 12/14/2022]
Abstract
Disposable single-port surgery devices have been used for transanal minimally invasive surgery (TAMIS). Their advantage, compared to transanal endoscopic microsurgery, is that they do not require special equipment or training. The aim of this study was to assess our initial experience using the single-site laparoscopic (SSL™) access system (Ethicon Endo-Surgery, Cincinnati, OH, USA) for TAMIS. Five patients eligible for local excision of rectal tumors, four males and one female, mean age 58 years (range 50-78), underwent surgery using the SSL™ device. The average distance from anal verge was 4 cm (range 1-6). Four patients had an initial diagnosis of adenoma, and one had a previous endoscopic excision of a T1 adenocarcinoma with positive margins. In one patient, due to the lack of exposure, the procedure was converted to a low anterior resection. In the remaining four patients, average setup time was 7 minutes (range 4-15) and average operative time was 52 minutes (range 38-72). All resection margins were tumor free. There were no postoperative complications. Two of the presumed adenomas were intramucosal adenocarcinomas, while one patient had a T2 tumor and underwent radical surgery. Although at the present time the appropriate use of local excision is still under debate, TAMIS is a technique with great potential. Because of its simplicity and similarity with conventional laparoscopic surgery, it can be learned easily by surgeons not trained in transanal endoscopic microsurgery.
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Affiliation(s)
- G Sevá-Pereira
- Department of Surgery, Pró-Gastro Institute, Av. Andrade Neves, 707/702, Campinas, SP, 13013-161, Brazil,
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Transanal minimally invasive surgery (TAMIS) for local excision of benign neoplasms and early-stage rectal cancer: efficacy and outcomes in the first 50 patients. Dis Colon Rectum 2013; 56:301-7. [PMID: 23392143 DOI: 10.1097/dcr.0b013e31827ca313] [Citation(s) in RCA: 190] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Since its inception in 2009, transanal minimally invasive surgery has been used increasingly in the United States and internationally as an alternative to local excision and transanal endoscopic microsurgery for local excision of neoplasms in the distal and mid rectum. Despite its increasing acceptance, the clinical benefits of transanal minimally invasive surgery have not yet been validated. OBJECTIVE The aim of this study is to assess the adequacy of transanal minimally invasive surgery for the local excision of benign and malignant lesions of the rectum. DESIGN This is a retrospective analysis of consecutive patients who underwent transanal minimally invasive surgery for local excision of neoplasms at a single institution. SETTINGS The study was conducted by a single group of colorectal surgeons at a tertiary referral center. PATIENTS Eligible patients with early-stage rectal cancer and benign neoplasms were offered transanal minimally invasive surgery as a means for local excision. Data from these patients were collected prospectively in a registry. MAIN OUTCOME MEASURES The primary outcome measures included the feasibility of transanal minimally invasive surgery for local excision, resection quality, and short-term clinical results. RESULTS : Fifty patients underwent transanal minimally invasive surgery between July 2009 and December 2011. Twenty-five benign neoplasms, 23 malignant lesions, and 2 neuroendocrine tumors were excised. All lesions were excised using transanal minimally invasive surgery without conversion to an alternate transanal platform. The average length of stay was 0.6 days (range, 0-6), and 68% of patients were discharged on the day of surgery. The average distance from the anal verge was 8.1 cm (range, 3-14 cm). All lesions were excised completely with only 2 fragmented specimens (4%). All specimens were removed with grossly negative margins, although 3 (6%) were found to have microscopically positive margins on final pathology. There were 2 recurrences (4%) at 6- and 18-month follow-up. Early complications occurred in 3 patients (6%). No long-term complications were observed at a median follow-up of 20 months. LIMITATIONS The study was limited by its retrospective nature and midterm follow-up. CONCLUSIONS Transanal minimally invasive surgery is an advanced transanal platform that provides a safe and effective method for resecting benign neoplasms, as well as carefully selected, early-stage malignancies of the mid and distal rectum.
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