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Lau S, Kong J, Bell S, Heriot A, Stevenson A, Moloney J, Hayes J, Merrie A, Eglinton T, Guest G, Clark D, Warrier S. Transanal mesorectal excision: early outcomes in Australia and New Zealand. Br J Surg 2021; 108:214-219. [PMID: 33711138 DOI: 10.1093/bjs/znaa098] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 10/22/2020] [Accepted: 10/24/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Transanal total mesorectal excision (taTME) aims to overcome some of the technical challenges faced when operating on mid and low rectal cancers. Specimen quality has been confirmed previously, but recent concerns have been raised about oncological safety. This multicentre prospective study aimed to evaluate the safety of taTME among early adopters in Australia and New Zealand. METHODS Data from all consecutive patients who had taTME for rectal cancer from July 2014 to February 2020 at six tertiary referral centres in Australasia were recorded and analysed. RESULTS A total of 308 patients of median age of 64 years underwent taTME. Some 75.6 per cent of patients were men, and the median BMI was 26.8 kg/m2. The median distance of tumour from anal verge was 7 cm. Neoadjuvant chemoradiotherapy was administered to 57.8 per cent of patients. The anastomotic leak rate was 8.1 per cent and there was no mortality within 30 days of surgery. Pathological examination found a complete mesorectum in 295 patients (95.8 per cent), a near-complete mesorectum in seven patients (2.3 per cent), and an incomplete mesorectum in six patients (1.9 per cent). The circumferential resection margin and distal resection margin was involved in nine patients (2.9 per cent), and two patients (0.6 per cent) respectively. Over a median follow-up of 22 months, the local recurrence rate was 1.9 per cent and median time to local recurrence was 30.5 months. CONCLUSION This study showed that, with appropriate training and supervision, skilled minimally invasive rectal cancer surgeons can perform taTME with similar pathological and oncological results to open and laparoscopic surgery.
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Affiliation(s)
- S Lau
- Department of Surgery, University Hospital Geelong, Geelong, Victoria, Australia
| | - J Kong
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - S Bell
- Department of Surgery, Alfred Hospital, Melbourne, Victoria, Australia
| | - A Heriot
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - A Stevenson
- Department of Surgery, Royal Brisbane Hospital, Herston, Queensland, Australia
| | - J Moloney
- Department of Surgery, Royal Brisbane Hospital, Herston, Queensland, Australia
| | - J Hayes
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | - A Merrie
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | - T Eglinton
- Department of Surgery, University of Otago, Christchurch, New Zealand
| | - G Guest
- Department of Surgery, University Hospital Geelong, Geelong, Victoria, Australia
| | - D Clark
- Department of Surgery, Royal Brisbane Hospital, Herston, Queensland, Australia
| | - S Warrier
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Surgery, Alfred Hospital, Melbourne, Victoria, Australia
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Warrier SK, Bell S, Guest G, Heriot A, Kong JC, Eglinton TW, Hayes J, Merrie A, Clark D, Stevenson A. Locoregional recurrences after transanal total mesorectal excision of rectal cancer during the exploration phase. Br J Surg 2020; 107:e353. [DOI: 10.1002/bjs.11753] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 05/11/2020] [Indexed: 11/07/2022]
Affiliation(s)
- S K Warrier
- Division of Cancer Surgery, Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Australia
- Department of Surgery, Alfred Hospital, Melbourne, Australia
| | - S Bell
- Department of Surgery, Alfred Hospital, Melbourne, Australia
| | - G Guest
- Department of Surgery, Geelong University Hospital, Geelong, Victoria, Australia
| | - A Heriot
- Division of Cancer Surgery, Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - J C Kong
- Division of Cancer Surgery, Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - T W Eglinton
- Department of Surgery, University of Otago, Christchurch, New Zealand
| | - J Hayes
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | - A Merrie
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | - D Clark
- Department of Surgery, University of Queensland, Brisbane, Queensland, Australia
| | - A Stevenson
- Department of Surgery, University of Queensland, Brisbane, Queensland, Australia
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Abbott SC, Stevenson ARL, Bell SW, Clark D, Merrie A, Hayes J, Ganesh S, Heriot AG, Warrier SK. An assessment of an Australasian pathway for the introduction of transanal total mesorectal excision (taTME). Colorectal Dis 2018; 20:O1-O6. [PMID: 29165862 DOI: 10.1111/codi.13964] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 10/03/2017] [Indexed: 02/08/2023]
Abstract
AIM To evaluate the use of a pathway for the introduction of transanal total mesorectal excision (taTME) into Australia and New Zealand. METHOD A pathway for surgeons with an appropriate level of specialist training and baseline skill set was initiated amongst colorectal surgeons; it includes an intensive course, a series of proctored cases and ongoing contribution to audit. Data were collected for patients who had taTME, for benign and malignant conditions, undertaken by the initial adopters of the technique. RESULTS A total of 133 taTME procedures were performed following the introduction of a training pathway in March 2015. The indication was rectal cancer in 84% of cases. There was one technique-specific visceral injury, which occurred prior to that surgeon completing the pathway. There were no cases of postoperative mortality; morbidity occurred in 27.1%. The distal resection margin was clear in all cases of rectal cancer, and the circumferential resection margin was positive in two cases. An intact or nearly intact total mesorectal excision was obtained in more than 98% of cases. CONCLUSION This study demonstrates the safe and controlled introduction of a new surgical technique in a defined surgeon population with the use of a pathway for training. The authors recommend a similar pathway to facilitate the introduction of taTME to colorectal surgical practice.
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Affiliation(s)
- S C Abbott
- Division of Colorectal Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - A R L Stevenson
- Division of Colorectal Surgery, Royal Brisbane Hospital, Brisbane, Queensland, Australia
| | - S W Bell
- Division of Colorectal Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - D Clark
- Division of Colorectal Surgery, Royal Brisbane Hospital, Brisbane, Queensland, Australia
| | - A Merrie
- Division of Colorectal Surgery, Auckland City Hospital, Auckland, New Zealand
| | - J Hayes
- Division of Colorectal Surgery, Auckland City Hospital, Auckland, New Zealand
| | - S Ganesh
- Division of Colorectal Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - A G Heriot
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Victoria, Australia
| | - S K Warrier
- Division of Colorectal Surgery, Alfred Health, Melbourne, Victoria, Australia.,Division of Cancer Surgery, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Victoria, Australia
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Osterblom H, Merrie A, Metian M, Boonstra WJ, Blenckner T, Watson JR, Rykaczewski RR, Ota Y, Sarmiento JL, Christensen V, Schluter M, Birnbaum S, Gustafsson BG, Humborg C, Morth CM, Muller-Karulis B, Tomczak MT, Troell M, Folke C. Modeling Social--Ecological Scenarios in Marine Systems. Bioscience 2013. [DOI: 10.1093/bioscience/63.9.735] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Muhlmann MD, Hayes J, Merrie A, Parry B, Bissett I. CR21P�COMPLEX ANAL FISTULAS: PLUG OR FLAP? ANZ J Surg 2009. [DOI: 10.1111/j.1445-2197.2009.04915_21.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Bach SP, Hill J, Monson JRT, Simson JNL, Lane L, Merrie A, Warren B, Mortensen NJM. A predictive model for local recurrence after transanal endoscopic microsurgery for rectal cancer. Br J Surg 2009; 96:280-90. [PMID: 19224520 DOI: 10.1002/bjs.6456] [Citation(s) in RCA: 250] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The outcome of local excision of early rectal cancer using transanal endoscopic microsurgery (TEM) lacks consensus. Screening has substantially increased the early diagnosis of tumours. Patients need local treatments that are oncologically equivalent to radical surgery but safer and functionally superior. METHODS A national database, collated prospectively from 21 regional centres, detailed TEM treatment in 487 subjects with rectal cancer. Data were used to construct a predictive model of local recurrence after TEM using semiparametric survival analyses. The model was internally validated using measures of calibration and discrimination. RESULTS Postoperative morbidity and mortality were 14.9 and 1.4 per cent respectively. The Cox regression model predicted local recurrence with a concordance index of 0.76 using age, depth of tumour invasion, tumour diameter, presence of lymphovascular invasion, poor differentiation and conversion to radical surgery after histopathological examination of the TEM specimen. CONCLUSION Patient selection for TEM is frequently governed by fitness for radical surgery rather than suitable tumour biology. TEM can produce long-term outcomes similar to those published for radical total mesorectal excision surgery if applied to a select group of biologically favourable tumours. Conversion to radical surgery based on adverse TEM histopathology appears safe for p T1 and p T2 lesions.
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Affiliation(s)
- S P Bach
- Academic Department of Surgery, Queen Elizabeth Hospital, Birmingham, UK.
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Abstract
BACKGROUND Transanal endoscopic microsurgery (TEM) allows locally complete excision of rectal tumours and provides an alternative to conventional surgery for benign tumours. However, its role in the curative treatment of invasive carcinoma is controversial. The aim of this study was to determine the morbidity and long-term results for rectal tumours excised by TEM. METHODS Between February 1993 and January 2005, 200 patients underwent TEM for excision of adenomas (148) or carcinomas (52). The median tumour distance from the anal verge was 8 (range 1-16) cm. RESULTS Mortality and morbidity rates were 0.5 and 14.0 per cent respectively. At a median follow-up of 33 (range 2-133) months, local recurrence had developed in 11 patients (7.6 per cent) with an adenoma. Histological examination of carcinomas revealed pathological tumour (pT) stage 1 in 31 patients, pT2 in 17 and pT3 in four. Immediate salvage surgery was performed in seven patients (13 per cent). At a median follow-up of 34 (range 1-102) months, eight patients (15 per cent) with carcinomas had developed local recurrence. The overall and disease-free 5-year survival rates for patients with carcinomas were 76 and 65 per cent respectively. CONCLUSION TEM is an appropriate surgical treatment option for benign rectal tumours. For carcinomas, it is oncologically safe provided that resection margins are clear, but strict patient selection is required.
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Affiliation(s)
- F Bretagnol
- Department of Colorectal Surgery, John Radcliffe Hospital, Oxford, UK
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Jones OM, Ramalingam T, Merrie A, Cunningham C, George BD, Mortensen NJM, Lindsey I. Randomized clinical trial of botulinum toxin plus glyceryl trinitrate vs. botulinum toxin alone for medically resistant chronic anal fissure: overall poor healing rates. Dis Colon Rectum 2006; 49:1574-80. [PMID: 16988850 DOI: 10.1007/s10350-006-0679-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This study was designed to assess whether addition of glyceryl trinitrate to botulinum toxin improves the healing rate of glyceryl trinitrate-resistant fissures over that achieved with botulinum toxin alone. METHODS Patients were randomized between botulinum toxin plus glyceryl trinitrate (Group A) and botulinum toxin plus placebo paste (Group B). Patients were seen at baseline, four and eight weeks, and six months. The primary end point was fissure healing at eight weeks. Secondary end points were symptomatic relief, need for surgery, side effects, and reduction in maximum resting and squeeze pressures. RESULTS Thirty patients were randomized. Two-thirds of patients had maximum anal resting pressures below or within the normal range at entry to the study. Healing rates in both treatment groups were disappointing. There was a nonsignificant trend to better outcomes in Group A compared with Group B in terms of fissure healing (47 vs. 27 percent), symptomatic improvement (87 vs. 67 percent), and resort to surgery (27 vs. 47 percent). CONCLUSIONS There is some evidence to suggest that combining glyceryl trinitrate with botulinum toxin is superior to the use of botulinum toxin alone for glyceryl trinitrate-resistant anal fissure. The poor healing rate may reflect the fact that many of the patients did not have significant anal spasm at trial entry.
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Affiliation(s)
- O M Jones
- Department of Colorectal Surgery, John Radcliffe Hospital, Headington, Oxford, OX3 9DU, United Kingdom
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Carne PWG, Frye JNR, Kennedy-Smith A, Keating J, Merrie A, Dennett E, Frizelle FA. Local invasion of the bladder with colorectal cancers: surgical management and patterns of local recurrence. Dis Colon Rectum 2004; 47:44-7. [PMID: 14719150 DOI: 10.1007/s10350-003-0011-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Colorectal cancers may be adherent to the urinary bladder. To achieve oncologic clearance of the cancer, en bloc bladder resection should be performed. This study describes the multicenter experiences of en bloc bladder resection for colorectal cancer in the major New Zealand public hospitals. METHODS A retrospective database of patients undergoing surgery for colorectal cancer adherent to the bladder between 1984 and 1999 was constructed. Data was analyzed for age, gender, disease stage, and outcome (local recurrence and survival). RESULTS Fifty-three patients were identified: International Union Against Cancer and American Joint Committee on Cancer Stage 1=0; Stage 2=23; Stage 3=22; Stage 4=6; unknown=2. Forty-five had en bloc partial cystectomy performed, four en bloc total cystectomy, and four had the adhesions disrupted and no bladder resection. The most common site of the primary colorectal cancer is sigmoid colon, with local invasion into the dome of the bladder. All patients who did not have en bloc resection developed local recurrence and died from their disease. Mean follow-up was 62 months. The extent of bladder resection did not seem important in determining local recurrence. CONCLUSIONS En bloc resection of the urinary bladder should be performed if the patient is to be offered an optimal oncologic resection for adherent colorectal cancer. The decision to perform total rather than partial cystectomy should be based on the anatomic location of the tumor. Because the sigmoid is usually the primary site, most patients will not have received preoperative radiation. Therefore, postoperative radiotherapy may reduce local recurrence in these patients.
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Affiliation(s)
- P W G Carne
- Colorectal Unit, Department of Surgery, Christchurch Hospital, Christchurch, New Zealand
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