Feasibility of transanal minimally invasive surgery for total pelvic exenteration for advanced primary and recurrent pelvic malignancies

BACKGROUND

The purpose of this study was to clarify the efficacy and safety of transanal minimally invasive surgery (TAMIS) for total pelvic exenteration (TPE) in advanced primary and recurrent pelvic malignancies.

METHODS

Using a prospectively collected database, we retrospectively analyzed the clinical, surgical, and pathological outcomes of TAMIS for TPE. Surgery was performed between September 2019 and April 2023. The median follow-up period was 22 months (2-45 months).

RESULTS

Fifteen consecutive patients were included in this analysis M:F = 14:1 and median (range) age was 63 (36-74). Their diagnoses were as follows: primary rectal cancer (n = 5; 33%), recurrent rectal cancer (n = 4; 27%), primary anorectal cancer (n = 5; 33%), and gastrointestinal stromal tumor (n = 1; 7%). Bladder-sparing TPE was selected for two patients (13%). In nine of 15 patients (60%) the anal sphincter could be successfully preserved, five patients (33%) required combined resection of the internal iliac vessels, and two (13%) required rectus muscle flap reconstruction. The median operative time was 723 min (561-1082), and the median intraoperative blood loss was 195 ml (30-1520). The Clavien-Dindo classifications of the postoperative complications were as follows: grade 0-2 (n = 11; 73%); 3a (n = 3; 20%); 3b (n = 1; 7%); and ≥ 4 (n = 0; 0%). No cases of conversion to laparotomy or mortality were observed. The pathological results demonstrated that R0 was achieved in 14 patients (93%).

CONCLUSIONS

The short-term outcomes of this initial experience proved that this novel approach is feasible for TPE, with low blood loss, acceptable postoperative complications, and a satisfactory R0 resection rate.

Direct stick embolization of a rectal venous malformation via transanal minimally invasive surgery

Rectal venous malformations (VMs) are rare clinical entities with variable patterns of presentation. Treatment requires unique, targeted strategies based on the symptoms, associated complications, and location, depth, and extent of the lesion. We present a rare case of a large, isolated rectal VM treated by direct stick embolization (DSE) using transanal minimally invasive surgery (TAMIS). A 49-year-old man had presented with a rectal mass incidentally detected on computed tomography urography. Magnetic resonance imaging and endoscopy revealed an isolated rectal VM. Elevated D-dimer levels concerning for localized intravascular coagulopathy warranted the use of prophylactic rivaroxaban. To avoid invasive surgery, DSE using TAMIS was performed successfully without complications. His postoperative recovery was uneventful, aside from a self-limiting and expected course of postembolization syndrome. To the best of our knowledge, this is the first reported case of TAMIS-assisted DSE of a colorectal VM. TAMIS shows promise for more widespread use in the minimally invasive, interventional management of colorectal vascular anomalies.

Short- and long-term outcomes in ypT2 rectal cancer patients after neoadjuvant therapy and local excision: a multicentre observational study

BACKGROUND

Although local excision (LE) after neoadjuvant treatment (NT) has achieved encouraging oncological outcomes in selected patients, radical surgery still remains the rule when unfavorable pathology occurs. However, there is a risk of undertreating patients not eligible for radical surgery. The aim of this study was to evaluate the outcomes of patients with pathological incomplete response (ypT2) in a multicentre cohort of patients undergoing LE after NT and to compare them with ypT0-is-1 rectal cancers.

METHODS

From 2010 to 2019, all patients who underwent LE after NT for rectal cancer were identified from five institutional retrospective databases. After excluding 12 patients with ypT3 tumors, patients with ypT2 tumors were compared to patients with ypT0-is-1 tumors). The endpoints of the study were early postoperative and long-term oncological outcomes.

RESULTS

A total of 177 patients (132 males, 45 females, median age 70 [IQR 16] years) underwent LE following NT. There were 46 ypT2 patients (39 males, 7 females, median age 72 [IQR 18.25] years) and 119 ypT0-is-1 patients (83 males, 36 females, median age 69 [IQR 15] years). Patients with pathological incomplete response (ypT2) were frailer than the ypT0-is-1 patients (mean Charlson Comorbidity Index 6.15 ± 2.43 vs. 5.29 ± 1.99; p = 0.02) and there was a significant difference in the type of NT used for the two groups (long- course radiotherapy: 100 (84%) vs. 23 (63%), p = 0.006; short-course radiotherapy: 19 (16%) vs. 17 (37%), p = 0.006). The postoperative rectal bleeding rate (13% vs. 1.7%; p = 0.008), readmission rate (10.9% vs. 0.8%; p = 0.008) and R1 resection rate (8.7% vs. 0; p = 0.008) was significantly higher in the ypT2 group. Recurrence rates were comparable between groups (5% vs. 13%; p = 0.15). Five-year overall survival was 91.3% and 94.9% in the ypT2 and ypT0-is-1 groups, respectively (p = 0.39), while 5-year cancer specific survival was 93.4% in the ypT2 group and 94.9% in the ypT0-is-1 group (p = 0.70). No difference was found in terms of 5-year local recurrence free-survival (p = 0.18) and 5-year distant recurrence free-survival (p = 0.37).

CONCLUSIONS

Patients with ypT2 tumors after NT and LE have a higher risk of late-onset rectal bleeding and positive resection margins than patients with complete or near complete response. However, long-term recurrence rates and survival seem comparable.

Multicenter clinical trial for the resection of rectal polyps using a new laparoendoscopic hybrid transanal access device

INTRODUCTION

Complex polyps require the use of advanced endoscopic techniques or minimally invasive surgery for their approach. In rectal polyps it is of special relevance to reach a consensus on the best approach to avoid under- or overtreatment that increases unnecessary morbidity and mortality.

METHODS

We describe a prospective, multicenter, pilot clinical trial with a first-in-human medical device. It is hypothesized that UNI-VEC® facilitates transanal laparoendoscopic surgery for the removal of early rectal tumors. The primary objective is to evaluate that it is safe and meets the established functional requirements. Secondary objectives are to evaluate results, complications and level of satisfaction.

RESULTS

16 patients were recruited in 12 months with a minimum follow-up of 2 months. The mean size was 3.4 cm with the largest polyp being 6 cm. Regarding location, the mean was 6.6 cm from the anal margin. Endoscopic Mucosal Resection (EMR) (6.3%), Endoscopic Submucosal Dissection ESD (43.8%), REC (6.3%) and TAMIS (43.8%) were performed. The mean time was 73.25 min. The 56.3% used a 30° camera and 43.8% used the flexible endoscope as a viewing instrument. The 56.3% were benign lesions and 43.8% malignant. Complete resection is achieved in 87.5%. Regarding complications, mild bleeding (Clavien I) occurred in 25%, 6.3% and 21.4% at 24 h, 48 h and 7 days respectively. Continence was assessed according to the Wexner scale. At 7 days, 60% showed perfect continence, 26.7% mild FI and 13.3% moderate FI. At 30 days, 66.7% had perfect continence, 20% mild FI and 13.3% moderate FI. At 2 months, 4 patients were reviewed who at 30 days had a Wexner's degree higher than preoperative and perfect continence was demonstrated in 25% of the patients, 50% mild and 25% moderate. In no case did rectal perforation or major complications requiring urgent reintervention occur. As for the level of reproducibility, safety, level of satisfaction with the device and evaluation of the blister, the evaluation on a scale of 0 to 10 (9.43, 9.71, 9.29 and 9.50 respectively). All the investigators have previous experience with transanal devices.

CONCLUSIONS

The study demonstrates the efficacy and safety of UNI-VEC® for the treatment of rectal lesions. It will facilitate the implementation of hybrid procedures that seek to solve the limitations of pure endoscopic techniques by allowing the concomitant use of conventional laparoscopic and robotic instrumentation with the flexible endoscope.

Assessment of the learning curve for the novel transanal minimally invasive surgery simulator model

BACKGROUND

Transanal minimally invasive surgery (TAMIS) is technically demanding and requires extensive training. We developed the TAMIS simulator model by remodeling an existing laparoscopic training system to educate trainees and analyzed their learning curves.

METHODS

Between March 2020 and June 2020, 12 trainees performed TAMIS simulator training sessions. The total operative time, including specimen removal and wound closure, was recorded. The wound closure and specimen quality, trainee self-confidence, and supervisor evaluation of technical performance were documented. A moving average was used to analyze the number of training sessions required to stabilize the procedure time, while a cumulative sum analysis was performed to identify that required to reach proficiency with each item.

RESULTS

Each trainee completed 20 TAMIS simulator training sessions. The median total procedure time was 13 min (range, 4-60 min), which stabilized after 15 training sessions. The median times for specimen removal and wound closure were 3 min (range, 1-18 min) and 10 min (range, 2-50 min), respectively, which stabilized after 7 and 15 training sessions, respectively. The mean specimen and wound closure quality scores were 2.9 ± 0.9 (on a scale from 1 to 4) and 2.3 ± 1.1 (on a scale from 1 to 4), respectively, competencies in which were achieved after 16 and 20 training sessions, respectively. The mean trainee self-confidence and supervisor evaluation of technical performance scores were 2.4 ± 1.2 (on a scale from 1 to 5) and 2.7 ± 1.2 (on a scale from 1 to 5), respectively, competencies in which were achieved after 20 and 17 training sessions, respectively.

CONCLUSION

Trainees required 15 training sessions to stabilize the procedure time and 16-20 training sessions to demonstrate competencies with the TAMIS simulator model. We expect this simulator model may help surgeons more rapidly acquire the skills required for TAMIS.

Multidisciplinary management of early rectal cancer - The role of surgical local excision in current and future clinical practice

The implementation of bowel cancer screening programs has led to a rise in the incidence of early rectal cancer. The combination of increased incidence and the growing interest in organ-sparing treatment options has led to an amplified importance of local excision techniques in treatment strategies for early rectal cancer. In addition, developments in new technologies of single-port surgery have popularized surgical techniques. Although local treatment of early rectal cancer seems promising, a multidisciplinary approach is necessary and awareness of the oncological robustness is warranted to enable shared decision-making. This review illustrates the position of surgical local excision in the treatment of early rectal cancer and reflects on its role in current and future clinical practice.

Can adjuvant pelvic radiation therapy after local excision or polypectomy for T1 and T2 rectal cancer offer an alternative option to radical surgery?

•

Adjuvant radiation therapy post local excision o f T1/T2 rectal cancer offers good disease control.

•

There were no locoregional recurrences at median follow up of 51 months.

•

This approach was well tolerated.

•

This approach may offer an alternative to TME surgery.

Purpose

To determine outcomes after adjuvant pelvic local radiation therapy (RT) +/− concurrent chemotherapy for T1 and T2 rectal carcinomas treated with local excision or polypectomy.

Methods

We retrospectively identified adult patients with histologically proven T1 and T2 rectal adenocarcinoma, diagnosed incidentally at time of local excision or polypectomy between 01 January 2007 and 31 December 2019, and appropriately staged to confirm N0 M0 status. Patients were excluded if they had recurrent cancer or had received total mesorectal excision (TME): anterior resection (AR) or abdominoperineal resection (APR). Patient, tumour and treatment factors, together with disease and toxicity outcomes were collected from institutional medical records, correspondence and investigation reports. Descriptive statistical analyses were employed. The primary endpoint was loco-regional control and secondary endpoints were treatment-related toxicity, disease free survival, overall survival and rate of surgical salvage for pelvic recurrence.

Results

The median age of the 15 eligible patients was 73 (range 49–82 years). There were 9 men (60%) and 6 women (40%). The majority had T1 disease (80%) and most had received endomucosal resection (80%). All patients received 43-52Gy (EQD2) to the primary and 43-48Gy (EQD2) to the pelvis with 46.6% receiving concurrent chemotherapy (infusional 5-FU or oral capecitabine). At median follow up of 51 months, there were no local or regional recurrences. One patient experienced an isolated distant relapse at 48 months without any locoregional recurrence.

Conclusion

Our findings demonstrate good locoregional disease control with the use of adjuvant pelvic RT for T1 and T2 rectal adenocarcinoma initially treated with polypectomy or local (non-oncological) excision. These findings indicate that adjuvant pelvic RT may provide an alternative to TME surgery in patients with incidentally detected early rectal cancers.

Management of early rectal cancer; current surgical options and future direction

Rectal cancer is the second commonest cause of cancer death within the United Kingdom. Utilization of national screening programmes have resulted in a greater proportion of patients presenting with early-stage disease. The technique of transanal endoscopic microsurgery was first described in 1984 following which further options for local excision have emerged with transanal endoscopic operation and, more recently, transanal minimally invasive surgery. Owing to the risks of local recurrence, the current role of minimally invasive techniques for local excision in the management of rectal cancer is limited to the treatment of pre-invasive disease and low risk early-stage rectal cancer (T1N0M0 disease). The roles of chemotherapy and radiotherapy for the management of early rectal cancer are yet to be fully established. However, results of high-quality research such as the GRECCAR II, TESAR and STAR-TREC randomised control trials may highlight a wider role for local excision surgery in the future, when used in combination with oncological therapies. The aim of our review is to provide an overview in the current management of early rectal cancer, the surgical options available for local excision and the future multimodal direction of early rectal cancer treatment.

The first robotic transanal minimally invasive surgery in Ireland: a case-based review

Transanal minimally invasive surgery (TAMIS) has gained worldwide acceptance as a means of local excision of early rectal cancers and benign rectal lesions. However, it is technically challenging due to the limitations of rigid laparoscopic instruments in the narrow rectal lumen. Robotic platforms offer improved ergonomics that are valuable in operative fields with limited space. Robotic TAMIS represents an exciting new development that may be more versatile than traditional TAMIS. In this review, we describe the first case of robotic TAMIS performed in our country and a review of current literature on the technique.

Endoscopic management versus transanal surgery for early primary or early locally recurrent rectal neoplasms-a systematic review and meta-analysis

BACKGROUND

Both endoscopic techniques and transanal surgery are viable options that allow organ preservation for early rectal neoplasms. Whilst endoscopic approaches are less invasive and carry less morbidity, it is unclear whether they are as oncologically effective.

AIM

To compare endoscopic techniques with transanal surgery in the management of early rectal neoplasms.

METHODS

A systematic literature search was performed for randomised and observational studies comparing these techniques. The pre-specified main outcomes measured were en bloc and R0 resection rates and recurrence. Pair-wise meta-analysis was performed.

RESULTS

This review included 1044 patients. Transanal surgery had increased R0 resection rates (odds ratio (OR) 2.66; 95% CI 1.64; 4.31; p < 0.001) versus endoscopic management. The latter was associated with higher rates of incomplete resection (OR 2.25; 95% CI 1.14, 4.46; p = 0.02) and further intervention (OR 1.78; 95% CI 1.09, 2.88; p = 0.02). There was no difference in the rates of late recurrence (OR 1.01; 95% CI 0.53, 1.91; p = 0.99) or further major surgery (OR 0.87; 95% CI 0.39, 1.94; p = 0.73) between the groups. Endoscopic treatment was associated with a shorter operating time (weighted mean difference (WMD) - 12.08; 95% CI - 18.97, - 5.19; p < 0.001) and LOS (WMD - 1.94; 95% CI - 2.43, - 1.44; p < 0.001), as well as lower rates of urinary retention post-operatively (OR 0.12; 95% CI 0.02, 0.63; p = 0.01).

CONCLUSION

Endoscopic techniques should be favoured in the setting of benign early rectal neoplasms given their decreased morbidity and increased cost-effectiveness. However, where malignancy is suspected transanal surgery should be the preferred option given the superior R0 resection rate.

Role of minimally invasive surgery for rectal cancer

Rectal cancer is one of the most common malignancies worldwide. Surgical resection for rectal cancer usually requires a proctectomy with respective lymphadenectomy (total mesorectal excision). This has traditionally been performed transabdominally through an open incision. Over the last thirty years, minimally invasive surgery platforms have rapidly evolved with the goal to accomplish the same quality rectal resection through a less invasive approach. There are currently three resective modalities that complement the traditional open operation: (1) Laparoscopic surgery; (2) Robotic surgery; and (3) Transanal total mesorectal excision. In addition, there are several platforms to carry out transluminal local excisions (without lymphadenectomy). Evidence on the various modalities is of mixed to moderate quality. It is unreasonable to expect a randomized comparison of all options in a single trial. This review aims at reviewing in detail the various techniques in regard to intra-/perioperative benchmarks, recovery and complications, oncological and functional outcomes.

Transanal minimally invasive surgery (TAMIS) versus endoscopic submucosal dissection (ESD) for resection of non-pedunculated rectal lesions (TRIASSIC study): study protocol of a European multicenter randomised controlled trial

BACKGROUND

In the recent years two innovative approaches have become available for minimally invasive en bloc resections of large non-pedunculated rectal lesions (polyps and early cancers). One is Transanal Minimally Invasive Surgery (TAMIS), the other is Endoscopic Submucosal Dissection (ESD). Both techniques are standard of care, but a direct randomised comparison is lacking. The choice between either of these procedures is dependent on local expertise or availability rather than evidence-based. The European Society for Endoscopy has recommended that a comparison between ESD and local surgical resection is needed to guide decision making for the optimal approach for the removal of large rectal lesions in Western countries. The aim of this study is to directly compare both procedures in a randomised setting with regard to effectiveness, safety and perceived patient burden.

METHODS

Multicenter randomised trial in 15 hospitals in the Netherlands. Patients with non-pedunculated lesions > 2 cm, where the bulk of the lesion is below 15 cm from the anal verge, will be randomised between either a TAMIS or an ESD procedure. Lesions judged to be deeply invasive by an expert panel will be excluded. The primary endpoint is the cumulative local recurrence rate at follow-up rectoscopy at 12 months. Secondary endpoints are: 1) Radical (R0-) resection rate; 2) Perceived burden and quality of life; 3) Cost effectiveness at 12 months; 4) Surgical referral rate at 12 months; 5) Complication rate; 6) Local recurrence rate at 6 months. For this non-inferiority trial, the total sample size of 198 is based on an expected local recurrence rate of 3% in the ESD group, 6% in the TAMIS group and considering a difference of less than 6% to be non-inferior.

DISCUSSION

This is the first European randomised controlled trial comparing the effectiveness and safety of TAMIS and ESD for the en bloc resection of large non-pedunculated rectal lesions. This is important as the detection rate of these adenomas is expected to further increase with the introduction of colorectal screening programs throughout Europe. This study will therefore support an optimal use of healthcare resources in the future.

TRIAL REGISTRATION

Netherlands Trial Register, NL7083 , 06 July 2018.

Outcomes of completion total mesorectal excision are not compromised by prior transanal minimally invasive surgery

AIM

Transanal minimally invasive surgery (TAMIS) is used increasingly often as an organ-preserving treatment for early rectal cancer. If final pathology reveals unfavourable histological prognostic features, completion total mesorectal excision (cTME) is recommended. This study is the first to investigate the results of cTME after TAMIS.

METHOD

Data were retrieved from the prospective database of the Elisabeth-TweeSteden Hospital. Completion TME patients were case matched with a control group of patients undergoing primary TME (pTME). Primary and secondary outcomes were surgical outcomes and oncological outcomes, respectively.

RESULTS

From 2011 to 2017, 20 patients underwent cTME and were compared with 40 patients undergoing pTME. There were no significant differences in operating time (238 min vs 226 min, P = 0.53), blood loss (137 ml vs. 158 ml, P = 0.88) or complications (45% vs 55%, P = 0.07) between both groups. There was no 90-day mortality in the cTME group. The mesorectal fascia was incomplete in three patients (15%) in the cTME group compared with no breaches in the pTME group (P = 0.083). There were no local recurrences in either group. In three patients (15%), distant metastases were detected after cTME compared with one patient (2.5%) in the pTME group (P = 0.069). After cTME patients had a 1- and 5-year disease-free survival of 85% compared with 97.5% for the pTME group (P = 0.062).

CONCLUSION

Completion TME surgery after TAMIS is not associated with increased peri- or postoperative morbidity or mortality compared with pTME surgery. After cTME surgery patients have a similar disease-free and overall survival when compared with patients undergoing pTME.

Should the rectal defect be sutured following TEMS/TAMIS carried out for neoplastic rectal lesions? A meta-analysis

INTRODUCTION

Management of the rectal defect following transanal endoscopic microsurgery (TEMS) or minimally invasive surgery (TAMIS) carried out for excision of neoplasm in the lower rectum is controversial. We aimed to extract evidence by carrying out a meta-analysis to compare the peri- and postoperative outcomes following rectal neoplasm excision carried out by TEMS and/or TAMIS, whereby the defect is either sutured or left open.

METHODS

A literature search of Ovid MEDLINE and EMBASE was performed. Full-text comparative studies published until November 2019, in English and of adult patients, whereby TEMS or TAMIS was undertaken for rectal neoplasms were included. The main outcome measures were postoperative bleeding, infection, operative time and hospital stay.

FINDINGS

Three studies (one randomised controlled trial and two comparative case series) yielded 555 cases (283 in the sutured group and 272 in the open group). The incidence of postoperative bleeding was higher and statistically significant (p = 0.006) where the rectal defect was left open following excision of the neoplasm (19/272, 6.99% vs 6/283, 2.12%). There was no statistical difference between the sutured and open groups regarding infection (p = 0.27; (10/283, 3.53% vs 5/272, 1.84%, respectively), operative time (p = 0.15) or length of stay (p = 0.67).

CONCLUSION

Suturing the rectal defect following excision of rectal neoplasm by TEMS/TAMIS reduces the incidence of postoperative bleeding in comparison to leaving the defect open. However, suturing makes the procedure slightly longer but there was no statistical difference between both groups when postoperative infection and length of hospital stay were compared.

[Transanal total mesorectal excision-a critical appraisal]

INTRODUCTION

Total mesorectal excision (TME) is the international standard for rectal cancer surgery. In addition to laparoscopic TME (lapTME), transanal TME (taTME) was developed in recent years to reduce the rate of incomplete TME, conversion to open surgery and postoperative functional impairment. Despite limited evidence, this technique is becoming increasingly more popular and is already routinely used by many hospitals for rectal cancer in varying tumor level locations. The aim of this review was to evaluate the taTME compared to anterior rectal resection with lapTME as the standard of care in rectal cancer surgery based on currently available evidence.

METHOD

The databases PubMed and Medline were systematically searched for publications on transanal total mesorectal excision (taTME) and transanal minimally invasive surgery (TAMIS). Relevant studies were selected and further research based on the reference lists was undertaken.

RESULTS

A total of 16 studies analyzing 3782 patients were identified. The taTME does not lead to a higher rate of complete TME-resected specimens compared to the standard procedure. So far, superiority could not be demonstrated for complication rates or for functional or oncological results. Serious complications secondary to dissection in incorrect planes were observed. The anastomotic level generally seems to be closer to the sphincter after taTME versus anterior lapTME.

CONCLUSION

Considering current evidence, taTME failed to show superiority compared to conventional anterior lapTME. Although taTME has some potential advantages, it carries substantial risks. If performed outside of clinical trials, it should therefore only be used in carefully selected patients with a high possibility of conversion, following adequate patient informed consent and after intense and systematic training of the surgeon.

Novel technique for anastomotic salvage using transanal minimally invasive surgery: A case report

BACKGROUND

Anastomotic leak (AL) after low anterior resection (LAR) can be a highly morbid complication. The incidence of AL ranges from 5% to 20% depending on patient characteristics and the distance of the anastomosis from the anal verge. Low anastomoses and leaks pose technical challenges for endoscopic treatment. The aim of this report was to describe the use of a commercially available laparoscopic energy device through a transanal minimally invasive surgery (TAMIS) port for the management of a symptomatic leak not requiring relaparotomy (grade B) after a LAR with diverting loop ileostomy.

CASE SUMMARY

A TAMIS GelPOINT Path port was inserted into the anus to access the distal rectum. Pneumorectum was achieved with AirSeal insufflation and a 30 degree laparoscope was introduced through a trocar. A LigaSure^TM Retractable L-Hook device was then used to perform a septotomy of the chronic sinus tract identified posterior to the coloproctostomy. The procedure was then repeated twice in three weeks intervals with ultimate resolution of the chronic leak cavity. Several months after serial TAMIS septotomies, barium enema demonstrated a patent anastomosis with no evidence of persistent leak or stricture. The patient subsequently underwent ileostomy reversal and has had no significant post-operative issues.

CONCLUSION

TAMIS septotomy with the LigaSure^TM Retractable L-Hook is a feasible and effective, minimally invasive salvage technique for the treatment of grade B ALs. Larger studies are needed to assess the generalizability and long-term results of this technique.

Surgical outcomes of robotic transanal minimally invasive surgery for selected rectal neoplasms: A single-hospital experience

BACKGROUND

Rectal neoplasm is one of the most common malignancies worldwide. Screening programs for rectal neoplasm result in early diagnosis and a decrease in disease-related mortality and morbidity. In selected patients, early rectal cancer may be treated with local excision. Owing to poor exposure during conventional transanal excision, transanal minimally invasive surgery (TAMIS) was developed, and TAMIS is feasible for the local excision of selected rectal neoplasms. However, the limited range of motion is a major disadvantage of this operation. Therefore, robotic TAMIS was developed to resolve this issue. This paper describes the surgical outcomes of robotic TAMIS for selected rectal tumors.

METHODS

The eligibility criteria for robotic TAMIS were as follows: benign neoplasms, early malignancy, complete remission after concurrent chemoradiotherapy, lesions located in the middle or lower rectum, and a lesion size of less than 5 cm. To gain access to the anal canal, a transanal access platform was used, and the da Vinci robotic system was mounted for surgery. Patient characteristics and surgical outcomes were recoded.

RESULTS

A total of 23 patients were included, and the median tumor size was 2.5 cm (range: 1.1-4.5 cm) on average. The median tumor location was 5 cm (range: 2-8 cm) from the anal verge. The median length of hospital stay was 3 days (range: 1-10 days). No intraoperative complications were reported, and no patient readmission occurred. The median follow-up period was 9.6 months. No recurrent lesion was found in the follow-up period.

CONCLUSION

Based on the short-term results, robotic TAMIS is a feasible and safe technique for the local excision of selected rectal neoplasms.

Radial incision and cutting method using a transanal approach for treatment of anastomotic strictures following rectal cancer surgery: a case report

Background

Development of an anastomotic stricture following rectal cancer surgery is not uncommon. Such strictures are usually managed by manual or instrumental dilatation techniques that are often insufficiently effective, as evidenced by the high recurrence rate. Various surgical procedures using minimally invasive approaches have also been reported. One of these procedures, endoscopic radial incision and cutting (RIC), has been extensively reported. However, RIC by transanal minimally invasive surgery (TAMIS) is yet to be reported. We here report a novel application of TAMIS for performing RIC for anastomotic rectal stenosis.

Case presentation

A 67-year-old man had suffered from constipation for 6 years after undergoing low anterior resection for stage II rectal cancer 7 years ago. Colonoscopy showed a 1-cm diameter stricture in the lower rectum. Balloon dilatation was performed many times because of repeated recurrences. Thus, surgical management was considered and the stricture was successfully excised via a RIC method using a TAMIS approach. Postoperatively, the patient had minimal leakage that resolved with conservative treatment.

Conclusions

A RIC method using a TAMIS approach is an effective minimally invasive means of managing anastomotic strictures following rectal cancer surgery.

The effect of proctoring on the learning curve of transanal minimally invasive surgery for local excision of rectal neoplasms

BACKGROUND

The current method of choice for local resection of benign and selected malignant rectal tumors is transanal endoscopic microsurgery. Transanal minimally invasive surgery (TAMIS) yields similar oncological results and better patient reported outcomes when compared to transanal endoscopic micro surgery. However, due to the technical complexity of TAMIS, a significant learning curve has been suggested. Data on the surgical learning curve are limited. The aim of our study was to investigate surgeon specific learning curves for TAMIS procedures for the local excision of selected rectal tumors, and analyze the effects of proctoring on operating time and outcome.

METHODS

The current study was prospective of all TAMIS procedures performed by two surgeons from October 2010 to November 2017. Margin positivity, specimen fragmentation, adverse events and operative time were evaluated with a cumulative sum analysis to determine the number of procedures required to reach proficiency. Cumulative sum (CUSUM) analysis was used to determine trends in changes over time.

RESULTS

The earliest adopter, surgeon A, performed 103 procedures, was not proctored and developed the standardized institutional program. Surgeon B, performed 26 cases, had the benefit of a proctorship and availability of a standardized program. The CUSUM curve for operative time showed a change after 36 cases for surgeon A and after 10 cases for surgeon B. For margin positivity proficiency was reached after 31 and 6 cases for surgeon A and B, respectively. The complications curve for surgeon A showed a three-phase learning curve with a decrease after the 26th case whereas surgeon B only had one (3.8%) complication in the learning phase with no change point in the CUSUM curve. Comparing pre- and post-proficiency periods there was a decrease in operating time for both surgeon A (84.4 ± 47.3 to 55.9 ± 30.1 min) and surgeon B (90.6 ± 64.to 53 ± 26.5 min; p < 0.001). Overall margin positivity rates decreased non significantly from 21.7 to 4.8% (p = 0.23). Complications were higher in the pre-proficiency period (21.7% vs. 13.0%; p = 0.02). Surgeon A had significantly more postoperative complications in pre-proficiency phase when compared to surgeon B (25% vs. none, p < 0.001), in the post-proficiency phase there was no statistically significant difference between both surgeons (p = 0.08).

CONCLUSIONS

Our results suggest that to reach satisfactory results for TAMIS, 18-31 procedures are required. Standardized institutional operative protocols together with proficient proctorship may contribute to a shorter learning curve with fewer cases (6-10) required to reach proficiency.

Comparative Quality of Life in Patients Following Transanal Minimally Invasive Surgery and Healthy Control Subjects

BACKGROUND

Transanal minimally invasive surgery (TAMIS) is considered the successor of transanal endoscopic microsurgery (TEMS). It makes use of more readily available laparoscopic instruments and single-port access platforms with similar perioperative, clinical and oncological outcomes. Little is known about quality of life (QoL) outcomes after the use of TAMIS. The aim of this study was to assess QoL after TAMIS in our patients and compare this with QoL in the healthy Dutch population.

METHODS

All patients undergoing TAMIS for selected rectal neoplasms between October 2011 and March 2014 were included in this analysis. Patients were studied for a minimal period of 24 months. QoL outcomes were measured using the Short-Form 36 Health Survey (SF-36) questionnaire; faecal continence was measured using the Faecal Incontinence Severity Index questionnaire. Patient reported outcomes were compared to case-matched healthy Dutch control subjects. We hypothesise that undergoing TAMIS will subsequently result in a decreased quality of life in patients compared to healthy individuals.

RESULTS

Thirty-seven patients (m:f = 17:20, median 67 years) were included in the current analysis. In four patients (10.8%), postoperative complications occurred. The median follow-up was 36 (range 21-47) months. Postoperative QoL scores are similar comparable to those reported by Dutch healthy controls. Patients reported a statistically significant better QoL score in the 'bodily pain' domain when compared to the controls (81.8 vs. 74.1 points) (p = 0.01). Significant worse QoL scores for the 'social functioning' domain were reported by patients after TAMIS (84.4 vs. 100 points) (p = 0.03).

CONCLUSION

TAMIS seems to be a safe technique with postoperative QoL scores similar to that of healthy case matched controls in 3-year follow-up. There seems to be no association between faecal incontinence and reported QoL. Negative effects of TAMIS on social functioning of patients should not be underestimated and should be discussed during preoperative counselling.

Transanal minimally invasive surgery for rectal polyps and selected malignant tumors: caution concerning intermediate-term functional results

PURPOSE

Transanal minimally invasive surgery (TAMIS) is gaining worldwide popularity as an alternative for the transanal endoscopic microsurgery (TEMS) method for the local excision of rectal polyps and selected neoplasms. Data on patient reported outcomes regarding short-term follow-up are scarce; data on functional outcomes for long-term follow-up is non-existent.

METHODS

We used the fecal incontinence severity index (FISI) to prospectively assess the fecal continence on the intermediate-term follow-up after TAMIS. The primary outcome measure is postoperative fecal continence. Secondary outcome measures are as follows: perioperative and intermediate-term morbidity.

RESULTS

Forty-two patients (m = 21:f = 21), median age 68.5 (range 34-94) years, were included in the analysis. In four patients (9.5%), postoperative complications occurred. The median follow-up was 36 months (range 24-48). Preoperative mean FISI score was 8.3 points. One year after TAMIS, mean FISI score was 5.4 points (p = 0.501). After 3 years of follow-up, mean FISI score was 10.1 points (p = 0.01). Fecal continence improved in 11 patients (26%). Continence decreased in 20 patients (47.6%) (mean FISI score 15.2 points, [range 3-31]).

CONCLUSIONS

This study found that the incidence of impaired fecal continence after TAMIS is substantial; however, the clinical significance of this deterioration seems minor. The present data is helpful in acquiring informed consent and emphasizes the need of proper patient information. Functional results seem to be comparable to results after TEMS. Furthermore, we confirmed TAMIS is safe and associated with low morbidity.

Should the rectal defect be closed following transanal local excision of rectal tumors? A systematic review and meta-analysis

BACKGROUND

Transanal local excision (TLE) has become the treatment of choice for benign and early-stage selected malignant tumors. However, closure of the rectal wall defect remains a controversial point and the available literature still remains unclear. Our aim was to determine through a systematic review of the literature and a meta-analysis of relevant studies whether or not the wall defect following TLE of rectal tumors should be closed.

METHODS

Medline and the Cochrane Trials Register were searched for trials published up to December 2016 comparing open versus closed management of the surgical rectal defect after TLE of rectal tumors. Meta-analysis was performed using Review Manager 5.0.

RESULTS

Four studies were analyzed, yielding 489 patients (317 in the closed group and 182 in the open group). Meta-analysis showed no significant difference between the closed and open groups regarding the overall morbidity rate (OR 1.26; 95% CI 0.32-4.91; p = 0.74), postoperative local infection rate (OR 0.62; 95% CI 0.23-1.62; p = 0.33), postoperative bleeding rate (OR 0.83; 95% CI 0.29-1.77; p = 0.63), and postoperative reintervention rate (OR 2.21; 95% CI 0.52-9.47; p = 0.29).

CONCLUSIONS

This review and meta-analysis suggest that there is no difference between closure or non-closure of wall defects after TLE.

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

INTRODUCTION

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

METHODS AND PROCEDURES

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

RESULTS

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

CONCLUSIONS

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

Comparative evaluation of colonoscopy-assisted transanal minimally invasive surgery via glove port and endoscopic submucosal dissection for early rectal tumor

BACKGROUND

Early rectal tumor is usually managed by local excision. A novel method-colonoscopy-assisted transanal minimally invasive surgery via glove port (CA-TAMIS-GP)-for resecting early rectal tumor was developed and compared with endoscopic submucosal dissection (ESD).

MATERIALS AND METHODS

We performed CA-TAMIS-GP surgery on 26 patients from January 2014 to February 2016. For better analysis, we retrospectively collected data from 31 patients who underwent ESD between October 2012 and December 2013; overall, 57 patients diagnosed with early rectal tumor were included in this study. Perioperative conditions and long-term outcomes of both groups were compared.

RESULTS

All lesions were dissected completely and successfully without conversion to open surgery or major complications. On histopathologic examination, all specimens in this study had negative margins. All patients had uneventful postoperative recoveries, except 3 patients of CA-TAMIS-GP with minor hematochezia, which resolved spontaneously; 7 ESD patients had late-onset bleeding and 3 needed colonoscopic hemostasis; 2 patients in each group had mild fever. The CA-TAMIS-GP group had a shorter operation time, less hemorrhage, and a lower average consumable cost than the ESD group (P < 0.05); moreover, the CA-TAMIS-GP group had no recurrence or long-term complications during a follow-up of 10-32 months, whereas3 patients in the ESD group developed local recurrence during a follow-up of 24-36 months.

CONCLUSIONS

The CA-TAMIS-GP is a new method that is safe and effective in patients with early rectal tumor and appears to have a shorter operation time and less blood loss as compared with ESD.

[Full thickness resection device (FTRD). Experience and outcome for benign neoplasms of the rectum and colon]

BACKGROUND

The diagnostic validity of a full-thickness resection is higher compared to endoscopic mucosal resection (EMR) or endoscopic mucosal dissection (ESD). Whereas transanal endoscopic microsurgery techniques (TEM, TAMIS) are established therapeutic procedures in the rectum no established and safe minimally invasive or endoscopic procedure exists in the colon.

AIM

In this study the novel endoscopic full thickness resection device (FTRD, Ovesco, Germany) was investigated concerning success rates with histologically proven full thickness resections, R0 status as well as patient and device safety for the rectum and colon.

METHOD

In the period from November 2014 to June 2015 full thickness resections in the rectum and colon were performed with the FTRD in 20 patients. Data on technical success, R0 resection rate and histologically confirmed full thickness resections were retrospectively analyzed.

RESULTS

The following indications were treated in the rectum (n = 11) and colon (n = 9): T1 carcinoma (n = 6) and neuroendocrine tumors (n = 2), untreated and nonlifting adenomas (n = 3) and incomplete resection of adenomas with low and high grade dysplasia (n = 9). The technical success rate was 75 %, 3 technical failures made a conventional polypectomy necessary in 2 patients and in 1 patient an operative resection of the duplicated intestinal wall had to be performed. The median endoscopic follow-up time was 61.5 days (n = 10) and in 7 patients the clip had dislodged at the first follow-up. A thermal perforation in one case of conventional polypectomy gave rise to indications for a partial resection of the colon. In one patient the lesion in the cecum could be reached but not treated for technical reasons. The histological R0 rate was 80 %, whereas the full thickness resection rate was 60 % (85.7 % in the colon and 54.6 % in the rectum). In two patients with carcinoma and incomplete FTRD, surgical treatment was performed. The median size of the resection specimen was 5  cm(2) (range 1.6-12.9  cm(2)).

CONCLUSION

The results show that FTRD is a safe and effective instrument for use in the lower gastrointestinal tract. Limitations of the FTRD system concerning full thickness resection are scarring, fibrosis and thickness of the intestinal wall, especially in the lower rectum; therefore, it is suggested that a simulation with a tube similar in size to the FTRD should be performed during the screening colonoscopy in order to establish whether an endoscopic resection with FTRD is possible.

Transanal endoscopic microsurgery and transanal minimally invasive surgery: is one technique superior?

BACKGROUND

Transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS) have been shown to improve the quality of transanal resections, allowing for improved visibility and access to the proximal rectum. This study compares the short-term outcomes between TEM and TAMIS among experienced colorectal surgeons.

METHOD

A retrospective review was conducted for TEM and TAMIS performed from 2012 to 2015 by local colorectal surgeons. Baseline patient demographics, operative variables, pathology results, and short-term outcomes were assessed.

RESULTS

Sixty-nine patients were identified (40 TEM and 29 TAMIS). Patient demographics, tumor characteristics, operative variables, margin status, and postoperative complications were similar for both. Volume of resection was higher for TAMIS (P < .001). Lymph node retrieval was achieved in 17.2% of TAMIS cases compared with 0% of TEM (P = .01).

CONCLUSIONS

TAMIS appears to have equivalent indications and outcomes compared with TEM. TAMIS is associated with larger specimens and more frequent presence of mesorectal lymph nodes.

TAMIS for rectal tumors: advancements of a new approach. Updates Surg. 2016;68:93-97. [PMID: 27052544 DOI: 10.1007/s13304-016-0362-3]

TAMIS allows transanal excision of rectal lesions by the means of a single-incision access port and traditional laparoscopic instruments. This technique represents a promising treatment of rectal neoplasms since it guarantees precise dissection and reproducible approaches. From May 2010 to September 2015, we performed excisions of rectal lesions in 55 patients using a SILS port. The pre-operative diagnosis was 26 tumours, 26 low and high grade displasias and 3 other benign neoplasias. 11 patients had a neoadjuvant treatment. Pneumorectum was established at a pressure of 15-20 mmHg CO2 with continuous insufflation, and ordinary laparoscopic instruments were used to perform full thickness resection of rectal neoplasm with a conventional 5-mm 30° laparoscopic camera. The average operative time was 78 min. Postoperative recovery was uneventful in 53 cases: in one case a Hartmann procedure was necessary at two postoperative days due to an intraoperative intraperitoneal perforation; in another case, a diverting colostomy was required at the five postoperative days due to an intraoperative perforation of the vaginal wall. Unclear resection margins were detected in six patients: thereafter five patients underwent radical surgery; the other patient was unfit for radical surgery, but is actually alive and well. Patients were discharged after a median of 3 days. Transanal minimally invasive surgery is an advanced transanal platform that provides a safe and effective method for low rectal tumors. The feasibility of TAMIS also for malignant lesions treated in a neoadjuvant setting could be cautiously evaluated in the future.

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.

Transanal total mesorectal excision: Towards standardization of technique

AIM: To describe the role of Transanal total mesorectal excision (TaTME) in minimally invasive rectal cancer surgery, to examine the differences in patient selection and in reported surgical techniques and their impacts on postoperative outcomes and to discuss the future of TaTME.

METHODS: MEDLINE (PubMed), EMBASE, and The Cochrane Library were systematically searched through the 1^st of March 2015 using a predefined search strategy.

RESULTS: A total of 20 studies with 323 patients were included. Most studies were single-arm prospective studies with fewer than 100 patients. Multiple transanal access platforms were used, and the laparoscopic approach was either multi- or single port. The procedure was initiated transanally or transabdominally. If a simultaneous approach with 2 operating surgeons was chosen, the operative time was significantly reduced.

CONCLUSION: TaTME was also associated with better TME specimens and a longer distal resection margin. TaTME is thus feasible in expert hands, but the learning curve and safety profile are not well defined. Long-term follow-up regarding anal function and oncological outcomes should be performed in the future.

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.

An experimental study in six fresh human cadavers using a novel approach to avoid abdominal wall incisions in total colectomy: totally transanal laparoendoscopic single-site pull-through colectomy with J-pouch creation

BACKGROUND

The use of transanal laparoscopic access to completely avoid abdominal wall incisions represents the most current evolution in minimally invasive surgery. The combination of single-site surgery and natural orifice transluminal endoscopic surgery (NOTES™) can be used for totally transanal laparoendoscopic pull-through colectomy with J-pouch creation (TLPC-J). The aim of the present study was to provide evidence for the feasibility of TLPC-J in adult human cadavers.

METHODS

TLPC-J was performed in six fresh adult human cadavers. The procedure involved endorectal submucosal dissection from 1 cm above the dentate line to a point above the peritoneal reflection, where the rectal muscle was divided circumferentially. The edge of the mucosal cuff was closed distally in order to prevent fecal contamination and the endorectal tube was placed back into the abdomen. A Triport+™ or QuadPort+™ system was introduced transanally, and it served as a multiport device (MD). Resection of the entire colon, mobilization of the distal ileal segment, and extracorporeal suture of the ileal J-loop were performed via the transanal approach. The J-pouch was created using Endo GIA™. After removal of the MD, the J-pouch was sutured to the rectal wall.

RESULTS

TLPC-J was performed in all cadavers, with a mean operation duration of 236 ± 22 min. Conversion to either transabdominal laparoscopy or laparotomy was not required in any of the cadavers. No bowel perforation or damage to other organs was observed. The use of a curved endoscope greatly facilitated visualization during transanal laparoscopic dissection for partial and total colectomy, making the procedure feasible. All specimens were retrieved through the anus, eliminating the need for additional transabdominal incisions.

CONCLUSIONS

TLPC-J was technically feasible in adult human cadavers, and abdominal wall incisions were not required. However, clinical studies are needed to determine its feasibility in living adults.

Transanal minimally invasive surgery: impact on quality of life and functional outcome

BACKGROUND

Transanal minimally invasive surgery (TAMIS) is emerging as an alternative to transanal endoscopic microsurgery. Quality of life (QOL) and functional outcome are important aspects when valuing a new technique. The aim of this prospective study was to assess both functional outcome and QOL after TAMIS.

METHODS

From 2011 to 2013, patients were prospectively studied prior to and at least 6 months after TAMIS for rectal adenomas and low-risk T1 carcinomas using a single-site laparoscopy port. Functional outcome was determined using the Faecal Incontinence Severity Index (FISI). Quality of life was measured using functional [Faecal Incontinence Quality of Life (FIQL)] and generic (EuroQol EQ-5D) questionnaires.

RESULTS

The study population consisted of 24 patients 13 men, median age 59 (range 42-83) with 24 tumours [median distance from the dentate line 8 cm (range 2-17 cm); median tumour size 6 cm(2) (range 0.25-51 cm(2)); 20 adenomas; 4 low-risk T1 carcinomas]. Post-operative complications occurred in one patient (4 %; grade IIIb according to Clavien Dindo classification). Compared to baseline, FISI remained unaffected (9.8 vs 7.3; P = 0.26), FIQL remained unaffected, and EuroQol EQ-5D improved (EQ-VAS: 77 vs 83; P = 0.04).

CONCLUSION

There was no detrimental effect of TAMIS on anorectal function. Overall QOL was improved after TAMIS, probably due to removal of the tumour, and at 6 months was equal to the general population.

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.

Laparoscopic natural orifice specimen extraction-colectomy: A systematic review

Over the last 20 years, laparoscopic colorectal surgery has shown equal efficacy for benign and malignant colorectal diseases when compared to open surgery. However, a laparoscopic approach reduces postoperative morbidity and shortens hospital stay. In the quest to optimize outcomes after laparoscopic colorectal surgery, reduction of access trauma could be a way to improve recovery. To date, one method to reduce access trauma is natural orifice specimen extraction (NOSE). NOSE aims to reduce access trauma in laparoscopic colorectal surgery. The specimen is delivered via a natural orifice and the anastomosis is created intracorporeally. Different methods are used to extract the specimen and to create a bowel anastomosis. Currently, specimens are delivered transcolonically, transrectally, transanally, or transvaginally. Each of these NOSE-procedures raises specific issues with regard to operative technique and application. The presumed benefits of NOSE-procedures are less pain, lower analgesia requirements, faster recovery, shorter hospital stay, better cosmetic results, and lower incisional hernia rates. Avoidance of extraction site laparotomy is the most important characteristic of NOSE. Concerns associated with the NOSE-technique include bacterial contamination of the peritoneal cavity, inflammatory response, and postoperative outcomes, including postoperative pain and the functional and oncologic outcomes. These issues need to be studied in prospective randomized controlled trials. The aim of this systematic review is to describe the role of NOSE in minimally invasive colorectal surgery.

Transanal minimally invasive surgery for benign and malignant rectal neoplasia

BACKGROUND

Transanal minimally invasive surgery (TAMIS), an alternative technique to transanal endoscopic microsurgery, was developed in 2009. Herein, we describe our initial experience using TAMIS for benign and malignant rectal neoplasia.

METHODS

This is an institutional review board approved, retrospective case series report.

RESULTS

TAMIS was performed in 32 patients for rectal adenoma (13), adenocarcinoma (16), and carcinoid (3). There were 14 women, with mean age 62 ± 15 years and body mass index 28 ± 5 kg/m(2). Lesion size ranged from .5 to 8.5 cm, distance from the dentate line 1 to 11 cm, and circumference of the lesion 10% to 100%. The mean operative time was 123 ± 62 minutes. Mean hospital length of stay was 2.5 ± 2 days. Complications included urinary tract infection (1), Clostridium difficile diarrhea (1), atrial fibrillation (1), rectal stenosis (1), and rectal bleeding (1).

CONCLUSION

TAMIS using a disposable transanal access platform is a safe and effective method to remove rectal lesions in this case series.