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Langenbeck's Archives of Surgery May 2024Transanal minimally invasive surgery has theoretical advantages for ileal pouch-anal anastomosis surgery. We performed a systematic review assessing technical approaches... (Meta-Analysis)
Meta-Analysis
PURPOSE
Transanal minimally invasive surgery has theoretical advantages for ileal pouch-anal anastomosis surgery. We performed a systematic review assessing technical approaches to transanal IPAA (Ta-IPAA) and meta-analysis comparing outcomes to transabdominal (abd-IPAA) approaches.
METHODS
Three databases were searched for articles investigating Ta-IPAA outcomes. Primary outcome was anastomotic leak rate. Secondary outcomes included conversion rate, post operative morbidity, and length of stay (LoS). Staging, plane of dissection, anastomosis, extraction site, operative time, and functional outcomes were also assessed.
RESULTS
Searches identified 13 studies with 404 unique Ta-IPAA and 563 abd-IPAA patients. Anastomotic leak rates were 6.3% and 8.4% (RD 0, 95% CI -0.066 to 0.065, p = 0.989) and conversion rates 2.5% and 12.5% (RD -0.106, 95% CI -0.155 to -0.057, p = 0.104) for Ta-IPAA and abd-IPAA. Average LoS was one day shorter (MD -1, 95% CI -1.876 to 0.302, p = 0.007). A three-stage approach was most common (47.6%), operative time was 261(± 60) mins, and total mesorectal excision and close rectal dissection were equally used (49.5% vs 50.5%). Functional outcomes were similar. Lack of randomised control trials, case-matched series, and significant study heterogeneity limited analysis, resulting in low to very low certainty of evidence.
CONCLUSIONS
Analysis demonstrated the feasibility and safety of Ta-IPAA with reduced LoS, trend towards less conversions, and comparable anastomotic leak rates and post operative morbidity. Though results are encouraging, they need to be interpreted with heterogeneity and selection bias in mind. Robust randomised clinical trials are warranted to adequately compare ta-IPAA to transabdominal approaches.
Topics: Humans; Proctocolectomy, Restorative; Anastomotic Leak; Transanal Endoscopic Surgery; Treatment Outcome; Length of Stay; Colonic Pouches; Operative Time; Anastomosis, Surgical
PubMed: 38705912
DOI: 10.1007/s00423-024-03343-7 -
Techniques in Coloproctology Oct 2017The surgical treatment of complex anal fistulae, particularly those involving a significant portion of the anal sphincter in which fistulotomy would compromise... (Review)
Review
BACKGROUND
The surgical treatment of complex anal fistulae, particularly those involving a significant portion of the anal sphincter in which fistulotomy would compromise continence, is challenging. Video-assisted anal fistula treatment (VAAFT), fistula tract laser closure (FiLaC™) and over-the-scope clip (OTSC) proctology system are all novel sphincter-sparing techniques targeted at healing anal fistulae. In this study, all published articles on these techniques were reviewed to determine efficacy, feasibility and safety.
METHODS
A systematic search of major databases was performed using defined terms. All studies reporting on experience of these techniques were included and outcomes (fistula healing and safety) evaluated.
RESULTS
Eighteen studies (VAAFT-12, FiLaC™-3, OTSC-3) including 1245 patients were analysed. All were case series, and outcomes were heterogeneous with follow-up ranging from 6 to 69 months and short-term (< 1 year) healing rates of 64-100%. Morbidity was low with only minor complications reported. There was one report of minor incontinence following the first reported study of FiLaC™, and this was treated successfully at 6 months with rubber band ligation of hypertrophied prolapsed mucosa. There are inconsistencies in the technique in studies of VAAFT and FiLaC™.
CONCLUSIONS
All three techniques appear to be safe and feasible options in the management of anal fistulae, and short-term healing rates are acceptable with no sustained effect on continence. There is, however, a paucity of robust data with long-term outcomes. These techniques are thus welcome additions; however, their long-term place in the colorectal surgeon's armamentarium, whether diagnostic or therapeutic, remains uncertain.
Topics: Anal Canal; Humans; Laser Therapy; Operative Time; Organ Sparing Treatments; Proctoscopy; Rectal Fistula; Video-Assisted Surgery
PubMed: 29080959
DOI: 10.1007/s10151-017-1699-4 -
Infection Dec 2017Meningitis occurs in 0.8-1.5% of patients undergoing neurosurgery. The aim of the study was to evaluate the characteristics of meningitis after endoscopic endonasal... (Review)
Review
BACKGROUND
Meningitis occurs in 0.8-1.5% of patients undergoing neurosurgery. The aim of the study was to evaluate the characteristics of meningitis after endoscopic endonasal transsphenoidal surgery (EETS) comparing the findings retrieved to those highlighted by literature search.
MATERIALS AND METHODS
Patients treated by EETS during an 18-year period in the Department of Neurosurgery of 'Federico II' University of Naples were evaluated and included in the study if they fulfilled criteria for meningitis. Epidemiological, demographic, laboratory, and microbiological findings were evaluated. A literature research according to PRISMA methodology completed the study.
RESULTS
EETS was performed on 1450 patients, 8 of them (0.6%) had meningitis [median age 46 years (range 33-73)]. Endoscopic surgery was performed 1-15 days (median 4 days) before diagnosis. Meningeal signs were always present. CSF examination revealed elevated cells [median 501 cells/μL (range 30-5728)], high protein [median 445 mg/dL (range 230-1210)], and low glucose [median 10 mg/dL (range 1-39)]. CSF culture revealed Gram-negative bacteria in four cases (Klebsiella pneumoniae, Escherichia coli, Alcaligenes spp., and Haemophilus influenzae), Streptococcus pneumoniae in two cases, Aspergillus fumigatus in one case. An abscess occupying the surgical site was observed in two cases. Six cases reported a favorable outcome; two died. Incidence of meningitis approached to 2%, as assessed by the literature search.
CONCLUSIONS
Incidence of meningitis after EETS is low despite endoscope goes through non-sterile structures; microorganisms retrieved are those present within sinus microenvironment. Meningitis must be suspected in patients with persistent fever and impaired conscience status after EETS.
Topics: Adult; Aged; Female; Humans; Incidence; Italy; Male; Meningitis; Middle Aged; Postoperative Complications; Sphenoid Bone; Sphenoid Sinus; Transanal Endoscopic Surgery; Treatment Outcome
PubMed: 28776163
DOI: 10.1007/s15010-017-1056-6 -
Diseases of the Colon and Rectum Jan 2015Local resection for early rectal cancer is thought to be less invasive but oncologically inferior to radical resection. (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
Local resection for early rectal cancer is thought to be less invasive but oncologically inferior to radical resection.
OBJECTIVE
The aim of this study was to compare local with radical resection in terms of oncologic control (survival and local recurrence), postoperative complications, and the need for a permanent stoma in adult patients with T1N0M0 rectal adenocarcinoma.
DATA SOURCES
Data were retrieved from Medline, Embase, Central, www.clinicaltrials.gov, and conference proceedings.
STUDY SELECTION
Two reviewers independently screened studies and assessed the risk of bias.
INTERVENTIONS
Local resection (transanal procedures, excluding endoscopic polypectomy) versus radical resection were considered.
MAIN OUTCOME MEASURES
The primary outcomes measured were overall survival, major postoperative complications, and the 'need for permanent stoma.'
RESULTS
: One randomized controlled trial and 12 observational studies contributed 2855 patients for analysis. The randomized controlled trial was inadequately powered. Observational study meta-analysis showed that local resection was associated with significantly lower 5-year overall survival (72 more deaths per 1000 patients; 95%CI 30-120). However, the transanal endoscopic microsurgery subgroup did not yield significantly lower overall survival than radical resection. Local resection was associated with higher local recurrence but with lower perioperative mortality (relative risk 0.31, 95% CI 0.14-0.71), major postoperative complications (relative risk 0.20, 95% CI 0.10-0.41), and need for a permanent stoma (relative risk 0.17, 95% CI 0.09-0.30). Findings were robust to sensitivity analyses. Meta-regression suggests that the higher overall survival associated with radical resection may be explained by increased use of local resection on tumors in the lower third of the rectum, which have poorer prognosis.
LIMITATIONS
This systematic review of nonrandomized studies had inherent biases that may persist despite our rigorous use of systematic review methodology and sensitivity analyses.
CONCLUSIONS
Local resection does not offer oncologic control comparable to radical surgery. However, this finding may be driven by the higher prevalence of cancers with poorer prognosis in local resection groups. Local resection is associated with lower postoperative complications, mortality, and the need for a permanent stoma. Local resection with transanal endoscopic microsurgery appears to offer oncologic control similar to that of radical resection while offering all the benefits of local resection.
Topics: Adenocarcinoma; Digestive System Surgical Procedures; Humans; Neoplasm Staging; Postoperative Complications; Proctoscopy; Rectal Neoplasms; Survival Rate
PubMed: 25489704
DOI: 10.1097/DCR.0000000000000293 -
International Journal of Colorectal... Feb 2023In the treatment of early-stage rectal cancer, a growing number of studies have shown that transanal endoscopic microsurgery is one of the alternatives to radical... (Meta-Analysis)
Meta-Analysis
PURPOSE
In the treatment of early-stage rectal cancer, a growing number of studies have shown that transanal endoscopic microsurgery is one of the alternatives to radical surgery adhering to total mesorectal excision that can reduce the incidence of adverse events without compromising treatment outcomes. The purpose of this meta-analysis is to compare the safety and treatment effect of transanal endoscopic microsurgery and radical surgery adhering to total mesorectal excision to provide a basis for clinical treatment selections.
METHOD
We searched the literatures of four major databases, PubMed, Embase, Web of science, and Cochrane Library, without limitation of time. The literatures included randomized controlled studies and cohort studies comparing two surgical procedures of transanal endoscopic microsurgery and radical surgery adhering to total mesorectal excision. Treatment effectiveness and safety results of transanal endoscopic microsurgery and radical surgery were extracted from the included literatures and statistically analyzed using RevMan5.4 and stata17.
RESULT
Ultimately, 13 papers were included in the study including 5 randomized controlled studies and 8 cohort studies. The results of the meta-analysis showed that the treatment effect and safety of both transanal endoscopic microsurgery and radical surgery in distant metastasis (RR, 0.59 (0.34, 1.02), P > 0.05), overall recurrence (RR, 1.49 (0.96, 2.31), P > 0.05), disease-specific-survival (RR, 0.74 (0.09, 1.57), P > 0.05), dehiscence of the sutureline or anastomosis leakage (RR, 0.57 (0.30, 1.06), P > 0.05), postoperative bleeding (RR, 0.47 (0.22, 0.99), P > 0.05), and pneumonia (RR, 0.37, (0.10, 1.40), P > 0.05) were not significantly different. However, they differ significantly in perioperative mortality (RR, 0.26 (0.07, 0.93, P < 0.05)), local recurrence (RR, 2.51 (1.53, 4.21), P < 0.05),_overall survival_ (RR, 0.88 (0.74, 1.00), P < 0.05), disease-free-survival (RR, 1.08 (0.97, 1.19), P < 0.05), temporary stoma (RR, 0.05 (0.01, 0.20), P < 0.05), permanent stoma (RR, 0.16 (0.08, 0.33), P < 0.05), postoperative complications (RR, 0.35 (0.21, 0.59), P < 0.05), rectal pain (RR, 1.47 (1.11, 1.95), P < 0.05), operation time (RR, -97.14 (-115.81, -78.47), P < 0.05), blood loss (RR, -315.52 (-472.47, -158.57), P < 0.05), and time of hospitalization (RR, -8.82 (-10.38, -7.26), P < 0.05).
CONCLUSION
Transanal endoscopic microsurgery seems to be one of the alternatives to radical surgery for early-stage rectal cancer, but more high-quality clinical studies are needed to provide a reliable basis.
Topics: Humans; Microsurgery; Neoplasm Staging; Rectal Neoplasms; Rectum; Retrospective Studies; Transanal Endoscopic Microsurgery; Treatment Outcome
PubMed: 36800079
DOI: 10.1007/s00384-023-04341-9 -
Colorectal Disease : the Official... May 2024Restorative proctocolectomy with transabdominal ileal pouch-anal anastomosis (abd-IPAA) has become the standard surgical treatment for medically refractory ulcerative... (Meta-Analysis)
Meta-Analysis Review
AIM
Restorative proctocolectomy with transabdominal ileal pouch-anal anastomosis (abd-IPAA) has become the standard surgical treatment for medically refractory ulcerative colitis (UC). However, it requires a technically difficult distal anorectal dissection and anastomosis due to the bony confines of the deep pelvis. To address these challenges, the transanal IPAA approach (ta-IPAA) was developed. This novel approach may offer increased visibility and range of motion compared with abd-IPAA, although its postoperative benefits remain unclear. The aim of this work was to perform a systematic review and meta-analysis to compare and inform the frequency of postoperative outcomes between ta-IPAA and abd-IPAA for patients with UC.
METHOD
Several databases were searched from inception until May 2022 for studies reporting postoperative outcomes of patients undergoing ta-IPAA. Reviewers, working independently and in duplicate, evaluated studies for inclusion and graded the risk of bias. Odds ratios (OR), mean differences (MD) and prevalence ratio (PR) and their corresponding 95% confidence intervals (CIs) were calculated using random-effects models. Sensitivity analysis was performed.
RESULTS
Ten retrospective studies comprising 284 patients with ta-IPAA were included. Total mesorectal excision was performed in 61.8% of cases and close rectal dissection in 27.9%. There was no difference in the odds of Clavien-Dindo (CD) I-II complications, CD III-IV and anastomotic leak (OR 0.96, 95% CI 0.27-3.40; OR 1.18, 95% CI 0.65-2.16; OR 1.37, 95% CI 0.58-3.23; respectively) between ta-IPAA and abd-IPAA. The ta-IPAA pooled CD I-II complication rate was 18% (95% CI 5%-35%) and for CD III-IV 10% (95% CI 5%-17%), and the anastomotic leak rate was 6% (95% CI 2%-10%). There were no deaths reported.
CONCLUSIONS
This meta-analysis compared the novel ta-IPAA procedure with abd-IPAA and found no difference in postoperative outcomes. While the need for randomized controlled trails and comparison of functional outcomes between both approaches remains, this evidence should assist colorectal surgeons to decide if ta-IPAA is a viable alternative.
Topics: Humans; Proctocolectomy, Restorative; Colitis, Ulcerative; Postoperative Complications; Treatment Outcome; Colonic Pouches; Anal Canal; Female; Male; Adult; Retrospective Studies; Middle Aged; Anastomosis, Surgical; Anastomotic Leak; Transanal Endoscopic Surgery; Inflammatory Bowel Diseases
PubMed: 38594838
DOI: 10.1111/codi.16977 -
Surgical Endoscopy Apr 2020While multiple studies have evaluated endoscopic submucosal dissection (ESD) and transanal endoscopic microsurgery (TEM) to remove large rectal tumors, there remains a... (Comparative Study)
Comparative Study Meta-Analysis
BACKGROUND
While multiple studies have evaluated endoscopic submucosal dissection (ESD) and transanal endoscopic microsurgery (TEM) to remove large rectal tumors, there remains a paucity of data to evaluate their comparative efficacy and safety. The primary aim of this study was to perform a structured systematic review and meta-analysis to compare efficacy and safety of ESD versus TEM for the treatment of rectal tumors.
METHODS
Individualized search strategies were developed from inception through November 2018 in accordance with PRISMA guidelines. Measured outcomes included pooled enbloc resection rates, margin-negative (R) resection rates, procedure-associated adverse events, and rates of recurrence. This was a cumulative meta-analysis performed by calculating pooled proportions. Heterogeneity was assessed with Cochran Q test and I statistics, and publication bias by funnel plot using Egger and Begg tests.
RESULTS
Three studies (n = 158 patients; 55.22% male) were included in this meta-analysis. Patients with ESD compared to TEM had similar age (P = 0.090), rectal tumor size (P = 0.108), and diagnosis rate of adenoma to cancer (P = 0.53). ESD lesions were more proximal as compared to TEM (8.41 ± 3.49 vs. 5.11 ± 1.43 cm from the anal verge; P < 0.001). Procedure time and hospital stay were shorter for ESD compared to TEM [(79.78 ± 24.45 vs. 116.61 ± 19.35 min; P < 0.001) and (3.99 ± 0.32 vs. 5.83 ± 0.94 days; P < 0.001), respectively]. No significant differences between enbloc resection rates [OR 0.98 (95% CI 0.22-4.33); P = 0.98; I = 0.00%] and R resection rates [OR 1.16 (95% CI 0.36-3.76); P = 0.80; I = 0.00%] were noted between ESD and TEM. ESD and TEM reported similar rates of adverse events [OR 1.15 (95% CI 0.47-2.77); P = 0.80; I = 0.00%] and rates of recurrence [OR 0.46 (95% CI 0.07-3.14); P = 0.43; I = 0.00%].
CONCLUSION
ESD and TEM possess similar rates of resection, adverse events, and recurrence for patients with large rectal tumors; however, ESD is associated with significantly shorter procedure times and duration of hospitalization. Future studies are needed to evaluate healthcare utilization for these two strategies.
Topics: Adenoma; Anal Canal; Comparative Effectiveness Research; Endoscopic Mucosal Resection; Female; Humans; Length of Stay; Male; Margins of Excision; Middle Aged; Neoplasm Recurrence, Local; Operative Time; Postoperative Complications; Rectal Neoplasms; Rectum; Transanal Endoscopic Microsurgery; Treatment Outcome
PubMed: 31292744
DOI: 10.1007/s00464-019-06945-1 -
Minerva Surgery Apr 2022Transanal endoscopic microsurgery (TEM) and transanal endoscopic operation (TEO) have been initially described for local excision of rectal adenomas and selected cases...
INTRODUCTION
Transanal endoscopic microsurgery (TEM) and transanal endoscopic operation (TEO) have been initially described for local excision of rectal adenomas and selected cases of rectal carcinomas. In the past decade, however, several new indications raised, and others could raise in the future. The aim of this review was to evaluate, both in the literature and in our personal experience, the use of TEM and TEO for non-conventional applications, different from rectal tumors.
EVIDENCE ACQUISITION
We conducted a systematic review of published papers and we selected articles reporting patients who underwent endoscopic surgery for other medical reason than polyp cancer resection, with TEM or TEO. PubMed, MEDLINE, EMBASE and bibliographies of the selected studies were searched for articles in English published up to May 2020 to identify all relevant articles. We excluded articles reporting TEM and TEO used for classical indications. We finally report our experience of non-conventional use of TEO in 5 patients with different diseases.
EVIDENCE SYNTHESIS
The research revealed 800 papers and among them we selected 52 articles for a total of 697 patients. Of all patients, only 52 had intraoperative or postoperative complications, with only 10 patients requiring major surgery.
CONCLUSIONS
Our study suggests that TEM and TEO may be valid alternatives to traditional surgery in situations other than its classical indication. These findings can positively impact on the care of patients, who could benefit from less invasive surgical procedures associated with lower morbidity.
Topics: Adenoma; Digestive System Surgical Procedures; Endoscopy; Humans; Rectal Neoplasms; Transanal Endoscopic Microsurgery
PubMed: 34047531
DOI: 10.23736/S2724-5691.21.08774-8 -
Langenbeck's Archives of Surgery Oct 2023Despite its profound impact on the oncologic outcomes of rectal cancer, the most optimal surgical approach to total mesorectal excision (TME) has not been identified... (Meta-Analysis)
Meta-Analysis Review
Impact of trans-anal versus laparoscopic total mesorectal excision on the surgical and pathologic outcomes of patients with rectal cancer: meta-analysis of randomized controlled trials.
BACKGROUND
Despite its profound impact on the oncologic outcomes of rectal cancer, the most optimal surgical approach to total mesorectal excision (TME) has not been identified yet. All previous meta-analyses on this subject have been based on observational studies. This meta-analysis was conducted to assess the surgical and oncologic outcomes of laparoscopic TME (LaTME) compared to trans-anal TME (TaTME), utilizing only randomized controlled trials.
DESIGN
Systematic review and meta-analysis of randomized controlled trials.
METHODS
We searched electronic databases (MEDLINE, Cochrane CENTRAL, Clinicaltials.gov) from 2010 onwards, for all published clinical trials comparing TaTME to LaTME. Results are presented as risk ratios, with 95% CI, and pooled using the random effects model.
RESULTS
A total of 1691 patients, from 6 eligible randomized controlled trials, were included for analysis. Analyzed data showed no significant difference in morbidity (RR: 0.85, p = 0.15), mortality (RR: 0.50, p = 0.44), conversion to open (RR: 0.40, p = 0.07), or anastomotic leakage (RR: 0.73, p = 0.10) between TaTME and LaTME. There was also no difference in the rate of positive distal resection margin (DRM) (RR: 0.55, p = 0.10) or positive circumferential resection margin (CRM) (RR: 0.67, p = 0.30). Patients undergoing TaTME were more likely to have a complete TME (RR: 1.06, p = 0.002) and shorter hospital stays (RR: - 0.97, p < 0.00001).
CONCLUSIONS
Patients undergoing TaTME for rectal cancer were more likely to have a complete TME when compared to LaTME, though this did not translate into improved distal or circumferential resection margin. Additionally, TaTME and LaTME had similar surgical outcomes except for shorter length of stay with TaTME.
Topics: Humans; Margins of Excision; Postoperative Complications; Treatment Outcome; Transanal Endoscopic Surgery; Randomized Controlled Trials as Topic; Rectal Neoplasms; Laparoscopy; Rectum
PubMed: 37861749
DOI: 10.1007/s00423-023-03147-1 -
Diseases of the Colon and Rectum May 2022Completion total mesorectal excision is recommended when local excision of early rectal cancers demonstrates high-risk histopathological features. Concerns regarding the... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Completion total mesorectal excision is recommended when local excision of early rectal cancers demonstrates high-risk histopathological features. Concerns regarding the quality of completion resections and the impact on oncological safety remain unanswered.
OBJECTIVE
This study aims to summarize and analyze the outcomes associated with completion surgery and undertake a comparative analysis with primary rectal resections.
DATA SOURCES
Data sources included PubMed, Cochrane library, MEDLINE, and Embase databases up to April 2021.
STUDY SELECTION
All studies reporting any outcome of completion surgery after transanal local excision of an early rectal cancer were selected. Case reports, studies of benign lesions, and studies using flexible endoscopic techniques were not included.
INTERVENTION
The intervention was completion total mesorectal excision after transanal local excision of early rectal cancers.
MAIN OUTCOME MEASURES
Primary outcome measures included histopathological and long-term oncological outcomes of completion total mesorectal excision. Secondary outcome measures included short-term perioperative outcomes.
RESULTS
Twenty-three studies including 646 patients met the eligibility criteria, and 8 studies were included in the meta-analyses. Patients undergoing completion surgery have longer operative times (standardized mean difference, 0.49; 95% CI, 0.23-0.75; p = 0.0002) and higher intraoperative blood loss (standardized mean difference, 0.25; 95% CI, 0.01-0.5; p = 0.04) compared with primary resections, but perioperative morbidity is comparable (risk ratio, 1.26; 95% CI, 0.98-1.62; p = 0.08). Completion surgery is associated with higher rates of incomplete mesorectal specimens (risk ratio, 3.06; 95% CI, 1.41-6.62; p = 0.005) and lower lymph node yields (standardized mean difference, -0.26; 95% CI, -0.47 to 0.06; p = 0.01). Comparative analysis on long-term outcomes is limited, but no evidence of inferior recurrence or survival rates is found.
LIMITATIONS
Only small retrospective cohort and case-control studies are published on this topic, with considerable heterogeneity limiting the effectiveness of meta-analysis.
CONCLUSIONS
This review provides the strongest evidence to date that completion surgery is associated with an inferior histopathological grade of the mesorectum and finds insufficient long-term results to satisfy concerns regarding oncological safety. International collaborative research is required to demonstrate noninferiority.
REGISTRATION NO
CRD42021245101.
Topics: Humans; Laparoscopy; Postoperative Complications; Proctectomy; Rectal Neoplasms; Rectum; Retrospective Studies; Transanal Endoscopic Surgery; Treatment Outcome
PubMed: 35143429
DOI: 10.1097/DCR.0000000000002407