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Diseases of the Colon and Rectum Feb 2015Transanal endoscopic microsurgery is the intraluminal excision of rectal lesions with the use of instrumentation to maintain a stable pneumorectum, enabling a magnified... (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
Transanal endoscopic microsurgery is the intraluminal excision of rectal lesions with the use of instrumentation to maintain a stable pneumorectum, enabling a magnified view of the target lesion. Despite suggested benefits over traditional transanal excision, there is no consensus on which technique is superior.
OBJECTIVE
The aim of the current study is to use meta-analytical techniques to compare transanal endoscopic microsurgery with transanal excision.
DATA SOURCES
A comprehensive literature search of PubMed, Embase, and The Cochrane Library was performed.
STUDY SELECTION
All studies comparing transanal endoscopic microsurgery with transanal excision were included.
INTERVENTIONS
Transanal endoscopic microsurgery was compared with transanal excision by using random-effects methods to combine data. Data are presented as ORs with 95% CIs.
MAIN OUTCOME MEASURES
The main outcomes measured were postoperative complication rate, negative microscopic margin rate, specimen fragmentation rate, and lesion recurrence.
RESULTS
Six comparative series comparing outcomes following 927 local excisions were identified. There was no difference between techniques in postoperative complication rate (OR, 1.018; 95% CI, 0.658-1.575; p = 0.937). Transanal endoscopic microsurgery had a higher rate of negative microscopic margins in comparison with transanal excision (OR, 5.281; 95% CI, 3.201-8.712; p < 0.001). Transanal endoscopic microsurgery had a reduced rate of specimen fragmentation (OR, 0.096; 95% CI, 0.044-0.209; p < 0.001) and lesion recurrence (OR, 0.248; 95% CI, 0.154-0.401; p < 0.001) compared with transanal excision. There was no across-study heterogeneity for any end point.
LIMITATIONS
Most studies were retrospectively designed, and there were variations in patient populations and duration of follow-up.
CONCLUSIONS
Available data are limited because of a lack of randomized controlled trials. However, based on current evidence, transanal endoscopic microsurgery is oncologically superior to transanal excision for the excision of rectal neoplasms.
Topics: Adenoma; Carcinoma; Disease-Free Survival; Humans; Microsurgery; Proctoscopy; Rectal Neoplasms; Rectum; Treatment Outcome
PubMed: 25585086
DOI: 10.1097/DCR.0000000000000309 -
Techniques in Coloproctology Dec 2017Transanal local excision (TLE) has become the treatment of choice for benign and early-stage selected malignant tumors. However, closure of the rectal wall defect... (Meta-Analysis)
Meta-Analysis Review
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.
Topics: Humans; Postoperative Hemorrhage; Rectal Neoplasms; Reoperation; Surgical Wound Infection; Transanal Endoscopic Surgery; Wound Closure Techniques
PubMed: 29134387
DOI: 10.1007/s10151-017-1714-9 -
Surgical Endoscopy May 2022Transanal total mesorectal excision (TaTME) appears to have favorable surgical and pathological outcomes. However, the evidence on survival outcomes remains unclear. We... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Transanal total mesorectal excision (TaTME) appears to have favorable surgical and pathological outcomes. However, the evidence on survival outcomes remains unclear. We performed a meta-analysis to compare long-term oncologic outcomes of TaTME with transabdominal TME for rectal cancer.
METHODS
PubMed, EMBASE, and the Cochrane Library were searched. Data were pooled, and overall effect size was calculated using random-effects models. Outcome measures were overall survival (OS), disease-free survival (DFS), and local and distant recurrence.
RESULTS
We included 11 nonrandomized studies that examined 2,143 patients for the meta-analysis. There were no significant differences between the two groups in OS, DFS, and local and distant recurrence with a RR of 0.65 (95% CI 0.39-1.09, I = 0%), 0.79 (95% CI 0.57-1.10, I = 0%), 1.14 (95% CI 0.44-2.91, I = 66%), and 0.75 (95% CI 0.40-1.41, I = 0%), respectively.
CONCLUSION
In terms of long-term oncologic outcomes, TaTME may be an alternative to transabdominal TME in patients with rectal cancer. Well-designed randomized trials are warranted to further verify these results.
Topics: Humans; Laparoscopy; Postoperative Complications; Rectal Neoplasms; Rectum; Transanal Endoscopic Surgery; Treatment Outcome
PubMed: 34169371
DOI: 10.1007/s00464-021-08615-7 -
Surgical Endoscopy Aug 2021Transanal total mesorectal excision (TaTME) is technically challenging even for experienced colorectal surgeons and there may be a higher risk of complications during...
INTRODUCTION
Transanal total mesorectal excision (TaTME) is technically challenging even for experienced colorectal surgeons and there may be a higher risk of complications during learning. Determining when a surgeon is ready to safely perform this technique independently remains a matter of debate. Therefore, the objective of this study was to systematically summarize the available evidence regarding measures of proficiency in TaTME for rectal adenocarcinoma.
METHODS
A systematic search of MEDLINE, Embase, PubMed Epub records, Biosis previews, Scopus, and Cochrane Library databases was performed according to PRISMA guidelines. All English and French language studies published between 2010 and 2018 that described proficiency metrics for TaTME were included. Study heterogeneity precluded meta-analysis, and therefore qualitative synthesis was performed. The primary outcomes were the methodology and measures used to define proficiency, and the number of cases needed to achieve proficiency.
RESULTS
Of 994 citations, five studies met inclusion criteria. Of these, only two used objective measures to define proficiency. These studies evaluated patient outcomes and defined proficiency through cumulative sum (CUSUM) analysis of the primary outcome(s): post-operative complications and TME quality. Two studies reported expert consensus to establish recommendations using a combination of electronic survey distributed to colorectal surgeons and consensus conferences with TaTME experts from 7 to 8 different countries. One study defined the learning phase as 16 months of TaTME practice, or the first 27 cases. Stated case volumes needed to achieve proficiency varied widely. Studies using objective outcome measures reported threshold volumes of 40 and 51 cases, respectively, while expert consensus studies recommended needing 6-30 procedures.
CONCLUSIONS
Significant heterogeneity exists regarding the determination of proficiency benchmarks for TaTME. Expert consensus documents recommend lower case numbers to obtain proficiency than those defined by objective measures, suggesting greater experience may be required than generally thought.
Topics: Humans; Laparoscopy; Postoperative Complications; Proctectomy; Rectal Neoplasms; Rectum; Transanal Endoscopic Surgery
PubMed: 32875417
DOI: 10.1007/s00464-020-07935-4 -
The Gulf Journal of Oncology Jan 2021Transanal total mesorectal excision (TaTME) is a new technique that is designed to overcome the limits encountered during laparoscopic total mesorectal excision (LaTME)... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Transanal total mesorectal excision (TaTME) is a new technique that is designed to overcome the limits encountered during laparoscopic total mesorectal excision (LaTME) for rectal cancer, especially in male, obese patients with a narrow pelvis and mid and low rectal tumours.
AIM
The objective of our meta-analysis is to evaluate short-term oncological and perioperative outcomes of transanal total mesorectal excision (TaTME) compared to laparoscopic total mesorectal excision (LaTME) for rectal cancer.
METHODS
A meta-analysis based on Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines was conducted in MEDLINE (PubMed). All original studies published in English that compared TaTME with laTME were included. The quality of the included studies was assessed by the Newcastle- Ottawa Quality Assessment Scale (NOS) and Cochrane Library Handbook 5.1.0. Data analysis was conducted using the Review Manager 5.3 software.
RESULTS
Twelve studies including 835 TaTME patients and 1707 LaTME patients with rectal cancer met the inclusion criteria in this meta-analysis. No statistical significant differences were observed in regard to positive circumferential resection margin (PCRM), positive distal resection margin (PDRM), macroscopic quality of mesorectum (MQM) and harvested lymph nodes (HLN). Concerning the perioperative outcomes, the results of conversion rates, operative time, hospital stay (HS), anastomotic leakage (AL) and postoperative complications were comparable between the two groups.
CONCLUSION
Our meta-analysis provides that TaTME may be a valid alternative approach for the treatment of rectal cancer in comparison with LaTME.
Topics: Anastomotic Leak; Female; Humans; Male; Rectal Neoplasms; Transanal Endoscopic Surgery; Treatment Outcome
PubMed: 33716215
DOI: No ID Found -
International Journal of Surgery... Dec 2018Trans-anal total mesorectal resection (TaTME) is a novel approach for rectal cancer. However, the perioperative and pathological outcomes of this procedure remain... (Meta-Analysis)
Meta-Analysis
Trans-anal or trans-abdominal total mesorectal excision? A systematic review and meta-analysis of recent comparative studies on perioperative outcomes and pathological result.
BACKGROUND
Trans-anal total mesorectal resection (TaTME) is a novel approach for rectal cancer. However, the perioperative and pathological outcomes of this procedure remain controversial.
METHOD
A systematic literature search was performed using PubMed, Embase, Wanfang (China) and the Cochrane Library databases without restriction to regions or languages. We included 17 trials comparing TaTME with Laparoscopic TME (LaTME) for meta-analysis (MA). Fixed and random-effect models were used to measure the pooled estimates.
RESULTS
A total of 17 trials including 1346 patients were eligible for this MA. Pooled perioperative data using TaTME was associated with a significant reduction in estimated blood loss (WMD: 41.40, CI: 76.83 to -5.97; p = 0.02), hospital stay (WMD: 1.27, CI: 2.32 to -0.23; p = 0.02), conversion (OR: 0.28 CI: 0.15-0.52; p < 0.0001), readmission rates (OR: 0.42, CI: 0.25-0.69; p = 0.0007) and overall postoperative complications (OR: 0.73, CI: 0.56-0.95; p = 0.02). TaTME did not compromise surgical duration (WMD: 11.61, CI: 26.62-3.41; p = 0.13) or enhance complications including anastomotic leakage, ileus, urinary dysfunction, wound infection and pelvic abscess. Concerning pathological outcomes, the TaTME group demonstrated longer circumferential resection margins (CRM) (WMD: 0.91, CI: 0.58-1.24; p < 0.00001) and reduced CRM involvement (OR: 0.47, CI: 0.29-0.75; p = 0.002), whilst the distal resection margin (DRM) quality of the mesorectum and harvested lymph node were comparable.
CONCLUSION
TaTME achieves similar surgical outcomes to LaTME, with the added advantage of a safe CRMs, reduced blood loss, shorter hospital stay, lower conversion and readmission rates, and lower postoperative morbidity. Long-term oncological and functional data are now required to confirm these findings.
Topics: Female; Humans; Length of Stay; Lymph Nodes; Male; Mesocolon; Patient Readmission; Postoperative Complications; Rectal Neoplasms; Transanal Endoscopic Surgery; Treatment Outcome
PubMed: 30415089
DOI: 10.1016/j.ijsu.2018.11.003 -
Annals of Surgery Jul 2019To compare techniques for rectal cancer resection. (Comparative Study)
Comparative Study Meta-Analysis
OBJECTIVE
To compare techniques for rectal cancer resection.
SUMMARY BACKGROUND DATA
Different surgical approaches exist for mesorectal excision.
METHODS
Systematic literature review and Bayesian network meta-analysis performed.
RESULTS
Twenty-nine randomized controlled trials included, reporting on 6237 participants, comparing: open versus laparoscopic versus robotic versus transanal mesorectal excision. No significant differences identified between treatments in intraoperative morbidity, conversion rate, grade III/IV morbidity, reoperation, anastomotic leak, nodes retrieved, involved distal margin, 5-year overall survival, and locoregional recurrence. Operative blood loss was less with laparoscopic surgery compared with open, and with robotic surgery compared with open and laparoscopic. Robotic operative time was longer compared with open, laparoscopic, and transanal. Laparoscopic operative time was longer compared with open. Laparoscopic surgery resulted in lower overall postoperative morbidity and fewer wound infections compared with open. Robotic surgery had fewer wound infections compared with open. Time to defecation was longer with open surgery compared with laparoscopic and robotic. Hospital stay was longer after open surgery compared with laparoscopic and robotic, and after laparoscopic surgery compared with robotic. Laparoscopic surgery resulted in more incomplete or nearly complete mesorectal excisions compared with open, and in more involved circumferential resection margins compared with transanal. Robotic surgery resulted in longer distal resection margins compared with open, laparoscopic, and transanal.
CONCLUSIONS
The different techniques result in comparable perioperative morbidity and long-term survival. The laparoscopic and robotic approaches may improve postoperative recovery, and the open and transanal approaches may improve oncological resection. Technique selection should be based on expected benefits by individual patient.
Topics: Bayes Theorem; Humans; Laparoscopy; Proctectomy; Randomized Controlled Trials as Topic; Rectal Neoplasms; Robotic Surgical Procedures; Transanal Endoscopic Surgery; Treatment Outcome
PubMed: 30720507
DOI: 10.1097/SLA.0000000000003227 -
International Urogynecology Journal Sep 2019Several posterior compartment surgical approaches are used to address posterior vaginal wall prolapse and obstructed defecation. We aimed to compare outcomes for both...
INTRODUCTION AND HYPOTHESIS
Several posterior compartment surgical approaches are used to address posterior vaginal wall prolapse and obstructed defecation. We aimed to compare outcomes for both conditions among different surgical approaches.
METHODS
A systematic review was performed comparing the impact of surgical interventions in the posterior compartment on prolapse and defecatory symptoms. MEDLINE, Embase, and ClinicalTrials.gov were searched from inception to 4 April 2018. Randomized controlled trials, prospective and retrospective comparative and single-group studies of women undergoing posterior vaginal compartment surgery for vaginal bulge or bowel symptoms were included. Studies had to include both anatomical and symptom outcomes both pre- and post-surgery.
RESULTS
Forty-six eligible studies reported on six surgery types. Prolapse and defecatory symptoms improved with native-tissue transvaginal rectocele repair, transanal rectocele repair, and stapled transanal rectocele repair (STARR) surgeries. Although prolapse was improved with sacrocolpoperineopexy, defecatory symptoms worsened. STARR caused high rates of fecal urgency postoperatively, but this symptom typically resolved with time. Site-specific posterior repairs improved prolapse stage and symptoms of obstructed defecation. Compared with the transanal route, native-tissue transvaginal repair resulted in greater improvement in anatomical outcomes, improved obstructed defecation symptoms, and lower chances of rectal injury, but higher rates of dyspareunia.
CONCLUSIONS
Surgery in the posterior vaginal compartment typically has a high rate of success for anatomical outcomes, obstructed defecation, and bulge symptoms, although these may not persist over time. Based on this evidence, to improve anatomical and symptomatic outcomes, a native-tissue transvaginal rectocele repair should be preferentially performed.
Topics: Constipation; Female; Gynecologic Surgical Procedures; Humans; Pelvic Organ Prolapse; Practice Guidelines as Topic; Prospective Studies; Randomized Controlled Trials as Topic; Rectocele; Retrospective Studies; Transanal Endoscopic Surgery; Vagina
PubMed: 31256222
DOI: 10.1007/s00192-019-04001-z -
The British Journal of Surgery Apr 2020Total mesorectal excision (TME) gives excellent oncological results in rectal cancer treatment, but patients may experience functional problems. A novel approach to... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Total mesorectal excision (TME) gives excellent oncological results in rectal cancer treatment, but patients may experience functional problems. A novel approach to performing TME is by single-port transanal minimally invasive surgery. This systematic review evaluated the functional outcomes and quality of life after transanal and laparoscopic TME.
METHODS
A comprehensive search in PubMed, the Cochrane Library, Embase and the trial registers was conducted in May 2019. PRISMA guidelines were used. Data for meta-analysis were pooled using a random-effects model.
RESULTS
A total of 11 660 studies were identified, from which 14 studies and six conference abstracts involving 846 patients (599 transanal TME, 247 laparoscopic TME) were included. A substantial number of patients experienced functional problems consistent with low anterior resection syndrome (LARS). Meta-analysis found no significant difference in major LARS between the two approaches (risk ratio 1·13, 95 per cent c.i. 0·94 to 1·35; P = 0·18). However, major heterogeneity was present in the studies together with poor reporting of functional baseline assessment.
CONCLUSION
No differences in function were observed between transanal and laparoscopic TME.
Topics: Fecal Incontinence; Female; Humans; Laparoscopy; Postoperative Complications; Proctectomy; Quality of Life; Rectal Neoplasms; Rectum; Sexual Dysfunction, Physiological; Transanal Endoscopic Surgery; Treatment Outcome
PubMed: 32154594
DOI: 10.1002/bjs.11566 -
Journal of Neurosurgical Sciences Dec 2018While open, microsurgical clipping and endovascular coiling remain the gold standards for treatment of cerebral aneurysms, a growing number of aneurysms treated via...
INTRODUCTION
While open, microsurgical clipping and endovascular coiling remain the gold standards for treatment of cerebral aneurysms, a growing number of aneurysms treated via endoscopic endonasal methods have been reported in the literature. The aim of this study was to conduct a systematic review of the literature to gain a more thorough appreciation of the potential benefits and drawbacks of the endoscopic endonasal strategy in this setting.
EVIDENCE ACQUISITION
We performed a detailed systematic review of the medical literature on endoscopic endonasal skull base surgery for treatment of cerebral aneurysms utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We identified 9 clinical studies describing treatment of 23 aneurysms utilizing the EEA. Eleven additional cadaveric studies investigating aspects of operative exposure and/or technique in this setting were identified. The full text of these articles was reviewed.
EVIDENCE SYNTHESIS
In the 9 clinical studies that met inclusion criteria, 23 aneurysms were treated in 21 patients. The mean patient age was 52.6 years. 15 aneurysms were unruptured and 8 were ruptured. Fourteen aneurysms involved the anterior circulation and 9 involved the posterior circulation. In 21 of 23 aneurysms, complete occlusion was achieved with endonasal clipping. Two aneurysms required additional treatment that included a takeback for clip repositioning and staged endovascular coiling. Complications included post-operative CSF leak (23.8%), stroke (19%), and meningitis (14.3%). Analysis of the combined literature revealed a significantly higher rate of CSF leak with endonasal clipping of posterior circulation aneurysms compared to anterior circulation aneurysms (P=0.047, Fisher's Exact Test). While there was a trend towards increased post-operative neurologic deficit following EEA for posterior circulation aneurysms, this did not reach statistical significance (P=0.063). The majority of post-operative complications in posterior circulation aneurysms occurred during clip application of aneurysms at the level of the basilar apex. In addition to the aforementioned clinical reports, 11 cadaveric studies were identified. 4 of these reports investigated approaches for individual anterior circulation aneurysms, 5 investigated approaches for posterior circulations aneurysms, and 2 involved both anterior and posterior circulation aneurysms.
CONCLUSIONS
Despite a moderate increase in utilization, caution should be exercised when choosing an endonasal strategy for treatment of aneurysmal pathology over more traditional and established methods such as microsurgical clip application and endovascular methods. Anecdotal evidence suggests that inferior and/or medial projecting aneurysms involving the paraclinoid ICA not amenable to traditional open/endovascular strategies may be reasonable to consider for EEA clip application. Wide-necked, midline, ventrolaterally-projecting aneurysms involving the vertebrobasilar system may represent an additional exception, as long as the location along the rostrocaudal axis is low enough so as not to compromise visualization. Future improvements in operative technology, including anticipated advances in endoscopic 3-D visualization, may further alter the landscape of treatment involving this complex pathology.
Topics: Humans; Intracranial Aneurysm; Microsurgery; Middle Aged; Neuroendoscopy; Neurosurgical Procedures; Skull Base; Transanal Endoscopic Surgery; Vascular Surgical Procedures
PubMed: 29582975
DOI: 10.23736/S0390-5616.18.04405-3