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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 -
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 -
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 -
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 -
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 -
Annals of the Royal College of Surgeons... Nov 2020Management of the rectal defect following transanal endoscopic microsurgery (TEMS) or minimally invasive surgery (TAMIS) carried out for excision of neoplasm in the... (Meta-Analysis)
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 ( = 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 ( = 0.27; (10/283, 3.53% vs 5/272, 1.84%, respectively), operative time ( = 0.15) or length of stay ( = 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.
Topics: Humans; Rectal Neoplasms; Rectum; Suture Techniques; Sutures; Transanal Endoscopic Microsurgery
PubMed: 32538129
DOI: 10.1308/rcsann.2020.0135 -
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 -
Minerva Surgery Aug 2023Total mesorectal excision (TME) during rectal resection is considered the gold standard for the treatment of rectal cancer. Transanal total mesorectal excision (TaTME)...
INTRODUCTION
Total mesorectal excision (TME) during rectal resection is considered the gold standard for the treatment of rectal cancer. Transanal total mesorectal excision (TaTME) was first described in 2010 and has been applied to humans since 2012 to overcome some of the technical difficulties associated with minimally invasive TMEs.
EVIDENCE ACQUSITION
A systematic review of the literature was conducted, and it focused on articles published between 2012 and 2022 to analyze the state of the art of surgical techniques and indications, as well as potential technical, oncological, and functional benefits.
EVIDENCE SYNTHESIS
The indications for TaTME are not yet standardized, and structured training programs are necessary to complete a safe learning curve for this new technique. The procedure, when compared with conventional open or minimally invasive TME, is feasible and safe with similar intraoperative and postoperative complications. On the other hand, some new specific complications of this new approach have been described. The short-term pathological and oncologic results are encouraging, especially in terms of the mesorectal specimen quality, distal resection margin and conversion rate. Also, the functional results seem encouraging when compared with other minimally invasive techniques.
CONCLUSIONS
Long-term follow-up and ongoing RCT trials are fundamental to evaluate the possible benefits in terms of local recurrence and survival. This will facilitate the comparison with other minimally invasive rectal resections.
Topics: Humans; Rectum; Laparoscopy; Treatment Outcome; Transanal Endoscopic Surgery; Rectal Neoplasms
PubMed: 36745469
DOI: 10.23736/S2724-5691.22.09837-9 -
Diseases of the Colon and Rectum May 2022
Meta-Analysis
Topics: Digestive System Surgical Procedures; Humans; Laparoscopy; Postoperative Complications; Proctectomy; Rectal Neoplasms; Rectum; Transanal Endoscopic Surgery; Treatment Outcome
PubMed: 35143430
DOI: 10.1097/DCR.0000000000002419