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BMC Surgery Mar 2022Robotic transanal minimally invasive surgery (R-TAMIS) is an appealing alternative to transanal minimally invasive surgery (TAMIS) and transanal endoscopic microsurgery...
BACKGROUND
Robotic transanal minimally invasive surgery (R-TAMIS) is an appealing alternative to transanal minimally invasive surgery (TAMIS) and transanal endoscopic microsurgery (TEM) for benign and early malignant rectal lesions that are not amenable to traditional open transanal excision. However, no studies to our knowledge have directly compared the three techniques. This study sought to compare peri-operative and pathologic outcomes of the three approaches.
METHODS
The records of 29 consecutive patients who underwent TEM, TAMIS, or R-TAMIS at a single academic center between 2016 and 2020 were reviewed. Intra-operative details, pathological diagnosis and margins, and post-operative outcomes were recorded. The three groups were compared using chi-square and Kruskal-Wallis tests.
RESULTS
Overall, 16/29 patients were women and the median age was 57 (interquartile range (IQR): 28-81). Thirteen patients underwent TEM, six had TAMIS, and 10 had R-TAMIS. BMI was lower in the R-TAMIS patients (24.7; IQR 23.8-28.7), than in TEM (29.3; IQR 19.9-30.2), and TAMIS (30.4; IQR 26.6-32.9) patients. High grade dysplasia and/or invasive cancer was more common in TAMIS (80%) and R-TAMIS (66.7%) patients than in TEM patients (41.7%). The three groups did not differ significantly in tumor type or distance from the anal verge. No R-TAMIS patients had a positive surgical margin compared to 23.1% in the TEM group and 16.7% in the TAMIS group. Length of stay (median 1 day for TEM and R-TAMIS patients, 0 days for TAMIS patients) and 30-day readmission rates (7.7% of TEM, 0% of TAMIS, 10% of R-TAMIS patients) also did not differ among the groups. Median operative time was 110 min for TEM, 105 min for TAMIS, and 76 min for R-TAMIS patients.
CONCLUSIONS
R-TAMIS may have several advantages over other advanced techniques for transanal excisions. R-TAMIS tended to be faster and to more often result in negative surgical margins compared to the two other techniques.
Topics: Anal Canal; Female; Humans; Middle Aged; Operative Time; Rectal Neoplasms; Rectum; Transanal Endoscopic Surgery
PubMed: 35346146
DOI: 10.1186/s12893-022-01543-w -
International Journal of Colorectal... May 2021There is concern regarding bioaerosols from patients having procedures impacting surgical team safety. As pathogens and pollutants have been found in surgical smoke, we...
BACKGROUND
There is concern regarding bioaerosols from patients having procedures impacting surgical team safety. As pathogens and pollutants have been found in surgical smoke, we examined the potential for aerosol escape during transanal minimally invasive surgery (TAMIS) which may be particularly important given the presence of faecal contamination in the operative workspace and the specifics of its access platforms.
METHODS
Both qualitative (thermographic imaging) and quantificative (particle counting) methods were used to assess for aerosol release during TAMIS in comparison to laparoscopic operations of similar duration and equipment both at times of surgical dissection and without. TAMIS was performed using a Gelport Path Device (Applied Medical) and Airseal insufflation with valveless trocar (ConMed).
RESULTS
Significant carbon dioxide (CO) escapes during TAMIS carrying with it considerable numbers of particles. In general, particle counts were low prior to tissue dissection phases of the operation but increased substantially (25 × 10/m or over 40× background counts) during hook cautery dissection. The majority of particles were in the 0.3-0.5 micron range (where counts were increased relative to background between 42× and 65) with the highest relative increase versus background in the 0.5-1.0 micron range. Particle counts < 5 were substantially greater during the TAMIS procedure versus laparoscopic procedures (a laparoscopic-assisted parastomal hernia repair and laparoscopic cholecystectomy) employing similar tools.
CONCLUSIONS
Considerable amounts of particle-rich aerosols escape during TAMIS procedures. Although pathogens are not proven to definitely spread to healthcare staff by such material nebulisation, N95/FFP2 masks, at a minimum, seem prudent while other methods evolve to eliminate this risk.
Topics: Anal Canal; Humans; Laparoscopy; Minimally Invasive Surgical Procedures; Rectal Neoplasms; Transanal Endoscopic Surgery
PubMed: 33184703
DOI: 10.1007/s00384-020-03796-4 -
ANZ Journal of Surgery Nov 2021Total mesorectal excision (TME) has been established as the standard for oncologic resection of rectal cancer, and has a direct impact on local recurrence and overall... (Meta-Analysis)
Meta-Analysis Review
BACKGROUNDS
Total mesorectal excision (TME) has been established as the standard for oncologic resection of rectal cancer, and has a direct impact on local recurrence and overall survival.
OBJECTIVES
Our meta-analysis aims to evaluate the oncological outcomes of the newer techniques of TME - robotic TME versus Transanal TME (TaTME). Primary outcome measures included CRM positivity, R0 resection status, distal resection margins and lymph node yield. Secondary outcome measures were overall complication rates, anastomotic leak and wound infection rates, post-operative ileus rates and mean operative time.
METHODS
A systematic literature search was performed to identify relevant studies through PubMEd and Embase from January 2000 to January 2021. Inclusion criteria included English language articles directly comparing TaTME and robotic TME.
RESULTS
Seven hundred and fourteen studies were identified, and only six studies were included for this meta-analysis. A total of 1065 participants, of which 632 (59.3%) underwent robotic TME, and 433 (40.7%) had TaTME. Robotic TME had a statistically significant higher lymph node yield (SMD -0.53, p = 0.020). There were no significant differences in the overall complication rates, wound infection and anastomotic leak rates, post-operative ileus, mean operative time and CRM positivity.
CONCLUSION
This is the first meta-analysis assessing the outcomes of robotic TME versus TaTME, and only lymph node yield was statistically higher in robotic TME group. These techniques are potentially complementary rather than competing, and we believe that these two approaches can be adopted after appropriate training.
Topics: Humans; Laparoscopy; Neoplasm Recurrence, Local; Postoperative Complications; Rectal Neoplasms; Rectum; Robotic Surgical Procedures; Transanal Endoscopic Surgery; Treatment Outcome
PubMed: 34553466
DOI: 10.1111/ans.17204 -
The Lancet. Gastroenterology &... Apr 2021Anal squamous cell carcinoma is the most common type of anal cancer and is largely associated with anal human papillomavirus infection. The incidence of anal squamous... (Review)
Review
Anal squamous cell carcinoma is the most common type of anal cancer and is largely associated with anal human papillomavirus infection. The incidence of anal squamous cell carcinoma is increasing, and although still uncommon in the general population, a high incidence has been noted in specific population groups (eg, patients with HIV, men who have sex with men [MSM], recipients of solid organ transplants, women with genital neoplasia, and patients with systemic lupus erythematosus or inflammatory bowel disease). The higher incidence among individuals who are HIV-positive makes anal squamous cell carcinoma one of the most common non-AIDS-defining cancers among HIV-positive individuals. Anal cancer screening in high-risk groups aims to detect high-grade squamous intraepithelial lesions, which are considered anal precancerous lesions, and for which identification can provide an opportunity for prevention. A blind anal cytology is normally the first screening method, and for patients with abnormal results, this approach can be followed by an examination of the anal canal and perianal area under magnification, along with staining-a technique known as high-resolution anoscopy. Digital anorectal examination can enable early anal cancer detection. Several societies are in favour of screening for HIV-positive MSM and recipients of transplants. There are no current recommendations for screening of anal precancerous lesions via endoscopy, but in high-risk groups, a careful observation of the squamocolumnar junction should be attempted. Several treatments can be used to treat high-grade squamous intraepithelial lesions, including argon plasma coagulation or radiofrequency ablation, which are largely limited by high recurrence rates. Gastroenterologists need to be aware of anal squamous cell carcinoma and anal precancerous lesions, given that patients at high risk are frequently encountered in the gastroenterology department. We summarise simple procedures that can help in early anal squamous cell carcinoma detection.
Topics: Anus Neoplasms; Carcinoma, Squamous Cell; Humans; Precancerous Conditions; Proctoscopy; Quality Improvement
PubMed: 33714370
DOI: 10.1016/S2468-1253(20)30304-6 -
Best Practice & Research. Clinical... Oct 2019Rectal neuroendocrine tumors (RNET) are rare tumors but their prevalence is constantly increasing due to a prolonged survival and rising incidence related to a growing... (Review)
Review
Rectal neuroendocrine tumors (RNET) are rare tumors but their prevalence is constantly increasing due to a prolonged survival and rising incidence related to a growing number of colonoscopies and improved knowledge. Their main prognostic determinant is tumor stage. While most RNET are localized, their management should be tailored depending on the presence or absence of the factors predictive of lymph-node metastases including tumor size, endoscopic aspect, T stage, grade and lymphovascular invasion. Endoscopic ultrasonography is the most relevant technique for locoregional assessment. Low-risk RNET can be treated using advanced endoscopic resection techniques or transanal endoscopic microsurgery, in expert centers because they require technicity and experience. Conversely, radical surgery with lymphadenectomy should be proposed in the presence of any pejorative factor. The long-term evolution of RNET remains to be specified, and prospective studies should be conducted in order to determine the relevance of the current management strategies.
Topics: Humans; Laparoscopy; Neuroendocrine Tumors; Postoperative Complications; Practice Guidelines as Topic; Rectal Neoplasms; Transanal Endoscopic Surgery
PubMed: 31326374
DOI: 10.1016/j.beem.2019.101293 -
Techniques in Coloproctology Feb 2021Rectal cancer treatment has evolved with the implementation of new surgical techniques. Transanal total mesorectal excision (TaTME) is the most recent approach developed...
BACKGROUND
Rectal cancer treatment has evolved with the implementation of new surgical techniques. Transanal total mesorectal excision (TaTME) is the most recent approach developed to facilitate pelvic dissection of mid- and distal rectal tumours. The purpose of this study was to analyse the short- and mid-term oncological outcomes of TaTME.
METHODS
A study was conducted on patients treated with TaTME for rectal cancer at two colorectal units in Portugal between March 2016 and December 2018. Clinical, pathological and oncological data were retrospectively analysed. Primary endpoints were 3-year overall survival, disease-free survival and local recurrence. Secondary endpoints were clinical and pathological outcomes.
RESULTS
Fifty patients (31 males, [62%], median age 66 years [range 40-85 years]) underwent TaTME, 49 (98%) for malignant and 1 (2%) for benign disease. There were no cases of conversion, 49 (98%) patients had complete or near-complete mesorectum, all the resections were R0 with adequate distal and circumferential margins. With a median follow-up of 36 months, there were 2 cases (4%) of local recurrence and 3-year estimated overall survival and disease-free survival were 90% and 79%, respectively.
CONCLUSIONS
TaTME can provide safe mid-term oncological outcomes, similar to what has been published for classic and laparoscopic TME. Our results also show how demanding this novel approach can be and the consequent need for audited data and standardized implementation.
Topics: Adult; Aged; Aged, 80 and over; Humans; Male; Middle Aged; Neoplasm Recurrence, Local; Proctectomy; Rectal Neoplasms; Rectum; Retrospective Studies; Transanal Endoscopic Surgery
PubMed: 33113009
DOI: 10.1007/s10151-020-02362-y -
World Journal of Gastroenterology Apr 2020Infliximab (IFX), as a drug of first-line therapy, can alter the natural progression of Crohn's disease (CD), promote mucosal healing and reduce complications,... (Review)
Review
Infliximab (IFX), as a drug of first-line therapy, can alter the natural progression of Crohn's disease (CD), promote mucosal healing and reduce complications, hospitalizations, and the incidence of surgery. Perianal fistulas are responsible for the refractoriness of CD and represent a more aggressive disease. IFX has been demonstrated as the most effective drug for the treatment of perianal fistulizing CD. Unfortunately, a significant proportion of patients only partially respond to IFX, and optimization of the therapeutic strategy may increase clinical remission. There is a significant association between serum drug concentrations and the rates of fistula healing. Higher IFX levels during induction are associated with a complete fistula response in these patients. Given the apparent relapse of perianal fistulizing CD, maintenance therapy with IFX over a longer period seems to be more beneficial. It appears that patients without deep remission are at an increased risk of relapse after stopping anti-tumor necrosis factor agents. Thus, only patients in prolonged clinical remission should be considered for withdrawal of IFX treatment when biomarker and endoscopic remission is demonstrated, especially when the hyperintense signals of fistulas on T2-weighed images have disappeared on magnetic resonance imaging. Fundamentally, the optimal timing of IFX use is highly individualized and should be determined by a multidisciplinary team.
Topics: Crohn Disease; Drug Administration Schedule; Humans; Infliximab; Magnetic Resonance Imaging; Proctoscopy; Rectal Fistula; Recurrence; Remission Induction; Secondary Prevention; Time Factors; Treatment Outcome; Wound Healing
PubMed: 32327905
DOI: 10.3748/wjg.v26.i14.1554 -
The Journal of Surgical Research Oct 2023Rigid proctosigmoidoscopy (RP) and flexible sigmoidoscopy (FS) are two modalities commonly used for intraoperative evaluation of colorectal anastomoses. This study seeks...
INTRODUCTION
Rigid proctosigmoidoscopy (RP) and flexible sigmoidoscopy (FS) are two modalities commonly used for intraoperative evaluation of colorectal anastomoses. This study seeks to determine whether there is an association between the endoscopic modality used to evaluate colorectal anastomoses and the rate of anastomotic leak (AL), organ space infection, and overall infectious complication.
METHODS
The 2012-2018 American College of Surgeons National Surgical Quality Improvement Program database was queried for patients undergoing colorectal anastomoses. Anastomotic evaluation method (RP versus FS) was identified by Current Procedural Terminologycoding and used for group classification. Outcomes measured included AL, organ space infections, and overall infection. Multivariable logistic regression analysis for predicting AL was performed.
RESULTS
We identified 7100 patients who underwent a colorectal anastomosis with intraoperative endoscopic evaluation. RP was utilized in 3397 (47.8%) and FS in 3703 (52.2%) patients. RP was used more commonly in diverticulitis (44.5% versus 36.2%, P < 0.01), while FS was used more frequently in malignancy (47.5% versus 36.7%, P < 0.01). Anastomotic evaluation with FS was associated with lower rates of organ space infection (3.8% versus 4.8%, P = 0.025) and AL (2.9% versus 3.8%, P = 0.028) compared to RP. On multivariate logistic regression modeling, anastomotic evaluation with RP was associated with a higher risk of AL (odds ratio 1.403, 95% CI 1.028-1.916, P = 0.033) compared to FS.
CONCLUSIONS
Compared to FS, rigid proctosigmoidoscopic evaluation of a colorectal anastomosis was associated with an increased rate of AL and organ space infection.
Topics: Humans; Proctoscopy; Anastomosis, Surgical; Anastomotic Leak; Rectum; Colorectal Neoplasms; Retrospective Studies
PubMed: 37182438
DOI: 10.1016/j.jss.2023.03.032 -
Surgical Endoscopy Jan 2022Treatment of early rectal cancer is evolving towards organ-preserving therapy which includes endoscopic resection and transanal approaches. We aimed to explore the role...
BACKGROUND
Treatment of early rectal cancer is evolving towards organ-preserving therapy which includes endoscopic resection and transanal approaches. We aimed to explore the role of local treatments such as endoscopic polypectomy (Endoscopic Mucosal Resection (EMR) or Endoscopic submucosal dissection (ESD)) and transanal endoscopic microsurgery/ transanal minimal invasive surgery (TEM/TAMIS) in patients who had early rectal cancer. We considered these outcomes alongside conventional major surgery using total mesorectal excision (TME) for early stage disease.
METHODS
All patients identified at MDT with early stage rectal cancer at our institution between 2010 and 2019 were included. Long-term outcomes in terms of local recurrence, survival and procedure-specific morbidity were analysed.
RESULTS
In total, 536 patients with rectal cancer were identified, of which 112 were included based on their pre-operative identification at the MDT on the basis that they had node-negative early rectal cancer. Among these, 30 patients (27%) had the lesion excised by flexible endoscopic polypectomy techniques (EMR/ESD), 67 (60%) underwent TEM/TAMIS and 15 (13%) had major surgery. There were no differences in patient demographics between the three groups except for TEM/TAMIS patients being more likely to be referred from another hospital (p < 0.001) and they were less active (WHO performance status p = 0.04). There were no significant differences in overall survival rates and cancer-specific survival between the three treatment groups. The 5-year overall survival rate for endoscopic polypectomy, TEM/TAMIS or major resection was 96% versus 90% and 88%, respectively (p = 0.89). The 5- year cancer-specific survival rate was 96%, versus 96% and 100%, respectively (p = 0.74).
CONCLUSION
Endoscopic polypectomy by EMR/ESD is an appropriate local treatment for early stage rectal cancer in selected patients. It is possible to achieve good oncological outcomes with a polypectomy similar to TEM/TAMIS and major surgery; however, a multidisciplinary approach is necessary enabling close surveillance and the use of adjuvant radiotherapy.
Topics: Endoscopic Mucosal Resection; Humans; Neoplasm Recurrence, Local; Radiotherapy, Adjuvant; Rectal Neoplasms; Rectum; Transanal Endoscopic Microsurgery; Treatment Outcome
PubMed: 33544250
DOI: 10.1007/s00464-021-08308-1 -
Surgical Endoscopy Sep 2020Transanal total mesorectal excision (taTME) is a novel approach to surgery for rectal cancer. The technique has gained significant popularity in the surgical community...
INTRODUCTION
Transanal total mesorectal excision (taTME) is a novel approach to surgery for rectal cancer. The technique has gained significant popularity in the surgical community due to the promising ability to overcome technical difficulties related to the access of the distal pelvis. Recently, Norwegian surgeons issued a local moratorium related to potential issues with the safety of the procedure. Early adopters of taTME in Canada have recognized the need to create guidelines for its adoption and supervision. The objective of the statement is to provide expert opinion based on the best available evidence and authors' experience.
METHODS
The procedure has been performed in Canada since 2014 at different institutions. In 2016, the first Canadian taTME congress was held in the city of Toronto, organized by two of the authors. In early 2019, a multicentric collaborative was established [The Canadian taTME expert Collaboration] which aimed at ensuring safe performance and adoption of taTME in Canada. Recently surgeons from 8 major Canadian rectal cancer centers met in the city of Toronto on December 7 of 2019, to discuss and develop a position statement. There in person, meeting was followed by 4 rounds of Delphi methodology.
RESULTS
The generated document focused on the need to ensure a unified approach among rectal cancer surgeons across the country considering its technical complexity and potential morbidity. The position statement addressed four domains: surgical setting, surgeons' requirements, patient selection, and quality assurance.
CONCLUSIONS
Authors agree transanal total mesorectal excision is technically demanding and has a significant risk for morbidity. As of now, there is uncertainty for some of the outcomes. We consider it is possible to safely adopt this operation and obtain adequate results, however for this purpose it is necessary to meet specific requirements in different domains.
Topics: Canada; Consensus; Humans; Laparoscopy; Proctectomy; Rectal Neoplasms; Rectum; Surgeons; Transanal Endoscopic Surgery
PubMed: 32504263
DOI: 10.1007/s00464-020-07680-8