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Khirurgiia 2022To analyze the results of transanal endoscopic microsurgery in patients with rectal tumors.
OBJECTIVE
To analyze the results of transanal endoscopic microsurgery in patients with rectal tumors.
MATERIAL AND METHODS
We analyzed 87 transanal endoscopic resections of rectal benign tumors (35 patients) and rectal cancer cT1N0M0 (52 patients) for the period since 2012.
RESULTS
There were 2 (3.8%) intraoperative intestinal wall perforations into abdominal cavity and 2 (3.8%) postoperative bleedings among patients with rectal cancer. Four (7.7%) patients developed recurrent rectal cancer (pT1N0M0 - 1 patient, pT2N0M0 - 3 patients; by tumor grades: G1 - 2 patients, G2 - 2 patients) within 1.6-5.2 years. All recurrent tumors were located on anterior rectal wall. In patients with rectal cancer, cumulative relapse-free survival was 0.923 (standard error 0.037), cumulative overall survival - 0.926 (standard error 0.043). There was 1 (4.3%) intraoperative intestinal wall perforation among patients with benign rectal tumors. Postoperative anastomotic leakage occurred in 1 (4.3%) patient. Recurrent benign tumors occurred in 2 (8.7%) patients with villous rectal tumors. No relapses were observed in patients with rectal adenomas (=1.0).
CONCLUSION
Transanal endoscopic rectal resection is effective for benign rectal tumors and rectal cancer pT1N0M0 with high relapse-free and overall survival and low complication rate. Risk factors of recurrence are tumor stage pT2N0M0, tumor location on anterior wall and distance from the anus over 10 cm.
Topics: Digestive System Surgical Procedures; Humans; Microsurgery; Neoplasm Recurrence, Local; Rectal Neoplasms; Rectum; Retrospective Studies; Transanal Endoscopic Surgery; Treatment Outcome
PubMed: 35080824
DOI: 10.17116/hirurgia202201130 -
Techniques in Coloproctology Feb 2022Placing a transanal endoscopic rectal purse-string suture (taEPS) is the crucial first component of transanal total mesorectal excision (taTME). However, no structured...
BACKGROUND
Placing a transanal endoscopic rectal purse-string suture (taEPS) is the crucial first component of transanal total mesorectal excision (taTME). However, no structured training is available to improve the procedure-specific skills for taEPS. The aim of this study was to create a performance rubric to improve taEPS skills and provide preliminary evidence for its validity.
METHODS
A performance rubric was created based on technical considerations for taEPS, identified by consulting with taTME surgical and performance assessment experts. Ten independent, blinded raters assessed 10 videotaped taEPS procedures of consecutive taTME cases, at National Cancer Center Hospital East (NCCHE), Chiba, Japan, in January 2018-March 2019 using the rubric and the Global Operative Assessment of Laparoscopic Skills (GOALS). Internal consistency and inter-rater reliabilities were calculated. Videotaped taEPS procedures were timed and assessed by the rubric. Correlation between rubric scores and suturing times were analyzed.
RESULTS
The rubric consists of four items: loading the needle (LN), atraumatic needle passage (AP), planned suture path (PS), and overall performance (OA). Videotaped performances were graded on a 3-point Likert scale; scores were calculated as sums of the points. Cronbach's α for internal consistency was 0.713. Inter-rater reliabilities were LN: 0.73, AP: 0.76, PS: 0.71, and OA: 0.70. Rubric and GOALS scores were strongly correlated (r = 0.964, p < 0.001). In 112 consecutive taEPS performances, rubric scores were strongly correlated with suturing time (r = - 0.69, p < 0.001). Surgeons' experience with taTME was associated with rubric scores and suturing time.
CONCLUSIONS
This study provides preliminary validation for the taEPS skill performance rubric. The rubric's structured training may facilitate skill acquisition by providing trainees with critical clinical considerations.
Topics: Humans; Laparoscopy; Postoperative Complications; Proctectomy; Rectal Neoplasms; Rectum; Sutures; Transanal Endoscopic Surgery
PubMed: 34761314
DOI: 10.1007/s10151-021-02545-1 -
Surgical Endoscopy Dec 2021There is no literature that mainly searched for rectal neuroendocrine tumor (rNET) using transanal minimal invasive surgery (TAMIS). We report our clinical experiences...
BACKGROUND
There is no literature that mainly searched for rectal neuroendocrine tumor (rNET) using transanal minimal invasive surgery (TAMIS). We report our clinical experiences of TAMIS for rectal neuroendocrine tumors to evaluate the feasibility and safety.
METHODS
Between December 2010 and March 2020, the 25 consecutive patients with rectal neoplasma underwent the TAMIS procedure performed by single laparoscopic surgeon at the two hospitals. Of these, ten patients with rectal neuroendocrine tumors were reviewed retrospectively. The full-thickness excision down to the outer fatty tissues was completed using TAMIS technique. Clinicopathological findings, perioperative and postoperative complications were recorded.
RESULTS
TAMIS for small rNET was successfully completed in all cases. There were seven cases with a tumor size of less than 10 mm, and three cases with a tumor size between 10 and 15 mm. Six patients underwent the primary tumor excision; the remaining four patients underwent resection for the scar after endoscopic procedure. The median surgical duration was 80.5 (53-124) minutes and the median blood loss was 1 (1-12) ml. All removed tumors in the 6 primary excisions were diagnosed as neuroendocrine tumor G1. The margins of specimens were completely free in all cases. Among the four patients after endoscopic procedure, all had no histological evidence of residual tumor. The median length of hospital stay was 7 days postoperatively. There was no post-operative mortality or severe complication. The median length of observation was 54 months. No recurrence, no local or distant metastasis and no mortality of all patients were observed.
CONCLUSIONS
TAMIS is safety and feasible procedure for small rNET. Further experience and clinical trials are needed to fully define the advantages, disadvantages, and indications of TAMIS for rNET.
Topics: Humans; Minimally Invasive Surgical Procedures; Neuroendocrine Tumors; Rectal Neoplasms; Rectum; Retrospective Studies; Transanal Endoscopic Surgery
PubMed: 33237462
DOI: 10.1007/s00464-020-08178-z -
Surgical Endoscopy Feb 2021To describe outcomes after transanal total mesorectal excision (TaTME) 5 years from implementation at a large-volume colorectal unit, including local recurrence,...
OBJECTIVE
To describe outcomes after transanal total mesorectal excision (TaTME) 5 years from implementation at a large-volume colorectal unit, including local recurrence, distant metastasis, and survival.
BACKGROUND
Transanal total mesorectal excision (TaTME) is a relatively new procedure for mid- and low-rectal cancer, with well-documented safety and feasibility. However, data on long-term results are limited.
METHODS
This study was based on a prospective data collection via a maintained database in a large colorectal unit. The database included patients who underwent TaTME from December 2013 through July 2019. We have updated the database through a review of patient charts, including radiology and pathology reports. Data collection included operative details, intraoperative findings, postoperative complications, pathologic results, and oncologic results.
RESULTS
During the study period, two hundred patients underwent TaTME in the study period (men = 147). The mean BMI was 26.7%, and the mean tumor height from the anal verge was 7.86 cm. Neoadjuvant treatment was given to 22% of patients. Anastomotic leakage occurred in 9.3% of patients, and the overall rate of postoperative complications was 24.5%. The TME specimen was incomplete in 11% of patients, and the CRM was positive in 5.5% of patients. Local recurrence (LR) occurred in seven patients with a follow-up of at least 2 years (4.7%). Distant metastasis (DM) occurred in 12% of patients. The overall survival was 90% and disease-free survival was 81%. The operating time was reduced in the later period of our experience.
CONCLUSIONS
This study showed that TaTME is feasible, safe, and had acceptable short-term outcomes and an acceptable rate of LR. The study included, however, one group that was non-randomized, and the follow-up was not long enough for most patients. Studies with longer follow-up data are awaited.
Topics: Aged; Female; History, 21st Century; Humans; Male; Prospective Studies; Rectum; Survival Analysis; Transanal Endoscopic Surgery; Treatment Outcome
PubMed: 32072292
DOI: 10.1007/s00464-020-07454-2 -
Colorectal Disease : the Official... Mar 2024Several methods for assessing anastomotic integrity have been proposed, but the best is yet to be defined. The aim of this study was to compare the different methods to...
Is proctoscopy sufficient for the evaluation of colorectal anastomosis prior to ileostomy reversal? A nationwide retrospective analysis of the Italian Society of Surgical Oncology Colorectal Cancer Network Collaborative group (SICO-CCN).
AIM
Several methods for assessing anastomotic integrity have been proposed, but the best is yet to be defined. The aim of this study was to compare the different methods to assess the integrity of colorectal anastomosis prior to ileostomy reversal.
METHOD
A retrospective cohort analysis on patients between 1 January 2010 and 31 December 2020 with a defunctioning stoma for middle and low rectal anterior resection was performed. A propensity score matching comparison between patients who underwent proctoscopy alone and patients who underwent proctoscopy plus any other preoperative method to assess the integrity of colorectal anastomosis prior to ileostomy reversal (transanal water-soluble contrast enema via conventional radiology, transanal water-soluble contrast enema via CT, and magnetic resonance) was performed.
RESULTS
The analysis involved 1045 patients from 26 Italian referral colorectal centres. The comparison between proctoscopy alone versus proctoscopy plus any other preoperative tool showed no significant differences in terms of stenoses (p = 0.217) or leakages (p = 0.103) prior to ileostomy reversal, as well as no differences in terms of misdiagnosed stenoses (p = 0.302) or leakages (p = 0.509). Interestingly, in the group that underwent proctoscopy and transanal water-soluble contrast enema the comparison between the two procedures demonstrated no significant differences in detecting stenoses (2 vs. 0, p = 0.98), while there was a significant difference in detecting leakages in favour of transanal water-soluble contrast enema via CT (3 vs. 12, p = 0.03).
CONCLUSIONS
We can confirm that proctoscopy alone should be considered sufficient prior to ileostomy reversal. However, in cases in which the results of proctoscopy are not completely clear or the surgeon remains suspicious of an anastomotic leakage, transanal water-soluble contrast enema via CT could guarantee its detection.
Topics: Humans; Proctoscopy; Ileostomy; Retrospective Studies; Constriction, Pathologic; Surgical Oncology; Rectal Neoplasms; Enema; Contrast Media; Anastomosis, Surgical; Anastomotic Leak; Water; Italy
PubMed: 38229251
DOI: 10.1111/codi.16864 -
Techniques in Coloproctology Apr 2022The Flex Robotic System (Medrobotics, Raynham, MA, USA) is the first miniaturised flexible endoscopic robot that aims to allow surgical manoeuvres beyond the area...
BACKGROUND
The Flex Robotic System (Medrobotics, Raynham, MA, USA) is the first miniaturised flexible endoscopic robot that aims to allow surgical manoeuvres beyond the area currently reached by transanal endoscopic microsurgery. The aim of this study is to evaluate our initial clinical experience with this novel tool.
METHODS
We prospectively collected all consecutive cases of local excisions of rectal lesions performed with the Flex Robotic System performed at the Department of Surgical Sciences of the University of Turin between October 2018 and December 2019. Indications were benign, or early rectal lesions judged unsuitable for endoscopic removal, within 20 cm of the anal verge. Debriefing meetings after each procedure allowed technology assessment leading to the modification, development, and implementation of tools according to the clinical experience. We analysed the data in terms of the safety and efficacy of treatment.
RESULTS
Between October 2018 and February 2020, 26 patients were treated. We performed a full-thickness excision in 14 patients and a submucosal dissection in 12. The median operating time was 115 min (range 45-360 min). In six patients (23.1%), we converted to standard transanal endoscopic operation (TEO) (Karl Storz, Tuttlingen, Germany) to complete the procedure. The 30-day morbidity rate was 11.5% (3/26). Positive resection margins were detected in 4 (15.4%) patients. At a minimum follow-up of 12 months, 2 (7.7%) local recurrences were observed.
CONCLUSIONS
This first clinical series demonstrates that the Flex Robotic System is a fascinating technology that deserves further development to increase surgical dexterity, thereby overcoming current technical limitations and improving clinical outcomes.
Topics: Anal Canal; Humans; Rectal Neoplasms; Rectum; Robotics; Transanal Endoscopic Microsurgery; Transanal Endoscopic Surgery; Treatment Outcome
PubMed: 35091792
DOI: 10.1007/s10151-022-02577-1 -
Digestive Diseases (Basel, Switzerland) 2023The local resection of recurrent rectal adenomas is a technically challenging task associated with increased local recurrence rate. Transanal endoscopic microsurgical...
BACKGROUND
The local resection of recurrent rectal adenomas is a technically challenging task associated with increased local recurrence rate. Transanal endoscopic microsurgical submucosal dissection (TEM-ESD) uses traction to better expose the fibrotic submucosal layer, and therefore, is a valuable alternative for the treatment of such lesions. The aim of our study was to assess the feasibility and outcomes of TEM-ESD for the resection of recurrent rectal adenomas.
METHODS
We retrospectively analysed all TEM-ESD procedures performed in the Karlsruhe Municipal Hospital between 2012 and 2021 and isolated all cases of recurrent adenomas. Subsequently, we matched these cases 1:1 to TEM-ESD cases for primary rectal adenomas according to the size, localization, and histological type of the lesions and compared the outcomes between the two groups.
RESULTS
We identified 19 cases matching our criteria. The median diameter of the lesions was 25 mm and the median operating time 39 min. Macroscopic en bloc resection was achieved in 100% of the cases and histological complete en bloc resection in 78.9%. There was 1 case of conservatively treated postoperative bleeding. After a median follow-up period of 36 months, there was one local recurrence. After comparing those findings to the outcomes of TEM-ESD for primary rectal lesions, we found no significant differences on total operating time, complete en bloc resection rates, adverse events, and local recurrence.
CONCLUSION
TEM-ESD is a feasible therapeutic option for the resection of recurrent rectal adenomas, offering short operating times as well as high en bloc resection and low recurrence rates.
Topics: Humans; Adenoma; Neoplasm Recurrence, Local; Precancerous Conditions; Rectal Neoplasms; Retrospective Studies; Transanal Endoscopic Surgery; Treatment Outcome; Feasibility Studies
PubMed: 35203076
DOI: 10.1159/000523672 -
Updates in Surgery Jun 2022Robotic transanal minimally invasive surgery (R-TAMIS) is a novel and evolving technique with limited reported outcomes in the literature. Compared to the laparoscopic...
Robotic transanal minimally invasive surgery (R-TAMIS) is a novel and evolving technique with limited reported outcomes in the literature. Compared to the laparoscopic approach, R-TAMIS provides enhanced optics, increased degrees of motion, superior ergonomics, and easier maneuverability in the confines of the rectum. We report a single institution experience at a large quaternary referral academic medical center with R-TAMIS using the da Vinci Xi® platform. This is a retrospective review of electronic medical records at the Mayo Clinic from September 2017 to April 2020. It includes all available clinical documentations for patients undergoing R-TAMIS at our institution. Patient demographics, intraoperative data (procedure time, tumor size and distance), complications, and pathology reports were reviewed. A total of 28 patients underwent R-TAMIS. Median follow-up was 23.65 months. Sixteen patients underwent R-TAMIS for endoscopically unresectable rectal polyps, eight for rectal adenocarcinoma, two for rectal gastrointestinal stromal tumor, and two for rectal carcinoid tumor. The mean size of the lesions was 4.1 cm (range 0.2-13.8 cm). The mean location of lesions was 7.8 cm (range 0-16 cm) from the anal verge. The mean operative time was 132.5 ± 46.8 min. There was one 30-day complication, and no deaths. Twenty-three (82%) patients were discharged the day of surgery. R-TAMIS is a safe, feasible, and effective technique for the surgical treatment of a variety of rectal pathology. A hybrid technique can be used for the resecting tumors extending into the anal canal.
Topics: Anal Canal; Humans; Minimally Invasive Surgical Procedures; Rectal Neoplasms; Rectum; Robotic Surgical Procedures; Transanal Endoscopic Surgery
PubMed: 35175536
DOI: 10.1007/s13304-021-01233-x -
Surgical Oncology Sep 2019The aim of this meta-analysis was to determine whether transanal total mesorectal excision (taTME) improves histopathology metrics and/or complication rates when... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The aim of this meta-analysis was to determine whether transanal total mesorectal excision (taTME) improves histopathology metrics and/or complication rates when compared to robotic total mesorectal excision (R-TME) of resectable rectal cancer.
METHODS
MEDLINE, Pubmed, Cochrane Library, and Scopus were systematically searched by two independent researchers. Six observational studies totaling 1,572 patients (811 taTME; 761 R-TME) were included after screening 14 potentially eligible records. Mantel-Haenszel method using odds ratios with 95% confidence intervals (OR (95%CI)) and inverse variance with mean difference with 95% confidence intervals (MD (95%CI)) as an effect measure for dichotomous and continuous variables, respectively, was employed for meta-analysis. Statistical heterogeneity among effect estimates was evaluated using I and Tau.
RESULTS
Circumferential resection margin (CRM) involvement rates (3.8% taTME; 5.3% R-TME) did not differ [OR (95%CI) = 0.86 (0.35, 2.15); p = 0.75] with low among-study heterogeneity (I = 21%). Complication rates (35.4% taTME; 32.3% R-TME) did not differ [OR (95%CI) = 0.92 (0.64, 1.32); p = 0.65], although with moderate among-study heterogeneity (I = 40%). CRM involvement [OR (95%CI) = 0.76 (0.40, 1.43); p = 0.40] and complication rates [OR (95%CI) = 0.84 (0.59, 1.21); p = 0.35] did not significantly differ in subgroup meta-analysis including mid- and low rectal cancer. Distal resection margin (mm) did not significantly differ between the interventions [MD (95%CI) = -0.41 (-1.29, 0.47); p = 0.37].
CONCLUSIONS
This meta-analysis found that taTME of rectal cancer does not improve histopathology metrics and complication rates when compared to R-TME.
Topics: Humans; Laparoscopy; Postoperative Complications; Rectal Neoplasms; Robotics; Transanal Endoscopic Surgery; Treatment Outcome
PubMed: 31500784
DOI: 10.1016/j.suronc.2019.05.012 -
Surgical Endoscopy Jul 2023Transanal minimally invasive surgery (TAMIS) is a surgical alternative to transanal endoscopic microsurgery (TEM), transanal excision and proctectomy in the management...
PURPOSE
Transanal minimally invasive surgery (TAMIS) is a surgical alternative to transanal endoscopic microsurgery (TEM), transanal excision and proctectomy in the management of benign rectal polyps and early rectal cancers. Low anterior resection syndrome (LARS) describes the constellation of symptoms which result from and are common after distal colorectal resection. Symptoms include incontinence, frequency, urgency and evacuatory dysfunction. The aim of the current study was to prospectively evaluate pre- and post-operative LARS in patients who undergo TAMIS.
METHODS
We conducted a prospective analysis of a consecutive series of patients who underwent TAMIS at our institution between January 2021 and February 2022. A LARS questionnaire was undertaken preoperatively, at 1 month and at 6 months post-operatively.
RESULTS
Twenty patients were recruited to this pilot study. The mean age was 63 ± 12 years, 11 of the patients were male, mean pre-operative BMI was 29 ± 6 kg/m, and 30% (n = 6) of patients underwent TAMIS for an invasive rectal cancer, with all patients receiving an R0 resection. Mean distance from the anal verge was 5.7 ± 3.2 cm, and mean lesion diameter was 46 ± 20.5 mm. A statistically significant interval reduction was observed between preoperative (20.3 ± 12.9) and 6-month post-operative (12.6 ± 9.7) LARS scores (p = 0.02) and also between 1-month (18.2 ± 10.6) and 6-month post-operative scores (p = 0.01).
CONCLUSIONS
We noted a high prevalence of LARS across our cohort preoperatively, and this had improved significantly at 6-month review post-TAMIS. This study reaffirms the safety and efficacy of TAMIS for the treatment of early rectal neoplasia.
Topics: Humans; Male; Middle Aged; Aged; Female; Rectal Neoplasms; Low Anterior Resection Syndrome; Postoperative Complications; Pilot Projects; Treatment Outcome; Transanal Endoscopic Surgery; Anal Canal; Minimally Invasive Surgical Procedures
PubMed: 36964292
DOI: 10.1007/s00464-023-10004-1