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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 -
Asian Journal of Surgery Sep 2019
Comparative Study
Topics: Aged; Female; Humans; Male; Middle Aged; Proctectomy; Prone Position; Rectal Neoplasms; Retrospective Studies; Supine Position
PubMed: 31255464
DOI: 10.1016/j.asjsur.2019.05.006 -
JRSM Open Feb 2023Rectal malignant melanomas (RMM) are remarkably uncommon, the rectal location represents less than one percent of all rectal cancer. Because of its low global survival...
Long recurrence-free survival of localized rectal melanoma after abdominoperineal resection in comparison to partial excision and highlighting the place of immunotherapy: A case report.
Rectal malignant melanomas (RMM) are remarkably uncommon, the rectal location represents less than one percent of all rectal cancer. Because of its low global survival rate, the surgical strategy is a subject of controversy for attaining a r0 resection. the palliative treatment is also debateable, but recently; radiotherapy and immunotherapy became the preferred treatment and offer the best outcome. to ensure r0 resection, abdominoperineal resection (apr) is considered the main surgical option, but because of its morbidity and functional limitations, local excision techniques such as endoscopic mucosal resection (emr) combined with chemoradiotherapy are being increasingly performed to preserve the quality of life and reduce local recurrence rate. In this report, we evaluate the place that apr still keeps as surgical procedure in comparison to partial excision. we report a case of a 72 years old patient, who presented rectal syndrome with rectorrhagia for 2 months, the diagnosis of localized rectal melanoma was confirmed by endoscopy, magnetic resonance imaging, histological analysis tissue with immunohistochemistry. the procedure strategy was a surgical treatment with apr. After a long recurrence-free survival period, the patient develops local recurrence and immunotherapy-resistant metastasis.
PubMed: 36762266
DOI: 10.1177/20542704221148059 -
International Journal of Surgery... Jul 2023
Meta-Analysis
How to reasonably deal with zero-events in meta-analysis of surgery-related outcomes? Oncologic outcomes of intersphincteric resection vs. abdominoperineal resection for lower rectal cancer: a systematic review and meta-analysis.
Topics: Humans; Rectal Neoplasms; Proctectomy; Treatment Outcome; Anal Canal
PubMed: 37300885
DOI: 10.1097/JS9.0000000000000379 -
JAMA Network Open Feb 2021Proponents of novel transanal total mesorectal excision (TME) suggest the procedure overcomes the technical and oncologic challenges of conventional approaches for...
IMPORTANCE
Proponents of novel transanal total mesorectal excision (TME) suggest the procedure overcomes the technical and oncologic challenges of conventional approaches for treating rectal cancer. Recently, however, there has been controversy regarding the oncologic safety of the procedure.
OBJECTIVE
To assess the association of transanal TME with the incidence of local recurrence (LR) of cancer and the probability of remaining free of LR during follow-up.
DESIGN, SETTING, AND PARTICIPANTS
This multicenter cohort study used data from 8 high-volume rectal cancer academic institutions from across Canada on all consecutive patients with primary rectal cancer treated by transanal TME at the participating centers. The study was conducted between January 2014 and December 2018, and data were analyzed from April 1, 2020, to September 15, 2020.
EXPOSURE
Transanal TME.
MAIN OUTCOMES AND MEASURES
The incidence of LR was reported as a direct measure of quality of resection. The cumulative probability of LR- and systemic recurrence (SR)-free survival at 36 months was estimated. Local recurrence and SR were defined as radiologic or endoscopic evidence of 1 or more new lesions in or outside the pelvis, respectively, documented during surveillance after the removal of the primary tumor.
RESULTS
Of 608 total patients included in the analysis, 423 (69.6%) were male; the median age was 63 years (interquartile range [IQR], 54-70 years). Local recurrence was identified in 22 patients (3.6%) after a median follow-up of 27 months (IQR, 18-38 months). The median time to LR was 13 months (IQR, 9-19 months). Sixteen of the 22 patients with LR (72.7%) were male, 14 (63.6%) received neoadjuvant chemoradiation, and 12 (54.5%) had American Joint Committee on Cancer stage III disease. Of those with LR, 16 (72.7%) had a negative circumferential radial margin and 20 (90.9%) had a negative distal resection margin, 2 (9.1%) experienced conversion to open surgery, and 15 (68.2%) also developed SR. The probability of LR-free survival at 36 months was 96% (95% CI, 94%-98%). According to the Cox proportional hazards regression model, the hazard ratio of LR was estimated to be 4.2 (95% CI, 2.9-6.2) times higher among patients with a positive circumferential radial margin than among those with a negative circumferential radial margin.
CONCLUSIONS AND RELEVANCE
In this cohort study, transanal TME performed by experienced surgeons was associated with an incidence of LR and SR that is in line with the published literature on open and laparoscopic TME, suggesting that transanal TME may be an acceptable approach for management of rectal cancer.
Topics: Aged; Anastomosis, Surgical; Canada; Chemoradiotherapy; Disease-Free Survival; Female; Humans; Ileostomy; Male; Margins of Excision; Mesentery; Middle Aged; Neoadjuvant Therapy; Neoplasm Recurrence, Local; Neoplasm Staging; Postoperative Complications; Proctectomy; Proportional Hazards Models; Rectal Neoplasms; Transanal Endoscopic Surgery; Tumor Burden; Video-Assisted Surgery
PubMed: 33533932
DOI: 10.1001/jamanetworkopen.2020.36330 -
Frontiers in Oncology 2022In two facilities in Chongqing, this research sought to retrospectively evaluate the effects of perineal wound infection on survival after laparoscopic abdominoperineal...
BACKGROUND
In two facilities in Chongqing, this research sought to retrospectively evaluate the effects of perineal wound infection on survival after laparoscopic abdominoperineal resection (LAPR) of rectal cancer.
METHODS
To obtain clinical information on patients who underwent LAPR between January 2013 and December 2021, we performed a multicenter cohort study. A total of 473 patients were enrolled: 314 in the non-infection group and 159 in the group with perineal infection. The general data, perioperative conditions, and tumor outcomes between groups were analyzed. The infection rates, recurrence rates, and survival rates of the two centers were compared.
RESULTS
The age, height, weight, body mass index (BMI), preoperative complications, preoperative treatment, and intraoperative conditions of patients in the LAPR infection group were not statistically different from those in the non-infection group. The percentage of men, typical postoperative hospital stay, length of initial postoperative therapy, and recurrence and metastasis rates were all considerably higher in the infection group than those in the non-infection group. Wound infection was an independent factor affecting tumor recurrence and metastasis after LAPR as well as an independent factor shortening patient survival time according to multivariate analysis. The incidence of wound infection, the rate of recurrence, and the rate of mortality did not vary significantly across sites.
CONCLUSION
Wound infection after LAPR increases the mean postoperative hospital stay, prolongs the time to first postoperative treatment, and decreases the disease-free survival (DFS) and overall survival (OS). Therefore, decreasing the rate of LAPR wound infection is expected to shorten the postoperative hospital stay and prolong the patient DFS and OS. Patients with postoperative infection may require intensive adjuvant therapy.
PubMed: 36686786
DOI: 10.3389/fonc.2022.1036241 -
The British Journal of Surgery Oct 2021The purpose of this study was to investigate the prevalence of ypN+ status according to ypT category in patients with locally advanced rectal cancer treated with... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The purpose of this study was to investigate the prevalence of ypN+ status according to ypT category in patients with locally advanced rectal cancer treated with chemoradiotherapy and total mesorectal excision, and to assess the impact of ypN+ on disease recurrence and survival by pooled analysis of individual-patient data.
METHODS
Individual-patient data from 10 studies of chemoradiotherapy for rectal cancer were included. Pooled rates of ypN+ disease were calculated with 95 per cent confidence interval for each ypT category. Kaplan-Meier and Cox regression analyses were undertaken to assess influence of ypN status on 5-year disease-free survival (DFS) and overall survival (OS).
RESULTS
Data on 1898 patients were included in the study. Median follow-up was 50 (range 0-219) months. The pooled rate of ypN+ disease was 7 per cent for ypT0, 12 per cent for ypT1, 17 per cent for ypT2, 40 per cent for ypT3, and 46 per cent for ypT4 tumours. Patients with ypN+ disease had lower 5-year DFS and OS (46.2 and 63.4 per cent respectively) than patients with ypN0 tumours (74.5 and 83.2 per cent) (P < 0.001). Cox regression analyses showed ypN+ status to be an independent predictor of recurrence and death.
CONCLUSION
Risk of nodal metastases (ypN+) after chemoradiotherapy increases with advancing ypT category and needs to be considered if an organ-preserving strategy is contemplated.
Topics: Aged; Aged, 80 and over; Chemoradiotherapy, Adjuvant; Female; Humans; Kaplan-Meier Estimate; Lymph Nodes; Lymphatic Metastasis; Male; Middle Aged; Neoplasm Invasiveness; Neoplasm Recurrence, Local; Proctectomy; Rectal Neoplasms; Regression Analysis
PubMed: 34240110
DOI: 10.1093/bjs/znab194 -
Annals of Coloproctology Feb 2021Malignant melanoma of the anorectum is a rare disorder. Patients often present with local symptoms similar to benign diseases. The prognosis is very poor, and almost all...
Malignant melanoma of the anorectum is a rare disorder. Patients often present with local symptoms similar to benign diseases. The prognosis is very poor, and almost all patients die because of metastases. We report 2 female patients with unremarkable histories. Both of them received previous operations before visiting our center after they were diagnosed with anorectal malignant melanoma. One case underwent abdominoperineal resection and postoperative chemotherapy. The other had been treated with ultralow anterior resection followed by immunotherapy.
PubMed: 33730798
DOI: 10.3393/ac.2020.01.07.1 -
BMC Cancer Dec 2021The optimal treatment of stage IV rectal cancer remains controversial. The purpose of this study was to assess the treatment outcomes and toxicity of neoadjuvant...
BACKGROUND
The optimal treatment of stage IV rectal cancer remains controversial. The purpose of this study was to assess the treatment outcomes and toxicity of neoadjuvant chemotherapy and radiotherapy followed by local treatment of all tumor sites and subsequent adjuvant chemotherapy in stage IV rectal cancer patients with potentially resectable metastases.
METHODS
Adult patients diagnosed with locally advanced rectal adenocarcinoma with potentially resectable metastases, who received neoadjuvant chemotherapy and radiotherapy from July 2013 and September 2019 at Sun Yat-sen University cancer center, were included. Completion of the whole treatment schedule, pathological response, treatment-related toxicity and survival were evaluated.
RESULTS
A total of 228 patients were analyzed with a median follow-up of 33 (range 3.3 to 93.4) months. Eventually, 112 (49.1%) patients finished the whole treatment schedule, of which complete response of all tumor sites and pathological downstaging of the rectal tumor were observed in three (2.7%) and 90 (80.4%) patients. The three-year overall survival (OS) and progression-free survival (PFS) of all patients were 56.6% (50.2 to 63.9%) and 38.6% (95% CI 32.5 to 45.8%), respectively. For patients who finished the treatment schedule, 3-year OS (74.4% vs 39.2%, P < 0.001) and 3-year PFS (45.5% vs 30.5%, P = 0.004) were significantly improved compared those who did not finish the treatment. Grade 3-4 chem-radiotherapy treatment toxicities were observed in 51 (22.4%) of all patients and surgical complications occurred in 22 (9.6%) of 142 patients who underwent surgery, respectively.
CONCLUSIONS
Neoadjuvant chemotherapy and radiotherapy followed by resection/ablation and subsequent adjuvant chemotherapy offered chances of long-term survival with tolerable toxicities for selected patients with potentially resectable stage IV rectal cancer, and could be considered as an option in clinical practice.
Topics: Ablation Techniques; Adenocarcinoma; Adult; Aged; Aged, 80 and over; Antineoplastic Protocols; Chemotherapy, Adjuvant; Combined Modality Therapy; Female; Follow-Up Studies; Humans; Male; Middle Aged; Neoadjuvant Therapy; Neoplasm Staging; Proctectomy; Progression-Free Survival; Radiotherapy, Adjuvant; Rectal Neoplasms; Remission Induction; Retrospective Studies; Survival Rate; Treatment Outcome
PubMed: 34906114
DOI: 10.1186/s12885-021-09089-5 -
Clinical Anatomy (New York, N.Y.) Sep 2020Knowledge of the anatomy of the male pelvic floor is important to avoid damaging the pelvic floor muscles during surgery. We set out to explore the structure and...
Knowledge of the anatomy of the male pelvic floor is important to avoid damaging the pelvic floor muscles during surgery. We set out to explore the structure and innervation of the smooth muscle (SM) of the whole pelvic floor using male fetuses. We removed en-bloc the entire pelvis of three male fetuses. The specimens were serially sectioned before being stained with Masson's trichrome and hematoxylin and eosin, and immunostained for SMs, and somatic, adrenergic, sensory and nitrergic nerve fibers. Slides were digitized for three-dimensional reconstruction. We individualized a middle compartment that contains SM cells. This compartment is in close relation with the levator ani muscle (LAM), rectum, and urethra. We describe a posterior part of the middle compartment posterior to the rectal wall and an anterior part anterior to the rectal wall. The anterior part is split into (1) a centro-levator area of SM cells localized between the right and left LAM, (2) an endo-levator area that upholsters the internal aspect of the LAM, and (3) an infra-levator area below the LAM. All these areas are innervated by autonomic nerves coming from the inferior hypogastric plexus. The core and the infra-levator area receive the cavernous nerve and nerves supplying the urethra. We thus demonstrate that these muscular structures are smooth and under autonomic influence. These findings are relevant for the pelvic surgeon, and especially the urologist, during radical prostatectomy, abdominoperineal resection and intersphincteric resection. Clin. Anat., 2019. © 2019 Wiley Periodicals, Inc.
Topics: Cadaver; Fetus; Humans; Imaging, Three-Dimensional; Male; Muscle, Smooth; Pelvic Floor
PubMed: 31746012
DOI: 10.1002/ca.23515