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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 -
BMJ Case Reports Jun 2021A 14-year-old girl, a rear seat passenger on a jet-ski not wearing suitable protective gear, was 'jumping' waves at a low velocity when she was ejected backwards off the...
A 14-year-old girl, a rear seat passenger on a jet-ski not wearing suitable protective gear, was 'jumping' waves at a low velocity when she was ejected backwards off the vehicle, suffering a complex and unusual hydrostatic perineal injury as a result of the high-pressure water stream propelling the jet-ski. She presented to the emergency room with rectal bleeding and perineal and abdominal pain. Initial investigations revealed signs of anorectal injury and both intraperitoneal and extraperitoneal free air and fluid, suggesting a possible rectal perforation. Proctoscopy confirmed the primary diagnosis and exploratory laparotomy revealed an intraperitoneal tear in the rectal wall. The tear was repaired, and protective loop colostomy was performed. Initial results of anal manometry, transrectal ultrasound and anal electromyography were unfavourable. However, 17 months after pelvic floor physiotherapy and biofeedback, the colostomy was reversed, and her continence has returned to her normal (preinjury) state.
Topics: Adolescent; Anal Canal; Colostomy; Female; Humans; Perineum; Rectal Diseases; Rectum
PubMed: 34155009
DOI: 10.1136/bcr-2020-241247 -
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 -
Surgical Endoscopy Sep 2022The standard treatment of rectal carcinoma is surgical resection according to the total mesorectal excision principle, either by open, laparoscopic, robot-assisted or... (Review)
Review
BACKGROUND
The standard treatment of rectal carcinoma is surgical resection according to the total mesorectal excision principle, either by open, laparoscopic, robot-assisted or transanal technique. No clear consensus exists regarding the length of the learning curve for the minimal invasive techniques. This systematic review aims to provide an overview of the current literature regarding the learning curve of minimal invasive TME.
METHODS
A systematic literature search was performed. PubMed, Embase and Cochrane Library were searched for studies with the primary or secondary aim to assess the learning curve of either laparoscopic, robot-assisted or transanal TME for rectal cancer. The primary outcome was length of the learning curve per minimal invasive technique. Descriptive statistics were used to present results and the MINORS tool was used to assess risk of bias.
RESULTS
45 studies, with 7562 patients, were included in this systematic review. Length of the learning curve based on intraoperative complications, postoperative complications, pathological outcomes, or a composite endpoint using a risk-adjusted CUSUM analysis was 50 procedures for the laparoscopic technique, 32-75 procedures for the robot-assisted technique and 36-54 procedures for the transanal technique. Due to the low quality of studies and a high level of heterogeneity a meta-analysis could not be performed. Heterogeneity was caused by patient-related factors, surgeon-related factors and differences in statistical methods.
CONCLUSION
Current high-quality literature regarding length of the learning curve of minimal invasive TME techniques is scarce. Available literature suggests equal lengths of the learning curves of laparoscopic, robot-assisted and transanal TME. Well-designed studies, using adequate statistical methods are required to properly assess the learning curve, while taking into account patient-related and surgeon-related factors.
Topics: Humans; Laparoscopy; Learning Curve; Postoperative Complications; Rectal Neoplasms; Rectum; Robotics; Transanal Endoscopic Surgery; Treatment Outcome
PubMed: 35697853
DOI: 10.1007/s00464-022-09087-z -
Medicine Jan 2024Laparoscopic total mesorectal excision (LaTME) and transanal total mesorectal excision (TaTME) are popular mid and low rectal cancer trends. However, there is currently... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Laparoscopic total mesorectal excision (LaTME) and transanal total mesorectal excision (TaTME) are popular mid and low rectal cancer trends. However, there is currently no systematic comparison between LaTME and TaTME of mid and low rectal cancer. Therefore, we systematically study the perioperative and pathological outcomes of LaTME and TaTME in mid and low rectal cancer.
METHODS
Articles included searching through the Embase, Cochrane Library, PubMed, Medline, and Web of science for articles on LaTME and TaTME. We calculated pooled standard mean difference (SMD), relative risk (RR), and 95% confidence intervals (CIs). The protocol for this review has been registered on PROSPERO (CRD42022380067).
RESULTS
There are 8761 participants included in 33 articles. Compared with TaTME, patients who underwent LaTME had no statistical difference in operation time (OP), estimated blood loss (EBL), postoperative hospital stay, over complications, intraoperative complications, postoperative complications, anastomotic stenosis, wound infection, circumferential resection margin, distal resection margin, major low anterior resection syndrom, lymph node yield, loop ileostomy, and diverting ileostomy. There are similarities between LaTME and TaTME for 2-year DFS rate, 2-year OS rate, distant metastasis rat, and local recurrence rate. However, patients who underwent LaTME had less anastomotic leak rates (RR 0.82; 95% CI: 0.70-0.97; I2 = 10.6%, P = .019) but TaTME had less end colostomy (RR 1.96; 95% CI: 1.19-3.23; I2 = 0%, P = .008).
CONCLUSION
This study comprehensively and systematically evaluated the differences in safety and effectiveness between LaTME and TaTME in the treatment of mid and low rectal cancer through meta-analysis. Patients who underwent LaTME had less anastomotic leak rate but TaTME had less end colostomy. There is no difference in other aspects. Of course, in the future, more scientific and rigorous conclusions need to be drawn from multi-center RCT research.
Topics: Humans; Animals; Rats; Rectum; Anastomotic Leak; Margins of Excision; Transanal Endoscopic Surgery; Rectal Neoplasms; Laparoscopy; Postoperative Complications; Treatment Outcome
PubMed: 38277570
DOI: 10.1097/MD.0000000000036859 -
PloS One 2023Minimally invasive total mesorectal excision is increasingly being used as an alternative to open surgery in the treatment of patients with rectal cancer. This...
OBJECTIVES
Minimally invasive total mesorectal excision is increasingly being used as an alternative to open surgery in the treatment of patients with rectal cancer. This systematic review aimed to compare the total, operative and hospitalization costs of open, laparoscopic, robot-assisted and transanal total mesorectal excision.
METHODS
This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA) (S1 File) A literature review was conducted (end-of-search date: January 1, 2023) and quality assessment performed using the Consensus Health Economic Criteria.
RESULTS
12 studies were included, reporting on 2542 patients (226 open, 1192 laparoscopic, 998 robot-assisted and 126 transanal total mesorectal excision). Total costs of minimally invasive total mesorectal excision were higher compared to the open technique in the majority of included studies. For robot-assisted total mesorectal excision, higher operative costs and lower hospitalization costs were reported compared to the open and laparoscopic technique. A meta-analysis could not be performed due to low study quality and a high level of heterogeneity. Heterogeneity was caused by differences in the learning curve and statistical methods used.
CONCLUSION
Literature regarding costs of total mesorectal excision techniques is limited in quality and number. Available evidence suggests minimally invasive techniques may be more expensive compared to open total mesorectal excision. High-quality economical evaluations, accounting for the learning curve, are needed to properly assess costs of the different techniques.
Topics: Humans; Robotics; Rectal Neoplasms; Proctectomy; Laparoscopy; Hospitalization; Transanal Endoscopic Surgery; Rectum; Treatment Outcome; Postoperative Complications
PubMed: 37506122
DOI: 10.1371/journal.pone.0289090 -
International Journal of Colorectal... Feb 2022While local excision by transanal endoscopic microsurgery (TEM) or transanal minimally invasive surgery (TAMIS) is an option for low-risk early rectal cancers,...
PURPOSE
While local excision by transanal endoscopic microsurgery (TEM) or transanal minimally invasive surgery (TAMIS) is an option for low-risk early rectal cancers, inaccuracies in preoperative staging may be revealed only upon histopathological evaluation of the resected specimen, demanding completion surgery (CS) by formal resection. The aim of this study was to evaluate the results of CS in a national cohort.
METHOD
This was a retrospective analysis of national registry data, identifying and comparing all Norwegian patients who, without prior radiochemotherapy, underwent local excision by TEM or TAMIS and subsequent CS, or a primary total mesorectal excision (pTME), for early rectal cancer during 2000-2017. Primary endpoints were 5-year overall and disease-free survival, 5-year local and distant recurrence, and the rate of R0 resection at completion surgery. The secondary endpoint was the rate of permanent stoma.
RESULTS
Forty-nine patients received CS, and 1098 underwent pTME. There was no difference in overall survival (OR 0.73, 95% CI 0.27-2.01), disease-free survival (OR 0.72, 95% CI 0.32-1.63), local recurrence (OR 1.08, 95% CI 0.14-8.27) or distant recurrence (OR 0.67, 95% CI 0.21-2.18). In the CS group, 53% had a permanent stoma vs. 32% in the pTME group (P = 0.002); however, the difference was not significant when adjusted for age, sex, and tumor level (OR 2.17, 0.95-5.02).
CONCLUSIONS
Oncological results were similar in the two groups. However, there may be an increased risk for a permanent stoma in the CS group.
Topics: Adenocarcinoma; Humans; Neoplasm Recurrence, Local; Rectal Neoplasms; Retrospective Studies; Transanal Endoscopic Microsurgery; Treatment Outcome
PubMed: 34914000
DOI: 10.1007/s00384-021-04083-6 -
Annals of Saudi Medicine 2023Although transanal minimally invasive surgery (TAMIS) for rectal neoplasia has gained wide acceptance, the mid-term and long-term outcomes are not widely reported in the...
BACKGROUND
Although transanal minimally invasive surgery (TAMIS) for rectal neoplasia has gained wide acceptance, the mid-term and long-term outcomes are not widely reported in the literature.
OBJECTIVE
Describe the mid-term outcomes of patients who underwent TAMIS for benign and malignant rectal lesions in a single center.
DESIGN
Retrospective cohort study.
SETTINGS
Tertiary referral center.
PATIENTS AND METHODS
Demographic, clinical, and oncological outcomes of patients who underwent TAMIS between January 2015 and December 2022 were prospectively collected. The indication for TAMIS was based on the National Comprehensive Cancer Network guidelines. The follow up for the cancer patients included clinical examination, tumor markers every 6 months and MRI rectum at the end of one year. In addition, colonoscopy and CT scan at years one and three and a final CT scan and colonoscopy at year five.
MAIN OUTCOME MEASURES
Mid-term oncological and clinical outcome.
RESULTS
Thirty elective TAMIS procedures included adenocarcinoma for 33.3% (n=10) of the patients, 20% (n=6) neuroendocrine tumor and the 40% (n=12) were adenomatous lesions. Negative resection margins were achieved in all malignant lesions. Perioperative complications occurred in 2 patients (6.6%), one patient had breaching into the peritoneal cavity, and postoperative hypotension occurred in another patient. The median follow-up time was 23 months (range: 5-72 months). Two patients with adenoma and positive margins developed recurrent adenoma (6.6%) and one patient with initial polypectomy biopsy of adenocarcinoma, had TAMIS with histopathology of adenoma and distant metastasis had developed.
CONCLUSIONS
TAMIS for local excision of rectal neoplasia is a valid option with favorable mid-term outcomes provided there is adherence to careful selection criteria.
LIMITATIONS
Retrospective nature and small number of the patients.
Topics: Humans; Rectum; Retrospective Studies; Treatment Outcome; Minimally Invasive Surgical Procedures; Rectal Neoplasms; Transanal Endoscopic Surgery; Adenoma; Adenocarcinoma; Anal Canal
PubMed: 38071443
DOI: 10.5144/0256-4947.2023.348 -
Colorectal Disease : the Official... Jan 2020A new artificial anal sphincter placed into the intersphincteric space, SphinKeeper™, has recently been proposed to improve outcomes in the treatment of faecal...
AIM
A new artificial anal sphincter placed into the intersphincteric space, SphinKeeper™, has recently been proposed to improve outcomes in the treatment of faecal incontinence (FI). We report our preliminary results with short-term follow-up, comparing preoperative and postoperative data after implant of SphinKeeper™ in patients suffering from FI.
METHODS
All patients older than 18 years were included with FI of at least 6 months, incontinence episodes occurring more than once a week and resistance to other conservative treatments. Anorectal manometry, endoanal ultrasound, Cleveland Clinic FI Score, FI Quality of Life score and total number of episodes of FI per week were recorded preoperatively and at the end of the 6-month follow-up period.
RESULTS
Thirteen consecutive patients were treated with SphinKeeper™. No intra-operative nor postoperative complications were reported. Two cases of prosthesis extrusion occurred, and in one case an anterior dislocation was detected. Maximum resting pressure, total number of episodes of FI per week and Cleveland Clinic FI Score were improved after 6 months (P < 0.05).
CONCLUSIONS
SphinKeeper™ could be a minimally invasive procedure for FI with good postoperative outcomes. If these results are confirmed by studies with more patients and longer follow-up, it could be a first-line approach in FI.
Topics: Adult; Anal Canal; Endosonography; Fecal Incontinence; Female; Humans; Male; Manometry; Middle Aged; Postoperative Period; Preoperative Period; Prosthesis Implantation; Quality of Life; Severity of Illness Index; Transanal Endoscopic Surgery; Treatment Outcome
PubMed: 31373152
DOI: 10.1111/codi.14801 -
Diagnostics (Basel, Switzerland) Feb 2023: One of the most known sexually transmitted diseases is Condylomata acuminata (CA), a skin lesion occurring due to infection from Human Papilloma Virus (HPV). CA has a...
: One of the most known sexually transmitted diseases is Condylomata acuminata (CA), a skin lesion occurring due to infection from Human Papilloma Virus (HPV). CA has a typical appearance of raised, skin-colored papules ranging in size from 1 mm to 5 mm. These lesions often form cauliflower-like plaques. Depending on the involved HPV-subtype (either high-risk or low-risk) and its malignant potential, these lesions are likely to lead to malignant transformation when specific HPV subtypes and other risk factors are present. Therefore, high clinical suspicion is required when examining the anal and perianal area. : In this article, the authors aim to present the results of a five-year case series (2016-2021) of anal and perianal cases of CA. : A total of 35 patients were included in this study. Patients were categorized based on specific criteria, which included gender, sex preferences, and human immunodeficiency virus infection. All patients underwent proctoscopy and excision biopsies were obtained. Based on dysplasia grade patients were further categorized. The group of patients where high-dysplasia squamous cell carcinoma was present was initially treated with chemoradiotherapy. Abdominoperineal resection was necessary in five cases after local recurrence. : CA remains a serious condition where several treatment options are available if detected early. Delay in diagnosis can lead to malignant transformation, often leaving abdominoperineal resection as the only option. Vaccination against HPV poses a key role in eliminating the transmission of the virus, and thus the prevalence of CA.
PubMed: 36832190
DOI: 10.3390/diagnostics13040702