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Techniques in Coloproctology Dec 2016Transanal total mesorectal excision (TaTME) has been developed to improve quality of TME for patients with mid and low rectal cancer. However, despite enthusiastic... (Review)
Review
Transanal total mesorectal excision (TaTME) has been developed to improve quality of TME for patients with mid and low rectal cancer. However, despite enthusiastic uptake and teaching facilities, concern exists for safe introduction. TaTME is a complex procedure and potentially a learning curve will hamper clinical outcome. With this systematic review, we aim to provide data regarding morbidity and safety of TaTME. A systematic literature search was performed in MEDLINE (PubMed), EMBASE (Ovid) and Cochrane Library. Case reports, cohort series and comparative series on TaTME for rectal cancer were included. To evaluate a potential effect of case volume, low-volume centres (n ≤ 30 total volume) were compared with high-volume centres (n > 30 total volume). Thirty-three studies were identified (three case reports, 25 case series, five comparative studies), including 794 patients. Conversion was performed in 3.0% of the procedures. The complication rate was 40.3, and 11.5% were major complications. The quality of the mesorectum was "complete" in 87.6%, and the circumferential resection margin (CRM) was involved in 4.7%. In low- versus high-volume centres, the conversion rate was 4.3 versus 2.7%, and major complication rates were 12.2 versus 10.5%, respectively. TME quality was "complete" in 80.5 versus 89.7%, and CRM involvement was 4.8 and 4.5% in low- versus high-volume centres, respectively. TaTME for mid and low rectal cancer is a promising technique; however, it is associated with considerable morbidity. Safe implementation of the TaTME should include proctoring and quality assurance preferably within a trial setting.
Topics: Aged; Aged, 80 and over; Clinical Competence; Conversion to Open Surgery; Female; Hospitals, High-Volume; Hospitals, Low-Volume; Humans; Learning Curve; Male; Mesocolon; Middle Aged; Postoperative Complications; Rectal Neoplasms; Rectum; Transanal Endoscopic Surgery; Treatment Outcome
PubMed: 27853973
DOI: 10.1007/s10151-016-1545-0 -
International Journal of Colorectal... Jun 2021There is concern that transanal total mesorectal excision (TaTME) may result in poorer functional outcomes as compared to laparoscopic TME (LaTME). These concerns arise... (Meta-Analysis)
Meta-Analysis
Comparing functional outcomes between transanal total mesorectal excision (TaTME) and laparoscopic total mesorectal excision (LaTME) for rectal cancer: a systematic review and meta-analysis.
BACKGROUND
There is concern that transanal total mesorectal excision (TaTME) may result in poorer functional outcomes as compared to laparoscopic TME (LaTME). These concerns arise from the fact that TaTME entails both a low anastomosis and prolonged dilatation of the anal sphincter from the transanal platform.
OBJECTIVES
This paper aimed to assess the comparative functional outcomes following TaTME and LaTME, with a focus on anorectal and genitourinary outcomes.
DATA SOURCES
A meta-analysis and systematic review was performed on available literature between 2000 and 2020 from the PubMed, EMBASE, Medline, and Cochrane Library databases.
STUDY SELECTION
All comparative studies assessing the functional outcomes following taTME versus LaTME in adults were included.
MAIN OUTCOME MEASURE
Functional anorectal and genitourinary outcomes were evaluated using validated scoring systems.
RESULTS
A total of seven studies were included, consisting of one randomised controlled trial and six non-randomised studies. There were 242 (52.0%) and 233 (48.0%) patients in the TaTME and LaTME groups respectively. Anorectal functional outcomes were similar in both groups with regard to LARS scores (30.6 in the TaTME group and 28.3 in the LaTME group), Jorge-Wexner incontinence scores, and EORTC QLQ C30/29 scores. Genitourinary function was similar in both groups with IPSS scores of 5.5 to 8.0 in the TaTME group, and 3.5 to 10.1 in the LaTME group. (p = 0.835).
CONCLUSION
This review corroborates findings from previous studies in showing that the transanal approach is not associated with increased anal sphincter damage. Further prospective clinical trials are needed in this field of research.
Topics: Adult; Humans; Laparoscopy; Postoperative Complications; Randomized Controlled Trials as Topic; Rectal Neoplasms; Rectum; Transanal Endoscopic Surgery
PubMed: 33580808
DOI: 10.1007/s00384-021-03849-2 -
Techniques in Coloproctology Oct 2017The surgical treatment of complex anal fistulae, particularly those involving a significant portion of the anal sphincter in which fistulotomy would compromise... (Review)
Review
BACKGROUND
The surgical treatment of complex anal fistulae, particularly those involving a significant portion of the anal sphincter in which fistulotomy would compromise continence, is challenging. Video-assisted anal fistula treatment (VAAFT), fistula tract laser closure (FiLaC™) and over-the-scope clip (OTSC) proctology system are all novel sphincter-sparing techniques targeted at healing anal fistulae. In this study, all published articles on these techniques were reviewed to determine efficacy, feasibility and safety.
METHODS
A systematic search of major databases was performed using defined terms. All studies reporting on experience of these techniques were included and outcomes (fistula healing and safety) evaluated.
RESULTS
Eighteen studies (VAAFT-12, FiLaC™-3, OTSC-3) including 1245 patients were analysed. All were case series, and outcomes were heterogeneous with follow-up ranging from 6 to 69 months and short-term (< 1 year) healing rates of 64-100%. Morbidity was low with only minor complications reported. There was one report of minor incontinence following the first reported study of FiLaC™, and this was treated successfully at 6 months with rubber band ligation of hypertrophied prolapsed mucosa. There are inconsistencies in the technique in studies of VAAFT and FiLaC™.
CONCLUSIONS
All three techniques appear to be safe and feasible options in the management of anal fistulae, and short-term healing rates are acceptable with no sustained effect on continence. There is, however, a paucity of robust data with long-term outcomes. These techniques are thus welcome additions; however, their long-term place in the colorectal surgeon's armamentarium, whether diagnostic or therapeutic, remains uncertain.
Topics: Anal Canal; Humans; Laser Therapy; Operative Time; Organ Sparing Treatments; Proctoscopy; Rectal Fistula; Video-Assisted Surgery
PubMed: 29080959
DOI: 10.1007/s10151-017-1699-4 -
Danish Medical Journal Jul 2015Total mesorectal excision (TME) is the standard surgical treatment for mid and low rectal cancer. The procedure is performed by open, laparoscopic or robotic approaches.... (Review)
Review
INTRODUCTION
Total mesorectal excision (TME) is the standard surgical treatment for mid and low rectal cancer. The procedure is performed by open, laparoscopic or robotic approaches. Transanal TME (TaTME) is a new procedure that potentially solves some difficulties in the pelvic part of the dissection. We aimed to evaluate the literature on TaTME.
METHODS
We performed a systematic search of the literature in the PubMed and Embase databases. Both authors assessed the studies. All publications on TaTME were included with the exception of review articles.
RESULTS
A total of 29 studies (336 patients) were included. Only low-quality evidence is available, and the literature consists of case reports and case series. Studies represent the initial experience of surgeons/centres. No precise indication for TaTME is yet specified other than the presence of mid and low rectal tumours, although the potential advantages seem to be related to a bulky mesorectum in the male pelvis. The preliminary results are encouraging and the most serious complication is urethral injury. The oncological results are acceptable, although the follow-up is short.
CONCLUSION
TaTME is a feasible approach for mid and low rectal cancers. Long-term follow-up data are awaited regarding functional results, local recurrence and survival, and to facilitate comparison with standard laparoscopic or robotic rectal resections.
Topics: Dissection; Female; Humans; Male; Rectal Neoplasms; Transanal Endoscopic Surgery
PubMed: 26183050
DOI: No ID Found -
Surgical Endoscopy Jul 2014Rectal carcinoids are increasing in incidence worldwide. Frequently thought of as a relatively benign condition, there are limited data regarding optimal treatment... (Review)
Review
BACKGROUND
Rectal carcinoids are increasing in incidence worldwide. Frequently thought of as a relatively benign condition, there are limited data regarding optimal treatment strategies for both localized and more advanced disease. The aim of this study was to summarize published experiences with rectal carcinoids and to present the most current data.
METHODS
Following PRISMA guidelines, an electronic literature search performed of PubMed, Medline, Embase, and the Cochrane Library using the terms "rectum" or "rectal" AND "carcinoid" over a 20-year study period from January 1993 to May 2013. Non-English-language studies, animal studies, and studies of fewer than 100 patients were excluded. Study end points included demographic information, tumor features, intervention and outcomes. All included articles were quality assessed.
RESULTS
Using the search parameters and exclusions as outlined above, a total of 14 articles were identified for detailed analysis. The quality of articles was low/moderate for all included scoring 9 to 17 of 27. The articles included 4,575 patients diagnosed with a rectal carcinoid. Approximately 80% of tumors were <10 mm, 15% 11-20 mm, and 5% >20 mm. Eight percent of patients presented with regional lymph node metastases, and 4% presented with distant metastases. Tumor size >10 mm, and muscular and lymphovascular invasion are independently associated with an increased risk of metastases. The 5-year survival was 93% in patients presenting with localized disease and 86% overall.
CONCLUSIONS
Small tumors up to 10 mm without any adverse features can be treated with endoscopic or local excision. The treatment of carcinoids between 10 and 20 mm is still contentious, but those up to 16 mm without adverse feature are suitable for local/endoscopic excision followed by careful histopathological assessment. Those >20 mm or with adverse features require radical surgery with mesorectal clearance in suitable patients.
Topics: Carcinoid Tumor; Female; Humans; Intestinal Mucosa; Ligation; Lymphatic Metastasis; Male; Middle Aged; Neoplasm Invasiveness; Neoplasm Staging; Proctoscopy; Rectal Neoplasms
PubMed: 24584484
DOI: 10.1007/s00464-014-3430-0 -
Infection Dec 2017Meningitis occurs in 0.8-1.5% of patients undergoing neurosurgery. The aim of the study was to evaluate the characteristics of meningitis after endoscopic endonasal... (Review)
Review
BACKGROUND
Meningitis occurs in 0.8-1.5% of patients undergoing neurosurgery. The aim of the study was to evaluate the characteristics of meningitis after endoscopic endonasal transsphenoidal surgery (EETS) comparing the findings retrieved to those highlighted by literature search.
MATERIALS AND METHODS
Patients treated by EETS during an 18-year period in the Department of Neurosurgery of 'Federico II' University of Naples were evaluated and included in the study if they fulfilled criteria for meningitis. Epidemiological, demographic, laboratory, and microbiological findings were evaluated. A literature research according to PRISMA methodology completed the study.
RESULTS
EETS was performed on 1450 patients, 8 of them (0.6%) had meningitis [median age 46 years (range 33-73)]. Endoscopic surgery was performed 1-15 days (median 4 days) before diagnosis. Meningeal signs were always present. CSF examination revealed elevated cells [median 501 cells/μL (range 30-5728)], high protein [median 445 mg/dL (range 230-1210)], and low glucose [median 10 mg/dL (range 1-39)]. CSF culture revealed Gram-negative bacteria in four cases (Klebsiella pneumoniae, Escherichia coli, Alcaligenes spp., and Haemophilus influenzae), Streptococcus pneumoniae in two cases, Aspergillus fumigatus in one case. An abscess occupying the surgical site was observed in two cases. Six cases reported a favorable outcome; two died. Incidence of meningitis approached to 2%, as assessed by the literature search.
CONCLUSIONS
Incidence of meningitis after EETS is low despite endoscope goes through non-sterile structures; microorganisms retrieved are those present within sinus microenvironment. Meningitis must be suspected in patients with persistent fever and impaired conscience status after EETS.
Topics: Adult; Aged; Female; Humans; Incidence; Italy; Male; Meningitis; Middle Aged; Postoperative Complications; Sphenoid Bone; Sphenoid Sinus; Transanal Endoscopic Surgery; Treatment Outcome
PubMed: 28776163
DOI: 10.1007/s15010-017-1056-6 -
Colorectal Disease : the Official... Dec 2013Anorectal varices are an uncommon, but significant, source of bleeding in patients with portal hypertension. The aim of this article was to review systematically the... (Review)
Review
AIM
Anorectal varices are an uncommon, but significant, source of bleeding in patients with portal hypertension. The aim of this article was to review systematically the available literature on the aetiology, clinical presentation and management of anorectal varices, and to suggest a simple treatment algorithm based on available evidence and local expertise.
METHOD
A systematic literature search was carried out to identify articles on anorectal varices, and the search strategy identified 57 relevant references. The inclusion criteria included a consecutive cohort of patients having treatment for anorectal varices with details of success rates and the number of different techniques used. Exclusion criteria included papers published in languages other than English with no English version and results not reported separately for anorectal varices.
RESULTS
Anorectal varices can occur in up to 89% of patients with portal hypertension, although the overall incidence in the general population is low. Diagnosis is best achieved with anoscopy or flexible sigmoidoscopy. The current evidence supports the use of local procedures, such as endoscopic band ligation, to arrest bleeding where feasible, with radiological or surgical procedures used in the event of failure.
CONCLUSION
As there are no large series on this pathology, we present a systematic approach for the patient with anorectal varices.
Topics: Anal Canal; Anus Diseases; Embolization, Therapeutic; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Ligation; Portasystemic Shunt, Transjugular Intrahepatic; Proctoscopy; Rectal Diseases; Rectum; Sclerotherapy; Suture Techniques; Varicose Veins
PubMed: 24020839
DOI: 10.1111/codi.12417 -
Langenbeck's Archives of Surgery May 2024Transanal minimally invasive surgery has theoretical advantages for ileal pouch-anal anastomosis surgery. We performed a systematic review assessing technical approaches... (Meta-Analysis)
Meta-Analysis
PURPOSE
Transanal minimally invasive surgery has theoretical advantages for ileal pouch-anal anastomosis surgery. We performed a systematic review assessing technical approaches to transanal IPAA (Ta-IPAA) and meta-analysis comparing outcomes to transabdominal (abd-IPAA) approaches.
METHODS
Three databases were searched for articles investigating Ta-IPAA outcomes. Primary outcome was anastomotic leak rate. Secondary outcomes included conversion rate, post operative morbidity, and length of stay (LoS). Staging, plane of dissection, anastomosis, extraction site, operative time, and functional outcomes were also assessed.
RESULTS
Searches identified 13 studies with 404 unique Ta-IPAA and 563 abd-IPAA patients. Anastomotic leak rates were 6.3% and 8.4% (RD 0, 95% CI -0.066 to 0.065, p = 0.989) and conversion rates 2.5% and 12.5% (RD -0.106, 95% CI -0.155 to -0.057, p = 0.104) for Ta-IPAA and abd-IPAA. Average LoS was one day shorter (MD -1, 95% CI -1.876 to 0.302, p = 0.007). A three-stage approach was most common (47.6%), operative time was 261(± 60) mins, and total mesorectal excision and close rectal dissection were equally used (49.5% vs 50.5%). Functional outcomes were similar. Lack of randomised control trials, case-matched series, and significant study heterogeneity limited analysis, resulting in low to very low certainty of evidence.
CONCLUSIONS
Analysis demonstrated the feasibility and safety of Ta-IPAA with reduced LoS, trend towards less conversions, and comparable anastomotic leak rates and post operative morbidity. Though results are encouraging, they need to be interpreted with heterogeneity and selection bias in mind. Robust randomised clinical trials are warranted to adequately compare ta-IPAA to transabdominal approaches.
Topics: Humans; Proctocolectomy, Restorative; Anastomotic Leak; Transanal Endoscopic Surgery; Treatment Outcome; Length of Stay; Colonic Pouches; Operative Time; Anastomosis, Surgical
PubMed: 38705912
DOI: 10.1007/s00423-024-03343-7 -
Diseases of the Colon and Rectum Jan 2015Local resection for early rectal cancer is thought to be less invasive but oncologically inferior to radical resection. (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
Local resection for early rectal cancer is thought to be less invasive but oncologically inferior to radical resection.
OBJECTIVE
The aim of this study was to compare local with radical resection in terms of oncologic control (survival and local recurrence), postoperative complications, and the need for a permanent stoma in adult patients with T1N0M0 rectal adenocarcinoma.
DATA SOURCES
Data were retrieved from Medline, Embase, Central, www.clinicaltrials.gov, and conference proceedings.
STUDY SELECTION
Two reviewers independently screened studies and assessed the risk of bias.
INTERVENTIONS
Local resection (transanal procedures, excluding endoscopic polypectomy) versus radical resection were considered.
MAIN OUTCOME MEASURES
The primary outcomes measured were overall survival, major postoperative complications, and the 'need for permanent stoma.'
RESULTS
: One randomized controlled trial and 12 observational studies contributed 2855 patients for analysis. The randomized controlled trial was inadequately powered. Observational study meta-analysis showed that local resection was associated with significantly lower 5-year overall survival (72 more deaths per 1000 patients; 95%CI 30-120). However, the transanal endoscopic microsurgery subgroup did not yield significantly lower overall survival than radical resection. Local resection was associated with higher local recurrence but with lower perioperative mortality (relative risk 0.31, 95% CI 0.14-0.71), major postoperative complications (relative risk 0.20, 95% CI 0.10-0.41), and need for a permanent stoma (relative risk 0.17, 95% CI 0.09-0.30). Findings were robust to sensitivity analyses. Meta-regression suggests that the higher overall survival associated with radical resection may be explained by increased use of local resection on tumors in the lower third of the rectum, which have poorer prognosis.
LIMITATIONS
This systematic review of nonrandomized studies had inherent biases that may persist despite our rigorous use of systematic review methodology and sensitivity analyses.
CONCLUSIONS
Local resection does not offer oncologic control comparable to radical surgery. However, this finding may be driven by the higher prevalence of cancers with poorer prognosis in local resection groups. Local resection is associated with lower postoperative complications, mortality, and the need for a permanent stoma. Local resection with transanal endoscopic microsurgery appears to offer oncologic control similar to that of radical resection while offering all the benefits of local resection.
Topics: Adenocarcinoma; Digestive System Surgical Procedures; Humans; Neoplasm Staging; Postoperative Complications; Proctoscopy; Rectal Neoplasms; Survival Rate
PubMed: 25489704
DOI: 10.1097/DCR.0000000000000293 -
Minerva Surgery Apr 2022Transanal endoscopic microsurgery (TEM) and transanal endoscopic operation (TEO) have been initially described for local excision of rectal adenomas and selected cases...
INTRODUCTION
Transanal endoscopic microsurgery (TEM) and transanal endoscopic operation (TEO) have been initially described for local excision of rectal adenomas and selected cases of rectal carcinomas. In the past decade, however, several new indications raised, and others could raise in the future. The aim of this review was to evaluate, both in the literature and in our personal experience, the use of TEM and TEO for non-conventional applications, different from rectal tumors.
EVIDENCE ACQUISITION
We conducted a systematic review of published papers and we selected articles reporting patients who underwent endoscopic surgery for other medical reason than polyp cancer resection, with TEM or TEO. PubMed, MEDLINE, EMBASE and bibliographies of the selected studies were searched for articles in English published up to May 2020 to identify all relevant articles. We excluded articles reporting TEM and TEO used for classical indications. We finally report our experience of non-conventional use of TEO in 5 patients with different diseases.
EVIDENCE SYNTHESIS
The research revealed 800 papers and among them we selected 52 articles for a total of 697 patients. Of all patients, only 52 had intraoperative or postoperative complications, with only 10 patients requiring major surgery.
CONCLUSIONS
Our study suggests that TEM and TEO may be valid alternatives to traditional surgery in situations other than its classical indication. These findings can positively impact on the care of patients, who could benefit from less invasive surgical procedures associated with lower morbidity.
Topics: Adenoma; Digestive System Surgical Procedures; Endoscopy; Humans; Rectal Neoplasms; Transanal Endoscopic Microsurgery
PubMed: 34047531
DOI: 10.23736/S2724-5691.21.08774-8