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Journal of Neurosurgical Sciences Dec 2018While open, microsurgical clipping and endovascular coiling remain the gold standards for treatment of cerebral aneurysms, a growing number of aneurysms treated via...
INTRODUCTION
While open, microsurgical clipping and endovascular coiling remain the gold standards for treatment of cerebral aneurysms, a growing number of aneurysms treated via endoscopic endonasal methods have been reported in the literature. The aim of this study was to conduct a systematic review of the literature to gain a more thorough appreciation of the potential benefits and drawbacks of the endoscopic endonasal strategy in this setting.
EVIDENCE ACQUISITION
We performed a detailed systematic review of the medical literature on endoscopic endonasal skull base surgery for treatment of cerebral aneurysms utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We identified 9 clinical studies describing treatment of 23 aneurysms utilizing the EEA. Eleven additional cadaveric studies investigating aspects of operative exposure and/or technique in this setting were identified. The full text of these articles was reviewed.
EVIDENCE SYNTHESIS
In the 9 clinical studies that met inclusion criteria, 23 aneurysms were treated in 21 patients. The mean patient age was 52.6 years. 15 aneurysms were unruptured and 8 were ruptured. Fourteen aneurysms involved the anterior circulation and 9 involved the posterior circulation. In 21 of 23 aneurysms, complete occlusion was achieved with endonasal clipping. Two aneurysms required additional treatment that included a takeback for clip repositioning and staged endovascular coiling. Complications included post-operative CSF leak (23.8%), stroke (19%), and meningitis (14.3%). Analysis of the combined literature revealed a significantly higher rate of CSF leak with endonasal clipping of posterior circulation aneurysms compared to anterior circulation aneurysms (P=0.047, Fisher's Exact Test). While there was a trend towards increased post-operative neurologic deficit following EEA for posterior circulation aneurysms, this did not reach statistical significance (P=0.063). The majority of post-operative complications in posterior circulation aneurysms occurred during clip application of aneurysms at the level of the basilar apex. In addition to the aforementioned clinical reports, 11 cadaveric studies were identified. 4 of these reports investigated approaches for individual anterior circulation aneurysms, 5 investigated approaches for posterior circulations aneurysms, and 2 involved both anterior and posterior circulation aneurysms.
CONCLUSIONS
Despite a moderate increase in utilization, caution should be exercised when choosing an endonasal strategy for treatment of aneurysmal pathology over more traditional and established methods such as microsurgical clip application and endovascular methods. Anecdotal evidence suggests that inferior and/or medial projecting aneurysms involving the paraclinoid ICA not amenable to traditional open/endovascular strategies may be reasonable to consider for EEA clip application. Wide-necked, midline, ventrolaterally-projecting aneurysms involving the vertebrobasilar system may represent an additional exception, as long as the location along the rostrocaudal axis is low enough so as not to compromise visualization. Future improvements in operative technology, including anticipated advances in endoscopic 3-D visualization, may further alter the landscape of treatment involving this complex pathology.
Topics: Humans; Intracranial Aneurysm; Microsurgery; Middle Aged; Neuroendoscopy; Neurosurgical Procedures; Skull Base; Transanal Endoscopic Surgery; Vascular Surgical Procedures
PubMed: 29582975
DOI: 10.23736/S0390-5616.18.04405-3 -
Minerva Surgery Aug 2023Total mesorectal excision (TME) during rectal resection is considered the gold standard for the treatment of rectal cancer. Transanal total mesorectal excision (TaTME)...
INTRODUCTION
Total mesorectal excision (TME) during rectal resection is considered the gold standard for the treatment of rectal cancer. Transanal total mesorectal excision (TaTME) was first described in 2010 and has been applied to humans since 2012 to overcome some of the technical difficulties associated with minimally invasive TMEs.
EVIDENCE ACQUSITION
A systematic review of the literature was conducted, and it focused on articles published between 2012 and 2022 to analyze the state of the art of surgical techniques and indications, as well as potential technical, oncological, and functional benefits.
EVIDENCE SYNTHESIS
The indications for TaTME are not yet standardized, and structured training programs are necessary to complete a safe learning curve for this new technique. The procedure, when compared with conventional open or minimally invasive TME, is feasible and safe with similar intraoperative and postoperative complications. On the other hand, some new specific complications of this new approach have been described. The short-term pathological and oncologic results are encouraging, especially in terms of the mesorectal specimen quality, distal resection margin and conversion rate. Also, the functional results seem encouraging when compared with other minimally invasive techniques.
CONCLUSIONS
Long-term follow-up and ongoing RCT trials are fundamental to evaluate the possible benefits in terms of local recurrence and survival. This will facilitate the comparison with other minimally invasive rectal resections.
Topics: Humans; Rectum; Laparoscopy; Treatment Outcome; Transanal Endoscopic Surgery; Rectal Neoplasms
PubMed: 36745469
DOI: 10.23736/S2724-5691.22.09837-9 -
Diseases of the Colon and Rectum Jul 2021A recent Norwegian moratorium challenged the status quo of transanal total mesorectal excision for rectal cancer by reporting increased early multifocal local... (Comparative Study)
Comparative Study Meta-Analysis
BACKGROUND
A recent Norwegian moratorium challenged the status quo of transanal total mesorectal excision for rectal cancer by reporting increased early multifocal local recurrences.
OBJECTIVE
The aim of this systematic review and meta-analysis was to evaluate the local recurrence rates following transanal total mesorectal excision as well as to assess statistical, clinical, and methodological bias in reports published to date.
DATA SOURCES
The PubMed and MEDLINE (via Ovid) databases were systematically searched.
STUDY SELECTION
Descriptive or comparative studies reporting rates of local recurrence at a median follow-up of 6 months (or more) after transanal total mesorectal excision were included.
INTERVENTIONS
Patients underwent transanal total mesorectal excision.
MAIN OUTCOME MEASURES
Local recurrence was any recurrence located in the pelvic surgery site. The untransformed proportion method of 1-arm meta-analysis was utilized. Untransformed percent proportion with 95% confidence interval was reported. Ad hoc meta-regression with the Omnibus test was utilized to assess risk factors for local recurrence. Among-study heterogeneity was evaluated: statistically by I2 and τ2, clinically by summary tables, and methodologically by a 33-item questionnaire.
RESULTS
Twenty-nine studies totaling 2906 patients were included. The pooled rate of local recurrence was 3.4% (2.7%-4.0%) at an average of 20.1 months with low statistical heterogeneity (I2 = 0%). Meta-regression yielded no correlation between complete total mesorectal excision quality (p = 0.855), circumferential resection margin (p = 0.268), distal margin (p = 0.886), and local recurrence rates. Clinical heterogeneity was substantial. Methodological heterogeneity was linked to the excitement of novelty, loss aversion, reactivity to criticism, indication for transanal total mesorectal excision, nonprobability sampling, circular reasoning, misclassification, inadequate follow-up, reporting bias, conflict of interest, and self-licensing.
LIMITATIONS
The studies included had an observational design and limited sample and follow-up.
CONCLUSION
This systematic review found a pooled rate of local recurrence of 3.4% at 20 months. However, given the substantial clinical and methodological heterogeneity across the studies, the evidence for or against transanal total mesorectal excision is inconclusive at this time.
Topics: Adult; Aged; Aged, 80 and over; Bias; Data Management; Female; Follow-Up Studies; Humans; Male; Margins of Excision; Middle Aged; Natural Orifice Endoscopic Surgery; Neoplasm Recurrence, Local; Norway; Observational Studies as Topic; Outcome Assessment, Health Care; Proctectomy; Rectal Neoplasms; Risk Factors; Transanal Endoscopic Surgery
PubMed: 33938532
DOI: 10.1097/DCR.0000000000002110 -
Annals of the Royal College of Surgeons... Nov 2020Management of the rectal defect following transanal endoscopic microsurgery (TEMS) or minimally invasive surgery (TAMIS) carried out for excision of neoplasm in the... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
Management of the rectal defect following transanal endoscopic microsurgery (TEMS) or minimally invasive surgery (TAMIS) carried out for excision of neoplasm in the lower rectum is controversial. We aimed to extract evidence by carrying out a meta-analysis to compare the peri- and postoperative outcomes following rectal neoplasm excision carried out by TEMS and/or TAMIS, whereby the defect is either sutured or left open.
METHODS
A literature search of Ovid MEDLINE and EMBASE was performed. Full-text comparative studies published until November 2019, in English and of adult patients, whereby TEMS or TAMIS was undertaken for rectal neoplasms were included. The main outcome measures were postoperative bleeding, infection, operative time and hospital stay.
FINDINGS
Three studies (one randomised controlled trial and two comparative case series) yielded 555 cases (283 in the sutured group and 272 in the open group). The incidence of postoperative bleeding was higher and statistically significant ( = 0.006) where the rectal defect was left open following excision of the neoplasm (19/272, 6.99% vs 6/283, 2.12%). There was no statistical difference between the sutured and open groups regarding infection ( = 0.27; (10/283, 3.53% vs 5/272, 1.84%, respectively), operative time ( = 0.15) or length of stay ( = 0.67).
CONCLUSION
Suturing the rectal defect following excision of rectal neoplasm by TEMS/TAMIS reduces the incidence of postoperative bleeding in comparison to leaving the defect open. However, suturing makes the procedure slightly longer but there was no statistical difference between both groups when postoperative infection and length of hospital stay were compared.
Topics: Humans; Rectal Neoplasms; Rectum; Suture Techniques; Sutures; Transanal Endoscopic Microsurgery
PubMed: 32538129
DOI: 10.1308/rcsann.2020.0135 -
Gastroenterology Jul 2020The benefits of prophylactic clipping to prevent bleeding after polypectomy are unclear. We conducted an updated meta-analysis of randomized trials to assess the... (Comparative Study)
Comparative Study Meta-Analysis
BACKGROUND & AIMS
The benefits of prophylactic clipping to prevent bleeding after polypectomy are unclear. We conducted an updated meta-analysis of randomized trials to assess the efficacy of clipping in preventing bleeding after polypectomy, overall and according to polyp size and location.
METHODS
We searched the MEDLINE/PubMed, Embase, and Scopus databases for randomized trials that compared the effects of clipping vs not clipping to prevent bleeding after polypectomy. We performed a random-effects meta-analysis to generate pooled relative risks (RRs) with 95% CIs. Multilevel random-effects metaregression analysis was used to combine data on bleeding after polypectomy and estimate associations between rates of bleeding and polyp characteristics.
RESULTS
We analyzed data from 9 trials, comprising 71897 colorectal lesions (22.5% 20 mm or larger; 49.2% with proximal location). Clipping, compared with no clipping, did not significantly reduce the overall risk of postpolypectomy bleeding (2.2% with clipping vs 3.3% with no clipping; RR, 0.69; 95% confidence interval [CI], 0.45-1.08; P = .072). Clipping significantly reduced risk of bleeding after removal of polyps that were 20 mm or larger (4.3% had bleeding after clipping vs 7.6% had bleeding with no clipping; RR, 0.51; 95% CI, 0.33-0.78; P = .020) or that were in a proximal location (3.0% had bleeding after clipping vs 6.2% had bleeding with no clipping; RR, 0.53; 95% CI, 0.35-0.81; P < .001). In multilevel metaregression analysis that adjusted for polyp size and location, prophylactic clipping was significantly associated with reduced risk of bleeding after removal of large proximal polyps (RR, 0.37; 95% CI, 0.22-0.61; P = .021) but not small proximal lesions (RR, 0.88; 95% CI, 0.48-1.62; P = .581).
CONCLUSIONS
In a meta-analysis of randomized trials, we found that routine use of prophylactic clipping does not reduce risk of postpolypectomy bleeding overall. However, clipping appeared to reduce bleeding after removal of large (more than 20 mm) proximal lesions.
Topics: Colonic Polyps; Colonoscopy; Colorectal Neoplasms; Humans; Postoperative Hemorrhage; Prevalence; Proctoscopy; Randomized Controlled Trials as Topic; Rectal Diseases; Treatment Outcome
PubMed: 32247023
DOI: 10.1053/j.gastro.2020.03.051 -
Surgical Endoscopy Jun 2018Since 2010, comparative studies on transanal and laparoscopic total mesorectal excision (TME) have been published and it remains unclear about the oncological benefit... (Comparative Study)
Comparative Study Meta-Analysis
BACKGROUND
Since 2010, comparative studies on transanal and laparoscopic total mesorectal excision (TME) have been published and it remains unclear about the oncological benefit from transanal total mesorectal excision (taTME).
METHODS
We have searched English databases to identify all taTME studies published between January 2010 and August 2017. Pathological outcomes included circumferential resection margin (CRM), positive CRM (< 1 M), length of distal resection margin (DRM), positive DRM, quality of mesorectum (complete mesorectum), harvested lymph node, and length of the specimen. Odds ratios (ORs) were calculated for dichotomous outcomes and weighted mean differences (WMDs) for continuous outcomes.
RESULTS
We have included ten studies comprising of 762 patients. Compared with laparoscopic TME, taTME had a longer CRM (WMD, 0.833; 95% CI 0.366-1.299; P < 0.001), a lower positive rate of CRM (OR, 0.505; 95% CI 0.258-0.991; P = 0.047), and a longer DRM (WMD, 6.261; 95% CI 1.049-11.472; P = 0.019). There were no significant differences in other pathological outcomes. Both cumulative meta-analysis and sensitivity analysis were unable to detect potential sources of the heterogeneity in DRM. There was no evidence of publication bias.
CONCLUSIONS
This meta-analysis revealed that taTME had more advantages on positive CRM, CRM, and DRM compared with laparoscopic TME. Compared with laparoscopic TME, more benefits of taTME on pathological outcomes remained undetected. The current findings are all based on observational studies, RCTs with adequate power are required.
Topics: Humans; Laparoscopy; Odds Ratio; Proctectomy; Rectal Neoplasms; Transanal Endoscopic Surgery; Treatment Outcome
PubMed: 29464401
DOI: 10.1007/s00464-018-6103-6 -
Techniques in Coloproctology Sep 2019An organ-preserving strategy may be a valid alternative in the treatment of selected patients with rectal cancer after neoadjuvant radiotherapy. Preoperative assessment... (Meta-Analysis)
Meta-Analysis
Individual participant data pooled-analysis of risk factors for recurrence after neoadjuvant radiotherapy and transanal local excision of rectal cancer: the PARTTLE study.
BACKGROUND
An organ-preserving strategy may be a valid alternative in the treatment of selected patients with rectal cancer after neoadjuvant radiotherapy. Preoperative assessment of the risk for tumor recurrence is a key component of surgical planning. The aim of the present study was to increase the current knowledge on the risk factors for tumor recurrence.
METHODS
The present study included individual participant data of published studies on rectal cancer surgery. The literature was reviewed according to according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Individual Participant Data checklist (PRISMA-IPD) guidelines. Series of patients, whose data were collected prospectively, having neoadjuvant radiotherapy followed by transanal local excision for rectal cancer were reviewed. Three independent series of univariate/multivariate binary logistic regression models were estimated for the risk of local, systemic and overall recurrence, respectively.
RESULTS
We identified 15 studies, and 7 centers provided individual data on 517 patients. The multivariate analysis showed higher local and overall recurrences for ypT3 stage (OR 4.79; 95% CI 2.25-10.16 and OR 6.43 95% CI 3.33-12.42), tumor size after radiotherapy > 10 mm (OR 5.86 95% CI 2.33-14.74 and OR 3.14 95% CI 1.68-5.87), and lack of combined chemotherapy (OR 3.68 95% CI 1.78-7.62 and OR 2.09 95% CI 1.10-3.97), while ypT3 was the only factor correlated with systemic recurrence (OR 5.93). The analysis of survival curves shows that the overall survival is associated with ypT and not with cT.
CONCLUSIONS
Local excision should be offered with caution after neoadjuvant chemoradiotherapy to selected patients with rectal cancers, who achieved a good response to neoadjuvant chemoradiotherapy.
Topics: Aged; Disease-Free Survival; Female; Humans; Male; Middle Aged; Neoadjuvant Therapy; Neoplasm Recurrence, Local; Neoplasm Staging; Postoperative Period; Proctectomy; Radiotherapy, Adjuvant; Rectal Neoplasms; Risk Factors; Transanal Endoscopic Surgery; Treatment Outcome
PubMed: 31388861
DOI: 10.1007/s10151-019-02049-z -
Colorectal Disease : the Official... Oct 2019In patients who have undergone a polypectomy of a malignant rectal polyp without histopathological risk factors other than an involved or unclear resection margin,... (Meta-Analysis)
Meta-Analysis
AIM
In patients who have undergone a polypectomy of a malignant rectal polyp without histopathological risk factors other than an involved or unclear resection margin, additional local excision is often performed. Evidence to support this approach is lacking. The aim of this systematic review and meta-analysis was to determine the outcome in terms of local recurrence, disease-free survival (DFS) and overall survival (OS) of additional local excision following incomplete polypectomy for low risk T1 rectal cancer.
METHODS
A comprehensive search for published studies was performed. Only studies in which there was incomplete (or ≤ 1 mm) removal of pT1 rectal polyps or in which the resection plane could not be assessed were included. For each included study data on tumour stage, histological factors, surgical technique, local recurrence rate, 5-year DFS and 5-year OS were extracted. The PROSPERO registration number is CRD42017062702.
RESULTS
A total of 580 studies were retrieved by the search in the MEDLINE database, Embase and the Cochrane Library. After careful appreciation, four studies were included in the analysis, comprising 102 patients of whom the majority had undeterminable (Rx) resection margins. Local excision via transanal endoscopic microsurgery was reported most frequently. Only 1% of patients developed a local recurrence. One study reported 5-year DFS and 5-year OS of 96% and 87% respectively.
CONCLUSION
This study supports the use of additional local excision techniques for rectal cancer patients who underwent an incomplete polypectomy for a malignant rectal polyp in the absence of risk factors other than an uncertain resection margin.
Topics: Aged; Disease-Free Survival; Female; Humans; Intestinal Polyps; Male; Margins of Excision; Middle Aged; Neoplasm Recurrence, Local; Neoplasm Staging; Proctectomy; Rectal Diseases; Rectal Neoplasms; Risk Factors; Survival Rate; Transanal Endoscopic Surgery; Treatment Outcome
PubMed: 31074574
DOI: 10.1111/codi.14659 -
Colorectal Disease : the Official... Jan 2019Minimally invasive transanal total mesorectal excision (TaTME) is a new approach for treating rectal cancer. 'Spin' can be defined as 'reporting strategies to highlight...
AIM
Minimally invasive transanal total mesorectal excision (TaTME) is a new approach for treating rectal cancer. 'Spin' can be defined as 'reporting strategies to highlight that the experimental treatment is beneficial' despite limitations in study design. The aim of this study was to assess spin within publications about TaTME.
METHOD
EMBASE and MEDLINE (2009-2017) were searched for publications assessing TaTME in rectal cancer. All papers published between 2009 and 2017 were eligible for inclusion. Study titles and abstracts were assessed for evidence of spin, as previously defined.
RESULTS
A total of 1202 studies were identified through our search, and 73 were included. The majority were case series (n = 48, 66%). A total of 55 publications (75%) had evidence of spin within at least one domain. The most common type of spin was claiming safety without describing how this was defined or tested (56%). Other strategies included claiming superiority without support (33%) and reporting nonsignificance as equivalence (42%). We did not find that year of publication (P = 0.61), study design (P = 0.60), number of patients (P = 0.85) or declared conflict of interest (P = 0.43) were associated with spin.
CONCLUSION
We have shown that spin is common within studies assessing TaTME for rectal cancer. Despite a lack of support from study results, in the majority of studies authors concluded that TaTME is safe for use in rectal cancer. Readers of study abstracts describing new techniques need to be cautious about accepting the authors' conclusions, especially in case series and observational studies.
Topics: Bias; Conflict of Interest; Humans; Mesentery; Proctectomy; Rectal Neoplasms; Research Design; Transanal Endoscopic Surgery
PubMed: 30341922
DOI: 10.1111/codi.14451 -
International Journal of Colorectal... May 2024Robotic transanal minimally invasive surgery (R-TAMIS) was introduced in 2012 for the excision of benign rectal polyps and low grade rectal cancer. Ergonomic...
INTRODUCTION
Robotic transanal minimally invasive surgery (R-TAMIS) was introduced in 2012 for the excision of benign rectal polyps and low grade rectal cancer. Ergonomic improvements over traditional laparoscopic TAMIS (L-TAMIS) include increased dexterity within a small operative field, with possibility of better surgical precision. We aim to collate the existing data surrounding the use of R-TAMIS to treat rectal neoplasms from cohort studies and larger case series, providing a foundation for future, large-scale, comparative studies.
METHODS
Medline, EMBASE and Web of Science were searched as part of our review. Randomised controlled trials (RCTs), cohort studies or large case series (≥ 5 patients) investigating the use of R-TAMIS to resect rectal neoplasia (benign or malignant) were eligible for inclusion in our analysis. Quality assessment of included studies was performed via the Newcastle Ottawa Scale (NOS) risk of bias tool. Outcomes extracted included basic participant characteristics, operative details and histopathological/oncological outcomes.
RESULTS
Eighteen studies on 317 participants were included in our analysis. The quality of studies was generally satisfactory. Overall complication rate from R-TAMIS was 9.7%. Clear margins (R0) were reported in 96.2% of patients. Local recurrence (benign or malignant) occurred in 2.2% of patients during the specified follow-up periods.
CONCLUSION
Our review highlights the current evidence for R-TAMIS in the local excision of rectal lesions. While R-TAMIS appears to have complication, margin negativity and recurrence rates superior to those of published L-TAMIS series, comparative studies are needed.
Topics: Female; Humans; Male; Middle Aged; Anal Canal; Margins of Excision; Minimally Invasive Surgical Procedures; Neoplasm Recurrence, Local; Postoperative Complications; Rectal Neoplasms; Robotic Surgical Procedures; Transanal Endoscopic Surgery; Treatment Outcome
PubMed: 38724801
DOI: 10.1007/s00384-024-04645-4