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The British Journal of Surgery Apr 2020Total mesorectal excision (TME) gives excellent oncological results in rectal cancer treatment, but patients may experience functional problems. A novel approach to... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Total mesorectal excision (TME) gives excellent oncological results in rectal cancer treatment, but patients may experience functional problems. A novel approach to performing TME is by single-port transanal minimally invasive surgery. This systematic review evaluated the functional outcomes and quality of life after transanal and laparoscopic TME.
METHODS
A comprehensive search in PubMed, the Cochrane Library, Embase and the trial registers was conducted in May 2019. PRISMA guidelines were used. Data for meta-analysis were pooled using a random-effects model.
RESULTS
A total of 11 660 studies were identified, from which 14 studies and six conference abstracts involving 846 patients (599 transanal TME, 247 laparoscopic TME) were included. A substantial number of patients experienced functional problems consistent with low anterior resection syndrome (LARS). Meta-analysis found no significant difference in major LARS between the two approaches (risk ratio 1·13, 95 per cent c.i. 0·94 to 1·35; P = 0·18). However, major heterogeneity was present in the studies together with poor reporting of functional baseline assessment.
CONCLUSION
No differences in function were observed between transanal and laparoscopic TME.
Topics: Fecal Incontinence; Female; Humans; Laparoscopy; Postoperative Complications; Proctectomy; Quality of Life; Rectal Neoplasms; Rectum; Sexual Dysfunction, Physiological; Transanal Endoscopic Surgery; Treatment Outcome
PubMed: 32154594
DOI: 10.1002/bjs.11566 -
International Journal of Colorectal... Jan 2020The introduction of transanal endoscopic or minimally invasive surgery has allowed organ preservation for rectal tumors with good oncological results. Data on functional...
PURPOSE
The introduction of transanal endoscopic or minimally invasive surgery has allowed organ preservation for rectal tumors with good oncological results. Data on functional and quality-of-life (QoL) outcomes are scarce and controversial. This systematic review sought to synthesize fecal continence, QoL, and manometric outcomes after transanal endoscopic microsurgery (TEM) or transanal minimally invasive surgery (TAMIS).
METHODS
A systematic review of the literature including Medline, Embase, and the Cochrane Library databases was conducted searching for articles reporting on functional outcomes after TEM or TAMIS between January 1995 and June 2018. The evaluated outcome parameters were pre- and postoperative fecal continence (primary endpoint), QoL, and manometric results. Data were extracted using the same scales and measurement units as from the original study.
RESULTS
A total of 29 studies comprising 1297 patients were included. Fecal continence outcomes were evaluated in 23 (79%) studies with a wide variety of assessment tools and divergent results. Ten studies (34%) analyzed QoL changes, and manometric variables were assessed in 15 studies (51%). Most studies reported some deterioration in manometric scores without major QoL impairment. Due to the heterogeneity of the data, it was not possible to perform any pooled analysis or meta-analysis.
CONCLUSIONS
These techniques do not seem to affect continence by themselves except in minor cases. The possibility of worsened function after TEM and TAMIS should not be underestimated. There is a need to homogenize or standardize functional and manometric outcomes assessment after TEM or TAMIS.
Topics: Fecal Incontinence; Humans; Manometry; Quality of Life; Rectal Neoplasms; Transanal Endoscopic Microsurgery; Transanal Endoscopic Surgery; Treatment Outcome
PubMed: 31761962
DOI: 10.1007/s00384-019-03439-3 -
Surgical Endoscopy Mar 2020Minimally invasive treatment of early-stage rectal lesion has presented good results, with lower morbidity than surgical resection. Transanal endoscopic microsurgery... (Comparative Study)
Comparative Study Meta-Analysis
BACKGROUND
Minimally invasive treatment of early-stage rectal lesion has presented good results, with lower morbidity than surgical resection. Transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS) are the main methods of transanal surgery. However, endoscopic submucosal dissection (ESD) has been gaining ground because it allows en bloc resections with low recurrence rates. The aim of this study was to analyze ESD in comparison with transanal endoscopic surgery.
METHODS
We searched MEDLINE, EMBASE, SciELO, Cochrane CENTRAL, and Lilacs/Bireme with no restrictions on the date or language of publication. The outcomes evaluated were recurrence rate, complete (R0) resection rate, en bloc resection rate, length of hospital stay, duration of the procedure, and complication rate.
RESULTS
Six retrospective cohort studies involving a collective total of 326 patients-191 in the ESD group and 135 in the transanal endoscopic surgery group were conducted. There were no statistically significant differences between the groups for any of the outcomes evaluated.
CONCLUSIONS
For the minimally invasive treatment of early rectal tumor, ESD and surgical techniques do not differ in terms of local recurrence, en bloc resection rate, R0 resection rate, duration of the procedure, length of hospital stay, or complication rate, however, evidence is very low.
Topics: Cohort Studies; Endoscopic Mucosal Resection; Hemorrhage; Humans; Length of Stay; Neoplasm Recurrence, Local; Publication Bias; Rectal Neoplasms; Transanal Endoscopic Surgery; Treatment Outcome
PubMed: 31754850
DOI: 10.1007/s00464-019-07271-2 -
Surgical Endoscopy Sep 2020Transanal total mesorectal excision (TaTME) appeared to be a challenging alternative to Laparoscopic Total Mesorectal Excision (LaTME) for low and middle rectal cancer.... (Comparative Study)
Comparative Study Meta-Analysis
BACKGROUND
Transanal total mesorectal excision (TaTME) appeared to be a challenging alternative to Laparoscopic Total Mesorectal Excision (LaTME) for low and middle rectal cancer. However, evidence remains low on the possible benefits of TaTME. The aim of this study was to perform a meta-analysis of comparative studies between TaTME and LaTME.
METHODS
A systematic review and meta-analysis based on Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) guidelines was conducted on Medline, Embase, and Cochrane database. The following outcomes were assessed: conversion, operative time, morbidity, length of stay, readmission rate, and pathological and oncological results.
RESULTS
After review of 756 identified records, 14 studies were included (case-matched control n = 10, prospective cohort n = 3, retrospective study n = 1) comparing 495 TaTME and 547 LaTME. No randomized trial was available. Following criteria were significantly improved after TaTME vs. LaTME: readmission's rate (9% after TaTME vs. 18% after LaTME, OR 0.44, 95%CI 0.26-0.74, p = 0.002), length of stay (OR - 2.17, 95%CI - 3.68 to - 0.66, p = 0.005), overall morbidity (34 vs. 41%, OR 0.65, 95%CI 0.46-0.91, p = 0.001), major morbidity (8.7 vs. 14%, OR 0.53, 95%CI 0.34-0.83, p = 0.005), anastomotic leak (6.4 vs. 11.6%, OR 0.53, 95%CI 0.31-0.93, p = 0.03), and circumferential resection margin (CRM) involvement (4 vs. 8.8%, OR 0.48, 95%CI 0.27-0.86, p = 0.01). No significant differences were observed between TaTME and LaTME regarding conversion's rate (3.2 vs. 8.8%, p = 0.09), operative time (OR - 10.73, p = 0.26), intraoperative complications (8.1 vs. 6.3%, p = 0.48), minor morbidity (27.9 vs. 29.6%, p = 0.27), positive distal resection margin (1.4 vs. 1.4%, p = 0.93), complete TME (75 vs. 75%, p = 0.74), harvested lymph nodes (OR 0.38, p = 0.44), and local recurrence rate (3.5 vs. 2.2%, p = 0.64).
CONCLUSION
This meta-analysis based on nonrandomized studies suggests that TaTME seems better than LaTME in terms of overall and major morbidities, anastomotic leak, readmission rate, CRM involvement, and length of stay. These results need to be confirmed by randomized controlled trial.
Topics: Aged; Anastomotic Leak; Female; Follow-Up Studies; Humans; Laparoscopy; Male; Middle Aged; Patient Readmission; Postoperative Care; Postoperative Complications; Prospective Studies; Publication Bias; Rectal Neoplasms; Rectum; Retrospective Studies; Risk; Time Factors; Transanal Endoscopic Surgery
PubMed: 31617090
DOI: 10.1007/s00464-019-07160-8 -
Journal of Plastic, Reconstructive &... Dec 2019Over the past several decades, technical advances in breast reconstruction have resulted in the development of flaps that are aimed at progressively decreasing abdominal...
Over the past several decades, technical advances in breast reconstruction have resulted in the development of flaps that are aimed at progressively decreasing abdominal wall morbidity. There is, however, ongoing controversy related to the superiority of deep inferior epigastric perforator (DIEP) flaps over muscle-sparing TRAM (MS-TRAM) flaps. Hence, the question remains unanswered as to which approach should be considered the standard of care, and more importantly, whether the rate of DIEP flap utilization should be considered a quality metric in breast reconstruction. In this review article, we examine the literature pertaining to abdominal free tissue transfer in breast reconstruction from both donor site and flap characteristics as well as the resultant complications and morbidity. The impact on the donor site remains a prevailing principle for autologous breast reconstruction; thus, must be adequately respected when classifying what is left behind following flap harvest. The most commonly used nomenclature is too simplistic. This, in turn, leads to inadequate incorporation of critical variables, such as degree of muscular preservation, fascial involvement, mesh implantation, and segmental nerve anatomy. Currently, there is insufficient evidence to support DIEP flap harvest as a quality indicator in breast reconstruction, as DIEP flap outcomes are not clearly superior when compared with MS-TRAM flaps.
Topics: Abdominal Muscles; Abdominal Wound Closure Techniques; Breast Neoplasms; Epigastric Arteries; Female; Humans; Mammaplasty; Organ Sparing Treatments; Perforator Flap; Quality Indicators, Health Care; Transanal Endoscopic Microsurgery; Transplant Donor Site; Transplantation, Autologous; Treatment Outcome; Wound Closure Techniques
PubMed: 31570216
DOI: 10.1016/j.bjps.2019.08.005 -
International Journal of Radiation... Dec 2019The goal of treatment for early stage rectal cancer is to optimize oncologic outcome while minimizing effect of treatment on quality of life. The standard of care...
The goal of treatment for early stage rectal cancer is to optimize oncologic outcome while minimizing effect of treatment on quality of life. The standard of care treatment for most early rectal cancers is radical surgery alone. Given the morbidity associated with radical surgery, local excision for early rectal cancers has been explored as an alternative approach associated with lower rates of morbidity. The American Radium Society Appropriate Use Criteria presented in this manuscript are evidence-based guidelines for the use of local excision in early stage rectal cancer that include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) used by a multidisciplinary expert panel to rate the appropriateness of imaging and treatment procedures. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. These guidelines are intended for the use of all practitioners and patients who desire information regarding the use of local excision in rectal cancer.
Topics: Alpha Particles; Antineoplastic Agents; Chemoradiotherapy, Adjuvant; Consensus; Delphi Technique; Evidence-Based Practice; Humans; Magnetic Resonance Imaging; Neoplasm Recurrence, Local; Neoplasm Staging; Patient Selection; Postoperative Complications; Proctectomy; Proctoscopy; Quality of Life; Rectal Neoplasms; Societies, Medical; Standard of Care; Treatment Outcome; United States; Watchful Waiting
PubMed: 31445109
DOI: 10.1016/j.ijrobp.2019.08.020 -
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 -
Surgical Endoscopy Apr 2020While multiple studies have evaluated endoscopic submucosal dissection (ESD) and transanal endoscopic microsurgery (TEM) to remove large rectal tumors, there remains a... (Comparative Study)
Comparative Study Meta-Analysis
BACKGROUND
While multiple studies have evaluated endoscopic submucosal dissection (ESD) and transanal endoscopic microsurgery (TEM) to remove large rectal tumors, there remains a paucity of data to evaluate their comparative efficacy and safety. The primary aim of this study was to perform a structured systematic review and meta-analysis to compare efficacy and safety of ESD versus TEM for the treatment of rectal tumors.
METHODS
Individualized search strategies were developed from inception through November 2018 in accordance with PRISMA guidelines. Measured outcomes included pooled enbloc resection rates, margin-negative (R) resection rates, procedure-associated adverse events, and rates of recurrence. This was a cumulative meta-analysis performed by calculating pooled proportions. Heterogeneity was assessed with Cochran Q test and I statistics, and publication bias by funnel plot using Egger and Begg tests.
RESULTS
Three studies (n = 158 patients; 55.22% male) were included in this meta-analysis. Patients with ESD compared to TEM had similar age (P = 0.090), rectal tumor size (P = 0.108), and diagnosis rate of adenoma to cancer (P = 0.53). ESD lesions were more proximal as compared to TEM (8.41 ± 3.49 vs. 5.11 ± 1.43 cm from the anal verge; P < 0.001). Procedure time and hospital stay were shorter for ESD compared to TEM [(79.78 ± 24.45 vs. 116.61 ± 19.35 min; P < 0.001) and (3.99 ± 0.32 vs. 5.83 ± 0.94 days; P < 0.001), respectively]. No significant differences between enbloc resection rates [OR 0.98 (95% CI 0.22-4.33); P = 0.98; I = 0.00%] and R resection rates [OR 1.16 (95% CI 0.36-3.76); P = 0.80; I = 0.00%] were noted between ESD and TEM. ESD and TEM reported similar rates of adverse events [OR 1.15 (95% CI 0.47-2.77); P = 0.80; I = 0.00%] and rates of recurrence [OR 0.46 (95% CI 0.07-3.14); P = 0.43; I = 0.00%].
CONCLUSION
ESD and TEM possess similar rates of resection, adverse events, and recurrence for patients with large rectal tumors; however, ESD is associated with significantly shorter procedure times and duration of hospitalization. Future studies are needed to evaluate healthcare utilization for these two strategies.
Topics: Adenoma; Anal Canal; Comparative Effectiveness Research; Endoscopic Mucosal Resection; Female; Humans; Length of Stay; Male; Margins of Excision; Middle Aged; Neoplasm Recurrence, Local; Operative Time; Postoperative Complications; Rectal Neoplasms; Rectum; Transanal Endoscopic Microsurgery; Treatment Outcome
PubMed: 31292744
DOI: 10.1007/s00464-019-06945-1 -
International Urogynecology Journal Sep 2019Several posterior compartment surgical approaches are used to address posterior vaginal wall prolapse and obstructed defecation. We aimed to compare outcomes for both...
INTRODUCTION AND HYPOTHESIS
Several posterior compartment surgical approaches are used to address posterior vaginal wall prolapse and obstructed defecation. We aimed to compare outcomes for both conditions among different surgical approaches.
METHODS
A systematic review was performed comparing the impact of surgical interventions in the posterior compartment on prolapse and defecatory symptoms. MEDLINE, Embase, and ClinicalTrials.gov were searched from inception to 4 April 2018. Randomized controlled trials, prospective and retrospective comparative and single-group studies of women undergoing posterior vaginal compartment surgery for vaginal bulge or bowel symptoms were included. Studies had to include both anatomical and symptom outcomes both pre- and post-surgery.
RESULTS
Forty-six eligible studies reported on six surgery types. Prolapse and defecatory symptoms improved with native-tissue transvaginal rectocele repair, transanal rectocele repair, and stapled transanal rectocele repair (STARR) surgeries. Although prolapse was improved with sacrocolpoperineopexy, defecatory symptoms worsened. STARR caused high rates of fecal urgency postoperatively, but this symptom typically resolved with time. Site-specific posterior repairs improved prolapse stage and symptoms of obstructed defecation. Compared with the transanal route, native-tissue transvaginal repair resulted in greater improvement in anatomical outcomes, improved obstructed defecation symptoms, and lower chances of rectal injury, but higher rates of dyspareunia.
CONCLUSIONS
Surgery in the posterior vaginal compartment typically has a high rate of success for anatomical outcomes, obstructed defecation, and bulge symptoms, although these may not persist over time. Based on this evidence, to improve anatomical and symptomatic outcomes, a native-tissue transvaginal rectocele repair should be preferentially performed.
Topics: Constipation; Female; Gynecologic Surgical Procedures; Humans; Pelvic Organ Prolapse; Practice Guidelines as Topic; Prospective Studies; Randomized Controlled Trials as Topic; Rectocele; Retrospective Studies; Transanal Endoscopic Surgery; Vagina
PubMed: 31256222
DOI: 10.1007/s00192-019-04001-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