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Techniques in Coloproctology Aug 2021The aim of this study was to compare long-term oncological, functional outcomes and quality of life (QoL) after transanal total mesorectal excision (TaTME) and... (Meta-Analysis)
Meta-Analysis Review
Comparison of oncological and functional outcomes and quality of life after transanal or laparoscopic total mesorectal excision for rectal cancer: a systematic review and meta-analysis.
BACKGROUND
The aim of this study was to compare long-term oncological, functional outcomes and quality of life (QoL) after transanal total mesorectal excision (TaTME) and laparoscopic total mesorectal excision (LaTME) for rectal cancer.
METHODS
A systematic review and meta-analysis based on Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were conducted on PubMed and Cochrane database. Non-randomized controlled trials (NRCTs) which compared TaTME with LaTME were included.
RESULTS
Ten non-randomized studies were identified, including a total of 638 patients (323 TaTME and 315 LaTME). Age, sex, body mass index, neoadjuvant treatment and American Society of Anesthesiologists (ASA) staging of patients in the two groups were comparable in all included studies. The follow-up period was significantly shorter in the TaTME group than in the LaTME group. No significant differences in local (p = 0.71) and distant (p = 0.23) recurrence rate, 2-year disease-free (p = 0.86) and overall (p = 0.25) survival was found. Also, no significant differences in function outcomes and QoL, including the Wexner score (p = 0.48) or the International Prostate Syndrome Score (IPSS) (p = 0.64) were found. However, the low anterior resection syndrome (LARS) score was significantly higher in the TaTME group (p = 0.04).
CONCLUSIONS
TaTME and LaTME have similar long-term oncological and functional outcomes as well as QoL. The only exception is higher LARS scores after TaTME. The current data are based mainly on observational studies and further randomized controlled trials are required.
Topics: Humans; Laparoscopy; Male; Neoplasm Recurrence, Local; Postoperative Complications; Quality of Life; Rectal Neoplasms; Rectum; Syndrome; Transanal Endoscopic Surgery
PubMed: 34002288
DOI: 10.1007/s10151-021-02420-z -
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 -
Surgical Oncology Jun 2021We aimed to compare the safety and oncological outcomes of transanal endoscopic microsurgery (TEM) and radical surgery (RS) for patients with T1 or T2 rectal cancer. (Meta-Analysis)
Meta-Analysis
AIM
We aimed to compare the safety and oncological outcomes of transanal endoscopic microsurgery (TEM) and radical surgery (RS) for patients with T1 or T2 rectal cancer.
METHOD
We searched Pubmed, Embase, Cochrane Library databases for relevant studies comparing TEM with RS in rectal cancer published until April 2020. We focused on safety and oncological outcomes.
RESULTS
This meta-analysis included 3526 patients from 12 studies. Compared with RS, TEM had a shorter operative time (weighted mean difference [WMD] -110.02, 95% confidence interval [CI]: 143.98, -76.06), less intraoperative blood loss (WMD -493.63, 95% CI: 772.66, -214.59), lower perioperative morality (risk ratio [RR] 0.25, 95% CI: 0.06, 0.99), and fewer postoperative surgical complications (RR 0.23, 95% CI: 0.11,0.45). TEM was associated with more patients with a positive margin or a doubtfully complete margin than RS (RR 7.36, 95% CI: 3.66, 14.78). TEM was associated with higher local recurrence (RR 2.63, 95% CI: 1.60, 4.31) and overall recurrence (RR 1.60, 95% CI: 1.09, 2.36). TEM had a negative effect on 5-year overall survival (hazard ratio [HR] 1.51, 95% CI: 1.16, 1.96), especially in the T2 without neoadjuvant therapy (NAT) subgroup (HR 2.02, 95% CI: 1.32, 3.09), but in the subgroups of T1 or T2 with NAT before TEM, TEM did not yield a significantly lower overall survival than RS.
CONCLUSION
TEM seems appropriate for T1 rectal cancer with favourable histopathology. For patients with T2 rectal cancer, NAT before TEM may contribute to achieving oncological outcomes equivalent to that achieved with RS.
Topics: Disease-Free Survival; Humans; Neoplasm Staging; Rectal Neoplasms; Survival Rate; Transanal Endoscopic Microsurgery; Treatment Outcome
PubMed: 33848762
DOI: 10.1016/j.suronc.2021.101561 -
The Gulf Journal of Oncology Jan 2021Transanal total mesorectal excision (TaTME) is a new technique that is designed to overcome the limits encountered during laparoscopic total mesorectal excision (LaTME)... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Transanal total mesorectal excision (TaTME) is a new technique that is designed to overcome the limits encountered during laparoscopic total mesorectal excision (LaTME) for rectal cancer, especially in male, obese patients with a narrow pelvis and mid and low rectal tumours.
AIM
The objective of our meta-analysis is to evaluate short-term oncological and perioperative outcomes of transanal total mesorectal excision (TaTME) compared to laparoscopic total mesorectal excision (LaTME) for rectal cancer.
METHODS
A meta-analysis based on Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines was conducted in MEDLINE (PubMed). All original studies published in English that compared TaTME with laTME were included. The quality of the included studies was assessed by the Newcastle- Ottawa Quality Assessment Scale (NOS) and Cochrane Library Handbook 5.1.0. Data analysis was conducted using the Review Manager 5.3 software.
RESULTS
Twelve studies including 835 TaTME patients and 1707 LaTME patients with rectal cancer met the inclusion criteria in this meta-analysis. No statistical significant differences were observed in regard to positive circumferential resection margin (PCRM), positive distal resection margin (PDRM), macroscopic quality of mesorectum (MQM) and harvested lymph nodes (HLN). Concerning the perioperative outcomes, the results of conversion rates, operative time, hospital stay (HS), anastomotic leakage (AL) and postoperative complications were comparable between the two groups.
CONCLUSION
Our meta-analysis provides that TaTME may be a valid alternative approach for the treatment of rectal cancer in comparison with LaTME.
Topics: Anastomotic Leak; Female; Humans; Male; Rectal Neoplasms; Transanal Endoscopic Surgery; Treatment Outcome
PubMed: 33716215
DOI: No ID Found -
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 -
Minerva Surgery Aug 2021Transanal endoscopic microsurgery (TEM) is a safe procedure and the rates of intra- and postoperative complications are low. The information in the literature on the...
INTRODUCTION
Transanal endoscopic microsurgery (TEM) is a safe procedure and the rates of intra- and postoperative complications are low. The information in the literature on the management of these complications is limited, and so their importance may be either under- or overestimated (which may in turn lead to under- or overtreatment). The present article reviews the most relevant series of TEM procedures and their complications and describes various approaches to their management.
EVIDENCE ACQUISITION
A systematic review of the literature, including TEM series of more than 150 cases each. We analyzed the population characteristics, surgical variables and intraoperative and postoperative complications.
EVIDENCE SYNTHESIS
A total of 1043 records were found. After review, 1031 were excluded. The review therefore includes 12 independent cohorts of TEM procedures with a total of 4395 patients. The rate of perforation into the peritoneal cavity was 5.1%, and conversion to abdominal approach was required in 0.8% of cases. The most frequent complications were acute urinary retention (AUR, 4.9%) and rectal bleeding (2.2%). Less common complications included abscesses (0.99%) and rectovaginal fistula (0.62%). Mortality rates were low, with a mean value of 0.29%.
CONCLUSIONS
Awareness and knowledge of TEM complications and their management can play an important role in their treatment and patient safety. Here, we present a review of the most important TEM series and their complication rates and describe various approaches to their management.
Topics: Female; Humans; Postoperative Complications; Rectal Neoplasms; Transanal Endoscopic Microsurgery; Transanal Endoscopic Surgery; Treatment Outcome
PubMed: 33433070
DOI: 10.23736/S2724-5691.20.08405-9 -
Surgical Endoscopy Aug 2021Transanal total mesorectal excision (TaTME) is technically challenging even for experienced colorectal surgeons and there may be a higher risk of complications during...
INTRODUCTION
Transanal total mesorectal excision (TaTME) is technically challenging even for experienced colorectal surgeons and there may be a higher risk of complications during learning. Determining when a surgeon is ready to safely perform this technique independently remains a matter of debate. Therefore, the objective of this study was to systematically summarize the available evidence regarding measures of proficiency in TaTME for rectal adenocarcinoma.
METHODS
A systematic search of MEDLINE, Embase, PubMed Epub records, Biosis previews, Scopus, and Cochrane Library databases was performed according to PRISMA guidelines. All English and French language studies published between 2010 and 2018 that described proficiency metrics for TaTME were included. Study heterogeneity precluded meta-analysis, and therefore qualitative synthesis was performed. The primary outcomes were the methodology and measures used to define proficiency, and the number of cases needed to achieve proficiency.
RESULTS
Of 994 citations, five studies met inclusion criteria. Of these, only two used objective measures to define proficiency. These studies evaluated patient outcomes and defined proficiency through cumulative sum (CUSUM) analysis of the primary outcome(s): post-operative complications and TME quality. Two studies reported expert consensus to establish recommendations using a combination of electronic survey distributed to colorectal surgeons and consensus conferences with TaTME experts from 7 to 8 different countries. One study defined the learning phase as 16 months of TaTME practice, or the first 27 cases. Stated case volumes needed to achieve proficiency varied widely. Studies using objective outcome measures reported threshold volumes of 40 and 51 cases, respectively, while expert consensus studies recommended needing 6-30 procedures.
CONCLUSIONS
Significant heterogeneity exists regarding the determination of proficiency benchmarks for TaTME. Expert consensus documents recommend lower case numbers to obtain proficiency than those defined by objective measures, suggesting greater experience may be required than generally thought.
Topics: Humans; Laparoscopy; Postoperative Complications; Proctectomy; Rectal Neoplasms; Rectum; Transanal Endoscopic Surgery
PubMed: 32875417
DOI: 10.1007/s00464-020-07935-4 -
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 -
International Journal of Colorectal... Jul 2020In order to assess the various surgical modalities for local resection of rectal tumors, a systematic review of the current literature and a network meta-analysis (NMA)... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
In order to assess the various surgical modalities for local resection of rectal tumors, a systematic review of the current literature and a network meta-analysis (NMA) was designed and conducted.
METHODS
The present study adhered to the PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions principles. Scholar databases (Medline, Scopus, Web of Science) were systematically screened up to 23/12/2019. A Bayesian NMA, implementing a Markov chain Monte Carlo analysis, was introduced for the probability ranking of the available surgical methods. Odds ratio (OR) and weighted mean difference (WMD) of the categorical and continuous variables, respectively, were reported with the corresponding 95% confidence interval (95%CI).
RESULTS
Overall, 16 studies and 2146 patients were introduced in our study. Transanal minimal invasive surgery (TAMIS) displayed the highest performance regarding the overall postoperative morbidity, the perioperative blood loss, the length of hospitalization, and the peritoneal violation rate. Transanal endoscopic microsurgery (TEM) was the most efficient modality for resecting an intact specimen. Although transanal local excision (TAE) had the highest ranking considering operative duration, it was associated with a significant risk for positive resection margins and tumor recurrence.
CONCLUSIONS
In conclusion, TEM and TAMIS display superior oncological results over TAE. Due to several limitations, validation of these results requires further RCTs of a higher methodological level.
Topics: Bayes Theorem; Humans; Neoplasm Recurrence, Local; Network Meta-Analysis; Rectal Neoplasms; Transanal Endoscopic Microsurgery; Treatment Outcome
PubMed: 32447481
DOI: 10.1007/s00384-020-03634-7 -
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