-
Clinical Experience of a Smart Articulating Digital Device for Transanal Minimally Invasive Surgery.Diseases of the Colon and Rectum Dec 2023The constrained access associated with transanal minimally invasive surgery has led surgeons to deploy robotic-assisted platforms to offset inherent maneuverability...
BACKGROUND
The constrained access associated with transanal minimally invasive surgery has led surgeons to deploy robotic-assisted platforms to offset inherent maneuverability limitations and, perhaps, skills deficits.
IMPACT OF INNOVATION
A handheld, powered 5-mm lightweighted laparoendoscopic electromechanical digital device (HandX, HumanXtensions, Israel) with hardware and software components that convert surgical hand movements precisely to the instrument's articulating tip and enable robotic transanal minimally invasive surgery with full tip roticulation for hook diathermy and suturing.
TECHNOLOGY, MATERIALS, AND METHODS
After bench and biomedical model training, HandX was used in 3 transanal minimally invasive surgery procedures (2 male patients and 1 female patient, mean age 66.3 years). The rectal lesions averaged 30 mm in maximum dimension and were located posteriorly (n = 2) and laterally (n = 1) a mean of 3 cm from the anal verge. Standard transanal minimally invasive surgery setup and instrumentation (Gelport Path, Applied Medical with Airseal, and Conmed) were used, adding the HandX device for circumferential lesion marking and hemostatic full-thickness excision as well as defect suturing where appropriate.
PRELIMINARY RESULTS
All procedures were completed without undue prolongation (operating times <1 hour) despite nuisance hemorrhoidal bleeding in 1 patient. All lesions were fully excised, with 2 being T1 cancers and 1 tubulovillous adenoma with high-grade dysplasia. All patients were discharged within 48 hours postoperatively (1 experienced secondary hemorrhage on postoperative day 5).
CONCLUSIONS AND FUTURE DIRECTIONS
HandX capably facilitated endoscopic robot-like instrument movement for transanal minimally invasive surgery without disrupting workflows. With time dedicated to instrument understanding and training, HandX increased dexterity with a small operating room footprint and may offer greater cost-effectiveness than other platforms.
Topics: Humans; Male; Female; Aged; Rectal Neoplasms; Rectum; Transanal Endoscopic Surgery; Anal Canal; Adenoma; Minimally Invasive Surgical Procedures
PubMed: 37787571
DOI: 10.1097/DCR.0000000000002987 -
Frontiers in Genetics 2023The standard treatment for locally advanced rectal cancer (LARC) is neoadjuvant chemoradiotherapy (nCRT). To select patients who would benefit the most from nCRT, there...
The standard treatment for locally advanced rectal cancer (LARC) is neoadjuvant chemoradiotherapy (nCRT). To select patients who would benefit the most from nCRT, there is a need for predictive biomarkers. The aim of this study was to evaluate the role of clinical, pathological, radiological, inflammation-related genetic, and hematological parameters in the prediction of post-nCRT response. analysis of published transcriptomics datasets was conducted to identify candidate genes, whose expression will be measured using quantitative Real Time PCR (qRT-PCR) in pretreatment formaline-fixed paraffin-embedded (FFPE) samples. In this study, 75 patients with LARC were prospectively included between June 2020-January 2022. Patients were assessed for tumor response in week 8 post-nCRT with pelvic MRI scan and rigid proctoscopy. For patients with a clinical complete response (cCR) and initially distant located tumor no immediate surgery was suggested ("watch and wait" approach). The response after surgery was assessed using histopathological tumor regression grading (TRG) categories from postoperative specimens by Mandard. Responders (R) were defined as patients with cCR without operative treatment, and those with TRG 1 and TRG 2 postoperative categories. Non-responders (NR) were patients classified as TRG 3-5. Responders group comprised 35 patients (46.6%) and NR group 53.4% of patients. Analysis of published transcriptomics data identified genes that could predict response to treatment and their significance was assessed in our cohort by qRT-PCR. When comparison was made in the subgroup of patients who were operated (TRG1 vs. TRG4), the expression of IDO1 was significantly deregulated ( < 0.05). Among hematological parameters between R and NR a significant difference in the response was detected for neutrophil-to-monocyte ratio (NMR), initial basophil, eosinophil and monocyte counts ( < 0.01). According to MRI findings, non-responders more often presented with extramural vascular invasion ( < 0.05). Based on logistic regression model, factors associated with favorable response to nCRT were tumor morphology and hematological parameters which can be easily and routinely derived from initial laboratory results (NMR, eosinophil, basophil and monocyte counts) in a minimally invasive manner. Using various metrics, an aggregated score of the initial eosinophil, basophil, and monocyte counts demonstrated the best predictive performance.
PubMed: 37719698
DOI: 10.3389/fgene.2023.1245594 -
Surgical Endoscopy Dec 2023Transanal TME (taTME) combines abdominal and transanal dissection to facilitate sphincter preservation in patients with low rectal tumors. Few phase II/III trials report...
BACKGROUND
Transanal TME (taTME) combines abdominal and transanal dissection to facilitate sphincter preservation in patients with low rectal tumors. Few phase II/III trials report long-term oncologic and functional results. We report early results from a North American prospective multicenter phase II trial of taTME (NCT03144765).
METHODS
100 patients with stage I-III rectal adenocarcinoma located ≤ 10 cm from the anal verge (AV) were enrolled across 11 centers. Primary and secondary endpoints were TME quality, pathologic outcomes, 30-day and 90-day outcomes, and stoma closure rate. Univariable regression analysis was performed to assess risk factors for incomplete TME and anastomotic complications.
RESULTS
Between September 2017 and April 2022, 70 males and 30 females with median age of 58 (IQR 49-62) years and BMI 27.8 (IQR 23.9-31.8) kg/m underwent 2-team taTME for tumors located a median 5.8 (IQR 4.5-7.0) cm from the AV. Neoadjuvant radiotherapy was completed in 69%. Intersphincteric resection was performed in 36% and all patients were diverted. Intraoperative complications occurred in 8% including 3 organ injuries, 2 abdominal and 1 transanal conversion. The 30-day and 90-day morbidity rates were 49% (Clavien-Dindo (CD) ≥ 3 in 28.6%) and 56% (CD ≥ 3 in 30.4% including 1 mortality), respectively. Anastomotic complications were reported in 18% including 10% diagnosed within 30 days. Higher anastomotic risk was noted among males (p = 0.05). At a median follow-up of 5 (IQR 3.1-7.4) months, 98% of stomas were closed. TME grade was complete or near complete in 90%, with positive margins in 2 cases (3%). Risk factors for incomplete TME were ASA ≥ 3 (p = 0.01), increased time between NRT and surgery (p = 0.03), and higher operative blood loss (p = 0.003).
CONCLUSION
When performed at expert centers, 2-team taTME in patients with low rectal tumors is safe with low conversion rates and high stoma closure rate. Mid-term results will further evaluate oncologic and functional outcomes.
Topics: Male; Female; Humans; Middle Aged; Rectum; Prospective Studies; Transanal Endoscopic Surgery; Rectal Neoplasms; Proctectomy; Laparoscopy; Postoperative Complications; Treatment Outcome
PubMed: 37700015
DOI: 10.1007/s00464-023-10266-9 -
Cureus Aug 2023The current literature suggests that serious complications after intrauterine contraceptive device (IUCD) insertion are rare. We present a rare case of a migrated IUCD...
The current literature suggests that serious complications after intrauterine contraceptive device (IUCD) insertion are rare. We present a rare case of a migrated IUCD into the rectosigmoid colon. A 33-year-old woman (parity one) presented to the emergency department with a three-day history of flank pain, upper urinary tract infection symptoms, and a low-grade fever. Differentials initially included renal colic or pyelonephritis. However, subsequent computed tomography of the kidneys, ureters, and bladder (CT-KUB) and magnetic resonance imaging of the pelvis (MRI-pelvis) showed a migrated IUCD posterior to the uterine body, with both ends closely abutting onto the adjacent proximal rectum. During further history-taking, she reported a past surgical history of an emergency caesarean section five years ago and the insertion of a copper-IUCD six weeks postnatally. She was subsequently referred to the gynaecologists. In view of the involvement of the bowels, the colorectal surgeons were consulted, and the patient was managed by a multidisciplinary team. The patient subsequently underwent diagnostic hysteroscopy, flexible sigmoidoscopy, diagnostic laparoscopy, removal of impacted IUCD, and repair of the rectum. Intraoperatively, her hysteroscopy noted a normal uterus with an intact cavity. Flexible sigmoidoscopy noted the horizontal arm of the IUCD abutting into the lumen of the rectosigmoid region; however, attempted removal with traction was unsuccessful. A partial rectotomy was done eventually to remove the IUCD. Migration of an IUCD is rare, with uterine perforation rates ranging from 0.04% to 0.2%. Albeit a rare complication, this case highlights the need for clinicians to be cognizant of complications arising from IUCD insertion, as symptoms are often non-specific and mild. This case also highlights the importance of a multidisciplinary discussion in the management of a migrated IUCD, which may include gynaecologists, colorectal surgeons, radiologists, and more. Many innovative ways were also discussed regarding the assessment of it, which includes preoperative imaging or endoscopic evaluation. Novel methods of removal of migrated IUCD in the rectosigmoid colon have also been proposed, including manual traction, proctoscopy, rigid sigmoidoscopy, and removal via a snare. They provide an alternative to the traditional diagnostic laparoscopy or laparotomy, thus reducing the need for general anaesthesia or operative intervention. Looking forward, long-term studies can be done to evaluate the need for intervention for asymptomatic patients where the risk of surgery may outweigh the benefits.
PubMed: 37664308
DOI: 10.7759/cureus.42851 -
Diseases of the Colon and Rectum Jan 2024
Topics: Humans; Proctectomy; Rectum; Laparoscopy; Prolapse; Rectal Neoplasms; Sutures; Transanal Endoscopic Surgery; Postoperative Complications; Treatment Outcome
PubMed: 37646648
DOI: 10.1097/DCR.0000000000002735 -
Diseases of the Colon and Rectum Jan 2024
Topics: Humans; Neuroendocrine Tumors; Rectal Neoplasms; Transanal Endoscopic Surgery; Minimally Invasive Surgical Procedures; Anal Canal
PubMed: 37610474
DOI: 10.1097/DCR.0000000000002722 -
Zhonghua Wei Chang Wai Ke Za Zhi =... Jun 2023Transanal total mesorectal resection (taTME) has come a long way since it was first used in the clinic in 2010.The learning curve of this procedure is long due to...
Transanal total mesorectal resection (taTME) has come a long way since it was first used in the clinic in 2010.The learning curve of this procedure is long due to different surgical approaches, different perspectives and different anatomical positions. Many surgeons experience complications during this procedure. Although the advantages and problems of this procedure have been reported in much literature, the anatomy and operation methods of taTME introduced in literatures and training centers are too complicated, which makes many surgeons encounter difficulties in carrying out taTME surgery. According to the author's experience in learning and carrying out this operation, spatial expansion process of ultralow rectal cancer was divided into three stages. At each stage, according to different pulling forces, three different schemes of triangular stability mechanics model were adopted for separation. From point to line, from line to plane, the model can protect the safety of peripheral blood vessels and nerves while ensuring total mesorectal excision . This model simplifies the complex surgical process and is convenient for beginners to master taTME surgical separation skills.
Topics: Humans; Rectum; Laparoscopy; Transanal Endoscopic Surgery; Rectal Neoplasms; Proctectomy; Postoperative Complications; Treatment Outcome
PubMed: 37583015
DOI: 10.3760/cma.j.cn441530-20221028-00437 -
Zhonghua Wei Chang Wai Ke Za Zhi =... Aug 2023Although transanal endoscopic surgery has been developed for more than 40 years, it remains relatively unknown to most domestic colleagues. In 2019, the Chinese Society...
Although transanal endoscopic surgery has been developed for more than 40 years, it remains relatively unknown to most domestic colleagues. In 2019, the Chinese Society of Transanal Total Mesorectal Excision (CSTa) and the Chinese Society of Colon and Rectal Surgeons (CSCRS) organized domestic experts to write and publish the "Chinese Expert Consensus on Transanal Endoscopic Surgery (2019 Edition)", which elaborated on the definition, surgical methods, indications, contraindications, basic principles, key issues and complications of transanal endoscopic surgery, and provided a certain theoretical foundation for the development of transanal endoscopic surgery in China. In the past four years, the scope of application of transanal endoscopic techniques has been expanded, and many prospective and retrospective clinical research have provided more evidence-based medical evidence. Therefore, the Chinese Society of Transanal Total Mesorectal Excision (CSTa) once again organized domestic experts to write the "Expert Consensus and Operation Guidelines for Transanal Endoscopic Surgery in China (2023 Edition)", updating the expert consensus opinions on the definition, indications, complications and learning curve of transanal endoscopic surgery and adding operation guidelines. The aim is to promote the standardized practices in transanal endoscopic surgery and facilitate a shorter learning curve for surgeons.
Topics: Humans; Rectum; Rectal Neoplasms; Consensus; Prospective Studies; Retrospective Studies; Transanal Endoscopic Surgery
PubMed: 37574287
DOI: 10.3760/cma.j.cn441530-20230705-00237 -
Techniques in Coloproctology Nov 2023
Topics: Humans; Transanal Endoscopic Surgery; Peritoneum; Rectal Neoplasms; Minimally Invasive Surgical Procedures
PubMed: 37555893
DOI: 10.1007/s10151-023-02851-w -
Advances in Surgery Sep 2023Transanal total mesorectal excision (taTME) is a technique where rectal dissection is begun transanally in a "bottom-up" fashion. This technique facilitates dissection... (Review)
Review
Transanal total mesorectal excision (taTME) is a technique where rectal dissection is begun transanally in a "bottom-up" fashion. This technique facilitates dissection of the most distal part of the rectum and allows the establishment of the distal margin for rectal cancer. TaTME has proven its utility in facilitating low rectal dissection with significantly lower conversion rates and acceptable perioperative, oncological, and functional outcomes. However, taTME remains a challenging technique to learn and adopt. This article describes the technique, indications, and outcomes of taTME in rectal cancer during the last decade.
Topics: Humans; Laparoscopy; Transanal Endoscopic Surgery; Rectal Neoplasms; Rectum; Proctectomy; Postoperative Complications; Treatment Outcome
PubMed: 37536853
DOI: 10.1016/j.yasu.2023.04.002