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World Journal of Surgical Oncology Nov 2022In rectal cancer (RC) surgery, the complexity of total mesorectal excision (TME) in laparoscopic sphincter-preserving surgery (lap-SPS) for RC near the anus has been a...
Transanal down-to-up dissection of the distal rectum as a viable approach to achieve total mesorectal excision in laparoscopic sphincter-preserving surgery for rectal cancer near the anus: a study of short- and long-term outcomes of 123 consecutive patients from a single Japanese institution.
BACKGROUND
In rectal cancer (RC) surgery, the complexity of total mesorectal excision (TME) in laparoscopic sphincter-preserving surgery (lap-SPS) for RC near the anus has been a critical issue. Recently, technical assistance via the anus for complete TME has been receiving attention. This study aimed at clarifying the transanal down-to-up dissection viability for achieving TME in lap-SPS for RC near the anus.
METHODS
We evaluated surgical and oncological outcomes of a total of 123 consecutive patients undergoing either a transanal rectal dissection (TARD) under direct vision mobilizing the most difficult portion of TME via the anus or the transanal TME by using an endoscopic system (TaTME) for achieving TME in lap-SPS for RC near the anus between January 2006 and February 2021.
RESULTS
A total of 123 consecutive patients (83 men) with a median age of 66 years (range 33-86 years) were included. TARD and TaTME were performed for 50 (40.7%) and for 73 (59.3%) patients, respectively. Preoperative treatment was performed for 40 (32.5%) patients, resulting in a complete pathological response in 5 (12.5%) patients. Intersphincteric resection was performed significantly more in the TARD group (p<0.001). Although the TaTME group needed a longer operative time at the transanal portion (p<0.001), the median blood loss was lower (p<0.001). Postoperative complications with the Clavien-Dindo classification grade ≧2 developed in 52 (42.3%) patients. Urinary dysfunction and stoma-related complications were found most frequently. More patients needing medication for urinary dysfunction were found in the TARD group, but a significant difference was not observed (10.0% vs. 6.8%, p=0.526). The quality of TME was good for almost all patients. Recurrence developed in 18 (14.6%) patients. The 5-year overall survival (OS) and relapse-free survival (RFS) rates in 123 patients were 95.8% and 88.8%, respectively. The 5-year OS and RFS between the two groups were comparable.
CONCLUSIONS
Our data suggested that a transanal down-to-up dissection of the distal rectum might be a viable approach in lap-SPS for RC near the anus. Further studies are needed to examine the differences between TARD and TaTME.
Topics: Humans; Male; Adult; Middle Aged; Aged; Aged, 80 and over; Rectum; Transanal Endoscopic Surgery; Anal Canal; Japan; Neoplasm Recurrence, Local; Treatment Outcome; Rectal Neoplasms; Laparoscopy; Postoperative Complications
PubMed: 36376924
DOI: 10.1186/s12957-022-02826-5 -
World Journal of Gastrointestinal... Oct 2022The role of HER2 overexpression in rectal cancer is controversial.
BACKGROUND
The role of HER2 overexpression in rectal cancer is controversial.
AIM
To assess the role of HER2 overexpression in the long-term prognosis of rectal cancer.
METHODS
Data from patients with locally advanced rectal cancer who underwent total mesorectal excision after short-course radiotherapy at Beijing Cancer Hospital between May 2002 and October 2005 were collected. A total of 151 tissue samples of rectal cancer were obtained using rigid proctoscopy before neoadjuvant radiotherapy, followed by immunohistochemistry and fluorescence hybridisation to determine the patients' HER2 expression status. Univariate and multivariate analyses of the associations between the clinicopathological factors and HER2 status were performed. Survival was estimated and compared using the Kaplan-Meier method based on HER2 expression status, and the differences between groups were verified using the log-rank test.
RESULTS
A total of 151 patients were enrolled in this study. A total of 27 (17.9%) patients were ultimately confirmed to be HER2-positive. The follow-up duration ranged from 9 mo to 210 mo, with a median of 134 mo. Distant metastasis and local recurrence occurred in 60 (39.7%) and 24 (15.9%) patients, respectively. HER2 positivity was significantly associated with the pre-treatment lymph node stage (pre-N) ( = 0.040), while there were no differences between HER2 status and age, sex, preoperative CEA levels (pre-CEA), T stage, and lympho-vascular invasion. In terms of prognosis, HER2 overexpression was correlated with distant metastasis ( = 0.002) rather than local recurrence ( > 0.05). The multivariate analysis demonstrated that elevated pre-CEA [ = 0.002, odds ratio (OR) = 3.277, 97.5% confidence interval (CI): 1.543-7.163], post N(+) ( = 0.022, OR = 2.437, 97.5%CI: 1.143-5.308) and HER2(+) ( = 0.003, OR = 4.222, 97.5%CI: 1.667-11.409) were risk factors for distant metastasis. The survival analysis showed that there were significant differences between rectal cancer patients in terms of disease-free survival (DFS) [hazard ratio: 1.69 (95%CI: 0.91-3.14); = 0.048] and overall survival (OS) [1.95 (1.05-3.63); = 0.0077].
CONCLUSION
HER2 overexpression is a potential biomarker for predicting lymph node metastasis and distant metastasis, which are associated with worse long-term DFS and OS in rectal cancer patients with locally advanced disease.
PubMed: 36310698
DOI: 10.4251/wjgo.v14.i10.2048 -
Canadian Journal of Surgery. Journal... 2022Transanal endoscopic surgery (TES) platforms have become quite popular. Many surgeons across the country have begun excising rectal lesions using these platforms;...
Transanal endoscopic surgery (TES) platforms have become quite popular. Many surgeons across the country have begun excising rectal lesions using these platforms; however, the perioperative decision-making surrounding these excisions can be quite variable. To facilitate care between providers, it would be helpful to standardize the way TES is reported. Synoptic operative reports have previously been established as an effective and efficient communication tool. For patients with rectal cancer, synoptic reports are required for pathology, radiology and major oncologic resections, but never previously for TES. We used a Delphi process including 15 stakeholders from across Canada to develop a TES synoptic report. Participants submitted items according to 6 categories: team characteristics, patient demographics, preoperative work-up, lesion characteristics, procedure details and postoperative details. Twenty-six surgeon-entered and 41 auto-populated items reached final inclusion. This will allow generation of a synoptic reporting template to improve perioperative communication for these patients.
Topics: Humans; Quality Indicators, Health Care; Transanal Endoscopic Surgery; Rectal Neoplasms; Surgeons; Canada
PubMed: 36302129
DOI: 10.1503/cjs.020021 -
Journal of Robotic Surgery Apr 2023Transanal excision of benign lesions, moderately or well-differentiated rectal T1 adenocarcinomas is typically completed via transanal endoscopic microsurgery (TEM) or... (Review)
Review
Transanal excision of benign lesions, moderately or well-differentiated rectal T1 adenocarcinomas is typically completed via transanal endoscopic microsurgery (TEM) or laparoscopic transanal minimally invasive surgery (TAMIS). Robotic platforms provide ergonomic comfort in an enclosed space, enhanced range of motion, and superior 3D visualization. This study sought to perform a literature review of robotic TAMIS (R-TAMIS) and provide expert commentary on the technique. A Pubmed literature search was performed. Study design, robot type, indication, techniques compared, surgical margins, conversion, complications, operative time, estimated blood loss, patient positioning, and defect closure were collected from included articles. Expert opinion on pre-operative planning, technical details, and possible pitfalls was provided, with an accompanying video. Twelve articles published between 2013 and 2022 were included. Five were case reports, three case series, two prospective cohort studies, one retrospective cohort study, and one Phase II trial. The Da Vinci Si (n = 3), Xi (n = 2), single port (n = 3) and flex robotic system (n = 2) were used. Five studies reported negative surgical margins, one reported positive margins, and six did not comment. Operating room time ranged from 45 to 552 min and EBL ranged from 0 to 100 mL. Patient positioning varied based on lesion location but included supine, prone, modified lithotomy, and prone jackknife positions. 11/12 studies reported defect closure, most commonly with V-Loc absorbable suture. We recommend pre-operative MRI abdomen/pelvis, digital rectal exam, and rigid proctoscopy; prone jackknife patient positioning to avoid collisions with robotic arms; and defect closure of full-thickness excisions with backhanded running V-Loc suture.
Topics: Humans; Robotics; Robotic Surgical Procedures; Retrospective Studies; Prospective Studies; Rectum; Rectal Neoplasms; Anal Canal
PubMed: 36244050
DOI: 10.1007/s11701-022-01469-8 -
Annals of Oncology : Official Journal... Jan 2023The standard treatment of T2-T3ab,N0,M0 rectal cancers is total mesorectal excision (TME) due to the high recurrence rates recorded with local excision. Initial reports... (Randomized Controlled Trial)
Randomized Controlled Trial
Short-term outcomes of chemoradiotherapy and local excision versus total mesorectal excision in T2-T3ab,N0,M0 rectal cancer: a multicentre randomised, controlled, phase III trial (the TAU-TEM study).
BACKGROUND
The standard treatment of T2-T3ab,N0,M0 rectal cancers is total mesorectal excision (TME) due to the high recurrence rates recorded with local excision. Initial reports of the combination of pre-operative chemoradiotherapy (CRT) and transanal endoscopic microsurgery (TEM) have shown reductions in local recurrence. The TAU-TEM study aims to demonstrate the non-inferiority of local recurrence and the improvement in morbidity achieved with CRT-TEM compared with TME. Here we describe morbidity rates and pathological outcomes.
PATIENTS AND METHODS
This was a prospective, multicentre, randomised controlled non-inferiority trial including patients with rectal adenocarcinoma staged as T2-T3ab,N0,M0. Patients were randomised to the CRT-TEM or the TME group. Patients included, tolerance of CRT and its adverse effects, surgical complications (Clavien-Dindo and Comprehensive Complication Index classifications) and pathological results (complete response in the CRT-TEM group) were recorded in both groups. Patients attended follow-up controls for local and systemic relapse.
TRIAL REGISTRATION
NCT01308190.
RESULTS
From July 2010 to October 2021, 173 patients from 17 Spanish hospitals were included (CRT-TEM: 86, TME: 87). Eleven were excluded after randomisation (CRT-TEM: 5, TME: 6). Modified intention-to-treat analysis thus included 81 patients in each group. There was no mortality after CRT. In the CRT-TEM group, one patient abandoned CRT, 1/81 (1.2%). The CRT-related morbidity rate was 29.6% (24/81). Post-operative morbidity was 17/82 (20.7%) in the CRT-TEM group and 41/81 (50.6%) in the TME group (P < 0.001, 95% confidence interval 42.9% to 16.7%). One patient died in each group (1.2%). Of the 81 patients in the CRT-TEM group who received the allocated treatment, 67 (82.7%) underwent organ preservation. Pathological complete response in the CRT-TEM group was 44.3% (35/79). In the TME group, pN1 were found in 17/81 (21%).
CONCLUSION
CRT-TEM treatment obtains high pathological complete response rates (44.3%) and a high CRT compliance rate (98.8%). Post-operative complications and hospitalisation rates were significantly lower than those in the TME group. We await the results of the follow-up regarding cancer outcomes and quality of life.
Topics: Humans; Transanal Endoscopic Microsurgery; Treatment Outcome; Prospective Studies; Quality of Life; Neoplasm Recurrence, Local; Rectal Neoplasms; Chemoradiotherapy; Neoadjuvant Therapy; Neoplasm Staging
PubMed: 36220461
DOI: 10.1016/j.annonc.2022.09.160 -
World Journal of Surgical Oncology Sep 2022As transanal total mesorectal excision (taTME) is performed worldwide, the optimization of existing training and guidance programs to enhance new taTME learners'...
PURPOSE
As transanal total mesorectal excision (taTME) is performed worldwide, the optimization of existing training and guidance programs to enhance new taTME learners' competence in performing this procedure is warranted. This study aimed to evaluate the taTME learning curve in patients with mid-low rectal cancer.
METHODS
Patients who underwent taTME for mid-low rectal cancer between October 2015 and August 2021 at a single center were included. A cumulative sum (CUSUM) learning curve analysis was performed with the total operation time as the study outcome. The learning curve was analyzed using risk-adjusted CUSUM analysis, with postoperative complications and anastomotic leakage (AL) as outcomes.
RESULTS
In total, 104 consecutive patients were included in this study. The CUSUM learning curve for total operative time started declining after 42 cases (309.1 ± 84.4 vs. 220.2 ± 46.4, P < 0.001). The risk-adjusted CUSUM (RA-CUSUM) learning curve for postoperative complications fluctuated in cases 44-75 and declined significantly after case 75. The RA-CUSUM learning curve for AL declined after 68 cases.
CONCLUSIONS
taTME had learning curves of 42, 75, and 68 cases for total operative time, postoperative complications, and AL, respectively. A surgeon may require 42 and 75 cases to achieve "proficiency" and "mastery" in taTME procedures, respectively.
Topics: Anastomotic Leak; Humans; Laparoscopy; Learning Curve; Postoperative Complications; Proctectomy; Rectal Neoplasms; Rectum; Transanal Endoscopic Surgery; Treatment Outcome
PubMed: 36138427
DOI: 10.1186/s12957-022-02763-3 -
Internal Medicine (Tokyo, Japan) May 2023A transoral endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) is a well-established tissue-sampling method. However, performing a transanal EUS-FNAB...
A Transanal Endoscopic Ultrasound-guided Fine-needle Aspiration Biopsy for an Intrapelvic Tumor Diagnosed as Recurrence of a Smooth Muscle Tumor of Uncertain Malignant Potential Following Uterine Morcellation.
A transoral endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) is a well-established tissue-sampling method. However, performing a transanal EUS-FNAB remains challenging. Uterine morcellation has emerged as a minimally invasive approach for benign tumor treatment. However, uterine myomas are heterogeneous and include malignant and indeterminate malignant cells. We herein report a rare case of intrapelvic tumor diagnosed by a transanal EUS-FNAB as a recurrence of smooth muscle tumors of uncertain malignant potential following uterine morcellation. Physicians should be aware that a previous uterine myoma resected under morcellation has the possibility of intra-abdominal recurrence. A transanal EUS-FNAB is a practical option for making a pathological diagnosis.
Topics: Humans; Endoscopic Ultrasound-Guided Fine Needle Aspiration; Smooth Muscle Tumor; Morcellation; Endosonography; Transanal Endoscopic Surgery
PubMed: 36130890
DOI: 10.2169/internalmedicine.0435-22 -
Colorectal Disease : the Official... Feb 2023
Topics: Female; Humans; Rectovaginal Fistula; Digestive System Surgical Procedures; Laparoscopy; Anastomosis, Surgical; Rectal Neoplasms; Transanal Endoscopic Surgery; Rectum
PubMed: 36004559
DOI: 10.1111/codi.16310 -
ANZ Journal of Surgery Nov 2022Rectal malignant polyps can be managed by use of trans-anal resections (TAR). Traditional techniques of resection have been replaced by use of platforms such as...
INTRODUCTION
Rectal malignant polyps can be managed by use of trans-anal resections (TAR). Traditional techniques of resection have been replaced by use of platforms such as trans-anal minimally invasive surgery (TAMIS) or trans-anal endoscopic microsurgery (TEM). This study reviewed the management of rectal malignant polyps, in particular focussing on when clinicians used TAR.
METHODS
A population wide cohort study of all malignant rectal polyps diagnosed in Queensland, Australia from 2011 to 2018 was undertaken. Patient and pathological factors were compared across the management strategies of polypectomy, TAR and rectal resection.
RESULTS
Overall 430 patients were diagnosed with a malignant rectal polyp during the study period, with 103 undergoing a TAR. There was increasing use of TAR across the study period as a management strategy (P < 0.001). Polypectomy alone was more likely to be the management strategy over TAR or rectal resection if there were clear margins (P < 0.001). The distance to the closest polypectomy margin was also significantly higher in the polypectomy group with mean clearance 2.09 mm in polypectomy group versus 0.86 mm in TAR group and 0.99 mm in resection group (P < 0.001). Rectal resection was more likely to be the management strategy over TAR if there was LVI (P < 0.001), depth of invasion was deeper (P < 0.001) and there was tumour budding (P = 0.001).
CONCLUSION
TAR is an effective management strategy for rectal polyps and is utilized particularly in rectal malignant polyps when there are close or involved margins. Future guideline development should consider incorporation of TAR given the advances in techniques afforded by TAMIS or TEM platforms.
Topics: Humans; Cohort Studies; Retrospective Studies; Treatment Outcome; Rectal Neoplasms; Anal Canal; Polyps; Margins of Excision; Transanal Endoscopic Surgery
PubMed: 35848607
DOI: 10.1111/ans.17917 -
Annals of Surgery Jan 2023To determine the morbidity, mortality, and pathologic outcomes of transanal total mesorectal resection (taTME) versus laparoscopic total mesorectal excision (laTME)... (Randomized Controlled Trial)
Randomized Controlled Trial
Morbidity, Mortality, and Pathologic Outcomes of Transanal Versus Laparoscopic Total Mesorectal Excision for Rectal Cancer Short-term Outcomes From a Multicenter Randomized Controlled Trial.
OBJECTIVE
To determine the morbidity, mortality, and pathologic outcomes of transanal total mesorectal resection (taTME) versus laparoscopic total mesorectal excision (laTME) among patients with rectal cancer with clinical stage I to III rectal cancer below the peritoneal reflection.
BACKGROUND
Studies with sufficient numbers of patients allowing clinical acceptance of taTME for rectal cancer are lacking. Thus, we launched a randomized clinical trial to compare the safety and efficacy of taTME versus laTME.
METHODS
A randomized, open-label, phase 3, noninferiority trial was performed at 16 different hospitals in 10 Chinese provinces. The primary endpoints were 3-year disease-free survival and 5-year overall survival. The morbidity and mortality within 30 days after surgery, and pathologic outcomes were compared based on a modified intention-to-treat principle; this analysis was preplanned.
RESULTS
Between April 13, 2016, and June 1, 2021, 1115 patients were randomized 1:1 to receive taTME or laTME. After exclusion of 26 cases, modified intention-to-treat set of taTME versus laTME groups included 544 versus 545 patients. There were no significant differences between taTME and laTME groups in intraoperative complications [26 (4.8%) vs 33 (6.1%); difference, -1.3%; 95% confidence interval (CI), -4.2% to 1.7%; P =0.42], postoperative morbidity [73 (13.4%) vs 66 (12.1%); difference, 1.2%; 95% CI, -2.8% to 5.2%; P =0.53), or mortality [1 (0.2%) vs 1 (0.2%)]. Successful resection occurred in 538 (98.9%) versus 538 (98.7%) patients in taTME versus laTME groups (difference, 0.2%; 95% CI, -1.9% to 2.2%; P >0.99).
CONCLUSIONS
Experienced surgeons can safely perform taTME in selected patients with rectal cancer.
Topics: Humans; Postoperative Complications; Transanal Endoscopic Surgery; Operative Time; Rectal Neoplasms; Laparoscopy; Morbidity; Rectum; Treatment Outcome
PubMed: 35815886
DOI: 10.1097/SLA.0000000000005523