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Hepato-gastroenterology Jun 2015Transanal minimally invasive surgery (TAMIS) has received attention as an alternative to transanal endoscopic microsurgery for rectal lesions. We review the... (Review)
Review
BACKGROUND/AIMS
Transanal minimally invasive surgery (TAMIS) has received attention as an alternative to transanal endoscopic microsurgery for rectal lesions. We review the effectiveness and safety of TAMIS for the treatment of rectal lesions.
METHODOLOGY
The MEDLINE, Web of Science, and Cochrane Library databases were searched using predefined inclusion criteria. The primary outcomes were positive margin rate, recurrence rate, conversion rate, range of applications, and complication rates. To derive pooled estimates of proportions with 95% Confidence Interval (CI) for the outcomes, a random effect model was used.
RESULTS
Twelve studies including 155 patients were identified. The weighted mean size of rectal lesions was 3.3 cm (range 0.2-10 cm) and the weighted mean distance from the anal verge was 7.4 cm (range 0-20 cm). Six studies enrolled only the patients with low and mid rectal lesions mainly to avoid peritoneal entrance during excision.
CONCLUSIONS
Based on the evidence from this limited number of studies, TAMIS appears to be an effective and safe treatment for rec tal lesions. However, the clinical outcome of TAMIS according to the location of the rectal lesions needs to be clarified. Comparison with other established surgical treatments are also mandatory.
Topics: Adenocarcinoma; Adenoma; Conversion to Open Surgery; Humans; Minimally Invasive Surgical Procedures; Neoplasm Recurrence, Local; Neoplasm, Residual; Rectal Neoplasms; Transanal Endoscopic Surgery; Treatment Outcome; Tumor Burden
PubMed: 26902017
DOI: No ID Found -
Colorectal Disease : the Official... Jan 2016The surgical technique used for transanal total mesorectal excision (TaTME) was reviewed including the oncological quality of resection and the peri-operative outcome. (Review)
Review
AIM
The surgical technique used for transanal total mesorectal excision (TaTME) was reviewed including the oncological quality of resection and the peri-operative outcome.
METHOD
A literature search of MEDLINE, Embase, Science Citation Index Expanded and Cochrane was performed in order to identify studies reporting on TaTME.
RESULTS
Thirty-six studies (eight case reports, 24 case series and four comparative studies) were identified, reporting 510 patients who underwent TaTME. The mean age ranged from 43 to 80 years and the mean body mass index from 21.7 to 31.8 kg/m(2) . The mean distance of the tumour from the anal verge ranged from 4 to 9.7 cm. The mean operation time ranged from 143 to 450 min and mean operative blood loss from 22 to 225 ml. The ratio of hand-sewn coloanal to stapled anastomoses performed was 2:1. One death was reported and the peri-operative morbidity rate was 35%. The anastomotic leakage rate was 6.1% and the reoperation rate was 3.7%. The mean hospital stay ranged from 4.3 to 16.6 days. The mesorectal excision was described as complete in 88% cases, nearly complete in 6% and incomplete in 6%. The circumferential resection margin was negative in 95% of cases and the distal resection margin was negative in 99.7%.
CONCLUSION
TaTME is a feasible and reproducible technique, with good quality of oncological resection. Standardization of the technique is required with formal training. Clear indications for this procedure need to be defined and its safety further assessed in future trials.
Topics: Adenocarcinoma; Anastomosis, Surgical; Anastomotic Leak; Blood Loss, Surgical; Humans; Operative Time; Peritoneum; Postoperative Complications; Rectal Neoplasms; Rectum; Transanal Endoscopic Surgery
PubMed: 26466751
DOI: 10.1111/codi.13151 -
Danish Medical Journal Jul 2015Total mesorectal excision (TME) is the standard surgical treatment for mid and low rectal cancer. The procedure is performed by open, laparoscopic or robotic approaches.... (Review)
Review
INTRODUCTION
Total mesorectal excision (TME) is the standard surgical treatment for mid and low rectal cancer. The procedure is performed by open, laparoscopic or robotic approaches. Transanal TME (TaTME) is a new procedure that potentially solves some difficulties in the pelvic part of the dissection. We aimed to evaluate the literature on TaTME.
METHODS
We performed a systematic search of the literature in the PubMed and Embase databases. Both authors assessed the studies. All publications on TaTME were included with the exception of review articles.
RESULTS
A total of 29 studies (336 patients) were included. Only low-quality evidence is available, and the literature consists of case reports and case series. Studies represent the initial experience of surgeons/centres. No precise indication for TaTME is yet specified other than the presence of mid and low rectal tumours, although the potential advantages seem to be related to a bulky mesorectum in the male pelvis. The preliminary results are encouraging and the most serious complication is urethral injury. The oncological results are acceptable, although the follow-up is short.
CONCLUSION
TaTME is a feasible approach for mid and low rectal cancers. Long-term follow-up data are awaited regarding functional results, local recurrence and survival, and to facilitate comparison with standard laparoscopic or robotic rectal resections.
Topics: Dissection; Female; Humans; Male; Rectal Neoplasms; Transanal Endoscopic Surgery
PubMed: 26183050
DOI: No ID Found -
Diseases of the Colon and Rectum Feb 2015Transanal endoscopic microsurgery is the intraluminal excision of rectal lesions with the use of instrumentation to maintain a stable pneumorectum, enabling a magnified... (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
Transanal endoscopic microsurgery is the intraluminal excision of rectal lesions with the use of instrumentation to maintain a stable pneumorectum, enabling a magnified view of the target lesion. Despite suggested benefits over traditional transanal excision, there is no consensus on which technique is superior.
OBJECTIVE
The aim of the current study is to use meta-analytical techniques to compare transanal endoscopic microsurgery with transanal excision.
DATA SOURCES
A comprehensive literature search of PubMed, Embase, and The Cochrane Library was performed.
STUDY SELECTION
All studies comparing transanal endoscopic microsurgery with transanal excision were included.
INTERVENTIONS
Transanal endoscopic microsurgery was compared with transanal excision by using random-effects methods to combine data. Data are presented as ORs with 95% CIs.
MAIN OUTCOME MEASURES
The main outcomes measured were postoperative complication rate, negative microscopic margin rate, specimen fragmentation rate, and lesion recurrence.
RESULTS
Six comparative series comparing outcomes following 927 local excisions were identified. There was no difference between techniques in postoperative complication rate (OR, 1.018; 95% CI, 0.658-1.575; p = 0.937). Transanal endoscopic microsurgery had a higher rate of negative microscopic margins in comparison with transanal excision (OR, 5.281; 95% CI, 3.201-8.712; p < 0.001). Transanal endoscopic microsurgery had a reduced rate of specimen fragmentation (OR, 0.096; 95% CI, 0.044-0.209; p < 0.001) and lesion recurrence (OR, 0.248; 95% CI, 0.154-0.401; p < 0.001) compared with transanal excision. There was no across-study heterogeneity for any end point.
LIMITATIONS
Most studies were retrospectively designed, and there were variations in patient populations and duration of follow-up.
CONCLUSIONS
Available data are limited because of a lack of randomized controlled trials. However, based on current evidence, transanal endoscopic microsurgery is oncologically superior to transanal excision for the excision of rectal neoplasms.
Topics: Adenoma; Carcinoma; Disease-Free Survival; Humans; Microsurgery; Proctoscopy; Rectal Neoplasms; Rectum; Treatment Outcome
PubMed: 25585086
DOI: 10.1097/DCR.0000000000000309 -
Diseases of the Colon and Rectum Jan 2015Local resection for early rectal cancer is thought to be less invasive but oncologically inferior to radical resection. (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
Local resection for early rectal cancer is thought to be less invasive but oncologically inferior to radical resection.
OBJECTIVE
The aim of this study was to compare local with radical resection in terms of oncologic control (survival and local recurrence), postoperative complications, and the need for a permanent stoma in adult patients with T1N0M0 rectal adenocarcinoma.
DATA SOURCES
Data were retrieved from Medline, Embase, Central, www.clinicaltrials.gov, and conference proceedings.
STUDY SELECTION
Two reviewers independently screened studies and assessed the risk of bias.
INTERVENTIONS
Local resection (transanal procedures, excluding endoscopic polypectomy) versus radical resection were considered.
MAIN OUTCOME MEASURES
The primary outcomes measured were overall survival, major postoperative complications, and the 'need for permanent stoma.'
RESULTS
: One randomized controlled trial and 12 observational studies contributed 2855 patients for analysis. The randomized controlled trial was inadequately powered. Observational study meta-analysis showed that local resection was associated with significantly lower 5-year overall survival (72 more deaths per 1000 patients; 95%CI 30-120). However, the transanal endoscopic microsurgery subgroup did not yield significantly lower overall survival than radical resection. Local resection was associated with higher local recurrence but with lower perioperative mortality (relative risk 0.31, 95% CI 0.14-0.71), major postoperative complications (relative risk 0.20, 95% CI 0.10-0.41), and need for a permanent stoma (relative risk 0.17, 95% CI 0.09-0.30). Findings were robust to sensitivity analyses. Meta-regression suggests that the higher overall survival associated with radical resection may be explained by increased use of local resection on tumors in the lower third of the rectum, which have poorer prognosis.
LIMITATIONS
This systematic review of nonrandomized studies had inherent biases that may persist despite our rigorous use of systematic review methodology and sensitivity analyses.
CONCLUSIONS
Local resection does not offer oncologic control comparable to radical surgery. However, this finding may be driven by the higher prevalence of cancers with poorer prognosis in local resection groups. Local resection is associated with lower postoperative complications, mortality, and the need for a permanent stoma. Local resection with transanal endoscopic microsurgery appears to offer oncologic control similar to that of radical resection while offering all the benefits of local resection.
Topics: Adenocarcinoma; Digestive System Surgical Procedures; Humans; Neoplasm Staging; Postoperative Complications; Proctoscopy; Rectal Neoplasms; Survival Rate
PubMed: 25489704
DOI: 10.1097/DCR.0000000000000293 -
European Archives of... Aug 2015The purpose of the study was to perform a systematic review and meta-analysis of the literature to compare the efficacy (and other postoperative outcomes) of... (Review)
Review
The purpose of the study was to perform a systematic review and meta-analysis of the literature to compare the efficacy (and other postoperative outcomes) of nonabsorbable versus absorbable nasal packing after functional endoscopic sinus surgery (FESS) for the treatment of chronic rhinosinusitis. Studies were considered for inclusion if they were published in English language, were randomized clinical trials, and reported on outcomes following postoperative synechia. The primary outcome for meta-analysis was the incidence of postoperative synechia; pooled odds ratios (ORs) and 95 % confidence intervals (CIs) were calculated using fixed-effects models. Five studies, involving 241 nasal cavities in each treatment group, were included in the systematic review. The prevalence of synechia ranged from 4.6 to 8.0 % in the absorbable groups and from 8.0 to 35.7 % in the nonabsorbable groups. Postoperative bleeding was lower in the absorbable groups, whereas there was no clear finding regarding postoperative pain. Postoperative edema was generally similar between groups. There were no consistent findings regarding bleeding and pain on packing removal. Two studies using the same type of packing material were included in the meta-analysis. The combined OR (0.33, 95 % CI 0.04-2.78) for postoperative synechia did not significantly favor (P = 0.308) absorbable packing over nonabsorbable packing. Although there is some evidence in the available literature that absorbable nasal packing may provide superior outcomes to nonabsorbable packing after FESS, the lack of homogeneity between studies makes definitive conclusions impossible. Further randomized clinical trials are needed to compare the efficacy of different types of absorbable nasal packing for preventing synechia after FESS.
Topics: Chronic Disease; Hemostasis, Surgical; Humans; Postoperative Hemorrhage; Rhinitis; Sinusitis; Transanal Endoscopic Surgery; Treatment Outcome
PubMed: 24927828
DOI: 10.1007/s00405-014-3107-2 -
Surgical Endoscopy Jul 2014Rectal carcinoids are increasing in incidence worldwide. Frequently thought of as a relatively benign condition, there are limited data regarding optimal treatment... (Review)
Review
BACKGROUND
Rectal carcinoids are increasing in incidence worldwide. Frequently thought of as a relatively benign condition, there are limited data regarding optimal treatment strategies for both localized and more advanced disease. The aim of this study was to summarize published experiences with rectal carcinoids and to present the most current data.
METHODS
Following PRISMA guidelines, an electronic literature search performed of PubMed, Medline, Embase, and the Cochrane Library using the terms "rectum" or "rectal" AND "carcinoid" over a 20-year study period from January 1993 to May 2013. Non-English-language studies, animal studies, and studies of fewer than 100 patients were excluded. Study end points included demographic information, tumor features, intervention and outcomes. All included articles were quality assessed.
RESULTS
Using the search parameters and exclusions as outlined above, a total of 14 articles were identified for detailed analysis. The quality of articles was low/moderate for all included scoring 9 to 17 of 27. The articles included 4,575 patients diagnosed with a rectal carcinoid. Approximately 80% of tumors were <10 mm, 15% 11-20 mm, and 5% >20 mm. Eight percent of patients presented with regional lymph node metastases, and 4% presented with distant metastases. Tumor size >10 mm, and muscular and lymphovascular invasion are independently associated with an increased risk of metastases. The 5-year survival was 93% in patients presenting with localized disease and 86% overall.
CONCLUSIONS
Small tumors up to 10 mm without any adverse features can be treated with endoscopic or local excision. The treatment of carcinoids between 10 and 20 mm is still contentious, but those up to 16 mm without adverse feature are suitable for local/endoscopic excision followed by careful histopathological assessment. Those >20 mm or with adverse features require radical surgery with mesorectal clearance in suitable patients.
Topics: Carcinoid Tumor; Female; Humans; Intestinal Mucosa; Ligation; Lymphatic Metastasis; Male; Middle Aged; Neoplasm Invasiveness; Neoplasm Staging; Proctoscopy; Rectal Neoplasms
PubMed: 24584484
DOI: 10.1007/s00464-014-3430-0 -
Colorectal Disease : the Official... Jan 2014A systematic analysis was conducted of trials comparing the effectiveness of transanal endoscopic microsurgery (TEMS) with radical resection (RR) for T1 and T2 rectal... (Comparative Study)
Comparative Study Meta-Analysis Review
Systematic review and meta-analysis of published trials comparing the effectiveness of transanal endoscopic microsurgery and radical resection in the management of early rectal cancer.
AIM
A systematic analysis was conducted of trials comparing the effectiveness of transanal endoscopic microsurgery (TEMS) with radical resection (RR) for T1 and T2 rectal cancer.
METHOD
An electronic search was carried out of trials reporting the effectiveness of TEMS and RR in the treatment of T1 and T2 rectal cancers.
RESULTS
Ten trials including 942 patients were retrieved. There was a trend toward a higher risk of local recurrence (odds ratio 2.78; 95% confidence interval 1.42, 5.44; z = 2.97; P < 0.003) and overall recurrence (P < 0.01) following TEMS compared with RR. The risk of distant recurrence, overall survival (odds ratio 0.90; 95% confidence interval 0.49, 1.66; z = 0.33; P = 0.74) and mortality was similar. TEMS was associated with a shorter operation time and hospital stay and a reduced risk of postoperative complications (P < 0.0001). The included studies, however, were significantly diverse in stage and grade of rectal cancer and the use of neoadjuvant chemoradiotherapy.
CONCLUSION
Transanal endoscopic microsurgery appears to have clinically measurable advantages in patients with early rectal cancer. The studies included in this review do not allow firm conclusions as to whether TEMS is superior to RR in the management of early rectal cancer. Larger, better designed and executed prospective studies are needed to answer this question.
Topics: Adenocarcinoma; Carcinoma; Humans; Microsurgery; Natural Orifice Endoscopic Surgery; Neoadjuvant Therapy; Neoplasm Staging; Proctoscopy; Rectal Neoplasms; Rectum; Treatment Outcome
PubMed: 24330432
DOI: 10.1111/codi.12474 -
Colorectal Disease : the Official... Dec 2013Anorectal varices are an uncommon, but significant, source of bleeding in patients with portal hypertension. The aim of this article was to review systematically the... (Review)
Review
AIM
Anorectal varices are an uncommon, but significant, source of bleeding in patients with portal hypertension. The aim of this article was to review systematically the available literature on the aetiology, clinical presentation and management of anorectal varices, and to suggest a simple treatment algorithm based on available evidence and local expertise.
METHOD
A systematic literature search was carried out to identify articles on anorectal varices, and the search strategy identified 57 relevant references. The inclusion criteria included a consecutive cohort of patients having treatment for anorectal varices with details of success rates and the number of different techniques used. Exclusion criteria included papers published in languages other than English with no English version and results not reported separately for anorectal varices.
RESULTS
Anorectal varices can occur in up to 89% of patients with portal hypertension, although the overall incidence in the general population is low. Diagnosis is best achieved with anoscopy or flexible sigmoidoscopy. The current evidence supports the use of local procedures, such as endoscopic band ligation, to arrest bleeding where feasible, with radiological or surgical procedures used in the event of failure.
CONCLUSION
As there are no large series on this pathology, we present a systematic approach for the patient with anorectal varices.
Topics: Anal Canal; Anus Diseases; Embolization, Therapeutic; Gastrointestinal Hemorrhage; Humans; Hypertension, Portal; Ligation; Portasystemic Shunt, Transjugular Intrahepatic; Proctoscopy; Rectal Diseases; Rectum; Sclerotherapy; Suture Techniques; Varicose Veins
PubMed: 24020839
DOI: 10.1111/codi.12417 -
Endoscopy Nov 2011Large ( > 2 cm) rectal adenomas are currently treated by either transanal endoscopic microsurgery (TEM) or piecemeal endoscopic mucosal resection (EMR). The potential... (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND AND STUDY AIMS
Large ( > 2 cm) rectal adenomas are currently treated by either transanal endoscopic microsurgery (TEM) or piecemeal endoscopic mucosal resection (EMR). The potential lower morbidity of EMR may become irrelevant if EMR is less effective. The aim of this study was to compare the safety and effectiveness of EMR and TEM for large rectal adenomas.
PATIENTS AND METHODS
A systematic review of the literature published between January 1980 and January 2009 was conducted. Pooled estimates of the proportion of patients with recurrence or complications in EMR and TEM studies were compared using random effects meta-regression analysis. Early (after single intervention) and late (excluding re-treatment of residual adenoma detected within 3 months) recurrence rates were calculated.
RESULTS
A total of 20 EMR studies and 48 TEM studies were included. No studies directly compared EMR with TEM. Mean polyp size was 31 mm (range 2 - 86 mm) for EMR vs. 37 mm (range 3 - 182 mm) for TEM (P = 0.02). Early recurrence rates were 11.2 % (95 % confidence interval [CI] 6.0 - 19.9) for EMR vs. 5.4 % (95 %CI 4.0 - 7.3) for TEM (P = 0.04). Late recurrence rates were 1.5 % (95 %CI 0.6 - 3.9) for EMR vs. 3.0 % (95 %CI 1.3 - 6.9) for TEM (P = 0.29). Postoperative complication rates were 3.8 % (95 %CI 2.8 - 5.3) for EMR vs. 13.0 % (95 %CI 9.8 - 17.0) for TEM (P < 0.001).
CONCLUSIONS
After single intervention, EMR for large rectal adenomas appears to be less effective but safer than TEM. When outcome data for re-treatment of residual adenoma within 3 months are included, EMR and TEM seem equally effective. Nevertheless, the added morbidity of additional EMRs could not be accounted for in this analysis. A prospective randomized trial seems imperative before making recommendations concerning the treatment of large rectal adenomas.
Topics: Adenoma; Humans; Intestinal Mucosa; Microsurgery; Neoplasm Recurrence, Local; Postoperative Complications; Proctoscopy; Rectal Neoplasms; Treatment Outcome
PubMed: 21971923
DOI: 10.1055/s-0030-1256765