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BJS Open May 2024Total mesorectal excision (TME) is the standard surgery for low/mid locally advanced rectal cancer. The aim of this study was to compare three minimally invasive... (Comparative Study)
Comparative Study
BACKGROUND
Total mesorectal excision (TME) is the standard surgery for low/mid locally advanced rectal cancer. The aim of this study was to compare three minimally invasive surgical approaches for TME with primary anastomosis (laparoscopic TME, robotic TME, and transanal TME).
METHODS
Records of patients undergoing laparoscopic TME, robotic TME, or transanal TME between 2013 and 2022 according to standardized techniques in expert centres contributing to the European MRI and Rectal Cancer Surgery III (EuMaRCS-III) database were analysed. Propensity score matching was applied to compare the three groups with respect to the complication rate (primary outcome), conversion rate, postoperative recovery, and survival.
RESULTS
A total of 468 patients (mean(s.d.) age of 64.1(11) years) were included; 190 (40.6%) patients underwent laparoscopic TME, 141 (30.1%) patients underwent robotic TME, and 137 (29.3%) patients underwent transanal TME. Comparative analyses after propensity score matching demonstrated a higher rate of postoperative complications for laparoscopic TME compared with both robotic TME (OR 1.80, 95% c.i. 1.11-2.91) and transanal TME (OR 2.87, 95% c.i. 1.72-4.80). Robotic TME was associated with a lower rate of grade A anastomotic leakage (2%) compared with both laparoscopic TME (8.8%) and transanal TME (8.1%) (P = 0.031). Robotic TME (1.4%) and transanal TME (0.7%) were both associated with a lower conversion rate to open surgery compared with laparoscopic TME (8.8%) (P < 0.001). Time to flatus and duration of hospital stay were shorter for patients treated with transanal TME (P = 0.003 and 0.001 respectively). There were no differences in operating time, intraoperative complications, blood loss, mortality, readmission, R0 resection, or survival.
CONCLUSION
In this multicentre, retrospective, propensity score-matched, cohort study of patients with locally advanced rectal cancer, newer minimally invasive approaches (robotic TME and transanal TME) demonstrated improved outcomes compared with laparoscopic TME.
Topics: Humans; Rectal Neoplasms; Male; Robotic Surgical Procedures; Female; Middle Aged; Laparoscopy; Propensity Score; Aged; Postoperative Complications; Europe; Retrospective Studies; Treatment Outcome; Transanal Endoscopic Surgery; Length of Stay; Rectum; Proctectomy
PubMed: 38805357
DOI: 10.1093/bjsopen/zrae044 -
BJS Open May 2024The routine use of MRI in rectal cancer treatment allows the use of a strict definition for low rectal cancer. This study aimed to compare minimally invasive total... (Comparative Study)
Comparative Study
Total mesorectal excision in MRI-defined low rectal cancer: multicentre study comparing oncological outcomes of robotic, laparoscopic and transanal total mesorectal excision in high-volume centres.
BACKGROUND
The routine use of MRI in rectal cancer treatment allows the use of a strict definition for low rectal cancer. This study aimed to compare minimally invasive total mesorectal excision in MRI-defined low rectal cancer in expert laparoscopic, transanal and robotic high-volume centres.
METHODS
All MRI-defined low rectal cancer operated on between 2015 and 2017 in 11 Dutch centres were included. Primary outcomes were: R1 rate, total mesorectal excision quality and 3-year local recurrence and survivals (overall and disease free). Secondary outcomes included conversion rate, complications and whether there was a perioperative change in the preoperative treatment plan.
RESULTS
Of 1071 eligible rectal cancers, 633 patients with low rectal cancer were identified. Quality of the total mesorectal excision specimen (P = 0.337), R1 rate (P = 0.107), conversion (P = 0.344), anastomotic leakage rate (P = 0.942), local recurrence (P = 0.809), overall survival (P = 0.436) and disease-free survival (P = 0.347) were comparable among the centres. The laparoscopic centre group had the highest rate of perioperative change in the preoperative treatment plan (10.4%), compared with robotic expert centres (5.2%) and transanal centres (2.1%), P = 0.004. The main reason for this change was stapling difficulty (43%), followed by low tumour location (29%). Multivariable analysis showed that laparoscopic surgery was the only independent risk factor for a change in the preoperative planned procedure, P = 0.024.
CONCLUSION
Centres with expertise in all three minimally invasive total mesorectal excision techniques can achieve good oncological resection in the treatment of MRI-defined low rectal cancer. However, compared with robotic expert centres and transanal centres, patients treated in laparoscopic centres have an increased risk of a change in the preoperative intended procedure due to technical limitations.
Topics: Humans; Rectal Neoplasms; Robotic Surgical Procedures; Male; Female; Laparoscopy; Middle Aged; Magnetic Resonance Imaging; Aged; Neoplasm Recurrence, Local; Hospitals, High-Volume; Netherlands; Treatment Outcome; Disease-Free Survival; Proctectomy; Postoperative Complications; Retrospective Studies; Transanal Endoscopic Surgery; Anastomotic Leak
PubMed: 38788679
DOI: 10.1093/bjsopen/zrae029 -
International Journal of Colorectal... May 2024Robotic transanal minimally invasive surgery (R-TAMIS) was introduced in 2012 for the excision of benign rectal polyps and low grade rectal cancer. Ergonomic...
INTRODUCTION
Robotic transanal minimally invasive surgery (R-TAMIS) was introduced in 2012 for the excision of benign rectal polyps and low grade rectal cancer. Ergonomic improvements over traditional laparoscopic TAMIS (L-TAMIS) include increased dexterity within a small operative field, with possibility of better surgical precision. We aim to collate the existing data surrounding the use of R-TAMIS to treat rectal neoplasms from cohort studies and larger case series, providing a foundation for future, large-scale, comparative studies.
METHODS
Medline, EMBASE and Web of Science were searched as part of our review. Randomised controlled trials (RCTs), cohort studies or large case series (≥ 5 patients) investigating the use of R-TAMIS to resect rectal neoplasia (benign or malignant) were eligible for inclusion in our analysis. Quality assessment of included studies was performed via the Newcastle Ottawa Scale (NOS) risk of bias tool. Outcomes extracted included basic participant characteristics, operative details and histopathological/oncological outcomes.
RESULTS
Eighteen studies on 317 participants were included in our analysis. The quality of studies was generally satisfactory. Overall complication rate from R-TAMIS was 9.7%. Clear margins (R0) were reported in 96.2% of patients. Local recurrence (benign or malignant) occurred in 2.2% of patients during the specified follow-up periods.
CONCLUSION
Our review highlights the current evidence for R-TAMIS in the local excision of rectal lesions. While R-TAMIS appears to have complication, margin negativity and recurrence rates superior to those of published L-TAMIS series, comparative studies are needed.
Topics: Female; Humans; Male; Middle Aged; Anal Canal; Margins of Excision; Minimally Invasive Surgical Procedures; Neoplasm Recurrence, Local; Postoperative Complications; Rectal Neoplasms; Robotic Surgical Procedures; Transanal Endoscopic Surgery; Treatment Outcome
PubMed: 38724801
DOI: 10.1007/s00384-024-04645-4 -
Surgical Endoscopy Jun 2024Transanal minimally invasive surgery (TAMIS) is an advanced technique for excision of early rectal cancers. Robotic TAMIS (r-TAMIS) has been introduced as technical...
BACKGROUND
Transanal minimally invasive surgery (TAMIS) is an advanced technique for excision of early rectal cancers. Robotic TAMIS (r-TAMIS) has been introduced as technical improvement and potential alternative to total mesorectal excision (TME) in early rectal cancers and in frail patients. This study reports the perioperative and short-term oncological outcomes of r-TAMIS for local excision of early-stage rectal cancers.
METHODS
Retrospective analysis of a prospectively collected r-TAMIS database (July 2021-July 2023). Demographics, clinicopathological features, short-term outcomes, recurrences, and survival were investigated.
RESULTS
Twenty patients were included. Median age and body mass index were 69.5 (62.0-77.7) years and 31.0 (21.0-36.5) kg/m. Male sex was prevalent (n = 12, 60.0%). ASA III accounted for 66.7%. Median distance from anal verge was 7.5 (5.0-11.7) cm. Median operation time was 90.0 (60.0-112.5) minutes. Blood loss was minimal. There were no conversions. Median postoperative stay was 2.0 (1.0-3.0) days. Minor and major complication rates were 25.0% and 0%, respectively. Seventeen (85.0%) patients had an adenocarcinoma whilst three patients had an adenoma. R0 rate was 90.0%. Most tumours were pT1 (55.0%), followed by pT2 (25.0%). One patient (5.0%) had a pT3 tumour. Specimen and tumour maximal median diameter were 51.0 (41.0-62.0) mm and 21.5 (17.2-42.0) mm, respectively. Median specimen area was 193.1 (134.3-323.3) cm. Median follow-up was 15.5 (10.0-24.0) months. One patient developed local recurrence (5.0%).
CONCLUSIONS
r-TAMIS, with strict postoperative surveillance, is a safe and feasible approach for local excision of early rectal cancer and may have a role in surgically unfit and elderly patients who refuse or cannot undergo TME surgery. Future prospective multicentre large-scale studies are needed to report the long-term oncological outcomes.
Topics: Humans; Rectal Neoplasms; Male; Robotic Surgical Procedures; Female; Middle Aged; Aged; Retrospective Studies; Transanal Endoscopic Surgery; Treatment Outcome; Operative Time; Length of Stay; Neoplasm Recurrence, Local
PubMed: 38710889
DOI: 10.1007/s00464-024-10829-4 -
Cureus Apr 2024Introduction Anorectal diseases are prevalent in the general population and may vary from benign disorders to malignant lesions that can metastasize. There is a variety...
Introduction Anorectal diseases are prevalent in the general population and may vary from benign disorders to malignant lesions that can metastasize. There is a variety of proctologic symptoms associated with each disease. The incidence of proctologic disease varies in different cultures due to dietary habits and variations in lifestyle. The present study was conducted to determine the spectrum of different proctologic diseases in female patients presenting with proctologic symptoms. Methods This cross-sectional study was conducted in the Surgery Department of Mardan Medical Complex, Mardan, and Khyber Teaching Hospital, Peshawar, from January 2022 to January 2023. Female patients with proctologic symptoms were included, while non-consenting patients were excluded. After obtaining a detailed history and examination by the experienced surgeon, digital rectal examination and proctoscopy/sigmoidoscopy were performed where necessary. Diagnoses were made, and the data regarding proctologic symptoms and their corresponding diagnoses was analyzed using Statistical Package for the Social Sciences (SPSS) version 20.0 (IBM SPSS Statistics, Armonk, NY) using mean and standard deviation for quantitative variables and frequency and percentage for qualitative variables. Results The mean age of 500 female study participants was 38.35±16.305 (range: 7-108) years. Bleeding per rectum, constipation, and pain per rectum were the commonest proctologic symptoms seen in 341 (68.2%), 287 (57.4%), and 272 (54.4%) cases, respectively. Anal fissures and hemorrhoids were the commonest proctologic diseases seen in 264 (52.8%) and 60 (12%) cases, respectively. Conclusion Bleeding per rectum is the commonest proctologic symptom in patients. Anal fissures and hemorrhoids are the commonest proctologic diseases in our setup. Bleeding per rectum and hemorrhoids in the female population cause loss of blood, which in turn will aggravate the clinical picture of underlying anemia, if any.
PubMed: 38707048
DOI: 10.7759/cureus.57600 -
Langenbeck's Archives of Surgery May 2024Transanal minimally invasive surgery has theoretical advantages for ileal pouch-anal anastomosis surgery. We performed a systematic review assessing technical approaches... (Meta-Analysis)
Meta-Analysis
PURPOSE
Transanal minimally invasive surgery has theoretical advantages for ileal pouch-anal anastomosis surgery. We performed a systematic review assessing technical approaches to transanal IPAA (Ta-IPAA) and meta-analysis comparing outcomes to transabdominal (abd-IPAA) approaches.
METHODS
Three databases were searched for articles investigating Ta-IPAA outcomes. Primary outcome was anastomotic leak rate. Secondary outcomes included conversion rate, post operative morbidity, and length of stay (LoS). Staging, plane of dissection, anastomosis, extraction site, operative time, and functional outcomes were also assessed.
RESULTS
Searches identified 13 studies with 404 unique Ta-IPAA and 563 abd-IPAA patients. Anastomotic leak rates were 6.3% and 8.4% (RD 0, 95% CI -0.066 to 0.065, p = 0.989) and conversion rates 2.5% and 12.5% (RD -0.106, 95% CI -0.155 to -0.057, p = 0.104) for Ta-IPAA and abd-IPAA. Average LoS was one day shorter (MD -1, 95% CI -1.876 to 0.302, p = 0.007). A three-stage approach was most common (47.6%), operative time was 261(± 60) mins, and total mesorectal excision and close rectal dissection were equally used (49.5% vs 50.5%). Functional outcomes were similar. Lack of randomised control trials, case-matched series, and significant study heterogeneity limited analysis, resulting in low to very low certainty of evidence.
CONCLUSIONS
Analysis demonstrated the feasibility and safety of Ta-IPAA with reduced LoS, trend towards less conversions, and comparable anastomotic leak rates and post operative morbidity. Though results are encouraging, they need to be interpreted with heterogeneity and selection bias in mind. Robust randomised clinical trials are warranted to adequately compare ta-IPAA to transabdominal approaches.
Topics: Humans; Proctocolectomy, Restorative; Anastomotic Leak; Transanal Endoscopic Surgery; Treatment Outcome; Length of Stay; Colonic Pouches; Operative Time; Anastomosis, Surgical
PubMed: 38705912
DOI: 10.1007/s00423-024-03343-7 -
BMC Surgery May 2024To comprehensively compare the effects of open Duhamel (OD), laparoscopic-assisted Duhamel (LD), transanal endorectal pull-through (TEPT), and laparoscopic-assisted... (Meta-Analysis)
Meta-Analysis Comparative Study
BACKGROUND
To comprehensively compare the effects of open Duhamel (OD), laparoscopic-assisted Duhamel (LD), transanal endorectal pull-through (TEPT), and laparoscopic-assisted endorectal pull-through (LEPT) in Hirschsprung disease.
METHODS
PubMed, Embase, Cochrane Library, Web of Science, CNKI, WanFang, and VIP were comprehensively searched up to August 4, 2022. The outcomes were operation-related indicators and complication-related indicators. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to evaluate the quality of evidence. Network plots, forest plots, league tables and rank probabilities were drawn for all outcomes. For measurement data, weighted mean differences (WMDs) and 95% credibility intervals (CrIs) were reported; for enumeration data, relative risks (RRs) and 95%CrIs were calculated.
RESULTS
Sixty-two studies of 4781 patients were included, with 2039 TEPT patients, 1669 LEPT patients, 951 OD patients and 122 LD patients. Intraoperative blood loss in the OD group was more than that in the LEPT group (pooled WMD = 44.00, 95%CrI: 27.33, 60.94). Patients lost more blood during TEPT versus LEPT (pooled WMD = 13.08, 95%CrI: 1.80, 24.30). In terms of intraoperative blood loss, LEPT was most likely to be the optimal procedure (79.76%). Patients undergoing OD had significantly longer gastrointestinal function recovery time, as compared with those undergoing LEPT (pooled WMD = 30.39, 95%CrI: 16.08, 44.94). The TEPT group had significantly longer gastrointestinal function recovery time than the LEPT group (pooled WMD = 11.49, 95%CrI: 0.96, 22.05). LEPT was most likely to be the best operation regarding gastrointestinal function recovery time (98.28%). Longer hospital stay was observed in patients with OD versus LEPT (pooled WMD = 5.24, 95%CrI: 2.98, 7.47). Hospital stay in the TEPT group was significantly longer than that in the LEPT group (pooled WMD = 1.99, 95%CrI: 0.37, 3.58). LEPT had the highest possibility to be the most effective operation with respect to hospital stay. The significantly reduced incidence of complications was found in the LEPT group versus the LD group (pooled RR = 0.24, 95%CrI: 0.12, 0.48). Compared with LEPT, OD was associated with a significantly increased incidence of complications (pooled RR = 5.10, 95%CrI: 3.48, 7.45). Patients undergoing TEPT had a significantly greater incidence of complications than those undergoing LEPT (pooled RR = 1.98, 95%CrI: 1.63, 2.42). For complications, LEPT is most likely to have the best effect (99.99%). Compared with the LEPT group, the OD group had a significantly increased incidence of anastomotic leakage (pooled RR = 5.35, 95%CrI: 1.45, 27.68). LEPT had the highest likelihood to be the best operation regarding anastomotic leakage (63.57%). The incidence of infection in the OD group was significantly higher than that in the LEPT group (pooled RR = 4.52, 95%CrI: 2.45, 8.84). The TEPT group had a significantly increased incidence of infection than the LEPT group (pooled RR = 1.87, 95%CrI: 1.13, 3.18). LEPT is most likely to be the best operation concerning infection (66.32%). Compared with LEPT, OD was associated with a significantly higher incidence of soiling (pooled RR = 1.91, 95%CrI: 1.16, 3.17). Patients with LEPT had the greatest likelihood not to develop soiling (86.16%). In contrast to LD, LEPT was significantly more effective in reducing the incidence of constipation (pooled RR = 0.39, 95%CrI: 0.15, 0.97). LEPT was most likely not to result in constipation (97.81%). LEPT was associated with a significantly lower incidence of Hirschprung-associated enterocolitis (HAEC) than LD (pooled RR = 0.34, 95%CrI: 0.13, 0.85). The OD group had a significantly higher incidence of HAEC than the LEPT group (pooled RR = 2.29, 95%CrI: 1.31, 4.0). The incidence of HAEC was significantly greater in the TEPT group versus the LEPT group (pooled RR = 1.74, 95%CrI: 1.24, 2.45). LEPT was most likely to be the optimal operation in terms of HAEC (98.76%).
CONCLUSION
LEPT may be a superior operation to OD, LD and TEPT in improving operation condition and complications, which might serve as a reference for Hirschsprung disease treatment.
Topics: Hirschsprung Disease; Humans; Network Meta-Analysis; Bayes Theorem; Laparoscopy; Digestive System Surgical Procedures; Postoperative Complications; Treatment Outcome; Transanal Endoscopic Surgery; Rectum
PubMed: 38702697
DOI: 10.1186/s12893-024-02416-0 -
Cureus Apr 2024The role of interns during general surgical rotation is crucial in shaping their future careers as surgeons. Surgical rotation offers a unique opportunity to gain...
BACKGROUND
The role of interns during general surgical rotation is crucial in shaping their future careers as surgeons. Surgical rotation offers a unique opportunity to gain valuable hands-on experience in fast-paced and challenging environments. However, interns often face significant challenges in obtaining the necessary practical training to develop proficiency in surgical techniques. This article aims to analyze some aspects of the accumulated competency of interns during their general surgery rotation, focusing on the range of skills and knowledge gained, in addition to the challenges faced.
SUBJECTS AND METHODS
We conducted a cross-sectional study using an anonymous web-based self-assessment questionnaire. The target population of the study included all Jazan University medical interns enrolled in the academic year 2022-2023.
RESULTS
Most participants showed low-to-average levels of proficiency in monitoring clinical evolution and treatment plans, ranging from fundamental awareness (n = 17, 17.5%) to working knowledge (n = 51, 52.6%), with only three participants (3.1%) reporting an expert level of proficiency. The same pattern was observed in the documentation of patient records (range: 7.2%, n = 7 for fundamental awareness to 42.3%, n = 41 for working knowledge). However, a significant proportion saw themselves as either proficient (n = 23, 23.7%) or experts (n = 15, 15.5%) in this aspect. Regarding bedside procedures, such as venipuncture, proctoscopy, nasogastric tube insertion, and urethral catheterization, the participants showed different proficiency levels, with the lowest in proctoscopy, where 66 (68.0%) of the participants reported only fundamental awareness. The results also revealed low perceived proficiency in performing surgical skin incisions, wound suturing, knot tying, application of surgical skin clips, and abscess drainage, with the lowest proficiency observed in the excision of superficial lumps as more than half of the participants reported only fundamental awareness (n = 51, 52.6%).
CONCLUSION
The results of this study indicate that documentation and monitoring of patient progress are the competencies mastered most by the majority of interns during their rotations in general surgery. However, the interns' overall level of proficiency in bedside procedures and basic surgical skills acquired during their rotation was low to average. Additionally, interns were dissatisfied with their training and the opportunities provided for them to actively engage in performing procedures in the operating room. This low proficiency is unrelated to pre-internship academic achievement, sex, or interest in future surgical careers. This suggests that efforts are needed to develop strategies to enhance interns' satisfaction and engagement, ultimately improving their overall experience during internships.
PubMed: 38694650
DOI: 10.7759/cureus.57412 -
Updates in Surgery Jun 2024Minimally invasive techniques for rectal cancer have demonstrated considerable advantages in terms of faster recovery and less post-operative complications. However, due...
Minimally invasive techniques for rectal cancer have demonstrated considerable advantages in terms of faster recovery and less post-operative complications. However, due to the complex anatomy and a limited surgical field, conversion to open surgery is still sometimes required, with a negative impact on the short-and long-term outcomes. The purpose of this study was to analyse the conversion rate to open abdominal surgery during laparoscopic transanal total mesorectal excision (TaTME) procedures performed at a high-volume Italian referral center. All consecutive TaTME performed for mid-to-low rectal cancer between 2015 and 2023 were reviewed, independently if treated with a primary anastomosis (with/without a diverting ostomy) or an end stoma. All procedures were performed using a standardized approach by the same surgical team. Patients with benign diagnosis that underwent different-from rectal resection procedures and cases pre-operatively scheduled for open surgery were excluded. The primary outcome of interest was the rate of conversion, defined as an un-planned intraoperative switch to open surgery using a midline laparotomy. Secondary aims included the comparison of patients who had a longer vs shorter operative time. Out of 220 patients, 210 were selected. In 187 cases, a primary anastomosis was performed, while 23 patients received a terminal colostomy (1 in the converted group; 22 in the full MIS- TaTME group, 10.6%). A surgical approach modification occurred in two cases, with a conversion rate of 0.95%. Median operative time was 281 min. Reasons for conversions included intra-operative difficulties impairing the mini-invasive procedure without intra-operative complications in one case, and difficulties in the laparoscopic control of an intraoperative bleeding due to a splenic lesion in another patient. Male sex and a higher BMI were found to be statistically significantly associated to longer operative time (respectively: p = 0.001 and p = 0.0025). In a high-volume center, a standardized TaTME is associated to a low conversion rate to open abdominal surgery.
Topics: Humans; Rectal Neoplasms; Male; Conversion to Open Surgery; Female; Aged; Middle Aged; Laparoscopy; Operative Time; Transanal Endoscopic Surgery; Rectum; Anastomosis, Surgical; Treatment Outcome; Aged, 80 and over; Retrospective Studies; Digestive System Surgical Procedures
PubMed: 38679626
DOI: 10.1007/s13304-024-01844-0 -
Journal of Clinical Medicine Feb 2024Rectal examination through proctoscopy or rigid sigmoidoscopy is a common investigation in clinical practice. It is an important diagnostic tool for the workup and...
Rectal examination through proctoscopy or rigid sigmoidoscopy is a common investigation in clinical practice. It is an important diagnostic tool for the workup and management of anorectal pathologies. Performing the examination can be daunting not only for patients but also for junior doctors. There are associated risks with the procedure, such as pain, diagnostic failure, and perforation of the bowel. Simulation-based training is recognised as an important adjunct in clinical education. It allows students and doctors to practice skills and techniques at their own pace in a risk-free environment. These skills can then be transferred to and developed further in clinical practice. There is extensive research published regarding the role of simulation-based training in endoscopy, however, we identified no published study regarding simulation-based training in rigid sigmoidoscopy or proctoscopy. This study aims to establish the initial face, content, and construct validity of a tool-based visual anorectal examination advanced simulator model for proctoscopy and rigid sigmoidoscopy. This innovative, highly realistic simulated environment aims to enhance the training of healthcare professionals and improve the efficiency of detecting and diagnosing distal colorectal disease.
PubMed: 38592245
DOI: 10.3390/jcm13051423