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Surgical Endoscopy May 2023In the advancement of transanal local excision, robot-assisted transanal minimal invasive surgery is the newest development. In the confined area of the rectum,... (Review)
Review
BACKGROUND
In the advancement of transanal local excision, robot-assisted transanal minimal invasive surgery is the newest development. In the confined area of the rectum, robot-assisted surgery should, theoretically, be superior due to articulated utensils, video enhancement, and tremor reduction, however, this has not yet been investigated. The aim of this study was to review the evidence reported to-date on experience of using robot-assisted transanal minimal invasive surgery for treatment of rectal neoplasms.
METHODS
A comprehensive literature search of Embase and PubMed from May to August 2021were performed. Studies including patients diagnosed with rectal neoplasia or benign polyps who underwent robot-assisted transanal minimal invasive surgery were included. All studies were assessed for risk of bias through assessment tools. Main outcome measures were feasibility, excision quality, and complications.
RESULTS
Twenty-five studies with a total of 322 local excisions were included. The studies included were all retrospective, primarily case-reports, -series, and cohort studies. The median distance from the anal verge ranged from 3.5 to 10 cm and the median size was between 2.5 and 5.3 cm. Overall, 4.6% of the resections had a positive resection margin. The overall complication rate was at 9.5% with severe complications (Clavien-Dindo score III) at 0.9%.
CONCLUSION
Based on limited, retrospective data, with a high risk of bias, robot-assisted transanal minimal invasive surgery seems feasible and safe for local excisions in the rectum.
Topics: Humans; Robotics; Retrospective Studies; Feasibility Studies; Rectum; Rectal Neoplasms; Anal Canal; Transanal Endoscopic Surgery; Margins of Excision; Treatment Outcome
PubMed: 36707419
DOI: 10.1007/s00464-022-09853-z -
Surgical Oncology Aug 2022At inception, transanal total mesorectal excision (TaTME) was hypothesized to be a solution for several problems encountered in pelvic surgery, particularly for distal...
At inception, transanal total mesorectal excision (TaTME) was hypothesized to be a solution for several problems encountered in pelvic surgery, particularly for distal rectal cancer. The transanal part of the procedure is less hampered by patient related factors such as visceral obesity and a narrow bony pelvis and can thus overcome access and visualization problems encountered with a pure abdominal approach. Clearly, as for any new technique, a learning curve needs to be negotiated, ideally without unacceptable harm to patients. In experienced hands, TaTME might overcome challenges found in anatomically challenging rectal cancer patients as well as for other indications. The role of TaTME is not to replace, but rather complement its abdominal counterpart.
Topics: Humans; Laparoscopy; Proctectomy; Rectal Neoplasms; Rectum; Transanal Endoscopic Surgery
PubMed: 34924223
DOI: 10.1016/j.suronc.2021.101695 -
Minerva Chirurgica Dec 2018Transanal excision (TAE) with conventional retractors and transanal endoscopic microsurgery (TEM) are two well established minimally invasive surgical options for the... (Review)
Review
Transanal excision (TAE) with conventional retractors and transanal endoscopic microsurgery (TEM) are two well established minimally invasive surgical options for the treatment of selected rectal cancers. TEM is nowadays considered the standard of care for the transanal excision of rectal tumors, since it is associated with significantly better quality of excision and lower rates of recurrence than TAE. When compared with rectal resection and total mesorectal excision, TEM has lower postoperative morbidity and better functional outcomes, with similar long-term survival rates in selected early rectal cancers. More recently, transanal minimally invasive surgery (TAMIS) has been developed as an alternative to TEM. Possible benefits of TAMIS are under evaluation.
Topics: Endoscopes; Equipment Design; Humans; Lymph Node Excision; Minimally Invasive Surgical Procedures; Neoplasm Recurrence, Local; Neoplasm Staging; Postoperative Complications; Rectal Neoplasms; Suture Techniques; Transanal Endoscopic Microsurgery; Transanal Endoscopic Surgery
PubMed: 29658675
DOI: 10.23736/S0026-4733.18.07702-7 -
World Journal of Gastroenterology Aug 2020Rectal cancer is one of the most common malignancies worldwide. Surgical resection for rectal cancer usually requires a proctectomy with respective lymphadenectomy... (Review)
Review
Rectal cancer is one of the most common malignancies worldwide. Surgical resection for rectal cancer usually requires a proctectomy with respective lymphadenectomy (total mesorectal excision). This has traditionally been performed transabdominally through an open incision. Over the last thirty years, minimally invasive surgery platforms have rapidly evolved with the goal to accomplish the same quality rectal resection through a less invasive approach. There are currently three resective modalities that complement the traditional open operation: (1) Laparoscopic surgery; (2) Robotic surgery; and (3) Transanal total mesorectal excision. In addition, there are several platforms to carry out transluminal local excisions (without lymphadenectomy). Evidence on the various modalities is of mixed to moderate quality. It is unreasonable to expect a randomized comparison of all options in a single trial. This review aims at reviewing in detail the various techniques in regard to intra-/perioperative benchmarks, recovery and complications, oncological and functional outcomes.
Topics: Digestive System Surgical Procedures; Humans; Laparoscopy; Minimally Invasive Surgical Procedures; Proctectomy; Rectal Neoplasms; Robotic Surgical Procedures; Transanal Endoscopic Surgery
PubMed: 32874053
DOI: 10.3748/wjg.v26.i30.4394 -
European Annals of Otorhinolaryngology,... Apr 2019Pituitary surgery is performed via a transsphenoidal approach in the vast majority of cases according to various methods that have changed over the years. A microscopic...
Pituitary surgery is performed via a transsphenoidal approach in the vast majority of cases according to various methods that have changed over the years. A microscopic transseptal approach via a sublabial mucosal incision or a nasal mucosal incision has also been extensively used. An endoscopic transnasal approach was first described in the 1990's, followed by the concept of a microscopic transseptal approach and an endoscopic strictly endonasal approach. We use an entirely endoscopic transseptal transsphenoidal approach via an incision in the nasal mucosa for both access and tumour resection. This procedure has a number of advantages: strictly midline approach to the sella turcica, large operative field, no interference between instruments and a low rate of nasal complications.
Topics: Adenoma; Anatomic Landmarks; Humans; Nasal Septum; Patient Positioning; Pituitary Neoplasms; Sella Turcica; Sphenoid Sinus; Suture Techniques; Transanal Endoscopic Surgery
PubMed: 30366871
DOI: 10.1016/j.anorl.2018.10.005 -
Applied Health Economics and Health... Feb 2019The Peristeen transanal irrigation system is intended to allow people with bowel dysfunction to flush out the lower part of the bowel as part of their bowel management... (Review)
Review
The Peristeen transanal irrigation system is intended to allow people with bowel dysfunction to flush out the lower part of the bowel as part of their bowel management strategy. Peristeen was the subject of an evaluation by the National Institute for Health and Care Excellence, through its Medical Technologies Evaluation Programme, for the management of bowel dysfunction. The company, Coloplast, submitted a case for adoption of the technology, claiming that the technology improves the severity of chronic constipation or faecal incontinence and improves quality of life for people with bowel dysfunction. Other claimed benefits included reduced frequency of UTIs, stoma surgery and hospitalisation rates, as well as reduced costs. The submission was critiqued by Cedar. The clinical evidence assessed included one randomised controlled trial, and 12 observational studies for adults and 11 studies for children. Although there are limitations in the evidence, the assessed studies show some improvement in outcomes for patients who choose to continue using Peristeen. The committee heard from patient experts that Peristeen had improved their lives and allowed them increased independence. The submitted economic evidence had numerous flaws, however following Cedar's changes to the model, and additional sensitivity analysis, the use of Peristeen was judged unlikely to be cost incurring compared with standard bowel care. The Peristeen transanal irrigation system received a positive recommendation in Medical Technologies Guidance 36.
Topics: Advisory Committees; Constipation; Cost-Benefit Analysis; England; Fecal Incontinence; Female; Gastric Lavage; Humans; Male; Middle Aged; Quality of Life; Transanal Endoscopic Surgery
PubMed: 30426450
DOI: 10.1007/s40258-018-0447-x -
Surgical Endoscopy Sep 2020Transanal total mesorectal excision (taTME) is a novel approach to surgery for rectal cancer. The technique has gained significant popularity in the surgical community...
INTRODUCTION
Transanal total mesorectal excision (taTME) is a novel approach to surgery for rectal cancer. The technique has gained significant popularity in the surgical community due to the promising ability to overcome technical difficulties related to the access of the distal pelvis. Recently, Norwegian surgeons issued a local moratorium related to potential issues with the safety of the procedure. Early adopters of taTME in Canada have recognized the need to create guidelines for its adoption and supervision. The objective of the statement is to provide expert opinion based on the best available evidence and authors' experience.
METHODS
The procedure has been performed in Canada since 2014 at different institutions. In 2016, the first Canadian taTME congress was held in the city of Toronto, organized by two of the authors. In early 2019, a multicentric collaborative was established [The Canadian taTME expert Collaboration] which aimed at ensuring safe performance and adoption of taTME in Canada. Recently surgeons from 8 major Canadian rectal cancer centers met in the city of Toronto on December 7 of 2019, to discuss and develop a position statement. There in person, meeting was followed by 4 rounds of Delphi methodology.
RESULTS
The generated document focused on the need to ensure a unified approach among rectal cancer surgeons across the country considering its technical complexity and potential morbidity. The position statement addressed four domains: surgical setting, surgeons' requirements, patient selection, and quality assurance.
CONCLUSIONS
Authors agree transanal total mesorectal excision is technically demanding and has a significant risk for morbidity. As of now, there is uncertainty for some of the outcomes. We consider it is possible to safely adopt this operation and obtain adequate results, however for this purpose it is necessary to meet specific requirements in different domains.
Topics: Canada; Consensus; Humans; Laparoscopy; Proctectomy; Rectal Neoplasms; Rectum; Surgeons; Transanal Endoscopic Surgery
PubMed: 32504263
DOI: 10.1007/s00464-020-07680-8 -
Medical Archives (Sarajevo, Bosnia and... Jun 2020The e physical anatomical characteristics of Vietnamese people are similar to those of other East Asian populations, with a deep and narrow pelvis but an average body...
INTRODUCTION
The e physical anatomical characteristics of Vietnamese people are similar to those of other East Asian populations, with a deep and narrow pelvis but an average body mass index (BMI) among patients at the advanced stage of rectal cancer.
AIM
This study aimed to prospectively evaluate the short-term outcomes of transanal total mesorectal excision (TaTME) for rectal cancer treatment in a Vietnamese population.
METHODS
A total of 64 patients who underwent TaTME were included in this study. The pelvic anatomical parameters, BMI, operative morbidities, macroscopic qualities of the mesorectal specimens, circumferential resection margins, and anal sphincter functional data were collected. The method popularized by Quirke and Kirwan's classification were used to assess to quality of the mesorectal specimens and the sphincter function, respectively. Statistical analysis was performed using SPSS 20.0.
RESULTS
The mean age and BMI of the patients were 66.4 years and 20.5 kg/m2, respectively. Most patients had narrow pelvises, with mean transverse pelvic outlet diameters of 10.12 ±1.85 cm, for males, and 10.43 ± 1.32 cm, for females, and pelvic depths of 12.36 ±2.03 cm, for males, and 11.73 ±1.12 cm, for females. The mean tumor size was 5.17 ±1.62 cm. Among the mesorectal specimens, 82.8% were complete and 14.1% were nearly complete. Disease-free survival and overall survival rates were 98.2% and 100%, respectively. Sphincter functions at 12 months post-operation were rated as 30.8% Kirwan I, 42.3% Kirwan II, and 26.9% Kirwan III.
CONCLUSION
TaTME surgery represents a safe and suitable option among Vietnamese patients with narrow and deep pelvises and advanced rectal tumors in the middle third and lower third of the rectum.
Topics: Aged; Aged, 80 and over; Anal Canal; Asian People; Disease-Free Survival; Female; Humans; Laparoscopy; Male; Middle Aged; Pelvis; Postoperative Period; Prospective Studies; Rectal Neoplasms; Survival Rate; Transanal Endoscopic Surgery; Tumor Burden; Vietnam
PubMed: 32801439
DOI: 10.5455/medarh.2020.74.216-223 -
JAMA Network Open Feb 2021Proponents of novel transanal total mesorectal excision (TME) suggest the procedure overcomes the technical and oncologic challenges of conventional approaches for...
IMPORTANCE
Proponents of novel transanal total mesorectal excision (TME) suggest the procedure overcomes the technical and oncologic challenges of conventional approaches for treating rectal cancer. Recently, however, there has been controversy regarding the oncologic safety of the procedure.
OBJECTIVE
To assess the association of transanal TME with the incidence of local recurrence (LR) of cancer and the probability of remaining free of LR during follow-up.
DESIGN, SETTING, AND PARTICIPANTS
This multicenter cohort study used data from 8 high-volume rectal cancer academic institutions from across Canada on all consecutive patients with primary rectal cancer treated by transanal TME at the participating centers. The study was conducted between January 2014 and December 2018, and data were analyzed from April 1, 2020, to September 15, 2020.
EXPOSURE
Transanal TME.
MAIN OUTCOMES AND MEASURES
The incidence of LR was reported as a direct measure of quality of resection. The cumulative probability of LR- and systemic recurrence (SR)-free survival at 36 months was estimated. Local recurrence and SR were defined as radiologic or endoscopic evidence of 1 or more new lesions in or outside the pelvis, respectively, documented during surveillance after the removal of the primary tumor.
RESULTS
Of 608 total patients included in the analysis, 423 (69.6%) were male; the median age was 63 years (interquartile range [IQR], 54-70 years). Local recurrence was identified in 22 patients (3.6%) after a median follow-up of 27 months (IQR, 18-38 months). The median time to LR was 13 months (IQR, 9-19 months). Sixteen of the 22 patients with LR (72.7%) were male, 14 (63.6%) received neoadjuvant chemoradiation, and 12 (54.5%) had American Joint Committee on Cancer stage III disease. Of those with LR, 16 (72.7%) had a negative circumferential radial margin and 20 (90.9%) had a negative distal resection margin, 2 (9.1%) experienced conversion to open surgery, and 15 (68.2%) also developed SR. The probability of LR-free survival at 36 months was 96% (95% CI, 94%-98%). According to the Cox proportional hazards regression model, the hazard ratio of LR was estimated to be 4.2 (95% CI, 2.9-6.2) times higher among patients with a positive circumferential radial margin than among those with a negative circumferential radial margin.
CONCLUSIONS AND RELEVANCE
In this cohort study, transanal TME performed by experienced surgeons was associated with an incidence of LR and SR that is in line with the published literature on open and laparoscopic TME, suggesting that transanal TME may be an acceptable approach for management of rectal cancer.
Topics: Aged; Anastomosis, Surgical; Canada; Chemoradiotherapy; Disease-Free Survival; Female; Humans; Ileostomy; Male; Margins of Excision; Mesentery; Middle Aged; Neoadjuvant Therapy; Neoplasm Recurrence, Local; Neoplasm Staging; Postoperative Complications; Proctectomy; Proportional Hazards Models; Rectal Neoplasms; Transanal Endoscopic Surgery; Tumor Burden; Video-Assisted Surgery
PubMed: 33533932
DOI: 10.1001/jamanetworkopen.2020.36330 -
The Lancet. Gastroenterology &... Feb 2021Radical surgery via total mesorectal excision might not be the optimal first-line treatment for early-stage rectal cancer. An organ-preserving strategy with selective... (Comparative Study)
Comparative Study Randomized Controlled Trial
Radical surgery versus organ preservation via short-course radiotherapy followed by transanal endoscopic microsurgery for early-stage rectal cancer (TREC): a randomised, open-label feasibility study.
BACKGROUND
Radical surgery via total mesorectal excision might not be the optimal first-line treatment for early-stage rectal cancer. An organ-preserving strategy with selective total mesorectal excision could reduce the adverse effects of treatment without substantially compromising oncological outcomes. We investigated the feasibility of recruiting patients to a randomised trial comparing an organ-preserving strategy with total mesorectal excision.
METHODS
TREC was a randomised, open-label feasibility study done at 21 tertiary referral centres in the UK. Eligible participants were aged 18 years or older with rectal adenocarcinoma, staged T2 or lower, with a maximum diameter of 30 mm or less; patients with lymph node involvement or metastases were excluded. Patients were randomly allocated (1:1) by use of a computer-based randomisation service to undergo organ preservation with short-course radiotherapy followed by transanal endoscopic microsurgery after 8-10 weeks, or total mesorectal excision. Where the transanal endoscopic microsurgery specimen showed histopathological features associated with an increased risk of local recurrence, patients were considered for planned early conversion to total mesorectal excision. A non-randomised prospective registry captured patients for whom randomisation was considered inappropriate, because of a strong clinical indication for one treatment group. The primary endpoint was cumulative randomisation at 12, 18, and 24 months. Secondary outcomes evaluated safety, efficacy, and health-related quality of life assessed with the European Organisation for Research and Treatment of Cancer (EORTC) QLQ C30 and CR29 in the intention-to-treat population. This trial is registered with the ISRCTN Registry, ISRCTN14422743.
FINDINGS
Between Feb 22, 2012, and Dec 19, 2014, 55 patients were randomly assigned at 15 sites; 27 to organ preservation and 28 to radical surgery. Cumulatively, 18 patients had been randomly assigned at 12 months, 31 at 18 months, and 39 at 24 months. No patients died within 30 days of initial treatment, but one patient randomly assigned to organ preservation died within 6 months following conversion to total mesorectal excision with anastomotic leakage. Eight (30%) of 27 patients randomly assigned to organ preservation were converted to total mesorectal excision. Serious adverse events were reported in four (15%) of 27 patients randomly assigned to organ preservation versus 11 (39%) of 28 randomly assigned to total mesorectal excision (p=0·04, χ test). Serious adverse events associated with organ preservation were most commonly due to rectal bleeding or pain following transanal endoscopic microsurgery (reported in three cases). Radical total mesorectal excision was associated with medical and surgical complications including anastomotic leakage (two patients), kidney injury (two patients), cardiac arrest (one patient), and pneumonia (two patients). Histopathological features that would be considered to be associated with increased risk of tumour recurrence if observed after transanal endoscopic microsurgery alone were present in 16 (59%) of 27 patients randomly assigned to organ preservation, versus 24 (86%) of 28 randomly assigned to total mesorectal excision (p=0·03, χ test). Eight (30%) of 27 patients assigned to organ preservation achieved a complete response to radiotherapy. Patients who were randomly assigned to organ preservation showed improvements in patient-reported bowel toxicities and quality of life and function scores in multiple items compared to those who were randomly assigned to total mesorectal excision, which were sustained over 36 months' follow-up. The non-randomised registry comprised 61 patients who underwent organ preservation and seven who underwent radical surgery. Non-randomised patients who underwent organ preservation were older than randomised patients and more likely to have life-limiting comorbidities. Serious adverse events occurred in ten (16%) of 61 non-randomised patients who underwent organ preservation versus one (14%) of seven who underwent total mesorectal excision. 24 (39%) of 61 non-randomised patients who underwent organ preservation had high-risk histopathological features, while 25 (41%) of 61 achieved a complete response. Overall, organ preservation was achieved in 19 (70%) of 27 randomised patients and 56 (92%) of 61 non-randomised patients.
INTERPRETATION
Short-course radiotherapy followed by transanal endoscopic microsurgery achieves high levels of organ preservation, with relatively low morbidity and indications of improved quality of life. These data support the use of organ preservation for patients considered unsuitable for primary total mesorectal excision due to the short-term risks associated with this surgery, and support further evaluation of short-course radiotherapy to achieve organ preservation in patients considered fit for total mesorectal excision. Larger randomised studies, such as the ongoing STAR-TREC study, are needed to more precisely determine oncological outcomes following different organ preservation treatment schedules.
FUNDING
Cancer Research UK.
Topics: Adenocarcinoma; Adolescent; Adult; Aged; Aged, 80 and over; Feasibility Studies; Female; Follow-Up Studies; Humans; Male; Middle Aged; Neoplasm Staging; Organ Sparing Treatments; Proctectomy; Radiotherapy, Adjuvant; Rectal Neoplasms; Transanal Endoscopic Microsurgery; Treatment Outcome; Young Adult
PubMed: 33308452
DOI: 10.1016/S2468-1253(20)30333-2