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Kashihara H, Tokunaga T, Yoshimoto T, Wada Y, Takasu C, Nishi M, Shimada M. Feasibility of hybrid robotic rectal surgery. Surg Today 2025:10.1007/s00595-025-03001-5. [PMID: 39921721 DOI: 10.1007/s00595-025-03001-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2024] [Accepted: 12/24/2024] [Indexed: 02/10/2025]
Abstract
PURPOSE To investigate the feasibility of combined robotic rectal surgery and transanal total mesorectal excision (hybrid robotic surgery). METHODS Among 143 robotic rectal surgeries performed from 2017 to 2022, 85 were hybrid robotic surgeries and were analyzed in this study. The cohort comprised 59 males and 26 females with a mean age of 65.8 years old and a mean body mass index of 22.6 kg/m2. The cStage was I in 20 cases, II in 21, III in 36, IV in 4, and other in 4. The operation types were low anterior resection in 21 cases, intersphincteric resection in 27, abdominoperineal resection in 32, total pelvic exenteration in 2, and other in 3. Twelve patients (14.1%) received neoadjuvant chemotherapy or chemoradiotherapy, and 39 (45.9%) underwent lateral lymph node dissection. RESULTS The mean operation time for total mesorectal excision was 302.7 min, and the median blood loss was 71.5 ml. No cases required conversion to laparotomy. The median length of postoperative hospital stay was 15.9 days. Complications of Clavien-Dindo grade ≥ 3 occurred in 3 cases (4.2%). Urinary dysfunction occurred in 6 cases (8.3%). Three (4.2%) patients were diagnosed with positive circumferential resection margins. CONCLUSION Hybrid robotic surgery is safe and oncologically feasible.
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Affiliation(s)
- Hideya Kashihara
- Department of Surgery, Institute of Health Biosciences, The University of Tokushima, 3-18-15 Kuramoto-Cho, Tokushima, 770-8503, Japan.
| | - Takuya Tokunaga
- Department of Surgery, Institute of Health Biosciences, The University of Tokushima, 3-18-15 Kuramoto-Cho, Tokushima, 770-8503, Japan
| | - Toshiaki Yoshimoto
- Department of Surgery, Institute of Health Biosciences, The University of Tokushima, 3-18-15 Kuramoto-Cho, Tokushima, 770-8503, Japan
| | - Yuma Wada
- Department of Surgery, Institute of Health Biosciences, The University of Tokushima, 3-18-15 Kuramoto-Cho, Tokushima, 770-8503, Japan
| | - Chie Takasu
- Department of Surgery, Institute of Health Biosciences, The University of Tokushima, 3-18-15 Kuramoto-Cho, Tokushima, 770-8503, Japan
| | - Masaaki Nishi
- Department of Surgery, Institute of Health Biosciences, The University of Tokushima, 3-18-15 Kuramoto-Cho, Tokushima, 770-8503, Japan
| | - Mitsuo Shimada
- Department of Surgery, Institute of Health Biosciences, The University of Tokushima, 3-18-15 Kuramoto-Cho, Tokushima, 770-8503, Japan
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Lu F, Tan SG, Zuo J, Jiang HH, Wang JH, Jiang YP. Comparative efficacy analysis of laparoscopic-assisted transanal total mesorectal excision vs laparoscopic transanal mesorectal excision for low-lying rectal cancer. World J Gastrointest Surg 2025; 17:100364. [PMID: 39872764 PMCID: PMC11757205 DOI: 10.4240/wjgs.v17.i1.100364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2024] [Revised: 10/10/2024] [Accepted: 10/15/2024] [Indexed: 12/27/2024] Open
Abstract
BACKGROUND With the continuous development of laparoscopic techniques in recent years, laparoscopic total mesorectal excision (LapTME) and laparoscopic-assisted transanal total mesorectal excision (TaTME) have gradually become important surgical techniques for treating low-lying rectal cancer (LRC). However, there is still controversy over the efficacy and safety of these two surgical modalities in LRC treatment. AIM To compare the efficacy of LapTME vs TaTME in patients with LRC. METHODS Ninety-four patients with LRC who visited and were treated at the Affiliated Hengyang Hospital of Hunan Normal University & Hengyang Central Hospital between December 2022 and March 2024 were selected and divided into the LapTME (n = 44) and TaTME (n = 50) groups. Clinical operation indexes, postoperative recovery indicators, and postoperative complications were recorded. The anal resting pressure (ARP), anal maximum systolic pressure (MSP), and maximum tolerated volume (MTV) of the anal canal were also measured. The intestinal function of patients was evaluated by the Memorial Sloan Kettering Cancer Center (MSKCC) bowel function questionnaire. Serum norepinephrine (NE), adrenaline (AD), and cortisol (Cor) levels were measured. The Quality of Life Questionnaire Core 30 (QLQ-C30) was used for quality of life assessment. RESULTS Compared with the LapTME group, the surgery time in the TaTME group was longer; intraoperative blood loss was low; time of anal exhaust, first postoperative ambulation, intestinal recovery, and hospital stay were shorter; and the distal incisal margin and specimen lengths were longer. The TaTME group also showed higher ARP, MSP, and MTV values and higher MSKCC and QLQ-C30 scores than the LapTME group 3 months postoperatively. Cor, AD, and NE levels were lower in the TaTME group than those in the LapTME group during recovery. CONCLUSION We demonstrated that TaTME better improved anal function, reduced postoperative stress, and accelerated postoperative recovery and, hence, was safer for patients with LRC.
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Affiliation(s)
- Feng Lu
- Department of Gastrointestinal Surgery, Affiliated Hengyang Hospital of Hunan Normal University & Hengyang Central Hospital, Hengyang 421001, Hunan Province, China
| | - Shu-Guang Tan
- Department of Gastrointestinal Surgery, Affiliated Hengyang Hospital of Hunan Normal University & Hengyang Central Hospital, Hengyang 421001, Hunan Province, China
| | - Juan Zuo
- Department of Hematology, The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang 421001, Hunan Province, China
| | - Hai-Hua Jiang
- Department of Gastrointestinal Surgery, Affiliated Hengyang Hospital of Hunan Normal University & Hengyang Central Hospital, Hengyang 421001, Hunan Province, China
| | - Jian-Hua Wang
- Department of Gastrointestinal Surgery, Affiliated Hengyang Hospital of Hunan Normal University & Hengyang Central Hospital, Hengyang 421001, Hunan Province, China
| | - Yu-Ping Jiang
- Department of Gastrointestinal Surgery, Nanhua Hospital Affiliated to University of South China, Hengyang 421002, Hunan Province, China
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Beppu N, Ito K, Otani M, Imada A, Matsubara T, Song J, Kimura K, Kataoka K, Kuwahara R, Horio Y, Uchino M, Ikeuchi H, Ikeda M. Feasibility of transanal minimally invasive surgery for total pelvic exenteration for advanced primary and recurrent pelvic malignancies. Tech Coloproctol 2023; 27:1367-1375. [PMID: 37878167 DOI: 10.1007/s10151-023-02869-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 10/02/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND The purpose of this study was to clarify the efficacy and safety of transanal minimally invasive surgery (TAMIS) for total pelvic exenteration (TPE) in advanced primary and recurrent pelvic malignancies. METHODS Using a prospectively collected database, we retrospectively analyzed the clinical, surgical, and pathological outcomes of TAMIS for TPE. Surgery was performed between September 2019 and April 2023. The median follow-up period was 22 months (2-45 months). RESULTS Fifteen consecutive patients were included in this analysis M:F = 14:1 and median (range) age was 63 (36-74). Their diagnoses were as follows: primary rectal cancer (n = 5; 33%), recurrent rectal cancer (n = 4; 27%), primary anorectal cancer (n = 5; 33%), and gastrointestinal stromal tumor (n = 1; 7%). Bladder-sparing TPE was selected for two patients (13%). In nine of 15 patients (60%) the anal sphincter could be successfully preserved, five patients (33%) required combined resection of the internal iliac vessels, and two (13%) required rectus muscle flap reconstruction. The median operative time was 723 min (561-1082), and the median intraoperative blood loss was 195 ml (30-1520). The Clavien-Dindo classifications of the postoperative complications were as follows: grade 0-2 (n = 11; 73%); 3a (n = 3; 20%); 3b (n = 1; 7%); and ≥ 4 (n = 0; 0%). No cases of conversion to laparotomy or mortality were observed. The pathological results demonstrated that R0 was achieved in 14 patients (93%). CONCLUSIONS The short-term outcomes of this initial experience proved that this novel approach is feasible for TPE, with low blood loss, acceptable postoperative complications, and a satisfactory R0 resection rate.
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Affiliation(s)
- N Beppu
- Division of Lower Gastrointestinal Surgery, Department of Gastroenterological Surgery, Hyogo Medical University, 1-1 Mukogawa-Tyo, Nishinomiya, Hyogo, 663-8501, Japan.
| | - K Ito
- Division of Lower Gastrointestinal Surgery, Department of Gastroenterological Surgery, Hyogo Medical University, 1-1 Mukogawa-Tyo, Nishinomiya, Hyogo, 663-8501, Japan
| | - M Otani
- Division of Lower Gastrointestinal Surgery, Department of Gastroenterological Surgery, Hyogo Medical University, 1-1 Mukogawa-Tyo, Nishinomiya, Hyogo, 663-8501, Japan
| | - A Imada
- Division of Lower Gastrointestinal Surgery, Department of Gastroenterological Surgery, Hyogo Medical University, 1-1 Mukogawa-Tyo, Nishinomiya, Hyogo, 663-8501, Japan
| | - T Matsubara
- Division of Lower Gastrointestinal Surgery, Department of Gastroenterological Surgery, Hyogo Medical University, 1-1 Mukogawa-Tyo, Nishinomiya, Hyogo, 663-8501, Japan
| | - J Song
- Division of Lower Gastrointestinal Surgery, Department of Gastroenterological Surgery, Hyogo Medical University, 1-1 Mukogawa-Tyo, Nishinomiya, Hyogo, 663-8501, Japan
| | - K Kimura
- Division of Lower Gastrointestinal Surgery, Department of Gastroenterological Surgery, Hyogo Medical University, 1-1 Mukogawa-Tyo, Nishinomiya, Hyogo, 663-8501, Japan
| | - K Kataoka
- Division of Lower Gastrointestinal Surgery, Department of Gastroenterological Surgery, Hyogo Medical University, 1-1 Mukogawa-Tyo, Nishinomiya, Hyogo, 663-8501, Japan
| | - R Kuwahara
- Division of Inflammatory Bowel Disease Surgery, Department of Gastroenterological Surgery, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Y Horio
- Division of Inflammatory Bowel Disease Surgery, Department of Gastroenterological Surgery, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - M Uchino
- Division of Inflammatory Bowel Disease Surgery, Department of Gastroenterological Surgery, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - H Ikeuchi
- Division of Inflammatory Bowel Disease Surgery, Department of Gastroenterological Surgery, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - M Ikeda
- Division of Lower Gastrointestinal Surgery, Department of Gastroenterological Surgery, Hyogo Medical University, 1-1 Mukogawa-Tyo, Nishinomiya, Hyogo, 663-8501, Japan
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Casey L, Larach JT, Waters PS, Kong JCH, McCormick JJ, Heriot AG, Warrier SK. Application of minimally invasive approaches to pelvic exenteration for locally advanced and locally recurrent pelvic malignancy - A narrative review of outcomes in an evolving field. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:2330-2337. [PMID: 36068124 DOI: 10.1016/j.ejso.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 07/26/2022] [Accepted: 08/05/2022] [Indexed: 11/28/2022]
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Kotze PG, Heuthorst L, Lightner AL, Damião AOMC, Bemelman WA. New insights on the surgical management of ulcerative colitis in the 21st century. Lancet Gastroenterol Hepatol 2022; 7:679-688. [DOI: 10.1016/s2468-1253(22)00001-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 12/19/2021] [Accepted: 12/21/2021] [Indexed: 10/18/2022]
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Chen SC, Futaba K, Leung WW, Wong C, Mak T, Ng S, Gregersen H. Functional anorectal studies in patients with low anterior resection syndrome. Neurogastroenterol Motil 2022; 34:e14208. [PMID: 34145694 DOI: 10.1111/nmo.14208] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 05/24/2021] [Accepted: 06/01/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Most patients who have undergone low anterior resection suffer from bowel dysfunction postoperatively. This condition is referred to as low anterior resection syndrome (LARS). The aim was to study defecatory patterns in LARS patients compared to a primary control group of fecal incontinence (FI) patients and normal subjects (NS) with the Fecobionics device. METHODS Fecobionics expulsion parameters were assessed in an interventional study design. The Fecobionics probe contained pressure sensors at the front, rear, and inside the bag. The bag was distended until urge sensation in rectum in 11 LARS patients (5F/6M, 63.2 ± 2.9 years), 11 FI subjects (7F/4M, 64.4 ± 2.5 years), and 11 NS (7F/4M, 63.6 ± 3.0 years). Defecation indices were computed from the Fecobionics data. All subjects had high-resolution anorectal manometry (ARM) and balloon expulsion test (BET) done. Symptoms were evaluated with LARS and Wexner scores. KEY RESULTS The LARS score in the LARS patients was 39.0 ± 0.6. The Wexner score in the LARS, FI, and NS groups was 14.2 ± 0.7, 10.1±1.0, and 0.0 ± 0.0 (p < 0.01). The resting anal pressure and squeeze pressure were lowest in LARS patients (p < 0.05). The urge volume was 11.8 ± 4.2, 59.6 ± 6.4, and 41.6 ± 6.4 ml in the LARS, FI, and NS groups, respectively (p < 0.001). The expulsion duration did not differ between groups. Defecation indices were lowest in the LARS patients (p < 0.05). ARM-BET confirmed the low urge volume in LARS patients whereas anal pressures did not differ between groups. CONCLUSIONS AND INFERENCES The LARS patients had low anal pressures and urge volume. Most Defecation Indices differed between the LARS group and the other groups.
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Affiliation(s)
- Ssu-Chi Chen
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Kaori Futaba
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Wing Wa Leung
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Cherry Wong
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Tony Mak
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Simon Ng
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Hans Gregersen
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong.,California Medical Innovations Institute, San Diego, CA, USA
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Abstract
Transanal surgery has gained in popularity during the latter part of the last decade for both rectal cancer and benign disease. The current role for local excision of early rectal neoplastic lesions has expanded due to better understanding of risk factors for lymph node metastasis and heightened awareness for the long-term sequelae of radical surgery. Transanal resection of the rectum (both for cancer or inflammatory bowel diseases) has now been established as a successful procedure that overcomes some of the limitations of the abdominal approaches. Once the feasibility, safety, and the oncologic results of transanal minimally invasive approaches for patients with rectal cancer have been acknowledged, quality of life and functional outcomes have become increasingly important issues. This article provides an overview of the different techniques currently available for the minimally invasive transanal treatment of rectal lesions, particularly focusing on functional outcomes.
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Affiliation(s)
- Caterina Foppa
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy,Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Francesco Maria Carrano
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy,Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Rozzano, Milan, Italy,Address for correspondence Antonino Spinelli, MD, PhD Division of Colon and Rectal Surgery, Department of Surgery, Humanitas Clinical and Research CenterIRCCS, Building 2, Via Manzoni 56, Rozzano, Milano 20089Italy
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Völkel V, Schatz S, Draeger T, Gerken M, Klinkhammer-Schalke M, Fürst A. Transanal total mesorectal excision: short- and long-term results of the first hundred cases of a certified colorectal cancer center in Germany. Surg Endosc 2022; 36:1172-1180. [PMID: 33650009 PMCID: PMC8758606 DOI: 10.1007/s00464-021-08384-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 02/09/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Since 2010, laparoscopic transanal total mesorectal excision (TaTME) has been increasingly used for low and very low rectal cancer. It is supposed to improve visibility and access to the dissection planes in the pelvis. This study reports on short- and long-term outcomes of the first 100 consecutive patients treated with TaTME in a certified German colorectal cancer center. PATIENTS AND METHODS Data were derived from digital patient files and official cancer registry reports for patients with TaTME tumor surgery between July 2014 and January 2020. The primary outcome was the 3-year local recurrence rate and local recurrence-free survival (LRFS). Secondary endpoints included overall survival (OAS), disease-free survival (DFS), operation time, completeness of local tumor resection, lymph node resection, and postoperative complications. The Kaplan-Meier method was employed for the survival analyses; competing risks were considered in the time-to-event analysis. RESULTS During the observation period, the average annual operation time decreased from 272 to 178 min. Complete local tumor resection was achieved in 97% of the procedures. Major postoperative complications (Clavien-Dindo 3-4) occurred in 11% of the cases. At a median follow-up time of 2.7 years, three patients had suffered from a local recurrence. Considering competing risks, this corresponds to a 3-year cumulative incidence rate for local recurrence of 2.2% and a 3-year LRFS of 81.9%. 3-year OAS was 82.9%, and 3-year DFS was 75.7%. CONCLUSION TaTME is associated with favorable short and long-term outcomes. Since it is technically demanding, structured training programs and more research on the topic are indispensable.
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Affiliation(s)
- Vinzenz Völkel
- Tumorzentrum Regensburg - Institut für Qualitätssicherung und Versorgungsforschung der Universität Regensburg, Am BioPark 9, 93053, Regensburg, Germany.
- Caritas Krankenhaus St. Josef Regensburg, Klinik für Allgemeine Innere Medizin, Gastroenterologie und Kardiologie, Landshuter Str. 65, 93053, Regensburg, Germany.
| | - Sabine Schatz
- Caritas Krankenhaus St. Josef Regensburg, Klinik für Allgemein-, Viszeral, Thoraxchirurgie und Adipositasmedizin, Landshuter Str. 65, 93053, Regensburg, Germany
| | - Teresa Draeger
- Tumorzentrum Regensburg - Institut für Qualitätssicherung und Versorgungsforschung der Universität Regensburg, Am BioPark 9, 93053, Regensburg, Germany
- Caritas Krankenhaus St. Josef Regensburg, Klinik für Allgemeine Innere Medizin, Gastroenterologie und Kardiologie, Landshuter Str. 65, 93053, Regensburg, Germany
| | - Michael Gerken
- Tumorzentrum Regensburg - Institut für Qualitätssicherung und Versorgungsforschung der Universität Regensburg, Am BioPark 9, 93053, Regensburg, Germany
| | - Monika Klinkhammer-Schalke
- Tumorzentrum Regensburg - Institut für Qualitätssicherung und Versorgungsforschung der Universität Regensburg, Am BioPark 9, 93053, Regensburg, Germany
| | - Alois Fürst
- Caritas Krankenhaus St. Josef Regensburg, Klinik für Allgemein-, Viszeral, Thoraxchirurgie und Adipositasmedizin, Landshuter Str. 65, 93053, Regensburg, Germany
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Elbarmelgi MY, Basiouny H, Khalifa A. Transanal Total Mesorectal Excision for Malignant Rectal Lesion: A Prospective Cohort Study. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.7962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
AIMS: The main outcome of this study was to use the transanal total mesorectal excision (TaTME) technique for rectal cancer resection and to assess as a primary endpoint the short-term oncological outcome; in terms of circumferential resection margin, longitudinal resection margins (proximally and distally), and lymph nodes (LN) retrieval, while secondary endpoints were operative time, estimated blood loss, length of hospital stay, cost per case, and overall complication rate.
METHODS: This was a prospective cohort study. Forty patients were included and subjected to TaTME from May 2018 to January 2020 and patients were followed up for a period of 6 months.
RESULTS: Primary endpoint: Depending on the post-operative specimen pathological assessment; circumferential resection margin (CRM) was free in all patients, proximal resection margins had a mean 14.37 2.87 cm, distal resection margins had a mean 2.08 ± 0.4 cm and LNs retrieval had a mean 13.27 ± 5.9, and number of positive LNs had a mean 2.40 ± 3.77. Secondary endpoints: Mean total operative time (from induction of anesthesia till skin closure) was 179.10, estimated blood loss (using gauze visual analog plus what was obtained in the OR suction device) was 133.67 66.59 ml, the length of hospital stay (admission till discharge) was 5.27 ± 1.08 days, cost per case had a mean (in 1000 USD) 2.95 ± 0.12, and overall complication rate was 10%.
CONCLUSION: TaTME represents a promising complementary technique to laparoscopic TME in the step of low rectal dissection.
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Lawday S, Flamey N, Fowler GE, Leaning M, Dyar N, Daniels IR, Smart NJ, Hyde C. Quality of life in restorative versus non-restorative resections for rectal cancer: systematic review. BJS Open 2021; 5:6510905. [PMID: 35040944 PMCID: PMC8765336 DOI: 10.1093/bjsopen/zrab101] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 08/27/2021] [Indexed: 02/06/2023] Open
Abstract
Background Low rectal cancers could be treated using restorative (anterior resection, AR) or non-restorative procedures with an end/permanent stoma (Hartmann’s, HE; or abdominoperineal excision, APE). Although the surgical choice is determined by tumour and patient factors, quality of life (QoL) will also influence the patient's future beyond cancer. This systematic review of the literature compared postoperative QoL between the restorative and non-restorative techniques using validated measurement tools. Methods The review was registered on PROSPERO (CRD42020131492). Embase and MEDLINE, along with grey literature and trials websites, were searched comprehensively for papers published since 2012. Inclusion criteria were original research in an adult population with rectal cancer that reported QoL using a validated tool, including the European Organization for Research and Treatment of Cancer QLQ-CR30, QLQ-CR29, and QLQ-CR38. Studies were included if they compared AR with APE (or HE), independent of study design. Risk of bias was assessed using the Risk Of Bias In Non-Randomized Studies of Interventions (ROBINS-I) tool. Outcomes of interest were: QoL, pain, gastrointestinal (GI) symptoms (stool frequency, flatulence, diarrhoea and constipation), and body image. Results Nineteen studies met the inclusion criteria with a total of 6453 patients; all papers were observational and just four included preoperative evaluations. There was no identifiable difference in global QoL and pain between the two surgical techniques. Reported results regarding GI symptoms and body image documented similar findings. The ROBINS-I tool highlighted a significant risk of bias across the studies. Conclusion Currently, it is not possible to draw a firm conclusion on postoperative QoL, pain, GI symptoms, and body image following restorative or non-restorative surgery. The included studies were generally of poor quality, lacked preoperative evaluations, and showed considerable bias in the data.
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Affiliation(s)
- Samuel Lawday
- HeSRU, Royal Devon and Exeter Hospital, Exeter, UK.,Bristol Centre for Surgical Research, University of Bristol, Bristol, UK.,College of Medicine and Health, University of Exeter, Exeter, UK
| | | | - George E Fowler
- HeSRU, Royal Devon and Exeter Hospital, Exeter, UK.,Bristol Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | - Nadine Dyar
- HeSRU, Royal Devon and Exeter Hospital, Exeter, UK
| | | | - Neil J Smart
- HeSRU, Royal Devon and Exeter Hospital, Exeter, UK.,College of Medicine and Health, University of Exeter, Exeter, UK
| | - Christopher Hyde
- College of Medicine and Health, University of Exeter, Exeter, UK
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Ose I, Perdawood SK. A nationwide comparison of short-term outcomes after transanal, open, laparoscopic, and robot-assisted total mesorectal excision. Colorectal Dis 2021; 23:2671-2680. [PMID: 34273239 DOI: 10.1111/codi.15809] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 06/28/2021] [Accepted: 07/08/2021] [Indexed: 12/24/2022]
Abstract
AIM Laparoscopic rectal cancer surgery has several limitations. Transanal total mesorectal excision (TaTME) can potentially overcome these limitations. The aim of this study was to compare the rates of non-radical surgery and anastomotic leakage after TaTME, open TME (OpTME), laparoscopic TME (LaTME) and robotic TME (RoTME) procedures in a nationwide cohort. METHODS We extracted the demographic, perioperative and pathological data of patients who underwent a curative OpTME, LaTME, RoTME or TaTME procedure between January 2014 and December 2018 from the national database of the Danish Colorectal Cancer Group (DCCG). We conducted multiple group-comparisons, uni- and multivariate analyses to determine the factors associated with positive resection margin (+RM) and anastomotic leakage. RESULTS We included 2393 patients (OpTME = 205, LaTME = 1163, RoTME = 713 and TaTME = 312). The rate of +RM was 5.7% after TaTME. The lowest rate of +RM was achieved after RoTME (8.2%, 4.7%, 2.52%, and 5.7%, after OpTME, LaTME, RoTME and TaTME respectively, p < 0.001). In multivariate analysis, having a T4 tumour and intraoperative bowel perforation were associated with the risk of +RM (p < 0.001, p < 0.001, respectively). The factors associated with anastomotic leakage in multivariate analysis were male gender, high BMI and intraoperative bowel perforation (p < 0.001, p = 0.049, p = 0.002, respectively). TaTME was associated with the highest rate of sphincter-saving procedures (79.8%, p < 0.001), the lowest rate of bowel perforation (2.9%, p = 0.028) and the lowest rate of conversion to open surgery (1.3%, p < 0.001). CONCLUSIONS In a nationwide audit of TME approaches, the rate of +RM was lowest after RoTME. No differences were found between the four approaches regarding the risk of anastomotic leakage. TaTME offered advantages related to sphincter-saving, perforation and conversion.
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Affiliation(s)
- Ilze Ose
- Department of Gastrointestinal Surgery, Slagelse Hospital, Slagelse, Denmark
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12
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Oshio H, Oshima Y, Yunome G, Okazaki S, Kawamura I, Ashitomi Y, Musha H, Kawai M, Motoi F. Transanal total mesorectal excision and transabdominal robotic surgery for rectal cancer: A retrospective study. Ann Med Surg (Lond) 2021; 70:102902. [PMID: 34691436 PMCID: PMC8519803 DOI: 10.1016/j.amsu.2021.102902] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 09/28/2021] [Accepted: 09/28/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Transabdominal robotic surgery and transanal total mesorectal excision (TaTME) are newly introduced strategies for rectal cancer. These procedures might have many advantages in rectal cancer treatment in terms of improving oncological and functional outcomes, especially in cases involving advanced cancer or technical difficulty. In the present study, we aimed to clarify the advantages and disadvantages of transabdominal robotic surgery and laparoscopic TaTME as a hybrid surgery for rectal cancer. MATERIALS AND METHODS We retrospectively evaluated six patients who underwent hybrid surgery for rectal cancer from August 2018 to April 2020. Both clinical and pathological outcomes were assessed. RESULTS Two patients showed circumferential margin involvement both before and after neoadjuvant therapy. Three patients were planned to undergo hybrid surgery with intersphincteric resection because of a narrow pelvis. One patient was planned to undergo hybrid surgery for a giant tumor of >10 cm. The median length of hospitalization was 17 days. No patients required conversion to an open procedure. All patients underwent formation of defunctioning ileostomies. Two patients had a stapled anastomosis and four had a hand-sewn coloanal anastomosis. Complications included one case of anastomotic leakage, which was managed conservatively with ultrasound- and computed tomography-guided drainage and antibiotics. Histological analysis revealed that all specimens had a negative radial margin and distal margin. The median number of lymph nodes harvested was 17.5. Two patients showed extensive lymph node metastases, including lateral node metastasis. CONCLUSION Hybrid surgery was performed safely and may improve oncological outcomes for rectal cancer. This technique has many potential benefits and would be alternative option in multimodal strategies for rectal cancer.
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Affiliation(s)
- Hiroshi Oshio
- Department of Surgery I, Yamagata University Hospital, 2-2-2 Iidanishi, Yamagata, Yamagata Prefecture, 990-9585, Japan
- Department of Surgery, Sendai Medical Center, 2-11-12 Miyagino, Miyagino-ku, Sendai, Miyagi Prefecture, 983-8520, Japan
| | - Yukiko Oshima
- Department of Surgery, Sendai Medical Center, 2-11-12 Miyagino, Miyagino-ku, Sendai, Miyagi Prefecture, 983-8520, Japan
| | - Gen Yunome
- Department of Surgery, Sendai Medical Center, 2-11-12 Miyagino, Miyagino-ku, Sendai, Miyagi Prefecture, 983-8520, Japan
| | - Shinji Okazaki
- Department of Surgery I, Yamagata University Hospital, 2-2-2 Iidanishi, Yamagata, Yamagata Prefecture, 990-9585, Japan
| | - Ichiro Kawamura
- Department of Surgery I, Yamagata University Hospital, 2-2-2 Iidanishi, Yamagata, Yamagata Prefecture, 990-9585, Japan
| | - Yuya Ashitomi
- Department of Surgery I, Yamagata University Hospital, 2-2-2 Iidanishi, Yamagata, Yamagata Prefecture, 990-9585, Japan
| | - Hiroaki Musha
- Department of Surgery I, Yamagata University Hospital, 2-2-2 Iidanishi, Yamagata, Yamagata Prefecture, 990-9585, Japan
| | - Masaaki Kawai
- Department of Surgery I, Yamagata University Hospital, 2-2-2 Iidanishi, Yamagata, Yamagata Prefecture, 990-9585, Japan
| | - Fuyuhiko Motoi
- Department of Surgery I, Yamagata University Hospital, 2-2-2 Iidanishi, Yamagata, Yamagata Prefecture, 990-9585, Japan
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13
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Tokunaga T, Kashihara H, Higashijima J, Yoshikawa K, Nishi M, Takasu C, Eto S, Yoshimoto T, Shimada M. A Transabdominal Robotic Purse-String Suture Technique for Transanal Total Mesorectal Excision. J Laparoendosc Adv Surg Tech A 2021; 31:937-941. [PMID: 34242512 DOI: 10.1089/lap.2021.0286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Introduction: Transanal total mesorectal excision (TaTME) is a novel technique that overcomes the problem of access to the deep pelvis during radical surgery for mid-rectal and lower rectal cancer. Although TaTME has several important steps, the creation of the distal purse-string suture following TaTME plays an important role in ensuring the integrity of the colorectal anastomosis. However, this procedure represents a major technical challenge for the surgeon. Robot-assisted surgery may make this suturing procedure easier than laparoscopic surgery because it permits intuitive wrist movements and a three-dimensional view. The aim of the present study was to investigate the usefulness of transabdominal robotic purse-string suture during anastomosis in TaTME. Methods: Twenty-seven patients, who underwent anastomosis using a single stapling technique (SST) during the TaTME of mid-rectal or lower rectal cancer, were enrolled in the study. The patients were allocated to two groups: 11 patients underwent transabdominal robotic purse-string suturing (the Robot group) and 16 patients underwent transanal purse-string suturing (the Transanal group). The characteristics and short-term surgical outcomes of the participants were compared between the two groups. Results: The Robot group tended to have a shorter purse-string suturing time (541 ± 206 seconds versus 729 ± 310 seconds; P = .07). Regarding the shape of the "donut" after SST anastomosis, in the Transanal group, 5 of the 16 participants had incomplete donuts with muscular defects and required additional suturing, whereas in the Robot group, all the participants had complete donuts (P = .04). Conclusions: Transabdominal robotic purse-string suturing may facilitate the suturing procedure and contribute to reliable anastomosis.
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Affiliation(s)
- Takuya Tokunaga
- Department of Surgery, Institute of Health Biosciences, University of Tokushima Graduate School, Tokushima, Japan
| | - Hideya Kashihara
- Department of Surgery, Institute of Health Biosciences, University of Tokushima Graduate School, Tokushima, Japan
| | - Jun Higashijima
- Department of Surgery, Institute of Health Biosciences, University of Tokushima Graduate School, Tokushima, Japan
| | - Kozo Yoshikawa
- Department of Surgery, Institute of Health Biosciences, University of Tokushima Graduate School, Tokushima, Japan
| | - Masaaki Nishi
- Department of Surgery, Institute of Health Biosciences, University of Tokushima Graduate School, Tokushima, Japan
| | - Chie Takasu
- Department of Surgery, Institute of Health Biosciences, University of Tokushima Graduate School, Tokushima, Japan
| | - Shohei Eto
- Department of Surgery, Institute of Health Biosciences, University of Tokushima Graduate School, Tokushima, Japan
| | - Toshiaki Yoshimoto
- Department of Surgery, Institute of Health Biosciences, University of Tokushima Graduate School, Tokushima, Japan
| | - Mitsuo Shimada
- Department of Surgery, Institute of Health Biosciences, University of Tokushima Graduate School, Tokushima, Japan
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14
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Tuan NA, Duc NM, Van Hiep P, Van Sy T, Van Du N, Khuong NT. The Efficacy of Transanal Total Mesorectal Excision: a Preliminary Vietnamese Report. Med Arch 2021; 74:216-223. [PMID: 32801439 PMCID: PMC7405999 DOI: 10.5455/medarh.2020.74.216-223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Nguyen Anh Tuan
- Digestive Surgery Department, 108 Military Central Hospital, Hanoi, Vietnam
| | - Nguyen Minh Duc
- Department of Radiology, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
| | - Pham Van Hiep
- Digestive Surgery Department, 108 Military Central Hospital, Hanoi, Vietnam
| | - Than Van Sy
- Department of Radiology, Viet Duc Hospital, Hanoi, Vietnam
| | - Nguyen Van Du
- Digestive Surgery Department, 108 Military Central Hospital, Hanoi, Vietnam
| | - Ngo Tien Khuong
- Digestive Surgery Department, 108 Military Central Hospital, Hanoi, Vietnam
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15
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Robertson RL, Karimuddin A, Phang T, Raval M, Brown C. Transanal versus conventional total mesorectal excision for rectal cancer using the IDEAL framework for implementation. BJS Open 2021; 5:6246778. [PMID: 33889949 PMCID: PMC8062257 DOI: 10.1093/bjsopen/zrab002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 12/11/2020] [Accepted: 01/01/2021] [Indexed: 01/04/2023] Open
Abstract
Background Transanal total mesorectal excision (TaTME) is an innovative technique for distal rectal cancer dissection. It has been shown to have similar short-term outcomes to conventional open and laparoscopic total mesorectal excision (cTME), but recent studies have raised concern about increased morbidity and local recurrence rates. The aim of this study was to assess outcomes after TaTME versus cTME for rectal cancer. Methods TaTME was implemented in 2014 using IDEAL principles in a single institution. The institution maintains databases for all patients undergoing rectal cancer surgery. This retrospective review compared data collected from all patients who had TaTME with those from a propensity-matched cohort of patients who underwent cTME. The primary outcome was a composite pathological measure combining margin status and quality of total mesorectal excision (TME). Short-term clinical and survival outcomes were also measured. Results Propensity matching created 109 matched pairs for analysis. Nine patients (8.3 per cent) undergoing TaTME had positive margins and/or incomplete TME, compared with 11 (10.5 per cent) undergoing cTME (P = 0.65). There were no significant differences in morbidity between the TaTME and cTME groups, including number of anastomotic leaks (13.8 versus 18.3 per cent; P = 0.37). The estimated 3-year local recurrence-free survival rate was 96.3 per cent in both groups (P = 0.39). Estimated 3-year overall (93.6 per cent for TaTME versus 94.5 per cent for cTME; P = 0.09) and disease-free (88.1 versus 76.1 per cent; P = 0.90) survival rates were similar. Conclusion TaTME provided similar outcomes to cTME for rectal cancer with the application of IDEAL principles.
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Affiliation(s)
- R L Robertson
- Department of Surgery, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - A Karimuddin
- Department of Surgery, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - T Phang
- Department of Surgery, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - M Raval
- Department of Surgery, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - C Brown
- Department of Surgery, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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16
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A prospective study of health related quality of life, bowel and sexual function after TaTME and conventional laparoscopic TME for mid and low rectal cancer. Tech Coloproctol 2021; 25:449-459. [PMID: 33646454 DOI: 10.1007/s10151-020-02397-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 12/27/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND The aim of our study was to evaluate short -term (3 months) and medium-term (12 months) postoperative effects on health related quality of life (HRQoL), bowel and sexual function after transanal total mesorectal excision (TaTME) in comparison with conventional laparoscopic total mesorectal excision (TME). METHODS A prospective study was conducted on consecutive patients who had conventional laparoscopic TME and TaTME at our institution from November 2014 to December 2018.We evaluated HRQoL and bowel function using validated scales including the European Organization for Research and Treatment of Cancer Quality of Life of colorectal cancer specific module (EORTC-QLQ-CR29), International Index of Erectile Function (IIEF-5), Female Sexual Function Index (FSFI), low anterior resection syndrome (LARS) score and Wexner score. Patients were matched one-to-one through propensity score matching. Outcomes of the questionnaires at 3 and 12 months were compared. RESULTS Sixty patients were enrolled in the study. There were 30 in the conventional laparoscopic group (13 males; median age 69.3 years [range 35-80 years]) and 30 in the TaTME group (14 males; median age 75.6 years [range 42-83 years]). Three months after ileostmy closure, patients in the TaTME group had significantly more buttock pain (p = 0.030), bloating (p = 0.023), stool frequency (p = 0.013), flatulence (p < 0.001) and fecal incontinence (p = 0.044), although none of these differences persisted at 12 months. Patients in the TaTME group had a higher median overall LARS score at 3 months (p = 0.032) but there was no difference at 12 months. At 12 months after TaTME female patients had better women's sexual interest (p = 0.039) and dyspareunia scores (p < 0.001), while male patients had better erectile function (p = 0.038). Other scales did not reveal a significant difference at either 3 of 12 months between groups. CONCLUSIONS Compared with patients with mid and low rectal cancer treated with conventional laparoscopic TME, those treated with TaTME have worse HRQoL and bowel function for a short period after primary resection, but seem to have better sexual function in the long term.
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17
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López-Sánchez A, Morandeira-Rivas A, Moreno-Sanz C, Cortina-Oliva FJ, Manzanera-Díaz M, Gonzales-Aguilar JD. Long-Term Anorectal Manometry Outcomes After Laparoscopic and Transanal Total Mesorectal Excision. J Laparoendosc Adv Surg Tech A 2021; 31:395-401. [PMID: 33617729 DOI: 10.1089/lap.2020.1005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: During transanal total mesorectal excision (TaTME), sustained dilation of the anal canal occurs, which can cause anatomical and functional damage to the sphincter complex. This study aimed to analyze the impact of laparoscopic total mesorectal excision (LaTME) and TaTME in anorectal sphincter function. Materials and Methods: An observational study was conducted comparing two cohorts of patients who underwent LaTME or TaTME for rectal cancer. The two groups were paired for comparison based on age, gender, and distance of the neoplasm to the anal margin. The anorectal function was assessed by manometry before surgery and at least 6 months after primary intervention or stoma closure. The intestinal function was assessed using the low anterior resection syndrome (LARS) score. Results: Twenty-two patients were included. There were no significant differences in baseline characteristics between groups except for the time between surgery and testing. A decrease in the mean resting and squeeze pressures between pre- and postoperative manometry was observed in both the treatment groups, the difference being only significant in the squeeze pressure values (TaTME P = .003; LaTME P = .004). After surgery, squeeze pressure reduction correlated with a worsening of the LARS point count (rho 0.587; P = .004). The time elapsed since surgery was negatively correlated with the LARS point count (rho -0.696; P = .001) and the difference between pre- and postoperative mean squeeze pressures (rho -0.499; P = .018). Conclusion: Manometric findings after TME are comparable between the laparoscopic and the transanal approach. Deterioration of both anal sphincter function and LARS improves with time after surgery.
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Affiliation(s)
- Ana López-Sánchez
- Department of Surgery, La Mancha Centro General Hospital, Alcázar de San Juan, Spain
| | | | - Carlos Moreno-Sanz
- Department of Surgery, La Mancha Centro General Hospital, Alcázar de San Juan, Spain
| | | | - Marina Manzanera-Díaz
- Department of Surgery, La Mancha Centro General Hospital, Alcázar de San Juan, Spain
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18
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Zuhdy M, Metwally IH, Eldamshety O, Roshdy S. Operative Feasibility and Short-Term Oncologic Outcome of Rigid Versus Flexible Platforms in Transanal Total Mesorectal Excision. Indian J Surg Oncol 2021; 12:222-228. [PMID: 33814857 DOI: 10.1007/s13193-021-01282-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 01/27/2021] [Indexed: 10/22/2022] Open
Abstract
Several transanal platforms were used to perform transanal total mesorectal excision (TaTME). They can be classified into rigid reusable platforms or flexible single-use platforms. The choice of transanal platform usually depends on the availability and the surgeon's discretion. To the best of our knowledge, this is the first study to compare the operative and oncologic outcome of flexible and rigid platforms during TaTME. This is a retrospective cohort study in which rectal cancer patients operated by TaTME in two tertiary centers from June 2013 to April 2019 were included. They were classified into two groups according to the platform used either the rigid platform group (n = 17) or the flexible platform (n = 14). Operative feasibility and short-term oncologic data were analyzed and reported. A total number of 31 patients were divided into either the rigid platform group (n = 17) versus the flexible platform one (n = 14). Shorter operating time, less blood loss, better TME specimens, and lymph node yield were reported in the flexible platform group. Flexible platforms were associated with better operative outcomes. Although there were no differences in circumferential and distal margins between the two groups, better TME specimens' quality and lymph node yield were reported in the flexible platform group. Future prospective trials are encouraged to provide better evidence.
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Affiliation(s)
- Mohammad Zuhdy
- Surgical Oncology Unit, Oncology Center Mansoura University (OCMU), Geehan Street, Mansoura, 35516 Egypt.,Department of Gastrointestinal Surgery, IRCCS San Raffaele, University Vita e Salute, San Raffaele Hospital and San Raffaele Vita-Salute University, Via Olgettina, 60 20132 Milan, Italy
| | - Islam H Metwally
- Surgical Oncology Unit, Oncology Center Mansoura University (OCMU), Geehan Street, Mansoura, 35516 Egypt
| | - Osama Eldamshety
- Surgical Oncology Unit, Oncology Center Mansoura University (OCMU), Geehan Street, Mansoura, 35516 Egypt
| | - Sameh Roshdy
- Surgical Oncology Unit, Oncology Center Mansoura University (OCMU), Geehan Street, Mansoura, 35516 Egypt
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19
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Gardner IH, Kelley KA, Abdelmoaty WF, Sharata A, Hayman AV, Whiteford MH. Transanal total mesorectal excision outcomes for advanced rectal cancer in a complex surgical population. Surg Endosc 2021; 36:167-175. [PMID: 33416990 DOI: 10.1007/s00464-020-08251-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 12/16/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND Total mesorectal excision (TME) is the gold standard for oncologic resection in low and mid rectal cancers. However, abdominal approaches to TME can be hampered by poor visibility, inadequate retraction, and distal margin delineation. Transanal TME (taTME) is a promising hybrid technique that was developed to mitigate the difficulties of operating in the low pelvis and to optimize the circumferential resection and distal margins. METHODS The objective of this study was to characterize our experience implementing taTME at our institution in a technically challenging patient population. We performed a retrospective review of consecutive patients who underwent taTMEs between November 2013 and May 2019 for rectal cancer at a tertiary community cancer center. Outcome measures included pathologic grading of TME specimen, post-operative complications, and oncologic outcomes. RESULTS Forty-four patients with mid and low rectal cancer underwent low anterior resection via taTME. The most common staging modality was rectal MRI which demonstrated T3 or T4 tumors in 89% of our patients prior to neoadjuvant. Eighty-six percent of patients underwent neoadjuvant chemoradiation. The initial cases were performed sequentially as a single team, but we later transitioned to a synchronous, two-team approach. Ninety-one percent of TME grades were complete or near complete. Only one patient (2.3%) had a positive circumferential margin. Six patients developed anastomotic leaks with an overall anastomotic complication rate of 18.2%. Two patients (4.5%) with primary rectal cancer developed local recurrence, one of which developed multifocal local recurrence. CONCLUSIONS Using the taTME approach on selected locally advanced low rectal cancers, especially in technically complex irradiated and obese male patients, has yielded comparably safe and effective outcomes to laparoscopic proctectomy.
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Affiliation(s)
- Ivy H Gardner
- Department of Surgery, Oregon Health and Science University, Portland, USA
| | | | - Walaa F Abdelmoaty
- Department of Surgery, Oregon Health and Science University, Portland, USA
| | - Ahmed Sharata
- Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, Providence Cancer Institute, 4805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA
| | - Amanda V Hayman
- Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, Providence Cancer Institute, 4805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA
| | - Mark H Whiteford
- Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, Providence Cancer Institute, 4805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA.
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20
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Suhardja TS, Smart PJ, Heriot AG, Warrier SK. Total robotic transabdominal and transanal total mesorectal excision - a video vignette. Colorectal Dis 2020; 22:1798-1799. [PMID: 32584471 DOI: 10.1111/codi.15219] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 06/10/2020] [Indexed: 02/08/2023]
Affiliation(s)
- T S Suhardja
- Colorectal Surgery Unit, Monash Health, Dandenong Hospital, Dandenong, Victoria, Australia
| | - P J Smart
- Epworth Healthcare, Melbourne, Victoria, Australia
| | - A G Heriot
- Epworth Healthcare, Melbourne, Victoria, Australia.,Department of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - S K Warrier
- Epworth Healthcare, Melbourne, Victoria, Australia.,Department of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Colorectal Surgery, Alfred Hospital, Melbourne, Victoria, Australia
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21
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Hsieh C, Cologne KG. Laparoscopic Approach to Rectal Cancer-The New Standard? Front Oncol 2020; 10:1239. [PMID: 32850374 PMCID: PMC7412716 DOI: 10.3389/fonc.2020.01239] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 06/16/2020] [Indexed: 12/20/2022] Open
Abstract
Minimally invasive surgery has revolutionized the way surgeons perform colorectal surgery, and new technologies continually upend the way surgeons view and operate within the deep pelvis. Among other benefits, it is associated with decreased lengths of stay, wound and surgical site infections, pain scores, and has an overall lower complication rate vs. open surgery (1). Recently, however, the role of minimally invasive surgery has been called into question in the effective and safe treatment of rectal cancer. This manuscript will outline the history of minimally invasive rectal cancer surgery, examine evidence detailing its safety (compared with alternatives), and discuss important aspects of use, most notably the considerable learning curve required to achieve proficiency, the extent of its current use, and potential pitfalls. The current evidence suggests minimally invasive surgery is a very safe way to treat rectal cancer when performed by experienced and specialty trained surgeons.
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Affiliation(s)
- Christine Hsieh
- Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Kyle G Cologne
- Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
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22
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Abstract
Large cohort and collaborative studies to date have shown that the short-term oncological outcomes appear to be at least as good as traditional laparoscopic surgery. These results need confirmation in randomized controlled trials, which are currently underway (GRECCAR 11 and COLOR III). The functional data on transanal total mesorectal excision is still very scarce and more mature data on quality of life and function outcomes are eagerly awaited.
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Affiliation(s)
- Roel Hompes
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marta Penna
- Department of Colorectal Surgery, Oxford University Hospitals, Oxford, United Kingdom
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23
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Zuhdy M, Elmore U, Shams N, Hegazy MAF, Roshdy S, Eldamshety O, Metwally IH, Rosati R. Transanal Versus Laparoscopic Total Mesorectal Excision: A Comparative Prospective Clinical Trial from Two Centers. J Laparoendosc Adv Surg Tech A 2020; 30:769-776. [PMID: 32240035 DOI: 10.1089/lap.2019.0828] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Purpose: Laparoscopic total mesorectal excision (LapTME) faced many obstacles in obese male with narrow pelvis and bulky mesorectum with increased risk of incomplete mesorectal excision and positive circumferential resection margin (CRM) and distal resection margin (DRM). Transanal total mesorectal excision (TaTME) is reported to result in a better quality total mesorectal excision (TME) specimen, lower incidence of CRM and DRM involvement, and higher rates of sphincter preservation. To date, there is still a debate about the feasibility and efficacy of transanal versus the laparoscopic approach for TME in middle and low rectal cancer. Materials and Methods: This is a prospective controlled clinical trial where 38 patients of middle or low rectal cancer from two tertiary centers were nonrandomly assigned to either TaTME or LapTME. Results: Eighteen patients were operated by TaTME versus 20 patients by LapTME. Mean body mass index was significantly higher in the TaTME group (30.74 ± 7.79) than in the LapTME group (25.99 ± 4.68) (P = .03). TaTME was associated with more transanal specimen extraction (55.5% versus 20%, P = .06). No significant differences were detected in CRM, DRM, peri- or postoperative complications, or conversion rates with more reported Clavien-Dindo grade III complications in the TaTME group (P = .29). Conclusions: TaTME facilitated rectal cancer surgery in obese patients and increased the chance of transanal specimen extraction with equivalent oncological outcomes to conventional LapTME. Further studies are recommended to build better evidence.
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Affiliation(s)
- Mohammad Zuhdy
- Surgical Oncology Unit, Oncology Center Mansoura University (OCMU), Mansoura, Egypt
| | - Ugo Elmore
- Department of Gastrointestinal Surgery, IRCCS San Raffaele, University Vita e Salute, Milan, Italy
| | - Nazem Shams
- Surgical Oncology Unit, Oncology Center Mansoura University (OCMU), Mansoura, Egypt
| | - Mohamed A F Hegazy
- Surgical Oncology Unit, Oncology Center Mansoura University (OCMU), Mansoura, Egypt
| | - Sameh Roshdy
- Surgical Oncology Unit, Oncology Center Mansoura University (OCMU), Mansoura, Egypt
| | - Osama Eldamshety
- Surgical Oncology Unit, Oncology Center Mansoura University (OCMU), Mansoura, Egypt
| | - Islam H Metwally
- Surgical Oncology Unit, Oncology Center Mansoura University (OCMU), Mansoura, Egypt
| | - Riccardo Rosati
- Department of Gastrointestinal Surgery, IRCCS San Raffaele, University Vita e Salute, Milan, Italy
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Tokunaga T, Higashijima J, Yoshikawa K, Nishi M, Kashihara H, Takasu C, Shimada M. The usefulness of intraoperative X-ray fluoroscopy in avoiding urethral injury during transanal total mesorectal excision. Asian J Endosc Surg 2020; 13:242-245. [PMID: 31215751 DOI: 10.1111/ases.12717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 02/15/2019] [Accepted: 04/22/2019] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Urethral injury is one of the most important complications that can occur during transanal total mesorectal excision in male patients with rectal cancer. This report shows the usefulness of intraoperative X-ray fluoroscopy to avoid urethral injury associated with transanal total mesorectal excision. MATERIALS AND SURGICAL TECHNIQUE Real-time navigation using fluoroscopy was performed to check the distance between the urethra and the dissection line at the level of the exposed rectourethral muscle, the middle level of the divided rectourethral muscle, and the level at which the prostate was identified. DISCUSSION The dissection was completed transanally up to the level of peritoneal reflection on the anterior side without urethral injury. Pathological examination confirmed that the circumferential resection margin was tumor free. This novel technique using intraoperative X-ray fluoroscopy is an easy-to-use approach that helps prevent urethral injury in male patient who undergo transanal total mesorectal excision for rectal cancer.
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Affiliation(s)
- Takuya Tokunaga
- Department of Surgery, Tokushima University, Tokushima, Japan
| | - Jun Higashijima
- Department of Surgery, Tokushima University, Tokushima, Japan
| | - Kozo Yoshikawa
- Department of Surgery, Tokushima University, Tokushima, Japan
| | - Masaaki Nishi
- Department of Surgery, Tokushima University, Tokushima, Japan
| | | | - Chie Takasu
- Department of Surgery, Tokushima University, Tokushima, Japan
| | - Mitsuo Shimada
- Department of Surgery, Tokushima University, Tokushima, Japan
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Perdawood SK, Kroeigaard J, Eriksen M, Mortensen P. Transanal total mesorectal excision: the Slagelse experience 2013-2019. Surg Endosc 2020; 35:826-836. [PMID: 32072292 DOI: 10.1007/s00464-020-07454-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 02/11/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To describe outcomes after transanal total mesorectal excision (TaTME) 5 years from implementation at a large-volume colorectal unit, including local recurrence, distant metastasis, and survival. BACKGROUND Transanal total mesorectal excision (TaTME) is a relatively new procedure for mid- and low-rectal cancer, with well-documented safety and feasibility. However, data on long-term results are limited. METHODS This study was based on a prospective data collection via a maintained database in a large colorectal unit. The database included patients who underwent TaTME from December 2013 through July 2019. We have updated the database through a review of patient charts, including radiology and pathology reports. Data collection included operative details, intraoperative findings, postoperative complications, pathologic results, and oncologic results. RESULTS During the study period, two hundred patients underwent TaTME in the study period (men = 147). The mean BMI was 26.7%, and the mean tumor height from the anal verge was 7.86 cm. Neoadjuvant treatment was given to 22% of patients. Anastomotic leakage occurred in 9.3% of patients, and the overall rate of postoperative complications was 24.5%. The TME specimen was incomplete in 11% of patients, and the CRM was positive in 5.5% of patients. Local recurrence (LR) occurred in seven patients with a follow-up of at least 2 years (4.7%). Distant metastasis (DM) occurred in 12% of patients. The overall survival was 90% and disease-free survival was 81%. The operating time was reduced in the later period of our experience. CONCLUSIONS This study showed that TaTME is feasible, safe, and had acceptable short-term outcomes and an acceptable rate of LR. The study included, however, one group that was non-randomized, and the follow-up was not long enough for most patients. Studies with longer follow-up data are awaited.
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Affiliation(s)
- Sharaf Karim Perdawood
- Department of Gastrointestinal Surgery, Slagelse Hospital, Faelledvej 11, 4200, Slagelse, Denmark.
| | - Jens Kroeigaard
- Department of Gastrointestinal Surgery, Slagelse Hospital, Faelledvej 11, 4200, Slagelse, Denmark
| | - Marianne Eriksen
- Department of Gastrointestinal Surgery, Slagelse Hospital, Faelledvej 11, 4200, Slagelse, Denmark
| | - Pauli Mortensen
- Department of Gastrointestinal Surgery, Slagelse Hospital, Faelledvej 11, 4200, Slagelse, Denmark
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Otero-Piñeiro AM, de Lacy FB, Van Laarhoven JJ, Martín-Perez B, Valverde S, Bravo R, Lacy AM. The impact of fluorescence angiography on anastomotic leak rate following transanal total mesorectal excision for rectal cancer: a comparative study. Surg Endosc 2020; 35:754-762. [DOI: 10.1007/s00464-020-07442-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 02/10/2020] [Indexed: 02/07/2023]
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Simillis C, Lal N, Thoukididou SN, Kontovounisios C, Smith JJ, Hompes R, Adamina M, Tekkis PP. Open Versus Laparoscopic Versus Robotic Versus Transanal Mesorectal Excision for Rectal Cancer: A Systematic Review and Network Meta-analysis. Ann Surg 2020; 270:59-68. [PMID: 30720507 DOI: 10.1097/sla.0000000000003227] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To compare techniques for rectal cancer resection. SUMMARY BACKGROUND DATA Different surgical approaches exist for mesorectal excision. METHODS Systematic literature review and Bayesian network meta-analysis performed. RESULTS Twenty-nine randomized controlled trials included, reporting on 6237 participants, comparing: open versus laparoscopic versus robotic versus transanal mesorectal excision. No significant differences identified between treatments in intraoperative morbidity, conversion rate, grade III/IV morbidity, reoperation, anastomotic leak, nodes retrieved, involved distal margin, 5-year overall survival, and locoregional recurrence. Operative blood loss was less with laparoscopic surgery compared with open, and with robotic surgery compared with open and laparoscopic. Robotic operative time was longer compared with open, laparoscopic, and transanal. Laparoscopic operative time was longer compared with open. Laparoscopic surgery resulted in lower overall postoperative morbidity and fewer wound infections compared with open. Robotic surgery had fewer wound infections compared with open. Time to defecation was longer with open surgery compared with laparoscopic and robotic. Hospital stay was longer after open surgery compared with laparoscopic and robotic, and after laparoscopic surgery compared with robotic. Laparoscopic surgery resulted in more incomplete or nearly complete mesorectal excisions compared with open, and in more involved circumferential resection margins compared with transanal. Robotic surgery resulted in longer distal resection margins compared with open, laparoscopic, and transanal. CONCLUSIONS The different techniques result in comparable perioperative morbidity and long-term survival. The laparoscopic and robotic approaches may improve postoperative recovery, and the open and transanal approaches may improve oncological resection. Technique selection should be based on expected benefits by individual patient.
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Affiliation(s)
- Constantinos Simillis
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - Nikhil Lal
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Sarah N Thoukididou
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Christos Kontovounisios
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - Jason J Smith
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - Roel Hompes
- Academic Medical Center, Amsterdam, The Netherlands
| | - Michel Adamina
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Paris P Tekkis
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK
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Kolarsick PA, Sacchi M, Spinelli A, Wexner SD. Minimizing the impact of colorectal surgery in the older patient: The role of minimally invasive surgery in the geriatric population. Eur J Surg Oncol 2020; 46:333-337. [PMID: 31926606 DOI: 10.1016/j.ejso.2019.12.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 09/24/2019] [Accepted: 12/19/2019] [Indexed: 11/18/2022] Open
Abstract
With an aging population comes a greater incidence of colorectal cancer and a corresponding need for surgical resection in the geriatric population. This heterogeneous group of patients may benefit from multidisciplinary pre-operative evaluation and optimization, prehabilitation, enhanced recovery protocols, and a minimally invasive approach to resection. Concerns regarding the ability of the older patient to tolerate the physiologic demands of pneumoperitoneum have not been validated. Conversely, these vulnerable patients may experience a greater reduction in morbidity than their younger counterparts through the use of minimally invasive techniques.
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Affiliation(s)
- Paul A Kolarsick
- Cleveland Clinic Florida, Department of Colorectal Surgery, Weston, FL, USA
| | - Matteo Sacchi
- Colon and Rectal Surgery, Humanitas Research Hospital, Humanitas University, Rozzano, Milano, Italy
| | - Antonino Spinelli
- Colon and Rectal Surgery, Humanitas Research Hospital, Humanitas University, Rozzano, Milano, Italy
| | - Steven D Wexner
- Cleveland Clinic Florida, Department of Colorectal Surgery, Weston, FL, USA.
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Transanal Minimally Invasive Surgical Management of Persisting Pelvic Sepsis or Chronic Sinus After Low Anterior Resection. Dis Colon Rectum 2019; 62:1458-1466. [PMID: 31567923 DOI: 10.1097/dcr.0000000000001483] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Redo surgery of persisting pelvic sepsis or chronic presacral sinus after low anterior resection for rectal cancer is challenging. Transanal minimally invasive surgery improves visibility and accessibility of the deep pelvis. OBJECTIVE The aim of this study was to compare the conventional approach with transanal minimally invasive surgery for redo pelvic surgery with or without anastomotic reconstruction. DESIGN This is a retrospective cohort study. SETTINGS This study was conducted in a tertiary referral center. PATIENTS All consecutive patients undergoing redo pelvic surgery after low anterior resection for rectal cancer between January 2005 and March 2018 were included. INTERVENTIONS Redo surgery was divided into redo anastomosis and intersphincteric completion proctectomy. Transanal minimally invasive surgery procedures since November 2014 were compared with the conventional approach. MAIN OUTCOME MEASURES Primary end points were procedural characteristics and 90-day major complications. RESULTS In total, 104 patients underwent redo surgery; 47 received a redo anastomosis (18 conventional and 29 transanal minimally invasive surgery) and 57 underwent intersphincteric completion proctectomy (35 conventional and 22 transanal minimally invasive surgery). The transabdominal part of the transanal minimally invasive surgery procedures was performed laparoscopically in 72% and 59% of redo anastomosis and intersphincteric completion proctectomy, compared with 6% and 34% in the conventional group (p < 0.001 and p = 0.100). The 90-day major complication rate was 33% and 45% after redo anastomosis (p=0.546) and 29% and 41% after intersphincteric completion proctectomy (p=0.349) in conventional surgery and transanal minimally invasive surgery. LIMITATIONS A limitation of this study is the relatively small sample size. CONCLUSIONS This study suggests that transanal minimally invasive surgery is a valid alternative to conventional top-down redo pelvic surgery for persisting pelvic sepsis or chronic sinus, with more often a laparoscopic approach for the abdominal part. See Video Abstract at http://links.lww.com/DCR/B87. MANEJO QUIRÚRGICO TRANSANAL MÍNIMAMENTE INVASIVO DE LA SEPSIS PÉLVICA PERSISTENTE O DE UN SENO CRÓNICO DESPUÉS DE RESECCIÓN ANTERIOR BAJA: La cirugía de reoperación por sepsis pélvica persistente o un seno presacro crónico después de una resección anterior baja por cáncer de recto es un desafío. La cirugía transanal mínimamente invasiva mejora la visibilidad y la accesibilidad a la región profunda de la pelvis.El objetivo de este estudio fue comparar el abordaje convencional con la cirugía transanal mínimamente invasiva para cirugía pélvica de reoperación con o sin reconstrucción anastomótica.Este es un estudio de cohorte retrospectiva.Este estudio se realizó en un centro de referencia terciario.Se incluyeron todos los pacientes consecutivos que se sometieron a una cirugía pélvica de reoperación después de una resección anterior baja por cáncer de recto entre enero de 2005 y marzo de 2018.La cirugía de reoperación se dividió en reconstrucción de anastomosis y proctectomía interesfintérica. Los procedimientos de cirugía transanal mínimamente invasiva desde noviembre de 2014 se compararon con el abordaje convencional.Los puntos primarios fueron las características del procedimiento y las complicaciones mayores a 90 días.En total, 104 pacientes fueron sometidos a cirugía de reoperación; 47 recibieron una reconstrucción de anastomosis (18 abordaje convencional y 29 cirugía transanal mínimamente invasiva) y 57 se sometieron a una proctectomía interesfintérica (35 abordaje convencional y 22 cirugía transanal mínimamente invasiva). La parte transabdominal de los procedimientos de cirugía transanal mínimamente invasiva se realizó por vía laparoscópica en el 72% y el 59% de las reconstrucciones de anastomosis y las proctectomías interesfintéricas, respectivamente, en comparación con el 6% y el 34%, respectivamente, en el grupo convencional (p <0.001 y p = 0.100). La tasa de complicaciones mayores a los 90 días fue del 33% y del 45% después de la anastomosis de reconstrucción (p = 0.546) y del 29% y 41% después de la proctectomía interesfintérica (p = 0.349) en cirugía convencional y cirugía transanal mínimamente invasiva, respectivamente.La limitación de este estudio es el tamaño relativamente pequeño de la muestra.Este estudio sugiere que la cirugía transanal mínimamente invasiva es una alternativa válida para la cirugía pélvica de reoperación convencional en sepsis pélvica persistente o seno crónico, con un abordaje laparoscópico utilizado más frecuentemente para la parte abdominal. Vea el Abstract del video en http://links.lww.com/DCR/B87.
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Thien HH, Hiep PN, Thanh PH, Xuan NT, Trung TN, Vy PT, Dong PX, Hieu MT, Son NH. Transanal total mesorectal excision for locally advanced middle-low rectal cancers. BJS Open 2019; 4:268-273. [PMID: 32207572 PMCID: PMC7093787 DOI: 10.1002/bjs5.50234] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 09/22/2019] [Accepted: 09/30/2019] [Indexed: 12/13/2022] Open
Abstract
Background This study investigated the results of transanal total mesorectal excision (TaTME) combined with laparoscopy for locally advanced mid–low rectal cancer. Methods Patients with mid–low locally advanced rectal cancer (T3 category or above and/or N+) who underwent rectal resection with TaTME technique were enrolled prospectively. Patients who had distant metastasis, multiple malignancies, intestinal obstruction or perforation, or a clinical complete response to chemoradiotherapy were excluded. Postoperative results, including morbidity, circumferential resection margin (CRM) assessment, short‐term survival and functional outcomes, were analysed. Results Thirty‐eight patients, with 25 mid and 13 low rectal tumours, who had elective resection by TaTME from March 2015 to September 2018 were included. There were 25 men and 13 women. Mean(s.d.) age was 58·2(16·4) years and mean(s.d.) BMI was 24·2(2·5) kg/m2. Tumours were 3–9 cm from the anal verge. Mean(s.d.) duration of surgery was 210(42) min. All patients had hand‐sewn anastomoses and protective ileostomies. There were no conversions, abdominal perineal resections or postoperative deaths. Four patients had a complication, including three presacral abscesses, all managed by transanastomotic drainage. At 3 months after ileostomy closure, all patients had perfect continence. Apart from a greater tumour diameter in patients with low rectal cancers (6·0 cm versus 4·6 cm in those with mid rectal tumours; P = 0·035), clinical features were similar in the two groups. CRM positivity was greater for low than for mid rectal tumours (3 of 13 versus 0 of 25 respectively; P = 0·034), and more patients with a low tumour had TME grade 2 (4 of 13 versus 1 of 25; P = 0·038). There was no difference in oncological outcomes at 17 months. Conclusion Although this study cohort was small, special attention should be paid to bulky low rectal tumours to reduce the rate of CRM positivity.
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Affiliation(s)
- H. H. Thien
- Department of Paediatric and Abdominal Emergency SurgeryHue Central HospitalHue CityVietnam
| | - P. N. Hiep
- Department of Paediatric and Abdominal Emergency SurgeryHue Central HospitalHue CityVietnam
| | - P. H. Thanh
- Department of Paediatric and Abdominal Emergency SurgeryHue Central HospitalHue CityVietnam
| | - N. T. Xuan
- Department of Paediatric and Abdominal Emergency SurgeryHue Central HospitalHue CityVietnam
| | - T. N. Trung
- Department of Paediatric and Abdominal Emergency SurgeryHue Central HospitalHue CityVietnam
| | - P. T. Vy
- Department of Paediatric and Abdominal Emergency SurgeryHue Central HospitalHue CityVietnam
| | - P. X. Dong
- Department of Paediatric and Abdominal Emergency SurgeryHue Central HospitalHue CityVietnam
| | - M. T. Hieu
- Department of Paediatric and Abdominal Emergency SurgeryHue Central HospitalHue CityVietnam
| | - N. H. Son
- Paediatric CentreHue Central HospitalHue CityVietnam
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Nikolic A, Waters PS, Peacock O, Choi CCM, Rajkomar A, Heriot AG, Smart P, Warrier S. Hybrid abdominal robotic approach with conventional transanal total mesorectal excision (TaTME) for rectal cancer: feasibility and outcomes from a single institution. J Robot Surg 2019; 14:633-641. [PMID: 31625075 DOI: 10.1007/s11701-019-01032-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 09/05/2019] [Indexed: 12/11/2022]
Abstract
Total mesorectal excision (TME) is currently recognised as the standard of care for patients with rectal cancer. Complete TME is known to be associated with lower rates of recurrence. Robotic and endoscopic TaTME approaches are reported to offer excellent proximal and distal rectal dissection into the TME plane, however, combining both approaches in a hybrid procedure could potentially optimise visualisation of the dissection plane and confer improved circumferential and distal margin rates. The aim of this study was to analyse the feasibility of a hybrid robotic abdominal approach with conventional TaTME for rectal cancer. Furthermore, pathological and patient outcomes were assessed. A review of prospectively maintained databases was undertaken to assess all patients undergoing robotic TME surgery for rectal tumours from August 2016 to October 2017. Patient demographics, tumour characteristics and outcomes were collated from patient charts and hospital databases. All patients underwent a modified Cecil approach after multidisciplinary team discussion. Eight patients (7 male, 1 female) underwent a combined hybrid approach with a median age of 60 years (range 47-73) and BMI of 29.5 (range 20-39.1) kg/m2. Median distance from the anorectal junction (ARJ) was 7.5 (range 4-13) cm. Six patients underwent neoadjuvant treatment with chemoradiotherapy. Patients had a median length of stay (LOS) of 9 (range 4-33) days. There were no intra-operative complications encountered and no patients required a conversion to an open procedure. Complications included one anastomotic leak and one presacral collection. All patients had a complete TME with RO resection with a median number of lymph nodes harvested was 22 (range 6-37) lymph nodes. This hybrid technique is a feasible, practical and operatively favourable approach to rectal cancer surgery with initial pathological outcomes and complication profile equivalent to other approaches.
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Affiliation(s)
- Amanda Nikolic
- General Surgery and Gastroenterology Clinical Institute, Epworth Healthcare, Richmond, Australia.,Department of Surgery, The Surgery Centre, Austin Health, 145 Studley Road, Heidelberg, Melbourne, VIC, 3084, Australia
| | - Peadar S Waters
- General Surgery and Gastroenterology Clinical Institute, Epworth Healthcare, Richmond, Australia.,Colorectal Surgery Unit, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC, 3000, Australia
| | - Oliver Peacock
- General Surgery and Gastroenterology Clinical Institute, Epworth Healthcare, Richmond, Australia.,Colorectal Surgery Unit, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC, 3000, Australia
| | - Colin Chan-Min Choi
- General Surgery and Gastroenterology Clinical Institute, Epworth Healthcare, Richmond, Australia
| | - Amrish Rajkomar
- General Surgery and Gastroenterology Clinical Institute, Epworth Healthcare, Richmond, Australia
| | - Alexander G Heriot
- General Surgery and Gastroenterology Clinical Institute, Epworth Healthcare, Richmond, Australia.,Colorectal Surgery Unit, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC, 3000, Australia.,The Alfred Hospital, 55 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Philip Smart
- General Surgery and Gastroenterology Clinical Institute, Epworth Healthcare, Richmond, Australia.,Department of Surgery, The Surgery Centre, Austin Health, 145 Studley Road, Heidelberg, Melbourne, VIC, 3084, Australia.,Department of Surgery, Eastern Health, 5 Arnold Street, Box Hill, Melbourne, VIC, 3128, Australia
| | - Satish Warrier
- General Surgery and Gastroenterology Clinical Institute, Epworth Healthcare, Richmond, Australia. .,Colorectal Surgery Unit, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC, 3000, Australia. .,The Alfred Hospital, 55 Commercial Road, Melbourne, VIC, 3004, Australia.
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Lee JM, Han YD, Cho MS, Hur H, Min BS, Lee KY, Kim NK. Prediction of transabdominal total mesorectal excision difficulty according to the angle of pelvic floor muscle. Surg Endosc 2019; 34:3043-3050. [PMID: 31482361 DOI: 10.1007/s00464-019-07102-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 08/21/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND Total mesorectal excision (TME) is challenging to perform in a deep, narrow pelvis. While previous studies used pelvimetry to assess bony pelvic structures, there is no consensus on exact definition of deep, narrow pelvis. We hypothesized that the shape of pelvic floor muscle may impact the performance of transabdominal pelvic dissection. We aimed to evaluate which parameters of the shape of pelvic floor muscle impact the difficulty of TME and present a predictive reference value for TME difficulty. METHODS From January 2015 to December 2015, 85 consecutive patients who had undergone curative resection for middle to lower rectal cancer were retrospectively studied. Pelvimetry was performed using preoperative T2-weighted magnetic resonance imaging. Predictive factor analysis for surgical duration was studied using linear regression. Mann-Whitney U test, comparing surgical duration between two groups classified by predictive factor, was used for the analysis of reference value. RESULTS Multivariate analysis revealed that body mass index, protective stoma, number of surgeon, and incline angle of pelvic floor muscle (β) were independent predictors of surgical duration. Test statistics of Mann-Whitney U for the difference in surgical duration between groups above and below a β of 54° were maximized. CONCLUSIONS The incline angle of pelvic floor muscle is an independent predictor of surgical duration. In patients with steeper incline of PFM, transabdominal TME is expected to be difficult. This index is novel, but needs to be further validated.
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Affiliation(s)
- Jong Min Lee
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, South Korea
| | - Yoon Dae Han
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, South Korea
| | - Min Soo Cho
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, South Korea
| | - Hyuk Hur
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, South Korea
| | - Byung Soh Min
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, South Korea
| | - Kang Young Lee
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, South Korea
| | - Nam Kyu Kim
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, South Korea.
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Holmer C, Benz S, Fichtner-Feigl S, Jehle EC, Kienle P, Post S, Schiedeck T, Weitz J, Kreis ME. [Transanal total mesorectal excision-a critical appraisal]. Chirurg 2019; 90:478-486. [PMID: 30911795 DOI: 10.1007/s00104-019-0945-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Total mesorectal excision (TME) is the international standard for rectal cancer surgery. In addition to laparoscopic TME (lapTME), transanal TME (taTME) was developed in recent years to reduce the rate of incomplete TME, conversion to open surgery and postoperative functional impairment. Despite limited evidence, this technique is becoming increasingly more popular and is already routinely used by many hospitals for rectal cancer in varying tumor level locations. The aim of this review was to evaluate the taTME compared to anterior rectal resection with lapTME as the standard of care in rectal cancer surgery based on currently available evidence. METHOD The databases PubMed and Medline were systematically searched for publications on transanal total mesorectal excision (taTME) and transanal minimally invasive surgery (TAMIS). Relevant studies were selected and further research based on the reference lists was undertaken. RESULTS A total of 16 studies analyzing 3782 patients were identified. The taTME does not lead to a higher rate of complete TME-resected specimens compared to the standard procedure. So far, superiority could not be demonstrated for complication rates or for functional or oncological results. Serious complications secondary to dissection in incorrect planes were observed. The anastomotic level generally seems to be closer to the sphincter after taTME versus anterior lapTME. CONCLUSION Considering current evidence, taTME failed to show superiority compared to conventional anterior lapTME. Although taTME has some potential advantages, it carries substantial risks. If performed outside of clinical trials, it should therefore only be used in carefully selected patients with a high possibility of conversion, following adequate patient informed consent and after intense and systematic training of the surgeon.
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Affiliation(s)
- C Holmer
- Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Hindenburgdamm 30, 12200, Berlin, Deutschland
| | - S Benz
- Klinikum Sindelfingen-Böblingen, Klinik für Allgemein‑, Viszeral- und Kinderchirurgie, Klinikverbund Südwest, Böblingen, Deutschland
| | - S Fichtner-Feigl
- Klinik für Allgemein- und Viszeralchirurgie, Department Chirurgie, Universitätsklinikum Freiburg, Freiburg, Deutschland
| | - E C Jehle
- Klinik für Allgemein- und Viszeralchirurgie, St. Elisabethen-Klinikum, Ravensburg, Deutschland
| | - P Kienle
- Klinik für Allgemein- und Viszeralchirurgie, Theresienkrankenhaus, Mannheim, Deutschland
| | - S Post
- Chirurgische Klinik, Universitätsklinikum Mannheim, Mannheim, Deutschland
| | - T Schiedeck
- Klinik für Allgemein- und Viszeralchirurgie, Klinikum Ludwigsburg, Ludwigsburg, Deutschland
| | - J Weitz
- Klinik und Poliklinik für Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus der TU Dresden, Dresden, Deutschland
| | - M E Kreis
- Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Hindenburgdamm 30, 12200, Berlin, Deutschland.
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Comment on “Distal Resection Margin Status in Transanal Total Mesorectal Excision (TA-TME)”. Ann Surg 2019; 270:e34-e35. [DOI: 10.1097/sla.0000000000003069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Affiliation(s)
- Amy L Lightner
- Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Sparreboom CL, Komen N, Rizopoulos D, van Westreenen HL, Doornebosch PG, Dekker JWT, Menon AG, Tuynman JB, Daams F, Lips D, van Grevenstein WMU, Karsten TM, Lange JF, D'Hoore A, Wolthuis AM. Transanal total mesorectal excision: how are we doing so far? Colorectal Dis 2019; 21:767-774. [PMID: 30844130 PMCID: PMC6850385 DOI: 10.1111/codi.14601] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 02/25/2019] [Indexed: 12/11/2022]
Abstract
AIM This subgroup analysis of a prospective multicentre cohort study aims to compare postoperative morbidity between transanal total mesorectal excision (TaTME) and laparoscopic total mesorectal excision (LaTME). METHOD The study was designed as a subgroup analysis of a prospective multicentre cohort study. Patients undergoing TaTME or LaTME for rectal cancer were selected. All patients were followed up until the first visit to the outpatient clinic after hospital discharge. Postoperative complications were classified according to the Clavien-Dindo classification and the comprehensive complication index (CCI). Propensity score matching was performed. RESULTS In total, 220 patients were selected from the overall prospective multicentre cohort study. After propensity score matching, 48 patients from each group were compared. The median tumour height for TaTME was 10.0 cm (6.0-10.8) and for LaTME was 9.5 cm (7.0-12.0) (P = 0.459). The duration of surgery and anaesthesia were both significantly longer for TaTME (221 vs 180 min, P < 0.001, and 264 vs 217 min, P < 0.001). TaTME was not converted to laparotomy whilst surgery in five patients undergoing LaTME was converted to laparotomy (0.0% vs 10.4%, P = 0.056). No statistically significant differences were observed for Clavien-Dindo classification, CCI, readmissions, reoperations and mortality. CONCLUSION The study showed that TaTME is a safe and feasible approach for rectal cancer resection. This new technique obtained similar postoperative morbidity to LaTME.
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Affiliation(s)
- C. L. Sparreboom
- Department of SurgeryErasmus University Medical CenterRotterdamThe Netherlands
| | - N. Komen
- Department of SurgeryUniversity Hospital AntwerpEdegemBelgium
| | - D. Rizopoulos
- Department of BiostatisticsErasmus University Medical CenterRotterdamThe Netherlands
| | | | - P. G. Doornebosch
- Department of SurgeryIJsselland ZiekenhuisCapelle aan den IJsselThe Netherlands
| | - J. W. T. Dekker
- Department of SurgeryReinier de Graaf GasthuisDelftThe Netherlands
| | - A. G. Menon
- Department of SurgeryIJsselland ZiekenhuisCapelle aan den IJsselThe Netherlands
| | - J. B. Tuynman
- Department of SurgeryVU University Medical CenterAmsterdamThe Netherlands
| | - F. Daams
- Department of SurgeryVU University Medical CenterAmsterdamThe Netherlands
| | - D. Lips
- Department of SurgeryJeroen Bosch ZiekenhuisHertogenboschThe Netherlands
| | | | - T. M. Karsten
- Department of SurgeryOnze Lieve Vrouwe GasthuisAmsterdamThe Netherlands
| | - J. F. Lange
- Department of SurgeryErasmus University Medical CenterRotterdamThe Netherlands
| | - A. D'Hoore
- Departmenf of Abdominal SurgeryUniversity Hospital LeuvenLeuvenBelgium
| | - A. M. Wolthuis
- Departmenf of Abdominal SurgeryUniversity Hospital LeuvenLeuvenBelgium
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Short-term postoperative outcomes following robotic versus laparoscopic ileal pouch-anal anastomosis are equivalent. Tech Coloproctol 2019; 23:259-266. [PMID: 30941619 DOI: 10.1007/s10151-019-01953-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 02/17/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Minimally invasive approaches have become the standard of care for ileal pouch-anal anastomoses (IPAA). There are few reports comparing outcomes following a laparoscopic versus robotic approach. Our aim was to determine if there were any differences in the 30-day postoperative outcomes following IPAA performed laparoscopically versus robotically. METHODS A retrospective chart review of all laparoscopic and robotic IPAA performed between January 1, 2015 and June 30, 2018 was carried out. Patients included were adult patients who underwent a proctectomy and IPAA utilizing either a laparoscopic or robotic approach. Data collected included patient demographics, operative variables, and 30-day postoperative outcomes. RESULTS A total of 132 patients had a minimally invasive IPAA; 58 were performed laparoscopically and 74 robotically. Less than half the patients were female (n = 55; 41.7%) with a median age of 37 years (range 18-68 years). The majority of patients had a diagnosis of ulcerative colitis (n = 103; 78.0%) with medically refractory disease (n = 87; 65.9%). A greater proportion of patients in the laparoscopic cohort had a prolonged length of stay (n = 27; 46.6% versus n = 18; 24.3%; p < 0.001) and a two-stage approach (n = 56; 96.6% versus n = 37; 50%; p < 0.001), but there were no differences in the rates between the laparoscopic versus robotic cohorts of superficial surgical site infection (6.9% versus 6.8%; p = 0.99), peripouch abscess (15.5% versus 6.8%; p = 0.11), anastomotic leak (6.9% versus 2.7%; p = 0.21), pelvic abscess (15.5% versus 6.8%; p = 0.11), and pelvic sepsis (15.5% versus 6.8%; p = 0.11), readmission (24.1% versus 17.6%; p = 0.35) or reoperation (6.9% versus 5.4%; p = 0.72). On multivariable analysis, only male sex remained predictive of prolonged length of stay, and a robotic approach trended toward a decreased rate of prolonged length of stay. CONCLUSIONS Laparoscopic and robotic IPAA have equivalent postoperative morbidity underscoring the safety of the continued expansion of the robotic platform for pouch surgery.
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Gustafsson UO, Scott MJ, Hubner M, Nygren J, Demartines N, Francis N, Rockall TA, Young-Fadok TM, Hill AG, Soop M, de Boer HD, Urman RD, Chang GJ, Fichera A, Kessler H, Grass F, Whang EE, Fawcett WJ, Carli F, Lobo DN, Rollins KE, Balfour A, Baldini G, Riedel B, Ljungqvist O. Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS ®) Society Recommendations: 2018. World J Surg 2019; 43:659-695. [PMID: 30426190 DOI: 10.1007/s00268-018-4844-y] [Citation(s) in RCA: 1171] [Impact Index Per Article: 195.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol. METHODS A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. RESULTS All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly. CONCLUSIONS The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.
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Affiliation(s)
- U O Gustafsson
- Department of Surgery, Danderyd Hospital and Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
| | - M J Scott
- Department of Anesthesia, Virginia Commonwealth University Hospital, Richmond, VA, USA
- Department of Anesthesiology, University of Pennsylvania, Philadelphia, USA
| | - M Hubner
- Department of Visceral Surgery, CHUV, Lausanne, Switzerland
| | - J Nygren
- Department of Surgery, Ersta Hospital and Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - N Demartines
- Department of Visceral Surgery, CHUV, Lausanne, Switzerland
| | - N Francis
- Colorectal Unit, Yeovil District Hospital, Higher Kingston, Yeovil, BA21 4AT, UK
- University of Bath, Wessex House Bath, BA2 7JU, UK
| | - T A Rockall
- Department of Surgery, Royal Surrey County Hospital NHS Trust, and Minimal Access Therapy Training Unit (MATTU), Guildford, UK
| | - T M Young-Fadok
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - A G Hill
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland Middlemore Hospital, Auckland, New Zealand
| | - M Soop
- Irving National Intestinal Failure Unit, The University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - H D de Boer
- Department of Anesthesiology, Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital, Groningen, The Netherlands
| | - R D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - G J Chang
- Department of Surgical Oncology and Department of Health Services Research, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - A Fichera
- Division of Gastrointestinal Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - H Kessler
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Ohio, USA
| | - F Grass
- Department of Visceral Surgery, CHUV, Lausanne, Switzerland
| | - E E Whang
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - W J Fawcett
- Department of Anaesthesia, Royal Surrey County Hospital NHS Foundation Trust and University of Surrey, Guildford, UK
| | - F Carli
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, QC, Canada
| | - D N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - K E Rollins
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - A Balfour
- Department of Colorectal Surgery, Surgical Services, Western General Hospital, NHS Lothian, Edinburgh, UK
| | - G Baldini
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, QC, Canada
| | - B Riedel
- Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Australia
| | - O Ljungqvist
- Department of Surgery, Örebro University and University Hospital, Örebro & Institute of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Abstract
INTRODUCTION Obesity is a burgeoning problem worldwide. Although beneficial in obese patients, conventional laparoscopic mesorectal excision for rectal cancer is technically challenging, with a higher conversion rate to open compared with nonobese patients. We describe novel strategies to circumvent these difficulties. TECHNIQUE The key steps are 1) lateral-to-medial colonic mobilization and left-sided mesorectal excision with the surgeon on the patient's right; 2) switching to the patient's left for right-sided mesorectal excision; 3) further rectal retraction with cotton tape and preperitoneal fat sling; and 4) caudal-to-cephalad mobilization of colon after distal transection, which facilitates extrapelvic mesenteric dissection and vessel ligation. RESULTS These techniques optimize gravity to negate the lack of exposure due to visceral obesity. Triangulation is improved by changing the surgeon's position during mesorectal dissection. This allows accurate identification of anatomical planes and avoids excessive pneumoperitoneum pressures and Trendelenburg tilt. CONCLUSIONS Adopting these strategies can facilitate laparoscopic mesorectal excision in the obese patient and may reduce conversion to open.
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Vignali A, Elmore U, Milone M, Rosati R. Transanal total mesorectal excision (TaTME): current status and future perspectives. Updates Surg 2019; 71:29-37. [PMID: 30734896 DOI: 10.1007/s13304-019-00630-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 02/02/2019] [Indexed: 12/14/2022]
Abstract
Total mesorectal excision (TME) is the gold standard surgical treatment for mid- and low rectal cancer; however, it is associated with specific technical hurdles. Transanal TME (TaTME) is a new procedure developed to overcome these difficulties, through an enhanced visualization of the dissection plane. This potentially could result in a more accurate distal dissection with a lower rate of positive circumferential resection margins, increasing the rate of sphincter-saving procedures. The indications for TaTME are currently expanding, despite not being yet standardized, and structured training programs are ongoing to help overcome the steep learning curve related to the technique. The procedure is feasible and safe with similar intraoperative complications and readmission rates when compared with conventional open or laparoscopic TME. Favorable short-term oncologic results have been reported: in particular, TaTME is associated with mesorectal specimen of a better quality and a longer distal resection margin that is established at the beginning of the procedure under direct view. Robotics, when available, will probably overcome the steep learning curve related to the complexity of TaTME. Long-term follow-up and ongoing RCT trials data are awaited regarding functional results, local recurrence and survival, and to facilitate the comparison with standard laparoscopic or robotic rectal resections. The present review is focused on critically analyzing the theoretical benefits and risks of the procedure, its indications, short- and long-term results and future direction in the application of TaTME.
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Affiliation(s)
- Andrea Vignali
- Department of Surgery, San Raffaele Hospital and San Raffaele Vita-Salute University, Via Olgettina 60, 20123, Milan, Italy.
| | - Ugo Elmore
- Department of Surgery, San Raffaele Hospital and San Raffaele Vita-Salute University, Via Olgettina 60, 20123, Milan, Italy
| | - Marco Milone
- Department of Surgical Specialties, Nephrology University "Federico II" of Naples, Naples, Italy
| | - Riccardo Rosati
- Department of Surgery, San Raffaele Hospital and San Raffaele Vita-Salute University, Via Olgettina 60, 20123, Milan, Italy
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Mikalauskas S, Uselis S, Jurkeviciutė D, Poskus T, Poskus E, Strupas K. Transanal Total Mesorectal Excision: Is There a Real Advantage? The Baltic View. Visc Med 2019; 35:145-150. [PMID: 31367610 DOI: 10.1159/000495309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background The novel surgical procedure transanal total mesorectal excision (taTME) has rapidly become an interest of research in order to overcome the shortcomings of laparoscopic surgery in the treatment of middle and low rectal cancer. taTME is a new natural orifice transluminal endoscopic surgery modality combining three rectal surgery techniques. Methods A retrospective clinical study was conducted in a single centre for a period of 3 years, and herein we report on our first 25 taTME procedures in patients with middle and lower third rectal adenocarcinoma. Results The main demographics were evaluated. The mean age of patients was 64 ± 12 years. There were predominantly males (72%) and 7 female patients (28%) with an average body mass index of 29 ± 4.8 kg/m<sup>2</sup>. High blood pressure, obesity, chronic heart insufficiency, chronic atrial fibrillation, and diabetes mellitus were commonly diagnosed in all patients. A circumferential resection margin >1 mm was achieved in 16% (n = 4), >2 mm in 40% (n = 10), and >3 mm in 44% (n = 11) of operated patients. The average CRM was 1.8 ± 0.9 cm. In 24% of cases, the distance of a tumour from the mesorectal fascia (MRF) was <1 mm; meanwhile, for 76% of patients, the tumour margin was >1 mm from the MRF. Recovery to flatus was 3 ± 1 days. The average length of hospital stay was 11 ± 3 days. The overall postoperative morbidity was 8%, i.e. one (4%) complication classified as Clavien-Dindo degree I and one (4%) major (IIIb) complication. Subsequently, all patients successfully recovered and were discharged from hospital. During the follow-up period no cancer recurrence was observed. Conclusion Our results nicely demonstrate that taTME can be safely performed with acceptable perioperative complications in patients with middle or lower third rectal cancer. In addition, the perioperative morbidity is also acceptable. However, taTME remains a technically highly demanding operation but is feasible and safe after the appropriate experience is gained. Nevertheless, larger multi-centre prospective randomised studies are ongoing to confirm the safety and to verify oncological results when compared to laparoscopic rectal surgery.
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Affiliation(s)
- Saulius Mikalauskas
- Center of Abdominal Surgery, Vilnius University.,Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | | | | | - Tomas Poskus
- Center of Abdominal Surgery, Vilnius University.,Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Eligijus Poskus
- Center of Abdominal Surgery, Vilnius University.,Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Kestutis Strupas
- Center of Abdominal Surgery, Vilnius University.,Faculty of Medicine, Vilnius University, Vilnius, Lithuania
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Caycedo-Marulanda A, Jiang HY, Kohtakangas EL. Outcomes of a Single Surgeon-Based Transanal-Total Mesorectal Excision (TATME) for Rectal Cancer. J Gastrointest Cancer 2019; 49:455-462. [PMID: 28702861 DOI: 10.1007/s12029-017-9989-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Several studies have shown the transanal total mesorectal excision (TATME) is emerging as a safe and effective technique for proctectomy. The majority of these studies to date, however, is based on procedures done in centers with teams of two surgeons working simultaneously. Few were performed by single-surgeon teams with sizeable case load. The objective of our study was to identify the feasibility and safety of a single-surgeon TATME. METHODS Chart review of prospectively collected data on 27 patients who underwent TATME at our institution from June 2015 to September 2016 were included in this study. Indications for TATME included mid and low rectal cancers. Only patients who underwent surgery for neoplastic lesions were included in the study. Outcomes assessed included mesorectal integrity, margin status, operative time, complications, morbidity, LOS, and 30-day readmission. RESULTS A total of 27 cases were available for inclusion. A single surgeon performed all procedures. The average BMI was 27.2 ± 1.3 kg/m2. The average tumor distance from anal verge was 6.8 ± 0.6 cm. The median operative time was 283 min. No intraoperative complications, including injuries and conversions, occurred. Circumferential resection margin (CRM) and distal resection margin (DRM) were R0 in 96 and 100% of patients, respectively. Mesorectal integrity was "Complete" in 67% and "Near complete" in 33% of patients. There were no incomplete specimens. The total lymph node (LN) harvest was 26 ± 2. The average LOS was 4 days for 75% of all patients. There were no mortalities. The overall morbidity was 33% (9/27). There were 4/27 anastomotic leaks, one required a laparoscopic ileostomy, one had laparoscopic drainage of an abscess, and the other two were endoscopically washed and trans-rectal drains inserted. CONCLUSION TATME performed by a one-surgeon team is oncologically adequate, and it is safe and feasible. Morbidities are comparable with existing literature data from two-surgeon teams. In addition, resection margins, mesorectal integrity, and LN harvests are also comparable or superior to some of the existing studies.
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Affiliation(s)
- Antonio Caycedo-Marulanda
- Department of Surgery, Health Sciences North, Sudbury, ON, Canada.
- Faculty of Medicine, Northern Ontario School of Medicine, 410-65 Larch Street, Sudbury, ON, P3E1B8, Canada.
| | - Henry Y Jiang
- Department of Surgery, Health Sciences North, Sudbury, ON, Canada
- Faculty of Medicine, Northern Ontario School of Medicine, 410-65 Larch Street, Sudbury, ON, P3E1B8, Canada
| | - Erica L Kohtakangas
- Department of Surgery, Health Sciences North, Sudbury, ON, Canada
- Faculty of Medicine, Northern Ontario School of Medicine, 410-65 Larch Street, Sudbury, ON, P3E1B8, Canada
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Mizrahi I, de Lacy FB, Abu-Gazala M, Fernandez LM, Otero A, Sands DR, Lacy AM, Wexner SD. Transanal total mesorectal excision for rectal cancer with indocyanine green fluorescence angiography. Tech Coloproctol 2018; 22:785-791. [PMID: 30430309 DOI: 10.1007/s10151-018-1869-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Accepted: 10/15/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the impact of fluorescence angiography (FA) on any change in proximal resection margin and/or anastomotic leak (AL) following transanal total mesorectal excision (TaTME) for rectal cancer (RC). METHODS This retrospective cohort study was conducted at two centers by three senior surgeons. Both institutions' prospectively maintained Institutional Review Board-approved databases were retrospectively queried for all consecutive patients between July 2015 and May 2017 who had laparoscopic hybrid trans-abdominal total mesorectal excision (TME) and TaTME for RC with colorectal or coloanal anastomosis < 10 cm from the anal verge. All patients had intraoperative FA to assess colonic perfusion of the planned proximal resection margin before bowel transection and after construction of the anastomosis. Primary outcomes measured any changes in proximal resection margins and AL rates. RESULTS Fifty-four patients (31 males; mean age 63 ± 12 years) were included; 30 (55%) of whom received neoadjuvant chemoradiation. The average anastomotic height was 3.6 cm from the anal verge and 8 (14.5%) patients required intersphincteric dissection. Forty-six patients (85%) had loop ileostomy. FA led to a change in the proximal resection margin in 10 patients (18.5%), one of whom had AL on postoperative day 3 requiring diagnostic laparoscopy and loop ileostomy. A second patient, without a change in the proximal resection margin, also had an AL. The overall AL rate was 3.7%. CONCLUSIONS FA changed the planned proximal resection margin in 18.5% of patients, possibly accounting for the relatively low AL rate. FA is imperfect, and subjective but does have the potential to improve outcomes.
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Affiliation(s)
- I Mizrahi
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - F B de Lacy
- Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clinic, IDIBAPS, Barcelona, Spain
| | - M Abu-Gazala
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - L M Fernandez
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - A Otero
- Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clinic, IDIBAPS, Barcelona, Spain
| | - D R Sands
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - A M Lacy
- Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clinic, IDIBAPS, Barcelona, Spain
| | - S D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA.
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Montroni I, Ugolini G, Saur NM, Spinelli A, Rostoft S, Millan M, Wolthuis A, Daniels IR, Hompes R, Penna M, Fürst A, Papamichael D, Desai AM, Cascinu S, Gèrard JP, Myint AS, Lemmens VE, Berho M, Lawler M, De Liguori Carino N, Potenti F, Nanni O, Altini M, Beets G, Rutten H, Winchester D, Wexner SD, Audisio RA. Personalized management of elderly patients with rectal cancer: Expert recommendations of the European Society of Surgical Oncology, European Society of Coloproctology, International Society of Geriatric Oncology, and American College of Surgeons Commission on Cancer. Eur J Surg Oncol 2018; 44:1685-1702. [DOI: 10.1016/j.ejso.2018.08.003] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 07/22/2018] [Accepted: 08/03/2018] [Indexed: 12/23/2022] Open
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Abstract
Transluminal surgery, also known as natural orifices endoluminal surgery, can be considered the most minimally invasive approach of gaining access to an organ. Although some approaches, such as transgastric or transvaginal cholecystectomy, have remained experimental, peroral endoscopic myotomy to treat achalasia and transanal total mesorectal excision to treat low rectal cancer have become accepted, safe, and feasible approaches by trained surgeons for selected patients. This article recapitulates the development of transluminal surgery from its experimental beginnings to the validated procedure it has become today.
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Affiliation(s)
- Antonio M Lacy
- Department of Gastrointestinal Surgery, ICMDM, IDIBAPS, CIBEREHD, AIS Channel, Hospital Clínic, Universitat de Barcelona, Villarroel 170, 08036 Barcelona, Spain.
| | - Fransisco Borja De Lacy
- Department of Gastrointestinal Surgery, ICMDM, IDIBAPS, CIBEREHD, AIS Channel, Hospital Clínic, Universitat de Barcelona, Villarroel 170, 08036 Barcelona, Spain
| | - Silvia Valverde
- Department of Gastrointestinal Surgery, ICMDM, IDIBAPS, CIBEREHD, AIS Channel, Hospital Clínic, Universitat de Barcelona, Villarroel 170, 08036 Barcelona, Spain
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Westwood DA, Cuda TJ, Hamilton AER, Clark D, Stevenson ARL. Transanal total mesorectal excision for rectal cancer: state of the art. Tech Coloproctol 2018; 22:649-655. [PMID: 30255213 DOI: 10.1007/s10151-018-1844-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 09/01/2018] [Indexed: 12/13/2022]
Abstract
Achieving a high-quality total mesorectal excision (TME) resection specimen is a central tenet of curative rectal cancer management. However, operating at the caudal extremity of the pelvis is inherently challenging and a number of patient- and tumour-related factors may increase the risk of obtaining a poor TME specimen and positive resection margins. Transanal TME (TaTME) is an advanced surgical technique developed to overcome the limitations in pelvic exposure and instrumentation of transabdominal surgery. This up-to-date narrative review describes the evolution of TME surgery, the indications for TaTME, current published outcomes, its limitations and future developments.
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Affiliation(s)
- David A Westwood
- Colorectal Unit, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Brisbane, QLD, Australia.
| | - Tahleesa J Cuda
- Colorectal Unit, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Brisbane, QLD, Australia
| | - A E Ricardo Hamilton
- Colorectal Unit, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Brisbane, QLD, Australia
| | - David Clark
- Colorectal Unit, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Brisbane, QLD, Australia.,Holy Spirit Northside Private Hospital, Brisbane, QLD, Australia
| | - Andrew R L Stevenson
- Colorectal Unit, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Brisbane, QLD, Australia.,Holy Spirit Northside Private Hospital, Brisbane, QLD, Australia
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Ng JL, Lai JH, Li HH, Tan EP, Tang CL. Totally-laparoscopic versus laparoscopic-assisted low anterior resection for rectal cancer: are outcomes different? ANZ J Surg 2018; 88:E818-E823. [PMID: 30211478 DOI: 10.1111/ans.14841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 06/30/2018] [Accepted: 08/05/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Laparoscopic low anterior resection for rectal cancer has superior short-term benefits compared to open surgery. When operative conditions do not favour a totally-laparoscopic (TL) approach, a hybrid operation can be performed. In this laparoscopic-assisted (LA) approach, mobilization and vessel ligation are performed laparoscopically, with total mesorectal excision and distal transection performed either partially or totally in an extra-corporeal fashion. We compared short-term post-operative and oncological outcomes of both approaches. METHODS A prospectively collected database of patients who underwent laparoscopic low anterior resection for rectal cancer between January 2009 and December 2014 was retrospectively analysed. Demographics, post-operative and oncological outcomes were compared. RESULTS Of 174 patients, 97 were completed by TL, 62 by LA and the remaining 15 were converted to open. Baseline demographics were similar. LA group compared to TL group had bulkier rectal cancers (6.75 cm3 versus 4.50 cm3 , P = 0.04) which were lower (6 cm versus 7 cm from anal verge, P = 0.02). They were of a more advanced tumour grade and had greater incidence of lymphovascular invasion. Yet, post-operative outcomes such as time to diet, pain scores, hospitalization duration, wound-related and anastomotic complications, 30-day morbidity and mortality were similar. There was no difference in oncological adequacy, including circumferential resection margins, distal margins, lymph node harvest and 2-year local recurrence rates. CONCLUSION Laparoscopic-assisted low anterior resection enables minimally invasive rectal surgery to be performed despite unfavourable tumour factors and technical challenges; and compares favourably with TL approach in terms of short-term outcomes and oncological safety.
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Affiliation(s)
- Jia Lin Ng
- Department of Colorectal Surgery, Singapore General Hospital, Singapore
| | - Jiunn Herng Lai
- Lai Endoscopy and Colorectal Surgery, Mount Elizabeth Medical Centre, Singapore
| | - Hui Hua Li
- Division of Medicine, Department of Health Services Research, Singapore General Hospital, Singapore
| | | | - Choong Leong Tang
- Department of Colorectal Surgery, Singapore General Hospital, Singapore
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Transanal Total Mesorectal Excision for Treatment of Carcinoma in the Middle or Lower Third Rectum: the Technical Feasibility of the Procedure, Pathological Results, and Clinical Outcome. Indian J Surg Oncol 2018; 9:442-451. [PMID: 30538370 DOI: 10.1007/s13193-018-0808-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 07/27/2018] [Indexed: 01/14/2023] Open
Abstract
We are trying to illustrate operative, short-term, and pathological outcomes of transanal total mesorectal excision (TaTME) as a surgical procedure for patients who are suffering cancer in the lower or middle rectum. This study included 25 consecutive patients who underwent TaTME for the mid and low cancer rectum. The primary outcome measures included frequency of postoperative (PO) bleeding, leakage, ileus, days to regain bowel function, days for Foley's removal, and erectile function. The secondary outcome measures included operation time, status of resection margins, number, the quality of TME, and duration PO hospital stay. No recorded intraoperative complications. The mean hospital stay was 6.9 ± 2.6 days. The mean duration need for urinary catheter removal and flatus passage were 2.4 ± 2.1 and 1.5 + 0.9 days, respectively. The mean IPSS was returned to normal 12 months after surgery. The mean distal margin distance was 1.9 ± 1.1. Circumferential margin distance was > 1 mm in 23 (92%) patients. The mesorectum was complete in 22 (88%) patients. The survival rate was 88% over 3 years. TaTME could be considered as a safe, feasible, and effective surgical modality for patients who had mid and lower rectal tumors with an excellent pathological outcome.
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