Factors influencing selection for a day-case or 23-h stay procedure in transanal endoscopic microsurgery

Evolution of Transanal Total Mesorectal Excision

Minimally invasive techniques continue to transform the field of colorectal surgery. Because traditional surgical approaches for rectal cancer are associated with significant mortality and morbidity, developing less invasive approaches to this disease is paramount. Natural orifice transluminal endoscopic surgery (NOTES), commonly known as "no incision surgery," represents the ultimate minimally invasive approach to disease. Although transgastric and transvaginal approaches for NOTES surgery were the initially explored, a transrectal approach for colorectal disease is intuitive given that it makes use of the resected organ for transluminal access. Furthermore, the transanal approach allows for improved, precise visualization of the presacral mesorectal plane compared with an abdominal viewpoint, particularly in the narrow, male pelvis. Finally, experience with existing transanal platforms that have been used for decades for local excision of rectal disease made the development of a transanal approach to total mesorectal excision (TME) feasible. Here, we will review the evolution of minimally invasive and transanal surgical techniques that allowed for the development of transanal TME and its introduction into clinical practice.

Factors Associated With Margin Positivity and Incidental Carcinoma in Patients Undergoing Transanal Endoscopic Microsurgery (TEMS) for the Management of Adenomatous and Dysplastic Rectal Lesions

PURPOSE

Colorectal cancer screening has resulted in an increased detection of early premalignant rectal lesions. Transanal endoscopic microsurgery (TEMS) is a minimally invasive procedure for the resection of dysplastic and selected early malignant lesions with organ and functional preservation. The aim of this study was to assess factors associated with positive resection margin and the underlying invasive component.

METHODS

This was an analysis of a prospective consecutive series of all TEMS procedures performed over the last 10-year period. Data was collated from hospital databases and operative theater registers. Statistical analysis was performed using Minitab-V18 with a P<0.05 regarded as significant.

RESULTS

In total, 328 procedures were performed on 292 patients. The cohort included 165 male patients and 127 female patients with a mean age of 66.3 years (19 to 95 years). A total of 274 procedures performed were en bloc excisions and 54 procedures were piecemeal debulking excisions for larger lesions follow by formal TEMs at an interval. The mean tumor size was 41.9 mm (10 to 150 mm), and the mean distance from anal verge was 9.3 cm (2 to 20 cm). Clear margins were achieved in 85% of cases. An overall 10.6% of patients had pathologic upgrading to invasive disease after TEMS. Lesion volume was found to influence the completeness of excision, and the widest diameter of the lesions was related to the presence of an invasive component on histology (P=0.002, 0.008, respectively).

CONCLUSIONS

TEMS is a minimally invasive technique for the resection of rectal lesions that are not amenable to endoscopic removal. Lesion size and endoscopic diameter were associated with invasive component and margin positivity, respectively. These factors should be taken into consideration when considering TEMS.

Morbidity after transanal endoscopic microsurgery: risk factors for postoperative complications and the design of a 1-day surgery program

BACKGROUND

Transanal endoscopic microsurgery (TEM) is a minimally invasive procedure with low morbidity. The definition of risk factors for postoperative complications would help to identify the patients likely to require more care and surveillance in an ambulatory or 1-day surgery (A-OdS) program. The main endpoints are overall 30-day morbidity and relevant morbidity. The secondary objectives are to detect risk factors for complications, rehospitalization, and the time of occurrence of the postoperative complications, and to describe the adverse effects following hospitalization that the A-OdS program would avoid.

METHODS

This is an observational study of consecutive patients undergoing TEM between June 2004 and December 2016. Overall and relevant morbidity based on the Clavien-Dindo (Cl-D) classification were recorded, as were demographic, preoperative, surgical, and pathology variables. Univariate and multivariate analyses of the risk factors were carried out.

RESULTS

Six hundred and ninety patients underwent surgery, of whom 639 were included in the study. Overall morbidity rate was 151/639 patients (23.6%); the clinically relevant morbidity rate was 36/639 (Cl-D > II) (5.6%) and mortality 2/639 (0.3%). The most frequent complication was rectal bleeding, recorded in 16.9% (108/639 patients) and grade I in 86/108 patients (78. 9%). The period with the greatest risk of complications was the first 2 days. The rehospitalization rate after 48 h was 7%. The risk factors for complications were as follows: tumor size > 6 cm (OR 3.2, 95% CI 1.3-7.8), anti-platelet medication (OR 2.3, 95% CI 1.1-5.1), and surgeon's experience < 150 procedures (OR 2.0, 95% CI 1-4.1).

CONCLUSIONS

TEM is a safe procedure. The low rates of morbidity, re-hospitalization, and postoperative complications in the first 2 days after surgery make the procedure suitable for A-OdS.

Early discharge following transanal endoscopic microsurgery is safe

AIM

Transanal endoscopic microsurgery (TEM) was developed as an alternative to major surgery for rectal tumors; however, there is no consensus as to the optimal postoperative length of stay. The aim of this large series is to show that a policy of presumed early discharge is safe.

PATIENTS AND METHODS

All patients undergoing TEM at a single center between 2008 and 2011 were included. Data on demographics, tumor morphology, length of stay, and complications were collected from a prospectively collected database and computer records.

RESULTS

Sixty-six patients were included, with a mean tumor size of 4.6 cm (range, 0.6-10 cm). The majority were adenomas (71%). Median stay was 1 day, with most (77%) patients being discharged within the 23-hour policy. Neither age nor tumor size affected the length of stay. There were five complications (7.6%), and 2 patients (3%) required readmission following discharge. No complications arose in patients discharged within 23 hours.

CONCLUSIONS

The majority of patients were safely discharged within 23 hours. No early-discharge patient suffered complications or required readmission. The overall complication rate was consistent with other published series, and neither age nor tumor size adversely affected outcome. A routine 23-hour discharge policy can thus be recommended for TEM patients.

Patient Selection for Day Case-eligible Surgery

Background:

Due to economic pressures and improvements in perioperative care, outpatient surgical procedures have become commonplace. However, risk factors for outpatient surgical morbidity and mortality remain unclear. There are no multicenter clinical data guiding patient selection for outpatient surgery. The authors hypothesize that specific risk factors increase the likelihood of day case-eligible surgical morbidity or mortality.

Methods:

The authors analyzed adults undergoing common day case-eligible surgical procedures by using the American College of Surgeons’ National Surgical Quality Improvement Program database from 2005 to 2010. Common day case-eligible surgical procedures were identified as the most common outpatient surgical Current Procedural Terminology codes provided by Blue Cross Blue Shield of Michigan and Medicare publications. Study variables included anthropometric data and relevant medical comorbidities. The primary outcome was morbidity or mortality within 72 h. Intraoperative complications included adverse cardiovascular events; postoperative complications included surgical, anesthetic, and medical adverse events.

Results:

Of 244,397 surgeries studied, 232 (0.1%) experienced early perioperative morbidity or mortality. Seven independent risk factors were identified while controlling for surgical complexity: overweight body mass index, obese body mass index, chronic obstructive pulmonary disease, history of transient ischemic attack/stroke, hypertension, previous cardiac surgical intervention, and prolonged operative time.

Conclusions:

The demonstrated low rate of perioperative morbidity and mortality confirms the safety of current day case-eligible surgeries. The authors obtained the first prospectively collected data identifying risk factors for morbidity and mortality with day case-eligible surgery. The results of the study provide new data to advance patient-selection processes for outpatient surgery.

Does the incidence of unexpected malignancy in 'benign' rectal neoplasms undergoing trans-anal endoscopic microsurgery vary according to lesion morphology?

AIM

Mucosectomy by trans-anal endoscopic microsurgery (TEMS) allows safe and effective excision of benign rectal lesions. Preoperative endoscopic, clinical and ultrasonographic assessment aims to select benign lesions whilst avoiding inappropriate mucosectomy in lesions with malignancy. This study examines the relationship between lesion morphology and accurate benign preoperative classification of rectal lesions undergoing TEMS.

METHOD

Primary lesions preoperatively assessed as benign were identified from a prospective TEMS database. Operative specimen morphology was independently classified by two blinded investigators, using photographs, into flat-sessile, exophytic or mixed morphology. The accuracy of the preoperative assessment by rectal ultrasonography was compared with the results of histological examination of the excised specimen (χ(2) and Fisher's exact tests).

RESULTS

Of 167 lesions with adequate data, the morphological classification showed 60 flat-sessile, 56 mixed morphology and 51 exophytic tumours, of which 5, 7 and 9, respectively, contained unexpected malignancy (P=0.48). Accurate preoperative assessment of a lesion as benign occurred in 89% of flat-sessile and mixed morphology (n=55 and 49, respectively) and in 70% of exophytic lesions (n=36) (P=0.01). Only the exophytic group contained patients in whom preoperative endoscopic and ultrasonographic staging could not be confidently made (uTx). Histology demonstrated six of the seven uTx cases to be benign.

CONCLUSION

In this study exophytic polyps were less likely to be accurately classified as benign using preoperative ultrasonography/endoscopy when compared with flat-sessile or mixed morphology polyps.

Identifying patients at high risk for venous thromboembolism requiring treatment after outpatient surgery

OBJECTIVE

To identify independent predictors of 30-day venous thromboembolism (VTE) events requiring treatment after outpatient surgery.

BACKGROUND

An increasing proportion of surgical procedures are performed in the outpatient setting. The incidence of VTE requiring treatment after outpatient surgery is unknown.

METHODS

Prospective observational cohort study using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2009. Adult patients who had outpatient surgery or surgery with subsequent 23-hour observation were included. The main outcome measure was 30-day VTE requiring treatment. Patients were randomly assigned to derivation (N = 173,501) or validation (N = 85,730) cohorts. Logistic regression examined independent risk factors for 30-day VTE. A weighted risk index was created and applied to the validation cohort. Stratified analyses examined 30-day VTE by risk level.

RESULTS

Thirty-day incidence of VTE for the overall cohort was 0.15%. Independent risk factors included current pregnancy (adjusted odds ratio [OR] = 7.80, P = 0.044), active cancer (OR = 3.66, P = 0.005), age 41 to 59 years (OR = 1.72, P = 0.008), age 60 years or more (OR = 2.48, P < 0.001), body mass index 40 kg/m or higher (OR = 1.81, P = 0.015), operative time 120 minutes or more (OR = 1.69, P = 0.027), arthroscopic surgery (OR = 5.16, P < 0.001), saphenofemoral junction surgery (OR = 13.20, P < 0.001), and venous surgery not involving the great saphenous vein (OR = 15.61, P < 0.001). The weighted risk index identified a 20-fold variation in 30-day VTE between low (0.06%) and highest risk (1.18%) patients.

CONCLUSIONS

Thirty-day VTE risk after outpatient surgery can be quantified using a weighted risk index. The risk index identifies a high-risk subgroup of patients with 30-day VTE rates of 1.18%.