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Li YJ, Wang L, Sun TT, Wu AW. Laparoscopy-assisted transanal total mesorectal excision for lower rectal cancer: A feasible and innovative technique. World J Gastrointest Oncol 2021; 13:12-23. [PMID: 33510846 PMCID: PMC7805274 DOI: 10.4251/wjgo.v13.i1.12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 09/28/2020] [Accepted: 12/17/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Transanal total mesorectal excision (taTME) is a new technique with many potential technical advantages. Laparoscopy-assisted taTME is a combination of transabdominal taTME and transluminal endoscopic surgery taTME. Laparoscopy-assisted taTME is a combination of techniques such as minimally invasive surgery, intersphincter-assisted resection, natural orifice extraction, ta minimally invasive surgery, and ultralow-level preservation of the anus.
AIM To verify the feasibility and safety of an innovative technique of taTME for treatment of cancer located in the lower rectum.
METHODS From January 2016 to March 2018, we attempted to perform laparoscopy-assisted taTME surgery in 24 patients with lower rectal cancer.
RESULTS The new technique of laparoscopy-assisted taTME was successfully performed in all 24 patients. Mean operating time was 310.0 min and mean intraoperative blood loss was 69.1 mL. The mean time to passing of first flatus was 3.1 d, and mean postoperative hospital stay was 9.2 d. Two patients were given postoperative analgesics due to anal pain. Twenty-three patients were able to walk in first 2 d, and five patients had postoperative complications.
CONCLUSION Laparoscopy-assisted taTME is suitable for selected patients with lower rectal cancer, and this technique is worthy of further recommendation.
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Affiliation(s)
- Ying-Jie Li
- Gastrointestinal Cancer Center Unit III, Beijing Cancer Hospital and Beijing Institute for Cancer Research, Beijing 100142, China
- Department of Gastrointestinal Surgery, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Beijing Cancer Hospital and Beijing Institute for Cancer Research, Beijing 100142, China
| | - Lin Wang
- Gastrointestinal Cancer Center Unit III, Beijing Cancer Hospital and Beijing Institute for Cancer Research, Beijing 100142, China
| | - Ting-Ting Sun
- Gastrointestinal Cancer Center Unit III, Beijing Cancer Hospital and Beijing Institute for Cancer Research, Beijing 100142, China
| | - Ai-Wen Wu
- Gastrointestinal Cancer Center Unit III, Beijing Cancer Hospital and Beijing Institute for Cancer Research, Beijing 100142, China
- Department of Gastrointestinal Surgery, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Beijing Cancer Hospital and Beijing Institute for Cancer Research, Beijing 100142, China
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Rouanet P, Gourgou S, Gogenur I, Jayne D, Ulrich A, Rautio T, Spinoglio G, Bouazza N, Moussion A, Gomez Ruiz M. Rectal Surgery Evaluation Trial: protocol for a parallel cohort trial of outcomes using surgical techniques for total mesorectal excision with low anterior resection in high-risk rectal cancer patients. Colorectal Dis 2019; 21:516-522. [PMID: 30740878 DOI: 10.1111/codi.14581] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 02/02/2019] [Indexed: 12/18/2022]
Abstract
AIM Total mesorectal excision (TME) is the standard of care for rectal cancer, which can be combined with low anterior resection (LAR) in patients with mid-to-low rectal cancer. The narrow pelvic space and difficulties in obtaining adequate exposure make surgery technically challenging. Four techniques are used to perform the surgery: open laparotomy, laparoscopy, robot-assisted surgery and transanal surgery. Comparative data for these techniques are required to provide clinical data on the surgical management of rectal cancers. METHODS The Rectal Surgery Evaluation Trial will be a prospective, observational, case-matched, four-cohort, multicentre trial designed to study TME with LAR using open laparotomy, laparoscopy, robot-assisted surgery or transanal surgery in high-surgical-risk patients with mid-to-low non-metastatic rectal cancer. All surgeries will be performed by surgeons experienced in at least one of the techniques. Oncological, morbidity and functional outcomes will be assessed in a composite primary outcome, with success defined as circumferential resection margin ≥ 1 mm, TME Grade III and minimal postoperative morbidity (absence of Clavien-Dindo Grade III-IV complications within 30 days after surgery). Secondary end-points will include the co-primary end-points over the long term (2 years), quality of surgery, quality of life, length of hospital stay, operative time and rate of unplanned conversions. DISCUSSION This will be the first trial to study all four surgical techniques currently used for TME with LAR in a specific group of high-risk patients. The knowledge obtained will contribute towards helping physicians determine the advantages of each technique and which may be the most appropriate for their patients.
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Affiliation(s)
- P Rouanet
- Surgery Department, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France
| | - S Gourgou
- Biometrics Unit, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France
| | - I Gogenur
- Zealand University Hospital, Roskilde, Denmark
| | - D Jayne
- St James University Hospital, Leeds, UK
| | - A Ulrich
- Department of Surgery, Lukaskrankenhaus Neuss, Neuss, Germany
| | - T Rautio
- Oulu University Hospital, Oulu, Finland
| | - G Spinoglio
- IEO European Institute of Oncology, Milan, Italy
| | - N Bouazza
- Clinical Research Department, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France
| | - A Moussion
- Clinical Research Department, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France
| | - M Gomez Ruiz
- Cirugía Colorrectal - Cirugía General y del Aparato Digestivo, Hospital Universitario Marqués de Valdecilla, Santander, Spain
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Ma XL, Guo XB, Jing CQ. Rationale and limitations of transanal total mesorectal excision for rectal tumors. Shijie Huaren Xiaohua Zazhi 2017; 25:2945-2949. [DOI: 10.11569/wcjd.v25.i33.2945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Transanal total mesorectal excision (taTME), belonging to natural-orifice transluminal endoscopic surgery, has been a hot topic in minimally invasive surgery for colorectal cancer in recent years. For low rectal tumors, taTME can offer more advantages than open or laparoscopic surgery, especially for obese patients and male patients with narrow pelvis. This technique may be possible to reduce positive circumferential resection margin rate and locoregional recurrence. However, surgeons may encounter some difficulties including being unfamiliar with the operation pathway, limited pelvic operation space, and being uneasy to ligate mesenteric vessels. Since taTME has not been applied for a very long time, there have been no sufficient number of cases available. Therefore, more cases and long-term follow-up are needed to improve this surgical technique.
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Affiliation(s)
- Xiao-Long Ma
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Ji'nan 250021, Shandong Province, China
| | - Xiao-Bo Guo
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Ji'nan 250021, Shandong Province, China
| | - Chang-Qing Jing
- Department of Gastrointestinal Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Ji'nan 250021, Shandong Province, China
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Penna M, Knol JJ, Tuynman JB, Tekkis PP, Mortensen NJ, Hompes R. Four anastomotic techniques following transanal total mesorectal excision (TaTME). Tech Coloproctol 2016; 20:185-91. [PMID: 26754653 PMCID: PMC4757625 DOI: 10.1007/s10151-015-1414-2] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 12/13/2015] [Indexed: 12/16/2022]
Abstract
Transanal total mesorectal excision (TaTME) is a novel approach pioneered to tackle the challenges posed by difficult pelvic dissections in rectal cancer and the restrictions in angulation of currently available laparoscopic staplers. To date, four techniques can be employed in order to create the colorectal/coloanal anastomosis following TaTME. We present a technical note describing these techniques and discuss the risks and benefits of each.
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Affiliation(s)
- M Penna
- Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Old Road, Oxford, OX3 7LE, UK.
| | - J J Knol
- Department of Colorectal Surgery, Jessa Hospital, Hasselt, Belgium
| | - J B Tuynman
- Department of Surgery, VU University Medical Centre, Amsterdam, The Netherlands
| | - P P Tekkis
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
| | - N J Mortensen
- Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Old Road, Oxford, OX3 7LE, UK
| | - R Hompes
- Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Old Road, Oxford, OX3 7LE, UK.
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Buchs NC, Nicholson GA, Yeung T, Mortensen NJ, Cunningham C, Jones OM, Guy R, Hompes R. Transanal rectal resection: an initial experience of 20 cases. Colorectal Dis 2016; 18:45-50. [PMID: 26639062 DOI: 10.1111/codi.13227] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 07/14/2015] [Indexed: 12/11/2022]
Abstract
AIM Low anterior resection (LAR) can present a formidable surgical challenge, particularly for tumours located in the distal third of the rectum. Transanal total mesorectal excision (taTME) aims to overcome some of these difficulties. We report our initial experience with this technique. METHOD From June 2013 to September 2014, 20 selected patients underwent transanal rectal resection for various malignant and benign low rectal pathologies. All patients with rectal cancer were discussed at a multidisciplinary team meeting. Data were entered into a prospective managed international database. RESULTS Of the 20 patients (14 male), seventeen (85%) had rectal cancer lying at a median distance of 2 cm (range 0-7) from the anorectal junction. The operations performed included LAR (16). Abdominoperineal excision (2) and completion proctectomy (2), all of which were performed by a minimally invasive approach with three conversions. The mean operation time was 315.3 min. There were six postoperative complications of which two (10%) were Clavien-Dindo Grade IIIb (pelvic haematoma and a late contained anastomotic leakage). The median length of stay was 7 days. The TME specimen was intact in 94.1% of cancer cases. The mean number of harvested lymph nodes was 23.2. There was only one positive circumferential resection margin (tumour deposit; R1 rate 5.9%). One patient developed a distant recurrence (median follow-up 10 months, range 6-21). CONCLUSION TaTME was safe in this small series of patients. It is especially attractive in patients with a narrow and irradiated pelvis and a tumour in the lower third of the rectum. TaTME is technically demanding, but the good outcomes should prompt randomized studies and prospective registration of all taTME cases in an international registry.
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Affiliation(s)
- N C Buchs
- Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK
| | - G A Nicholson
- Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK
| | - T Yeung
- Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK
| | - N J Mortensen
- Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK
| | - C Cunningham
- Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK
| | - O M Jones
- Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK
| | - R Guy
- Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK
| | - R Hompes
- Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK
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Simillis C, Hompes R, Penna M, Rasheed S, Tekkis PP. A systematic review of transanal total mesorectal excision: is this the future of rectal cancer surgery? Colorectal Dis 2016; 18:19-36. [PMID: 26466751 DOI: 10.1111/codi.13151] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 09/21/2015] [Indexed: 12/17/2022]
Abstract
AIM The surgical technique used for transanal total mesorectal excision (TaTME) was reviewed including the oncological quality of resection and the peri-operative outcome. METHOD A literature search of MEDLINE, Embase, Science Citation Index Expanded and Cochrane was performed in order to identify studies reporting on TaTME. RESULTS Thirty-six studies (eight case reports, 24 case series and four comparative studies) were identified, reporting 510 patients who underwent TaTME. The mean age ranged from 43 to 80 years and the mean body mass index from 21.7 to 31.8 kg/m(2) . The mean distance of the tumour from the anal verge ranged from 4 to 9.7 cm. The mean operation time ranged from 143 to 450 min and mean operative blood loss from 22 to 225 ml. The ratio of hand-sewn coloanal to stapled anastomoses performed was 2:1. One death was reported and the peri-operative morbidity rate was 35%. The anastomotic leakage rate was 6.1% and the reoperation rate was 3.7%. The mean hospital stay ranged from 4.3 to 16.6 days. The mesorectal excision was described as complete in 88% cases, nearly complete in 6% and incomplete in 6%. The circumferential resection margin was negative in 95% of cases and the distal resection margin was negative in 99.7%. CONCLUSION TaTME is a feasible and reproducible technique, with good quality of oncological resection. Standardization of the technique is required with formal training. Clear indications for this procedure need to be defined and its safety further assessed in future trials.
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Affiliation(s)
- C Simillis
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
| | - R Hompes
- Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Headington, Oxford, UK
| | - M Penna
- Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Headington, Oxford, UK
| | - S Rasheed
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
| | - P P Tekkis
- Department of Colorectal Surgery, Royal Marsden Hospital, London, UK
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Buchs NC, Nicholson GA, Ris F, Mortensen NJ, Hompes R. Transanal total mesorectal excision: A valid option for rectal cancer? World J Gastroenterol 2015; 21:11700-11708. [PMID: 26556997 PMCID: PMC4631971 DOI: 10.3748/wjg.v21.i41.11700] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 07/21/2015] [Accepted: 09/14/2015] [Indexed: 02/06/2023] Open
Abstract
Low anterior resection can be a challenging operation, especially in obese male patients and in particular after radiotherapy. Transanal total mesorectal excision (TaTME) might offer technical advantages over laparoscopic or open approaches particularly for tumors in the distal third of the rectum. The aim of this article is to review the current experience with TaTME. The limits and future developments are also explored. Although the experience with TaTME is still limited, it might be a promising alternative to laparoscopic TME, especially for difficult cases where laparoscopy is too demanding. The preliminary data on complications and short-term oncological outcomes are good, but also emphasize the importance of careful patient selection. Finally, there is a need for large-scale trials focusing on long-term outcomes and oncological safety before widespread adoption can be recommended.
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Nicholson G, Knol J, Houben B, Cunningham C, Ashraf S, Hompes R. Optimal dissection for transanal total mesorectal excision using modified CO2 insufflation and smoke extraction. Colorectal Dis 2015. [PMID: 26218459 DOI: 10.1111/codi.13074] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AIM The new approach of transanal total mesorectal excision is technically challenging and demands a stable field of dissection with optimal view of anatomical landmarks. We aimed to describe and demonstrate a modification of both the insufflation of carbon dioxide and smoke evacuation, in order to optimize dissection. METHOD The comparison of standard insufflation to an AirSeal platform demonstrates a clear difference. This is shown in the accompanying video-recordings. RESULTS A more stable pneumorectum and better smoke evacuation as well as more convenient and precise dissection were achieved with the AirSeal platform. CONCLUSION Using the technique outlined, the operating surgeon is able to perform the surgical dissection in a stable operating environment with increased visibility compared to the standard approach.
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Affiliation(s)
- G Nicholson
- Department of Colorectal Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
| | - J Knol
- Department of Visceral Surgery, Jessa Hospital, Hasselt, Belgium
| | - B Houben
- Department of Visceral Surgery, Jessa Hospital, Hasselt, Belgium
| | - C Cunningham
- Department of Colorectal Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
| | - S Ashraf
- Department of Colorectal Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
| | - R Hompes
- Department of Colorectal Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
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Hompes R, Arnold S, Warusavitarne J. Towards the safe introduction of transanal total mesorectal excision: the role of a clinical registry. Colorectal Dis 2014; 16:498-501. [PMID: 24806149 DOI: 10.1111/codi.12661] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 04/29/2014] [Indexed: 02/06/2023]
Affiliation(s)
- R Hompes
- Oxford University Hospitals NHS Trust, Churchill Hospital, Old Road, Headington, Oxford, OX3 7LE, UK
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