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Zewde MG, Peyser DK, Yu AT, Bonaccorso A, Moshier E, Alavi K, Goldstone R, Marks JH, Maykel JA, McLemore EC, Sands D, Steele SR, Wexner SD, Whiteford M, Sylla P. Oncologic outcomes following transanal total mesorectal excision: the United States experience. Surg Endosc 2024:10.1007/s00464-024-10896-7. [PMID: 38782828 DOI: 10.1007/s00464-024-10896-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 05/02/2024] [Indexed: 05/25/2024]
Abstract
AIM The benefits and short-term outcomes of transanal total mesorectal excision (taTME) for rectal cancer have been demonstrated previously, but questions remain regarding the oncologic outcomes following this challenging procedure. The purpose of this study was to analyze the oncologic outcomes following taTME at high-volume centers in the USA. METHODS This was a multicenter, retrospective observational study of 8 tertiary care centers. All consecutive taTME cases for primary rectal cancer performed between 2011 and 2020 were included. Clinical, histopathologic, and oncologic data were analyzed. Primary endpoints were rate of local recurrence, distal recurrence, 3-year disease recurrence, and 3-year overall survival. Secondary endpoints included perioperative complications and TME specimen quality. RESULTS A total of 391 patients were included in the study. The median age was 57 years (IQR: 49, 66), 68% of patients were male, and the median BMI was 27.4 (IQR: 24.1, 31.0). TME specimen was complete or near complete in 94.5% of cases and the rates of positive circumferential radial margin and distal resection margin were 2.0% and 0.3%, respectively. Median follow-up time was 30.7 months as calculated using reverse-KM estimator (CI 28.1-33.8) and there were 9 cases (2.5%) of local recurrence not accounting for competing risk. The 3-year estimated rate of disease recurrence was 19% (CI 15-25%) and the 3-year estimated overall survival was 90% (CI 87-94%). CONCLUSION This large multicenter study confirms the oncologic safety and perioperative benefits of taTME for rectal cancer when performed by experienced surgeons at experienced referral centers.
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Affiliation(s)
- Makda Getachew Zewde
- Division of Colon and Rectal Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY, 10029, USA
| | - Daniel K Peyser
- Division of Colon and Rectal Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY, 10029, USA
| | - Allen T Yu
- Division of Colon and Rectal Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY, 10029, USA
| | - Antoinette Bonaccorso
- Division of Colon and Rectal Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY, 10029, USA
| | - Erin Moshier
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Karim Alavi
- Department of Surgery, University of Massachusetts Medical School, Worcester, USA
| | - Robert Goldstone
- Department of Surgery, Massachusetts General Hospital, Boston, USA
| | - John H Marks
- Department of Surgery, Lankenau Institute for Medical Research, Wynnewood, USA
| | - Justin A Maykel
- Department of Surgery, University of Massachusetts Medical School, Worcester, USA
| | - Elisabeth C McLemore
- Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, USA
| | - Dana Sands
- Department of Surgery, Cleveland Clinic Florida, Weston, USA
| | - Scott R Steele
- Department of Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, USA
| | - Steven D Wexner
- Department of Surgery, Cleveland Clinic Florida, Weston, USA
| | - Mark Whiteford
- Department of Surgery, Providence Portland Medical Center, Portland, USA
| | - Patricia Sylla
- Division of Colon and Rectal Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY, 10029, USA.
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Neary E, Ibrahim T, Verschoor CP, Zhang L, Patel SV, Chadi SA, Caycedo-Marulanda A. A systematic review and meta-analysis of oncological outcomes with transanal total mesorectal excision for rectal cancer. Colorectal Dis 2024; 26:837-850. [PMID: 38590019 DOI: 10.1111/codi.16982] [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: 05/23/2023] [Revised: 09/17/2023] [Accepted: 01/21/2024] [Indexed: 04/10/2024]
Abstract
AIM Transanal total mesorectal (taTME) excision is a method used to assist in the radical removal of the rectum. By adopting the concept of natural orifice surgery, it offers potential benefits over conventional techniques. Early enthusiasm for this strategy led to its rapid and widespread adoption. The imposing of a local moratorium was precipitated by the discovery in Norway of an uncommon multifocal pattern of locoregional recurrence. The aim of this systematic review and meta-analysis was to determine the incidence of local recurrence after taTME for rectal cancer. METHOD Conforming to the Cochrane Handbook for Systematic Reviews of Interventions and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines checklist, a systematic review and meta-analysis was conducted. This included case series and comparative studies between taTME and preferentially laparoscopic procedures published between 2010 and 2021. RESULTS There were a total of 1175 studies retrieved. After removal and screening for quality and relevance, the final analysis contained 40 studies. The local recurrence rate following taTME was 3.4% (95% CI 2.9%-3.9%, I2 = 0%) in 4987 patients with follow-up durations ranging from 0.7 to 5.5 years. Compared with laparoscopic TME, local recurrence was not statistically different for the taTME group (p = 0.076); however, it was less probable (OR = 0.51, 95% CI 0.24-1.09, I2 = 0%). Systemic recurrence and circumferential resection margin status were secondary outcomes; however, the differences were not statistically significant. CONCLUSION Our data suggest that the local recurrence for regular laparoscopic and transanal TME surgeries may be comparable, suggesting that taTME can be performed without influencing locoregional oncological outcomes in patients treated at specialized institutions and who have been cautiously selected.
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Affiliation(s)
- Emma Neary
- Queen's University, Kingston, Ontario, Canada
| | - Tarek Ibrahim
- Division of Oncology, Department of Surgery, University Health Network and Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Chris P Verschoor
- Health Sciences North Research Institute, Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | - Lisa Zhang
- Queen's University, Kingston, Ontario, Canada
| | - Sunil V Patel
- Queen's University, Kingston, Ontario, Canada
- Department of Surgery, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Sami A Chadi
- Division of Oncology, Department of Surgery, University Health Network and Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Antonio Caycedo-Marulanda
- Queen's University, Kingston, Ontario, Canada
- Health Sciences North Research Institute, Northern Ontario School of Medicine, Sudbury, Ontario, Canada
- Orlando Health Colon and Rectal Institute, Orlando, Florida, USA
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3
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Marks JH, Reif de Paula T, Saidi H, Ikner TP, Schoonyoung H, Marks G, Keller DS. Longitudinal Analysis of Local Recurrence and Survival After Transanal Abdominal Transanal Radical Proctosigmoidectomy for Low Rectal Cancer Treated With Neoadjuvant Chemoradiation Therapy. Dis Colon Rectum 2024; 67:377-386. [PMID: 38064243 DOI: 10.1097/dcr.0000000000003146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
BACKGROUND The transanal abdominal transanal radical proctosigmoidectomy was developed in 1984 as a sphincter preservation surgery in patients with low rectal cancers after preoperative radiation therapy. While serving as a catalyst for disruptive sphincter preservation surgery, it continues to be used and evolve. With the controversy over safety and local recurrence in other sphincter-preserving surgery, review of transanal abdominal transanal radical proctosigmoidectomy long-term oncologic outcomes is warranted. OBJECTIVE To assess local recurrence and survival after transanal abdominal transanal radical proctosigmoidectomy after neoadjuvant chemoradiation therapy. DESIGN Retrospective cohort study of a prospectively maintained database. SETTINGS Tertiary rectal cancer referral center. PATIENTS Patients with low adenocarcinoma (≤5 cm anorectal ring) receiving neoadjuvant chemoradiation therapy and then transanal abdominal transanal radical proctosigmoidectomy for curative resection between 1998 and 2021. MAIN OUTCOME MEASURES Local recurrence rates and overall survival rates. RESULTS Of 255 included patients, 67.8% were men (n = 173); the mean age was 58.7 years (SD 11.5) and the mean BMI was 27.1 (SD 5.4), with 50.2% (n = 128) having ASA class II and 49.8% (n = 127) having ASA class III/IV. The mean tumor size was 4.8 cm (SD 1.9), the majority of patients had clinical T3 disease (81.8%; n = 184), and 52.1% had nodal disease (n = 100). The median radiation dose was 5400 cGy, with 73.7% (n = 149) achieving good response and 90.2% (n = 230) receiving minimally invasive surgery. The complete total mesorectal excision rate was 94.3%, and 100% of patients (n = 255) had negative distal margins. The mean number of examined lymph nodes were 13.9 (SD 10.7). After a median follow-up of 55.4 months, 5.1% of patients (n = 13) developed local recurrence at a median time of 29.6 months. The 5-year overall survival was 84.1% (95% CI, 78.8-89.4). LIMITATIONS Retrospective review with risk of bias and lack of generalizability. CONCLUSIONS In this longitudinal study, the transanal abdominal transanal radical proctosigmoidectomy demonstrated excellent long-term locoregional control and survival in very low rectal cancers. The superior transanal abdominal transanal radical proctosigmoidectomy outcomes are durable over time, warranting expansion of the sphincter-preserving surgery technique. See Video Abstract . ANLISIS LONGITUDINAL DE LA RECURRENCIA LOCAL Y LA SUPERVIVENCIA DESPUS DE LA PROCTOSIGMOIDECTOMA RADICAL TRANSANAL ABDOMINAL TATA PARA EL CNCER DE RECTO BAJO TRATADO CON QUIMIORRADIACIN NEOADYUVANTE ANTECEDENTES:La proctosigmoidectomía radical transanal abdominal se desarrolló en 1984 como una cirugía de preservación del esfínter en cánceres de recto bajo después de la radiación preoperatoria. Si bien sirve como catalizador para la cirugía disruptiva de preservación del esfínter, continúa utilizándose y evolucionando. Con la controversia sobre la seguridad y la recurrencia local en otras cirugías que preservan el esfínter, se justifica la revisión de los resultados oncológicos a largo plazo de la proctosigmoidectomía radical transanal abdominal.OBJETIVO:Evaluar localmente después de Proctosigmoidectomía Radical Transanal Abdominal Transanal después de quimiorradiación neoadyuvante.DISEÑO:Estudio de cohorte retrospectivo de una base de datos mantenida de forma prospectiva.AJUSTES:Centro terciario de referencia para el cáncer de recto.PACIENTES:Adenocarcinoma bajo (=/
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Affiliation(s)
- John H Marks
- Lankenau Medical Center, Lankenau Institute for Medical Research, Wynnewood, Pennsylvania
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Langenfeld SJ, Davis BR, Vogel JD, Davids JS, Temple LKF, Cologne KG, Hendren S, Hunt S, Garcia Aguilar J, Feingold DL, Lightner AL, Paquette IM. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Rectal Cancer 2023 Supplement. Dis Colon Rectum 2024; 67:18-31. [PMID: 37647138 DOI: 10.1097/dcr.0000000000003057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Affiliation(s)
- Sean J Langenfeld
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska
| | - Bradley R Davis
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Jon D Vogel
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | | | - Larissa K F Temple
- Colorectal Surgery Division, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Kyle G Cologne
- Department of Surgery, Division of Colorectal Surgery, University of Southern California, Los Angeles, California
| | - Samantha Hendren
- Division of Colon and Rectal Surgery, Department of Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan
| | - Steven Hunt
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Julio Garcia Aguilar
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel L Feingold
- Department of Surgery, Rutgers University, New Brunswick, New Jersey
| | - Amy L Lightner
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ian M Paquette
- Department of Surgery, Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
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5
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Harji D, Fernandez B, Boissieras L, Celerier B, Rullier E, Denost Q. IDEAL Stage 2a/b prospective cohort study of transanal transection and single-stapled anastomosis for rectal cancer. Colorectal Dis 2023; 25:2346-2353. [PMID: 37919463 DOI: 10.1111/codi.16789] [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: 08/10/2022] [Revised: 09/06/2023] [Accepted: 09/08/2023] [Indexed: 11/04/2023]
Abstract
AIM There are several anastomotic techniques available to facilitate restorative rectal cancer surgery after total mesorectal excision (TME), including double-stapled anastomosis (DST) and handsewn coloanal anastomosis (CAA). However, to date no one technique is superior with regard to anastomotic leakage (AL) or functional outcomes. Transanal transection single-stapled anastomosis (TTSS) aims to overcome some of the technical challenges and offer comparable clinical and functional outcomes to traditional anastomotic techniques. The aim of this study was to explore the role of TTSS in modern rectal cancer surgery and to provide comparative clinical and functional outcome data with DST and CAA. METHOD A prospective cohort study was undertaken to assess the safety and clinical and patient-reported outcomes associated with the TTSS procedure. All patients undergoing sphincter-preserving surgery for rectal cancer with an anastomosis performed within 6 cm of the anal verge between January 2016 and April 2021 were prospectively enrolled into this study. Clinical and patient-reported outcome data, including low anterior resection syndrome (LARS) assessment, were collected. The primary endpoint was anastomotic leakage within 30 days. RESULTS A total of 275 patients participated in this study, with 70 (25%) patients undergoing a TTSS, 110 (40%) undergoing a DST and 95 (35%) undergoing a CAA. Patients undergoing a CAA had more distal tumours than those having a TTSS or DST, with a median tumour height of 5, 7 and 9 cm (p < 0.001), respectively. We observed a statistically significant reduction in AL in the TTSS group compared with the DST group, with rates of 8.6% versus 20.9% (p = 0.028). There was no difference in LARS scores between patients undergoing TTSS and DST (p = 0.228), while patients with a CAA had worse LARS scores than TTSS patients (p = 0.002). CONCLUSION TTSS is a technically safe and feasible anastomotic technique in rectal cancer surgery as an alternative to DST and CAA. Its advantages over DST are a reduced AL rate and, over CAA, improved function. It should therefore be considered as an alternative technique to improve clinical and patient-reported outcomes in restorative rectal cancer surgery.
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Affiliation(s)
- Deena Harji
- Bordeaux Colorectal Institute, Clinique Tivoli, Bordeaux, France
| | - Benjamin Fernandez
- Centre Hospitalier Universitaire de Bordeaux Centre Medico-Chirurgical Magellan Service d Hepato-Gastroenterologie et d Oncologie Digestive Ringgold standard institution, Pessac, France
| | - Lara Boissieras
- Centre Hospitalier Universitaire de Bordeaux Centre Medico-Chirurgical Magellan Service d Hepato-Gastroenterologie et d Oncologie Digestive Ringgold standard institution, Pessac, France
| | - Bertrand Celerier
- Centre Hospitalier Universitaire de Bordeaux Centre Medico-Chirurgical Magellan Service d Hepato-Gastroenterologie et d Oncologie Digestive Ringgold standard institution, Pessac, France
| | - Eric Rullier
- Centre Hospitalier Universitaire de Bordeaux Centre Medico-Chirurgical Magellan Service d Hepato-Gastroenterologie et d Oncologie Digestive Ringgold standard institution, Pessac, France
| | - Quentin Denost
- Bordeaux Colorectal Institute, Clinique Tivoli, Bordeaux, France
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Francis NK, Penna M, Dritsas S, Kinsey H, Moran B, Nicol D, Courtney E, Carter F, Roodbeen S, Arnold S, Mortensen N, White P, Hompes R, Wynn G. Oncological outcomes after transanal total mesorectal excision for rectal cancer. Br J Surg 2023; 110:1614-1617. [PMID: 37311697 PMCID: PMC10638524 DOI: 10.1093/bjs/znad168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 05/09/2023] [Accepted: 05/13/2023] [Indexed: 06/15/2023]
Affiliation(s)
- Nader K Francis
- Department of Colorectal Surgery, Yeovil District Hospital Foundation Trust, Yeovil, UK
- Division of Surgery and Interventional Science, UCL, London, UK
| | - Marta Penna
- Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Spyridon Dritsas
- Department of Colorectal Surgery, Yeovil District Hospital Foundation Trust, Yeovil, UK
| | - Harry Kinsey
- Department of Colorectal Surgery, Yeovil District Hospital Foundation Trust, Yeovil, UK
| | - Brendan Moran
- Department of Colorectal Surgery, Basingstoke and North Hampshire Hospital, Basingstoke Hospital, Basingstoke, UK
| | - Deborah Nicol
- Department of Colorectal Surgery, Worcestershire Royal Hospital, Worcestershire Acute Hospitals NHS Trust, Worcestershire, Worcester, UK
| | - Edward Courtney
- Department of Colorectal Surgery, Royal United Hospital Bath, Bath, UK
| | - Fiona Carter
- Southwest Surgical Training Network Community Interest Company, Yeovil, UK
| | - Sapho Roodbeen
- Department of Colon and Rectal Surgery, Humanitas Clinical and Research Centre, Milan, Italy
| | - Steve Arnold
- Department of Colorectal Surgery, Basingstoke and North Hampshire Hospital, Basingstoke Hospital, Basingstoke, UK
| | - Neil Mortensen
- Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK
| | - Paul White
- Department of Data Science and Mathematics, University of the West of England, Bristol, UK
| | - Roel Hompes
- Department of Surgery, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - Greg Wynn
- ICENI Centre, North Essex Foundation Trust, London, UK
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7
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Fleming C, Fernandez B, Boissieras L, Cauvin T, Denost Q. Integrating a tumour appropriate transanal or robotic assisted approach to total mesorectal excision in high-volume rectal cancer practice is safe and cost-effective. J Robot Surg 2023; 17:1979-1987. [PMID: 37099264 DOI: 10.1007/s11701-023-01577-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 03/11/2023] [Indexed: 04/27/2023]
Abstract
Total mesorectal excision (TME) is accepted as the gold standard for oncological resection in rectal cancer. The best approach to TME is debated and often surgeons will select a preferred approach. In this study, we aimed to describe how both robotic (R-TME) and transanal (TaTME) TME can be integrated into high-volume rectal cancer surgeon practice with a comparison of clinical and oncological outcomes and cost analysis. A prospective comparative cohort study was performed in a high-volume rectal cancer centre comparing the previous 50 R-TME and 50 TaTME performed by the same surgeon. A comparison of tumour characteristics was performed to highlight a specific role for each technique. Clinical outcomes (operative duration, length of stay (LOS) and perioperative morbidity), cancer quality indicators (resection margin and completeness of TME) and cost analysis were compared. Statistical analysis was performed using IBM SPSS, version 20. R-TME was preferred in mid-rectal cancer, compared to TaTME preferred in low rectal cancer (9 cm vs. 5 cm, p < 0.001). Operative duration was longer in R-TME compared to TaTME (265 vs. 179 min, p < 0.001). Major complications (CD III-IV complications) were experienced in 10% of R-TME and 14% of TaTME (p = 0.476). A 98% (n = 49) clear R0 resection margin was achieved with both R-TME and TaTME and mesorectum quality defined as 'complete' in 86% (n = 43) in R-TME and 82% (n = 41) in TaTME. Length of hospital stay was shorter in R-TME (5 vs. 7 days, p = 0.624). An overall difference of €131 was observed favouring TaTME. In high-volume rectal cancer surgery practice, both R-TME and TaTME can be practised and tailored according to patients and tumour characteristics, with comparable clinical and cancer outcomes and is cost-effective.
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Affiliation(s)
| | | | - Lara Boissieras
- Department of Colorectal Surgery, CHU Bordeaux, Bordeaux, France
| | - Thomas Cauvin
- Department of Colorectal Surgery, CHU Bordeaux, Bordeaux, France
| | - Quentin Denost
- Bordeaux Colorectal Institute, Clinique Tivoli, 220 Rue Mandron, 33000, Bordeaux, France.
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8
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Walshaw J, Huo B, McClean A, Gajos S, Kwan JY, Tomlinson J, Biyani CS, Dimashki S, Chetter I, Yiasemidou M. Innovation in gastrointestinal surgery: the evolution of minimally invasive surgery-a narrative review. Front Surg 2023; 10:1193486. [PMID: 37288133 PMCID: PMC10242011 DOI: 10.3389/fsurg.2023.1193486] [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: 03/24/2023] [Accepted: 05/04/2023] [Indexed: 06/09/2023] Open
Abstract
Background Minimally invasive (MI) surgery has revolutionised surgery, becoming the standard of care in many countries around the globe. Observed benefits over traditional open surgery include reduced pain, shorter hospital stay, and decreased recovery time. Gastrointestinal surgery in particular was an early adaptor to both laparoscopic and robotic surgery. Within this review, we provide a comprehensive overview of the evolution of minimally invasive gastrointestinal surgery and a critical outlook on the evidence surrounding its effectiveness and safety. Methods A literature review was conducted to identify relevant articles for the topic of this review. The literature search was performed using Medical Subject Heading terms on PubMed. The methodology for evidence synthesis was in line with the four steps for narrative reviews outlined in current literature. The key words used were minimally invasive, robotic, laparoscopic colorectal, colon, rectal surgery. Conclusion The introduction of minimally surgery has revolutionised patient care. Despite the evidence supporting this technique in gastrointestinal surgery, several controversies remain. Here we discuss some of them; the lack of high level evidence regarding the oncological outcomes of TaTME and lack of supporting evidence for robotic colorectalrectal surgery and upper GI surgery. These controversies open pathways for future research opportunities with RCTs focusing on comparing robotic to laparoscopic with different primary outcomes including ergonomics and surgeon comfort.
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Affiliation(s)
- Josephine Walshaw
- Academic Vascular Surgical Unit, Hull University Teaching Hospitals NHS Trust, Hull, United Kingdom
| | - Bright Huo
- Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Adam McClean
- Department of General Surgery, Bradford Teaching Hospitals NHS Trust, Bradford, United Kingdom
| | - Samantha Gajos
- Emergency Medicine Department, York and Scarborough Teaching Hospitals NHS Foundation Trust, York, United Kingdom
| | - Jing Yi Kwan
- Department of General Surgery, Bradford Teaching Hospitals NHS Trust, Bradford, United Kingdom
- Department of Vascular Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - James Tomlinson
- Department of Spinal Surgery, SheffieldTeaching Hospitals, Sheffield, United Kingdom
| | - Chandra Shekhar Biyani
- Department of Vascular Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Safaa Dimashki
- Department of General Surgery, Bradford Teaching Hospitals NHS Trust, Bradford, United Kingdom
| | - Ian Chetter
- Academic Vascular Surgical Unit, Hull University Teaching Hospitals NHS Trust, Hull, United Kingdom
| | - Marina Yiasemidou
- NIHR Academic Clinical Lecturer General Surgery, University of Hull, Hull, United Kingdom
- Hull York Medical School, University of York, York, United Kingdom
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9
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Somashekhar SP, Saklani A, Dixit J, Kothari J, Nayak S, Sudheer OV, Dabas S, Goud J, Munikrishnan V, Sugoor P, Penumadu P, Ramachandra C, Mehendale S, Dahiya A. Clinical Robotic Surgery Association (India Chapter) and Indian rectal cancer expert group’s practical consensus statements for surgical management of localized and locally advanced rectal cancer. Front Oncol 2022; 12:1002530. [PMID: 36267970 PMCID: PMC9577482 DOI: 10.3389/fonc.2022.1002530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 09/16/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction There are standard treatment guidelines for the surgical management of rectal cancer, that are advocated by recognized physician societies. But, owing to disparities in access and affordability of various treatment options, there remains an unmet need for personalizing these international guidelines to Indian settings. Methods Clinical Robotic Surgery Association (CRSA) set up the Indian rectal cancer expert group, with a pre-defined selection criterion and comprised of the leading surgical oncologists and gastrointestinal surgeons managing rectal cancer in India. Following the constitution of the expert Group, members identified three areas of focus and 12 clinical questions. A thorough review of the literature was performed, and the evidence was graded as per the levels of evidence by Oxford Centre for Evidence-Based Medicine. The consensus was built using the modified Delphi methodology of consensus development. A consensus statement was accepted only if ≥75% of the experts were in agreement. Results Using the results of the review of the literature and experts’ opinions; the expert group members drafted and agreed on the final consensus statements, and these were classified as “strong or weak”, based on the GRADE framework. Conclusion The expert group adapted international guidelines for the surgical management of localized and locally advanced rectal cancer to Indian settings. It will be vital to disseminate these to the wider surgical oncologists and gastrointestinal surgeons’ community in India.
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Affiliation(s)
- S. P. Somashekhar
- Department of Surgical Oncology, Manipal Hospital, Bengaluru, Karnataka, India
- *Correspondence: S. P. Somashekhar,
| | - Avanish Saklani
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Jagannath Dixit
- Department of GI Surgery, HCG Hospital, Bengaluru, Karnataka, India
| | - Jagdish Kothari
- Department of Surgical Oncology HCG Hospital, Ahmedabad, Gujarat, India
| | - Sandeep Nayak
- Department of Surgical Oncology, Fortis Hospital, Bengaluru, Karnataka, India
| | - O. V. Sudheer
- Department of GI Surgery and Surgical Oncology, Amrita Institute of Medical Science, Kochi, Kerala, India
| | - Surender Dabas
- Department of Surgical Oncology, BL Kapur-Max Superspeciality Hospital, Delhi, India
| | - Jagadishwar Goud
- Department of Surgical Oncology, AOI Hospital, Hyderabad, Telangana, India
| | | | - Pavan Sugoor
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
| | | | - C. Ramachandra
- Director and Head, Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
| | - Shilpa Mehendale
- Director and Head, Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
| | - Akhil Dahiya
- Department of Clinical and Medical Affairs, Intuitive Surgical, California, CA, United States
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Celentano V, Tekkis P, Nordenvall C, Mills S, Spinelli A, Smart N, Selvaggi F, Warren O, Espin-Basany E, Kontovounisios C, Pellino G, Warusavitarne J, Hancock L, Myrelid P, Remzi F. Standardization of ileoanal J-pouch surgery technique: Quality assessment of minimally invasive ileoanal J-pouch surgery videos. Surgery 2022; 172:53-59. [PMID: 34980484 DOI: 10.1016/j.surg.2021.11.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 11/18/2021] [Accepted: 11/29/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Ileal pouch anal anastomosis is a complex procedure associated with significant morbidity, with several complications after ileal pouch anal anastomosis surgery leading to pouch failure. The aim of the study is to evaluate the heterogeneity surrounding the technique of ileoanal J-pouch surgery by assessing the safety and quality of published online peer-reviewed surgical videos. METHODS Ileal pouch anal anastomosis videos published on peer-reviewed surgical journals and video channels were edited and anonymized to demonstrate specific steps of the surgical procedure: mobilization and division of the rectum, formation of the ileoanal J-pouch reservoir, anastomosis, and lengthening techniques. The anonymized videos were presented to a group of reviewers with expertise in ileal pouch anal anastomosis blinded to the names and affiliations of the surgeons performing the procedure. Primary outcome was the rate of interobserver variability in the assessment of specific technical steps of the ileal pouch anal anastomosis surgery procedure. Secondary outcome was the appropriateness of the use of surgical videos review as an assessment tool for ileal pouch anal anastomosis surgery, measured as rate of reviewers being unable to answer for poor video quality. RESULTS In total, 29 video fragments were distributed, and 13 assessors completed a 60-item survey, organized in 7 major domains. The survey completion rate was 93.4%. Out of a total 729 answers, in 23 (3.2%) the reviewers indicated they were unable to comment due to poor video image, and in 48 (6.5%) were unable to comment due to the particular step not being shown in the procedure. The proportion of assessors rating rectal mobilization technically appropriate ranged from 30.7% to 92.3% and from 7.7% to 69.2% for safety. The level of rectal division was considered appropriate in 0 to 53.8% of the videos, whereas the stapling technique used for rectal division was appropriate in 0 to 70% of the videos. CONCLUSION Our study assessed published peer-reviewed videos on ileal pouch anal anastomosis surgery and reported heterogeneity in the safety of the demonstrated techniques. Blind assessment of published peer-reviewed ileal pouch anal anastomosis videos reported a high rate of unsafe or inappropriate technique for rectal mobilization and transection in the reviewed videos, with fair interobserver agreement among reviewers. There is a need for consensus on what is considered safe and appropriate in ileal pouch anal anastomosis surgery. Peer review of ileal pouch anal anastomosis surgery videos could facilitate training and accreditation in this complex procedure.
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Affiliation(s)
- Valerio Celentano
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK; Department of Surgery and Cancer, Imperial College, London, UK.
| | - Paris Tekkis
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK; Department of Surgery and Cancer, Imperial College, London, UK
| | - Caroline Nordenvall
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Sarah Mills
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK; Department of Surgery and Cancer, Imperial College, London, UK
| | - Antonino Spinelli
- Humanitas Clinical and Research Center IRCCS, Division of Colon and Rectal Surgery, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Neil Smart
- Exeter Health Services, Research Unit, Royal Devon & Exeter Hospital, UK
| | - Francesco Selvaggi
- Department of Advanced Medical and Surgical Sciences, Universita' degli Studi della Campania "Luigi Vanvitelli," Naples, Italy
| | - Oliver Warren
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK; Department of Surgery and Cancer, Imperial College, London, UK
| | - Eloy Espin-Basany
- Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Christos Kontovounisios
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK; Department of Surgery and Cancer, Imperial College, London, UK
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Universita' degli Studi della Campania "Luigi Vanvitelli," Naples, Italy; Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - Laura Hancock
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Par Myrelid
- Division of Surgery, Department of Biomedical and Clinical Sciences, Faulty of Health Sciences, Linköping University, Sweden; Department of Surgery, County Council of Östergötland Linköping, Sweden
| | - Feza Remzi
- Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY; NYU Grossman School of Medicine, New York, NY
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Maykel JA, Hahn SJ, Beauharnais CC, Meyer DC, Hill SS, Sturrock PR, Davids JS, Alavi K. Oncologic Outcomes After Transanal Total Mesorectal Excision for Rectal Cancer. Dis Colon Rectum 2022; 65:827-836. [PMID: 34629431 PMCID: PMC9067092 DOI: 10.1097/dcr.0000000000002173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Recent series have raised concerns about the oncologic outcomes of transanal total mesorectal excision for mid and low rectal cancer. There is a paucity of large data sets from the United States to contribute to the ongoing international discourse. OBJECTIVE This study aimed to investigate the rate of local recurrence and other oncologic outcomes in patients undergoing transanal total mesorectal excision for rectal adenocarcinoma. DESIGN This study is a retrospective review of patients undergoing transanal total mesorectal excision for primary rectal cancer from January 2014 to December 2019. SETTINGS This study was conducted at a single academic tertiary care medical center in the United States. PATIENTS Consecutive patients aged ≥18 years undergoing surgical resection for primary rectal cancer were selected. INTERVENTION The transanal total mesorectal excision procedures were performed utilizing a 2-team approach. MAIN OUTCOME MEASURES Primary outcomes were pathologic quality, local and distant recurrence, treatment-related complications, and overall- and cancer-specific survival. RESULTS Seventy-nine consecutive patients were included. The median age was 58 years (interquartile range, 50-64), and median BMI was 28 kg/m2 (interquartile range, 24.6-32.4). The mesorectum was complete in 69 patients (87.3%), nearly complete in 9 (11.4%), and incomplete in 1 (1.3%). There was circumferential resection margin involvement (<1 mm) in 4 patients (5.1%), and no patients had a positive distal margin (<1 mm) or intraoperative rectal perforation. Composite optimal pathology was achieved in 94.9% of specimens. Median follow-up was 29 months (range, 6-68). There were no local recurrences. Distant metastases were found in 10 (13.5%) patients and diagnosed after a median of 14 months (range, 0.6-53). Disease-free survival was 91.2% at 2 years, and overall survival was 94.7% at 2 years. LIMITATIONS Retrospective design, a single center, and relatively short follow-up period were limitations of this study. CONCLUSION The oncologic outcomes of this cohort support the use of transanal total mesorectal excision in the surgical management of mid to low rectal cancer at centers with appropriate expertise. See Video Abstract at http://links.lww.com/DCR/B723. RESULTADOS ONCOLGICOS DESPUS DE LA EXCISIN TOTAL DEL MESORRECTO POR VA TRANSANAL EN CASOS DE CNCER RECTAL ANTECEDENTES:Estudios recientes han suscitado preocupación sobre los resultados oncológicos de la excisión total del mesorecto por vía transanal en casos de cáncer de recto medio y bajo. Existe una gran escasez de conjuntos de datos en los Estados Unidos, para contribuir en el actual discurso internacional sobre el tema.OBJETIVO:Investigar la tasa de recurrencia local y otros resultados oncológicos en pacientes sometidos a una excisión total del mesorrecto por vía transanal por adenocarcinomas de recto.DISEÑO:Revisión retrospectiva de pacientes sometidos a excisión total del mesorecto por vía transanal en casos de cáncer de recto primario desde enero de 2014 hasta diciembre de 2019.AJUSTE:Centro médico Universitario de atención terciaria único en los Estados Unidos.PACIENTES:Aquellos pacientes consecutivos de ≥ 18 años de edad, sometidos a resección quirúrgica por cáncer de recto primario.INTERVENCIÓN:Los procedimientos de excisión total del mesorecto por vía transanal se realizaron utilizando un enfoque de dos equipos.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados primarios fueron la calidad anatomo-patológica de las piezas, la recidiva local y a distancia, las complicaciones relacionadas con el tratamiento y la sobrevida global específica para el cáncer.RESULTADOS:Se incluyeron 79 pacientes consecutivos. La mediana de edades fue de 58 años (IQR, 50-64) y la mediana del índice de masa corporal fue de 28 kg / m (IQR, 24,6-32,4). El mesorrecto se encontraba completo en 69 pacientes (87,3%), casi completo en 9 (11,4%) e incompleto en 1 (1,3%). Hubo afectación de CRM (<1 mm) en 4 pacientes (5,1%) y ningún paciente tuvo un margen distal positivo (<1 mm) o perforación rectal intraoperatoria. La histopatología óptima compuesta se logró en el 94,9% de las muestras. La mediana de seguimiento fue de 29 meses (rango 6-68). No se presentaron recurrencias locales. Se encontraron metástasis a distancia en 10 (13,5%) pacientes y se diagnosticaron después de una mediana de 14 meses (rango 0,6-53). La sobrevida libre de enfermedad fue del 91,2% a los 2 años y la sobrevida global fue del 94,7% a los 2 años.LIMITACIONES:Diseño retrospectivo, unicéntrico y período de seguimiento relativamente corto.CONCLUSIÓN:Los resultados oncológicos de este estudio de cohortes, apoyan la realización de excisión total del mesorecto por vía transanal para el tratamiento quirúrgico del cáncer de recto medio y bajo, en centros con la experiencia adecuada. Consulte Video Resumen en http://links.lww.com/DCR/B723. (Traducción-Dr. Xavier Delgadillo).
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Affiliation(s)
- Justin A. Maykel
- University of Massachusetts Memorial Medical Center, Worcester, Massachusetts
| | - Sue J. Hahn
- University of Massachusetts Memorial Medical Center, Worcester, Massachusetts
| | | | - David C. Meyer
- University of Massachusetts Memorial Medical Center, Worcester, Massachusetts
| | - Susanna S. Hill
- University of Massachusetts Memorial Medical Center, Worcester, Massachusetts
| | - Paul R. Sturrock
- University of Massachusetts Memorial Medical Center, Worcester, Massachusetts
| | - Jennifer S. Davids
- University of Massachusetts Memorial Medical Center, Worcester, Massachusetts
| | - Karim Alavi
- University of Massachusetts Memorial Medical Center, Worcester, Massachusetts
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12
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Naghawi H, Chau J, Madani A, Kaneva P, Monson J, Mueller C, Lee L. Development and evaluation of a virtual knowledge assessment tool for transanal total mesorectal excision. Tech Coloproctol 2022; 26:551-560. [PMID: 35503143 DOI: 10.1007/s10151-022-02621-0] [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] [Received: 09/15/2021] [Accepted: 04/10/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Transanal total mesorectal excision (TATME) is difficult to learn and can result in serious complications. Current paradigms for assessing performance and competency may be insufficient. This study aims to develop and provide preliminary validity evidence for a TATME virtual assessment tool (TATME-VAT) to assess the cognitive skills necessary to safely complete TATME dissection. METHODS Participants from North America, Europe, Japan and China completed the test via an interactive online platform between 11/2019 and 05/2020. They were grouped into expert, experienced and novice surgeons depending on the number of independently performed TATMEs. TATME-VAT is a 24-item web-based assessment evaluating advanced cognitive skills, designed according to a blueprint from consensus guidelines. Eight items were multiple choice questions. Sixteen items required making annotations on still frames of TATME videos (VCT) and were scored using a validated algorithm derived from experts' responses. Annotation (range 0-100), multiple choice (range 0-100), and overall scores (sum of annotation and multiple-choice scores, normalized to μ = 50 and σ = 10) were reported. RESULTS There were significant differences between the expert, experienced, and novice groups for the annotation (p < 0.001), multiple-choice (p < 0.001), and overall scores (p < 0.001). The annotation (p = 0.439) and overall (p = 0.152) scores were similar between the experienced and novice groups. Annotation scores were higher in participants with 51 or more vs. 30-50 vs. less than 30 cases. Scores were also lower in users with a self-reported recent complication vs. those without. CONCLUSIONS This study describes the development of an interactive video-based virtual assessment tool for TATME dissection and provides initial validity evidence for its use.
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Affiliation(s)
- Hamzeh Naghawi
- The Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University Health Center, Montreal, QC, Canada
| | - Johnny Chau
- The Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University Health Center, Montreal, QC, Canada
| | - Amin Madani
- The University Health Network - Toronto General Hospital, Toronto, ON, Canada
| | - Pepa Kaneva
- The Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University Health Center, Montreal, QC, Canada
| | - John Monson
- AdventHealth Medical Group, Orlando, FL, USA
| | - Carmen Mueller
- The Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University Health Center, Montreal, QC, Canada
| | - Lawrence Lee
- The Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University Health Center, Montreal, QC, Canada. .,Colon and Rectal Surgery, Department of Surgery, McGill University Health Centre, 1001 Decarie Boulevard, DS1-3310, Montreal, QC, H4A 3J1, Canada.
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13
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Caycedo-Marulanda A, Verschoor CP, Brown CP, Karimuddin A, Raval M, Phang T, Vikis E, Melich G, Patel SV. Transanal total mesorectal excision for abdominoperineal resection is associated with poor oncological outcomes in rectal cancer patients: A word of caution from a multicentric Canadian cohort study. Colorectal Dis 2022; 24:380-387. [PMID: 34957663 DOI: 10.1111/codi.16033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 10/15/2021] [Accepted: 10/22/2021] [Indexed: 02/08/2023]
Abstract
AIM The main objective of this study was to compare the oncological outcomes of patients undergoing abdominoperineal resection (APR) versus low anterior resection (LAR) through a transanal total mesorectal excision (taTME) approach. METHOD A total of 360 adult patients with a diagnosis of rectal cancer were enrolled at participating centres from the Canadian taTME Expert Collaboration. Forty-three patients received taTME-APR and received 317 taTME-LAR. Demographic, operative, pathological and follow-up data were collected and merged into a single database. Results are presented as hazard ratio (HR) and 95% confidence interval. All analyses were performed in the R environment (v.3.6). RESULTS The proportion of patients with a positive circumferential radial margin status was higher in the taTME-APR group than the taTME-LAR group (21% vs. 9%, p = 0.001). Complete TME was achieved in 91% of those undergoing APR compared with 96% of those undergoing LAR (p = 0.25). APR was associated with a greater rate of local recurrence relative to LAR, although it was not significant [crude HR = 3.53 (95% CI 0.92-13.53)]. Circumferential margin positivity was significantly associated with a higher rate of systemic recurrence [crude HR = 3.59 (95% CI 1.38-9.3)]. CONCLUSION Our results demonstrate inferior outcomes in those undergoing taTME-APR compared with taTME-LAR. The use of this technique for this particular indication needs to be carefully considered.
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Affiliation(s)
- Antonio Caycedo-Marulanda
- Kingston General Hospital, Queen's University, Kingston, ON, Canada.,Health Sciences North Research Institute, Sudbury, ON, Canada
| | | | - Carl P Brown
- St Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Ahmer Karimuddin
- St Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Manoj Raval
- St Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Terry Phang
- St Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Elena Vikis
- Royal Columbian Hospital/Eagle Ridge Hospital, University of British Columbia, Vancouver, BC, Canada
| | - George Melich
- Royal Columbian Hospital/Eagle Ridge Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Sunil V Patel
- Kingston General Hospital, Queen's University, Kingston, ON, Canada
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14
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Hahn SJ, Sylla P. Technological Advances in the Surgical Treatment of Colorectal Cancer. Surg Oncol Clin N Am 2022; 31:183-218. [DOI: 10.1016/j.soc.2022.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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15
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Milone M, Adamina M, Arezzo A, Bejinariu N, Boni L, Bouvy N, de Lacy FB, Dresen R, Ferentinos K, Francis NK, Mahaffey J, Penna M, Theodoropoulos G, Kontouli KM, Mavridis D, Vandvik PO, Antoniou SA. UEG and EAES rapid guideline: Systematic review, meta-analysis, GRADE assessment and evidence-informed European recommendations on TaTME for rectal cancer. Surg Endosc 2022; 36:2221-2232. [PMID: 35212821 PMCID: PMC8921163 DOI: 10.1007/s00464-022-09090-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 12/31/2021] [Indexed: 12/13/2022]
Abstract
Background Evidence and practice recommendations on the use of transanal total mesorectal excision (TaTME) for rectal cancer are conflicting. Objective We aimed to summarize best evidence and develop a rapid guideline using transparent, trustworthy, and standardized methodology. Methods We developed a rapid guideline in accordance with GRADE, G-I-N, and AGREE II standards. The steering group consisted of general surgeons, members of the EAES Research Committee/Guidelines Subcommittee with expertise and experience in guideline development, advanced medical statistics and evidence synthesis, biostatisticians, and a guideline methodologist. The guideline panel consisted of four general surgeons practicing colorectal surgery, a radiologist with expertise in rectal cancer, a radiation oncologist, a pathologist, and a patient representative. We conducted a systematic review and the results of evidence synthesis by means of meta-analyses were summarized in evidence tables. Recommendations were authored and published through an online authoring and publication platform (MAGICapp), with the guideline panel making use of an evidence-to-decision framework and a Delphi process to arrive at consensus. Results This rapid guideline provides a weak recommendation for the use of TaTME over laparoscopic or robotic TME for low rectal cancer when expertise is available. Furthermore, it details evidence gaps to be addressed by future research and discusses policy considerations. The guideline, with recommendations, evidence summaries, and decision aids in user-friendly formats can also be accessed in MAGICapp: https://app.magicapp.org/#/guideline/4494. Conclusions This rapid guideline provides evidence-informed trustworthy recommendations on the use of TaTME for rectal cancer. Supplementary Information The online version contains supplementary material available at 10.1007/s00464-022-09090-4.
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Affiliation(s)
- Marco Milone
- Department of Clinical Medicine and Surgery, University "Federico II" of Naples, Naples, Italy.
| | - Michel Adamina
- Department of Surgery, Clinic of Visceral and Thoracic Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
- Department of Biomedical Engineering, Faculty of Medicine, University of Basel, Allschwil, Switzerland
| | - Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Nona Bejinariu
- Department of Pathology, Santomar Oncodiagnostic, Cluj-Napoca, Romania
| | - Luigi Boni
- Department of Surgery, Fondazione IRCCS - Ca' Granda - Ospedale Maggiore Policlinico University of Milan, Milan, Italy
| | - Nicole Bouvy
- Department of Surgery, Maastricht University Medical Center, Maastricht, Netherlands
| | - F Borja de Lacy
- Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clinic of Barcelona, Barcelona, Spain
| | | | - Konstantinos Ferentinos
- Department of Radiation Oncology, German Oncology Center, Limassol, Cyprus
- European University Cyprus, Nicosia, Cyprus
| | - Nader K Francis
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Yeovil, UK
| | | | | | - George Theodoropoulos
- First Department of Propaedeutic Surgery of Athens, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Katerina Maria Kontouli
- Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece
| | - Dimitris Mavridis
- Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece
- Faculté de Médecine, Université Paris Descartes, Paris, France
| | - Per Olav Vandvik
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
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Concepts and prospects of minimally invasive colorectal cancer surgery. Clin Radiol 2021; 76:889-895. [PMID: 34654544 DOI: 10.1016/j.crad.2021.09.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 09/15/2021] [Indexed: 01/18/2023]
Abstract
It is important that clinical radiologists understand and appreciate the minimally invasive surgery (MIS) options available to surgeons. Operative technologies are constantly evolving, and accurate, informed interpretation of clinical imaging is essential for optimum surgical management. Concurrent advancements in both MIS and radiological staging have certainly improved treatment decisions and outcomes. This article outlines the history, current concepts, evolving techniques, and future prospects of MIS as it pertains to colorectal cancer surgery.
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Transanal (TaTME) vs. laparoscopic total mesorectal excision for mid and low rectal cancer: a propensity score-matched analysis of early and long-term outcomes. Int J Colorectal Dis 2021; 36:2271-2279. [PMID: 34467413 DOI: 10.1007/s00384-021-04019-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/19/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Transanal total mesorectal excision (TaTME) has been proposed as an alternative to laparoscopic total mesorectal excision (LapTME) in distal rectal tumors. Despite encouraging reports, mid- and long-term oncological results are limited. In this study, we aimed at comparing TaTME versus LapTME in patients with mid and low rectal cancer. METHODS From January 2012 to December 2019, all patients undergoing either TaTME or LapTME for rectal adenocarcinoma ≤ 12 cm from the anal verge were included. Demographic, clinical, and follow-up data were retrieved from a prospective and audited database, and a propensity score-matched analysis was performed. RESULTS A total of 144 patients were included, 38 underwent TaTME, and 106 LapTME. The median age was 68.0 (60.2-75.8) years, and 96 (66.7%) patients were male. Median follow-up was 30.6 (20.2-39.8) months in the TaTME group and 49.5 (22.6-68.5) months in the LapTME group. There was one (2.6%) local recurrence in the TaTME group and two (1.9%) in the LapTME group (p = 0.788). There was no difference in the 3-year disease-free survival between groups both in the primary (93% vs. 86%, p = 0.274) and the propensity score-matched analyses (93% vs. 81%, p = 0.132). Conversion to open surgery was less frequent in the TaTME group (none vs. 4 (11.4%), p = 0.041). Intra- and postoperative complications, length of stay, specimen quality, and resection margins were similar between groups. CONCLUSIONS In our experience, TaTME was associated with a less frequent conversion to open surgery but otherwise had similar post-operative results compared to LapTME. Local recurrence and 3-year survival rates were similar.
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Van Oostendorp SE, Belgers HJ(E, Hol JC, Doornebosch PG, Belt EJT, Oosterling SJ, Kusters M, Bonjer HJ(J, Sietses C, Tuynman JB. The learning curve of transanal total mesorectal excision for rectal cancer is associated with local recurrence: results from a multicentre external audit. Colorectal Dis 2021; 23:2020-2029. [PMID: 33969621 PMCID: PMC8453958 DOI: 10.1111/codi.15722] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 03/19/2021] [Accepted: 05/02/2021] [Indexed: 12/14/2022]
Abstract
AIM Transanal total mesorectal excision (TaTME) has been suggested as a potential solution for the resection of challenging mid and low rectal cancer. This relatively complex procedure has been implemented in many centres over the last years, despite the absence of long-term safety data. Recently, concern has arisen because of an increase in local recurrence in the implementation phase. The aim of this study was to assess the correlation between accumulated experience and local recurrences. METHOD An independent clinical researcher performed an external audit of consecutive series of all TaTME procedures in six centres in the Netherlands. Kaplan-Meier estimated local recurrence rates were calculated and multivariate Cox proportional hazards regression analysis performed to assess risk factors for local recurrence. Primary outcome was the local recurrence rate in the initial implementation (cases 1-10), continued adoption (cases 11-40) and prolonged experience (case 41 onward). RESULTS Six hundred and twenty-four consecutive patients underwent TaTME for rectal cancer with a median follow-up of 27 months (range 1-82 months). The estimated 2- and 3-year local recurrence rates were 4.6% and 6.6%, respectively. Cox proportional hazards regression revealed procedural experience to be an independent factor in multivariate analysis next to advanced stage (ycMRF+, pT3-4, pN+) and pelvic sepsis. Corrected analysis projected the 3-year local recurrence rates to be 9.7%, 3.3% and 3.5% for the implementation, continued adoption and prolonged experience cohorts, respectively. CONCLUSION This multicentre study shows a high local recurrence rate (12.5%) after implementation of TaTME which lowers to an acceptable rate (3.4%) when experience increases. Therefore, intensified proctoring and further precautions must be implemented to reduce the unacceptably high risk of local recurrence at units starting this technique.
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Affiliation(s)
- Stefan E. Van Oostendorp
- Department of SurgeryAmsterdam UMCVrije Universiteit AmsterdamCancer Centre AmsterdamAmsterdamThe Netherlands
| | | | - Jeroen C. Hol
- Department of SurgeryAmsterdam UMCVrije Universiteit AmsterdamCancer Centre AmsterdamAmsterdamThe Netherlands
- Department of SurgeryGelderse Vallei HospitalEdeThe Netherlands
| | | | - Eric J. Th. Belt
- Department of SurgeryAlbert Schweitzer HospitalDordrechtThe Netherlands
| | | | - Miranda Kusters
- Department of SurgeryAmsterdam UMCVrije Universiteit AmsterdamCancer Centre AmsterdamAmsterdamThe Netherlands
| | - H. J. (Jaap) Bonjer
- Department of SurgeryAmsterdam UMCVrije Universiteit AmsterdamCancer Centre AmsterdamAmsterdamThe Netherlands
| | - Colin Sietses
- Department of SurgeryGelderse Vallei HospitalEdeThe Netherlands
| | - Jurriaan B. Tuynman
- Department of SurgeryAmsterdam UMCVrije Universiteit AmsterdamCancer Centre AmsterdamAmsterdamThe Netherlands
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19
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Podda M, Sylla P, Baiocchi G, Adamina M, Agnoletti V, Agresta F, Ansaloni L, Arezzo A, Avenia N, Biffl W, Biondi A, Bui S, Campanile FC, Carcoforo P, Commisso C, Crucitti A, De'Angelis N, De'Angelis GL, De Filippo M, De Simone B, Di Saverio S, Ercolani G, Fraga GP, Gabrielli F, Gaiani F, Guerrieri M, Guttadauro A, Kluger Y, Leppaniemi AK, Loffredo A, Meschi T, Moore EE, Ortenzi M, Pata F, Parini D, Pisanu A, Poggioli G, Polistena A, Puzziello A, Rondelli F, Sartelli M, Smart N, Sugrue ME, Tejedor P, Vacante M, Coccolini F, Davies J, Catena F. Multidisciplinary management of elderly patients with rectal cancer: recommendations from the SICG (Italian Society of Geriatric Surgery), SIFIPAC (Italian Society of Surgical Pathophysiology), SICE (Italian Society of Endoscopic Surgery and new technologies), and the WSES (World Society of Emergency Surgery) International Consensus Project. World J Emerg Surg 2021; 16:35. [PMID: 34215310 PMCID: PMC8254305 DOI: 10.1186/s13017-021-00378-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 06/18/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND AIMS Although rectal cancer is predominantly a disease of older patients, current guidelines do not incorporate optimal treatment recommendations for the elderly and address only partially the associated specific challenges encountered in this population. This results in a wide variation and disparity in delivering a standard of care to this subset of patients. As the burden of rectal cancer in the elderly population continues to increase, it is crucial to assess whether current recommendations on treatment strategies for the general population can be adopted for the older adults, with the same beneficial oncological and functional outcomes. This multidisciplinary experts' consensus aims to refine current rectal cancer-specific guidelines for the elderly population in order to help to maximize rectal cancer therapeutic strategies while minimizing adverse impacts on functional outcomes and quality of life for these patients. METHODS The discussion among the steering group of clinical experts and methodologists from the societies' expert panel involved clinicians practicing in general surgery, colorectal surgery, surgical oncology, geriatric oncology, geriatrics, gastroenterologists, radiologists, oncologists, radiation oncologists, and endoscopists. Research topics and questions were formulated, revised, and unanimously approved by all experts in two subsequent modified Delphi rounds in December 2020-January 2021. The steering committee was divided into nine teams following the main research field of members. Each conducted their literature search and drafted statements and recommendations on their research question. Literature search has been updated up to 2020 and statements and recommendations have been developed according to the GRADE methodology. A modified Delphi methodology was implemented to reach agreement among the experts on all statements and recommendations. CONCLUSIONS The 2021 SICG-SIFIPAC-SICE-WSES consensus for the multidisciplinary management of elderly patients with rectal cancer aims to provide updated evidence-based statements and recommendations on each of the following topics: epidemiology, pre-intervention strategies, diagnosis and staging, neoadjuvant chemoradiation, surgery, watch and wait strategy, adjuvant chemotherapy, synchronous liver metastases, and emergency presentation of rectal cancer.
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Affiliation(s)
- Mauro Podda
- Department of Emergency Surgery, Cagliari University Hospital "D. Casula", Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy.
| | - Patricia Sylla
- Division of Colon and Rectal Surgery, Mount Sinai Hospital, New York, NY, USA
| | - Gianluca Baiocchi
- ASST Cremona, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Michel Adamina
- Department of Colorectal Surgery, Cantonal Hospital of Winterthur, Winterthur - University of Basel, Basel, Switzerland
| | | | - Ferdinando Agresta
- Department of General Surgery, Vittorio Veneto Hospital, AULSS2 Trevigiana del Veneto, Vittorio Veneto, Italy
| | - Luca Ansaloni
- 1st General Surgery Unit, University of Pavia, Pavia, Italy
| | - Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Nicola Avenia
- SC Chirurgia Generale e Specialità Chirurgiche Azienda Ospedaliera Santa Maria, Università degli Studi di Perugia, Terni, Italy
| | - Walter Biffl
- Trauma and Acute Care Surgery, Scripps Memorial Hospital, La Jolla, CA, USA
| | - Antonio Biondi
- Department of General Surgery and Medical - Surgical Specialties, University of Catania, Catania, Italy
| | - Simona Bui
- Department of Medical Oncology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Fabio C Campanile
- Department of Surgery, ASL VT - Ospedale "San Giovanni Decollato - Andosilla", Civita Castellana, Italy
| | - Paolo Carcoforo
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara, University of Ferrara, Ferrara, Italy
| | - Claudia Commisso
- Department of Radiology, University Hospital of Parma, Parma, Italy
| | - Antonio Crucitti
- General and Minimally Invasive Surgery Unit, Cristo Re Hospital and Catholic University, Rome, Italy
| | - Nicola De'Angelis
- Unit of Minimally Invasive and Robotic Digestive Surgery, Regional General Hospital F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - Gian Luigi De'Angelis
- Department of Medicine and Surgery, Gastroenterology and Endoscopy Unit, University of Parma, Parma, Italy
| | | | - Belinda De Simone
- Department of General and Metabolic Surgery, Poissy and Saint Germain en Laye Hospitals, Poissy, France
| | | | - Giorgio Ercolani
- General and Oncologic Surgery, Morgagni-Pierantoni Hospital, AUSL Romagna, Forlì, Italy
| | - Gustavo P Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, SP, Brazil
| | | | - Federica Gaiani
- Department of Medicine and Surgery, Gastroenterology and Endoscopy Unit, University of Parma, Parma, Italy
| | | | | | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ari K Leppaniemi
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Andrea Loffredo
- UOC Chirurgia Generale - AOU san Giovanni di Dio e Ruggi d'Aragona, Università di Salerno, Salerno, Italy
| | - Tiziana Meschi
- Department of Medicine and Surgery, University of Parma Geriatric-Rehabilitation Department, Parma University Hospital, Parma, Italy
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, Denver, USA
| | | | | | - Dario Parini
- Santa Maria della Misericordia Hospital, Rovigo, Italy
| | - Adolfo Pisanu
- Department of Emergency Surgery, Cagliari University Hospital "D. Casula", Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy
| | - Gilberto Poggioli
- Surgery of the Alimentary Tract, Sant'Orsola Hospital, Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Andrea Polistena
- Dipartimento di Chirurgia Pietro Valdoni Policlinico Umberto I, Sapienza Università degli Studi di Roma, Rome, Italy
| | - Alessandro Puzziello
- UOC Chirurgia Generale - AOU san Giovanni di Dio e Ruggi d'Aragona, Università di Salerno, Salerno, Italy
| | - Fabio Rondelli
- SC Chirurgia Generale e Specialità Chirurgiche Azienda Ospedaliera Santa Maria, Università degli Studi di Perugia, Terni, Italy
| | | | | | - Michael E Sugrue
- Letterkenny University Hospital and CPM sEUBP Interreg Project, Letterkenny, Ireland
| | | | - Marco Vacante
- Department of General Surgery and Medical - Surgical Specialties, University of Catania, Catania, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Justin Davies
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge, UK
| | - Fausto Catena
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
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20
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Statistical, Clinical, Methodological Evaluation of Local Recurrence Following Transanal Total Mesorectal Excision for Rectal Cancer: A Systematic Review. Dis Colon Rectum 2021; 64:899-914. [PMID: 33938532 DOI: 10.1097/dcr.0000000000002110] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND A recent Norwegian moratorium challenged the status quo of transanal total mesorectal excision for rectal cancer by reporting increased early multifocal local recurrences. OBJECTIVE The aim of this systematic review and meta-analysis was to evaluate the local recurrence rates following transanal total mesorectal excision as well as to assess statistical, clinical, and methodological bias in reports published to date. DATA SOURCES The PubMed and MEDLINE (via Ovid) databases were systematically searched. STUDY SELECTION Descriptive or comparative studies reporting rates of local recurrence at a median follow-up of 6 months (or more) after transanal total mesorectal excision were included. INTERVENTIONS Patients underwent transanal total mesorectal excision. MAIN OUTCOME MEASURES Local recurrence was any recurrence located in the pelvic surgery site. The untransformed proportion method of 1-arm meta-analysis was utilized. Untransformed percent proportion with 95% confidence interval was reported. Ad hoc meta-regression with the Omnibus test was utilized to assess risk factors for local recurrence. Among-study heterogeneity was evaluated: statistically by I2 and τ2, clinically by summary tables, and methodologically by a 33-item questionnaire. RESULTS Twenty-nine studies totaling 2906 patients were included. The pooled rate of local recurrence was 3.4% (2.7%-4.0%) at an average of 20.1 months with low statistical heterogeneity (I2 = 0%). Meta-regression yielded no correlation between complete total mesorectal excision quality (p = 0.855), circumferential resection margin (p = 0.268), distal margin (p = 0.886), and local recurrence rates. Clinical heterogeneity was substantial. Methodological heterogeneity was linked to the excitement of novelty, loss aversion, reactivity to criticism, indication for transanal total mesorectal excision, nonprobability sampling, circular reasoning, misclassification, inadequate follow-up, reporting bias, conflict of interest, and self-licensing. LIMITATIONS The studies included had an observational design and limited sample and follow-up. CONCLUSION This systematic review found a pooled rate of local recurrence of 3.4% at 20 months. However, given the substantial clinical and methodological heterogeneity across the studies, the evidence for or against transanal total mesorectal excision is inconclusive at this time.
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21
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Shen H, Zheng H, Tong W. Reply to: Robotic-assisted transanal total mesorectal excision for rectal cancer: more questions than answers. Tech Coloproctol 2021; 25:989-990. [PMID: 34089399 DOI: 10.1007/s10151-021-02435-6] [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: 01/25/2021] [Accepted: 03/08/2021] [Indexed: 11/30/2022]
Affiliation(s)
- H Shen
- Department of General Surgery, Army Medical Center (Daping Hospital), Army Medical University, Chongqing, China
| | - H Zheng
- Department of General Surgery, Army Medical Center (Daping Hospital), Army Medical University, Chongqing, China
| | - W Tong
- Department of General Surgery, Army Medical Center (Daping Hospital), Army Medical University, Chongqing, China.
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22
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Udayasiri DK, Skandarajah A, Hayes IP. Transanal total mesorectal excision: is there a problem with using case series to assess new operative techniques? ANZ J Surg 2021; 91:780-781. [PMID: 33999529 DOI: 10.1111/ans.16507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 12/09/2020] [Accepted: 12/12/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Dilshan K Udayasiri
- Colorectal Surgical Unit, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of General Surgical Specialties, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - Anita Skandarajah
- Department of General Surgical Specialties, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - Ian P Hayes
- Colorectal Surgical Unit, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of General Surgical Specialties, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
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23
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Rockall TA. Transanal total mesorectal excision: the race to the bottom. Br J Surg 2021; 108:3-4. [PMID: 33640943 DOI: 10.1093/bjs/znaa053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 10/02/2020] [Indexed: 12/11/2022]
Affiliation(s)
- T A Rockall
- Minimal Access Therapy Training Unit, Royal Surrey County Hospital NHS Foundation Trust, Egerton Road, Guildford GU2 7XX, UK
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24
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van der Heijden JAG, Qaderi SM, Verhoeven R, Custers JAE, Klarenbeek BR, Maaskant-Braat AJG, de Wilt JHW. Transanal total mesorectal excision and low anterior resection syndrome. Br J Surg 2021; 108:991-997. [PMID: 33837383 DOI: 10.1093/bjs/znab056] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/22/2021] [Accepted: 01/27/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Bowel dysfunction after rectal cancer surgery is common, with some experiencing low anterior resection syndrome (LARS) is common after rectal cancer surgery. This study examined if transanal total mesorectal excision (TaTME) has a similar risk of LARS and altered quality of life (QoL) as patients who undergo low anterior resection (LAR). METHODS Patients who underwent TaTME or traditionally approached total mesorectal excision in a prospective colorectal cancer cohort study (2014-2019) were propensity score matched in a 1 : 1 ratio. LARS and QoL scores were assessed before and after surgery with a primary endpoint of major LARS at 12 months analysed for possible association between factors by logistic regression. RESULTS Of 61 TaTME and 317 LAR patients eligible, 55 from each group were propensity score matched. Higher LARS scores (30.6 versus 25.4, P = 0.010) and more major LARS (65 versus 42 per cent, P = 0.013; OR 2.64, 95 per cent c.i. 1.22 to 5.71) were reported after TaTME. Additionally, QoL score differences (body image, bowel frequency, and embarrassment) were worse in the TaTME group. CONCLUSIONS TaTME may be associated with more severe bowel dysfunction than traditional approaches to rectal cancer.
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Affiliation(s)
- J A G van der Heijden
- Department of Surgical Oncology, Radboud Institute for Health Science (RIHS), Radboud University Medical Centre, Nijmegen, the Netherlands
| | - S M Qaderi
- Department of Surgical Oncology, Radboud Institute for Health Science (RIHS), Radboud University Medical Centre, Nijmegen, the Netherlands
| | - R Verhoeven
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands.,Amsterdam UMC, Department of Medical Oncology, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - J A E Custers
- Department of Medical Psychology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - B R Klarenbeek
- Department of Surgical Oncology, Radboud Institute for Health Science (RIHS), Radboud University Medical Centre, Nijmegen, the Netherlands
| | - A J G Maaskant-Braat
- Department of Surgical Oncology, Máxima Medical Centre, Veldhoven, the Netherlands
| | - J H W de Wilt
- Department of Surgical Oncology, Radboud Institute for Health Science (RIHS), Radboud University Medical Centre, Nijmegen, the Netherlands
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25
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Larach JT, Rajkomar AKS, Smart PJ, McCormick JJ, Heriot AG, Warrier SK. Beyond transanal total mesorectal excision: short-term outcomes of transanal total mesorectal excision in locally advanced rectal cancer requiring resection beyond total mesorectal excision. Colorectal Dis 2021; 23:823-833. [PMID: 33217140 DOI: 10.1111/codi.15446] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 10/14/2020] [Accepted: 11/03/2020] [Indexed: 12/24/2022]
Abstract
AIM The aim of this work was to define the role of transanal total mesorectal excision (taTME) in locally advanced rectal cancer (LARC) requiring resection beyond the mesorectal plane. METHOD We performed a retrospective review of the outcomes of a case series of patients undergoing taTME for rectal cancer with mesorectal fascia or adjacent organ involvement. RESULTS Eleven patients (six men) underwent taTME for LARC requiring resection beyond total mesorectal excision (TME). All had a restorative procedure. The transabdominal approach was open in five and minimally invasive in six cases. All patients required the resection of at least one adjacent structure, including presacral fascia, internal iliac vessels, nerve roots, uterus, vagina or seminal vesicles. Four patients required a pelvic side-wall lymph node dissection and four had intraoperative radiotherapy. In all cases, the transanal approach was useful to disconnect the rectum distally, resect adjacent organs or control the R1 risk-point. Three patients had a complication of Clavien-Dindo grade III or above (one mechanical bowel obstruction, one pelvic collection and one urine sepsis). There were no anastomotic complications. Ten patients had an R0 resection. During a median follow-up of 11 (8.6-16) months there were no local recurrences, but two patients had distant metastases. During the study period, eight patients underwent closure of their stoma whilst the remaining three have had normal anastomotic assessments and will be closed in the future. CONCLUSION This early series shows that implementation of taTME for resections beyond TME may be feasible and safe in a highly selected setting.
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Affiliation(s)
- José Tomás Larach
- Division of Cancer Surgery, PeterMacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia.,Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Amrish K S Rajkomar
- General Surgery and Gastrointestinal Clinical Institute, Epworth Healthcare, Melbourne, Victoria, Australia
| | - Philip J Smart
- General Surgery and Gastrointestinal Clinical Institute, Epworth Healthcare, Melbourne, Victoria, Australia.,Department of Surgery, Austin Health, Melbourne, Victoria, Australia
| | - Jacob J McCormick
- Division of Cancer Surgery, PeterMacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia.,General Surgery and Gastrointestinal Clinical Institute, Epworth Healthcare, Melbourne, Victoria, Australia
| | - Alexander G Heriot
- Division of Cancer Surgery, PeterMacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia.,General Surgery and Gastrointestinal Clinical Institute, Epworth Healthcare, Melbourne, Victoria, Australia
| | - Satish K Warrier
- Division of Cancer Surgery, PeterMacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia.,General Surgery and Gastrointestinal Clinical Institute, Epworth Healthcare, Melbourne, Victoria, Australia
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26
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Creavin B, Kelly ME, Ryan ÉJ, Ryan OK, Winter DC. Oncological outcomes of laparoscopic versus open rectal cancer resections: meta-analysis of randomized clinical trials. Br J Surg 2021; 108:469-476. [PMID: 33748848 DOI: 10.1093/bjs/znaa154] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/24/2020] [Accepted: 11/28/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND The role of laparoscopic rectal cancer surgery has been questioned owing to conflicting reports on pathological outcomes from recent RCTs. However, it is unclear whether these pathological markers and the surgical approach have an impact on oncological outcomes. This study assessed oncological outcomes of laparoscopic and open rectal cancer resections. METHODS A meta-analysis of RCTs was performed. Primary endpoints included oncological outcomes (disease-free survival (DFS), overall survival (OS), local recurrence). Secondary endpoints included surrogate markers for the quality of surgical resection. RESULTS Twelve RCTs including 3744 patients (2133 laparoscopic, 1611 open) were included. There was no significant difference in OS (hazard ratio (HR) 0.87, 95 per cent c.i. 0.73 to 1.04; P = 0.12; I2 = 0 per cent) and DFS (HR 0.95, 0.81 to 1.11; P = 0.52; I2 = 0 per cent) between laparoscopic and open rectal resections. There was no significant difference in locoregional (odds ratio (OR) 1.03, 95 per cent c.i. 0.72 to 1.48; P = 0.86; I2 = 0 per cent) or distant (OR 0.87, 0.70 to 1.08; P = 0.20; I2 = 7 per cent) recurrence between the groups. Achieving a successful composite score (intact mesorectal excision, clear circumferential resection margin and distal margin) was significantly associated with improved DFS (OR 0.55, 0.33 to 0.74; P < 0.001; I2 = 0 per cent). An intact or acceptable mesorectal excision (intact mesorectal excision with or without superficial defects) had no impact on DFS. Finally, a positive CRM was associated with worse DFS. CONCLUSION Well performed surgery (laparoscopic or open) achieves excellent oncological outcomes with very little difference between the two modalities. The advantage and benefit of minimally invasive surgery should be assessed on an individual basis.
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Affiliation(s)
- B Creavin
- Department of Colorectal Surgery, St Vincent's University Hospital, Dublin, Ireland
| | - M E Kelly
- Department of Colorectal Surgery, St Vincent's University Hospital, Dublin, Ireland
| | - É J Ryan
- Department of Colorectal Surgery, St Vincent's University Hospital, Dublin, Ireland
| | - O K Ryan
- Department of Colorectal Surgery, St Vincent's University Hospital, Dublin, Ireland
| | - D C Winter
- Department of Colorectal Surgery, St Vincent's University Hospital, Dublin, Ireland
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27
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Fahy MR, Kelly ME, Nugent T, Hannan E, Winter DC. Lateral pelvic lymphadenectomy for low rectal cancer: a META-analysis of recurrence rates. Int J Colorectal Dis 2021; 36:551-558. [PMID: 33242114 DOI: 10.1007/s00384-020-03804-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/17/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Locoregional recurrence (LR) remains a problem for patients with lower rectal cancer despite standardized surgery and improved neoadjuvant treatment regimens. Lateral pelvic lymph node dissection (LPLND) has been routine practice for some time in the Orient/East, but other regions have concerns about morbidity. As perioperative care and surgical approaches are refined, this has been revisited for selected patients. The question as to whether LPLND improves oncological outcomes was explored here. METHODS A systematic review of patients who underwent TME with or without LPLND from 2000 to 2020 was performed. The primary endpoint was the rate of LR between the two groups. RESULTS Seven papers met the predefined search criteria in which 2000 patients underwent TME alone, while 1563 patients had TME and LPLND. The rate of LR was marginally higher with TME alone when compared with TME plus LPLND, but this result was not statistically significant (9.8 vs 9.4%, odds ratio 0.75, 95% CI 0.41-1.38, *p = 0.35). In addition, four studies reported on distant recurrence rates, with TME and LPLND showing a slight reduction in overall rates (27.3 vs 29.9%, respectively, OR 0.65, 95% CI 0.45-0.92, *p = 0.02). CONCLUSION The addition of LPLND to TME is not associated with a significantly lower risk of LR in patients who undergo surgery for lower rectal cancer.
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Affiliation(s)
- M R Fahy
- University College Dublin, Dublin, Ireland.
| | - M E Kelly
- University College Dublin, Dublin, Ireland
| | - T Nugent
- Trinity College Dublin, Dublin, Ireland
| | - E Hannan
- Department of Surgery, St Vincent's University Hospital, Dublin, Ireland
| | - D C Winter
- Department of Surgery, St Vincent's University Hospital, Dublin, Ireland
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28
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Hallam S, Ahmed F, Gouvas N, Pandey S, Nicol D. Oncological outcomes and stoma-free survival following TaTME, a prospective cohort study. Tech Coloproctol 2021; 25:439-447. [PMID: 33606129 DOI: 10.1007/s10151-020-02390-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 12/10/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Transanal TME (TaTME) was introduced to improve access to the pelvis in difficult cases (male sex, obesity and mid to low rectal cancers) and reduce the risk of anastomotic leak by avoiding cross stapling. In April 2018 the Norwegian hospital to whom all local; recurrences for rectal cancer are referred reported an unexpected rise in early multifocal local recurrences of 9.5% following TaTME compared with 3.4% following conventional TME leading to a nationwide moratorium on the procedure and ending, in an editorial published on the British Journal of Surgery in August 2020, by saying that other countries should consider the issue in the context of local practices and results. There are limited data concerning oncological outcomes of TaTME compared to conventional TME. The aim of this study was to report perioperative and oncological outcomes for patients with rectal cancer treated with TaTME in a high-volume, experienced UK centre. METHODS From January 2015 to January 2020 consecutive patients with histologically confirmed rectal cancer having TaTME at Worcestershire Royal Hospital NHS were prospectively entered into an online international registry. Patients were followed according to local protocol with clinical examination, tumour markers, endoscopy and radiology. RESULTS Seventy patients underwent TaTME for rectal cancer. The median distance of the tumour from the anorectal junction was 4 cm (IQR 2-5). The mesorectal margin was involved in 20 (1%) patients, all of whom received neoadjuvant chemoradiotherapy. Overall survival was 94% at a median follow-up of 15 months (IQR 9-31 months). Distant recurrence occurred in 12 (17%) of patients at a median of 14 months (IQR 10-17 months). The 18-month stoma-free survival rate was 66%. CONCLUSIONS A local recurrence rate of 5.7% supports the oncological safety of TaTME for rectal cancer.
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Affiliation(s)
- S Hallam
- Worcestershire Acute Hospitals NHS Trust, Colorectal Surgery, Worcester, UK.
| | - F Ahmed
- Worcestershire Acute Hospitals NHS Trust, Colorectal Surgery, Worcester, UK
| | - N Gouvas
- Worcestershire Acute Hospitals NHS Trust, Colorectal Surgery, Worcester, UK
| | - S Pandey
- Worcestershire Acute Hospitals NHS Trust, Colorectal Surgery, Worcester, UK
| | - D Nicol
- Worcestershire Acute Hospitals NHS Trust, Colorectal Surgery, Worcester, UK
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29
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Faerden AE, Wasmuth HH. Guidance for transanal total mesorectal excision had to be a general halt of the procedure. Colorectal Dis 2021; 23:549-550. [PMID: 33140574 DOI: 10.1111/codi.15421] [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: 10/17/2020] [Accepted: 10/27/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Arne E Faerden
- Department of Digestive Surgery, Akershus University Hospital, Lørenskog, Norway.,Clinic of Surgical Science, University of Oslo, Oslo, Norway
| | - Hans H Wasmuth
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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30
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Caycedo-Marulanda A, Lee L, Chadi SA, Verschoor CP, Crosina J, Ashamalla S, Brown CJ. Association of Transanal Total Mesorectal Excision With Local Recurrence of Rectal Cancer. JAMA Netw Open 2021; 4:e2036330. [PMID: 33533932 PMCID: PMC7859847 DOI: 10.1001/jamanetworkopen.2020.36330] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Proponents of novel transanal total mesorectal excision (TME) suggest the procedure overcomes the technical and oncologic challenges of conventional approaches for treating rectal cancer. Recently, however, there has been controversy regarding the oncologic safety of the procedure. OBJECTIVE To assess the association of transanal TME with the incidence of local recurrence (LR) of cancer and the probability of remaining free of LR during follow-up. DESIGN, SETTING, AND PARTICIPANTS This multicenter cohort study used data from 8 high-volume rectal cancer academic institutions from across Canada on all consecutive patients with primary rectal cancer treated by transanal TME at the participating centers. The study was conducted between January 2014 and December 2018, and data were analyzed from April 1, 2020, to September 15, 2020. EXPOSURE Transanal TME. MAIN OUTCOMES AND MEASURES The incidence of LR was reported as a direct measure of quality of resection. The cumulative probability of LR- and systemic recurrence (SR)-free survival at 36 months was estimated. Local recurrence and SR were defined as radiologic or endoscopic evidence of 1 or more new lesions in or outside the pelvis, respectively, documented during surveillance after the removal of the primary tumor. RESULTS Of 608 total patients included in the analysis, 423 (69.6%) were male; the median age was 63 years (interquartile range [IQR], 54-70 years). Local recurrence was identified in 22 patients (3.6%) after a median follow-up of 27 months (IQR, 18-38 months). The median time to LR was 13 months (IQR, 9-19 months). Sixteen of the 22 patients with LR (72.7%) were male, 14 (63.6%) received neoadjuvant chemoradiation, and 12 (54.5%) had American Joint Committee on Cancer stage III disease. Of those with LR, 16 (72.7%) had a negative circumferential radial margin and 20 (90.9%) had a negative distal resection margin, 2 (9.1%) experienced conversion to open surgery, and 15 (68.2%) also developed SR. The probability of LR-free survival at 36 months was 96% (95% CI, 94%-98%). According to the Cox proportional hazards regression model, the hazard ratio of LR was estimated to be 4.2 (95% CI, 2.9-6.2) times higher among patients with a positive circumferential radial margin than among those with a negative circumferential radial margin. CONCLUSIONS AND RELEVANCE In this cohort study, transanal TME performed by experienced surgeons was associated with an incidence of LR and SR that is in line with the published literature on open and laparoscopic TME, suggesting that transanal TME may be an acceptable approach for management of rectal cancer.
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Affiliation(s)
- Antonio Caycedo-Marulanda
- Department of Surgery, Kingston Health Sciences Centre, Queen’s University, Kingston, Ontario, Canada
- Health Sciences North Research Institute, Sudbury, Ontario, Canada
| | - Lawrence Lee
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Sami A. Chadi
- Division of Surgical Oncology and General Surgery, University Health Network and Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Jordan Crosina
- Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | - Shady Ashamalla
- Department of Surgery Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Carl J. Brown
- Department of Surgery, St Paul’s Hospital, The University of British Columbia, Vancouver, British Columbia, Canada
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Di Saverio S, Gallo G, Davies RJ, Bergamaschi R, Wheeler J, Sileri P, Fearnhead N. Robotic-assisted transanal total mesorectal excision for rectal cancer: more questions than answers. Tech Coloproctol 2021; 25:987-988. [PMID: 33449254 DOI: 10.1007/s10151-020-02402-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 12/28/2020] [Indexed: 02/08/2023]
Affiliation(s)
- S Di Saverio
- General Surgery Unit 1, Ospedale Di Circolo, Department of General Surgery, University of Insubria, University, ASST Sette Laghi, Regione Lombardia, Varese, Italy.
| | - G Gallo
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - R J Davies
- Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge Biomedical Campus, Hills Road, Cambridge, UK
| | - R Bergamaschi
- Section of Colorectal Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - J Wheeler
- Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge Biomedical Campus, Hills Road, Cambridge, UK
| | - P Sileri
- Colorectal Unit, University Vita-Salute San Raffaele, Milan, Italy
| | - N Fearnhead
- Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge Biomedical Campus, Hills Road, Cambridge, UK
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Brown SR, Shorthouse AJ, Finan PJ. Thirty years of the Association of Coloproctology of Great Britain and Ireland. Colorectal Dis 2020; 22:2298-2314. [PMID: 33049103 PMCID: PMC7839506 DOI: 10.1111/codi.15356] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 09/03/2020] [Accepted: 09/06/2020] [Indexed: 12/26/2022]
Abstract
This is a summary of the history of the Association of Coloproctology of Great Britain and Ireland from its inception in the late 1980s to the present day.
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Affiliation(s)
- Steven R. Brown
- Sheffield Teaching Hospitals NHS FTNorthern General HospitalSheffieldUK
| | - Andrew J. Shorthouse
- Sheffield Teaching Hospitals NHS FTNorthern General HospitalSheffieldUK,Sheffield Hallam UniversitySheffieldUK
| | - Paul J. Finan
- University of LeedsLeedsUK,Leeds Teaching Hospitals NHS TrustLeedsUK
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Caycedo-Marulanda A, Nadeau K, Verschoor CP, Sands D, Spinelli A, Ashamalla S, Patel SV, Di Candido F, Mujukian A, Zaghiyan K, Stevenson G, Wolthuis A, Clark DA, D'Hoore A, Stevenson A, Wexner SD. Exploring the perioperative outcomes of a sample of successful adopters of transanal total mesorectal excision (taTME) during the learning phase. Surgery 2020; 169:774-781. [PMID: 33243484 DOI: 10.1016/j.surg.2020.10.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 10/06/2020] [Accepted: 10/19/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Transanal total mesorectal excision can be a technically challenging operation to master. While many early adopters have reported adequate outcomes, others have failed to reproduce these results. There are contradicting data on oncologic outcomes during the learning phase of this technique. Thus, our objective was to perform a multicentered assessment of oncological outcomes in patients undergoing transanal total mesorectal excision during the learning phase in a sample of successful adopting centers. METHODS Surgeons from 8 centers with experience in the management of rectal cancer were invited to participate. The initial 51 consecutive benign and malignant cases of the participating units were retrospectively reviewed, but only 366 cancer cases were included in the analysis. Procedures were divided into implementation (ie, the first 10 cases) and postimplementation (ie, case 11 on onwards) groups, and the main outcome was the incidence of local recurrence. RESULTS The overall prevalence of local recurrence was 4.1% at a median follow-up of 35 months (interquartile range 20.3-44.2); among implementation and postimplementation groups local recurrence was 7.5% and 3.1%, respectively, and the rate of local recurrence was observed to be nearly 60% lower in the postimplementation group (hazard ratio [95% confidence interval] = 0.43 [0.26-0.72]) Total mesorectal excision specimens were complete or nearly complete in 87.7% of cases, and the circumferential and distal margins were clear in 93.2% and 92.6%, respectively CONCLUSION: Local recurrence rate was low during the learning phase of the transanal total mesorectal excision in a sample of rectal cancer surgeons with acceptable surgical and oncologic outcomes. Both the prevalence and rate of local recurrence were markedly lower in the postimplementation phase, indicating improvement as experience accumulated.
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Affiliation(s)
- Antonio Caycedo-Marulanda
- Department of Surgery, Queen's University, Kingston, Canada; Health Sciences North Research Institute, Sudbury, Canada.
| | - Kara Nadeau
- Department of Surgery, Northern Ontario School of Medicine, Health Sciences North, Sudbury, Canada
| | | | - Dana Sands
- Department of Surgery, Cleveland Clinic, Weston, FL
| | - Antonino Spinelli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, IRCCS, Rozzano-Milano, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milano, Italy
| | - Shady Ashamalla
- Department of Surgery, University Health Network, Toronto, Canada
| | - Sunil V Patel
- Department of Surgery, Queen's University, Kingston, Canada
| | - Francesca Di Candido
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, IRCCS, Rozzano-Milano, Italy
| | - Angela Mujukian
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Karen Zaghiyan
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Grant Stevenson
- School of Public Health, Faculty of Medicine, University of Queensland, Brisbane, Australia; Department of Surgery, University of Queensland, Brisbane, Australia
| | | | - David A Clark
- Department of Surgery, University of Queensland, Brisbane, Australia; Department of Surgery, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Andre D'Hoore
- Department of Surgery, University Hospital Leuven, Belgium
| | - Andrew Stevenson
- Department of Surgery, University of Queensland, Brisbane, Australia; Department of Surgery, Royal Brisbane and Women's Hospital, Brisbane, Australia
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Gómez Ruiz M, Lainez Escribano M, Cagigas Fernández C, Cristobal Poch L, Santarrufina Martínez S. Robotic surgery for colorectal cancer. Ann Gastroenterol Surg 2020; 4:646-651. [PMID: 33319154 PMCID: PMC7726686 DOI: 10.1002/ags3.12401] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/24/2020] [Accepted: 08/27/2020] [Indexed: 12/15/2022] Open
Abstract
Minimally invasive surgery has demonstrated many benefits in general surgery, particularly in colon and rectal procedures. On the other hand, it has some limitations that must be taken into account, especially technical drawback. Robotic surgery has incorporated many improvements to overcome this disadvantage, such as 3D visualization, articulating instruments assisting complex and precise movements. As a result, robotic colorectal surgery shows less intraoperative blood loss, shorter time to oral tolerance and initial flatus (particularly associated with "Enhanced Recovery After Surgery" protocol), less conversion rate to open surgery, shortened hospital stay, and longer distal margins compared to laparoscopic and open surgery. This approach also shows a shorter learning curve. Some studies suggest that it could decrease perioperatively or 30 days after the intervention's mortality, raise overall survival, reduce wound infection, and improve functional results, while others show no significant difference. However, it lengthens surgical time. Otherwise, the studies included do not show statistically significant changes in the number of resected lymph nodes and anastomotic leaks. Economic costs remain one of the major concerns, although to date there are no large-scale studies that have evaluated this aspect from a global point of view. Robotic surgery represents a qualitative leap in surgical instruments and, although there is no strong evidence in favor of the use of robotic surgery over laparoscopic or open surgery, there is enough evidence to support its use in colorectal surgery, with potential advantages for patients.
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Affiliation(s)
- Marcos Gómez Ruiz
- Colorectal Surgery UnitGeneral Surgery DepartmentMarqués de Valdecilla University HospitalSantanderSpain
- Valdecilla Biomedical Research Institute (IDIVAL)SantanderSpain
| | - Mario Lainez Escribano
- Colorectal Surgery UnitGeneral Surgery DepartmentMarqués de Valdecilla University HospitalSantanderSpain
| | - Carmen Cagigas Fernández
- Colorectal Surgery UnitGeneral Surgery DepartmentMarqués de Valdecilla University HospitalSantanderSpain
- Valdecilla Biomedical Research Institute (IDIVAL)SantanderSpain
| | - Lidia Cristobal Poch
- Colorectal Surgery UnitGeneral Surgery DepartmentMarqués de Valdecilla University HospitalSantanderSpain
- Valdecilla Biomedical Research Institute (IDIVAL)SantanderSpain
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