Current status of transanal total mesorectal excision for rectal cancer and the expanding indications of the transanal approach for extended pelvic surgeries

MRI navigation surgery for T4b rectal cancer using multiple minimally invasive surgical approaches

BACKGROUND

These days, various surgical techniques such as trans-anal, trans-perineal total mesorectal excision, and transvaginal natural orifice transluminal endoscopic surgery have been utilized with flexibility, which was not possible before the laparoscopic era.

METHODS

From January 2014 to January 2023, 40 cases of c(yc)T4b rectal cancer underwent local curative surgery laparoscopically at Kansai Medical University Hospital. In 25 consecutive cases, we adopted multiple approaches (trans-anal total mesorectal excision, transvaginal natural orifice transluminal endoscopic surgery, trans-perineal total mesorectal excision, or prone position first abdominoperineal excision) to remove the deepest part of the tumor indicated by MRI last as the specimen-oriented surgery. The remaining 15 patients underwent top-to-bottom surgery based on standard surgery. The primary endpoint was the local recurrence rate of the specimen-oriented surgery group compared to that of the standard surgery group.

RESULTS

The specimen-oriented surgery group had a median follow-up of 3.9 (0.4-7.4) years with no local recurrence, while the standard surgery group had a median follow-up of 1.5 (0.7-3.7) years with 5 of 15 patients (33%) experiencing more local recurrence than specimen-oriented surgery group (p = 0.005). Comparison of the local recurrence ( +) and ( -) groups showed significant differences in pCRM positive rate, neoadjuvant therapy, tumor size, and approach (specimen-oriented surgery vs. standard surgery) in univariate analysis (p < 0.05). Still, no significant differences were found in the multivariate analysis.

CONCLUSIONS

In the laparoscopic setting, local cure of c(yc)T4b rectal cancer requires a different strategy than open surgery, and specimen-oriented surgery may be a promising procedure.

Reversed anatomy in transanal lateral lymph node dissection: landmarks and pitfalls

Lateral lymph node dissection (LLND) is getting global attention as an a surgical option to reduce local recurrence in locally advanced rectal cancer. As the transanal total mesorectal excision (TaTME) is gaining popularity worldwide, a novel LLND approach was established adopting a two-team approach that combines the transabdominal and transanal approaches using the TaTME technique. This narrative review describes the advantages, anatomical landmarks, surgical techniques, and pitfalls of transanal LLND (TaLLND). The advantages of TaLLND include a magnified view and enhanced maneuverability of the laparoscopic instruments in the deep pelvis. TaLLND is also beneficial for LLND in patients with a history of pelvic surgery because surgeons can have access to the areas unaffected by previous surgery. To master the TaLLND technique, the procedure should be understood according to the following steps: S4 nerve identification, lateral space entry, lateral dissection, obturator vein, artery, and nerve identification, dissection along the external iliac vein, medial dissection, median and bottom dissection, dissection along the internal iliac artery, and dissection along the obturator nerve. TaLLND can be applied to highly advanced disease that requires combined resection of the major internal iliac vessels, pelvic nerves, or adjacent organs. In such cases, simultaneous transanal and transabdomiinal LLND utilizing a two team approach has advantages as these approaches can provide mutual complementary roles. TaLLND is expected to overcome the difficulty of transabdominal LLND and improve the quality of LLND.

Elderly Rectal Cancer: An Updated Review

PURPOSE OF REVIEW

Treatment of rectal cancer patients of advanced age should be modulated by life expectancy and tolerance. Due to the rapid advance of this field, we aim to conduct an updated review of this topic.

RECENT FINDINGS

The field of elderly rectal cancer has advanced a lot. This review covers all the treatment aspects of elderly rectal cancer, including the prognostic factor, surgery, radiotherapy, chemotherapy, and palliative treatment. We also provide the future aspect of the management of elderly rectal cancer. The advancement of prognostic factor research, surgery, radiotherapy, chemotherapy, and palliative treatment has made the care of elderly rectal cancer patients better. The future of these fields should focus on the definition of the elderly and the application of particle therapy.