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Devane LA, Daly MC, Albert MR. Transanal Endoscopic Platforms: TAMIS versus Rigid Platforms: Pros and Cons. Clin Colon Rectal Surg 2022; 35:93-98. [PMID: 35237103 PMCID: PMC8885160 DOI: 10.1055/s-0041-1742108] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Transanal endoscopic surgery encompasses the minimally invasive surgical techniques used to operate in the rectum under magnification while maintaining pneumorectum via a resectoscope or port. The view, magnification, and surgical precision afforded by these advanced transanal techniques have resulted in excellent specimen quality and low recurrence rates, especially compared with traditional transanal surgery. For rigid platforms, the surgeon operates through a rigid 4-cm diameter steel proctoscope of varying lengths that is clamped to the operating table with an articulating arm. Transanal minimally invasive surgery (TAMIS) is a newer flexible platform using a disposable port which "hooks" into the anorectal ring to remain in place. The cost-effectiveness and versatility of the TAMIS platform have resulted in its popularity and use in more advanced applications such as transanal total mesorectal excision. Ultimately, the choice of operating platform should be based on surgeon preference, patient characteristics, availability, and cost. The pros and cons of each platform will be discussed in this article.
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Affiliation(s)
- Liam A. Devane
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland
| | - Meghan C. Daly
- AdventHealth, Digestive Health and Surgical Institute, Department of Colorectal Surgery, Orlando, FL
| | - Matthew R. Albert
- AdventHealth, Digestive Health and Surgical Institute, Department of Colorectal Surgery, Orlando, FL,Address for correspondence Matthew R. Albert, MD AdventHealth, Digestive Health and Surgical Institute, Department of Colorectal Surgery2501 North Orange Ave, Orlando, FL 32804
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Serra-Aracil X, Lucas-Guerrero V, Mora-López L. Complex Procedures in Transanal Endoscopic Microsurgery: Intraperitoneal Entry, Ultra Large Rectal Tumors, High Lesions, and Resection in the Anal Canal. Clin Colon Rectal Surg 2022; 35:129-134. [PMID: 35237108 PMCID: PMC8885161 DOI: 10.1055/s-0041-1742113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Transanal endoscopic microsurgery (TEM) allows the local excision of rectal tumors and achieves lower morbidity and mortality rates than total mesorectal excision. TEM can treat lesions up to 18 to 20 cm from the anal verge, obtaining good oncological results in T1 stage cancers and preserving sphincter function. TEM is technically demanding. Large lesions (>5 cm), those with high risk of perforation into the peritoneal cavity, those in the upper rectum or the rectosigmoid junction, and those in the anal canal are specially challenging. Primary suture after peritoneal perforation during TEM is safe and it does not necessarily require the creation of a protective stoma. We recommend closing the wall defect in all cases to avoid the risk of inadvertent perforation. It is important to identify these complex lesions promptly to transfer them to reference centers. This article summarizes complex procedures in TEM.
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Affiliation(s)
- Xavier Serra-Aracil
- Division of Colorectal Surgery, Department of General and Digestive Surgery, Parc Taulí University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain,Address for correspondence Xavier Serra-Aracil, MD, PhD Coloproctology Unit, Department of General and Digestive Surgery, Parc Tauli University Hospital, Universitat Autònoma de BarcelonaParc Tauli s/n., 08208 Sabadell, BarcelonaSpain
| | - Victoria Lucas-Guerrero
- Division of Colorectal Surgery, Department of General and Digestive Surgery, Parc Taulí University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Laura Mora-López
- Division of Colorectal Surgery, Department of General and Digestive Surgery, Parc Taulí University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
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de Lacy FB, Turrado-Rodriguez V, Torroella A, van Laarhoven J, Otero-Piñeiro A, Almenara R, Lacima G, Castells A, Lacy AM. Functional Outcomes and Quality of Life After Transanal Total Mesorectal Excision for Rectal Cancer: A Prospective Observational Study. Dis Colon Rectum 2022; 65:46-54. [PMID: 34596984 DOI: 10.1097/dcr.0000000000001939] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Few studies have addressed the functional impact after transanal total mesorectal excision. OBJECTIVE This study aimed to evaluate function and health-related quality of life among patients with rectal cancer treated with transanal total mesorectal excision. DESIGN Consecutive patients treated between 2016 and 2018 were selected. Their function and quality of life were studied preoperatively and at 3 and 12 months after surgery. SETTING This is a prospective case series. PATIENTS Patients were eligible if they had primary anastomosis, their diverting stoma had been reversed, and they did not have anastomotic leakage. Forty-five patients were finally included. A total of 31 (68.8%) and 32 patients (71.1%) completed the 3- and 12-month surveys. INTERVENTIONS Standard transanal total mesorectal excision was performed. MAIN OUTCOME MEASURES The primary end point was functional and quality-of-life outcomes using validated questionnaires. Secondary end points included values obtained with endoanal ultrasounds, anorectal manometries, and rectal sensation testing. RESULTS Wexner and Low Anterior Resection Syndrome scores significantly increased 3 months after surgery but returned to baseline values at 12 months. The rate of "major low anterior resection syndrome" at the end of follow-up was 25.0% (+11.7% compared with baseline, p = 0.314). Sexual and urinary functions remained stable throughout the study, although a meaningful clinical improvement was detected in male sexual interest. Among quality-of-life domains, all deteriorations returned to baseline values 12 months after surgery, except worsening of flatulence symptoms, and improvement in insomnia and constipation. At 12 months, an expected decrease in the mean width of the internal sphincter, the anal resting pressure, and the tenesmus threshold volume was found. LIMITATIONS This study was limited by its small sample size, the absence of a comparative group, and significant missing data in female sexual difficulty and in ultrasounds and manometries at 3 months. CONCLUSIONS Patients undergoing transanal total mesorectal excision report acceptable quality-of-life and functional outcomes 12 months after surgery. See Video Abstract at http://links.lww.com/DCR/B541. RESULTADOS FUNCIONALES Y CALIDAD DE VIDA DE LOS PACIENTES DESPUS DE LA ESCISIN MESORRECTAL TOTAL TRANSANAL PARA CNCER DE RECTO UN ESTUDIO PROSPECTIVO OBSERVACIONAL ANTECEDENTES:Pocos estudios han abordado el impacto funcional después de la escisión mesorrectal total transanal.OBJETIVO:Evaluar la función y la calidad de vida relacionada con la salud en pacientes con cáncer de recto tratados con escisión mesorrectal total transanal.DISEÑO:Se seleccionaron pacientes consecutivos tratados entre 2016 y 2018. Se estudió su función y calidad de vida, en la etapa preoperatoria, a los tres y doce meses postoperatorios.METODO:Serie de casos prospectivos.PACIENTES:Los pacientes eran incluidos en presencia de anastomosis primaria, cierre del estoma de derivación y en ausencia de fuga anastomótica. Finalmente se incluyeron cuarenta y cinco pacientes. Un total de 31 (68,8%) y 32 pacientes (71,1%) completaron las encuestas de tres y doce meses, respectivamente.INTERVENCIONES:Escisión mesorrectal total transanal estándar.PRINCIPALES MEDIDAS DE RESULTADO:Los criterio de evaluación principal fueron los resultados funcionales y de calidad de vida mediante cuestionarios previamente validados. Los criterios de evaluación secundarios incluyeron los valores obtenidos con ecografía endoanal, manometría anorrectal y prueba de sensibilidad rectal.RESULTADOS:La escala de Wexner y el síndrome de resección anterior baja aumentaron significativamente tres meses después de la cirugía, pero volvieron a los valores iniciales a los doce meses. La tasa de "síndrome de resección anterior inferior grave" al final del seguimiento fue del 25,0% (+ 11,7% en comparación con el valor inicial, p = 0,314). La función sexual y urinaria se mantuvo estable durante todo el estudio, aunque se detectó una mejora clínica significativa en la libido masculina. Entre los criterios que evalúan la calidad de vida, todas las alteraciones en la misma volvieron a los valores iniciales, doce meses después de la cirugía, excepto el aumento de flatulencia, la mejoría del insomnio y el estreñimiento. A los doce meses, se encontró una disminución esperada en el grosor medio del esfínter interno, la presión anal en reposo y el volumen umbral para la presencia de tenesmo.LIMITACIONES:Tamaño de muestra limitado, ausencia de un grupo comparativo, falta significativa de datos para identificar la dificultad para la actividad sexual femenina y el efectuar ecografía y manometría a los tres meses.CONCLUSIONES:Los pacientes sometidos a escisión mesorrectal total transanal refieren una calidad de vida y resultados funcionales aceptables a los doce meses después de la cirugía. Consulte Video Resumen en http://links.lww.com/DCR/B541.
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Affiliation(s)
- F Borja de Lacy
- Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clinic, IDIBAPS, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBERehd), University of Barcelona, Centro Esther Koplowitz, and Cellex Biomedical Research Centre, Barcelona, Catalonia, Spain
| | - Víctor Turrado-Rodriguez
- Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clinic, IDIBAPS, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBERehd), University of Barcelona, Centro Esther Koplowitz, and Cellex Biomedical Research Centre, Barcelona, Catalonia, Spain
| | - Alba Torroella
- Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clinic, IDIBAPS, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBERehd), University of Barcelona, Centro Esther Koplowitz, and Cellex Biomedical Research Centre, Barcelona, Catalonia, Spain
| | | | - Ana Otero-Piñeiro
- Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clinic, IDIBAPS, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBERehd), University of Barcelona, Centro Esther Koplowitz, and Cellex Biomedical Research Centre, Barcelona, Catalonia, Spain
| | - Raúl Almenara
- Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clinic, IDIBAPS, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBERehd), University of Barcelona, Centro Esther Koplowitz, and Cellex Biomedical Research Centre, Barcelona, Catalonia, Spain
| | - Glòria Lacima
- Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clinic, IDIBAPS, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBERehd), University of Barcelona, Centro Esther Koplowitz, and Cellex Biomedical Research Centre, Barcelona, Catalonia, Spain
| | - Antoni Castells
- Department of Gastroenterology, Institute of Digestive and Metabolic Diseases, Hospital Clinic, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBERehd), IDIBAPS, University of Barcelona, Centro Esther Koplowitz, and Cellex Biomedical Research Centre, Barcelona, Catalonia, Spain
| | - Antonio M Lacy
- Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clinic, IDIBAPS, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBERehd), University of Barcelona, Centro Esther Koplowitz, and Cellex Biomedical Research Centre, Barcelona, Catalonia, Spain
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Abstract
BACKGROUND An important drawback of local surgery for lesions in the anal canal is the difficulty of achieving en bloc full-thickness resections. The aim of this study is to evaluate TEM/TEO in lesions of this type from the point of view of morbidity, mortality and the quality of the pathology specimen. METHODS This is an observational study with prospective data collection from June 2004 to July 2018. Two groups are defined: group A (rectal tumors with proximal margin between 0 and ≤4 cm from anal verge) and group B (distal margin > 4 cm from anal verge). A technical description is provided; resections and postoperative complications in both groups are compared. RESULTS During the study period, 757 patients underwent TEM/TEO. Finally, 692 patients were included, 192 patients in group A and 500 patients in group B. An en bloc surgical specimen was obtained in 176/192 patients (91.7%), although the defect was completely sutured in 132 (68.8%). In the comparative analysis, group A did not present significantly greater fragmentation of the resected piece [16/192 (8.3%) vs. 36/500 (7.2%), p = 0.630], although group A was associated with greater involvement of the surgical margin [28/192 (14.6%), 32/500 (6.4%), p = 0.001] and clinically relevant morbidity [16/192 (8.3%), 20/500 (4%), p = 0.034]. There was no mortality. CONCLUSIONS The use of TEM/TEO to remove lesions originating in the anal canal is feasible. But we have to take into account that there is an increase in complications, technical difficulties and affected margins resection.
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Transanal endoscopic micro-surgery in elderly and very elderly patients: a safe option? Observational study with prospective data collection. Surg Endosc 2019; 33:184-191. [PMID: 29934869 DOI: 10.1007/s00464-018-6292-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 06/18/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND Although the incidence of colorectal cancer increases with the patient's age, the elderly continue to be less likely to be scheduled for surgery. Transanal endoscopic micro-surgery (TEM) is a surgical alternative to total mesorectal excision (TME) in early stage rectal cancer and/or in selected patients that could decrease morbidity and mortality rates in this group of patients. Our main objective is to assess the safety and feasibility of TEM in elderly (75-84 years) and very elderly (≥ 85 years) patients. METHODS Observational study was conducted with prospective data collection of all consecutive patients who underwent TEM between April 2004 and January 2017. Patients were assigned to groups according to age. Descriptive and comparative analyses between groups were performed. RESULTS We analyzed 693 patients, 429 patients < 75 years (61.9%), 220 patients between the ages of 75 and 84 (31.7%), and 44 patients ≥ 85 years old (6.3%). The tendency in our series is to increase comorbidities with age. Palliative or consensus intent was more frequently performed in elderly (10.5%, 34/220), and very elderly (45.4%, 20/44), compared with the youngest (6.3%, 27/429), (p < 0.001). Global morbidity presented an increasing trend related to age from 20.3% in < 75 years, to 25.9% in elderly and 34.1% in very elderly. Surgical complications were recorded in 18.5% (128/693) of patients with no significant differences between groups. The most common one was rectal bleeding 16.1% (111/693). Significant differences were found in non-surgical complications, recorded in 7.3% (16/220) in the elderly, and 15.9% (7/44) in the group above 84 years (p = 0.013). CONCLUSIONS TEM presents acceptable morbidity rates mainly due to non-surgical-related adverse effects in elderly and very elderly patients and may be a feasible and safe alternative in this population in both curative and non-curative indications.
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Spychalski M, Skulimowski A, Nishimura M, Dziki A. Comparison of Endoscopic Submucosal Dissection for Primary and Recurrent Colorectal Lesions: A Single-Center European Study. J Laparoendosc Adv Surg Tech A 2018; 29:366-373. [PMID: 30359169 DOI: 10.1089/lap.2018.0429] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Endoscopic submucosal dissection (ESD) is an acknowledged endoscopic technique for the management of early gastrointestinal neoplasia. The clinical experience and the research from the Eastern ESD centers show that experienced endoscopists can successfully treat even the most demanding recurrent colorectal lesions. AIM The aim of this study was to analyze the clinical outcomes of the management of recurrent colorectal lesions in comparison with those of primary lesions in the setting of high-volume European center. METHODS A retrospective analysis of 298 cases (228 primary lesions and 70 recurrent lesions) performed by a single endoscopist was carried out. Evaluating learning curves for both primary and recurrent lesions, cumulative sum analysis was performed. RESULTS Primary lesions had ∼9% higher R0 resection rate (86.84% versus 78.51%). Yet, this difference did not reach statistical significance (P = .091). The presence of recurrent lesion and lengthy procedure (≥150 min) are risks factors of R1 resection, whereas rectal localization of the lesion was associated with lower risk of R1 resection. The cumulative R0 of 80% was achieved at 36th procedure in the primary lesions group, whereas for the recurrent lesions it was reached at 50th procedure (overall 229 procedures). CONCLUSIONS Our study underlines the importance of proper experience in ESD before the management of recurrent lesions. Even after the completion of high volume of primary lesions, first recurrent lesions can pose a challenge. Nevertheless, the final outcomes are promising, as the complications do not pose a serious risk to the patients and high R0 resection rate can be achieved in a reasonable timeframe.
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Affiliation(s)
- Michał Spychalski
- 1 Department of General and Colorectal Surgery, Multidisciplinary Hospital Brzeziny , Brzeziny, Poland
| | - Aleksander Skulimowski
- 1 Department of General and Colorectal Surgery, Multidisciplinary Hospital Brzeziny , Brzeziny, Poland
| | - Makoto Nishimura
- 2 Department of Gastrointestinal Endoscopy, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology , Tokyo, Japan
| | - Adam Dziki
- 3 Department of General and Colorectal Surgery, Medical University of Lodz , Lodz, Poland
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