1
|
Polese L. Removal of a large rectal polyp with endoscopic submucosal dissection-trans-anal rectoscopic assisted minimally invasive surgery hybrid technique: A case report. World J Gastrointest Surg 2023; 15:2932-2937. [PMID: 38221999 PMCID: PMC10784841 DOI: 10.4240/wjgs.v15.i12.2932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 11/08/2023] [Accepted: 12/08/2023] [Indexed: 12/27/2023] Open
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) can be used for the en-bloc removal of superficial rectal lesions; however, the lack of a traction system makes the procedure long and difficult in the presence of extensive lesions. CASE SUMMARY A large polyp occupying 2/3 of the rectal circumference and extending 5 cm in length was removed by ESD with the help of laparoscopic forceps introduced via trans-anal rectoscopic assisted minimally invasive surgery, a disposable platform designed to aid in transanal minimally invasive surgery. Traction of the polyp by forceps during the operation was dynamic, and applied at various points and in various directions. The polyp was removed en-bloc without complications in 1 h and 55 min. A sigmoidoscopy performed 50 d later showed normal healing without polyp recurrence. CONCLUSION The technique presented here could overcome the issues caused by lack of traction during ESD for rectal lesions.
Collapse
Affiliation(s)
- Lino Polese
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova 35128, Italy
| |
Collapse
|
2
|
Shilo Yaacobi D, Berger Y, Shaltiel T, Bekhor EY, Khalifa M, Issa N. Excision of malignant and pre-malignant rectal lesions by transanal endoscopic microsurgery in patients under 50 years of age. World J Gastrointest Surg 2023; 15:1892-1900. [PMID: 37901725 PMCID: PMC10600772 DOI: 10.4240/wjgs.v15.i9.1892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/24/2023] [Accepted: 07/29/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND The most common technique for treating benign and early malignant rectal lesions is transanal endoscopic microsurgery (TEM). Local excision is an acceptable technique for high-risk and elderly patients, but there are hardly any data regarding young patients. AIM To describe TEM outcomes in patients under 50 years of age. METHODS We collected demographic, clinical, and pathological data from all patients under the age of 50 years who underwent the TEM procedure at Hasharon Rabin Medical Center from January 2005 to December 2018. RESULTS During the study period, a total of 26 patients under the age of 50 years underwent TEM procedures. Their mean age was 43.3 years. Eleven (42.0%) were male. The mean operative time was 67 min, and the mean tumor size was 2.39 cm, with a mean anal verge distance of 8.50 cm. No major intraoperative or postoperative complications were recorded. The median length of stay was 2 d. Seven (26.9%) lesions were adenomas with low-grade dysplasia, four (15.4%) were high-grade dysplasia adenomas, two were T1 carcinomas (7.8%), and three were T2 carcinomas (11.5%). No residual disease was found following endoscopic polypectomy in two patients (7.8%), but four (15.4%) had other pathologies. Surgical margins were negative in all cases. Local recurrence was detected in one patient 33 mo following surgery. CONCLUSION Among young adult patients, TEM for benign rectal lesions has excellent outcomes. It may also offer a balance between the efficacy of complete oncologic resection and postoperative quality of life in the treatment of rectal cancer. In some cases, it may be considered an alternative to radical surgery.
Collapse
Affiliation(s)
- Dafna Shilo Yaacobi
- Department of Plastic Surgery & Burns, Rabin Medical Center, Petah Tikva 4941492, Israel
| | - Yael Berger
- Department of Surgery, Rabin Medical Center-Hasharon Hospital, Petah Tikva 4941492, Israel
| | - Tali Shaltiel
- Department of Surgery, Rabin Medical Center-Hasharon Hospital, Petah Tikva 4941492, Israel
| | - Eliahu Y Bekhor
- Department of Surgery, Rabin Medical Center-Hasharon Hospital, Petah Tikva 4941492, Israel
| | - Muhammad Khalifa
- Department of Surgery, Rabin Medical Center-Hasharon Hospital, Petah Tikva 4941492, Israel
| | - Nidal Issa
- Department of Surgery, Rabin Medical Center-Hasharon Hospital, Petah Tikva 4941492, Israel
| |
Collapse
|
3
|
Khomyakov E, Chernyshov S, Fomenko O, Rybakov E. Does transanal endoscopic microsurgery affect rectal function? Ann Coloproctol 2023; 39:326-331. [PMID: 36375444 PMCID: PMC10475803 DOI: 10.3393/ac.2022.00220.0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 04/26/2022] [Accepted: 05/16/2022] [Indexed: 11/15/2022] Open
Abstract
PURPOSE Transanal endoscopic microsurgery (TEM) is the most standardized method for the local excision of rectal neoplasms. Unfortunately, local excisions of rectal lesions by means of TEM are not completely free from undesirable functional sequela. This study was performed to evaluate the risk factors of major loss of function after TEM. METHODS Eighty-nine patients underwent TEM between 2019 and 2020. Anorectal manometry was performed before the surgery and 3, 6, and 12 months after the surgery. The quality of life (QoL) was assessed using the Fecal Incontinence Quality of Life scale. RESULTS The major decrease in QoL was observed in women in 3 months after the surgery in terms of lifestyle and frustration domains (3.6 and 3.64 points, respectively). In 3 months after the surgery, there was a significant decrease in resting pressure both in male and female patients (P=0.01). This difference remained significant 6 months after the surgery (P=0.01). In 12 months after the surgery, resting pressure returned to the preoperative level in most patients (P=0.50). A significant decrease in manometric parameters appeared when the surgery time is more than 55 minutes (P=0.05), the tumor localization is lower than 3 cm from the anus (P=0.03), and the tumor size is over 3 cm (P=0.001). CONCLUSION The most significant risk factors for the development of functional disorders after TEM are surgery time of >55 minutes, tumor localization at <3 cm from the anal verge, and tumor size of >3 cm.
Collapse
Affiliation(s)
- Evgeniy Khomyakov
- Ryzhikh National Medical Research Center of Coloproctology, Moscow, Russia
- Russian Medical Academy of Continuous Professional Education, Moscow, Russia
| | | | - Oksana Fomenko
- Ryzhikh National Medical Research Center of Coloproctology, Moscow, Russia
| | - Evgeny Rybakov
- Ryzhikh National Medical Research Center of Coloproctology, Moscow, Russia
| |
Collapse
|
4
|
Marin FS, Abou Ali E, Belle A, Beuvon F, Coriat R, Chaussade S. " Transanal endoscopic microsurgery" with a flexible colonoscope (F-TEM): a new endoscopic treatment for suspicious deep submucosal invasion T1 rectal carcinoma. Surg Endosc 2023:10.1007/s00464-023-10141-7. [PMID: 37231174 DOI: 10.1007/s00464-023-10141-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 05/16/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Endoscopic techniques allow resections of deep submucosal invasion rectal carcinoma, but mostly are facing issues such as costs, follow-up care or size limit. Our aim was to design a new endoscopic technique, which retains the advantages over surgical resections while eliminating the disadvantages mentioned above. PATIENTS AND METHODS We propose a technique for the resection of the superficial rectal tumours, with highly suspicious deep submucosal invasion. It combines steps of endoscopic submucosal dissection, muscular resection and edge-to-edge suture of the muscular layers, finally performing the equivalent of a "transanal endoscopic microsurgery" with a flexible colonoscope (F-TEM). RESULTS A 60-year-old patient was referred to our unit, following the discovery of a 15 mm distal rectum adenocarcinoma. The computed tomography and the endoscopic ultrasound examination revealed a T1 tumour, without secondary lesions. Considering that the initial endoscopic evaluation highlighted a depressed central part of the lesion, with several avascular zones, an F-TEM was performed, without severe complication. The histopathological examination revealed negative resection margins, without risk factors for lymph node metastasis, no adjuvant therapy being proposed. CONCLUSION F-TEM allows endoscopic resection of highly suspicious deep submucosal invasion T1 rectal carcinoma and it proves to be a feasible alternative to surgical resection or other endoscopic treatments as endoscopic submucosal dissection or intermuscular dissection.
Collapse
Affiliation(s)
- Flavius-Stefan Marin
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France.
| | - Einas Abou Ali
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France
| | - Arthur Belle
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France
| | - Frédéric Beuvon
- Faculty of Medicine, Paris Cité University, Paris, France
- Department of Pathology, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Romain Coriat
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France
- Faculty of Medicine, Paris Cité University, Paris, France
| | - Stanislas Chaussade
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France
- Faculty of Medicine, Paris Cité University, Paris, France
| |
Collapse
|
5
|
Li W, Xiang XX, Da Wang H, Cai CJ, Cao YH, Liu T. Transanal endoscopic microsurgery versus radical resection for early-stage rectal cancer: a systematic review and meta- analysis. Int J Colorectal Dis 2023; 38:49. [PMID: 36800079 PMCID: PMC9938057 DOI: 10.1007/s00384-023-04341-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/07/2023] [Indexed: 02/18/2023]
Abstract
PURPOSE In the treatment of early-stage rectal cancer, a growing number of studies have shown that transanal endoscopic microsurgery is one of the alternatives to radical surgery adhering to total mesorectal excision that can reduce the incidence of adverse events without compromising treatment outcomes. The purpose of this meta-analysis is to compare the safety and treatment effect of transanal endoscopic microsurgery and radical surgery adhering to total mesorectal excision to provide a basis for clinical treatment selections. METHOD We searched the literatures of four major databases, PubMed, Embase, Web of science, and Cochrane Library, without limitation of time. The literatures included randomized controlled studies and cohort studies comparing two surgical procedures of transanal endoscopic microsurgery and radical surgery adhering to total mesorectal excision. Treatment effectiveness and safety results of transanal endoscopic microsurgery and radical surgery were extracted from the included literatures and statistically analyzed using RevMan5.4 and stata17. RESULT Ultimately, 13 papers were included in the study including 5 randomized controlled studies and 8 cohort studies. The results of the meta-analysis showed that the treatment effect and safety of both transanal endoscopic microsurgery and radical surgery in distant metastasis (RR, 0.59 (0.34, 1.02), P > 0.05), overall recurrence (RR, 1.49 (0.96, 2.31), P > 0.05), disease-specific-survival (RR, 0.74 (0.09, 1.57), P > 0.05), dehiscence of the sutureline or anastomosis leakage (RR, 0.57 (0.30, 1.06), P > 0.05), postoperative bleeding (RR, 0.47 (0.22, 0.99), P > 0.05), and pneumonia (RR, 0.37, (0.10, 1.40), P > 0.05) were not significantly different. However, they differ significantly in perioperative mortality (RR, 0.26 (0.07, 0.93, P < 0.05)), local recurrence (RR, 2.51 (1.53, 4.21), P < 0.05),_overall survival_ (RR, 0.88 (0.74, 1.00), P < 0.05), disease-free-survival (RR, 1.08 (0.97, 1.19), P < 0.05), temporary stoma (RR, 0.05 (0.01, 0.20), P < 0.05), permanent stoma (RR, 0.16 (0.08, 0.33), P < 0.05), postoperative complications (RR, 0.35 (0.21, 0.59), P < 0.05), rectal pain (RR, 1.47 (1.11, 1.95), P < 0.05), operation time (RR, -97.14 (-115.81, -78.47), P < 0.05), blood loss (RR, -315.52 (-472.47, -158.57), P < 0.05), and time of hospitalization (RR, -8.82 (-10.38, -7.26), P < 0.05). CONCLUSION Transanal endoscopic microsurgery seems to be one of the alternatives to radical surgery for early-stage rectal cancer, but more high-quality clinical studies are needed to provide a reliable basis.
Collapse
Affiliation(s)
- Wei Li
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan , Hubei Province, 430022, China
| | - Xing Xing Xiang
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan , Hubei Province, 430022, China
| | - Hong Da Wang
- Department of Trauma Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan , Hubei Province, 430022, China
| | - Chen Jun Cai
- Department of Trauma Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan , Hubei Province, 430022, China
| | - Ying Hao Cao
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
| | - Tao Liu
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
| |
Collapse
|
6
|
Peltrini R, Castiglioni S, Imperatore N, Ortenzi M, Rega D, Romeo V, Caracino V, Liberatore E, Basti M, Santoro E, Bracale U, Delrio P, Mucilli F, Guerrieri M, Corcione F. Short- and long-term outcomes in ypT2 rectal cancer patients after neoadjuvant therapy and local excision: a multicentre observational study. Tech Coloproctol 2023; 27:53-61. [PMID: 36239872 DOI: 10.1007/s10151-022-02712-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 10/04/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Although local excision (LE) after neoadjuvant treatment (NT) has achieved encouraging oncological outcomes in selected patients, radical surgery still remains the rule when unfavorable pathology occurs. However, there is a risk of undertreating patients not eligible for radical surgery. The aim of this study was to evaluate the outcomes of patients with pathological incomplete response (ypT2) in a multicentre cohort of patients undergoing LE after NT and to compare them with ypT0-is-1 rectal cancers. METHODS From 2010 to 2019, all patients who underwent LE after NT for rectal cancer were identified from five institutional retrospective databases. After excluding 12 patients with ypT3 tumors, patients with ypT2 tumors were compared to patients with ypT0-is-1 tumors). The endpoints of the study were early postoperative and long-term oncological outcomes. RESULTS A total of 177 patients (132 males, 45 females, median age 70 [IQR 16] years) underwent LE following NT. There were 46 ypT2 patients (39 males, 7 females, median age 72 [IQR 18.25] years) and 119 ypT0-is-1 patients (83 males, 36 females, median age 69 [IQR 15] years). Patients with pathological incomplete response (ypT2) were frailer than the ypT0-is-1 patients (mean Charlson Comorbidity Index 6.15 ± 2.43 vs. 5.29 ± 1.99; p = 0.02) and there was a significant difference in the type of NT used for the two groups (long- course radiotherapy: 100 (84%) vs. 23 (63%), p = 0.006; short-course radiotherapy: 19 (16%) vs. 17 (37%), p = 0.006). The postoperative rectal bleeding rate (13% vs. 1.7%; p = 0.008), readmission rate (10.9% vs. 0.8%; p = 0.008) and R1 resection rate (8.7% vs. 0; p = 0.008) was significantly higher in the ypT2 group. Recurrence rates were comparable between groups (5% vs. 13%; p = 0.15). Five-year overall survival was 91.3% and 94.9% in the ypT2 and ypT0-is-1 groups, respectively (p = 0.39), while 5-year cancer specific survival was 93.4% in the ypT2 group and 94.9% in the ypT0-is-1 group (p = 0.70). No difference was found in terms of 5-year local recurrence free-survival (p = 0.18) and 5-year distant recurrence free-survival (p = 0.37). CONCLUSIONS Patients with ypT2 tumors after NT and LE have a higher risk of late-onset rectal bleeding and positive resection margins than patients with complete or near complete response. However, long-term recurrence rates and survival seem comparable.
Collapse
|
7
|
Kouladouros K, Baral J. Transanal Endoscopic Microsurgical Submucosal Dissection: An Efficient Treatment Option for Giant Superficial Neoplastic Lesions of the Rectum. Visc Med 2022; 38:282-287. [PMID: 36160819 PMCID: PMC9421700 DOI: 10.1159/000522367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 01/28/2022] [Indexed: 08/03/2023] Open
Abstract
Introduction The resection of giant superficial neoplastic lesions of the rectum (>5 cm) is challenging even for experienced specialists. Endoscopic mucosal resection, endoscopic submucosal dissection (ESD), and transanal endoscopic microsurgery (TEM) have all been used for the treatment of such tumors. However, because of their individual disadvantages, the ideal technique for the treatment of these lesions has yet to be determined. Transanal endoscopic microsurgical submucosal dissection (TEM-ESD) is a recently developed hybrid technique that combines the advantages of conventional TEM and flexible ESD. The aim of our study was to assess the feasibility and outcomes of TEM-ESD for the resection of giant superficial rectal neoplasms. Methods We retrospectively analyzed all cases of TEM-ESD performed in the Department of Surgery of the Municipal Hospital of Karlsruhe between 2010 and 2020 and isolated 43 patients with superficial rectal lesions >5 cm according to the postoperative histology report. The diagnostic, perioperative, histological, and follow-up data of the patients were analyzed in the form of a retrospective, observational cohort study. Results We identified 43 cases matching our criteria, including 35 adenomas and 8 occult adenocarcinomas. The median size of the lesions was 75 mm and the median operating time was 81.5 min. En bloc resection was possible in all cases, and histologically complete en bloc resection was confirmed in 29 cases. Five patients presented with postoperative bleeding, 2 of which were treated conservatively, 2 were treated endoscopically, and 1 required revision surgery. The median follow-up period was 15 months. There was no recurrence among patients with adenomas, 1 recurrence of a low-risk carcinoma, and 1 recurrence after the resection of a high-risk carcinoma in a patient that refused further treatment. During the follow-up period, 3 patients developed a stenosis, which was treated endoscopically. Conclusions TEM-ESD is a feasible and safe therapeutic option for the treatment of giant superficial rectal neoplasms.
Collapse
Affiliation(s)
- Konstantinos Kouladouros
- Central Interdisciplinary Endoscopy Department, Mannheim University Hospital, University of Heidelberg, Mannheim, Germany
| | - Jörg Baral
- Surgery Department, Karlsruhe Municipal Hospital, Karlsruhe, Germany
| |
Collapse
|
8
|
Gascon MA, Aguilella V, Martinez T, Antinolfi L, Valencia J, Ramírez JM. Local full-thickness excision for sessile adenoma and cT1-2 rectal cancer: long-term oncological outcome. Langenbecks Arch Surg 2022; 407:2431-2439. [PMID: 35732844 PMCID: PMC9467953 DOI: 10.1007/s00423-022-02593-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 06/15/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE We analyzed all patients who underwent local transanal surgery at our institution to determine oncological outcomes and perioperative risk. METHODS In 1997, we developed a prospective protocol for rectal tumors: transanal local full-thickness excision was considered curative in patients with benign adenoma and early cancers. In this analysis, 404 patients were included. To analyze survival, only those patients exposed to the risk of dying for at least 5 years were considered for the study. RESULTS The final pathological analysis revealed that 262 (64.8%) patients had benign lesions, whereas 142 had malignant lesions. Postoperative complications were recorded in 12.6%. At the median time of 21 months, 14% of the adenomas and 12% of cancers had recurred, half of which were surgically resected. The overall 5-year survival rate was 94%. CONCLUSION With similar outcomes and significantly lower morbidity, we found local surgery to be an adequate alternative to radical surgery in selected cases of early rectal cancer.
Collapse
Affiliation(s)
- Maria A Gascon
- Department of Surgery, "Lozano Blesa" University Hospital, San Juan Bosco 15, 50009, Saragossa, Spain
| | - Vicente Aguilella
- Department of Surgery, "Lozano Blesa" University Hospital, San Juan Bosco 15, 50009, Saragossa, Spain
| | - Tomas Martinez
- Department of Microbiology, Preventive Medicine and Public Health, University of Zaragoza, Domingo Miral s/n 50009-Saragossa, Spain
| | - Luigi Antinolfi
- Department of Surgery, "Lozano Blesa" University Hospital, San Juan Bosco 15, 50009, Saragossa, Spain
| | - Javier Valencia
- Department of Radiotherapy, "Lozano Blesa" University Hospital, San Juan Bosco 15, 50009, Saragossa, Spain
| | - Jose M Ramírez
- Department of Surgery, "Lozano Blesa" University Hospital, San Juan Bosco 15, 50009, Saragossa, Spain.
- Aragon Health Research Institute, San Juan Bosco 13, 50009, Saragossa, Spain.
| |
Collapse
|
9
|
Kouladouros K, Baral J. Transanal endoscopic microsurgical submucosal dissection (TEM-ESD) for rectal adenomas: a retrospective cohort study of 145 consecutive cases. Langenbecks Arch Surg 2022; 407:2423-2430. [PMID: 35652960 DOI: 10.1007/s00423-022-02562-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 05/18/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE Transanal endoscopic microsurgery (TEM) and endoscopic submucosal dissection (ESD) are currently the two most popular methods for resecting large rectal adenomas en bloc. However, damage to the mesorectum in the case of TEM, plus the technical challenges and long procedure times of flexible ESD, are major disadvantages of these procedures. Transanal endoscopic microsurgical submucosal dissection (TEM-ESD) is a new technique, combining the ergonomic features of TEM with the minimally invasive approach of ESD. The aim of our study was to assess the feasibility and safety of TEM-ESD for resection of large rectal adenomas. METHODS We retrospectively analyzed all TEM-ESD procedures performed in Karlsruhe Municipal Hospital between 2012 and 2019, isolated all cases of adenomas, and analyzed the perioperative and follow-up data of the patients. RESULTS We identified 145 cases matching our criteria. The median size of the lesions was 4.2 cm, and the median operating time was 45 min. The en bloc resection rate was 100%, and the complete en bloc resection rate was 78.6%. The overall morbidity rate was 6.9%. In a median follow-up period of 24 months, there was a local recurrence in 4.8% of the cases. CONCLUSIONS TEM-ESD is a safe and feasible therapeutic option for resecting large rectal adenomas, offering high en bloc resection and low recurrence rates combined with short operating time and low morbidity. TRIAL REGISTRATION NUMBER (CLINICALTRIALS.GOV): NCT04870931.
Collapse
Affiliation(s)
- Konstantinos Kouladouros
- Central Interdisciplinary Endoscopy Department, Department of Surgery, Mannheim University Hospital, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany. .,Surgery Department, Karlsruhe Municipal Hospital, Moltkestrasse 90, 76133, Karlsruhe, Germany.
| | - Jörg Baral
- Central Interdisciplinary Endoscopy Department, Department of Surgery, Mannheim University Hospital, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.,Surgery Department, Karlsruhe Municipal Hospital, Moltkestrasse 90, 76133, Karlsruhe, Germany
| |
Collapse
|
10
|
Abstract
BACKGROUND The local resection of recurrent rectal adenomas is a technically challenging task associated with increased local recurrence rate. Transanal endoscopic microsurgical submucosal dissection (TEM-ESD) uses traction to better expose the fibrotic submucosal layer, and therefore, is a valuable alternative for the treatment of such lesions. The aim of our study was to assess the feasibility and outcomes of TEM-ESD for the resection of recurrent rectal adenomas. METHODS We retrospectively analysed all TEM-ESD procedures performed in the Karlsruhe Municipal Hospital between 2012 and 2021 and isolated all cases of recurrent adenomas. Subsequently, we matched these cases 1:1 to TEM-ESD cases for primary rectal adenomas according to the size, localization, and histological type of the lesions and compared the outcomes between the two groups. RESULTS We identified 19 cases matching our criteria. The median diameter of the lesions was 25 mm and the median operating time 39 min. Macroscopic en bloc resection was achieved in 100% of the cases and histological complete en bloc resection in 78.9%. There was 1 case of conservatively treated postoperative bleeding. After a median follow-up period of 36 months, there was one local recurrence. After comparing those findings to the outcomes of TEM-ESD for primary rectal lesions, we found no significant differences on total operating time, complete en bloc resection rates, adverse events, and local recurrence. CONCLUSION TEM-ESD is a feasible therapeutic option for the resection of recurrent rectal adenomas, offering short operating times as well as high en bloc resection and low recurrence rates.
Collapse
Affiliation(s)
- Konstantinos Kouladouros
- Central Interdisciplinary Endoscopy Department, Mannheim University Hospital, University of Heidelberg, Mannheim, Germany
| | - Jörg Baral
- Surgery Department, Karlsruhe Municipal Hospital, Karlsruhe, Germany
| |
Collapse
|
11
|
Shi WK, Hou R, Li YH, Qiu XY, Liu YX, Wu B, Xiao Y, Zhou JL, Lin GL. Long-term outcomes of transanal endoscopic microsurgery for the treatment of rectal neuroendocrine tumors. BMC Surg 2022; 22:43. [PMID: 35120483 PMCID: PMC8817465 DOI: 10.1186/s12893-022-01494-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 01/18/2022] [Indexed: 11/10/2022] Open
Abstract
Background Transanal endoscopic microsurgery (TEM) has been accepted worldwide for the treatment of local rectal lesions. We aimed to assess the efficacy and safety of TEM in the treatment of rectal neuroendocrine tumors (RNET). Methods A retrospective study of patients who had undergone TEM for RNET at our institution between December 2006 and June 2019 was performed. Demographic and tumor characteristics, operative and pathological details, complications, anal function questionnaires, and follow-up data were included. Results A total of 144 patients was included. TEM was performed as primary excision in 54 patients, after endoscopic forceps biopsy in 57 patients, and after incomplete resection by endoscopic excision in 33 patients. The median size of all primary tumors was 0.6 cm (range, 0.3–2.0 cm), and the negative resection margin was achieved in 142 (98.6%) patients. Postoperative complications (referring to only bleeding) occurred in 3 (2.1%) patients and was successfully managed with conservative method. After a median follow-up of 75.5 months after surgery, 3 patients died of other causes, and 2 patients suffered metastasis. An anal function questionnaire was posted 24 months after TEM. Among the results, 3 (2.1%) patients complained of major low anterior resection syndrome (LARS), including 1 (0.7%) who suffered from complete incontinence, while 6 (4.2%) patients had minor LARS. Conclusions TEM has satisfying long-term outcomes and relatively low anal function disturbance as for the treatment of small RNET. TEM also acts as a preferred salvage treatment for incomplete endoscopic excision.
Collapse
Affiliation(s)
- Wei-Kun Shi
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Shuaifuyuan 1, Beijing, 100730, China
| | - Rui Hou
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Shuaifuyuan 1, Beijing, 100730, China
| | - Yun-Hao Li
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Shuaifuyuan 1, Beijing, 100730, China
| | - Xiao-Yuan Qiu
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Shuaifuyuan 1, Beijing, 100730, China
| | - Yu-Xin Liu
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Shuaifuyuan 1, Beijing, 100730, China
| | - Bin Wu
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Shuaifuyuan 1, Beijing, 100730, China
| | - Yi Xiao
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Shuaifuyuan 1, Beijing, 100730, China
| | - Jiao-Lin Zhou
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Shuaifuyuan 1, Beijing, 100730, China
| | - Guo-Le Lin
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Shuaifuyuan 1, Beijing, 100730, China.
| |
Collapse
|
12
|
Morino M, Forcignanò E, Arezzo A. Initial clinical experience with a novel flexible endoscopic robot for transanal surgery. Tech Coloproctol 2022. [PMID: 35091792 DOI: 10.1007/s10151-022-02577-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 01/17/2022] [Indexed: 12/04/2022]
Abstract
Background The Flex® Robotic System (Medrobotics, Raynham, MA, USA) is the first miniaturised flexible endoscopic robot that aims to allow surgical manoeuvres beyond the area currently reached by transanal endoscopic microsurgery. The aim of this study is to evaluate our initial clinical experience with this novel tool. Methods We prospectively collected all consecutive cases of local excisions of rectal lesions performed with the Flex® Robotic System performed at the Department of Surgical Sciences of the University of Turin between October 2018 and December 2019. Indications were benign, or early rectal lesions judged unsuitable for endoscopic removal, within 20 cm of the anal verge. Debriefing meetings after each procedure allowed technology assessment leading to the modification, development, and implementation of tools according to the clinical experience. We analysed the data in terms of the safety and efficacy of treatment. Results Between October 2018 and February 2020, 26 patients were treated. We performed a full-thickness excision in 14 patients and a submucosal dissection in 12. The median operating time was 115 min (range 45–360 min). In six patients (23.1%), we converted to standard transanal endoscopic operation (TEO®) (Karl Storz, Tuttlingen, Germany) to complete the procedure. The 30-day morbidity rate was 11.5% (3/26). Positive resection margins were detected in 4 (15.4%) patients. At a minimum follow-up of 12 months, 2 (7.7%) local recurrences were observed. Conclusions This first clinical series demonstrates that the Flex® Robotic System is a fascinating technology that deserves further development to increase surgical dexterity, thereby overcoming current technical limitations and improving clinical outcomes. Supplementary Information The online version contains supplementary material available at 10.1007/s10151-022-02577-1.
Collapse
|
13
|
Chaouch MA, Khan J, Gill TS, Mehrabi A, Reissfelder C, Rahberi N, Elhadedy H, Oweira H. Early salvage total mesorectal excision (sTME) after organ preservation failure in rectal cancer does not worsen postoperative outcomes compared to primary TME: systematic review and meta-analysis. Int J Colorectal Dis 2021; 36:2375-86. [PMID: 34244857 DOI: 10.1007/s00384-021-03989-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/26/2021] [Indexed: 02/04/2023]
Abstract
IMPORTANCE While oncological outcomes of early salvage total mesorectal excision (sTME) after local excision (LE) have been well studied, the impact of LE before TME on postoperative outcomes remains unclear. We aimed to compare early sTME with a primary TME for rectal cancer. METHODS Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines with the random-effects model were adopted using Review Manager Version 5.3 for pooled estimates. RESULTS We retrieved eleven relevant articles including 1728 patients (350 patients in the sTME group and 1438 patients in the TME group). There was no significant difference between the two groups in terms of mortality (OR = 0.90, 95%CI [0.21 to 3.77], p = 0.88), morbidity (OR = 1.19, 95%CI [0.59 to 2.38], p = 0.63), conversion to open surgery (OR = 1.34, 95%CI [0.61 to 2.94], p = 0.47), anastomotic leak (OR = 1.38, 95%CI [0.50 to 3.83], p = 0.53), hospital stay (MD = 0.23 day, 95%CI [- 1.63 to 2.10], p < 0.81), diverting stoma rate (OR = 0.69, 95%CI [0.44 to 1.09], p = 0.11), abdominoperineal resection rate (OR = 1.47, 95%CI [0.91 to 2.37], p = 0.11), local recurrence (OR = 0.94, 95%CI [0.44 to 2.04], p = 0.88), and distant recurrence (OR = 0.88, 95%CI [0.52 to 1.48], p = 0.62). sTME was associated with significantly longer operative time (MD = 25.62 min, 95%CI[11.92 to 39.32], p < 0.001) lower number of harvested lymph nodes (MD = - 2.25 lymph node, 95%CI [- 3.86 to - 0.65], p = 0.006), and higher proportion of incomplete TME (OR = 0.25, 95%CI [0.11 to 0.61], p = 0.002). CONCLUSIONS sTME is not associated with increased postoperative morbidity, mortality, or local recurrence. However, the operative times are longer and yield a poor specimen quality.
Collapse
|
14
|
Kim MJ, Lee TG. Transanal minimally invasive surgery using laparoscopic instruments of the rectum: A review. World J Gastrointest Surg 2021; 13:1149-1165. [PMID: 34754384 PMCID: PMC8554714 DOI: 10.4240/wjgs.v13.i10.1149] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 07/18/2021] [Accepted: 09/16/2021] [Indexed: 02/06/2023] Open
Abstract
Transanal minimally invasive surgery (TAMIS) was first described in 2010 as an alternative to transanal endoscopic microsurgery (TEM). The TAMIS technique can be access to the proximal and mid-rectum for resection of benign and early-stage malignant rectal lesions and also used for noncurative intent surgery of more advanced lesions in patients who are not candidates for radical surgery. TAMIS has a shorter learning curve, reduced device setup time, flexibility in instrument use, and versatility in application than TEM. Also, TAMIS shows similar results in a view of the operation time, conversion rate, reoperation rate, and complication to TEM. For these reasons, TAMIS is an easily accessible, technically feasible, and cost-effective alternative to TEM. Overall, TAMIS has enabled the performance of high-quality local excision of rectal lesions by many colorectal surgeons. As TAMIS becomes more broadly utilized such as pelvic abscess drainage, rectal stenosis, and treatment of anastomotic dehiscence, the acquisition of appropriate training must be ensured, and the continued assessment and assurance of outcome must be maintained.
Collapse
Affiliation(s)
- Myung Jo Kim
- Department of Surgery, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju 28644, South Korea
| | - Taek-Gu Lee
- Department of Surgery, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju 28644, South Korea
| |
Collapse
|
15
|
Ikezawa N, Toyonaga T, Tanaka S, Nakano Y, Ishida T, Yoshihara T, Uraoka M, Morita Y, Suzuki N, Haji A, Kodama Y. Feasibility and Safety of Endoscopic Submucosal Dissection for Recurrent Rectal Lesions that after Transanal Endoscopic Microsurgery: A Case Series. Digestion 2021; 102:446-452. [PMID: 32023620 DOI: 10.1159/000505619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 12/24/2019] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Recently, several studies have demonstrated the usefulness of endoscopic submucosal dissection (ESD) for residual or locally recurrent colorectal lesions after endoscopic treatment. However, the feasibility of ESD for recurrent rectal lesions after transanal endoscopic microsurgery (TEM) has not been fully investigated. In this study, we evaluated the feasibility and safety of ESD for recurrent rectal lesions after TEM. METHODS The treatment outcomes of 10 lesions in 9 patients, who underwent ESD between January 2006 and March 2018 for recurrent rectal lesions after transanal endoscopic microsurgery, were evaluated. RESULTS All lesions were successfully resected en bloc, and the R0 resection rate was 90%. The median size of the resected specimens and lesions (range) was 44 mm (21-70) and 27.5 mm (5-60), respectively. The pathological diagnoses included 4 adenomas and 6 cancerous lesions. The cancerous lesions included 5 cases of mucosal cancer and 1 case of superficial submucosal invasive cancer (depth of submucosal invasion <1,000 μm from the muscularis mucosae). No adverse events occurred. There was no recurrence during the follow-up period. CONCLUSIONS ESD for recurrent rectal lesions after TEM by expert's hands appears to be safe and feasible.
Collapse
Affiliation(s)
- Nobuaki Ikezawa
- Divison of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Takashi Toyonaga
- Department of Endoscopy, Kobe University Hospital, Kobe, Japan, .,Department of Gastroenterology, Kishiwada Tokushukai Hospital, Osaka, Japan,
| | - Shinwa Tanaka
- Divison of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Yoshiko Nakano
- Divison of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Tsukasa Ishida
- Divison of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan.,Department of Gastroenterology, Akashi Medical Center, Akashi, Japan
| | - Tomoatsu Yoshihara
- Department of Gastroenterology, Kishiwada Tokushukai Hospital, Osaka, Japan
| | - Masanao Uraoka
- Department of Gastroenterology, Kishiwada Tokushukai Hospital, Osaka, Japan
| | - Yoshinori Morita
- Divison of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Noriko Suzuki
- Wolfson Unit for Endoscopy, St Mark's Hospital, Harrow, United Kingdom
| | - Amyn Haji
- Department of Therapeutic Endoscopy, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Yuzo Kodama
- Divison of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan
| |
Collapse
|
16
|
Chavda V, Siaw O, Chaudhri S, Runau F. Management of early rectal cancer; current surgical options and future direction. World J Gastrointest Surg 2021; 13:655-667. [PMID: 34354799 PMCID: PMC8316852 DOI: 10.4240/wjgs.v13.i7.655] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 04/13/2021] [Accepted: 06/16/2021] [Indexed: 02/06/2023] Open
Abstract
Rectal cancer is the second commonest cause of cancer death within the United Kingdom. Utilization of national screening programmes have resulted in a greater proportion of patients presenting with early-stage disease. The technique of transanal endoscopic microsurgery was first described in 1984 following which further options for local excision have emerged with transanal endoscopic operation and, more recently, transanal minimally invasive surgery. Owing to the risks of local recurrence, the current role of minimally invasive techniques for local excision in the management of rectal cancer is limited to the treatment of pre-invasive disease and low risk early-stage rectal cancer (T1N0M0 disease). The roles of chemotherapy and radiotherapy for the management of early rectal cancer are yet to be fully established. However, results of high-quality research such as the GRECCAR II, TESAR and STAR-TREC randomised control trials may highlight a wider role for local excision surgery in the future, when used in combination with oncological therapies. The aim of our review is to provide an overview in the current management of early rectal cancer, the surgical options available for local excision and the future multimodal direction of early rectal cancer treatment.
Collapse
Affiliation(s)
- Vijay Chavda
- Department of General Surgery, Leicester General Hospital, Leicester LE5 4PW, United Kingdom
| | - Oliver Siaw
- Department of General Surgery, Leicester General Hospital, Leicester LE5 4PW, United Kingdom
| | - Sanjay Chaudhri
- Department of General Surgery, Leicester General Hospital, Leicester LE5 4PW, United Kingdom
| | - Franscois Runau
- Department of General Surgery, Leicester General Hospital, Leicester LE5 4PW, United Kingdom
| |
Collapse
|
17
|
González JEB, Lavernia HC, Fraga JGP, Lemus SQ. Long-term outcomes of transanal endoscopic microsurgery for clinical complete response after neoadjuvant treatment in T2-3 rectal cancer. Surg Endosc 2021. [PMID: 34231071 DOI: 10.1007/s00464-021-08583-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 06/02/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Organ sparing by the transanal endoscopic microsurgery (TEM) procedure is a treatment for patients with locally advanced rectal cancer after chemoradiotherapy (CRT) and complete clinical response (cCR). AIMS To assess the surgical and long-term oncological outcomes of TEM for the treatment in T2-3 rectal cancer after CRT and cCR. METHODS This study was a retrospective review of a prospective database of patients with rectal cancer who underwent TEM after CRT and cCR from April 2011 to March 2020. RESULTS 52 patients underwent TEM during a period of 9 years. This group of patients included 27 females and 25 males. The median age was 62 (32-86) years, lesion size was 2.5 (1-4) cm, and lesion distance from the anal verge 7.3 (4-10) cm. Median operative time was 79.5 (25-120) min and hospital stay was 1 day (14 h-4 days). Morbidity rate was 13.5% and reoperation rate due to major complications was 3.8%. Final histological findings confirmed 34 (65.4%) patients with ypT0, 7 (13.5%), 6 (11.5%), and 5 (9.6%) patients with carcinoma ypT1, ypT2, and ypT3, respectively. After a median follow-up period of 86 (5-107) months, 1 (2.4%) patient had local recurrences and 3 (7.3%) distant metastases. The 5-year disease-free survival was 91.7% and 5-year overall survival 89.5%. CONCLUSION Our experience has shown significant rates of ypT0 and ypT1 associated with excellent long-term results. Performing TEM to treat T2-3N0 rectal cancer after CRT and cCR appears to be an oncologically safe and effective procedure.
Collapse
|
18
|
Zinicola R, Nascimbeni R, Cirocchi R, Gagliardi G, Cracco N, Giuffrida M, Pedrazzi G, Binda GA. The impact of transanal local excision of early rectal cancer on completion rectal resection without neoadjuvant chemoradiotherapy: a systematic review. Tech Coloproctol 2021; 25:997-1010. [PMID: 34173121 DOI: 10.1007/s10151-020-02401-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 12/28/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND The impact of transanal local excision (TAE) of early rectal cancer (ERC) on subsequent completion rectal resection (CRR) for unfavorable histology or margin involvement is unclear. The aim of this study was to provide a comprehensive review of the literature on the impact of TAE on CRR in patients without neoadjuvant chemoradiotherapy (CRT). METHODS We performed a systematic review of the literature up to March 2020. Medline and Cochrane libraries were searched for studies reporting outcomes of CRR after TAE for ERC. We excluded patients who had neoadjuvant CRT and endoscopic local excision. Surgical, functional, pathological and oncological outcomes were assessed. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. RESULTS Sixteen studies involving 353 patients were included. Pathology following TAE was as follows T0 = 2 (0.5%); T1 = 154 (44.7%); T2 = 142 (41.2%); T3 = 43 (12.5%); Tx = 3 (0.8%); T not reported = 9. Fifty-three percent were > T1. Abdominoperineal resection (APR) was performed in 80 (23.2%) patients. Postoperative major morbidity and mortality occurred in 22 (11.4%) and 3 (1.1%), patients, respectively. An incomplete mesorectal fascia resulting in defects of the mesorectum was reported in 30 (24.6%) cases. Thirteen (12%) patients developed recurrence: 8 (3.1%) local, 19 (7.3%) distant, 4 (1.5%) local and distant. The 5-year cancer-specific survival was 92%. Only 1 study assessed anal function reporting no continence disorders in 11 patients. In the meta-analysis, CRR after TAE showed an increased APR rate (OR 5.25; 95% CI 1.27-21.8; p 0.020) and incomplete mesorectum rate (OR 3.48; 95% CI 1.32-9.19; p 0.010) compared to primary total mesorectal excision (TME). Two case matched studies reported no difference in recurrence rate and disease free survival respectively. CONCLUSIONS The data are incomplete and of low quality. There was a tendency towards an increased risk of APR and poor specimen quality. It is necessary to improve the accuracy of preoperative staging of malignant rectal tumors in patients scheduled for TAE.
Collapse
|
19
|
Xiong X, Wang C, Wang B, Shen Z, Jiang K, Gao Z, Ye Y. Can transanal endoscopic microsurgery effectively treat T1 or T2 rectal cancer?A systematic review and meta-analysis. Surg Oncol 2021; 37:101561. [PMID: 33848762 DOI: 10.1016/j.suronc.2021.101561] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 03/03/2021] [Accepted: 03/28/2021] [Indexed: 02/07/2023]
Abstract
AIM We aimed to compare the safety and oncological outcomes of transanal endoscopic microsurgery (TEM) and radical surgery (RS) for patients with T1 or T2 rectal cancer. METHOD We searched Pubmed, Embase, Cochrane Library databases for relevant studies comparing TEM with RS in rectal cancer published until April 2020. We focused on safety and oncological outcomes. RESULTS This meta-analysis included 3526 patients from 12 studies. Compared with RS, TEM had a shorter operative time (weighted mean difference [WMD] -110.02, 95% confidence interval [CI]: 143.98, -76.06), less intraoperative blood loss (WMD -493.63, 95% CI: 772.66, -214.59), lower perioperative morality (risk ratio [RR] 0.25, 95% CI: 0.06, 0.99), and fewer postoperative surgical complications (RR 0.23, 95% CI: 0.11,0.45). TEM was associated with more patients with a positive margin or a doubtfully complete margin than RS (RR 7.36, 95% CI: 3.66, 14.78). TEM was associated with higher local recurrence (RR 2.63, 95% CI: 1.60, 4.31) and overall recurrence (RR 1.60, 95% CI: 1.09, 2.36). TEM had a negative effect on 5-year overall survival (hazard ratio [HR] 1.51, 95% CI: 1.16, 1.96), especially in the T2 without neoadjuvant therapy (NAT) subgroup (HR 2.02, 95% CI: 1.32, 3.09), but in the subgroups of T1 or T2 with NAT before TEM, TEM did not yield a significantly lower overall survival than RS. CONCLUSION TEM seems appropriate for T1 rectal cancer with favourable histopathology. For patients with T2 rectal cancer, NAT before TEM may contribute to achieving oncological outcomes equivalent to that achieved with RS.
Collapse
Affiliation(s)
- Xiaoyu Xiong
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, 100044, PR China
| | - Chao Wang
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, 100044, PR China; Laboratory of Surgical Oncology, Peking University People's Hospital, Beijing, 100044, PR China
| | - Bo Wang
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, 100044, PR China; Laboratory of Surgical Oncology, Peking University People's Hospital, Beijing, 100044, PR China
| | - Zhanlong Shen
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, 100044, PR China; Laboratory of Surgical Oncology, Peking University People's Hospital, Beijing, 100044, PR China
| | - Kewei Jiang
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, 100044, PR China; Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Peking University People's Hospital, Beijing, 100044, PR China
| | - Zhidong Gao
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, 100044, PR China; Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Peking University People's Hospital, Beijing, 100044, PR China.
| | - Yingjiang Ye
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, 100044, PR China; Laboratory of Surgical Oncology, Peking University People's Hospital, Beijing, 100044, PR China.
| |
Collapse
|
20
|
Levic Souzani K, Bulut O, Kuhlmann TP, Gögenur I, Bisgaard T. Completion total mesorectal excision following transanal endoscopic microsurgery does not compromise outcomes in patients with rectal cancer. Surg Endosc 2021; 36:1181-1190. [PMID: 33629183 DOI: 10.1007/s00464-021-08385-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 02/09/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Transanal endoscopic microsurgery (TEM) represents a choice of treatment in patients with neoplastic lesions in the rectum. When TEM fails, completion total mesorectal excision (cTME) is often required. However, a concern is whether cTME increases the rate of abdominoperineal resections (APR) and is associated with higher risk of incomplete mesorectal fascia (MRF) resection. The aim of this study was to compare outcomes of cTME with primary TME (pTME) in patients with rectal cancer. METHODS This was a nationwide study on all patients with cTME from the Danish Colorectal Cancer Group database between 2005 and 2015. Patients with cTME were compared to patients with pTME after propensity score matching (matching ratio 1:2). Matching variables were age, gender, tumor distance from anal verge, American Society of Anesthesiologists (ASA) score and American Joint Committee on Cancer (AJCC) stage. RESULTS A total of 60 patients with cTME were compared with 120 patients with pTME. Patients with cTME experienced more intraoperative complications as compared to pTME patients (18.3% vs. 6.7%, p = 0.021). However, there was no difference in the rate of perforations at or near the tumor/previous TEM site (6.7% vs. 2.5%, p = 0.224), conversion to open surgery (p = 0.733) or 30-day morbidity (p = 0.86). On multivariate analysis, cTME was not a risk factor for APR (OR 2.49; 95% CI 0.95-6.56; p = 0.064) or incomplete MRF (OR 1.32; 95% CI 0.48-3.63; p = 0.596). There was no difference in the rate of local recurrence between cTME and pTME (5.2% vs. 4.3%, p = 0.1), distant metastases (6.8% vs. 6.8%, p = 1), or survival (p = 0.081). The mean follow-up time was 6 years. CONCLUSION In our study, the largest so far on the subject, we find no difference in postoperative short- or long-term outcomes between cTME and pTME.
Collapse
Affiliation(s)
- Katarina Levic Souzani
- Gastrounit - Surgical Division, Center for Surgical Research, Copenhagen University Hospital Hvidovre, Kettegaards Allé 30, 2650, Hvidovre, Denmark.
| | - Orhan Bulut
- Gastrounit - Surgical Division, Center for Surgical Research, Copenhagen University Hospital Hvidovre, Kettegaards Allé 30, 2650, Hvidovre, Denmark.,Institution of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Tine Plato Kuhlmann
- Department of Pathology, Herlev University Hospital, Copenhagen, Denmark.,Institution of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Danish Colorectal Cancer Group, Copenhagen, Denmark
| | - Ismail Gögenur
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Køge, Denmark.,Institution of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Danish Colorectal Cancer Group, Copenhagen, Denmark
| | - Thue Bisgaard
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Køge, Denmark.,Danish Colorectal Cancer Group, Copenhagen, Denmark
| |
Collapse
|
21
|
Rizzo G, Pafundi DP, Sionne F, D'Agostino L, Pietricola G, Gambacorta MA, Valentini V, Coco C. Preoperative chemoradiotherapy affects postoperative outcomes and functional results in patients treated with transanal endoscopic microsurgery for rectal neoplasms. Tech Coloproctol 2021; 25:319-331. [PMID: 33459969 DOI: 10.1007/s10151-020-02394-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 12/20/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND The aim of this study was to quantify the incidence of short-term postoperative complications and functional disorders at 1 year from transanal endoscopic microsurgery (TEM) for rectal neoplasms, to compare patients treated with TEM alone and with TEM after preoperative chemoradiotherapy (CRT) and to analyse factors influencing postoperative morbidity and functional outcomes. METHODS A retrospective study was conducted on all patients treated with TEM for rectal neoplasms at our institution in January 2000-December 2017. Data from a prospectively maintained database were retrospectively analysed. Patients were divided into two groups: adenoma or early rectal cancer (no CRT group) and locally advanced extraperitoneal rectal cancer with major or complete clinical response after preoperative CRT (CRT group). Short-term postoperative mortality and morbidity and the functional results at 1 year were recorded. The two groups were compared, and a statistical analysis of factors influencing postoperative morbidity and functional outcomes was performed. Functional outcome was also evaluated with the low anterior resection syndrome (LARS) score (0-20 no LARS, 21-29 minor LARS and 30-42 major LARS). RESULTS One hundred and thirteen patients (71 males, 42 females, median age 64 years [range 41-80 years]) were included in the study (46 in the CRT group). The overall postoperative complication rate was 23.0%, lower in the noCRT group (p < 0.001), but only 2.7% were grade ≥ 3. The most frequent complication was suture dehiscence (17.6%), which occurred less frequently in the noCRT group (p < 0.001). At 1 year from TEM, the most frequent symptoms was urgency (11.9%, without significant differences between the CRT group and the noCRT group); the noCRT group experienced a lower rate of soiling than the CRT group (0% vs. 7.7%; p: 0.027). The incidence of LARS was evaluated in 47 patients from May 2012 on and was 21.3% occurring less frequently in the noCRT group (10% vs. 41.2%; p: 0.012). Only 6.4% of the patients evaluated experienced major LARS. In multivariate analysis, preoperative CRT significantly worsened postoperative morbidity and functional outcomes. CONCLUSIONS TEM is a safe procedure associated with only low risk of severe postoperative complications and major LARS. Preoperative CRT seems to increase the rate of postoperative morbidity after TEM and led to worse functional outcomes at 1 year after surgery.
Collapse
Affiliation(s)
- G Rizzo
- U.O.C. Chirurgia Generale 2, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy.
| | - D P Pafundi
- U.O.C. Chirurgia Generale 2, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - F Sionne
- U.O.C. Chirurgia Generale 2, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - L D'Agostino
- U.O.C. Chirurgia Generale 2, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - G Pietricola
- U.O.C. Chirurgia Generale 2, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - M A Gambacorta
- U.O.C. Radioterapia Oncologica, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - V Valentini
- U.O.C. Radioterapia Oncologica, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - C Coco
- U.O.C. Chirurgia Generale 2, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy
| |
Collapse
|
22
|
Kanehira E, Tanida T, Kanehira AK, Takahashi K, Obana Y, Iwasaki M, Sagawa K. A New Technique to Repair Vesicorectal Fistula: Overlapping Rectal Muscle Plasty by Transanal Endoscopic Surgery. Urol Int 2021; 105:309-315. [PMID: 33429395 DOI: 10.1159/000512379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 10/15/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate clinical results of a novel surgical technique, we developed to repair vesicorectal fistula (VRF) occurring after prostatectomy, hospital records of the patients, who underwent the new surgical treatment, were assessed. METHODS The novel surgical technique is called "overlapping rectal muscle plasty," which is performed under transanal endoscopic microsurgery (TEM). During the new procedure, a complete fistulectomy was first performed, and then the proper muscle layer of the rectum was folded, overlapped, and sutured to create a thick wall between the rectum and urinary bladder. This operation was carried out in 15 patients with VRF following radical prostatectomy. RESULTS The operation was safely performed in all patients with an average time of 127.2 min. Fistula was corrected in 13 patients (86.7%), who were then freed from both urinary and intestinal diversions. CONCLUSIONS Overlapping rectal muscle plasty by TEM is a safe procedure. The success rate seems to be acceptable in selected patients. This new repair method may be considered as a minimally invasive option in the surgical treatment of VRF after prostatectomy.
Collapse
Affiliation(s)
- Eiji Kanehira
- Department of Surgery, Medical Topia Soka, Soka City, Japan,
| | - Takashi Tanida
- Department of Surgery, Medical Topia Soka, Soka City, Japan
| | | | | | - Yuichi Obana
- Department of Surgery, Medical Topia Soka, Soka City, Japan
| | | | - Koji Sagawa
- Department of Urology, Medical Topia Soka, Soka City, Japan
| |
Collapse
|
23
|
Naughton AP, Ryan ÉJ, Bardon CT, Boland MR, Aherne TM, Kelly ME, Whelan M, Neary PC, McNamara D, O'Riordan JM, Kavanagh DO. Endoscopic management versus transanal surgery for early primary or early locally recurrent rectal neoplasms-a systematic review and meta-analysis. Int J Colorectal Dis 2020; 35:2347-2359. [PMID: 32860082 DOI: 10.1007/s00384-020-03715-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/10/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Both endoscopic techniques and transanal surgery are viable options that allow organ preservation for early rectal neoplasms. Whilst endoscopic approaches are less invasive and carry less morbidity, it is unclear whether they are as oncologically effective. AIM To compare endoscopic techniques with transanal surgery in the management of early rectal neoplasms. METHODS A systematic literature search was performed for randomised and observational studies comparing these techniques. The pre-specified main outcomes measured were en bloc and R0 resection rates and recurrence. Pair-wise meta-analysis was performed. RESULTS This review included 1044 patients. Transanal surgery had increased R0 resection rates (odds ratio (OR) 2.66; 95% CI 1.64; 4.31; p < 0.001) versus endoscopic management. The latter was associated with higher rates of incomplete resection (OR 2.25; 95% CI 1.14, 4.46; p = 0.02) and further intervention (OR 1.78; 95% CI 1.09, 2.88; p = 0.02). There was no difference in the rates of late recurrence (OR 1.01; 95% CI 0.53, 1.91; p = 0.99) or further major surgery (OR 0.87; 95% CI 0.39, 1.94; p = 0.73) between the groups. Endoscopic treatment was associated with a shorter operating time (weighted mean difference (WMD) - 12.08; 95% CI - 18.97, - 5.19; p < 0.001) and LOS (WMD - 1.94; 95% CI - 2.43, - 1.44; p < 0.001), as well as lower rates of urinary retention post-operatively (OR 0.12; 95% CI 0.02, 0.63; p = 0.01). CONCLUSION Endoscopic techniques should be favoured in the setting of benign early rectal neoplasms given their decreased morbidity and increased cost-effectiveness. However, where malignancy is suspected transanal surgery should be the preferred option given the superior R0 resection rate.
Collapse
Affiliation(s)
- Ailish P Naughton
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
| | - Éanna J Ryan
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland.
| | | | - Michael R Boland
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
| | - Thomas M Aherne
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
| | - Michael E Kelly
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
| | - Maria Whelan
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
| | - Paul C Neary
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
- School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Deirdre McNamara
- School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
- Department of Gastroenterology, Tallaght University Hospital, Dublin, Ireland
| | - James M O'Riordan
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
- School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Dara O Kavanagh
- Department of Surgery, Tallaght University Hospital, Dublin, Ireland
- School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| |
Collapse
|
24
|
Bai X, Zhou W, Li Y, Lin G. Transanal endoscopic microsurgery with alternative neoadjuvant imatinib for localized rectal gastrointestinal stromal tumor: a single center experience with long-term surveillance. Surg Endosc 2020; 35:3607-3617. [PMID: 32968924 DOI: 10.1007/s00464-020-07837-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 07/22/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Transanal endoscopic microsurgery (TEM) is widely used in the treatment of local rectal lesions and helps avoid radical surgery. This study evaluated the management and outcome in a long-term followed cohort of patients with localized rectal GIST underwent TEM with alternative neodajuvant imatinib (nIM). METHODS A retrospective cohort study was undertaken of patients identified from a case database at Department of General Surgery, Peking Union Medical College Hospital (PUMCH) over a continuous period, from January 2006 to December 2017. RESULTS Over 12 years, 42 patients presented with a primary rectal GIST in PUMCH. Median age was 49 (range 27-77) years. Neoadjuvant imatinib (nIM) therapy was used in 16 patients, significantly reducing mean tumor size from 4.41 to 2.46 cm (p < 0.001) and mitotic index (p = 0.041). All of these patients underwent TEM with no tumor rupture, nIM therapy enabled sphincter-preserving surgery to be undertaken in 16 (16/42) patients who would otherwise have required abdominoperineal resection or pelvic exenteration for tumor clearance and all patients (42/42) achieve R0 resection and negative margin. Imatinib was also used as postoperative adjuvant treatment in 15 patients with high-risk GIST. Median follow-up was 77 (range 14-144) and overall survival is 100%. In 42 patients, Local recurrence (LR) occurred in 3 of 42 patients and 1 of 42 patients developed distant metastasis (DM) in 112 months after TEM. In the univariate analysis, mitotic index (p = 0.028), NIH risk categories (p = 0.047) were predictive feature of local relapse. CONCLUSION The application of nIM significantly decreased tumor size in large localized rectal GIST, which permitted TEM to preserve sphincter. The TEM procedure with alternative neoadjuvant imatinib therapy is a practicable treatment for patients with rectal GIST to preserve anus and have satisfied anal function.
Collapse
Affiliation(s)
- Xueshan Bai
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No. 1 Shuai Fu Yuan, Dong Cheng District, Beijing, 100730, China
| | - Weixun Zhou
- Department of Pathology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No. 1 Shuai Fu Yuan, Dong Cheng District, Beijing, 100730, China
| | - Yunhao Li
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No. 1 Shuai Fu Yuan, Dong Cheng District, Beijing, 100730, China
| | - Guole Lin
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No. 1 Shuai Fu Yuan, Dong Cheng District, Beijing, 100730, China.
| |
Collapse
|
25
|
Khan K, Hunter IA, Manzoor T. Should the rectal defect be sutured following TEMS/TAMIS carried out for neoplastic rectal lesions? A meta-analysis. Ann R Coll Surg Engl 2020; 102:647-653. [PMID: 32538129 DOI: 10.1308/rcsann.2020.0135] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Management of the rectal defect following transanal endoscopic microsurgery (TEMS) or minimally invasive surgery (TAMIS) carried out for excision of neoplasm in the lower rectum is controversial. We aimed to extract evidence by carrying out a meta-analysis to compare the peri- and postoperative outcomes following rectal neoplasm excision carried out by TEMS and/or TAMIS, whereby the defect is either sutured or left open. METHODS A literature search of Ovid MEDLINE and EMBASE was performed. Full-text comparative studies published until November 2019, in English and of adult patients, whereby TEMS or TAMIS was undertaken for rectal neoplasms were included. The main outcome measures were postoperative bleeding, infection, operative time and hospital stay. FINDINGS Three studies (one randomised controlled trial and two comparative case series) yielded 555 cases (283 in the sutured group and 272 in the open group). The incidence of postoperative bleeding was higher and statistically significant (p = 0.006) where the rectal defect was left open following excision of the neoplasm (19/272, 6.99% vs 6/283, 2.12%). There was no statistical difference between the sutured and open groups regarding infection (p = 0.27; (10/283, 3.53% vs 5/272, 1.84%, respectively), operative time (p = 0.15) or length of stay (p = 0.67). CONCLUSION Suturing the rectal defect following excision of rectal neoplasm by TEMS/TAMIS reduces the incidence of postoperative bleeding in comparison to leaving the defect open. However, suturing makes the procedure slightly longer but there was no statistical difference between both groups when postoperative infection and length of hospital stay were compared.
Collapse
Affiliation(s)
- K Khan
- Castle Hill Hospital, Hull University Teaching Hospitals, East Yorkshire, UK
| | - I A Hunter
- Castle Hill Hospital, Hull University Teaching Hospitals, East Yorkshire, UK
| | - T Manzoor
- Castle Hill Hospital, Hull University Teaching Hospitals, East Yorkshire, UK
| |
Collapse
|
26
|
D'Ambrosio G, Lamazza A, Palma R, Picchetto A, Panetta C, Trecca A, Pontone S, Lezoche E. Transanal Endoscopic Microsurgery: Endoscopy Assisted Treatment of Colorectal Anastomotic Stenosis. Ann Coloproctol 2020; 36:285-288. [PMID: 32178496 PMCID: PMC7508482 DOI: 10.3393/ac.2019.09.30.3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 09/30/2019] [Indexed: 12/17/2022] Open
Abstract
Transanal endoscopic microsurgery (TEM) is a type of natural orifice transluminal endoscopic surgery, developed for rectal tumors and used also to treat other rectal diseases. Anastomotic complications after colorectal surgery, including stenosis, represent a challenging problem. We present the case of a 36-year-old woman with a diagnosis of Hirschsprung disease that was submitted to a modified Duhamel operation. A postoperative barium enema showed a complete stricture of the anastomosis that was impossible to resolve by flexible endoscopic approach. Then an intraoperative endoscopic approach to facilitate the localization of preanastomotic colon (proximal colon from the anastomosis) was performed by a small colotomy and the colonic recanalization was obtained by the creation of a neo-anastomosis by TEM, under fluoroscopic-endoscopic control. The patient underwent a control barium enema showing regular retrograde transit of contrast medium without evidence of stenosis. In our experience, transanal approach by TEM-colonoscopy assisted is safe and feasible and represents a model of combined minimally invasive technique.
Collapse
Affiliation(s)
- Giancarlo D'Ambrosio
- Department of General Surgery, Surgical Specialties and Organ Transplantation "Paride Stefanini," Sapienza University, Rome, Italy
| | - Antonietta Lamazza
- Department of Surgery, Istituto Pietro Valdoni, Sapienza University of Rome, Rome, Italy
| | - Rossella Palma
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - Andrea Picchetto
- Department of General Surgery, Surgical Specialties and Organ Transplantation "Paride Stefanini," Sapienza University, Rome, Italy
| | - Cristina Panetta
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Stefano Pontone
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - Emanuele Lezoche
- Department of General Surgery, Surgical Specialties and Organ Transplantation "Paride Stefanini," Sapienza University, Rome, Italy
| |
Collapse
|
27
|
Serra-Aracil X, Gil-Barrionuevo E, Lobato-Gil R, Gonzalez-Costa A, Mora-López L, Pallisera-Lloveras A, Serra-Pla S, Navarro-Soto S. Is obesity a factor of surgical difficulty in transanal endoscopic surgery? Am J Surg 2020; 220:687-692. [PMID: 31983409 DOI: 10.1016/j.amjsurg.2020.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 01/15/2020] [Accepted: 01/17/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The aim of this study is to assess the feasibility of transanal endoscopic surgery (TES) in obese patients. METHODS Observational descriptive study evaluating the feasibility of TES in obese rectal tumors between June 2004 and January 2019. Patients were assigned to two groups: body mass index (BMI) < 30 kg/m2 and BMI ≥30 kg/m2, the latter defined as obese. RESULTS From 775 patients, 681 were enrolled in the study, 145 (21.3%) of them obese. No statistically significant differences between groups were found with respect to overall morbidity (27, 18.6%).The obese patients presented trends towards shorter mean surgical time (65 min, IQR 48 min), less perforation in the peritoneal cavity (eight, 5.5%), and 133 (91.7%) presented a lower rate of lesion fragmentation. CONCLUSION There were no significant differences in postoperative outcomes in obese patients (BMI ≥30 kg/m2). TES in those obese patients does not represent a factor of surgical difficulty.
Collapse
Affiliation(s)
- Xavier Serra-Aracil
- Department of Colorectal Surgery, Department of General and Digestive Surgery, Parc Taulí University Hospital, Universidad Autonoma de Barcelona (UAB), Parc Taulí S/n, 08208, Sabadell, Barcelona, Spain.
| | - Esther Gil-Barrionuevo
- Department of Colorectal Surgery, Department of General and Digestive Surgery, Parc Taulí University Hospital, Universidad Autonoma de Barcelona (UAB), Parc Taulí S/n, 08208, Sabadell, Barcelona, Spain
| | - Raquel Lobato-Gil
- Department of Colorectal Surgery, Department of General and Digestive Surgery, Parc Taulí University Hospital, Universidad Autonoma de Barcelona (UAB), Parc Taulí S/n, 08208, Sabadell, Barcelona, Spain
| | - Anna Gonzalez-Costa
- Department of Colorectal Surgery, Department of General and Digestive Surgery, Parc Taulí University Hospital, Universidad Autonoma de Barcelona (UAB), Parc Taulí S/n, 08208, Sabadell, Barcelona, Spain
| | - Laura Mora-López
- Department of Colorectal Surgery, Department of General and Digestive Surgery, Parc Taulí University Hospital, Universidad Autonoma de Barcelona (UAB), Parc Taulí S/n, 08208, Sabadell, Barcelona, Spain
| | - Anna Pallisera-Lloveras
- Department of Colorectal Surgery, Department of General and Digestive Surgery, Parc Taulí University Hospital, Universidad Autonoma de Barcelona (UAB), Parc Taulí S/n, 08208, Sabadell, Barcelona, Spain
| | - Sheila Serra-Pla
- Department of Colorectal Surgery, Department of General and Digestive Surgery, Parc Taulí University Hospital, Universidad Autonoma de Barcelona (UAB), Parc Taulí S/n, 08208, Sabadell, Barcelona, Spain
| | - Salvador Navarro-Soto
- Department of Colorectal Surgery, Department of General and Digestive Surgery, Parc Taulí University Hospital, Universidad Autonoma de Barcelona (UAB), Parc Taulí S/n, 08208, Sabadell, Barcelona, Spain
| |
Collapse
|
28
|
Sagae VMT, Ribeiro IB, de Moura DTH, Brunaldi VO, Logiudice FP, Funari MP, Baba ER, Bernardo WM, de Moura EGH. Endoscopic submucosal dissection versus transanal endoscopic surgery for the treatment of early rectal tumor: a systematic review and meta-analysis. Surg Endosc 2019; 34:1025-1034. [PMID: 31754850 DOI: 10.1007/s00464-019-07271-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 11/12/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Minimally invasive treatment of early-stage rectal lesion has presented good results, with lower morbidity than surgical resection. Transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS) are the main methods of transanal surgery. However, endoscopic submucosal dissection (ESD) has been gaining ground because it allows en bloc resections with low recurrence rates. The aim of this study was to analyze ESD in comparison with transanal endoscopic surgery. METHODS We searched MEDLINE, EMBASE, SciELO, Cochrane CENTRAL, and Lilacs/Bireme with no restrictions on the date or language of publication. The outcomes evaluated were recurrence rate, complete (R0) resection rate, en bloc resection rate, length of hospital stay, duration of the procedure, and complication rate. RESULTS Six retrospective cohort studies involving a collective total of 326 patients-191 in the ESD group and 135 in the transanal endoscopic surgery group were conducted. There were no statistically significant differences between the groups for any of the outcomes evaluated. CONCLUSIONS For the minimally invasive treatment of early rectal tumor, ESD and surgical techniques do not differ in terms of local recurrence, en bloc resection rate, R0 resection rate, duration of the procedure, length of hospital stay, or complication rate, however, evidence is very low.
Collapse
Affiliation(s)
- Vitor Massaro Takamatsu Sagae
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Av. Dr. Enéas de Carvalho Aguiar, 255 - Instituto Central - Prédio dos Ambulatórios - Cerqueira César, São Paulo, SP, CEP: 05403-000, Brazil
| | - Igor Braga Ribeiro
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Av. Dr. Enéas de Carvalho Aguiar, 255 - Instituto Central - Prédio dos Ambulatórios - Cerqueira César, São Paulo, SP, CEP: 05403-000, Brazil.
| | - Diogo Turiani Hourneaux de Moura
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Av. Dr. Enéas de Carvalho Aguiar, 255 - Instituto Central - Prédio dos Ambulatórios - Cerqueira César, São Paulo, SP, CEP: 05403-000, Brazil
- Division of Gastroenterology, Hepatology and Endoscopy, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - Vitor Ottoboni Brunaldi
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Av. Dr. Enéas de Carvalho Aguiar, 255 - Instituto Central - Prédio dos Ambulatórios - Cerqueira César, São Paulo, SP, CEP: 05403-000, Brazil
| | - Fernanda Prado Logiudice
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Av. Dr. Enéas de Carvalho Aguiar, 255 - Instituto Central - Prédio dos Ambulatórios - Cerqueira César, São Paulo, SP, CEP: 05403-000, Brazil
| | - Mateus Pereira Funari
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Av. Dr. Enéas de Carvalho Aguiar, 255 - Instituto Central - Prédio dos Ambulatórios - Cerqueira César, São Paulo, SP, CEP: 05403-000, Brazil
| | - Elisa Ryoka Baba
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Av. Dr. Enéas de Carvalho Aguiar, 255 - Instituto Central - Prédio dos Ambulatórios - Cerqueira César, São Paulo, SP, CEP: 05403-000, Brazil
| | - Wanderley Marques Bernardo
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Av. Dr. Enéas de Carvalho Aguiar, 255 - Instituto Central - Prédio dos Ambulatórios - Cerqueira César, São Paulo, SP, CEP: 05403-000, Brazil
| | - Eduardo Guimarães Hourneaux de Moura
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - HC/FMUSP, Av. Dr. Enéas de Carvalho Aguiar, 255 - Instituto Central - Prédio dos Ambulatórios - Cerqueira César, São Paulo, SP, CEP: 05403-000, Brazil
| |
Collapse
|
29
|
Peltrini R, Sacco M, Luglio G, Bucci L. Local excision following chemoradiotherapy in T2-T3 rectal cancer: current status and critical appraisal. Updates Surg 2020; 72:29-37. [PMID: 31621033 DOI: 10.1007/s13304-019-00689-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 10/10/2019] [Indexed: 12/18/2022]
Abstract
Local excision following chemoradiotherapy in rectal cancer is an organ-preserving procedure which aims at reducing morbidity and functional disorders associated with total mesorectal excision (TME) in selected patients. Although TME after chemoradiotherapy remains the gold standard for locally advanced mid and low rectal cancer, in the last years multicenter research trials have offered encouraging oncologic results which have allowed to preserve the rectum in patients with a pathologic complete response after chemoradiotherapy. A review of the available literature on this topic was conducted to define the state of the art of this conservative approach and to focus on the most controversial aspects concerning local excision performed after chemoradiotherapy, in particular tumor scatter and lymph node status, completion and salvage surgery, morbidity and quality of life. The analysis of these topics should be considered, in trial setting or in current practice, for their clinical implications. Oncologic outcomes of recent trials are encouraging for part of the patients presenting T2 rectal cancer; however, TME still remains the standard treatment in clinical practice. In such cases, local excision should include a surgical safety margin of at least 1 cm from the resection margin to achieve a true negative margin from residual tumor cells. The selection of the patients should be carefully performed and their consensus extremely detailed because TME is necessary in about 30% of cases. Failing that, morbidity and quality of life are negatively affected. However, about half of these patients refuse radical surgery (45%), thus undergoing only palliative care.
Collapse
|
30
|
Chan T, Karimuddin AA, Raval MJ, Phang PT, Tang V, Brown CJ. Predictors of rectal adenoma recurrence following transanal endoscopic surgery: a retrospective cohort study. Surg Endosc 2020; 34:3398-407. [PMID: 31512037 DOI: 10.1007/s00464-019-07114-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 08/29/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND Transanal endoscopic surgery is the treatment of choice in patients with rectal adenomas that cannot be removed by endoscopy. However, the risk of adenoma recurrence and optimal surveillance is not well defined. The objective of this study was to characterize the timing and frequency of rectal adenoma recurrence after removal by transanal endoscopic surgery and identify recurrence risk factors. METHODS This was a retrospective cohort study of a large, single-center academic institution in Vancouver, BC, Canada. Consecutive patients between May 1, 2007 and September 30, 2016 with pathology-confirmed rectal adenoma treated by primary excision with transanal endoscopic surgery and at least 1 year of confirmed endoscopic follow-up were included. Main outcome measures were recurrence rates following TEM as well as risk factors for recurrence. RESULTS 297 patients met inclusion criteria. The mean age of patients was 66.5 ± 11.5 years and 57.9% were male. Median follow-up was 623 (range 56-3841) days. A total of 62 recurrences occurred in 41 patients (13.8% of study population). Recurrences were managed with repeat transanal endoscopic surgery or endoscopic resection 67.7% and 25.8% of the time, respectively. Radical resection was required for adenocarcinoma in 4 patients. Recurrence-free survival rates were 93.4% at 1 year, 86.2% at 2 years, and 73.1% at 5 years. After adjusting for individual surgeons, adenoma height, size > 3 cm, high-grade dysplasia, positive margins, and management of the rectal defect, patients who underwent surgery in the latter 5 years of the study had lower odds of recurrence (OR 0.42, 95% CI 0.19, 0.93, p = 0.03). CONCLUSIONS Rectal adenomas managed by transanal endoscopic surgery are lesions at high risk for recurrence; surveillance should be performed within the first 2 years and continued for a total of at least 5 years. Most recurrences can be successfully treated with repeat TEM or endoscopic resection.
Collapse
|
31
|
Feeney G, Sehgal R, Sheehan M, Hogan A, Regan M, Joyce M, Kerin M. Neoadjuvant radiotherapy for rectal cancer management. World J Gastroenterol 2019; 25:4850-4869. [PMID: 31543678 PMCID: PMC6737323 DOI: 10.3748/wjg.v25.i33.4850] [Citation(s) in RCA: 107] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 07/28/2019] [Accepted: 08/07/2019] [Indexed: 02/06/2023] Open
Abstract
Thirty per cent of all colorectal tumours develop in the rectum. The location of the rectum within the bony pelvis and its proximity to vital structures presents significant therapeutic challenges when considering neoadjuvant options and surgical interventions. Most patients with early rectal cancer can be adequately managed by surgery alone. However, a significant proportion of patients with rectal cancer present with locally advanced disease and will potentially benefit from down staging prior to surgery. Neoadjuvant therapy involves a variety of options including radiotherapy, chemotherapy used alone or in combination. Neoadjuvant radiotherapy in rectal cancer has been shown to be effective in reducing tumour burden in advance of curative surgery. The gold standard surgical rectal cancer management aims to achieve surgical removal of the tumour and all draining lymph nodes, within an intact mesorectal package, in order to minimise local recurrence. It is critically important that all rectal cancer cases are discussed at a multidisciplinary meeting represented by all relevant specialties. Pre-operative staging including CT thorax, abdomen, pelvis to assess for distal disease and magnetic resonance imaging to assess local involvement is essential. Staging radiology and MDT discussion are integral in identifying patients who require neoadjuvant radiotherapy. While Neoadjuvant radiotherapy is potentially beneficial it may also result in morbidity and thus should be reserved for those patients who are at a high risk of local failure, which includes patients with nodal involvement, extramural venous invasion and threatened circumferential margin. The aim of this review is to discuss the role of neoadjuvant radiotherapy in the management of rectal cancer.
Collapse
Affiliation(s)
- Gerard Feeney
- Department of General/Colorectal Surgery, Galway University Hospital, Galway H91 YR71, Ireland
| | - Rishabh Sehgal
- Department of General/Colorectal Surgery, Galway University Hospital, Galway H91 YR71, Ireland
| | - Margaret Sheehan
- Department of Histopathology, Galway University Hospital, Galway H91 YR71, Ireland
| | - Aisling Hogan
- Department of General/Colorectal Surgery, Galway University Hospital, Galway H91 YR71, Ireland
| | - Mark Regan
- Department of General/Colorectal Surgery, Galway University Hospital, Galway H91 YR71, Ireland
| | - Myles Joyce
- Department of General/Colorectal Surgery, Galway University Hospital, Galway H91 YR71, Ireland
| | - Michael Kerin
- Department of General/Colorectal Surgery, Galway University Hospital, Galway H91 YR71, Ireland
| |
Collapse
|
32
|
Arezzo A, Lo Secco G, Passera R, Esposito L, Guerrieri M, Ortenzi M, Bujko K, Perez RO, Habr-Gama A, Stipa F, Picchio M, Restivo A, Zorcolo L, Coco C, Rizzo G, Mistrangelo M, Morino M. Individual participant data pooled-analysis of risk factors for recurrence after neoadjuvant radiotherapy and transanal local excision of rectal cancer: the PARTTLE study. Tech Coloproctol 2019; 23:831-842. [PMID: 31388861 DOI: 10.1007/s10151-019-02049-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 07/19/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND An organ-preserving strategy may be a valid alternative in the treatment of selected patients with rectal cancer after neoadjuvant radiotherapy. Preoperative assessment of the risk for tumor recurrence is a key component of surgical planning. The aim of the present study was to increase the current knowledge on the risk factors for tumor recurrence. METHODS The present study included individual participant data of published studies on rectal cancer surgery. The literature was reviewed according to according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Individual Participant Data checklist (PRISMA-IPD) guidelines. Series of patients, whose data were collected prospectively, having neoadjuvant radiotherapy followed by transanal local excision for rectal cancer were reviewed. Three independent series of univariate/multivariate binary logistic regression models were estimated for the risk of local, systemic and overall recurrence, respectively. RESULTS We identified 15 studies, and 7 centers provided individual data on 517 patients. The multivariate analysis showed higher local and overall recurrences for ypT3 stage (OR 4.79; 95% CI 2.25-10.16 and OR 6.43 95% CI 3.33-12.42), tumor size after radiotherapy > 10 mm (OR 5.86 95% CI 2.33-14.74 and OR 3.14 95% CI 1.68-5.87), and lack of combined chemotherapy (OR 3.68 95% CI 1.78-7.62 and OR 2.09 95% CI 1.10-3.97), while ypT3 was the only factor correlated with systemic recurrence (OR 5.93). The analysis of survival curves shows that the overall survival is associated with ypT and not with cT. CONCLUSIONS Local excision should be offered with caution after neoadjuvant chemoradiotherapy to selected patients with rectal cancers, who achieved a good response to neoadjuvant chemoradiotherapy.
Collapse
Affiliation(s)
- A Arezzo
- Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Turin, Italy.
| | - G Lo Secco
- Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Turin, Italy
| | - R Passera
- Department of Nuclear Medicine, San Giovanni Battista Hospital, University of Turin, Turin, Italy
| | - L Esposito
- Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Turin, Italy
| | - M Guerrieri
- Department of General Surgery, Università Politecnica delle Marche, Ancona, Italy
| | - M Ortenzi
- Department of General Surgery, Università Politecnica delle Marche, Ancona, Italy
| | - K Bujko
- Department of Radiotherapy, Maria Sklodowska-Curie Memorial Cancer Centre, Warsaw, Poland
| | - R O Perez
- Colorectal Surgery Division, University of São Paulo School of Medicine, São Paulo, Brazil
| | - A Habr-Gama
- Colorectal Surgery Division, University of São Paulo School of Medicine, São Paulo, Brazil
| | - F Stipa
- Department of Surgery, Azienda Ospedaliera San Giovanni-Addolorata, Rome, Italy
| | - M Picchio
- Department of Surgery, Azienda Ospedaliera San Giovanni-Addolorata, Rome, Italy
| | - A Restivo
- Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - L Zorcolo
- Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - C Coco
- Department of Surgical Sciences, Catholic University of Sacred Heart, Rome, Italy
| | - G Rizzo
- Department of Surgical Sciences, Catholic University of Sacred Heart, Rome, Italy
| | - M Mistrangelo
- Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Turin, Italy
| | - M Morino
- Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Turin, Italy
| |
Collapse
|
33
|
Brown CJ, Hochman D, Raval MJ, Moloo H, Phang PT, Bouchard A, Williams L, Drolet S, Boushey R. A multi-centre randomized controlled trial of open vs closed management of the rectal defect after transanal endoscopic microsurgery. Colorectal Dis 2019; 21:1025-1031. [PMID: 31081281 DOI: 10.1111/codi.14689] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 04/12/2019] [Indexed: 01/17/2023]
Abstract
AIM Transanal endoscopic microsurgery (TEM) is a technically challenging strategy that allows expanded indications for local excision of rectal lesions. Transluminal suturing is difficult, so open management of the resultant defect is appealing. Expert opinion suggests there is more pain when the defect is left open. The aim of this study was to determine if closure of the defect created during full thickness excision of rectal lesions with TEM leads to less postoperative pain compared to leaving the defect open. METHOD At the time of surgery, patients undergoing a full thickness TEM were randomized to sutured (TEM-S) or open (TEM-O) management of the rectal defect. At five Canadian academic colorectal surgery centres, experienced TEM surgeons enrolled patients ≥ 18 years treated by full thickness TEM. The primary outcome was postoperative pain measured by the visual analogue scale. Secondary outcomes included postoperative pain medication use and 30-day postoperative complications, including bleeding, infection and hospital readmission. RESULTS Between March 2012 and October 2013, 50 patients were enrolled and randomized to sutured (TEM-S, n = 28) or open (TEM-O, n = 22) management of the rectal defect. There was no difference between the two study groups in postoperative pain on postoperative day 1 (2.8 vs 2.6, P = 0.76), day 3 (2.8 vs 2.1, P = 0.23) and day 7 (2.8 vs 1.7, P = 0.10). CONCLUSION In this multicentre randomized controlled trial, there was no difference in postoperative pain between sutured or open defect management in patients having a full thickness excision with TEM.
Collapse
Affiliation(s)
- C J Brown
- Department of Surgery, University of British Columbia and St Paul's Hospital, Vancouver, British Columbia, Canada
| | - D Hochman
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - M J Raval
- Department of Surgery, University of British Columbia and St Paul's Hospital, Vancouver, British Columbia, Canada
| | - H Moloo
- Department of Surgery, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - P T Phang
- Department of Surgery, University of British Columbia and St Paul's Hospital, Vancouver, British Columbia, Canada
| | - A Bouchard
- Department of Surgery, CHU de Québec - Université Laval, Quebec City, Quebec, Canada
| | - L Williams
- Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - S Drolet
- Department of Surgery, CHU de Québec - Université Laval, Quebec City, Quebec, Canada
| | - R Boushey
- Department of Surgery, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| |
Collapse
|
34
|
Xue XQ, Zhou JL, Lin GL, Bai XS, Xiao Y, Wu B, Qiu HZ. [An initial exploration of the application of transanal endoscopic microsurgery in rectal cancer patients with clinical complete response after neoadjuvant chemoradiotherapy]. Zhonghua Wei Chang Wai Ke Za Zhi 2019; 22:560-565. [PMID: 31238635 DOI: 10.3760/cma.j.issn.1671-0274.2019.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objective: To preliminarily explore the value of transanal endoscopic microsurgery (TEM) in rectal cancer patients with clinical complete response (cCR) following neoadjuvant chemoradiotherapy (nCRT). Methods: Using descriptive case series method, Clinical data of 13 patients who met the criteria of nCRT and were considered to be cCR after MRI or CT scanning, digital rectal examination and colonoscopic biopsy, as well as no lymph node or distant metastasis were found, then underwent TEM from 2013 to 2016 at the Department of General Surgery of Peking Union Medical College Hospital were collected retrospectively. A 3-course combination of capecitabine and oxaliplatin (XELOX) was used for chemotherapy. Besides, a 6MV-X ray radiation was used as radiotherapy simultaneously. Six to eight weeks after completion of radiotherapy, a preoperative assessment was carried out with intrarectal ultrasound, MRI, or pelvic abdominal CT examination. TEM was performed afterwards with informed consent. Postoperative pathological findings and follow-up results were used to evaluate the value of diagnosis and treatment of TEM on those patients. Results: There were 8 males and 5 females with a median age of 63 (27-80) years. Preoperative examination showed that the lesions were located in the anterior wall in 3 cases, the posterior wall in 3 cases, the left side wall in 4 cases, and the right side wall in 3 cases. Before nCRT, the distance between tumor and anal margin was (4.8±1.1) (2.0-7.5) cm; after nCRT, this distance was (5.2±1.3) (3.0-7.5) cm. All the 13 patients underwent extended local resection of rectal cancer via TEM with the placement of urethral catheter. The average operative time was (52.2±3.7) (42-70) minutes, and the average intraoperative blood loss was (19.2±2.8) (5-30) ml. All the patients could engage in daily activities on postoperative day 1, and could cater themselves orally on postoperative day 2. The main discomfort was postoperative anal pain and foreign body sensation (n=5), which could be alleviated by non-steroidal anti-inflammatory drugs. One case had postoperative lung infection and was cured by antibiotic treatment. One case had urinary retention after removing urine catheter, and then a urine catheter was re-inserted. Average postoperative hospital stay was (2.8±2.4) (2-12) days. All specimens were completely resected via TEM. Histopathological examination confirmed that 7 specimens had achieved pathologic complete response (pCR) and the other 6 specimens had obtained partial tumor response of CAP grade 2. Seven patients with pCR received a median follow-up of 24 (8-48) months and no local recurrence or distant metastasis was reported during follow-up period. Among these 7 cases, one developed defecation dysfunction after discharge, mainly for defecation pain and even dare to defecate, who returned to normal defecation within 2 months after surgery; One developed severe anal pain within six months after surgery and the pain disappeared after symptomatic pain relief. The other 6 patients with CAP grade 2 refused to undergo further radical operation because of their strong desire in preserving anus, and received remedial adjuvant chemotherapy instead. Conclusion: For rectal cancer patients with cCR after nCRT, TEM does have certain application values if the patient has a strong desire to preserve anus.
Collapse
Affiliation(s)
- X Q Xue
- Department of Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - J L Zhou
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - G L Lin
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - X S Bai
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Y Xiao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - B Wu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - H Z Qiu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| |
Collapse
|
35
|
van Heinsbergen M, Leijtens JW, Slooter GD, Janssen-Heijnen ML, Konsten JL. Quality of Life and Bowel Dysfunction after Transanal Endoscopic Microsurgery for Rectal Cancer: One Third of Patients Experience Major Low Anterior Resection Syndrome. Dig Surg 2019; 37:39-46. [PMID: 31185474 DOI: 10.1159/000496434] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 12/19/2018] [Indexed: 12/10/2022]
Abstract
BACKGROUND/AIMS The low anterior resection syndrome (LARS) severely affects quality of life (QoL) after rectal cancer surgery. Studies investigating LARS and the effect on QoL after transanal endoscopic microsurgery (TEM) for rectal cancer are scarce. The aim of our study was to assess bowel dysfunction and QoL after TEM. METHODS Seventy-three -patients who underwent TEM for stage I rectal cancer were included in this single-centre, cross-sectional study Bowel dysfunction was assessed by the LARS-Score, QoL by the -European Organization for the Research and Treatment of Cancer QLQ-C30 and -CR29 questionnaires. RESULTS Fifty-five respondents (75.3%) could be included for the analyses. The median interval since treatment was 4.3 years, and the median age at the follow-up point was 72 years. "Major LARS" was observed in 29% of patients and "minor LARS" in 26%. Female gender (OR 4.00; 95% CI 1.20-13.36), neo-adjuvant chemoradiotherapy (OR 3.63; 95% CI 1.08-12.17) and specimen thickness in millimetres (OR 1.10 for each mm increase in thickness; 95% CI 1.01-1.20) were associated with the development of major LARS. Patients with major LARS fared worse in most QoL domains. CONCLUSION This is the first study demonstrating major LARS after TEM treatment for rectal cancer, with a negative effect on QoL, even years after treatment. Our data provides an adequate counselling before TEM in terms of postoperative bowel dysfunction and its effect on QoL.
Collapse
Affiliation(s)
| | - Jeroen W Leijtens
- Department of Surgery, Laurentius Medical Centre, Roermond, The Netherlands
| | - Gerrit D Slooter
- Department of Surgery, Maxima Medical Centre, Veldhoven, The Netherlands
| | - Maryska L Janssen-Heijnen
- Department of Clinical Epidemiology, VieCuri Medical Centre, Venlo, The Netherlands.,Department of Epidemiology, Maastricht University Medical Centre, GROW School for Oncology and Developmental Biology, Maastricht, The Netherlands
| | - Joop L Konsten
- Department of Surgery, VieCuri Medical Centre, Venlo, The Netherlands
| |
Collapse
|
36
|
Ramkumar J, Letarte F, Karimuddin AA, Phang PT, Raval MJ, Brown CJ. Assessing the safety and outcomes of repeat transanal endoscopic microsurgery. Surg Endosc 2019; 33:1976-1980. [PMID: 30746573 DOI: 10.1007/s00464-018-6501-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 10/11/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Transanal endoscopic microsurgery (TEM) is the treatment of choice for benign rectal tumors and select early rectal cancers. This surgical approach has become ubiquitous and surgeons are seeing recurrent lesions after TEM resection. This study aims to outline the safety and outcomes of repeat TEM when compared to primary TEM procedures. METHODS At St. Paul's Hospital, demographic, surgical, pathologic, and follow-up data for patients treated by TEM are maintained in a prospectively populated database. Two groups were established for comparison: patients undergoing first TEM procedure (TEM-P) and patients undergoing repeat TEM procedure (TEM-R). RESULTS Between 2007 and 2017, 669 patients had their first TEM procedure. Over this time frame, 57 of these patients required repeat TEM procedures, including 15 of these patients treated by 3 or more TEMs. Indications for repeat TEM included recurrence (78%), positive margins (15%), and metachronous lesions (7%). There were no differences between the groups in patient age, gender, or tumor histology. Compared to TEM-P, TEM-R had shorter operative times (38 vs. 52 min, p < 0.001), more distal lesions (5 vs. 7 cm, p < 0.004), and smaller lesions (3 vs. 4 cm, p < 0.0003). The TEM-R group had similar length of hospital stay (0.45 vs. 0.56 days, p = 0.65), rates of clear margins on pathology (81% vs. 88%, p = 0.09), and 30-day readmission rates (7% vs. 4%, p = 0.27) when compared to TEM-P group. TEM-R was more likely to be managed without suturing the surgical defect (72% vs. 32%, p < 0.0001). Repeat TEM was associated with similar post-operative complications as primary TEM graded on the Clavien-Dindo classification scale (Grade 1: 5% vs. 5%, Grade 2: 5% vs. 4%, Grade 3: 5% vs. 1%, p = 0.53). No 30-day mortality occurred in either group. CONCLUSIONS The St. Paul's Hospital TEM experience suggests repeat TEM is a safe and feasible procedure with similar outcomes as patients undergoing first TEM.
Collapse
Affiliation(s)
- Jonathan Ramkumar
- Division of General Surgery, Vancouver General Hospital, 950 West 10th Avenue, Vancouver, Canada
| | - Francois Letarte
- Department of Surgery, St. Paul's Hospital, Vancouver, BC, Canada
| | - Ahmer A Karimuddin
- Department of Surgery, St. Paul's Hospital, Vancouver, BC, Canada.,Section of Colorectal Surgery, St. Paul's Hospital, Room C310 - 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - P Terry Phang
- Department of Surgery, St. Paul's Hospital, Vancouver, BC, Canada.,Section of Colorectal Surgery, St. Paul's Hospital, Room C310 - 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Manoj J Raval
- Department of Surgery, St. Paul's Hospital, Vancouver, BC, Canada.,Section of Colorectal Surgery, St. Paul's Hospital, Room C310 - 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Carl J Brown
- Department of Surgery, St. Paul's Hospital, Vancouver, BC, Canada. .,Section of Colorectal Surgery, St. Paul's Hospital, Room C310 - 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
| |
Collapse
|
37
|
Raynaud L, Mege D, Zappa M, Guedj N, Vilgrain V, Panis Y. Is magnetic resonance imaging useful for the management of patients with rectal villous adenoma? A study of 45 consecutive patients treated by transanal endoscopic microsurgery. Int J Colorectal Dis 2018; 33:1695-1701. [PMID: 30136172 DOI: 10.1007/s00384-018-3148-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/14/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE Very few data are available about the clinical relevance of magnetic resonance (MR) imaging in preoperative evaluation of rectal villous adenoma. The aim is to evaluate the impact of MR imaging for the surgical management of rectal villous adenoma treated by transanal endoscopic microsurgery (TEM). METHODS All patients with histologically proven rectal villous tumours operated by TEM who had a preoperative MR imaging between 2009 and 2017 were retrospectively reviewed. All patients underwent TEM because preoperative evaluation suggested systematically usT0 or usT1 tumour. Pathological stage was blindly compared to preoperative MR imaging (location according to the anal verge and the peritoneal reflection, amount of circumferential involvement, tumour size and staging) and preoperative transrectal ultrasonography (TRUS) results. RESULTS Forty-five patients were included (24 men, mean age 65 ± 8 years) with TRUS data available only in 37. Pathologic results were pT0-pTis in 32, pT1 in 10 and pT2 in 3. TRUS diagnosed correctly 36/37 lesions (97%) and understaged one pT2 tumour. A significant correlation between TRUS and pathologic results was noted (r = 0.99; p = 0.01). MR imaging diagnosed correctly 19/42 pTis-T1 and 1/3 pT2 tumours (46%). Overstaging by MR imaging was noted in 25 cases (54%). No correlation between MR imaging and pathologic results was noted (r = 0.7; p = 0.3). CONCLUSION Preoperative evaluation of rectal villous adenoma is overstaged by MRI in more than half of the patients. This study suggests that the indication of local excision by TEM for rectal villous adenoma should be based on TRUS rather than on MRI.
Collapse
Affiliation(s)
- Lucas Raynaud
- Department of Radiology, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris VII, Clichy, France
| | - Diane Mege
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris VII, 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - Magaly Zappa
- Department of Radiology, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris VII, Clichy, France.,University Paris Diderot, Sorbonne Paris Cité, 75018, Paris, France.,UMR1149 CRI, INSERM, 75018, Paris, France
| | - Nathalie Guedj
- Department of Pathology, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris VII, Clichy, France
| | - Valérie Vilgrain
- Department of Radiology, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris VII, Clichy, France.,University Paris Diderot, Sorbonne Paris Cité, 75018, Paris, France.,UMR1149 CRI, INSERM, 75018, Paris, France
| | - Yves Panis
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris VII, 100 Boulevard du Général Leclerc, 92110, Clichy, France. .,University Paris Diderot, Sorbonne Paris Cité, 75018, Paris, France.
| |
Collapse
|
38
|
Leijtens JW, Koedam TW, Borstlap WA, Maas M, Doornebosch PG, Karsten TM, Derksen EJ, Stassen LP, Rosman C, de Graaf EJ, Bremers AJ, Heemskerk J, Beets GL, Tuynman JB, Rademakers KL. Transanal Endoscopic Microsurgery with or without Completion Total Mesorectal Excision for T2 and T3 Rectal Carcinoma. Dig Surg 2018; 36:76-82. [PMID: 29791891 PMCID: PMC6390444 DOI: 10.1159/000486555] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 12/30/2017] [Indexed: 01/22/2023]
Abstract
AIM Transanal endoscopic microsurgery (TEM) is used for the resection of large rectal adenomas and well or moderately differentiated T1 carcinomas. Due to difficulty in preoperative staging, final pathology may reveal a carcinoma not suitable for TEM. Although completion total mesorectal excision is considered standard of care in T2 or more invasive carcinomas, this completion surgery is not always performed. The purpose of this article is to evaluate the outcome of patients after TEM-only, when completion surgery would be indicated. METHODS In this retrospective multicenter, observational cohort study, outcome after TEM-only (n = 41) and completion surgery (n = 40) following TEM for a pT2-3 rectal adenocarcinoma was compared. RESULTS Median follow-up was 29 months for the TEM-only group and 31 months for the completion surgery group. Local recurrence rate was 35 and 11% for the TEM-only and completion surgery groups respectively. Distant metastasis occurred in 16% of the patients in both groups. The 3-year overall survival was 63% in the TEM-only group and 91% in the completion surgery group respectively. Three-year disease-specific survival was 91 versus 93% respectively. CONCLUSIONS Although local recurrence after TEM-only for pT2-3 rectal cancer is worse compared to the recurrence that occurs after completion surgery, disease-specific survival is comparable between both groups. The lower unadjusted overall survival in the TEM-only group indicates that TEM-only may be a valid alternative in older and frail patients, especially when high morbidity of completion surgery is taken into consideration. Nevertheless, completion surgery should always be advised when curation is intended.
Collapse
Affiliation(s)
| | - Thomas W.A. Koedam
- Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands,*Thomas W.A. Koedam, Department of Surgery, VU University Medical Center, Boelelaan 1117, NL-1081 HV Amsterdam (The Netherlands), E-Mail
| | | | - Monique Maas
- Deparment of Radiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Tom M. Karsten
- Department of Surgery, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - Eric J. Derksen
- Department of Surgery, MC Slotervaart, Amsterdam, The Netherlands
| | - Laurents P.S. Stassen
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Camiel Rosman
- Department of Surgery, Netherlands Cancer Institute Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Eelco J.R. de Graaf
- Department of Surgery, IJsselland Hospital, Capelle aan den IJssel, The Netherlands
| | | | - Jeroen Heemskerk
- Department of Surgery, Laurentius Hospital, Roermond, The Netherlands
| | - Geerard L. Beets
- Department of Surgery, Netherlands Cancer Institute Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Jurriaan B. Tuynman
- Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | | |
Collapse
|
39
|
Brown CJ, Gentles JQ, Phang TP, Karimuddin AA, Raval MJ. Transanal endoscopic microsurgery as day surgery - a single-centre experience with 500 patients. Colorectal Dis 2018; 20:O310-O315. [PMID: 29992737 DOI: 10.1111/codi.14337] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 07/02/2018] [Indexed: 02/08/2023]
Abstract
AIM Transanal endoscopic microsurgery (TEM) is the current treatment of choice for rectal adenomas and early rectal cancer. Postoperative admission to hospital is common but possibly unnecessary. Our objective was to analyse predictors and outcomes of TEM patients having same day discharge (TEM-D) compared with those who were admitted to hospital (TEM-A). METHOD At St Paul's Hospital (SPH), demographic, surgical, pathological and follow-up data have been collected prospectively since TEM was started in 2007. Trends in admission and readmission rates were analysed using the Cochran-Armitage trend test, and predictors of admission were analysed using univariate and multivariate logistic regressions. RESULTS Between 2007 and 2016, 500 patients were treated by TEM at SPH. The overall admission rate was 29% (145/500), but this decreased to 19% in the last 3 years of the study (P < 0.001). The readmission rate was 5.2% (n = 26/500) and did not change significantly over the study period (P = 0.30). Reasons for admission included the following: surgeon discretion/monitoring (35%), urinary retention (26%), haemorrhage (10%), breach of peritoneal cavity (7%), infection (7%) and other (15%). The most common reasons for readmission were haemorrhage (54%, n = 14), pain (19%, n = 5) and infection (12%, n = 3). Factors associated with admission were as follows: tumour height (OR 1.09, 1.02-1.17), prolonged operative time (OR 1.25, 1.14-1.37), unsutured surgical defect (OR 1.99, 1.22-3.25) and surgeon experience (OR 4.62, 2.75-7.77). CONCLUSION Outpatient TEM is safe and carries a low risk of readmission. In centres with an outpatient TEM strategy, predictors of hospital admission include proximal tumours, prolonged surgical time and open management of the surgical defect.
Collapse
Affiliation(s)
- C J Brown
- Department of Surgery, University of British Columbia and St Paul's Hospital, Vancouver, BC, Canada.,Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - J Q Gentles
- Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - T P Phang
- Department of Surgery, University of British Columbia and St Paul's Hospital, Vancouver, BC, Canada.,Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - A A Karimuddin
- Department of Surgery, University of British Columbia and St Paul's Hospital, Vancouver, BC, Canada.,Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - M J Raval
- Department of Surgery, University of British Columbia and St Paul's Hospital, Vancouver, BC, Canada.,Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| |
Collapse
|
40
|
Ramkumar J, Karimuddin AA, Phang PT, Raval MJ, Brown CJ. Peritoneal perforation during transanal endoscopic microsurgery is not associated with significant short-term complications. Surg Endosc 2019; 33:849-53. [PMID: 30022287 DOI: 10.1007/s00464-018-6351-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 07/06/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND In patients treated by transanal endoscopic microsurgery (TEM), breach of the peritoneal cavity is a feared intraoperative challenge. Our aim is to analyze predictors and short-term outcomes of patients with peritoneal perforation (TEM-P) when compared to similar patients with no peritoneal compromise (TEM-N). METHODS At St. Paul's Hospital, demographic, surgical, pathologic, and follow-up data for all patients treated by TEM is maintained in a prospectively populated database. A retrospective review was performed and two groups were established for comparison: TEM-P and TEM-N. Statistical analysis was performed using student's t or chi-squared test, where appropriate. RESULTS Of 619 patients treated by TEM between 2007 and 2016, 39 (6%) patients were in the TEM-P group and 580 (94%) in the TEM-N group. There were no differences between the groups in patient age, gender, histology, or tumor size. Patients who had peritoneal perforations had more proximal lesions (11 vs. 7 cm, p < 0.0001), anterior lesions (56 vs. 43%, p < 0.05), and longer operations (80 vs. 51 min, p < 0.005). While most defects were closed endoluminally, 2 patients with perforation were converted to transabdominal surgery. There was a difference in overall hospital stay with TEM-P patients staying on average 2 days in hospital with fewer patients managed as day surgery (31 vs. 73%, p < 0.0001). There were no mortalities or significant 30-day complications in the TEM-P group and only one patient required readmission. CONCLUSIONS The St. Paul's Hospital TEM experience suggests patients with peritoneal breach during TEM can be safely managed with outcomes similar to patients without peritoneal entry. Proximal, anterior lesions are at highest risk of peritoneal perforation.
Collapse
|
41
|
Serra-Aracil X, Gràcia R, Mora-López L, Serra-Pla S, Pallisera-Lloveras A, Labró M, Navarro-Soto S. How to deal with rectal lesions more than 15 cm from the anal verge through transanal endoscopic microsurgery. Am J Surg 2018; 217:53-58. [PMID: 29709273 DOI: 10.1016/j.amjsurg.2018.04.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 04/12/2018] [Accepted: 04/17/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND The aim of this study is to assess postoperative morbidity and mortality in tumors with a proximal margin 15 cm or more from the anal verge operated with transanal endoscopic microsurgery (TEM). METHODS This observational study of consecutive rectal tumor patients undergoing TEM was carried out from July 2004 to June 2017. We compared the results of rectal tumors at distances of ≥15 cm (group A) and <15 cm (group B) from the anal verge. RESULTS During the study period 667 patients were included: 118 in group A and 549 in group B. In the comparative analysis there were no significant differences in morbidity (p = 0.23), mortality (p = 0.32) or free margin involvement (p = 0.545). Differences were observed in terms of lesion size (p < 0.001), surgical time (p < 0.001) and peritoneal cavity perforation, which were all increased in group A. CONCLUSION TEM for lesions in the rectosigmoid junction is feasible and is not associated with higher morbidity or mortality.
Collapse
Affiliation(s)
- Xavier Serra-Aracil
- Coloproctology Unit. General and Digestive Surgery Service, Parc Tauli University Hospital, Sabadell, Universitat Autonoma de Barcelona, Parc Tauli s/n, 08208, Sabadell (Barcelona), Spain.
| | - Raquel Gràcia
- Coloproctology Unit. General and Digestive Surgery Service, Parc Tauli University Hospital, Sabadell, Universitat Autonoma de Barcelona, Parc Tauli s/n, 08208, Sabadell (Barcelona), Spain
| | - Laura Mora-López
- Coloproctology Unit. General and Digestive Surgery Service, Parc Tauli University Hospital, Sabadell, Universitat Autonoma de Barcelona, Parc Tauli s/n, 08208, Sabadell (Barcelona), Spain
| | - Sheila Serra-Pla
- Coloproctology Unit. General and Digestive Surgery Service, Parc Tauli University Hospital, Sabadell, Universitat Autonoma de Barcelona, Parc Tauli s/n, 08208, Sabadell (Barcelona), Spain
| | - Anna Pallisera-Lloveras
- Coloproctology Unit. General and Digestive Surgery Service, Parc Tauli University Hospital, Sabadell, Universitat Autonoma de Barcelona, Parc Tauli s/n, 08208, Sabadell (Barcelona), Spain
| | - Maritxell Labró
- Coloproctology Unit. General and Digestive Surgery Service, Parc Tauli University Hospital, Sabadell, Universitat Autonoma de Barcelona, Parc Tauli s/n, 08208, Sabadell (Barcelona), Spain
| | - Salvador Navarro-Soto
- Coloproctology Unit. General and Digestive Surgery Service, Parc Tauli University Hospital, Sabadell, Universitat Autonoma de Barcelona, Parc Tauli s/n, 08208, Sabadell (Barcelona), Spain
| |
Collapse
|
42
|
Jakubauskas M, Jotautas V, Poskus E, Mikalauskas S, Valeikaite-Tauginiene G, Strupas K, Poskus T. Fecal incontinence after transanal endoscopic microsurgery. Int J Colorectal Dis 2018; 33:467-472. [PMID: 29470728 DOI: 10.1007/s00384-018-2983-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/12/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE Transanal endoscopic microsurgery (TEM) procedure could potentially influence the development of fecal incontinence later in life. The aim of our study was to assess long-term functional outcomes after TEM and to determine possible variables related to incontinence. METHODS Patients, enrolled in a prospectively collected TEM operation database, were interviewed using a postal questionnaire. The questionnaire consisted of EuroQol (EQ)-5D-5L quality of life questionnaire, Wexner fecal incontinence grading scale, and additional questions about other perianal operations and obstetric history for women. We divided patients into two groups: no or minor fecal incontinence (Wexner score of 2 and less) and non-minor incontinence (Wexner score of 3 or more). RESULTS One hundred thirty-two patients were included in the study. Patients' median follow-up time was 96 (12-168) months from their operation. Thirty-eight patients (28.8%) reported Wexner score of 3 or more, and they reported significantly worse quality of life in all tested life spheres. They were older at the time of the operation (63 (18-82) vs. 68 (50-89) years; p = 0.004), underwent longer operations (50 (10-140) vs. 60 (15-210) min; p = 0.017), and more often were operated for malignant lesions (17 (18.3%) vs. 14 (36.8%); p = 0.040). Older age at the time of operation was an independent risk factor in multivariate model (OR 1.057, 95% CI 1.010-1.106; p = 0.016). CONCLUSIONS Fecal incontinence after TEM is more common than thought previously, resulting in significantly impaired quality of life. Older age at the time of operation was an independent risk factor for developing significant fecal incontinence.
Collapse
Affiliation(s)
| | - Valdemaras Jotautas
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Center of Abdominal Surgery, Vilnius University Hospital "Santaros Klinikos", Santariskiu Str. 2, LT-08661, Vilnius, Lithuania
| | - Eligijus Poskus
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Center of Abdominal Surgery, Vilnius University Hospital "Santaros Klinikos", Santariskiu Str. 2, LT-08661, Vilnius, Lithuania
| | - Saulius Mikalauskas
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Center of Abdominal Surgery, Vilnius University Hospital "Santaros Klinikos", Santariskiu Str. 2, LT-08661, Vilnius, Lithuania
| | - Gintare Valeikaite-Tauginiene
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Center of Abdominal Surgery, Vilnius University Hospital "Santaros Klinikos", Santariskiu Str. 2, LT-08661, Vilnius, Lithuania
| | - Kestutis Strupas
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Center of Abdominal Surgery, Vilnius University Hospital "Santaros Klinikos", Santariskiu Str. 2, LT-08661, Vilnius, Lithuania
| | - Tomas Poskus
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania.
- Center of Abdominal Surgery, Vilnius University Hospital "Santaros Klinikos", Santariskiu Str. 2, LT-08661, Vilnius, Lithuania.
| |
Collapse
|
43
|
Clermonts SHEM, van Loon YT, Schiphorst AHW, Wasowicz DK, Zimmerman DDE. Transanal minimally invasive surgery for rectal polyps and selected malignant tumors: caution concerning intermediate-term functional results. Int J Colorectal Dis 2017; 32:1677-85. [PMID: 28905101 DOI: 10.1007/s00384-017-2893-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/30/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE Transanal minimally invasive surgery (TAMIS) is gaining worldwide popularity as an alternative for the transanal endoscopic microsurgery (TEMS) method for the local excision of rectal polyps and selected neoplasms. Data on patient reported outcomes regarding short-term follow-up are scarce; data on functional outcomes for long-term follow-up is non-existent. METHODS We used the fecal incontinence severity index (FISI) to prospectively assess the fecal continence on the intermediate-term follow-up after TAMIS. The primary outcome measure is postoperative fecal continence. Secondary outcome measures are as follows: perioperative and intermediate-term morbidity. RESULTS Forty-two patients (m = 21:f = 21), median age 68.5 (range 34-94) years, were included in the analysis. In four patients (9.5%), postoperative complications occurred. The median follow-up was 36 months (range 24-48). Preoperative mean FISI score was 8.3 points. One year after TAMIS, mean FISI score was 5.4 points (p = 0.501). After 3 years of follow-up, mean FISI score was 10.1 points (p = 0.01). Fecal continence improved in 11 patients (26%). Continence decreased in 20 patients (47.6%) (mean FISI score 15.2 points, [range 3-31]). CONCLUSIONS This study found that the incidence of impaired fecal continence after TAMIS is substantial; however, the clinical significance of this deterioration seems minor. The present data is helpful in acquiring informed consent and emphasizes the need of proper patient information. Functional results seem to be comparable to results after TEMS. Furthermore, we confirmed TAMIS is safe and associated with low morbidity.
Collapse
|
44
|
Dulskas A, Kilius A, Petrulis K, Samalavicius NE. Transanal endoscopic microsurgery for giant benign rectal tumours: is large size a contraindication? Int J Colorectal Dis 2017; 32:1759-61. [PMID: 28963594 DOI: 10.1007/s00384-017-2910-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/26/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE The purpose of this study is to look at our early postoperative results, recurrence rates and need for further radical surgery in treating large (> 5 cm) rectal tumours by transanal endoscopic microsurgery (TEM). METHODS Patients who underwent TEM for rectal tumours greater than 5 cm were included. Tumour diameter was determined based on fresh specimen measurements. We recorded the demographics, operative details, final pathology, length of hospital stay, complications and recurrence rates. RESULTS Mean tumour size was 5.9 ± 1.5 cm. 68.4% of tumours (13/19) were in the middle part of the rectum. Three patients (15.8%) developed postoperative complications: two had postoperative bleeding (10.5%), one had wound dehiscence (5.3%). Three patients had involved margins (15.8%). After a median follow up of 25.2 months, there were two recurrences (10.5%). One patient developed rectal cancer 6 years after removal of rectal adenoma. CONCLUSION TEM is feasible and safe for the treatment of giant benign rectal tumours. It may be an alternative method for proctectomy in selected patients.
Collapse
|
45
|
Menahem B, Alves A, Morello R, Lubrano J. Should the rectal defect be closed following transanal local excision of rectal tumors? A systematic review and meta-analysis. Tech Coloproctol 2017; 21:929-936. [PMID: 29134387 DOI: 10.1007/s10151-017-1714-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 09/25/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Transanal local excision (TLE) has become the treatment of choice for benign and early-stage selected malignant tumors. However, closure of the rectal wall defect remains a controversial point and the available literature still remains unclear. Our aim was to determine through a systematic review of the literature and a meta-analysis of relevant studies whether or not the wall defect following TLE of rectal tumors should be closed. METHODS Medline and the Cochrane Trials Register were searched for trials published up to December 2016 comparing open versus closed management of the surgical rectal defect after TLE of rectal tumors. Meta-analysis was performed using Review Manager 5.0. RESULTS Four studies were analyzed, yielding 489 patients (317 in the closed group and 182 in the open group). Meta-analysis showed no significant difference between the closed and open groups regarding the overall morbidity rate (OR 1.26; 95% CI 0.32-4.91; p = 0.74), postoperative local infection rate (OR 0.62; 95% CI 0.23-1.62; p = 0.33), postoperative bleeding rate (OR 0.83; 95% CI 0.29-1.77; p = 0.63), and postoperative reintervention rate (OR 2.21; 95% CI 0.52-9.47; p = 0.29). CONCLUSIONS This review and meta-analysis suggest that there is no difference between closure or non-closure of wall defects after TLE.
Collapse
Affiliation(s)
- B Menahem
- Department of Digestive Surgery, Caen University Hospital, Avenue de la Côte de Nacre, 14032, Caen Cedex, France.
- UMR, French National Institute for Health and Medical Research U1086 Cancer and Prevention, The François Baclesse Center, Caen, France.
- UFR of Medicine, Caen, France.
| | - A Alves
- Department of Digestive Surgery, Caen University Hospital, Avenue de la Côte de Nacre, 14032, Caen Cedex, France
- UMR, French National Institute for Health and Medical Research U1086 Cancer and Prevention, The François Baclesse Center, Caen, France
- UFR of Medicine, Caen, France
| | - R Morello
- Department of Digestive Surgery, Caen University Hospital, Avenue de la Côte de Nacre, 14032, Caen Cedex, France
- UFR of Medicine, Caen, France
- Department of Clinical Research and Biostatistics, Caen University Hospital, Caen, France
| | - J Lubrano
- Department of Digestive Surgery, Caen University Hospital, Avenue de la Côte de Nacre, 14032, Caen Cedex, France
- UMR, French National Institute for Health and Medical Research U1086 Cancer and Prevention, The François Baclesse Center, Caen, France
- UFR of Medicine, Caen, France
| |
Collapse
|
46
|
Ortenzi M, Ghiselli R, Paolucci A, Guerrieri M. The feasibility of laparoscopic rectal resection in patients undergoing reoperation after transanal endoscopic microsurgery (TEM). Surg Endosc 2018; 32:2020-5. [PMID: 29052070 DOI: 10.1007/s00464-017-5898-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 09/17/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND The success of transanal endoscopic microsurgery (TEM) for early rectal cancer depends on proper indications and strict patient selection. When unfavorable pathologic features are identified after TEM operation, total mesorectal excision is recommended to minimize the risk of recurrence. In this study, data were collected in a retrospective series of patients to determine the results of laparoscopic reoperation after TEM. METHODS All patients underwent an accurate rectal-digital examination and clinical tumor staging by transanal endosonography, CT, and/or MRI. The histologic examination included an evaluation of the free margins, depth of tumor infiltration according to International Union Against Cancer guidelines, degree of tumor differentiation, and the presence of lymphovascular and perineural invasion. When a high-risk tumor was identified, reoperation was performed within 6 weeks from TEM. The patients were divided into two groups according to the procedure performed: laparoscopic anterior resection (LAR) or laparoscopic abdominal perineal amputation (LAPR). RESULTS Sixty-eight patients (5.3%) underwent reoperation: 38 underwent LAR and 30 underwent LAPR. The mean operative time was 148.24 min (± 35.8, p = 0.62). Meanwhile, the mean distance of the TEM scar from the anal verge differed statistically between the two groups (p = 0.003) and was statistically correlated with abdominal perineal amputation (p = 0.0001) in multivariate analysis. Conversion to open surgery was required in 6 patients (15.7%) in the LAR group and 3 patients (10%) in the LAPR group (p = 0.38). The histologic examination revealed residual cancer cells in 3 cases (3 pT2N0) and 1 case (1 pT3N0), respectively, and lymph node metastases in 4 cases. No residual neoplasms were detected in the remaining 60 cases (88.3%). After a mean follow-up of 108 months, the overall disease-free survival was 98% (95% CI 88-99%). CONCLUSIONS In our experience, reoperation after TEM using a laparoscopic approach is feasible and safe, with low conversion rates and optimal postoperative results.
Collapse
|
47
|
Mege D, Petrucciani N, Maggiori L, Panis Y. Peritoneal perforation is less a complication than an expected event during transanal endoscopic microsurgery: experience from 194 consecutive cases. Tech Coloproctol 2017; 21:729-736. [PMID: 28871476 DOI: 10.1007/s10151-017-1676-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Accepted: 07/27/2017] [Indexed: 01/29/2023]
Abstract
BACKGROUND Indications for transanal endoscopic microsurgery (TEM) have been extended to technically challenging tumors, which may be associated with an increased risk of peritoneal perforation (PP). The aim of the present study was to investigate the occurrence, management and outcome of PP in patients having TEM. METHODS All the patients who had TEM for rectal adenoma or adenocarcinoma in our unit were included. Patients in whom PP occurred (Group A) were compared to those without PP (Group B). RESULTS From 2007 to 2015, 194 TEM (116 men, median age 66 [range 21-100] years) were divided into Groups A (n = 28, 14%) and B (n = 166). The latter group included four patients, in whom a laparoscopy did not confirm suspicion of PP made during TEM. In 2 of 28 patients (7%), the diagnosis of PP was made postoperatively during reoperation for peritonitis. For the 26 other patients (93%), routine exploratory laparoscopy was performed with suture of the peritoneal defect on the pouch of Douglas in 24 cases and a rectal suture alone in 2 cases. Independent predictive factors for PP were: distance from the anal verge >10 cm (OR = 3.6), circumferential tumor (OR = 3.0) and anterior location (OR = 2.7). Hospital stay was significantly longer in Group A (7.5 [3-31] days) than in Group B (4 [1-38] days; p < 0.0001), whereas there was no significant difference regarding postoperative morbidity and recurrence rate. CONCLUSIONS Our results suggested that PP is not a very rare event during TEM, especially in anterior, circumferential and/or high rectal tumors. Laparoscopic treatment of PP is feasible and safe. The occurrence of PP is not associated with poor oncologic results.
Collapse
Affiliation(s)
- D Mege
- Department of Colorectal Surgery, Beaujon Hospital, Paris University, 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - N Petrucciani
- Department of Colorectal Surgery, Beaujon Hospital, Paris University, 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - L Maggiori
- Department of Colorectal Surgery, Beaujon Hospital, Paris University, 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - Y Panis
- Department of Colorectal Surgery, Beaujon Hospital, Paris University, 100 Boulevard du Général Leclerc, 92110, Clichy, France.
| |
Collapse
|
48
|
Mege D, Bridoux V, Maggiori L, Tuech JJ, Panis Y. What is the best tool for transanal endoscopic microsurgery (TEM)? A case-matched study in 74 patients comparing a standard platform and a disposable material. Int J Colorectal Dis 2017; 32:1041-5. [PMID: 28011978 DOI: 10.1007/s00384-016-2733-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/30/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE Transanal endoscopic microsurgery (TEM) is the gold standard for local excision of rectal lesions, but no study exists concerning the best material. The objective was to compare TEM using a disposable material vs a standard platform through a case-matched study. METHODS Patients who underwent TEM for rectal neoplasms were identified from prospective databases in two tertiary referral centers and matched according to four criteria (sex, tumor location, size, distance from the anal verge): TEM using a disposable material (GelPoint Applied®; group A) and TEM using a standard TEO® platform (Karl Storz, Tuttlingen, Germany; group B). RESULTS A total of 74 patients were included and divided into group A (n = 33) and group B (n = 41). Full-thickness resection was less frequent in group A (85%) than B (100%; p = 0.01). Adenocarcinoma was less frequent in group A than B: 27 vs 42% (p = 0.03). No difference was noted regarding median operative time (53 vs 53 min; p = 0.6) and a peritoneal perforation rate (6 vs 20%; p = 0.17). Median length of stay was shorter in group A than B (4 vs 5 days; p < 0.008). No significant difference was noted for major morbidity (12 vs 10%; p = 0.66), R1 resection (21 vs 10%; p = 0.2), and recurrence rates (8 vs 7%; p = 0.62). No difference was noted for rectal stenosis (3 vs 12%; p = 0.22) and transit disorder rates (12 vs 17%; p = 0.74). CONCLUSIONS Our study suggested that TEM can be performed using either a TEO® platform or a disposable material, with similar surgical results. The TEO® platform seems to be superior to obtain full-thickness and R0 resection.
Collapse
|
49
|
Martins BAA, Coura MDMA, de Almeida RM, Moreira NM, de Sousa JB, de Oliveira PG. Pneumoretroperitoneum and Sepsis After Transanal Endoscopic Resection of a Rectal Lateral Spreading Tumor. Ann Coloproctol 2017; 33:115-118. [PMID: 28761873 PMCID: PMC5534495 DOI: 10.3393/ac.2017.33.3.115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Accepted: 02/19/2017] [Indexed: 12/26/2022] Open
Abstract
Transanal endoscopic microsurgery is considered a safe, appropriate, and minimally invasive approach, and complications after endoscopic microsurgery are rare. We report a case of sepsis and pneumoretroperitoneum after resection of a rectal lateral spreading tumor. The patient presented with rectal mucous discharge. Colonoscopy revealed a rectal lateral spreading tumor. The patient underwent an endoscopic transanal resection of the lesion. He presented with sepsis of the abdominal focus, and imaging tests revealed pneumoretroperitoneum. A new surgical intervention was performed with a loop colostomy. Despite the existence of other reports on pneumoretroperitoneum after transanal endoscopic microsurgery, what draws attention to this case is the association with sepsis.
Collapse
Affiliation(s)
| | | | | | - Natascha Mourão Moreira
- Division of Colorectal Surgery, School of Medicine, University of Brasília, Brasília, Brazil
| | - João Batista de Sousa
- Division of Colorectal Surgery, School of Medicine, University of Brasília, Brasília, Brazil
| | | |
Collapse
|
50
|
Ferrer-Márquez M, Rubio-Gil F, Ortega-Ruiz S, Blesa-Sierra I, Álvarez-García A, Jorge-Cerrudo J, Vidaña-Márquez E, Belda-Lozano R, Reina-Duarte Á. Transanal endoscopic microsurgery for the treatment of uncommon rectal lesions. Cir Esp 2017. [PMID: 28647042 DOI: 10.1016/j.ciresp.2017.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Transanal endoscopic microsurgery (TEM) was developed as a less aggressive alternative treatment for rectal lesions (mainly adenomas and adenocarcinomas). However, its use for other rectal lesions has become more frequent, trying to reduce the morbidity associated with more invasive techniques. The aim of this study is to describe our experience in the use of TEM in other rectal lesions. METHODS Retrospective and descriptive study including patients operated with TEM (from June 2008 to December 2016) for the treatment of rectal lesions different from adenomas or adenocarcinomas. RESULTS Among the 138 patients treated by TEM in our department, 10 patients were operated on for rectal lesions other than adenomas or adenocarcinomas. Rectal lesions were 3neuroendocrine tumours, a neuroendocrine tumour metastasis, a rectal stenosis, a cloacogenic polyp, an endometrioma, a retrorrectal tumour, a presacral abscess and a lesion in the rectovaginal septum. Mean operative time was 72min and postoperative stay was 4.2 days. Only one patient needed a reoperation, due to rectal bleeding. CONCLUSIONS TEM could be a useful tool for the treatment of rectal lesions different from adenomas or adenocarcinomas, potentially decreasing the morbidity associated with more aggressive surgical techniques.
Collapse
Affiliation(s)
- Manuel Ferrer-Márquez
- Servicio de Cirugía General y del Aparato Digestivo, Complejo Hospitalario Torrecárdenas, Almería, España.
| | - Francisco Rubio-Gil
- Servicio de Cirugía General y del Aparato Digestivo, Complejo Hospitalario Torrecárdenas, Almería, España
| | - Sofía Ortega-Ruiz
- Servicio de Cirugía General y del Aparato Digestivo, Complejo Hospitalario Torrecárdenas, Almería, España
| | - Isabel Blesa-Sierra
- Servicio de Cirugía General y del Aparato Digestivo, Complejo Hospitalario Torrecárdenas, Almería, España
| | - Antonio Álvarez-García
- Servicio de Cirugía General y del Aparato Digestivo, Complejo Hospitalario Torrecárdenas, Almería, España
| | - Jaime Jorge-Cerrudo
- Servicio de Cirugía General y del Aparato Digestivo, Complejo Hospitalario Torrecárdenas, Almería, España
| | - Elisabet Vidaña-Márquez
- Servicio de Cirugía General y del Aparato Digestivo, Complejo Hospitalario Torrecárdenas, Almería, España
| | - Ricardo Belda-Lozano
- Servicio de Cirugía General y del Aparato Digestivo, Complejo Hospitalario Torrecárdenas, Almería, España
| | - Ángel Reina-Duarte
- Servicio de Cirugía General y del Aparato Digestivo, Complejo Hospitalario Torrecárdenas, Almería, España
| |
Collapse
|