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Migaczewski M, Rymarowicz J, Kołodziejska K, Grochowska A, Wysocki M, Twardowska H, Pędziwiatr M, Rubinkiewicz M. A longer pelvis is associated with longer operative time in transanal total mesorectal excision (TME) but not in laparoscopic TME. Results from a retrospective cohort study. Wideochir Inne Tech Maloinwazyjne 2023; 18:287-297. [PMID: 37680730 PMCID: PMC10481442 DOI: 10.5114/wiitm.2023.125294] [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: 11/07/2022] [Accepted: 01/15/2023] [Indexed: 09/09/2023] Open
Abstract
Introduction A narrow pelvis, obesity, and bulky low rectal tumor are perceived as risk factors for intraoperative difficulties during total mesorectal excision (TME), particularly in the laparoscopic approach. A transanal approach has been developed to overcome the difficulties encountered during laparoscopic TME. There is no clear definition of a narrow pelvis that would guide preoperative surgical planning. Aim To evaluate different MRI-based pelvic measurements in patients undergoing TME to identify factors predictive of intraoperative difficulties in transabdominal compared to the transanal approach. Material and methods A retrospective analysis of 48 patients treated with laparoscopic TME and 62 with transanal TME for rectal tumors was performed. Multiple logistic regressions analyzed demographic, tumor, and pelvimetry factors that correlate with intraoperative difficulties measured as intraoperative blood loss, operation time, and perioperative complications in both surgical approaches. Results Multivariate analysis showed that age was associated with higher blood loss (OR = 1.09, 95% CI: 1.00-1.18, p = 0.038), male gender (OR = 0.13, 95% CI: 0.02-0.86, p = 0.029) and body mass index with longer operating time (OR = 1.32, 95% CI: 1.06-1.64, p = 0.010) in the LAR group. Multivariate analysis showed that age increased the odds of intraoperative blood loss > 100 ml (OR = 1.08, 95% CI: 1.02-1.15, p = 0.013), and pelvic length > 119 mm increased operating time (OR = 5.76, 95% CI: 1.33-25.01, p = 0.016) in the TaTME group. Conclusions Pelvic measurements are not associated with intraoperative difficulties in LAR. Longer pelvis was associated with longer operative time in TaTME.
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Affiliation(s)
- Marcin Migaczewski
- 2 Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Justyna Rymarowicz
- 2 Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Katarzyna Kołodziejska
- 2 Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Anna Grochowska
- 2 Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Michał Wysocki
- Department of General Surgery and Surgical Oncology, Ludwik Rydygier Memorial Hospital in Krakow, Krakow, Poland
| | - Hanna Twardowska
- 2 Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Michał Pędziwiatr
- 2 Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Mateusz Rubinkiewicz
- 2 Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
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Uehara K, Ogura A, Murata Y, Sando M, Mukai T, Aiba T, Yamamura T, Nakamura M. Current status of transanal total mesorectal excision for rectal cancer and the expanding indications of the transanal approach for extended pelvic surgeries. Dig Endosc 2023; 35:243-254. [PMID: 36342054 DOI: 10.1111/den.14464] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 11/04/2022] [Indexed: 11/09/2022]
Abstract
Transanal total mesorectal excision (taTME) has been rapidly accepted as a promising surgical approach to the distal rectum. The benefits include ease of access to the bottom of the deep pelvis linearly over a short distance in order to easily visualize the important anatomy. Furthermore, the distal resection margins can be secured under direct vision. Additionally, a two-team approach combining taTME with a transabdominal approach could decrease the operative time and conversion rate. Although taTME was expected to become more rapidly popularized worldwide, enthusiasm for it has stalled due to unfamiliar intraoperative complications, a lack of oncologic evidence from randomized trials, and the widespread use of robotic surgery. While international registries have reported favorable short- and medium-term outcomes from taTME, a Norwegian national study reported a high local recurrence rate of 9.5%. The characteristics of the recurrences included rapid, multifocal growth in the pelvis, which was quite different from recurrences following traditional transabdominal TME; thus, the Norwegian Colorectal Cancer Group reached a consensus for a temporary moratorium on the performance of taTME. To ensure acceptable baseline quality and patient safety, taTME should be performed by well-trained colorectal surgeons. Although the appropriate indications for taTME remain controversial, the transanal approach is extremely important as a means of goal setting in difficult TME cases and as an aid to the transabdominal approach in various types of extended pelvic surgeries. The benefits in transanal lateral lymph node dissection and pelvic exenteration are presented herein.
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Affiliation(s)
- Kay Uehara
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Atsushi Ogura
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Yuki Murata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Masanori Sando
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Toshiki Mukai
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Toshisada Aiba
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Takeshi Yamamura
- Department of Gastroenterology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Masanao Nakamura
- Department of Gastroenterology, Nagoya University Graduate School of Medicine, Aichi, Japan
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3
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Wlodarczyk JR, Lee SW. New Frontiers in Management of Early and Advanced Rectal Cancer. Cancers (Basel) 2022; 14:938. [PMID: 35205685 PMCID: PMC8870151 DOI: 10.3390/cancers14040938] [Citation(s) in RCA: 1] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 01/29/2022] [Accepted: 02/08/2022] [Indexed: 02/04/2023] Open
Abstract
It is important to understand advances in treatment options for rectal cancer. We attempt to highlight advances in rectal cancer treatment in the form of a systematic review. Early-stage rectal cancer focuses on minimally invasive endoluminal surgery, with importance placed on patient selection as the driving factor for improved outcomes. To achieve a complete pathologic response, various neoadjuvant chemoradiation regimens have been employed. Short-course radiation therapy, total neoadjuvant chemotherapy, and others provide unique advantages with select patient populations best suited for each. With a clinical complete response, a "watch and wait" non-operative surveillance has been introduced with preliminary equivalency to radical resection. Various modalities for total mesorectal excision, such as robotic or transanal, have advantages and can be utilized in select patient populations. Tumors demonstrating solid organ or peritoneal spread, traditionally defined as unresectable lesions conveying a terminal diagnosis, have recently undergone advances in hepatic and pulmonary metastasectomy. Hepatic and pulmonary metastasectomy has demonstrated clear advantages in 5-year survival over standard chemotherapy. With the peritoneal spread of colorectal cancer, HIPEC with cytoreductive therapy has emerged as the preferred treatment. Understanding the various therapeutic interventions will pave the way for improved patient outcomes.
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Affiliation(s)
| | - Sang W. Lee
- Division of Colorectal Surgery, Norris Cancer Center, Keck School of Medicine, University of Southern California, 1441 Eastlake Avenue, Suite NTT-7418, Los Angeles, CA 90033, USA;
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Lau SYC, Choy KT, Yang TWW, Heriot A, Warrier SK, Guest GD, Kong JC. Defining the learning curve of transanal total mesorectal excision: a systematic review and meta-analysis. ANZ J Surg 2021; 92:355-364. [PMID: 34676655 DOI: 10.1111/ans.17262] [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] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/14/2021] [Accepted: 09/19/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Transanal total mesorectal excision (taTME) represents a novel approach to rectal dissection. Although many structured training programs have been developed worldwide to assist surgeons in implementing this new technique, the learning curve (LC) of taTME has yet to be conclusively defined. This is particularly important given the concerns regarding the complication profile and oncological safety of taTME. The aim of this review was to provide an up-to-date systematic review and meta-analysis of the LC for taTME, comparing the difference of outcomes between the LC and after learning curve (ALC) groups. METHODS An up-to-date systematic review was performed on the available literature between 2010-2020 on PubMed, EMBASE, Medline and Cochrane Library databases. All studies comparing taTME procedures before and after LC were analysed. RESULTS Seven retrospective studies of prospectively collected databases were included, comparing 333 (51.0%) patients in the LC group and 320 (49.0%) patients in the ALC group. There was a significantly reduced number of adverse intra-operative events, anastomotic leaks and improved quality of mesorectal excision in the ALC group. CONCLUSION This review shows that there is a significant improvement in clinical outcomes between the LC and ALC groups which supports the need for careful mastery and ongoing technical refinement during the LC in taTME. This procedure should be performed on a subset of carefully selected patients in the hands of experienced and well-trained teams dedicated to ongoing audit.
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Affiliation(s)
- Steve Yee Chiang Lau
- Department of Surgery, University Hospital Geelong, Geelong, Victoria, Australia.,Department of Surgery, Epworth Geelong Hospital, Deakin University, Geelong, Victoria, Australia
| | - Kay Tai Choy
- Department of Surgery, Austin Hospital, Melbourne, Victoria, Australia
| | - Tze Wei Wilson Yang
- Department of Colorectal Surgery, Alfred Hospital, Melbourne, Victoria, Australia
| | - Alexander Heriot
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - Satish K Warrier
- Department of Colorectal Surgery, Alfred Hospital, Melbourne, Victoria, Australia.,Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - Glenn D Guest
- Department of Surgery, University Hospital Geelong, Geelong, Victoria, Australia.,Department of Surgery, Epworth Geelong Hospital, Deakin University, Geelong, Victoria, Australia
| | - Joseph C Kong
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
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5
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Larach JT, Rajkomar AKS, Smart PJ, McCormick JJ, Heriot AG, Warrier SK. Beyond transanal total mesorectal excision: short-term outcomes of transanal total mesorectal excision in locally advanced rectal cancer requiring resection beyond total mesorectal excision. Colorectal Dis 2021; 23:823-833. [PMID: 33217140 DOI: 10.1111/codi.15446] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [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: 07/19/2020] [Revised: 10/14/2020] [Accepted: 11/03/2020] [Indexed: 12/24/2022]
Abstract
AIM The aim of this work was to define the role of transanal total mesorectal excision (taTME) in locally advanced rectal cancer (LARC) requiring resection beyond the mesorectal plane. METHOD We performed a retrospective review of the outcomes of a case series of patients undergoing taTME for rectal cancer with mesorectal fascia or adjacent organ involvement. RESULTS Eleven patients (six men) underwent taTME for LARC requiring resection beyond total mesorectal excision (TME). All had a restorative procedure. The transabdominal approach was open in five and minimally invasive in six cases. All patients required the resection of at least one adjacent structure, including presacral fascia, internal iliac vessels, nerve roots, uterus, vagina or seminal vesicles. Four patients required a pelvic side-wall lymph node dissection and four had intraoperative radiotherapy. In all cases, the transanal approach was useful to disconnect the rectum distally, resect adjacent organs or control the R1 risk-point. Three patients had a complication of Clavien-Dindo grade III or above (one mechanical bowel obstruction, one pelvic collection and one urine sepsis). There were no anastomotic complications. Ten patients had an R0 resection. During a median follow-up of 11 (8.6-16) months there were no local recurrences, but two patients had distant metastases. During the study period, eight patients underwent closure of their stoma whilst the remaining three have had normal anastomotic assessments and will be closed in the future. CONCLUSION This early series shows that implementation of taTME for resections beyond TME may be feasible and safe in a highly selected setting.
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Affiliation(s)
- José Tomás Larach
- Division of Cancer Surgery, PeterMacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia.,Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Amrish K S Rajkomar
- General Surgery and Gastrointestinal Clinical Institute, Epworth Healthcare, Melbourne, Victoria, Australia
| | - Philip J Smart
- General Surgery and Gastrointestinal Clinical Institute, Epworth Healthcare, Melbourne, Victoria, Australia.,Department of Surgery, Austin Health, Melbourne, Victoria, Australia
| | - Jacob J McCormick
- Division of Cancer Surgery, PeterMacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia.,General Surgery and Gastrointestinal Clinical Institute, Epworth Healthcare, Melbourne, Victoria, Australia
| | - Alexander G Heriot
- Division of Cancer Surgery, PeterMacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia.,General Surgery and Gastrointestinal Clinical Institute, Epworth Healthcare, Melbourne, Victoria, Australia
| | - Satish K Warrier
- Division of Cancer Surgery, PeterMacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia.,General Surgery and Gastrointestinal Clinical Institute, Epworth Healthcare, Melbourne, Victoria, Australia
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Hasegawa S, Yoshida Y, Morimoto M, Kojima D, Komono A, Aisu N, Taketomi H, Nagano H, Matsumoto Y, Munechika T, Kajitani R. Transanal TME: new standard or fad? J Anus Rectum Colon 2019; 3:1-9. [PMID: 31559361 PMCID: PMC6752130 DOI: 10.23922/jarc.2018-030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 11/19/2018] [Indexed: 12/27/2022]
Abstract
Transanal total mesorectal excision (taTME) has been developed to overcome the difficulty of laparoscopic dissection and transection in the deep pelvis. TaTME has several clinical benefits over laparoscopic surgery, such as better exposure of the distal rectum and direct determination of distal resection margin. Although evidence demonstrating the true benefits of taTME over laparoscopic TME (LapTME) is still insufficient, accumulating data have revealed that, as compared with LapTME, taTME is associated with shorter operative time and a lower conversion rate without jeopardizing other short-term outcomes. However, taTME is a technically demanding procedure with specific complications such as urethral injury, and so sufficient experience of LapTME and step-by-step acquisition of the skills needed for this procedure are requisite. The role of transanal endoscopic surgery is expected to change, along with the recent progress in the treatment of rectal cancer, such as robotic surgery and the watch-and-wait strategy. Optimization of treatment will be needed in the future in terms not only of oncological but also of functional outcomes.
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Affiliation(s)
- Suguru Hasegawa
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Yoichiro Yoshida
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Mitsuaki Morimoto
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Daibo Kojima
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Akira Komono
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Naoya Aisu
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Hirotaka Taketomi
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Hideki Nagano
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Yoshiko Matsumoto
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Taro Munechika
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Ryuji Kajitani
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
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7
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Rubinkiewicz M, Nowakowski M, Wierdak M, Mizera M, Dembiński M, Pisarska M, Major P, Małczak P, Budzyński A, Pędziwiatr M. Transanal total mesorectal excision for low rectal cancer: a case-matched study comparing TaTME versus standard laparoscopic TME. Cancer Manag Res 2018; 10:5239-5245. [PMID: 30464621 PMCID: PMC6219401 DOI: 10.2147/cmar.s181214] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background Transanal total mesorectal excision (TaTME) is emerging as a novel alternative to laparoscopic total mesorectal excision (LaTME). The aim of this study was to compare clinical and pathological results from these two techniques in patients undergoing rectal resections because of low rectal cancer. Materials and methods Thirty-five patients undergoing TaTME were matched with 35 patients operated on using LaTME. Composite primary endpoint (complete TME, negative circumferential resection margin [pCRM], and distal resection margin [pDRM]) was used to assess pathological quality specimens. Secondary outcomes included operative and postoperative parameters (operative time, total blood loss, postoperative morbidity, length of stay, 30-day mortality). Results Composite primary endpoint was achieved by 85% of subjects in the TaTME group and 82% of subjects in the LaTME group (P=0.66). Mean pCRM was 1.1±1.29 vs 0.99±0.78 mm (P=0.25). Distal pDRM was 1.57±0.92 and 1.98±1.22 cm (P=0.15). In the TaTME and LaTME groups, respectively, complete mesorectal excision was achieved in 89% and 83% of subjects, while excision was nearly complete for the remaining 11% and 17% (P=0.23). Conclusion TaTME appears to be a noninferior alternative to laparoscopic surgery. TaTME allows for quality retrieval of surgical specimens with comparable clinical outcomes with LaTME.
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Affiliation(s)
- Mateusz Rubinkiewicz
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland,
| | - Michał Nowakowski
- Department of Medical Education, Jagiellonian University Medical College, Krakow, Poland,
| | - Mateusz Wierdak
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland, .,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
| | - Magdalena Mizera
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland,
| | - Marcin Dembiński
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland,
| | - Magdalena Pisarska
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland, .,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
| | - Piotr Major
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland, .,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
| | - Piotr Małczak
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland, .,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
| | - Andrzej Budzyński
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland, .,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
| | - Michał Pędziwiatr
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland, .,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
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8
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An international multicentre prospective audit of elective rectal cancer surgery; operative approach versus outcome, including transanal total mesorectal excision (TaTME). Colorectal Dis 2018; 20 Suppl 6:33-46. [PMID: 30255642 DOI: 10.1111/codi.14376] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [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: 05/30/2018] [Accepted: 08/06/2018] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Transanal total mesorectal excision (TaTME) has rapidly emerged as a novel approach for rectal cancer surgery. Safety profiles are still emerging and more comparative data is urgently needed. This study aimed to compare indications and short-term outcomes of TaTME, open, laparoscopic, and robotic TME internationally. METHODS A pre-planned analysis of the European Society of Coloproctology (ESCP) 2017 audit was performed. Patients undergoing elective total mesorectal excision (TME) for malignancy between 1 January 2017 and 15 March 2017 by any operative approach were included. The primary outcome measure was anastomotic leak. RESULTS Of 2579 included patients, 76.2% (1966/2579) underwent TME with restorative anastomosis of which 19.9% (312/1966) had a minimally invasive approach (laparoscopic or robotic) which included a transanal component (TaTME). Overall, 9.0% (175/1951, 15 missing outcome data) of patients suffered an anastomotic leak. On univariate analysis both laparoscopic TaTME (OR 1.61, 1.02-2.48, P = 0.04) and robotic TaTME (OR 3.05, 1.10-7.34, P = 0.02) were associated with a higher risk of anastomotic leak than non-transanal laparoscopic TME. However this association was lost in the mixed-effects model controlling for patient and disease factors (OR 1.23, 0.77-1.97, P = 0.39 and OR 2.11, 0.79-5.62, P = 0.14 respectively), whilst low rectal anastomosis (OR 2.72, 1.55-4.77, P < 0.001) and male gender (OR 2.29, 1.52-3.44, P < 0.001) remained strongly associated. The overall positive circumferential margin resection rate was 4.0%, which varied between operative approaches: laparoscopic 3.2%, transanal 3.8%, open 4.7%, robotic 1%. CONCLUSION This contemporaneous international snapshot shows that uptake of the TaTME approach is widespread and is associated with surgically and pathologically acceptable results.
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Affiliation(s)
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- European Society of Coloproctology (ESCP) Cohort Studies Committee, Department of Surgery, Aalborg University Hospital, Aalborg, Denmark
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Buchs NC, Kraus R, Mortensen NJ, Cunningham C, George B, Jones O, Guy R, Ashraf S, Lindsey I, Hompes R. Endoscopically assisted extralevator abdominoperineal excision. Colorectal Dis 2015; 17:O277-80. [PMID: 26454256 DOI: 10.1111/codi.13144] [Citation(s) in RCA: 16] [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: 01/26/2015] [Accepted: 08/04/2015] [Indexed: 02/08/2023]
Abstract
AIM Extralevator abdominoperineal excision (ELAPE) has been advocated to optimize clearance of lower third rectal cancers with an involved or threatened circumferential resection margin. ELAPE could reduce positive margins and specimen perforation compared with standard abdominoperineal excision. However, there can be difficulties with ELAPE, particularly in identifying the anterior plane in male patients. Usually, the dissection is performed in the prone position, which can be hazardous, particularly in obese patients in whom wound problems are commonly encountered. We describe an endoscopically assisted approach for ELAPE in the lithotomy position. METHOD Three male patients with a rectal tumour located at the anorectal junction underwent an endoscopically assisted ELAPE in the lithotomy position after preoperative radiotherapy. RESULTS All the procedures were performed successfully with operation times of 180, 390 and 420 mins. There were no instances of intra-operative perforation or other complications. One patient developed postoperative intestinal obstruction which resolved on conservative management. There were no wound complications. Histopathological examination demonstrated clear margins and intact mesorectal planes in each patient. CONCLUSION We report a good outcome in three patients after endoscopically assisted ELAPE. This approach allows the patient to be operated on in the lithotomy position giving excellent views of the anterior dissection.
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Affiliation(s)
- N C Buchs
- Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK
| | - R Kraus
- Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK
| | - N J Mortensen
- Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK
| | - C Cunningham
- Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK
| | - B George
- Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK
| | - O Jones
- Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK
| | - R Guy
- Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK
| | - S Ashraf
- Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK
| | - I Lindsey
- Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK
| | - R Hompes
- Department of Colorectal Surgery, Churchill Hospital, University Hospitals of Oxford, Oxford, UK
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Nicholson G, Knol J, Houben B, Cunningham C, Ashraf S, Hompes R. Optimal dissection for transanal total mesorectal excision using modified CO2 insufflation and smoke extraction. Colorectal Dis 2015. [PMID: 26218459 DOI: 10.1111/codi.13074] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AIM The new approach of transanal total mesorectal excision is technically challenging and demands a stable field of dissection with optimal view of anatomical landmarks. We aimed to describe and demonstrate a modification of both the insufflation of carbon dioxide and smoke evacuation, in order to optimize dissection. METHOD The comparison of standard insufflation to an AirSeal platform demonstrates a clear difference. This is shown in the accompanying video-recordings. RESULTS A more stable pneumorectum and better smoke evacuation as well as more convenient and precise dissection were achieved with the AirSeal platform. CONCLUSION Using the technique outlined, the operating surgeon is able to perform the surgical dissection in a stable operating environment with increased visibility compared to the standard approach.
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Affiliation(s)
- G Nicholson
- Department of Colorectal Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
| | - J Knol
- Department of Visceral Surgery, Jessa Hospital, Hasselt, Belgium
| | - B Houben
- Department of Visceral Surgery, Jessa Hospital, Hasselt, Belgium
| | - C Cunningham
- Department of Colorectal Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
| | - S Ashraf
- Department of Colorectal Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
| | - R Hompes
- Department of Colorectal Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
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11
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Bracey E, Knol J, Buchs N, Jones O, Cunningham C, Guy R, Mortensen N, Hompes R. Technique for a stapled anastomosis following transanal total mesorectal excision for rectal cancer. Colorectal Dis 2015. [PMID: 26218610 DOI: 10.1111/codi.13075] [Citation(s) in RCA: 12] [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] [Indexed: 02/08/2023]
Abstract
AIM Transanal total mesorectal excision (taTME) is an emerging and exciting new technique in rectal cancer surgery. As with all novel techniques, new challenges arise, requiring small modifications of the technique. Here we present a simple technique that we have devised to facilitate a stapled anastomosis using standard circular staplers following a taTME. METHOD We describe the technique in a stepwise fashion with picture - and video illustration. Our experience with this anastomosis in a small cohort of patients is reported. RESULTS No anastomotic leaks occurred in 12 consecutive patients using this technique following taTME. In one patient a small defect was noticed on direct visualisation of the anastomosis intra-operative, and was closed transanally. So far 8/12 patient had their protective ileostomy reversed with satisfactory function. CONCLUSION We believe that this technique for a transanal, stapled anastomosis after a transanal TME procedure is safe and reproducible. Objective assessment of longterm functional outcome is required and outcomes need to be compared to other stapled techniques and handsewn anastomoses.
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Affiliation(s)
- E Bracey
- Department of Colorectal Surgery, Oxford University Hospitals, Oxford, UK
| | - J Knol
- Virga Jesse Hospital, Hasselt, Belgium
| | - N Buchs
- Department of Colorectal Surgery, Oxford University Hospitals, Oxford, UK
| | - O Jones
- Department of Colorectal Surgery, Oxford University Hospitals, Oxford, UK
| | - C Cunningham
- Department of Colorectal Surgery, Oxford University Hospitals, Oxford, UK
| | - R Guy
- Department of Colorectal Surgery, Oxford University Hospitals, Oxford, UK
| | - N Mortensen
- Department of Colorectal Surgery, Oxford University Hospitals, Oxford, UK
| | - R Hompes
- Department of Colorectal Surgery, Oxford University Hospitals, Oxford, UK
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