Endoscopic Stricturoplasty with Linear Stapler: An Efficient Alternative for the Refractory Rectal Anastomotic Stricture

INTRODUCTION

Symptomatic anastomotic stricture is a rare but major complication after left-sided colorectal surgery. Hydraulic balloon dilatation is the first-line treatment in cases where the complication occurs, but 20% of patients present with refractory strictures after multiple sessions. Endoscopic stricturoplasty with the use of a linear stapler is a novel therapeutic alternative for those difficult cases.

MATERIALS AND METHODS

We identified all patients in our department who underwent endoscopic stricturoplasty with a linear stapler between 2004 and 2022. The technical, periinterventional, and follow-up data of the patients were retrospectively analyzed.

RESULTS

We identified nine patients who fulfilled our inclusion criteria. The procedure was technically possible in eight cases, whereas in one case, the anatomy of the anastomosis did not allow for a correct placement of the stapler. All patients with a technically successful procedure were relieved from their symptoms and could have their ostomy reversed. There was no periprocedural morbidity and mortality. Two patients presented with a recurrent stricture eight and 26 months after the initial stricturoplasty, and the procedure was successfully repeated in both cases.

CONCLUSIONS

Endoscopic stricturoplasty is a feasible, safe, and minimally invasive alternative for the treatment of refractory anastomotic strictures in the distal colon and rectum for patients with a suitable anatomy.

A novel step-by-step training program for transanal endoscopic surgery

BACKGROUND

The objective of our study is to develop an effective training platform for transanal endoscopic surgery and to validate a step-by-step training program for learning the basic skills necessary for this approach.

METHODS

We have designed a two-part study: an experimental study (with the aim to design the training platform and the training exercises - on synthetic and biological material) and a prospective analytical study, in order to validate the training program by enrolling as participants general surgery residents and specialists, without previous experience in transanal endoscopic interventions. The performance of the participants was assessed based on the time of completion, as well as the quality of the execution.

RESULTS

We have developed three different diameter platforms (5 cm, 7.5 and 10 cm), that can be used with both the TEO and TAMIS platforms; specific exercises were developed to train different surgical skills like manipulation of tissue, cutting, dissection and suturing. Forty participants were enrolled for the validation of the proposed training program (12 young residents, 16 senior residents and 12 specialist surgeons). A statistically significant improvement of the performance time, from round to round, was observed for all participants in all exercises. The time of completion for the exercises, considering the correct technical execution, was the shortest for more experienced surgeons: specialist surgeons, followed by senior residents and young residents. The biological material exercises, that closely recreate intraoperative conditions and had more strict technical requirements, were difficult to be performed by young residents; better completion rates were seen in senior residents, while all the participants in the specialist surgeons group have completed these exercises.

CONCLUSIONS

Our training program is an effective simulation based educational model for recreating intraoperative conditions particular to transanal endoscopic surgery. The proposed step-by-step training program has demonstrated to be useful in developing the important basic skills needed for transanal endoscopic surgery and assured the progress of all the participants, regardless of their surgical experience.

Transanal full-thickness excision for rectal neoplasm: is it advisable to leave the defect open?

PURPOSE

After a full-thickness total wall excision of a rectal tumor, suturing the defect is generally recommended. Recently, due to various contradictory studies, there is a trend to leave the defects open. Therefore, this study aimed to determine whether leaving the defect open is an adequate management strategy compared with suturing it closed based on postoperative outcomes and recurrences.

METHODS

A retrospective review of our prospectively maintained database was conducted. Adult patients who underwent transanal surgery for rectal neoplasm in our institution from 1997 to 2019 were analyzed. Patients were divided into two groups: sutured (group A) or unsutured (group B) rectal defect. The primary outcomes were morbidity (early and late) and recurrence.

RESULTS

In total, 404 (239 men) patients were analyzed, 143 (35.4%) from group A and 261 (64.6%) from group B. No differences were observed in tumor size, distance from the anal verge or operation time. The overall incidence of complications was significantly higher in patients from group B, which nearly double the rate of group A. With a mean follow-up of 58 (range, 12-96) months, seven patients presented with a rectal stricture, all of them from group B.

CONCLUSIONS

We acknowledge the occasional impossibility of closing the defect in patients who undergo local excision; however, when it is possible, the present data suggest that there may be advantages to suturing the defect closed.

Long-term results of minimally invasive transanal surgery for rectal tumors in 249 consecutive patients

PURPOSE

To delineate the long-term results of minimally invasive transanal surgery (MITAS) for selected rectal tumors.

METHODS

We analyzed data, retrospectively, on consecutive patients who underwent MITAS between 1995 and 2015, to establish the feasibility, excision quality, and perioperative and oncological outcomes of this procedure.

RESULTS

MITAS was performed on 243 patients. The final histology included 142 cancers, 47 adenomas, and 52 neuroendocrine tumors (NET G1). A positive margin of 1.6% and 100% en bloc resection were achieved. The mean operative time was 27.4 min. Postoperative morbidity occurred in 7% of patients, with 0% mortality. The median follow-up was 100 months (up to ≥ 5 years or until death in 91.8% of patients). Recurrence developed in 2.9% of the patients. The 10-year overall survival rate was 100% for patients with NET G1 and 80.3% for those with cancer. The 5-year DFS was 100% for patients with Tis cancer, 90.6% for those with T1 cancer, and 87.5% for those with T2 or deeper cancers. MITAS for rectal tumors ≥ 3 cm resulted in perioperative and oncologic outcomes equivalent to those for tumors < 3 cm.

CONCLUSION

MITAS is feasible for the local excision (LE) of selected rectal tumors, including tumors ≥ 3 cm. It reduces operative time and secures excision quality and long-term oncological outcomes.

Multicenter clinical trial for the resection of rectal polyps using a new laparoendoscopic hybrid transanal access device

INTRODUCTION

Complex polyps require the use of advanced endoscopic techniques or minimally invasive surgery for their approach. In rectal polyps it is of special relevance to reach a consensus on the best approach to avoid under- or overtreatment that increases unnecessary morbidity and mortality.

METHODS

We describe a prospective, multicenter, pilot clinical trial with a first-in-human medical device. It is hypothesized that UNI-VEC® facilitates transanal laparoendoscopic surgery for the removal of early rectal tumors. The primary objective is to evaluate that it is safe and meets the established functional requirements. Secondary objectives are to evaluate results, complications and level of satisfaction.

RESULTS

16 patients were recruited in 12 months with a minimum follow-up of 2 months. The mean size was 3.4 cm with the largest polyp being 6 cm. Regarding location, the mean was 6.6 cm from the anal margin. Endoscopic Mucosal Resection (EMR) (6.3%), Endoscopic Submucosal Dissection ESD (43.8%), REC (6.3%) and TAMIS (43.8%) were performed. The mean time was 73.25 min. The 56.3% used a 30° camera and 43.8% used the flexible endoscope as a viewing instrument. The 56.3% were benign lesions and 43.8% malignant. Complete resection is achieved in 87.5%. Regarding complications, mild bleeding (Clavien I) occurred in 25%, 6.3% and 21.4% at 24 h, 48 h and 7 days respectively. Continence was assessed according to the Wexner scale. At 7 days, 60% showed perfect continence, 26.7% mild FI and 13.3% moderate FI. At 30 days, 66.7% had perfect continence, 20% mild FI and 13.3% moderate FI. At 2 months, 4 patients were reviewed who at 30 days had a Wexner's degree higher than preoperative and perfect continence was demonstrated in 25% of the patients, 50% mild and 25% moderate. In no case did rectal perforation or major complications requiring urgent reintervention occur. As for the level of reproducibility, safety, level of satisfaction with the device and evaluation of the blister, the evaluation on a scale of 0 to 10 (9.43, 9.71, 9.29 and 9.50 respectively). All the investigators have previous experience with transanal devices.

CONCLUSIONS

The study demonstrates the efficacy and safety of UNI-VEC® for the treatment of rectal lesions. It will facilitate the implementation of hybrid procedures that seek to solve the limitations of pure endoscopic techniques by allowing the concomitant use of conventional laparoscopic and robotic instrumentation with the flexible endoscope.

Transanal Endoscopic Microsurgical Submucosal Dissection: An Efficient Treatment Option for Giant Superficial Neoplastic Lesions of the Rectum

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.

Transanal endoscopic microsurgical submucosal dissection (TEM-ESD) for rectal adenomas: a retrospective cohort study of 145 consecutive cases

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.

Transanal Endoscopic Microsurgical Submucosal Dissection for Recurrent Rectal Adenomas

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.

Transanal (TaTME) vs. laparoscopic total mesorectal excision for mid and low rectal cancer: a propensity score-matched analysis of early and long-term outcomes

PURPOSE

Transanal total mesorectal excision (TaTME) has been proposed as an alternative to laparoscopic total mesorectal excision (LapTME) in distal rectal tumors. Despite encouraging reports, mid- and long-term oncological results are limited. In this study, we aimed at comparing TaTME versus LapTME in patients with mid and low rectal cancer.

METHODS

From January 2012 to December 2019, all patients undergoing either TaTME or LapTME for rectal adenocarcinoma ≤ 12 cm from the anal verge were included. Demographic, clinical, and follow-up data were retrieved from a prospective and audited database, and a propensity score-matched analysis was performed.

RESULTS

A total of 144 patients were included, 38 underwent TaTME, and 106 LapTME. The median age was 68.0 (60.2-75.8) years, and 96 (66.7%) patients were male. Median follow-up was 30.6 (20.2-39.8) months in the TaTME group and 49.5 (22.6-68.5) months in the LapTME group. There was one (2.6%) local recurrence in the TaTME group and two (1.9%) in the LapTME group (p = 0.788). There was no difference in the 3-year disease-free survival between groups both in the primary (93% vs. 86%, p = 0.274) and the propensity score-matched analyses (93% vs. 81%, p = 0.132). Conversion to open surgery was less frequent in the TaTME group (none vs. 4 (11.4%), p = 0.041). Intra- and postoperative complications, length of stay, specimen quality, and resection margins were similar between groups.

CONCLUSIONS

In our experience, TaTME was associated with a less frequent conversion to open surgery but otherwise had similar post-operative results compared to LapTME. Local recurrence and 3-year survival rates were similar.

Transanal endoscopic microsurgical submucosal dissection (TEM-ESD): A novel approach to the local treatment of early rectal cancer

BACKGROUND

Complete local resection is currently the treatment of choice for low-risk early rectal cancer; however, the ideal resection technique for such tumours is still debated. Transanal endoscopic microsurgical submucosal dissection (TEM-ESD) is a new technique which combines the ergonomic advantages of transanal endoscopic microsurgery (TEM) with the minimally invasive approach of endoscopic submucosal dissection (ESD). The aim of our study was to assess the feasibility, safety, and long-term outcomes of TEM-ESD in treating early rectal cancer.

MATERIALS AND METHODS

We retrospectively analysed all cases of rectal adenocarcinomas treated with TEM-ESD in Karlsruhe Municipal Hospital between 2012 and 2019, as well as the perioperative and follow-up data of the patients.

RESULTS

We identified 40 cases (19 low-risk and 21 high-risk carcinomas) matching our criteria. The median size of the lesions was 3.8 cm and the median operating time 48.5 min. En bloc resection was possible in all cases, while histologically complete resection was confirmed in 18 of 19 low-risk tumours and in 30 out of all lesions. The resection was curative in 19 cases. No scarring of the mesorectum was reported during the completion of total mesorectal excision for high-risk tumours. There was only 1 case of local recurrence among patients treated with curative intent, with an overall survival rate of 100% and a disease-free survival rate of 96% at both 2 and 5 years for these patients.

CONCLUSION

TEM-ESD is a safe and feasible therapeutic option for resecting early rectal cancer, offering very good long-term outcomes.

The first robotic transanal minimally invasive surgery in Ireland: a case-based review

Transanal minimally invasive surgery (TAMIS) has gained worldwide acceptance as a means of local excision of early rectal cancers and benign rectal lesions. However, it is technically challenging due to the limitations of rigid laparoscopic instruments in the narrow rectal lumen. Robotic platforms offer improved ergonomics that are valuable in operative fields with limited space. Robotic TAMIS represents an exciting new development that may be more versatile than traditional TAMIS. In this review, we describe the first case of robotic TAMIS performed in our country and a review of current literature on the technique.

SP rTaTME: initial clinical experience with single-port robotic transanal total mesorectal excision (SP rTaTME)

BACKGROUND

The technical difficulty and steep learning curve of transanal total mesorectal excision (taTME) has limited widespread adoption. The single-port (SP) daVinci robot is designed to facilitate single-incision and natural-orifice transluminal endoscopic surgery (NOTES). This paper describes the first clinical experience of single-port robotic taTME (SP rTaTME).

METHODS

This was a prospective study on consecutive patients with rectal cancer who underwent SP rTaTME proctosigmoidectomy with handsewn coloanal anastomosis in December 2018 and January 2019. The primary outcome was technical feasibility of the procedure. The secondary outcomes include blood loss, intraoperative complications, length of hospital stay, quality of the TME specimen, short- and long-term morbidity and mortality, as well as short-term oncologic follow -up.

RESULTS

There were two patients, a 48-year-old male and a 38-year-old female. Both operations were completed successfully without complications or conversion. Estimated blood loss was 200 mL and 130 mL. In both cases the TME was completed transanally using the SP robot. In the first patient, the abdominal portion was completed through an abdominal single-incision; in the second patient the operation was entirely performed transanally as a pure NOTES procedure. In both cases, the final pathology report showed a complete TME with negative margins. Patients were discharged on postoperative day 3 and 4,respectively. There was no long-term morbidity or mortality.

CONCLUSIONS

SP rTaTME is feasible and can be safely performed. It provides excellent optics and dexterity to work in a limited space. Future studies are required to further define the safety profile and the ultimate utility of the SP robot for taTME.

Re-exploring the pelvic neuroanatomy from a new perspective and a potential guidance for TaTME: a "bottom-up" approach

Neuro-anatomy of the perineum has gained renewed attention due to its significance in the transanal procedures for rectal cancer (eg TaTME). Surgeons embarking on this technique must have sophisticated knowledge and a precise anatomical understanding of the perineum before proceeding with this reversed rectal approach. We report anatomical observations deriving from a relevant experience in the colorectal surgery field. The collective multicenter experience of the present study is clinically relevant and based on the rectal and transanal resections performed in colorectal centers of excellence from Greece, UK, and Italy over the last 10 years (2011-2020). From the original anatomical and intraoperative observations derived from collective cases operated by this multicenter group of colorectal surgical centers in three European countries, data were retrieved and analyzed in collaboration with specialist researchers of human anatomy and interpreted for their clinical significance and potential use for preoperative planning and intraoperative guidance during TaTME. This descriptive article demonstrates in detail the neurogenic pathways encountered in the perineum and pelvic cavity during transanal procedures. Specific anatomical and topographic implications are also included serving as a guide for colorectal surgeons to perform a nerve-sparing procedure. transanal approach for rectal excision offers new insights into the complex pelvic and perineal neuroanatomy while the procedure itself remains a challenge for surgeons. Preoperative anatomical planning and 3D reconstruction may help in anticipating technical difficulties, resulting in more precise surgical dissections and decreased postoperative complications.

Endoscopic management versus transanal surgery for early primary or early locally recurrent rectal neoplasms-a systematic review and meta-analysis

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.

First clinical experience with single-port robotic transanal minimally invasive surgery (SP rTAMIS) for benign rectal neoplasms

BACKGROUND

The new da Vinci Single-Port (SP) robot is a single-arm four-channel robotic system well suited for endoluminal surgery. We report our initial experience performing SP robotic transanal minimally invasive surgery (SP rTAMIS) for rectal neoplasms.

METHODS

Under Institutional Review Board approval, two patients with rectal neoplasms were prospectively enrolled for elective SP rTAMIS. The primary endpoint was to report the safety and feasibility of successful procedure completion with the SP robot. Secondary endpoints included patient characteristics and perioperative metrics.

RESULTS

Both patients underwent successful SP rTAMIS resection of rectal neoplasms without intraoperative complications or conversions. The lesions were 4.0 cm and 3.0 cm in size, located 6 cm and 7 cm cephalad to the anorectal ring. Excisions were full thickness with no piecemeal extractions or specimen fragmentation. Estimated blood loss was 0 mL and 30 mL. The mean excised area was 13.4 cm² (22.7 cm² and 9.0 cm²). The mean docking time was 5.25 min (range 2-8 min) and mean console time was 122.5 min (98 min and 147 min). Patients tolerated a liquid diet on postoperative day (POD) 0 and were discharged on POD 1 after tolerating a low residue diet and having bowel function. Pathology showed two adenomas with negative margins. There was no immediate or delayed morbidity or mortality.

CONCLUSIONS

Our initial experience indicates that SP rTAMIS is a safe and feasible approach for local excision of rectal lesions. While SP rTAMIS is very promising, more experience with this approach is necessary to determine its widespread applicability.

Robotic-assisted transanal total mesorectal excision for rectal cancer: technique and results from a single institution

BACKGROUND

Total mesorectal excision (TME) has greatly reduced the local recurrence rate of rectal cancer after colorectal surgery. Transanal TME (TaTME) is potentially a suitable option for patients with mid and low rectal cancer. Robotic systems overcome the limitations of laparoscopic surgery. The aim of this study was to investigate the safety and feasibility of robotic-assisted transanal total mesorectal excision (RTaTME) in patients with rectal cancer.

METHODS

The clinical data of patients who underwent RTaTME for rectal cancer between May 2017 and January 2020 were reviewed. The perioperative data and short-term outcomes of all the patients were retrospectively analysed. Last follow-up was in May 2020.

RESULTS

A total of 13 patients had RTaTME during the 36-month study period. The median docking time was 18 (IQR 16-20) minutes, median transanal phase time was 95 (IQR 74-100) minutes, median total operation time was 240 (IQR 195-270) minutes, median estimated blood loss was 60 (IQR 50-100) ml, the median number of lymph nodes retrieved was 15 (IQR 13-16) and median length of postoperative hospital stay was 7 (IQR 6-10) days. There was no mortality. Three (23%) patients suffered a postoperative complication including one anastomotic leak and one prolonged ileus, none of them required any intervention. Patients were followed up for a median of 15 (IQR 11-18) months, and no local tumour recurrences, metastasis or deaths were reported.

CONCLUSIONS

Our preliminary results suggest that RTaTME for rectal cancer is feasible. This innovative approach may offer patients potential benefits-further studies are needed.

Transanal Ileal Pouch-Anal Anastomosis for Ulcerative Colitis has Comparable Long-Term Functional Outcomes to Transabdominal Approach: A Multicentre Comparative Study

BACKGROUND

The transanal approach to ileal pouch-anal anastomosis [Ta-IPAA] provides better access to the lower pelvis with lower short-term morbidity in ulcerative colitis [UC]. The aim of this study was to assess the long-term functional outcomes after Ta-IPAA vs transabdominal IPAA [Abd-IPAA] in UC.

METHODS

A multicentre cohort analysis was performed between March 2002 and September 2017. Patient characteristics, surgical details and postoperative outcomes were compared. CGQL [Cleveland global quality of life] score at 12 months with a functioning pouch was considered the primary end point.

RESULTS

A total of 374 patients [100 Ta-IPAA vs 274 Abd-IPAA] were included. Ta-IPAA demonstrated a comparable overall quality of life [CGQL score] to Abd-IPAA [0.75 ± 0.11 vs 0.71 ± 0.14; respectively, p = 0.1]. Quality of life [7.71 ± 1.17 vs 7.30 ± 1.46; p = 0.04] and energy-level items [7.16 ± 1.52 vs 6.66 ± 1.68; p = 0.03] were significantly better after Ta-IPAA, while the quality of health item was comparable [7.68 ± 1.26 vs 7.64 ± 1.44; p = 0.96]. Analysis excluding anastomotic leaks did not change the overall CGQL scores. Stool frequencies [>10/24 h: 22% vs 21%; p = 1.0] and the rate of a single episode of major incontinence during the following 12-month period [27% vs 26%; p = 0.89] were similar. The differences in 30-day morbidity rates [33% vs 41%; p = 0.2] and anastomotic leak rates were not significant [6% vs 13%; p = 0.09].

CONCLUSIONS

This study provides evidence of comparable long-term functional outcome and quality of life after Ta-IPAA and Abd-IPAA for UC.

[Innovation, development and improvement of transanal endoscopic instruments]

According to the main features of transanal total mesorectal excision (taTME), we have designed a series of patented operating techniques, such as anal retractor, anal speculum and transanal port, to reduce the difficulty of transanal operation, shorten the surgeon's learning curve, and expand the indications of transanal surgery.

Introduction of new techniques and technologies in surgery: Where is transanal total mesorectal excision today?

The introduction of new surgical techniques and technologies has traditionally been unregulated. In many settings surgeons frequently adopt novel procedures without following a structured program of implementation or supervision. The appearance of innovative technology played a pivotal role in the advancement of new surgical techniques during the industrial revolution. Innovation has been an essential component of surgical development, which led to contemporary surgical techniques such as minimally invasive surgery. Different initiatives have been developed to guide the safe introduction of new surgical techniques and other procedures. Those include comprehensive concepts such as the Idea, Development, Exploration, Assessment, Long-term study framework, which could be particularly relevant when reflecting on the novel transanal total mesorectal excision (taTME), introduced a decade ago. This relatively novel and complex procedure promised to overcome some of the major limitations of traditional surgical approaches for rectal cancer. According to the Idea, Development, Exploration, Assessment, Long-term study framework, taTME is in the phase of exploration, where there is an existing and increasing number of reports being published as the experience grows. The current management of rectal cancer is in a state of radical evolution, with multiple options that were not previously available. TaTME is only one technique amongst many which could be part of a rectal cancer surgeon’s armamentarium; however, it requires further rigorous study and evaluation.

[Long term evaluation of transanal surgery with automatic suture in Hirschsprung's disease]

OBJECTIVE

Retrospective and descriptive study of patients with diagnosis of Hirschsprung disease (HD) in whom transanal pull-through was performed in our center.

MATERIAL AND METHODS

All patients with diagnosis of HD in whom transanal surgery was performed between 2006 and 2018 in our center were selected. In all cases laparoscopic biopsy was performed in the previous dilated area. Once intraoperatory biopsy revealed the presence of ganglionic cells, transanal De la Torre surgery was performed, until reaching the localization of the biopsied area. Circular automatic suture was performed in all cases.

RESULTS

Surgery was performed in 21 patients (16 boys and 5 girls) with a median age of 12 months (5-62). No patient had enterocolitis. The median resection length was 14.5 cm (3-45) and no intraoperative complications happened. One patient (5%) developed a rectosigmoideal abscess, which was solved with antibiotic. One case (5%) needed another surgery due to umbilical trochar eventration. No patient had enterocolitis after the surgery. One patient (5%) had stenosis, solved by its section and other case (5%) had sleeve compression which was solved by laparoscopic section. After a median follow up of 97 months (12-159), one child (5%) developed encopresis, which is treated with periodic anal irrigations and other patient (5%) has chronic constipation, which require periodic enemas. The rest of the patients have no symptomatology.

CONCLUSION

In conclusion, in our series of cases, transanal pull-through with circular automatic suture was a safe and useful technique. It has a low rate of operative and postoperative complications and provides good prospective results.

[Transanal total mesorectal excision-a critical appraisal]

INTRODUCTION

Total mesorectal excision (TME) is the international standard for rectal cancer surgery. In addition to laparoscopic TME (lapTME), transanal TME (taTME) was developed in recent years to reduce the rate of incomplete TME, conversion to open surgery and postoperative functional impairment. Despite limited evidence, this technique is becoming increasingly more popular and is already routinely used by many hospitals for rectal cancer in varying tumor level locations. The aim of this review was to evaluate the taTME compared to anterior rectal resection with lapTME as the standard of care in rectal cancer surgery based on currently available evidence.

METHOD

The databases PubMed and Medline were systematically searched for publications on transanal total mesorectal excision (taTME) and transanal minimally invasive surgery (TAMIS). Relevant studies were selected and further research based on the reference lists was undertaken.

RESULTS

A total of 16 studies analyzing 3782 patients were identified. The taTME does not lead to a higher rate of complete TME-resected specimens compared to the standard procedure. So far, superiority could not be demonstrated for complication rates or for functional or oncological results. Serious complications secondary to dissection in incorrect planes were observed. The anastomotic level generally seems to be closer to the sphincter after taTME versus anterior lapTME.

CONCLUSION

Considering current evidence, taTME failed to show superiority compared to conventional anterior lapTME. Although taTME has some potential advantages, it carries substantial risks. If performed outside of clinical trials, it should therefore only be used in carefully selected patients with a high possibility of conversion, following adequate patient informed consent and after intense and systematic training of the surgeon.

[Transanal lateral lymph node dissection surgery for 5 cases of mid-low rectal cancer]

Objective: To evaluate the feasibility and safety of transanal lateral lymph node dissection for mid-low rectal cancer. Methods: A descriptive case series research method was used. Clinical and pathological data of 5 mid-low rectal cancer patients who underwent transanal lateral lymph node dissection at Department of Colorectal Surgery, the Sixth Affiliated Hospital of Sun Yat-sen University from November 2018 to May 2019 were retrospectively collected and analyzed. Of 5 cases, 4 were male and 1 was female with mean age of (43.2±13.2) years and mean body mass index of (21.2±2.6) kg/m(2); the mean diameter of tumor was (3.2±2.4) cm; the mean distance between tumor and anus was (6.3±2.5) cm; 3 received preoperative neoadjuvant chemotherapy. In preoperative TNM staging, 2 cases were T3N1M0, 1 was T3cN2aM0, 1 was T3cN2bM0, and 1 was T2N1M0. All the patients had no intestinal obstruction before operation. Surgical methods: (1) total mesorectal excision: using general transanal and transabdominal methods to mobilize and resect total mesorectum, and dissect No.252, No.253 lymph nodes; (2) transanal lateral lymph node dissection: dissect the adipose lymphoid tissue on the surface of the iliococcygeal muscle, the coccygeal muscle, and the obturator muscle (the No.283 lymph nodes) upward, and dissect No.263d and No.263p lymph nodes with fat tissue sequentially till the bifurcation of the internal and external iliac artery; (3) take out the specimen from anus, and make anastomosis between proximal colon and anal canal. Intraoperative and postoperative variables was observed. Results: All the 5 patients completed surgery successfully, and no patient needed to convert to open approach. The mean operative time was (295.6±97.7) minutes, and the median intraoperative blood loss was 70 (50-500) ml. The mean length of specimen was (12.9±3.0) cm, and the mean number of harvested lymph node was 30.4±9.9. The positive lateral lymph nodes were founder in 4 patients. The median distance between tumor and distal resection margin was 1.5 (1.2-8.0) cm. The resection margin in all the patients was negative. The mean time to postoperative flatus was (4.2±1.6) days, the mean postoperative spontaneous urination was (3.0±1.9) days, time to drainage tube removal was (5.6±1.9) days, and the mean postoperative hospital stay was (9.4±2.1) days. The postoperative TNM staging by pathology was 1 case with T1N0M0, 1 with T2N1M0, 1 with T3N2bM0, and 2 with T3N2M0. Five patients were moderately differentiated adenocarcinoma. Only 1 patient developed postoperative abdominal bleeding, who was healed after conservative treatment. The other 4 patients did not develop any perioperative complications, such as incision infection, presacral abscess, pelvic abscess, anastomotic leakage, or anastomotic stricture. Four patients underwent postoperative chemotherapy. All the patients were followed up for 2 to 28 weeks after surgery and they all felt well. The patients with stoma had fluent bowel. Conclusions: Transanal lateral lymph node dissection is feasible and safe in the treatment of mid-low rectal cancer, which can achieve the purpose of extended radical resection of mid-low movement rectal cancer. Moreover, this procedure is a new method to treat rectal cancer patients with lateral lymph node metastasis.

The value of force and torque measurements in transanal total mesorectal excision (TaTME)

Background

Transanal total mesorectal excision (TaTME) is associated with a relatively long learning curve. Force, motion, and time parameters are increasingly used for objective assessment of skills to enhance laparoscopic training efficacy. The aim of this study was to identify relevant metrics for accurate skill assessment in more complex transanal purse-string suturing.

Methods

A box trainer was designed for TaTME and equipped with two custom made multi-DOF force/torque sensors. These sensors measured the applied forces in the axial direction of the instruments (Fz), instrument load orientation expressed in torque (Mx and My) on the entrance port, and the full tissue interaction force (Fft) at the intestine fixation point. In a construct validity study, novices for TaTME performed a purse-string suture to investigate which parameters can be used best to identify meaningful events during tissue manipulation and instrument handling.

Results

Significant differences exist between pre- and post-training assessment for the mean axial force at the entrance port Fz (p = 0.01), mean torque in the entrance port Mx (p = 0.03) and mean force on the intestine during suturing Fft (p = 0.05). Furthermore, force levels during suturing exceed safety threshold values, potentially leading to dangerous complications such as rupture of the rectum.

Conclusions

Forces and torque measured at the entrance port, and the tissue interaction force signatures provide detailed insight into instrument handling, instrument loading, and tissue handling during purse-string suturing in a TaTME training setup. This newly developed training setup for single-port laparoscopy that enables objective feedback has the potential to enhance surgical training in TaTME.

Transanal surgery: A tool in the colorectal anastomotic leakage

The treatment of anastomotic leakage after oncological surgery for rectal cancer is a surgical challenge. The goal of this study is to show how transanal surgery combined with the abdominal approach is a very useful tool to decide on individualized treatment depending on the degree of dehiscence and to assist us in its local management. We present three cases of patients with colorectal anastomotic dehiscence. In two, we demonstrate the treatment of acute colorectal leakage and how transanal surgery allows us to confirm its viability and rule out any underlying ischemia. Furthermore, it facilitates good drainage of the adjacent collection as well as the placement of a vacuum system, if necessary, and its subsequent replacements. The last case is a delayed dehiscence with chronic presacral sinus, and its treatment by transanal access for fenestration.

Stapled transanal rectal resection for the treatment of rectocele associated with obstructed defecation syndrome: a large series of 262 consecutive patients

BACKGROUND

This study aims to investigate functional results and recurrence rate after stapled transanal rectal resection (STARR) for rectocele associated with obstructive defection syndrome (ODS).

METHODS

A study was conducted on patients with ODS symptoms associated with symptomatic rectocele ≥ 3 cm on dynamic defecography who had STARR at our institution between 01/2007 and 12/2015. Data were prospectively collected and analyzed. ODS was evaluated using the Wexner constipation score. Primary outcomes were functional results, determined by the improvement in 6-month postoperative Wexner constipation score, and 1-year recurrence. Secondary outcomes were operative time, time to return to work, pain intensity measured using the visual analogue scale (VAS), patient satisfaction, and overall postoperative morbidity and mortality at 30 days.

RESULTS

Two-hundred-sixty-two consecutive female patients [median age 54 years (range 20-78)] were enrolled in the study. The median duration of follow-up was 79 months (range 30-138). Sixty (23%) patients experienced postoperative complications, but only 9 patients required reinterventions for surgical hemostasis (n = 7), fecal diversion for anastomotic leakage (n = 1), and recto-vaginal fistula repair (n = 1). Only 1 intraoperative complication (stapler misfire) was reported, and there were no deaths. There was a statistically significant (p < 0.001) reduction in the median (range) Wexner constipation score from 19 (14-24) preoperatively to 9 (5-15) 6 months postoperatively. Only 10 (4%) patients experienced recurrence and only 3 of them required additional reintervention. Patient satisfaction at 1 year was excellent in 86%, good in 13%, and poor in 1% of patients.

CONCLUSIONS

STARR is a safe, effective, and minimally invasive technique for the treatment of rectocele associated with ODS.

Transanal total mesorectal excision (TaTME): single-centre early experience in a selected population

Total mesorectal excision (TME) represents the key principle in the surgical treatment of rectal cancer. Transanal mesorectal excision was introduced as a complement to conventional surgery to overcome its technical difficulties. The aim of this study was to evaluate the early surgical results following the introduction of this novel technique at our Unit. Between January and May 2016, 12 patients diagnosed with mid-low rectal adenocarcinoma were enrolled into this study and evaluated with regards demography, histopathology, peri-operative data and postoperative complications. The tumor was located in the middle rectum in 6 patients (50%), in the lower rectum in 6 patients (50%). Mean operative time was 356.5 ± 76.2 min (range 240-494). Eleven out 12 patients (91.6%) had less than 200 mL of intraoperative blood loss. Mean hospital stay was 10.9 ± 4.6 days (range 5-19). No mortality was recorded. Intraoperative complications were recorded in 1, while early post-operative complications (< 30 days) were observed in 5 patients (41.6%). Histopathology showed in all cases an intact mesorectum. Mean number of lymphnodes harvested was 13.6 ± 6.6 (range 4-29). Distal and circumferential margin was, respectively, of 20.8 ± 14.2 mm (range 2-45 mm) and 16.1 ± 7.6 mm (range 3-30 mm). The comparative analysis showed significant differences concerning mean operative time (p = 0.0473) and estimated blood loss (p = 0.0367). This study confirms this technique is safe and feasible, but more evidence to support its use over conventional laparoscopic surgery is needed.

Transanal endoscopic microsurgical submucosa dissection in the treatment of rectal adenomas and T1 rectal cancer

Background

The treatment of flat rectal adenomas is challenging. The technical difficulty and the potential of malignancy in suspected benign lesions are the factors in question. Surgical and interventional endoscopic techniques are implemented in Europe without a clear strategy. To minimize recurrent adenoma and unclear histopathological work up en bloc excision is desirable.

Methods and results

We demonstrate in this article the transanal endoscopic microsurgical submucosa dissection (TEM-ESD) procedure as a feasible method for en bloc excision of rectal adenomas and early rectal cancer. The surgical technique is demonstrated in detail with the help of a video of the operation that is available online. The results of a consecutive series of 78 patients are presented.

Conclusion

TEM-ESD is a safe procedure for resection of rectal adenomas and low risk carcinomas. It offers the possibility of organ preservation and minimizes functional disturbances. In case of a necessary salvage operation, the preserved integrity of the rectal muscle tube grants maximal oncological safety.

Electronic supplementary material

The online version of this article (10.1007/s00053-018-0291-3) includes a video on the surgical technique: TEM ESD. The article and supplemental material are available at http://www.springermedizin.de/der-chirurg. The supplemental material can be found at the end of the article under “Supplementary material”.

Review and update: robotic transanal surgery (RTAS)

As the field of surgery advances, new approaches have allowed surgeons additional flexibility to perform further interventions with minimal or no external incisions. For many years, single site access (SSA) has been used for transanal procedures, and platforms allowing modified endoscopic approaches have been available. These platforms have limitations related to access, visualization, dexterity, camera control, and instrumentation. Recently, surgical robotics companies have developed and introduced new technologies and platforms, which may help address some of these limitations. Comprehensive internet, open access, and medical and industry conference reviews of robotic surgery platforms and technology available for use in SSA surgery were conducted and 30 articles were found using keywords "robotic surgery, transanal, single site, robotic transanal surgery". A PubMed, Medline, Journals @OVID and open access search for data related to these platforms and technologies was also performed yielding 11 articles. Abstracts were reviewed for those written in the English language, leaving 40 articles which were then filtered for those pertaining to robotic surgery, transanal. 58 abstracts were found, duplicates were eliminated, and the remaining 35 articles were read in their entirety by two reviewers. Several new and existing platforms are identified for use in SSA surgery for transanal surgery as well as abdominal and transoral surgery. These are reviewed, including brand, features, approved and suggested uses, and potential limitations. New robotic technologies serve to enhance the ability of surgeons to perform SSA surgery. This next generation of robotic surgery technology overcomes some of the limitations of preceding endoscopic SSA surgery technology and will enhance the advancement of robotic transanal surgery, but outcomes and performance data are still limited.

Ectopic air localizations after transanal procedures: A systematic literature review

BACKGROUND

Aim of this study is to report and to analyze the incidence, clinical impact and treatment options of ectopic air localizations after transanal procedures.

METHODS

A systematic literature review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The research was carried out using the PubMed database, identifying 40 articles with the following keywords: "transanal" AND "emphysema"; "transanal" AND "subcutaneous emphysema"; "transanal" AND "pneumomediastinum"; "transanal" AND "pneumothoraces"; "transanal" AND "pneumopericardium"; "transanal" AND "retropneumoperitoneum".

RESULTS

Nineteen articles, published between 1993 and 2017, were included in the study for a total of 29 patients. The most frequent air localization was in the retroperitoneum, followed by subcutaneous tissues, mediastinum and neck. This condition was treated conservatively in 20 patients, with colostomy in 4 patients, with bowel resection and negative diagnostic laparoscopy in one patient each. In three cases the treatment was not specified. Ectopic air location resolved in all cases.

CONCLUSIONS

Pneumo-mediastinum and pneumo-retroperitoneum after transanal procedures are unusual complications with a dramatic radiological appearance but can be managed successfully with a completely benign course in most cases. Initially, a conservative approach is recommended. Surgical treatment should be reserved only in case of fluid collection or suture dehiscence.

Perianal minimally invasive surgery (PAMIS) for rectal stump resection after previous colectomy

PURPOSE

Resection of a long rectal stump after previous colectomy or Hartmann procedure often requires a combined transperitoneal and transperineal approach because of limited access through a perineal incision alone. Risks associated with this procedure include iatrogenic injury to bowels, nerves, ureters, vessels and sexual organs. This study reports on the feasibility and safety of perianal minimally invasive surgery (PAMIS) for the resection of long rectal stumps that would otherwise require a combined transperitoneal and perianal approach.

METHODS

PAMIS utilizes standard laparoscopic equipment and a single access port to dissect the rectal stump following the mesorectal fascia into the pelvis after excision of the anal canal. Three PAMIS procedures were performed between February and April 2016. Feasibility, safety and outcome were analysed.

RESULTS

Three patients with previous colectomy and ostomy creation due to colitis ulcerosa (n = 2) and idiopathic enteropathy (n = 1) underwent PAMIS. The rectal stump length ranged between 10 and 19 cm. The median postoperative length of stay was 9 (range 6 to 11) days and the median operating time was 90 (range 80 to 120) min. There were no perioperative complications.

CONCLUSION

PAMIS is a feasible, safe and efficient procedure for rectal stump resection avoiding the transperitoneal approach for pelvic dissection.

Robotic Assisted Transanal Polypectomies: Is There Any Indication?

OBJECTIVES

Robotic assisted transanal polipectomy may have advantages compared with the conventional transanal minimally invasive surgery technique. We evaluate the safety, feasibility and advantages of this technique.

METHODS

Between February 2014 and October 2015, 9patients underwent robotic transanal polypectomy. We performed a retrospective study in which we analyse prospectively collected data regarding patient and tumor characteristics, perioperative outcomes, pathological report, morbidity and mortality.

RESULTS

A total of 5 male and 4 female patients underwent robotic TAMIS. Lesions were 6,22cm from the anal verge. Mean size was 15,8cm². All procedures were performed in the lithotomy position. Closure of the defect was performed in all cases. Mean blood loss was 39,8ml. Mean operative time was 71,9min. No severe postoperative complications or readmissions occured. Median hospital stay was 2,5 days.

CONCLUSIONS

Robotic TAMIS is useful to treat complex rectal lesions. Our transanal platform allowed a wider range of movements of the robotic arms and to perform all procedures in the lithotomy position.

Transanal surgery for obstructed defecation syndrome: Literature review and a single-center experience

Obstructed defecation syndrome (ODS) is a functional disorder commonly encountered by colorectal surgeons and gastroenterologists, and greatly affects the quality of life of patients from both societal and psychological aspects. The underlying anatomical and pathophysiological changes of ODS are complex. However, intra-rectal intussusception and rectocele are frequently found in patients with ODS and both are thought to play an important role in the pathogenesis of ODS. With the development of evaluation methods in anorectal physiology laboratories and radiology studies, a great variety of new operative procedures, especially transanal procedures, have been invented to treat ODS. However, no procedure has been proved to be superior to others at present. Each operation has its own merits and defects. Thus, choosing appropriate transanal surgical procedures for the treatment of ODS remains a challenge for all surgeons. This review provides an introduction of the current problems and options for treatment of ODS and a detailed summary of the essential assessments needed for patient evaluation before carrying out transanal surgery. Besides, an overview of the benefits and problems of current transanal surgical procedures for treatment of ODS is summarized in this review. A report of clinical experience of some transanal surgical techniques used in the authors’ center is also presented.

Long-term results of transanal pull-through for Hirschsprung's disease: a meta-analysis

INTRODUCTION

Several operative techniques have been developed for the treatment of Hirschsprung's disease (HD) in the past decades. Since one-stage transanal pull-through (TAPT) was first performed in 1998, multiple studies have shown favourable short-and midterm results compared to other techniques with shorter operation length, shorter hospital stay and lower complication rates. The aim of this meta-analysis was to determine the longterm results following TAPT for HD.

METHODS

A systematic literature search for relevant articles was performed in four databases using the following terms "Hirschsprung/Hirschsprung's disease", "aganglionosis", "transanal", "pullthrough/pull-through", "longterm/long-term" "results", "follow-up" and "outcome". A meta-analysis was conducted for relevant articles for one-stage transanal pull-through for HD with a minimal follow-up of median 36 months regarding constipation, incontinence/soiling, enterocolitis and secondary operations. Odds ratio (OR) with 95 % confidence intervals (CI) were calculated.

RESULTS

Six studies with 316 patients matched the set criteria and were included in this analysis. Overall 45 (14.2 %) patients had disturbances of bowel function (OR 0.05, 95 % CI 0.03-0.07, p < 0.00001). Of these, 24 (53.3 %) patients experienced constipation, 8 (17.8 %) incontinence/soiling and 13 (28.9 %) enterocolitis. 10 (3.2 %) patients developed complications requiring secondary surgery. Most patients had a daily defecation frequency of 1-3 bowel movements 3 years postoperatively, resembling the stooling patterns of healthy controls.

CONCLUSION

Nearly 15 % of all patients operated with TAPT for HD continue to experience persistent bowel symptoms with constipation as the main problem. Further studies on the long-term outcome of children operated with this technique for HD are necessary to evaluate stooling patterns, urinary and sexual function as well as general quality of life during adolescence and adulthood.

Minimally Invasive Surgery for the Treatment of Colorectal Cancer

BACKGROUND

Reduction in operative trauma along with an improvement in endoscopic access has undoubtedly occupied surgical minds for at least the past 3 decades. It is not at all surprising that minimally invasive colon surgery has come a long way since the first laparoscopic appendectomy by Semm in 1981. It is common knowledge that the recent developments in video and robotic technologies have significantly furthered advancements in laparoscopic and minimally invasive surgery. This has led to the overall acceptance of the treatment of benign colorectal pathology via the endoscopic route. Malignant disease, however, is still primarily treated by conventional approaches.

METHODS AND RESULTS

This review article is based on a literature search pertaining to advances in minimally invasive colorectal surgery for the treatment of malignant pathology, as well as on personal experience in the field over the same period of time. Our search was limited to level I and II clinical papers only, according to the evidence-based medicine guidelines. We attempted to present our unbiased view on the subject relying only on the evidence available.

CONCLUSION

Focusing on advances in colorectal minimally invasive surgery, it has to be stated that there are still a number of unanswered questions regarding the surgical management of malignant diseases with this approach. These questions do not only relate to the area of boundaries set for the use of minimally invasive techniques in this field but also to the exact modality best suited to the treatment of every particular case whilst maintaining state-of-the-art oncological principles.

A population-based, complete follow-up of 146 consecutive patients after transanal mucosectomy for Hirschsprung disease

OBJECTIVE

The objective of the study is to define the population-based bowel functional outcomes and enterocolitis following transanal endorectal pull-through (TEPT) in patients with Hirschsprung disease (HD) treated at our institution between 1986 and 2011.

METHODS

146 consecutive patients who had undergone primary surgical treatment for HD were included. The median follow-up time was 15 (3-33) years. The clinical details and prevalence of enterocolitis were evaluated in all patients, and bowel function in patients >3 years of age with functional intestino-anal continuity.

RESULTS

No patients were lost to follow-up. Overall survival was 98%. The level of disease was rectosigmoid in 83%, long segment in 7%, total colonic in 4%, and extending up to the small bowel in 6%. 29% had an associated syndrome. 22% had a preoperative stoma. Operations included TEPT (89%), proctocolectomy with ileoanal anastomosis in 9%, and 3% had a permanent endostomy owing to small intestinal aganglionosis. One patient underwent intestinal transplantation. At the latest follow-up, 42% had occasional soiling, 12% had frequent soiling and 46% had no soiling. Constipation occurred in 9%. An associated syndrome was the only predictor for soiling or constipation (OR 4.3, 95% CI 1.5-12). 44% developed recurrent postoperative enterocolitis, which was predicted by extended aganglionosis (OR 6.9, 95% CI 2.4-20) and syndromatic disease (OR 2.4, 95% CI 1.2-5.0).

CONCLUSION

The major functional sequelae following TEPT were recurrent enterocolitis and fecal soiling, which was mostly occasional. An associated syndrome was a predictor of a reduced bowel functional outcome, and alongside extended aganglionosis were significant risk factors for recurrent postoperative enterocolitis.

Management of rectourinary fistula after urological interventions using biodesigned mesh: first experiences of an innovative technique

PURPOSE

Rectourinary fistula (RUF) is an uncommon but devastating condition that usually occurs as a complication of surgical treatment or radiotherapy of prostate cancer. Although operative fistula repair remains the most successful treatment, there still is no consensus concerning the management of RUF. We present first experiences and transanal surgical technique using biological mesh for fistula repair after urological intervention.

MATERIAL AND METHODS

From January 2009 to December 2013, four cases of RUF were reported at our university hospital. Fistula occurred after extraperitoneal laparoscopic radical prostatectomy, open radical prostatectomy, and high-intensity focused ultrasound, respectively. All patients were initially treated with transanal Cook Biodesign™ mesh, whereas two patients received reoperation with rectal mucosa advancement flap and gracilis muscle flap interposition, respectively. Mean follow-up was 36 months (range 9-62).

RESULTS

Fistula diameters ranged from 0.6 to 3.0 cm and were located 5 to 6 cm of anocutaneous line. The time from diagnosis to fistula repair was 3 to 7 weeks. The median operative time for Cook Biodesing™ mesh procedure was 79 min (IQR 60, 98). The initial success rate for biological mesh was 50 % (2/4 patients). Larger fistulae were minimalized successfully and finally closed with reoperation mentioned above. No deterioration of continence was documented.

CONCLUSIONS

Management of rectourinary fistula is still challenging. Using biomaterials for fistula closure seems to be a promising and minimally invasive transanal technique in future. Further analysis including more patients is needed to clarify its exact role in comparison to traditional surgical techniques.

Impact of technology on indications and limitations for transanal surgical removal of rectal neoplasms

Transanal surgery has and continues to be well accepted for local excision of benign rectal disease not amenable to endoscopic resection. More recently, there has been increasing interest in applying transanal surgery to local resection of early malignant disease. In addition, some groups have started utilizing a transanal route in order to accomplish total mesorectal excision (TME) for more advanced rectal malignancies. We aim to review the role of various transanal and endoscopic techniques in the local resection of benign and malignant rectal disease based on published trial data. Preliminary data on the use of transanal platforms to accomplish TME will also be highlighted. For endoscopically unresectable rectal adenomas, transanal surgery remains a widely accepted method with minimal morbidity that avoids the downsides of a major abdomino-pelvic operation. Transanal endoscopic microsurgery and transanal minimally invasive surgery offer improved visualization and magnification, allowing for finer and more precise dissection of more proximal and larger rectal lesions without compromising patient outcome. Some studies have demonstrated efficacy in utilizing transanal platforms in the surgical management of early rectal malignancies in selected patients. There is an overall higher recurrence rate with transanal surgery with the concern that neither chemoradiation nor salvage surgery may compensate for previous approach and correct the inferior outcome. Application of transanal platforms to accomplish transanal TME in a natural orifice fashion are still in their infancy and currently should be considered experimental. The current data demonstrate that transanal surgery remains an excellent option in the surgical management of benign rectal disease. However, care should be used when selecting patients with malignant disease. The application of transanal platforms continues to evolve. While the new uses of transanal platforms in TME for more advanced rectal malignancy are exciting, it is important to remain cognizant and not sacrifice long term survival for short term decrease in morbidity and improved cosmesis.

Robotic transanal endoscopic microsurgery in benign rectal tumour

AIM

To present a case of resection of a rectal tumour by a transanal robotic approach.

PATIENT

A 58-year-old woman with a 3-cm tumour located 6 cm proximal to anal verge (uT1N0).

RESULTS

We describe the details of the surgical technique. A complete resection with adequate margins was accomplished. The defect was closed with a running suture. Operation time was 180 min. There were no complications and the patient was discharged 24 h after surgery.

CONCLUSION

A complete resection of a rectal tumour by a robotic approach is feasible and safe. More studies are needed to clearly define the indications where this new approach can show clear advantages over other transanal resection approaches.

Single trocar transanal endoscopy in a child

Single trocar transanal endoscopic surgery (STTE) is a well-known technique for evaluation and management of rectal lesions in adults. We used an 11mm balloon trocar with a 10mm operative optic, introduced into the anal canal to excise a rectal lesion along with multiple rectal biopsies in a child. Rectal visibility was good with an ease to maintain the rectum insufflated.