Excision Of Rectal Tumors Research Articles

Cirugía transanal mínimamente invasiva: experiencia en un servicio especializado en Perú

Introduction. Transanal minimally invasive surgery (TAMIS) is a procedure implemented in several centers around the world, showing high-quality local excision in rectal neoplasms. Objective. To describe the results of the experience of minimally invasive transanal surgery for local excision of rectal tumors at the Guillermo Almenara National Hospital, Lima, Peru. Methods. A descriptive, cross-sectional design study was carried out on all patients undergoing TAMIS during the period June 1, 2019 to December 31, 2023. Evaluating clinical, surgical, pathological variables and complications. Results. 16 patients were included. The mean age was 57 years (range 15 - 82). The mean size of the lesions was 3.5 cm (range 1.3 - 9 cm) and the mean height of the tumor at the anal margin was 8.6cm (range 4 - 20 cm). The final pathology results were: 9 benign lesions, 1 neuroendocrine tumor and 6 rectal adenocarcinomas, within these 4 cases were Tis, 1 was T1 sm1 and the other T1 sm2. 3 cases with preoperative adenoma biopsy turned out to have adenocarcinoma in the final pathology. The frequency of fragmented pieces was 6.3%. The mean postoperative stay was 4.4 days. The frequency of complications was 12.5%. No local recurrence was evident during follow-up. Conclusions. TAMIS is a safe, feasible and low-morbidity procedure for the resection of benign neoplasms and in selected cases of early-stage rectal cancer.

A Case of Transanal Endoscopic Excision for Rectal Tumor Using Surgical Instruments With Multi-jointed Structures.

Transanal endoscopic local excision requires fine operation in a very narrow space in the rectum. We report a case in which the use of surgical instruments with a multi-jointed structure allowed safe resection of a lesion with a stable field of view, resulting in preservation of postoperative function. The patient was a 49-year-old man who had a rectal neuroendocrine tumor (NET) (G1) with erosive changes in the lower rectum. Preoperative imaging showed no evidence of surrounding lymph node or distant metastasis; thus, we performed a transanal endoscopic local excision of the tumor. After positioning the patient under general anesthesia and securing the field of view in the intra-rectal cavity, the flexion of the surgical instruments with a multi-jointed structure was used to secure the operating space to not interfere with the camera and the surgeon's right hand. The operating field was developed, and the tumor was incised by stable traction. After the excision, the needle was advanced in the direction of the intestinal axis using the multi-jointed holder, and continuous suturing was performed. The patient has no recurrence without any defecation disorder. The use of multi-jointed surgical instruments in transanal endoscopic excision of rectal tumors can provide a stable operative field and preserve postoperative function. The advanced flexibility of these instruments allows precise manipulation in the narrow rectal space, resulting in successful tumor resection with minimal invasiveness and no postoperative complications. These findings suggest that multi-jointed instruments are valuable for enhancing the safety and efficacy of minimally invasive rectal surgery.

Complex Procedures in Transanal Endoscopic Microsurgery: Intraperitoneal Entry, Ultra Large Rectal Tumors, High Lesions, and Resection in the Anal Canal.

Transanal endoscopic microsurgery (TEM) allows the local excision of rectal tumors and achieves lower morbidity and mortality rates than total mesorectal excision. TEM can treat lesions up to 18 to 20 cm from the anal verge, obtaining good oncological results in T1 stage cancers and preserving sphincter function. TEM is technically demanding. Large lesions (>5 cm), those with high risk of perforation into the peritoneal cavity, those in the upper rectum or the rectosigmoid junction, and those in the anal canal are specially challenging. Primary suture after peritoneal perforation during TEM is safe and it does not necessarily require the creation of a protective stoma. We recommend closing the wall defect in all cases to avoid the risk of inadvertent perforation. It is important to identify these complex lesions promptly to transfer them to reference centers. This article summarizes complex procedures in TEM.

Transanal minimally invasive surgery for rectal cancer.

Due to the increased uptake of rectal cancer screening and the increasing rates of complete clinical response to chemoradiotherapy, more early‐stage and down‐staged rectal cancers are being treated. This has triggered surgeons to question the necessity for proctectomy and its associated morbidity and consider local excision and organ preservation in selected cases. Transanal minimally invasive surgery (TAMIS) has evolved as an oncologically safe yet cost‐effective platform for local excision of rectal tumors using traditional laparoscopic instruments. This review highlights the recent advances and current role of TAMIS in the treatment of rectal cancer.

Single-port robotic transanal minimally invasive surgery (SPR-TAMIS) approach to local excision of rectal tumors.

Trans-anal excision is the surgical treatment of choice for endoscopically unresectable rectal polyps, early rectal cancers, small carcinoid tumors, and other low-risk tumors. The single-port robotic (SPR) platform is the newest development in robotic surgery capable of performing trans-anal minimally invasive surgery (TAMIS). In theory, the single incision design would naturally lend itself to the size limitation of the anal canal, but in practice, this method has not been tested. Herein we describe the techniques and first reports of performing TAMIS using the SPR platform. We describe in detail how to perform the SPR-TAMIS technique using lessons and experience gained from performing this on five patients who had endoscopically unresectable rectal polyps or T1 rectal cancers. Each patient was followed for a minimum of 30days and was seen in clinic post-operatively. A retrospective chart review was performed to obtain information on technical success, anatomic measurements, and reported complications. The SPR TAMIS was successfully performed on all five patients without any reported complications. All underwent a non-piecemeal excision and had return of regular bowel function at 30-day follow-up. All patients were discharged from the hospital the same day as their operation. SPR-TAMIS is a novel, safe, and feasible procedure capable of achieving non-piecemeal resections of low-risk rectal tumors. Further study needs to be conducted to determine complication rates, functional and oncologic outcomes, and ensure the long-term safety profile.

Comparison between High andLow Binding of the InferiorMesenteric Artery inMesorectal Excision of Rectal Tumor

Background: Colorectal tumor is one of the most common tumors in both men and women worldwide. However, whether high or low inferior mesenteric artery (IMA) ligation should be performed in the laparoscopic resection of resectable rectal tumor remains controversial. Objectives: The aim of the work was to compare low vs high IMA binding in patients undergoing laparoscopic mesorectal excision for rectal tumor. Patients and methods: This retrospective archived-based data study included a total of 161 patients with rectal tumor who were eligible for total mesorectal excision, attending at Al-Azhar University Hospitals. This study was conducted between 2010, and 2017. The high IMA binding (HIMAB) was conducted for 87 patients and low IMA binding (LIMAB) was conducted for 74 patients. Baseline data were retrospectively analyzed for patients in both groups. Results: The LIMAB group showed more high anus retention ratio (P = 0.022), more brief hospital stay (P = 0.025), less medical costs (P = 0.032), lower anastomotic leakage (P = 0.023), and lower frequency of postoperative genitourinary dysfunction (P = 0.003) when compared with HIMAB group. Analysis of the Cox regression showed local recurrence, distant metastases, tumor differentials. Conclusion: It could be concluded that laparoscopic radical rectal cancer resection with low IMA binding tends to be correlated with reduced anastomotic leakage risk, anastomotic stringency risk, the risk of instability of the genitourinary system, less time of hospitalization, and decreased costs. By comparison, it was found that the rate of excised lymph node, tumor recurrence, metastasis, or mortality was not associated with the level of IMA binding

Comparison of the transanal surgical techniques for local excision of rectal tumors: a network meta-analysis.

In order to assess the various surgical modalities for local resection of rectal tumors, a systematic review of the current literature and a network meta-analysis (NMA) was designed and conducted. The present study adhered to the PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions principles. Scholar databases (Medline, Scopus, Web of Science) were systematically screened up to 23/12/2019. A Bayesian NMA, implementing a Markov chain Monte Carlo analysis, was introduced for the probability ranking of the available surgical methods. Odds ratio (OR) and weighted mean difference (WMD) of the categorical and continuous variables, respectively, were reported with the corresponding 95% confidence interval (95%CI). Overall, 16 studies and 2146 patients were introduced in our study. Transanal minimal invasive surgery (TAMIS) displayed the highest performance regarding the overall postoperative morbidity, the perioperative blood loss, the length of hospitalization, and the peritoneal violation rate. Transanal endoscopic microsurgery (TEM) was the most efficient modality for resecting an intact specimen. Although transanal local excision (TAE) had the highest ranking considering operative duration, it was associated with a significant risk for positive resection margins and tumor recurrence. In conclusion, TEM and TAMIS display superior oncological results over TAE. Due to several limitations, validation of these results requires further RCTs of a higher methodological level.

Patterns of opioid use and prescribing for outpatient anorectal operations

BackgroundSurgery for anorectal diseases is thought to cause significant pain postoperatively. There is little known regarding standardized opioid-prescribing trends and patient use following surgery for anorectal diseases. We aimed to evaluate and analyze opioid-prescribing trends and patient use for outpatient anorectal operations. Materials and methodsAll patients who underwent outpatient anorectal surgery performed over a 1-y period at a single institution were eligible. Procedures included hemorrhoidectomy, anal fistula repair/seton, anal fissure treatment with sphincterotomy, and transanal excision of rectal tumors. Demographic, operative, and postoperative data were obtained. Patients were given a survey to determine postoperative pain control with opioid and non-narcotic analgesia use; respondents were included in analysis. ResultsForty-two outpatient anorectal surgery patients were included: 13 had hemorrhoidectomy, 22 had anal fistula repair/seton, one had sphincterotomy, and six had transanal excisions. All patients had multimodality treatment with either an anal block and/or postoperative nonopioid analgesics. Ninety percent were prescribed opioids postoperatively with a median of 20 pills (range: 0-120 pills). Forty-three percent (18/42) did not fill their prescription. For those who used opioids, the median number of pills taken was four. Eighty percent of pills prescribed were not used. One patient required a refill. Greater than 60% of respondents reported good to excellent pain control on a five-point scale. ConclusionsMost patients had adequate pain control after anorectal surgery with little to no use of opioids and that more than 80% of opioid pills prescribed were not consumed. We intend to standardize our prescribing opioid quantities for outpatient anorectal operations to reflect this reduced use.

Endoscopic submucosal injection: a novel technique facilitatingdissectionin transanal minimally invasive surgery (TAMIS).

Transanal minimally invasive surgery (TAMIS) is a surgical platform that enables local excision of rectal tumours, originally described by Atallah et al. [1]. It has mainly been used for the excision of benign lesions, but has also been used in the management of early malignant lesions. As with any local approach to rectal malignancy lack of lymph node resection is a concern [2]. TAMIS has the advantages of being easy and safe to perform [3]. Dissection in TAMIS is achieved by traction and counter-traction in a rather confined space (the pneumorectum), which can be difficult. Visualisation of tissue planes can be challenging. We adopted a well-developed endoscopic technique known as endoscopic submucosal injection (ESI) to facilitate dissection...

Local excision for rectal cancer: a minimally invasive option.

Transanal excision (TAE) with conventional retractors and transanal endoscopic microsurgery (TEM) are two well established minimally invasive surgical options for the treatment of selected rectal cancers. TEM is nowadays considered the standard of care for the transanal excision of rectal tumors, since it is associated with significantly better quality of excision and lower rates of recurrence than TAE. When compared with rectal resection and total mesorectal excision, TEM has lower postoperative morbidity and better functional outcomes, with similar long-term survival rates in selected early rectal cancers. More recently, transanal minimally invasive surgery (TAMIS) has been developed as an alternative to TEM. Possible benefits of TAMIS are under evaluation.

Rationale and limitations of transanal total mesorectal excision for rectal tumors

Rationale and limitations of transanal total mesorectal excision for rectal tumors

Should the rectal defect be closed following transanal local excision of rectal tumors? A systematic review and meta-analysis.

Transanal local excision (TLE) has become the treatment of choice for benign and early-stage selected malignant tumors. However, closure of the rectal wall defect remains a controversial point and the available literature still remains unclear. Our aim was to determine through a systematic review of the literature and a meta-analysis of relevant studies whether or not the wall defect following TLE of rectal tumors should be closed. Medline and the Cochrane Trials Register were searched for trials published up to December 2016 comparing open versus closed management of the surgical rectal defect after TLE of rectal tumors. Meta-analysis was performed using Review Manager 5.0. Four studies were analyzed, yielding 489 patients (317 in the closed group and 182 in the open group). Meta-analysis showed no significant difference between the closed and open groups regarding the overall morbidity rate (OR 1.26; 95% CI 0.32-4.91; p=0.74), postoperative local infection rate (OR 0.62; 95% CI 0.23-1.62; p=0.33), postoperative bleeding rate (OR 0.83; 95% CI 0.29-1.77; p=0.63), and postoperative reintervention rate (OR 2.21; 95% CI 0.52-9.47; p=0.29). This review and meta-analysis suggest that there is no difference between closure or non-closure of wall defects after TLE.

Comparison of trans-anal endoscopic operation and trans-anal excision of rectal tumors.

BackgroundTrans-anal endoscopic operation (TEO) has developed to facilitate proper tumor location and ensure excision safely.MethodsWe reviewed 92 patients enrolled in our database between 2006 and 2014 who were diagnosed with early rectal tumors and who underwent conventional trans-anal excision (TAE) or TEO. Clinical data were collected prospectively to compare safety and feasibility between two techniques.ResultsNinety-two patients underwent trans-anal local excision for lower rectal tumors. TEO and TAE were performed in 48 and 44 patients, respectively. Age, sex, and comorbidities were similar. There was no significant difference in tumor diameter (1.6 ± 1.68 cm vs. 1.17 ± 1.17, respectively). Tumor height, however, was higher in the TEO (7.46 ± 3 cm) than the TAE group (3.84 ± 1.88 cm, p < 0.001). Four complications, perianal abscess, and two perforations, occurred in the TEO group, whereas no major complications occurred in the TAE. Seven patients (14.6%) underwent TEO underwent a salvage operation compared to only a single patient in TAE group (2.3%, p = 0.039). Eight patients (17.4%) diagnosed with adenocarcinoma developed recurrence, four in each group. Disease-free survival was similar between groups (TEO – 41.8 months, 95% RI 39.4–44.1; TAE 79.7 months, 95% RI 72.2–87.3). However, more TAE patients (n = 7, 15.9%) than TEO patients (n = 2, 4.2%) underwent chemotherapy.ConclusionsTEO treatment of local rectal tumors is safe and feasible and can achieve an adequate resection margin. Local recurrence was similar in both groups. However, the numbers of salvage operations and minor complications were higher in the TEO group.

Peer review report 3 on “Comparison of Trans-anal Endoscopic Operation and Trans-anal Excision of Rectal Tumors”

Peer review report 3 on “Comparison of Trans-anal Endoscopic Operation and Trans-anal Excision of Rectal Tumors”

Peer review report 1 on “Comparison of Trans-anal Endoscopic Operation and Trans-anal Excision of Rectal Tumors”

Peer review report 1 on “Comparison of Trans-anal Endoscopic Operation and Trans-anal Excision of Rectal Tumors”

Peer review report 2 on “Comparison of Trans-anal Endoscopic Operation and Trans-anal Excision of Rectal Tumors”

Peer review report 2 on “Comparison of Trans-anal Endoscopic Operation and Trans-anal Excision of Rectal Tumors”

Peer review report 4 on “Comparison of Trans-anal Endoscopic Operation and Trans-anal Excision of Rectal Tumors”

Peer review report 4 on “Comparison of Trans-anal Endoscopic Operation and Trans-anal Excision of Rectal Tumors”

Transanal endoscopic microsurgery for rectal cancer: T1 and beyond? An evidence-based review.

The last three decades have witnessed significant improvements in the diagnosis, staging and treatment of rectal cancer leading to a more tailored approach. One of the most clinically relevant advances in this field is represented by transanal endoscopic microsurgery (TEM). Several studies have investigated its role in the treatment of rectal cancer. However, evidence-based recommendations are limited. The aim of this report is to provide an evidence-based review of current indications, controversies and future perspectives of TEM in the management of rectal cancer. A review of the literature has been performed in PubMed/Medline electronic databases and the Cochrane Library. Quality of evidence was evaluated according to the GRADE system. TEM allows to perform a more accurate en bloc full-thickness local excision of rectal tumors than transanal excision. TEM alone seems to provide similar oncologic results in selected T1sm1 N0 rectal cancers to those achieved by rectal resection and total mesorectal excision (TME), without impairing anorectal function. The oncologic outcomes of neoadjuvant therapy followed by TEM for selected T2 N0 rectal cancers are promising, but this approach is still under evaluation. A word of caution comes from the increased rate of suture dehiscence and rectal pain after TEM. TEM is a promising tool for the surgical treatment of locally advanced rectal cancer as a platform for transanal TME. Selected T1 rectal cancers with favorable features may be effectively treated with TEM without jeopardizing long-term oncologic outcomes. The lack of adequate lymphadenectomy represents the main concern of this approach for the treatment of rectal cancer. Several approaches are under evaluation to overcome this limitation.

Transanal approach for rectal tumors: recent updates and future perspectives

Local excision of rectal tumors has long been performed. With the development of new technologies for endoluminal operation, there have been significant advances in the transanal approach in the last 30 years. It started with conventional transanal excision (TAE) and was developed by introduction of transanal total mesorectal excision (taTME). Appropriate patient selection for transanal approaches is the key for good outcomes. TAE of rectal tumors has been advocated for premalignant lesions and used as definitive treatment for early rectal cancers in select groups without adverse prognostic features. Regardless of procedures, the morbidity and mortality of tansanal technique are lower than for radical surgery. According to the experience in the last decades, transanal endoscopic surgery has been accepted as effective treatments in selected patients with early rectal cancer, with similar oncologic outcomes to and better functional effects than those of radical surgery. The latest development in transanal approaches is taTME. Although taTME is another new technique with great promise, the supporting data are preliminary, and further studies with larger cohorts of patients are needed to evaluate long term functional and oncological outcomes. Transanal approaches have enabled mid and upper rectal lesion and sphincter salvage, leading to a better quality of life. transanal approaches including taTME should be considered as good options for the treatment of rectal cancer because these techniques are definitely useful in selected patients.

Risk of complications and long-term functional alterations after local excision of rectal tumors with transanal endoscopic microsurgery (TEM).

Transanal endoscopic microsurgery (TEM) is a consolidated technique for the excision of rectal tumors. However, many aspects relating to its morbidity, risk of functional alterations, and therapeutic outcomes are still unclear. The aim of this study was to assess the rate of morbidity and fecal incontinence after TEM, and to identify associated risk factors. We prospectively recorded the clinical data of 157 patients who underwent TEM from 1996 to 2013. Among these, 89 patients answered a questionnaire for the assessment of fecal continence at a median follow-up time of 40 months. Intraoperative and postoperative TEM complication rates were 3.8 and 20.4%. The mortality rate was 0.6%. A distance from the anal verge of more than 6 cm correlated with a higher risk of perforation, while patients with cancer were more likely to have postoperative bleeding. Incontinence was reported by 32 (36%) patients, of which 7 (8%) experienced transitory symptoms only, while 25 (28%) reported persistent symptoms. We found a correlation between patients receiving preoperative radiotherapy (RT) and the development of fecal incontinence. The recurrence rate was 3% (1/32) in pT1, 80% (4/5) in pT2, and 100% (1/1) in pT3. After radiotherapy, 7% (1/9) showed a good response (pT0-1), and 18% (2/7) showed no response (pT2-3). TEM is associated with low morbidity but the risk of developing functional alterations is not negligible and should be discussed with the patient before the operation. Good oncological outcomes are possible for early invasive cancers and for selected advanced cancers following a good response to preoperative RT.