Laparoscope-assisted Transanal Total Mesorectal Excision Research Articles

Evaluation of defecation function after laparoscopic-assisted transanal total mesorectal excision for low rectal cancer and influencing factors analysis

Objective To evaluate the defecation function of patients with low rectal cancer after laparoscopic-assisted transanal total mesorectal excision (TaTME), and analyze the influencing factors. Methods The retrospective case-control study was conducted. The clinicopathological data of 55 patients with low rectal cancer who underwent laparoscopic-assisted TaTME in the First Hospital of Jilin University from May 2017 to December 2018 were collected. There were 39 males and 16 females, aged (60±11)years, with a range from 24 to 80 years. Among the 55 patients, 21 were in TNM stage Ⅰ, 14 were in TNM stage Ⅱ, and 20 were in TNM stage Ⅲ; 24 were in pathological stage T1-2 and 31 were in pathological stage T3. Observation indicators: (1) surgical and postoperative conditions; (2) follow-up; (3) analysis of influencing factors for postoperative defecation function. Follow-up was performed using questionnaires by telephone interview to detect the complications at 3 and 6 months after surgery up to June 2019. The measurement data with normal distribution were expressed as Mean±SD, and comparison between groups was done using the t test. Count data were expressed as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test or Fisher exact probability. Univariate and multivariate analyses were performed using logistic regression models. Results (1) Surgical and postoperative conditions: 55 patients successfully underwent laparoscopic-assisted TaTME without conversion to open surgery. The operation time, volume of intraoperative blood loss, diameter of postoperative pathological specimen, time to urinary catheter removal, distance between the anastomostic stoma and anal verge, and tumor diameter were (246±62)minutes, (69±27)mL, (3.5±0.7) cm, (2.1±0.9)days, (2.4±0.5)cm, and (3.9±1.6)cm, respectively. (2) Follow-up: 55 patients were followed up at 3 months and 6 months after surgery, and the low anterior resection syndrome questionnaires were completed. Among the 55 patients, 35 had low anterior resection syndrome at 3 months after surgery, and 24 had low anterior resection syndrome at 6 months after surgery, showing a significant difference (χ2=4.42, P 5 cm were independent risk factors affecting the defecation function of patients at 3 months after surgery (odds ratio=1.135, 6.057, 95% confidence interval: 1.089-1.323, 1.206-30.435, P<0.05). The distance between the anastomotic stoma and anal verge <2 cm was an independent risk factor affecting the defecation function of patients at 6 months after surgery (odds ratio=2.724, 95% confidence interval: 1.982-3.066, P<0.05). Conclusions The incidence of low anterior resection syndrome after laparoscopic-assisted TaTME for low rectal cancer is high. Distance between the anastomotic storna and anal verge and tumor diameter are independent risk factors for the postoperative defecation founction. Key words: Rectal neoplasms; Rectal cancer; Transanal total mesorectal excision; Low anterior resection syndrome; Laparocopy

Postoperative short-term complications of laparoscope-assisted transanal total mesorectal excision for rectal cancer after neoadjuvant therapy and their management: a single center report

To summarize and analyze the postoperative short-term complications of laparoscope-assisted transanal total mesorectal excision (taTME) for rectal cancer patients after neoadjuvant therapy. A prospectively established database on taTME patients at Peking University Cancer Hospital was screened with the following conditions: data retrieval from June 2016 to August 2018, pathologically confirmed adenocarcinoma, receiving preoperative neoadjuvant chemoradiotherapy or chemotherapy. The transabdominal procedure and the transanal procedure were performed simultaneously in the taTME operation. Occurrence of complications during perioperative period (within postoperative 3 months) in these patients, especially anastomosis-related complications and their management were analyzed. The relevant complications were recorded according to the Clavien-Dindo (CD) grading criteria. The severity of anastomotic leakage and anastomotic stenosis was evaluated according to criteria developed by the International Rectal Cancer Research Group. A total of 29 patients were enrolled in this study. In the 29 patients, 25 (86.2%) were male and 4 (13.8%) were female, the median age was 60 (range, 30 to 72) years, the median body mass index was 25.8 (range, 19.8 to 36.4) kg/m2, the median distance from the tumor to anal verge was 4 (range, 2 to 8) cm. All the patients completed laparoscope-assisted taTME operations successfully without conversion to laparotomy, intra-operative severe complication or death. The median operation time was 300 (range, 198 to 405) minutes, and the median intra-operative blood loss was 100 (range, 50 to 200) ml. All the TME specimens were complete according to the Nagtegaal standard. All the patients underwent prophylactic ileostomy. Hartmann procedure was performed in one case due to poor blood supply in the proximal bowel without the possibility of anastomosis. Anal sphincter preservation rate was 96.6% (28/29). The median postoperative exhaust time was 2 (range, 1 to 10) days, and the median postoperative hospital stay was 9 (range, 7 to 24) days. Fifteen patients (51.7%) had postoperative complications, among which serious complication (CD grade IIIb and above) accounted for 6.9% (2/29). No perioperative death was observed. Five patients (17.2%) presented anastomosis-related complications, including 2 cases of grade C anastomotic leakage due to anastomotic rupture, who underwent abdominal perineal resection 1 month after operation; 2 cases of grade B anastomotic leakage, who improved after conservative treatment; 1 case of grade A anastomotic stenosis, who improved with anal expansion 1 month after operation. The incidence of postoperative infection was 24.1% (7/29), including 6 cases of pelvic infection and 1 case of trocar site infection, all of which were CD grade II. One case had incomplete intestinal obstruction (CD grade II); 1 case had gastroplegia; 1 case had abdominal trocar hernia. All the patients were followed up for a median of 12.0 (range, 3.9 to 29.9) months. Seven cases did not undergo ileal stoma closure. The anal sphincter preservation rate was 75.9% (22/29). Pelvic infection and anastomosis-related complications are common after laparoscope-assisted taTME surgery for rectal cancer patients following neoadjuvant chemoradiotherapy, which require active management and appropriate treatment.

Long-term efficacy of laparoscope-assisted transanal total mesorectal excision for rectal cancer

To investigate the long-term outcome of laparoscope-assisted transanal total mesorectal excision (taTME) for rectal cancer. Clinicopathological data of 29 patients with mid-low rectal cancer undergoing laparoscope-assisted taTME at Department of Gastrointestinal Surgery, the First Affiliated Hospital of Guangzhou Medical University from May 2010 to December 2015 were collected for the retrospective case-series study. All the operations were performed with transabdominal and transanal procedure simultaneously or sequentially. Perioperative presentations, pathological examinations, and oncologic outcomes were retrospectively analyzed. Long-term recurrence, metastasis and survival were assessed during follow-up. Outpatient clinic and telephone survey were used for follow-up. The follow-up time ended in December 2018. The overall survival (OS) rate and disease-free survival (DFS) rate were calculated by the Kaplan-Meier method. The average intra-operative blood loss was (75.9±9.5) ml (range,20 to 200). The average operating time was (223.6±4.1) minutes (range, 165 to 280). The average number of harvested lymph node was 22.3±2.0. The average length of pathological specimen was (13.1±0.6) cm. The average distal resection margin was (2.9±0.2) cm. 89.7% (26/29) of specimens was complete and 10.3% (3/29) near complete. Two cases (6.9%) had positive cutting circumferential margin. Median follow-up was 56 (range, 22 to 91) months. Local recurrence rate, distant metastasis rate, 3-year OS rate, 3-year DFS rate, 5-year OS rate, 5-year DFS rate were 10.3% (3/29), 20.7%(6/29), 96.6%, 83.2%, 87.6% and 79.6%, respectively. No incisional hernia or adhesive intestinal obstruction was found. Long-term outcomes of mid-low rectal cancer patients undergoing laparoscope-assisted taTME are satisfactory.

Comparison of short- and long-term outcomes between laparoscope-assisted transanal total mesorectal excision and laparoscopic total mesorectal excision for the treatment of mid and low rectal cancer: a meta-analysis

To evaluate systematically the short- and long-term outcomes between laparoscope-assisted transanal total mesorectal excision (LA-taTME) and laparoscopic total mesorectal excision (L-TME) in the treatment of mid and low rectal cancer. Literatures comparing LA-taTME with L-TME published from January 2014 to January 2018 were systematically selected through searching PubMed, Ovid, EMbase, Cochrane Library, CNKI and Wanfang databases. Literature screening and methodology quality evaluation were carried out by two surgeons independently. Randomized controlled trial (RCT) was evaluated by the modified Jadad rating scale, in which 1 to 3 and 4 to 7 were considered as low and high quality,respectively(total scores: 7). Non-randomized controlled trial (NRCT) was assessed by the modified Newcastle Ottawa Scale (NOS), in which 1 to 3, 4 to 6, and 7 to 9 were defined as low, moderate, and high quality, respectively (total score: 9). Ratio of incomplete mesorectum, positive rate of circumferential resection margin (CRM), number of harvested lymph node, distance of distal resection margin, operation time, intraoperative blood loss, morbidity of postoperative complication, conversion rate, hospital stay, recurrence, 2-year disease-free survival (DFS) and 2-year overall survival (OS) were compared and analyzed by using Stata/SE12.0 software. Fourteen studies including 1 RCT and 13 NRCTs were enrolled finally. Among them, the RCT with a score of 6 was considered to be of high quality; all NRCTs (2 with 6 stars, 5 with 7 stars, and another 6 with 8 stars) were indicative of moderate to high quality; 450 patients underwent LA-taTME and 498 patients underwent L-TME. No significant differences were observed in terms of age, gender, tumor location and TNM stage between two approaches (all P>0.05). Compared to L-TME, LA-taTME had lower ratio of incomplete mesorectum (RR=0.53, 95%CI: 0.31 to 0.93, P=0.026), lower positive rate of CRM (RR=0.50, 95%CI: 0.29 to 0.86, P=0.012), lower conversion rate(RR=0.48, 95%CI: 0.26 to 0.86, P=0.014), lower morbidity of postoperative complication (RR=0.81, 95%CI: 0.67 to 0.99, P=0.036) and less intraoperative blood loss (SMD=-0.38, 95%CI:-0.68 to -0.08, P=0.013). While the differences between two groups had no statistical significance in terms of operative duration, number of harvested lymph node, distance of distal resection margin, hospital stay, overall recurrence, 2-year DFS and 2-year OS (all P>0.05). The short- and long-term outcomes of LA-taTME and L-TME for the treatment of mid and low rectal cancer are comparable, while LA-taTME can reduce the ratio of incomplete mesorectum, positive rate of CRM, conversion rate, and morbidity of postoperative complication, and intraoperative blood loss.

Clinical efficacy of the laparoscope-assisted transanal total mesorectal excision for middle-low rectal cancer

Objective To explore the clinical efficacy of laparoscope-assisted transanal total mesorectal excision (La-TaTME) for middle-low rectal cancer. Methods The retrospective cross-sectional study was conducted. The clinical data of 16 patients with middle-low rectal cancer who underwent La-TaTME in the Peking University Third Hospital from August 2015 to August 2016 were collected. Sequential surgery of La-TaTME was applied to patients in the same team, with laparoscopic surgery first and then transanal surgery. Observation indicators: (1) operation and postoperative recovery situations: conversion to open surgery, anastomosis method, operation time, volume of intraoperative blood loss, intraoperative complications, time for out-of-bed activity, time for liquid diet intake, postoperative complications and duration of postoperative hospital stay. (2) postoperative pathological situations: length of surgical specimen, tumor diameter, distance from tumor to resected distant intestinal canal, complete degree of mesorectum, circumferential resection margin, pathological T stage, pathological N stage, number of lymph node detected and tumor cell differentiation. (3) follow-up. Patients in stage Ⅲ-Ⅳ of TNM stage of RC underwent postoperative adjuvant chemotherapy. Follow-up using outpatient examination was performed once every 3 months postoperatively to detect the patients′ survival and tumor recurrence up to December 2016. Measurement data were represented as M (range). Results (1) Operation and postoperative recovery situations: all the 16 patients underwent successful La-TaTME without conversion to open surgery, including 10 with colorectal anastomosis, 3 with colon-canalis analis anastomosis and 3 with permanent colostomy. Operation time and volume of intraoperative blood loss were 290 minutes (range, 215-420 minutes) and 50 mL (range, 30-100 mL), respectively. One patient had intraoperative complication, showing broken ends ischemia of sigmoid colon after dragging out resected rectum from the anus, following free splenic flexure of colon, about 5 cm ischemic sigmoid colon were resected, and descending colon-rectum anastomosis was performed. Time for out-of-bed activity and time for liquid diet intake were 1 days (range, 1-3 days) and 2 days (range, 1-9 days), respectively. Among 3 patients with postoperative complications (Ⅱ stage of Clavien-Dindo), 2 with incomplete intestinal obstruction were improved by gastrointestinal decompression and total parenteral nutrition, and 1 with presacral infection was improved by drainage and antibiotic therapy. Duration of postoperative hospital stay was 7 days (range, 5-21 days). (2) Postoperative pathological situations: length of surgecal specimen, tumor diameter and distance from tumor to resected distant intestinal canal were respectively 18.0 cm (range, 12.0-24.0 cm), 3.5 cm (range, 0.5-6.8 cm) and 2.5 cm (range, 1.0-5.0 cm). Evaluation of mesorectum of surgical specimen: 14 patients had complete mesorectum of surgical specimen and 2 had nearly complete mesorectum. There was no residual tumor at circumferential resection margin, proximal and distal ends. Pathological T stage of 16 patients: T0 (pathological complete response after neoadjuvant therapy), T1, T2 and T3 stages were found in 1, 1, 4 and 10 patients, respectively. Pathological N stage: 12, 2 and 2 patients were detected in N0, N1 and N2 stages, respectively. Number of lymph node detected was 16 (range, 6-32). Tumor cell differentiation: no tumor cell (pathological complete response after neoadjuvant therapy), high-, moderate- and low-differentiated tumors were respectively detected in 1, 2, 7 and 6 patients. (3) Follow-up. All the patients were followed up for 12 months (range, 4-16 months). There were no local tumor recurrence or distant metastasis and death. Conclusion La-TaTME may be a new, safe and effective resection for middle-low rectal cancer. Key words: Rectal neoplasms, middle-low; Total mesorectal excision; Transanal; Laparoscopy

Comments on "Clinical efficacy of the laparoscope-assisted transanal total mesorectal excision for middle-low rectal cancer" : laparoscope-assisted transanal total mesorectal excision is a promsing surgery

Comments on "Clinical efficacy of the laparoscope-assisted transanal total mesorectal excision for middle-low rectal cancer" : laparoscope-assisted transanal total mesorectal excision is a promsing surgery

Laparoscopic-assisted Transanal Total Mesorectal Excision for Middle-Low Rectal Carcinoma: A Clinical Study of 19 Cases.

To explore the safety, feasibility and short-term outcomes of laparoscopic-assisted transanal total mesorectal excision (La-TaTME) of middle-low rectal carcinoma. This retrospective research collected and analyzed the clinical data of 19 patients diagnosed with middle and low rectal carcinoma who underwent La-TaTME from August 2015 to February 2017. No case was converted to laparotomy. In none of the enrolled cases, did the circumferential resection margin test positive by histopathology examination. Also, there was no detected residual tumor at the proximal and distal resection margins. The rate of postoperative morbidity was 15.8% (Clavien-Dindo grade 2). During the follow-up period, no local recurrence or metastasis was observed. La-TaTME is a safe alternative to standard laparoscopic TME in middle-low rectal carcinoma when operated by an experienced colorectal surgeon. However, large-scaled randomized multi-centered comparative trials are still needed to further test its oncological effectiveness.

Comments on "Clinical efficacy of the laparoscope-assisted transanal total mesorectal excision for middle-low rectal cancer"

Comments on "Clinical efficacy of the laparoscope-assisted transanal total mesorectal excision for middle-low rectal cancer"

Midterm functional results of taTME with neuromapping for low rectal cancer.

Information on functional outcomes after laparoscopic-assisted transanal total mesorectal excision (taTME) is limited. This study analyzed the functional results in patients with low rectal cancer. Ten consecutive patients (nine males) undergoing electrophysiologically controlled nerve-sparing taTME were investigated prospectively and asked to complete functional questionnaires [the International Prostate Symptom Score (IPSS), International Index of Erectile Function, Female Sexual Function Index, Wexner score, and low anterior resection syndrome (LARS) score]. Bladder function was also assessed according to residual urine volume. Preoperative function was compared to the functional outcome 3 and 6 months, and 9 months if eligible, after stoma closure or surgery in the absence of a diverting stoma. Prior to therapy, urinary and sexual function was impaired in 40 and 60% of patients, respectively. None of the patients developed pathological residual urine volumes after at least unilateral functional pelvic nerve-sparing. Median IPSS was lower than preoperative scores (p > 0.05). Two males with incomplete nerve preservation were considered impotent during a median follow-up of 15 months (range 6-20 months). The female was judged to be sexually inactive. The median Wexner score was 1 (range 0-7) prior to any therapy and increased to 7 (range 0-15) at 6 months (p = 0.029), with 40% of patients categorized as having no LARS and 50% minor LARS. The median LARS score was 28 (range 9-38) at 3 months and 26 (range 9-32) at 6 months (p = 0.165). Despite a small sample size and confounding factors, data indicate that taTME has the potential to preserve continence, sufficient bowel function, and urogenital function.