Local Excision Of Rectal Tumors Research Articles

Does transanal endoscopic microsurgery affect rectal function?

Transanal endoscopic microsurgery (TEM) is the most standardized method for the local excision of rectal neoplasms. Unfortunately, local excisions of rectal lesions by means of TEM are not completely free from undesirable functional sequela. This study was performed to evaluate the risk factors of major loss of function after TEM. Eighty-nine patients underwent TEM between 2019 and 2020. Anorectal manometry was performed before the surgery and 3, 6, and 12 months after the surgery. The quality of life (QoL) was assessed using the Fecal Incontinence Quality of Life scale. The major decrease in QoL was observed in women in 3 months after the surgery in terms of lifestyle and frustration domains (3.6 and 3.64 points, respectively). In 3 months after the surgery, there was a significant decrease in resting pressure both in male and female patients (P=0.01). This difference remained significant 6 months after the surgery (P=0.01). In 12 months after the surgery, resting pressure returned to the preoperative level in most patients (P=0.50). A significant decrease in manometric parameters appeared when the surgery time is more than 55 minutes (P=0.05), the tumor localization is lower than 3 cm from the anus (P=0.03), and the tumor size is over 3 cm (P=0.001). The most significant risk factors for the development of functional disorders after TEM are surgery time of >55 minutes, tumor localization at <3 cm from the anal verge, and tumor size of >3 cm.

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 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.

Nuances on assessment of transanal minimally invasive surgery learning curve for local excision of rectal neoplasms

We read with great interest the recent article “Establishing the learning curve of transanal minimally invasive surgery for local excision of rectal neoplasms. Surgical Endoscopy February 2017.” by Lee and co-workers (1). We congratulate the authors on their excellent work in defining the learning curve for transanal minimally invasive surgery (TAMIS) and being the first to publish it. In addition, we feel that using TAMIS for the local excision of early rectal cancer is a technique that needs more emphasis especially since the introduction of national screening programs has led to the increase detection of stage I rectal cancer (2).

Is a learning curve needed for transanal minimally invasive surgery for rectal lesions

The article “Establishing the learning curve of transanal minimally invasive surgery for local excision of rectal neoplasms,” which was published in Surgical Endoscopy on March 2018, investigated the learning curve for transanal minimally invasive surgery (TAMIS) in the treatment of rectal neoplasms, by using group-specific cumulative sum (CUSUM) analysis and moving average plots. The authors analyzed 254 TAMIS procedures, and their main proficiency outcome was the rate of margin positivity.

Nuances on assessment of transanal minimally invasive surgery learning curve for local excision of rectal neoplasms

We read with great interest the recent article “Establishing the learning curve of transanal minimally invasive surgery for local excision of rectal neoplasms. Surgical Endoscopy February 2017.” by Lee and co-workers (1). We congratulate the authors on their excellent work in defining the learning curve for transanal minimally invasive surgery (TAMIS) and being the first to publish it. In addition, we feel that using TAMIS for the local excision of early rectal cancer is a technique that needs more emphasis especially since the introduction of national screening programs has led to the increase detection of stage I rectal cancer (2).

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...

Outcomes of Closed Versus Open Defects After Local Excision of Rectal Neoplasms: A Multi-institutional Matched Analysis

The management of the rectal wall defect after local excision of rectal neoplasms remains controversial, and the existing data are equivocal. This study aimed to determine the effect of open versus closed defects on postoperative outcomes after local excision of rectal neoplasms. Data from 3 institutions were analyzed. Propensity score matching was performed in one-to-one fashion to create a balanced cohort comparing open and closed defects. This study was conducted at high-volume specialist referral hospitals. Adult patients undergoing local excision via transanal endoscopic surgery from 2004 to 2016 were included. Patients were assigned to open- and closed-defect groups, and further stratified by full- or partial-thickness excision. Closure of the rectal wall defect was performed at the surgeon's discretion. The primary outcome measured was the incidence of 30-day complications. A total of 991 patients were eligible (593 full-thickness excision with 114 open and 479 closed, and 398 partial-thickness excision with 263 open and 135 closed). After matching, balanced cohorts consisting of 220 patients with full-thickness excision and 210 patients with partial-thickness excision were created. Operative time was similar for open and closed defects for both full-and partial-thickness excision. The incidence of 30-day complications was similar for open and closed defects after full- (15% vs. 12%, p = 0.432) and partial-thickness excision (7% vs 5%, p = 0.552). The total number of complications was also similar after full- or partial-thickness excision. Patients undergoing full-thickness excision with open defects had a higher incidence of clinically significant bleeding complications (9% vs 3%, p = 0.045). Data were obtained from 3 institutions with different equipment and perioperative management over a long time period. There was no difference in overall complications between open and closed defects for patients undergoing local excision of rectal neoplasms, but there may be more bleeding complications in open defects after full-thickness excision. A selective approach to defect closure may be appropriate. See Video Abstract at http://links.lww.com/DCR/A470.

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.

Establishing the learning curve of transanal minimally invasive surgery for local excision of rectal neoplasms.

Transanal minimally invasive surgery (TAMIS) is an endoscopic operating platform for local excision of rectal neoplasms. However, it may be technically demanding, and its learning curve has yet to be adequately defined. The objective of this study was to determine the number of TAMIS procedures for the local excision of rectal neoplasm required to reach proficiency. All TAMIS cases performed from 07/2009 to 12/2016 at a single high-volume tertiary care institution for local excision of benign and malignant rectal neoplasia were identified from a prospective database. A cumulative summation (CUSUM) analysis was performed to determine the number of cases required to reach proficiency. The main proficiency outcome was rate of margin positivity (R1 resection). The acceptable and unacceptable R1 rates were defined as the R1 rate of transanal endoscopic microsurgery (TEM-10%) and traditional transanal excision (TAE-26%), which was obtained from previously published meta-analyses. Comparisons of patient, tumor, and operative characteristics before and after TAMIS proficiency were performed. A total of 254 TAMIS procedures were included in this study. The overall R1 resection rate was 7%. The indication for TAMIS was malignancy in 57%. CUSUM analysis reported that TAMIS reached an acceptable R1 rate between 14 and 24 cases. Moving average plots also showed that the mean operative times stabilized by proficiency gain. The mean lesion size was larger after proficiency gain (3.0cm (SD 1.5) vs. 2.3cm (SD 1.3), p=0.008). All other patient, tumor, and operative characteristics were similar before and after proficiency gain. TAMIS for local excision of rectal neoplasms is a complex procedure that requires a minimum of 14-24 cases to reach an acceptable R1 resection rate and lower operative duration.

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.

A training programme for operating theatre personnel in transanal endoscopic operation procedures for local excision of rectal tumours.

The transanal endoscopic operation (TEO) is a minimal access surgical procedure for the removal of benign and early malignant rectal tumours (Nieuwenhuis et al 2009). This surgery involves specialist equipment, set up and positioning by the perioperative team. We report on and evaluate the first ever TEO course designed specifically for theatre practitioners.

A systematic review of transanal minimally invasive surgery (TAMIS) from 2010 to 2013.

Transanal minimally invasive surgery (TAMIS) was introduced as an alternative to transanal endoscopic microsurgery in 2010. Over the past 4years, considerable international experience has been gained with this approach. Most published reports focus on TAMIS for local excision of rectal neoplasia, but there are other important applications such as transanal mesorectal excision for rectal cancer. This comprehensive review details the progress with TAMIS since its inception. Robotic transanal surgery is a natural evolution of TAMIS still in its early infancy, which is also reviewed. A comprehensive search of PubMed, EMBASE, the Cochrane Library, and Web of Knowledge was performed. Since the inception of TAMIS in 2009, 33 retrospective studies and case reports, and 3 abstracts have been published on TAMIS for local excision of rectal neoplasms, which represents a combined n=390 TAMIS procedures performed worldwide using eight different types of TAMIS platforms. A total of 152 lesions were excised for benign disease including adenomas and high-grade dysplasias (39%), 209 for malignancy for carcinomas in situ and adenocarcinomas (53.5%). Twenty-nine (7.5%) of TAMIS resections were for other pathology, of which the majority (23/29) were neuroendocrine lesions. The remaining resections were for mucocele, gastrointestinal stromal tumor, melanoma, and fibrosis. Robotic-TAMIS has also been reported, however, data are extremely limited as there are only 7 case reports (combined n=11) in the published literature. Success with Robotic-TAMIS has been demonstrated with various patient positions and by use of a special glove port. Transanal total mesorectal excision using the TAMIS platform has also been demonstrated is several small series, and the feasibility of performing pure transanal total mesorectal excision has also been reported. Combined, n=78 cases of transanal total mesorectal excision have been performed using TAMIS. The advantages of TAMIS-assisted transanal total mesorectal excision are discussed.

Robotic transanal surgery for local excision of rectal neoplasms.

Robotic transanal surgery (RTS) has been a natural evolution of transanal minimally invasive surgery. This video demonstrates how RTS is performed for the full-thickness excision of a malignant rectal polyp, with endoluminal robotic suturing of the rectal wall defect. The general approach to RTS, including the approach to docking of the robotic cart, are also illustrated in video format.

Robotic transanal minimally invasive surgery for local excision of rectal neoplasms

Robotic transanal minimally invasive surgery (TAMIS) may be an option for rectum-preserving excision of neoplasms. Recent cadaveric studies showed improved vision, control and manoeuvrability compared with use of laparoscopic instruments. This study reports the clinical application. Consecutive patients eligible for transanal endoscopic microsurgery (TEM) or TAMIS in three participating centres were operated on using a robotic platform and transanal glove port. Patient demographics, lesion characteristics, perioperative data, complications and follow-up of all patients were recorded prospectively. Sixteen patients underwent robotic TAMIS for rectal lesions with a median (range) distance from the anal verge of 8 (range 3-10) cm. The median size of the resected specimen was 5·3 (0·5-21) cm(2) . The median docking time and duration of operation were 36 (18-75) and 108 (40-180) min respectively. One conversion to regular (non-robotic) TAMIS was needed owing to difficulties accessing the rectum. Glove puncture necessitated replacement in four procedures, an unstable pneumorectum arose during one operation and one patient developed a pneumoperitoneum. One patient required catheterization for urinary retention. The median hospital stay was 1·3 (0-4) days. The additional cost of the robotic approach was approximately €1000 per procedure (excluding the capital expenditure on the robotic system and its maintenance). Robotic TAMIS is feasible in patients with rectal lesions. Potential advantages over TEM and non-robotic TAMIS will need to be balanced against the cost of the robotic system.

Robotic transanal minimally invasive surgery for local excision of rectal neoplasms (Br J Surg 2014; 101: 578–581)

Robotic transanal minimally invasive surgery for local excision of rectal neoplasms (<i>Br J Surg</i> 2014; 101: 578–581)