Transanal Endoscopic Surgery Research Articles

Safety analysis of natural orifice specimen extraction surgery for colorectal cancer.

SummaryThis study investigated the safety, feasibility, and clinical outcomes of natural orifice specimen extraction surgery (NOSES) by collecting clinical from patients who underwent complete laparoscopic radical resection for colorectal cancer versus those who underwent conventional laparoscopic radical resection for colorectal cancer. Patients with colorectal cancer were selected as the study sample and grouped according to the different surgical methods. A total of 182 patients were eligible for enrollment in the study, including 92 patients who underwent NOSES (NOSES group) and 90 patients who underwent conventional laparoscopic radical colorectal cancer surgery. In the NOSES group, a total of 14 cases were observed to have a postoperative abdominal infection, and the remaining 78 cases did not have an abdominal infection, which we refer to as the infected and uninfected groups in this paper for further analysis. There was no difference in surgical outcome between NOSES surgery and conventional laparoscopic surgery. Diabetes mellitus, prolonged drain retention, and prolonged operative time were risk factors for the development of abdominal infection in NOSES. In contrast, intraoperative use of specimen retrieval bags, use of transanal endoscopic operations, and intraoperative flushing of the abdominal cavity with dilute iodophenol were protective factors for the development of postoperative abdominal infections. NOSES for colorectal cancer is worth promoting because of its small trauma and quick postoperative recovery.

Transanal Endoscopic Operation Approach to Mesorectal Lesions: Local Excision of Lymph Node Metastasis of Neuroendocrine Tumor.

Transanal Endoscopic Operation Approach to Mesorectal Lesions: Local Excision of Lymph Node Metastasis of Neuroendocrine Tumor.

When is transanal endoscopic surgery appropriate?

Rectal cancer is a complex medical diagnosis which requires critical decision-making on the part of physician and patient. Organ preservation with local excision for early stage rectal cancer, if done under the correct circumstances, allows for oncologically sound surgery with good patient outcomes. However, locally advanced disease as well as tumor location and size can change potential long-term outcomes. This article will investigate the technical and clinical aspects of transanal surgery and the decision-making algorithms for clinicians and patients.

Transanal Endoscopic Surgery: Who Should Be Doing This Procedure?

Transanal endoscopic surgery (TES) was introduced in the 1980s, but more widely adopted in the late 2000s with innovations in instrumentation and training. Moreover, the global adoption of minimally invasive approaches to abdominal procedures has led to translatable skills for TES among colorectal and general surgeons. While there are similarities to laparoscopic surgery, TES has unique challenges related to the narrow confines of intraluminal surgery, angled instrumentation, and relatively uncommon indications limiting the opportunity to practice. The following review discusses the current evidence on TES learning curves, including potential limitations related to the broad adoption of TES by general surgeons. This article aims to provide general recommendations for the safe expansion of TES.

The Role of Transanal Endoscopic Surgery for Early Rectal Cancer.

Transanal endoscopic surgery (TES), which is performed through a variety of transanal endoluminal multitasking surgical platforms, was developed to facilitate endoscopic en bloc excision of rectal lesions as a minimally invasive alternative to radical proctectomy. Although the oncologic safety of TES in the treatment of malignant rectal tumors has been an area of vigorous controversy over the past two decades, TES is currently accepted as an oncologically safe approach for the treatment of carefully selected early and superficial rectal cancers. TES can also serve as both a diagnostic and potentially curative treatment of partially resected unsuspected malignant polyps. In this article, indications and contraindications for transanal endoscopic excision of early rectal cancer lesions are reviewed, as well as selection criteria for the most appropriate transanal excisional approach. Preoperative preparation and surgical technique for complications of TES will be reviewed, as well as recommended surveillance and management of upstaged tumors.

Initial clinical experience with a novel flexible endoscopic robot for transanal surgery

BackgroundThe Flex® Robotic System (Medrobotics, Raynham, MA, USA) is the first miniaturised flexible endoscopic robot that aims to allow surgical manoeuvres beyond the area currently reached by transanal endoscopic microsurgery. The aim of this study is to evaluate our initial clinical experience with this novel tool.MethodsWe prospectively collected all consecutive cases of local excisions of rectal lesions performed with the Flex® Robotic System performed at the Department of Surgical Sciences of the University of Turin between October 2018 and December 2019. Indications were benign, or early rectal lesions judged unsuitable for endoscopic removal, within 20 cm of the anal verge. Debriefing meetings after each procedure allowed technology assessment leading to the modification, development, and implementation of tools according to the clinical experience. We analysed the data in terms of the safety and efficacy of treatment.ResultsBetween October 2018 and February 2020, 26 patients were treated. We performed a full-thickness excision in 14 patients and a submucosal dissection in 12. The median operating time was 115 min (range 45–360 min). In six patients (23.1%), we converted to standard transanal endoscopic operation (TEO®) (Karl Storz, Tuttlingen, Germany) to complete the procedure. The 30-day morbidity rate was 11.5% (3/26). Positive resection margins were detected in 4 (15.4%) patients. At a minimum follow-up of 12 months, 2 (7.7%) local recurrences were observed.ConclusionsThis first clinical series demonstrates that the Flex® Robotic System is a fascinating technology that deserves further development to increase surgical dexterity, thereby overcoming current technical limitations and improving clinical outcomes.

TREATMENT OF EARLY GLOTTIC CARCINOMA WITH TRANSORAL ENDOSCOPIC LASER SURGERY.

Laryngeal carcinoma is one of the most common tumors of the head and neck, just after skin cancer. Alongside open surgery, transoral endoscopic laser surgery (TOLS) has become widespread as a treatment method. Our aim was to assess the efficacy of transoral laser cordectomy in a group of patients with early glottic carcinoma. We retrospectively analyzed data on 131 patients who underwent TOLS in the 2017-2021 period. We divided patients into groups according to tumor stage and type of cordectomy performed, and compared outcomes between the groups. Our results revealed a higher number of patients in the group with Tis and T1a than in those with T1b and T2 who underwent type III cordectomy, and also a higher number of those for whom outpatient follow-ups were sufficient after surgery in the same group. We did not observe significant difference in outcomes according to cordectomy type except for type V (a-d), where a higher number of patients had to undergo radiotherapy. This study underlines the importance of careful patient selection for TOLS, as well as the need for close cooperation with pathology and radiology specialists to ensure optimal approach and extent of surgery for each individual patient. It also displayed TOLS as a sound therapeutic option for early stages of glottic carcinoma but also indicated the need for similar studies in a larger number of patients to elucidate the effectiveness in certain glottis areas.

2021 Canadian Surgery Forum: Virtual, online Sept. 21-24, 2021.

# 01. Design and validation of a unique endoscopy simulator using a commercial video game {#article-title-2} Procedural simulation has been shown to enhance early endoscopy training. In this proof of concept study, we aimed to show that a first-person shooter (FPS) video game with a novel in-house

Trans-oral endoscopic endocrine surgery vestibular approach: Pioneering the technique in the Gulf Cooperation Council Countries – A case series

BackgroundWe present our experience with the first five thyroidectomies and parathyroidectomy in Kuwait performed via the transoral endoscopic vestibular approach. MethodsRetrospective data collection for all trans-oral endoscopic vestibular approach endocrine surgeries performed at a single institution in Kuwait between November 2019 and February 2021. Information on patient demographics, perioperative management and complications were collected and reviewed. OutcomesAll 5 cases were completed successfully; the intended specimen was extracted successfully via the trans-oral endoscopic vestibular approach and conversion to traditional trans-cervical approach (TCA) was not required. Operative time for the parathyroidectomy case was 225 min and the average operative time for the remaining 4 cases, thyroidectomies, was 151 min. Blood loss was minimal, and length of hospital stay was between 24 and 48 h. One patient had a transient mental nerve injury, and one patient experienced a postoperative seroma which required aspiration. One case required completion thyroidectomy as histopathology revealed papillary thyroid carcinoma. ConclusionTransoral vestibular approach is a scar free and safe approach to thyroidectomies and parathyroidectomies. Careful patient selection and counselling with regards to risk versus benefit is required. It is an excellent alternative to the traditional transcervical approach and offers great cosmetic results.

TaTME (transanal total mesorectal excision) - state of the art.

Transanal total mesorectal excision (TaTME) is a modern hybrid method, which has emerged by conjunction of two minimally invasive techniques - laparoscopy and transanal minimally invasive surgery. The main aim of the method is to offer a better operative approach into the narrow pelvis and thus to support an oncosurgically radical TME. Mesorectal excision is performed transanally via a flexible single port platform. Safe implementation of the technique requires advanced skills in minimally invasive surgery, transanal endoscopic surgery as well as experience with surgical dissection from different points of view. Controversial results regarding TaTME in the available literature suggest that oncosurgical radicality of the method has to be examined by prospective clinical studies. Currently, two randomised studies (COLOR III and ETAP-GRECCAR 11) are ongoing which might soon clarify a proper position of TaTME in clinical practice.

SP1.1.15Long-term Outcomes of Open Verses Closed Rectal Defect After Transanal Endoscopic Microscopic Surgery

Abstract Aims Management of rectal defect after TEMS is a matter of debate. Data are lacking on the effect of these techniques on long term outcomes and continence of patients. We sought to analyse these in our patient cohort. Methods Patients who underwent TEMS between 2012 and 2019 were examined retrospectively from a prospectively maintained database. These were divided into two groups – open and closed rectal defect. Patient demographics were recorded and outcomes assessed including oncological staging, morbidity, mortality, length of stay and FISI scores. Results 170 matched patients were included, with 70 patients in the open and 100 in the closed rectal defect group. Short-term complications were 18.8% with no significant difference between the two groups. Most of the defects were well healed upon endoscopic follow-up; more unhealed/sinus formation was noticed in the open group (p = 0.01); more strictures were encountered in the closed group (p = 0.04). Overall, there was a significant difference in pre and post TEMS FISI scores in all three groups (p < 0.00001, p < 0.00001, p = 0.02). Comparing the open and closed defect groups, there was no difference in the functional outcome of patients in those who developed sinus or stricture but a significant difference in those with healed scar, with those in closed rectal defect group with worsening function (p = 0.02) Conclusion Both the approaches of rectal defect management are associated with pros and cons. Long term complications should be expected and actively followed up for. Patients should be thoroughly counselled about these and possible deterioration in continence post-TEMS

The impact of socioeconomic and geographic factors on access to transoral robotic/endoscopic surgery for early stage oropharyngeal malignancy

ObjectiveTo evaluate the role of social and geographic factors on the likelihood of receiving transoral robotic surgery (TORS) or non-robotic transoral endoscopic surgery treatment in early stage oropharyngeal squamous cell carcinoma (OPSCC). Materials and methodsThe National Cancer Database was queried to form a cohort of patients with T1-T2 N0-N1 M0 OPSCC (AJCC v.7) who underwent treatment from 2010 to 2016. Demographics, tumor characteristics, treatment type, social, and geographic factors were all collected. Univariate analysis and multivariate logistic regression were then performed. ResultsAmong 9267 identified patients, 1774 (19.1%) received transoral robotic surgery (TORS), 1191 (12.9%) received transoral endoscopic surgery, and 6302 (68%) received radiation therapy. We found that lower cancer stage, lower comorbidity burden and HPV- positive status predicted a statistically significant increased likelihood of receiving surgery. Patients who reside in suburban or small urban areas (>1 million population), were low-to- middle income, or rely on Medicaid were less likely to receive surgery. Patients that reside in Medicaid-expansion states were more likely to receive TORS (p > .0001). Patients that reside in states that expanded Medicaid January 2014 and after were more likely to receive non-robotic transoral endoscopic surgery (p > .0001). ConclusionsPoorer baseline health, lower socioeconomic status and residence in small urban areas may act as barriers to accessing minimally invasive transoral surgery while residence in a Medicaid-expansion state may improve access. Barriers to accessing robotic surgery may be greater than accessing non-robotic surgery.

Research progress and future development prospect of transanal total mesorectal excision

Transanal total mesorectal excision (taTME) is one of the hotspots in colorectal surgery in recent years. Although most studies confirm that taTME is safe and feasible, some studies still showed that the morbidity of complication and local recurrence rate of taTME were higher than traditional laparoscopic surgery. This article reviews and analyzes the short-term and long-term outcomes of taTME and the related progress of postoperative function. The results showed that there were no significant differences in the main short-term and long-term efficacy between taTME and traditional laparoscopic TME, but taTME had potential advantages in postoperative functional recovery. The results of case study after passing the learning curve suggested that taTME had better short-term and long-term efficacy. Moreover, with the maturity of taTME technology, transanal endoscopic surgery has gradually shown its advantages in the treatment of complex pelvic diseases. In the future, the application of single-port robot will further promote the development of natural orifice transluminal endoscopic colorectal surgery.

Long-term outcomes of open versus closed rectal defect after transanal endoscopic microscopic surgery.

Management of the rectal defect after transanal endoscopic microsurgery (TEM) is a matter of debate. Data are lacking on long term outcomes and continence of patients with open or closed rectal defect. We sought to analyse these in a retrospective cohort study. Patients undergoing TEM via the Specialist Early Rectal Cancer (SERC) MDT between 2012 and 2019 were included from a prospectively maintained database. These were divided into two groups - open and closed, based on management of rectal defect. Patient demographics and outcomes, including pre- and postoperative oncological staging, morbidity, mortality, length of stay and faecal incontinence severity score (FISI) scores were assessed. A total of 170 matched patients were included (70-open, 100-closed rectal defects). Short-term complications (bleeding, infection, urinary retention and infection, length of stay and pain) were 18.8% with no significant difference between the two groups (22% vs. 16%). Most of the defects were well healed upon endoscopic follow-up; more unhealed/sinus formation was noticed in the open group (p=0.01); more strictures were encountered in the closed group (p=0.04). Comparing the open and closed defect groups, there was no difference in the functional outcome of patients in those who developed sinus (p=0.87) or stricture (p=0.79) but a significant difference in post-TEMS FISI scores in those with healed scar, with those in closed rectal defect group with worsening function (p=0.02). There are pros and cons associated with both rectal defect management approaches. Long-term complications should be expected and actively followed up. Patients should be thoroughly counselled about these and possible deterioration in continence post-TEM.

Management of early rectal cancer; current surgical options and future direction.

Rectal cancer is the second commonest cause of cancer death within the United Kingdom. Utilization of national screening programmes have resulted in a greater proportion of patients presenting with early-stage disease. The technique of transanal endoscopic microsurgery was first described in 1984 following which further options for local excision have emerged with transanal endoscopic operation and, more recently, transanal minimally invasive surgery. Owing to the risks of local recurrence, the current role of minimally invasive techniques for local excision in the management of rectal cancer is limited to the treatment of pre-invasive disease and low risk early-stage rectal cancer (T1N0M0 disease). The roles of chemotherapy and radiotherapy for the management of early rectal cancer are yet to be fully established. However, results of high-quality research such as the GRECCAR II, TESAR and STAR-TREC randomised control trials may highlight a wider role for local excision surgery in the future, when used in combination with oncological therapies. The aim of our review is to provide an overview in the current management of early rectal cancer, the surgical options available for local excision and the future multimodal direction of early rectal cancer treatment.

ТРАНСОРАЛЬНАЯ ТИРЕОИД- И ПАРАТИРЕОИДЭКТОМИЯ: СЕРИЯ НАБЛЮДЕНИЙ

Objective. To present the results of the author’s own series of transoral operations in patients with pathology of the thyroid and parathyroid glands. Methods. Transoral surgery was performed in women (n=20) and (n=1) man. All patients were operated on for the primary disease and met the selection criteria based on ultrasound and cytological examinations, hormonal levels, and somatic status. Indications for surgery were: nodular goiter in 17 cases, diffuse toxic goiter - in 2 cases, parathyroid adenoma - in 2 cases. The surgical technique included a three-port approach in the lower fornix of the vestibule of the mouth and a gas technique for maintaining the working cavity. Standard laparoscopic instruments and an energy based ultrasonic device were used for the operation. In the postoperative period, patients underwent a test for subjective assessment of the aesthetic result of the operation using the survey of thedermatology life quality index. Results. Thyroidectomy was performed in 4 patients, hemithyroidectomy - in 15 patients and parathyroidectomy - in 2 patients. In one patient, transoralparathyroidectomy was performed as a part of a simultaneous operation for multiple endocrine neoplasia type 1 syndrome. Papillary cancer T1N0M0 was verified in two patients after surgery. The mean operation time was 196.1 min (range 110 - 300 min). Average blood loss - 3 9.5 ml (range 10 - 300 ml). The nineth operation required the conversion due to severebleeding. In one case, the temporary recurrent laryngeal nerve(RLN)injury was reported, in one case - hematoma. After surgery, the median and average values of thedermatology life quality index were 1 (IQR 0-4) and 2.05, respectively, which indicates an insignificant effect on the quality of life. Conclusion. Transoral endoscopic surgery on the thyroid and parathyroid glands would be thepromising optimal choice in patients to avoid scarring on the neck.

Perirectal fascial anatomy and pelvic autonomic nerve preservation during the transanal total mesorectal excision

The difficulty of transanal total mesorectal excision (TME) is to find the correct dissection plane of perirectal space. As a complex new surgical procedure, the fascial anatomic landmarks of transanal approach operation are more likely to be ignored. It is often found that dissection plane is false after the secondary injury occurs during the operation, which results in the damage of pelvic autonomic nerves. Meanwhile, the mesorectum is easily damaged if the dissection plane is too close to the rectum. Thus, the safety of oncologic outcomes could be limited by difficulty achieving adequate TME quality. The promotion and development of the theory of perirectal fascial anatomy provides a new thought for researchers to design a precise approach for transanal endoscopic surgery. Transanal total mesorectal excision based on fascial anatomy offers a solution to identify the transanal anatomic landmarks precisely and achieves pelvic autonomic nerve preservation. In this paper, the authors focus on the surgical experience of transanal total mesorectal excision based on the theory of perirectal fascial anatomy, and discuss the feature of perirectal fascial anatomy dissection and technique of pelvic autonomic nerve preservation during transanal approach operation.

Preoperative Diagnostic Uncertainty in T2-T3 Rectal Adenomas and T1-T2 Adenocarcinomas and a Therapeutic Dilemma: Transanal Endoscopic Surgery, or Total Mesorectal Excision?

Simple SummaryEndorectal ultrasound and rectal magnetic resonance are sometimes unable to differentiate between stages T2 and T3 in rectal adenomas that are possible adenocarcinomas, and between stages T1 and T2 in rectal adenocarcinomas. These cases of diagnostic uncertainty raise a therapeutic dilemma: should they be treated with transanal endoscopic surgery (TES) or total mesorectal excision (TME)? We present an observational study of a cohort of 803 patients who underwent TES between 2004 and 2021. Five hundred and twenty-nine patients operated on for adenoma (group I) and 109 for low-grade adenocarcinoma (group II) were included. Diagnosis was uncertain in 113/529 patients (21.4%) in group I, and in 8/109 (7.3%) in group II. The definitive pathology diagnosis showed 17 cases in group I (15%) to be adenocarcinomas greater than T1, and two cases in group II. On the strength of these data, in cases of diagnostic uncertainty we recommend TES as the initial indication.Background: Endorectal ultrasound and rectal magnetic resonance are sometimes unable to differentiate between stages T2 and T3 in rectal adenomas that are possible adenocarcinomas, or between stages T1 and T2 in rectal adenocarcinomas. These cases of diagnostic uncertainty raise a therapeutic dilemma: transanal endoscopic surgery (TES) or total mesorectal excision (TME)? Methods: An observational study of a cohort of 803 patients who underwent TES from 2004 to 2021. Patients operated on for adenoma (group I) and low-grade T1 adenocarcinoma (group II) were included. The variables related to uncertain diagnosis, and to the definitive pathological diagnosis of adenocarcinoma stage higher than T1, were analyzed. Results: A total of 638 patients were included. Group I comprised 529 patients, 113 (21.4%) with uncertain diagnosis. Seventeen (15%) eventually had a pathological diagnosis of adenocarcinoma higher than T1. However, the variable diagnostic uncertainty was a risk factor for adenocarcinoma above T1 (OR 2.3, 95% CI 1.1–4.7). Group II included 109 patients, eight with uncertain diagnosis (7.3%). Two patients presented a definitive pathological diagnosis of adenocarcinoma above T1. Conclusions: On the strength of these data, we recommend TES as the initial indication in cases of diagnostic uncertainty. Multicenter studies with larger samples for both groups should now be performed to further assess this strategy of initiating treatment with TES.

Transoral endoscopic coblation tongue base surgery in obstructive sleep apnea; Resection versus Ablation

Obstructive sleep apnea (OSA) is a common serious social health problem that affects 2% to 4% of the adult population. The gold standard for diagnosis is polysomnography (PSG). Continuous positive airway pressure (CPAP) remains the mainstay treatment despite low patient compliance. Surgical treatment is an important alternative option. Sleep endoscopy reveals that enlarged tongue base is an obstructive condition in many OSA cases. Multiple surgical measures aimed at reduction of tongue base hypertrophy. Recently, coblation is a relatively available and affordable technology for handling this disease category. In this study, the coblation technology was used at the level of tongue base, and resection was compared versus ablation.AIM OF THE WORKThe aim of the current study was to assess efficacy of transoral endoscopic coblation tongue base surgery in OSA patients and to compare resection versus ablation of tongue base hypertrophy.PATIENTSThe study included fifty patients with moderate to severe OSA, presented to the outpatient clinic at Otorhinolaryngology Department, Alexandria Main University Hospital, Alexandria, Egypt.

How to Learn a Complex Endoscopic Procedure: Knots in Transanal Endoscopic Surgery: Different Skill Among Surgeons.

The intrarectal suture is considered a high technically complex procedure. The study's objectives were to assess the feasibility of making an intrarectal knot, through an in vitro study and assessing whether the video tutorial facilitates learning. A detailed description of the technique. A comparative observational cross-sectional study in surgeons with no previous experience in intrarectal knots. Twenty-one of these 32 participants passed the intrarectal knot test without video tutorial (T1) (65.6%), and 26 (81.2%) after the video tutorial (T2) (P=0.26). The mean time taken to tie the knot fell from 74 seconds (SD=46) in T1 to 41 seconds (SD=41) in T2 (P<0.001). At T1, 26 participants (81.3%) described the technique as difficult, but only 7 (21.9%) at T2 (P<0.001). Performing the intrarectal knot suture is feasible. Despite the technical difficulty, the video tutorial is sufficient for surgeons to learn the technique.