Transanal Mesorectal Excision Research Articles

Robot-assisted resection of exposed colon with TaTME after heavy ion radiotherapy for locally recurrent rectal cancer

Abstract Introduction Heavy ion radiotherapy has shown promising results in treating pelvic recurrence of rectal cancer. We report a case where a patient underwent robot-assisted low anterior resection with transanal mesorectal excision (TaTME) following heavy ion radiotherapy, owing to challenges associated with spacer placement. Case presentation A 54-year-old man was diagnosed with upper rectal cancer. He underwent robot-assisted low anterior resection. Eight courses of CapeOX were administered as postoperative adjuvant chemotherapy. Immediately after completion of adjuvant chemotherapy (8 months postoperatively), computer tomography (CT) scan revealed a 30-mm large nodule on the dorsal surface of the oral anastomotic intestine, which was detected by PET-CT. Given that the tumor had an indistinct border with the sacrum and its superior margin extended to the second sacrum, it was concluded that a combined sacral resection was not advisable, and heavy ion radiotherapy was indicated. Robot-assisted low anterior resection combined with TaTME was performed approximately 2 months after heavy particle radiotherapy (73.6 Gy (RBE)/16 sessions). CT scan conducted 3 months after irradiation revealed substantial shrinkage of the recurrent tumor. Conclusions Robot-assisted resection of exposed colon with TaTME after heavy ion radiotherapy is regarded as an effective strategy for treating locally recurrent rectal cancer.

Long-term outcomes of transanal total mesorectal excision for rectal cancer: what could we do to improve them?

Long-term outcomes of transanal mesorectal excision are still controversial. The aim of this study was to analyze long-term oncological and functional results of TaTME. Fifty patients with mid-low rectal cancer were included: 20 underwent TaTME and 30 laparoscopic total mesorectal excision. Clinical characteristics of patients and tumors and quality indicators for rectal surgery were described. Long-term functional outcomes were compared in two groups (TaTME vs. laTME). Local recurrence rate was calculated. Kaplan-Meier curves were performed for disease-free and overall survival and log-rank test was used to compare two groups. There were not significant differences between two groups in sex, age ASA Score, neoadjuvant therapy, tumor stage and quality indicators of rectal surgery. After a median follow-up of 46 (41-51) months functional outcomes were significantly worse in TaTME group in terms of rates of maior low anterior resection syndrome score (10% vs. 0%, P=0.009), faucal incontinence (15% vs. 3%, P=0.017), urinary disfunction (10% vs. 0%, P=0.009) and sexual disfunction (15% vs. 13%, P=0.047). Only one patient presented local recurrence (TaTME group, ypT3N0). Overall survival at 1 and 3 years were 92.6% and 90% respectively and disease-free survival at 1 and 3 years were 96% and 90% respectively. There were not significant differences in overall survival and disease-free survival between two groups. Overall survival and disease-free survival after TaTME for rectal cancer were similar to laparoscopic total mesorectal excision. However functional outcomes were worse after TaTME.

Robotic Transanal Total Mesorectal Excision (RTaTME): State of the Art.

Total mesorectal excision (TME) is the gold standard technique for the surgical management of rectal cancer. The transanal approach to the mesorectum was introduced to overcome the technical difficulties related to the distal rectal dissection. Since its inception, interest in transanal mesorectal excision has grown exponentially and it appears that the benefits are maximal in patients with mid-low rectal cancer where anatomical and pathological features represent the greatest challenges. Current evidence demonstrates that this approach is safe and feasible, with oncological and functional outcome comparable to conventional approaches, but with specific complications related to the technique. Robotics might potentially simplify the technical steps of distal rectal dissection, with a shorter learning curve compared to the laparoscopic transanal approach, but with higher costs. The objective of this review is to critically analyze the available literature concerning robotic transanal TME in order to define its role in the management of rectal cancer and to depict future perspectives in this field of research.

Transanal mesorectal excision: early outcomes in Australia and New Zealand.

Transanal total mesorectal excision (taTME) aims to overcome some of the technical challenges faced when operating on mid and low rectal cancers. Specimen quality has been confirmed previously, but recent concerns have been raised about oncological safety. This multicentre prospective study aimed to evaluate the safety of taTME among early adopters in Australia and New Zealand. Data from all consecutive patients who had taTME for rectal cancer from July 2014 to February 2020 at six tertiary referral centres in Australasia were recorded and analysed. A total of 308 patients of median age of 64 years underwent taTME. Some 75.6 per cent of patients were men, and the median BMI was 26.8 kg/m2. The median distance of tumour from anal verge was 7 cm. Neoadjuvant chemoradiotherapy was administered to 57.8 per cent of patients. The anastomotic leak rate was 8.1 per cent and there was no mortality within 30 days of surgery. Pathological examination found a complete mesorectum in 295 patients (95.8 per cent), a near-complete mesorectum in seven patients (2.3 per cent), and an incomplete mesorectum in six patients (1.9 per cent). The circumferential resection margin and distal resection margin was involved in nine patients (2.9 per cent), and two patients (0.6 per cent) respectively. Over a median follow-up of 22 months, the local recurrence rate was 1.9 per cent and median time to local recurrence was 30.5 months. This study showed that, with appropriate training and supervision, skilled minimally invasive rectal cancer surgeons can perform taTME with similar pathological and oncological results to open and laparoscopic surgery.

Initial Experience with the Safe Implementation of Transanal Total Mesorectal Excision (TaTME) as a Standardized Procedure for Low Rectal Cancer

Introduction: The laparoscopic approach for TME is proven to be non-inferior in oncological outcome compared to open surgery. Anatomical limitations in the male and obese pelvis with resulting pathological shortcomings and high conversion rates were stimuli for alternative approaches. The transanal approach for TME (TaTME) was introduced to overcome these limitations. The aim of this study was to evaluate the outcomes of TaTME for mid and low rectal cancer at our center. Methods: TaTME is a hybrid procedure of simultaneously laparoscopic and transanal mesorectal excision. A retrospective analysis of all consecutive TaTME procedures performed at our center for mid and low rectal cancer between December 2014 and January 2020 was conducted. Results: A total of 157 patients underwent TaTME, with 72.6% receiving neoadjuvant chemoradiation. Mean tumor height was 6.1 ± 2.3 cm from the anal verge, 72.6% of patients had undergone neoadjuvant chemoradiotherapy, and 34.2% of patients presented with a threatened CRM upon pretherapeutic MRI. Abdominal conversion rate was 5.7% with no conversion for the transanal dissection. Early anastomotic leakage occurred in 7.0% of the patients. Mesorectum specimen was complete in 87.3%, R1 resection rate was 4.5% (involved distal resection margin) and in 7.6%, the CRM was positive. The three-year local recurrence rate of 58 patients with a follow-up ≥ 36 months was 3.4%. Overall survival was 92.0% after 12 months, and 82.2% after 36 months. Conclusion: TaTME can be performed safely with acceptable long-term oncological outcome. Low rectal cancer can be well addressed by TaTME, which is an appropriate alternative with low conversion, local recurrence, adequate mesorectal quality and CRM positivity rates.

Development and validation of a transanal endoscopic rectal purse string simulator.

Rectal purse string placement for transanal mesorectal excision is challenging, and practice is difficult. The objective of this study is to build an endoscopic rectal purse string simulator and provide evidence for the validity of its use. A low-cost transanal endoscopic rectal purse string simulator was created and used to measure the performance of participants. Participants included general surgery residents, fellows, and staff surgeons from several Canadian university-affiliated institutions across Canada. The performance of the rectal purse string placement was measured by the time to completion of the task as well scoring with a modified objective structured assessment of technical skills (OSATS) score and a modified advanced laparoscopic suturing (ALS) score. Thirty-nine participants were recruited into the study. Participants were split into three groups, based on prior experience with laparoscopic suturing, for the analysis of suturing a rectal purse string on the simulator based on three performance measures. There was a significant difference found in all three measures of performance in the three groups (time to completion p = 0.014, mean blinded OSATS score p = 0.007, mean blinded ALS score p = 0.020). Participants with previous laparoscopic suturing had significantly faster times to completion and higher skills scores when compared to residents (time: 5.1 ± 1.4min vs 9.0 ± 4.8min, p = 0.005; OSATS: 19.7 ± 2.8 vs 13.0 ± 5.8, p = 0.00398, ALS: 27.4 ± 4.0 vs 18.9 ± 8.5, p = 0.0151). A transanal endoscopic purse string simulator was constructed and preliminary testing has shown variable performance based on prior laparoscopic suturing experience.

LAPAROSCOPIC, OPEN AND TRANSANAL MESORECTAL EXCISION IN RECTAL CANCER SURGERY

INTRODUCTION: there are no studies comparing laparoscopic, open, and transanal mesorectal excision for rectal cancer.AIM: to compare quality of total mesorectal excision (TME) according to the P. Quirke protocol, to assess circular resection margins (CRM), to assess distal resection margins (DRM) and perioperative morbidity.PATIENTS AND METHODS: prospective study was performed to compare the effectiveness of different methods of TME.RESULTS: eighty-eight patients were included in the study, 29 – in the laparoscopic (LA TME) group, 29 – in the open TME group, 30 – in the transanal (TA TME) group. The groups were comparable in clinical, demographic and tumor parameters. There was no significant difference between LA TME, open TME and TA TME in quality of mesorectal excision (p=0.67). There was also no significant difference in rates of positive CRM and positive DRM (p=0.38). No significant difference was obtained between intraoperative and postoperative complications rates (p=0.38; p=0.45). CONCLUSION: all three methods of TME showed the same results for quality, circular and distal resection margins and perioperative morbidity.

Tansanal total mesorectal excision (TaTME): systematization and mediated results in 10 patients

BackgroundTransanal total mesorectal excision is a surgical technique for minimally invasive resection of the rectum and perirectal tissues. It is indicated for patients with medial and distal rectum cancer confined to the mesorectal envelope. This study describes a series of patients undergoing transanal total mesorectal excision. MethodsTen patients were selected to undergo transanal total mesorectal excision using the SILS-Port® platform. All patients included here had middle or low rectal cancer. Abdominal access for proximal colon mobilization was performed by laparoscopy in all cases. As a rule, in 9 of the 10 cases, the surgical specimen was removed transanally. ResultsDuring a 41-month period, 10 patients underwent transanal total mesorectal excision based on curative intent. The first indication for transanal total mesorectum excision was medial and distal rectal cancer, locally invasive and confined to the mesortal envelope. The median age of patients with rectal cancer at the time of surgery was 61 years (mean 59.4 years, range 22–78 years), with 80% (8) female and 20% (2) male. The median surgical time was 305′ (mean 314′, range 260‒420′). The median postoperative length of stay was five days (average of 7.3 days, interval of 3–23 days). There was no postoperative mortality. Surgical complications included postoperative ileus (n = 1), bladder paresis (n = 1), and ileostomy stenosis (n = 1). All patients had negative surgical margins for neoplasia and more than 12 resected lymph nodes. The tumors were between 1 and 9 cm from the anal margin. ConclusionTotal transanal mesorectal excision has been shown to be a viable method for oncologic resection of locally advanced rectal cancer with curative intent.

Carbon Dioxide Embolism Associated With Total Mesorectal Excision Surgery: A Report From the International Registries

Carbon dioxide embolus has been reported as a rare but clinically important risk associated with transanal total mesorectal excision surgery. To date, there exists limited data describing the incidence, risk factors, and management of carbon dioxide embolus in transanal total mesorectal excision. This study aimed to obtain data from the transanal total mesorectal excision registries to identify trends and potential risk factors for carbon dioxide embolus specific to this surgical technique. Contributors to both the LOREC and OSTRiCh transanal total mesorectal excision registries were invited to report their incidence of carbon dioxide embolus. Case report forms were collected detailing the patient-specific and technical factors of each event. The study was conducted at the collaborating centers from the international transanal total mesorectal excision registries. Characteristics and outcomes of patients with carbon dioxide embolus associated with transanal mesorectal excision were measured. Twenty-five cases were reported. The incidence of carbon dioxide embolus during transanal total mesorectal excision is estimated to be ≈0.4% (25/6375 cases). A fall in end tidal carbon dioxide was noted as the initial feature in 22 cases, with 13 (52%) developing signs of hemodynamic compromise. All of the events occurred in the transanal component of dissection, with mean (range) insufflation pressures of 15 mm Hg (12-20 mm Hg). Patients were predominantly (68%) in a Trendelenburg position, between 30° and 45°. Venous bleeding was reported in 20 cases at the time of carbon dioxide embolus, with periprostatic veins documented as the most common site (40%). After carbon dioxide embolus, 84% of cases were completed after hemodynamic stabilization. Two patients required cardiopulmonary resuscitation because of cardiovascular collapse. There were no deaths. This is a retrospective study surveying reported outcomes by surgeons and anesthetists. Surgeons undertaking transanal total mesorectal excision must be aware of the possibility of carbon dioxide embolus and its potential risk factors, including venous bleeding (wrong plane surgery), high insufflation pressures, and patient positioning. Prompt recognition and management can limit the clinical impact of such events. See Video Abstract at http://links.lww.com/DCR/A961.

Short-term results following first 35 cases performed by TaTME (Transanal Mesorectal Excision) for low rectal cancer

Background: Surgical treatment of low-rectal cancer may involve many technical difficulties. This applies in particular to men, obese patients and those with a narrow pelvis. Presented in 2010 by A. Lacy et al. TaTME technique (Transanal Total Mesorectal Excision) significantly improved the insight into the surgical field and facilitated the operation of low-located tumors. In addition, many authors have presented good surgical and oncological outcomes.

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

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

Single-port endoscopic mesocolic and mesorectal excision using an extraperitoneal approach.

The extraperitoneal rectal dissection via a transanal approach facilitates the mesorectal dissection. The retroperitoneal approach for mesocolic excision may also offer some similar advantages. To complete the lymphadenectomy of extraperitoneal mesorectal resection, we developed an innovative approach for upper rectal and mesocolic excision via an exclusive retroperitoneal dissection using a single-port access at the site of the future stomy. This study was a prospective pilot study and was conducted between 2013 and 2015 at two oncologic centers. Five consecutive patients, with ano-rectal cancer requiring permanent stoma, underwent this procedure. The bowel was never touched or mobilized to perform the lymphadenectomy, and no Trendelenburg was required. The median operative duration was 300min (range 205-310). The quality of the surgical plane was classified as good (mesorectal) in the five patients. The median circumferential and distal margins were, respectively, 5mm (range 1-20) and 20mm (range 5-25). The median number of harvested lymph nodes was 11 (range 5-18). No laparotomy or multiport laparoscopy was required. There was no death. Two patients had perineal wound dehiscence (one minor and one major). The mesocolic excision via a retroperitoneal approach is feasible, completes naturally the transanal mesorectal excision and may confer several advantages including no morbidity of small bowel manipulation or Trendelenburg position. Further studies are required to analyze this approach.

Treatment of Rectal Cancer with Trans-Anal Mesorectal Excision: A Mini-Review of the Literature

Background: The aim of this mini-review is to summarize the body of literature based on studies on the perioperative and oncological outcomes of transanal total mesorectal excision (TaTME) for the treatment of rectal cancer. Methods: A literature search of PubMED database was performed using subject headings and keywords related to rectal adenocarcinoma and transanal mesorectal excision. Results: Five case series were identified, reporting on a total of 378 patients with mean/median age ranging from 56.5 to 67.6 years and body mass index ranging from 25.2 to 27.5 kg/m2. The mean/median operative time was 166 to 270 minutes. Conversion rate to open approach ranged from 0% to 7.3% whereas postoperative complication rate ranged from 26% to 39%. The length of stay ranged from 4.5 to 10 days. The completeness of circumferential resection margin (CRM) was reported to be between 72% to 97.1%. CRM positivity ranged from 2.5% to 6.4%. The distal resection margin (DRM) ranged from 10 mm to 37.1 mm and DRM positivity ranged from 0% to 2%. The mean/median lymph node harvested ranged from 12 to 20. Short-term oncological outcome (median follow-up period of 15.1 to 29 months) was reported with local recurrence rate from 1.9% to 4% and distal recurrence rate of 3.9% to 14.5%. Conclusions: TaTME appears to be a safe technique for treatment of rectal cancer although the current evidence is limited by the heterogeneity of the quality of available studies. Randomized control trials would be necessary to assess the longterm safety and oncological outcomes of TaTME as compared to conventional rectal surgery techniques.

Hand-sewn coloanal anastomosis for low rectal cancer: technique and long-term outcome.

This study compared the operative outcome and long-term survival of three types of hand-sewn coloanal anastomosis (CAA) for low rectal cancer. Patients presenting with low rectal cancer at a single centre between 2006 and 2014 were classified into three types of hand-sewn CAA: type 1 (supra-anal tumours undergoing transabdominal division of the rectum with transanal mucosectomy); type 2 (juxta-anal tumours, undergoing partial intersphincteric resection); and type 3 (intra-anal tumours, undergoing near-total intersphincteric resection with transanal mesorectal excision). Seventy-one patients with low rectal cancer underwent CAA: 17 type 1; 39 type 2; and 15 type 3. The median age of patients was 61.6 years, with a male/female ratio of 2:1. Neoadjuvant therapy was given to 56 (79%) patients. R0 resection was achieved in 69 (97.2%) patients. Adverse events occurred in 25 (35.2%) of the 71 patients with a higher complication rate in type 1 vs type 2 vs type 3 (47.1% vs 38.5% vs 13.3%, respectively; P = 0.035). Anastomotic separation was identified in six (8.5%) patients and pelvic haematoma/seroma in five (7%); two (8.3%) female patients developed a recto-vaginal fistula. Ten (14.1%) patients were indefinitely diverted, with a trend towards higher long-term anastomotic failure in type 1 vs type 2 vs type 3 (17.6% vs 15.5% vs 6.7%). The type of anastomosis did not influence the overall or disease-free survival. CAA is a safe technique in which anorectal continuity can be preserved either as a primary restorative option in elective cases of low rectal cancer or as a salvage procedure following a failed stapled anastomosis with a less successful outcome in the latter. CAA has acceptable morbidity with good long-term survival in carefully selected patients.

127. Transanal mesorectal excision with laparoscopic assistance for rectal carcinoma–Preliminary results

Aim: to evaluate preliminary results of transanal mesorectal excision (ME) using laparoscopic assistance in terms the feasibility and oncological adequacy.

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.