|
1
|
Khomyakov E, Chernyshov S, Fomenko O, Rybakov E. Does transanal endoscopic microsurgery affect rectal function? Ann Coloproctol 2023; 39:326-331. [PMID: 36375444 PMCID: PMC10475803 DOI: 10.3393/ac.2022.00220.0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 04/26/2022] [Accepted: 05/16/2022] [Indexed: 11/15/2022] Open
Abstract
PURPOSE 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. METHODS 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. RESULTS 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). CONCLUSION 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.
Collapse
Affiliation(s)
- Evgeniy Khomyakov
- Ryzhikh National Medical Research Center of Coloproctology, Moscow, Russia
- Russian Medical Academy of Continuous Professional Education, Moscow, Russia
| | | | - Oksana Fomenko
- Ryzhikh National Medical Research Center of Coloproctology, Moscow, Russia
| | - Evgeny Rybakov
- Ryzhikh National Medical Research Center of Coloproctology, Moscow, Russia
| |
Collapse
|
|
2
|
Sailer M. [Transanal Tumor Resection: Indication, Surgical Technique and Management of Complications]. Zentralbl Chir 2023; 148:244-253. [PMID: 37267979 DOI: 10.1055/a-2063-3578] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Transanal resection procedures are special operations for the minimally invasive treatment of rectal tumours. Apart from benign tumours, this procedure is suitable for the excision of low-risk T1 rectal carcinomas, if these can be completely removed (R0 resection). With stringent patient selection, very good oncological results are achieved. Various international trials are currently evaluating whether local resection procedures are oncologically sufficient if there is a complete or near complete response after neoadjuvant radio-/chemotherapy. Numerous studies have shown that the functional results and the postoperative quality of life after local resection are excellent, especially considering the well-known functional deficits of alternative operations, such as low anterior or abdominoperineal resection.Severe complications are very rare. Most complications, such as urinary retention or subfebrile temperatures, are minor in nature. Suture line dehiscences are usually clinically unremarkable. Major complications comprise significant haemorrhage and the opening of the peritoneal cavity. The latter must be recognized intraoperatively and can usually be managed by primary suture. Infection, abscess formation, rectovaginal fistula, injury of the prostate or even urethra are extremely rare complications.
Collapse
Affiliation(s)
- Marco Sailer
- Klinik für Chirurgie, Agaplesion Bethesda Krankenhaus Bergedorf, Hamburg, Deutschland
| |
Collapse
|
|
3
|
Turchan WT, Liauw SL. Chemoradiation for Anal Cancer: Clinical Outcomes and Strategies to Optimize the Therapeutic Ratio According to HPV Status. Semin Radiat Oncol 2021; 31:349-360. [PMID: 34455990 DOI: 10.1016/j.semradonc.2021.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The incidence of anal cancer in the United States has increased in recent years, primarily related to the increasing incidence of HPV-associated anal squamous cell carcinoma, which is estimated to represent 80%-95% of anal cancers. Similar to head and neck cancer, HPV association has been demonstrated to be a strong positive prognostic factor in patients with anal cancer. Encouraging results from a number of studies investigating treatment de-escalation for HPV-associated oropharyngeal cancer support the notion that similar attempts may be feasible in HPV-associated anal cancer; however, the data to support this hypothesis are currently lacking. Studies are needed to determine how, if at all, HPV status should impact the management of patients with anal cancer. This review summarizes the relationship between HPV association and outcomes for patients with anal cancer, and how HPV status may impact the treatment of patients with anal cancer going forward.
Collapse
Affiliation(s)
| | - Stanley L Liauw
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL.
| |
Collapse
|
|
4
|
Podda M, Sylla P, Baiocchi G, Adamina M, Agnoletti V, Agresta F, Ansaloni L, Arezzo A, Avenia N, Biffl W, Biondi A, Bui S, Campanile FC, Carcoforo P, Commisso C, Crucitti A, De'Angelis N, De'Angelis GL, De Filippo M, De Simone B, Di Saverio S, Ercolani G, Fraga GP, Gabrielli F, Gaiani F, Guerrieri M, Guttadauro A, Kluger Y, Leppaniemi AK, Loffredo A, Meschi T, Moore EE, Ortenzi M, Pata F, Parini D, Pisanu A, Poggioli G, Polistena A, Puzziello A, Rondelli F, Sartelli M, Smart N, Sugrue ME, Tejedor P, Vacante M, Coccolini F, Davies J, Catena F. Multidisciplinary management of elderly patients with rectal cancer: recommendations from the SICG (Italian Society of Geriatric Surgery), SIFIPAC (Italian Society of Surgical Pathophysiology), SICE (Italian Society of Endoscopic Surgery and new technologies), and the WSES (World Society of Emergency Surgery) International Consensus Project. World J Emerg Surg 2021; 16:35. [PMID: 34215310 PMCID: PMC8254305 DOI: 10.1186/s13017-021-00378-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 06/18/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND AIMS Although rectal cancer is predominantly a disease of older patients, current guidelines do not incorporate optimal treatment recommendations for the elderly and address only partially the associated specific challenges encountered in this population. This results in a wide variation and disparity in delivering a standard of care to this subset of patients. As the burden of rectal cancer in the elderly population continues to increase, it is crucial to assess whether current recommendations on treatment strategies for the general population can be adopted for the older adults, with the same beneficial oncological and functional outcomes. This multidisciplinary experts' consensus aims to refine current rectal cancer-specific guidelines for the elderly population in order to help to maximize rectal cancer therapeutic strategies while minimizing adverse impacts on functional outcomes and quality of life for these patients. METHODS The discussion among the steering group of clinical experts and methodologists from the societies' expert panel involved clinicians practicing in general surgery, colorectal surgery, surgical oncology, geriatric oncology, geriatrics, gastroenterologists, radiologists, oncologists, radiation oncologists, and endoscopists. Research topics and questions were formulated, revised, and unanimously approved by all experts in two subsequent modified Delphi rounds in December 2020-January 2021. The steering committee was divided into nine teams following the main research field of members. Each conducted their literature search and drafted statements and recommendations on their research question. Literature search has been updated up to 2020 and statements and recommendations have been developed according to the GRADE methodology. A modified Delphi methodology was implemented to reach agreement among the experts on all statements and recommendations. CONCLUSIONS The 2021 SICG-SIFIPAC-SICE-WSES consensus for the multidisciplinary management of elderly patients with rectal cancer aims to provide updated evidence-based statements and recommendations on each of the following topics: epidemiology, pre-intervention strategies, diagnosis and staging, neoadjuvant chemoradiation, surgery, watch and wait strategy, adjuvant chemotherapy, synchronous liver metastases, and emergency presentation of rectal cancer.
Collapse
Affiliation(s)
- Mauro Podda
- Department of Emergency Surgery, Cagliari University Hospital "D. Casula", Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy.
| | - Patricia Sylla
- Division of Colon and Rectal Surgery, Mount Sinai Hospital, New York, NY, USA
| | - Gianluca Baiocchi
- ASST Cremona, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Michel Adamina
- Department of Colorectal Surgery, Cantonal Hospital of Winterthur, Winterthur - University of Basel, Basel, Switzerland
| | | | - Ferdinando Agresta
- Department of General Surgery, Vittorio Veneto Hospital, AULSS2 Trevigiana del Veneto, Vittorio Veneto, Italy
| | - Luca Ansaloni
- 1st General Surgery Unit, University of Pavia, Pavia, Italy
| | - Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Nicola Avenia
- SC Chirurgia Generale e Specialità Chirurgiche Azienda Ospedaliera Santa Maria, Università degli Studi di Perugia, Terni, Italy
| | - Walter Biffl
- Trauma and Acute Care Surgery, Scripps Memorial Hospital, La Jolla, CA, USA
| | - Antonio Biondi
- Department of General Surgery and Medical - Surgical Specialties, University of Catania, Catania, Italy
| | - Simona Bui
- Department of Medical Oncology, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Fabio C Campanile
- Department of Surgery, ASL VT - Ospedale "San Giovanni Decollato - Andosilla", Civita Castellana, Italy
| | - Paolo Carcoforo
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara, University of Ferrara, Ferrara, Italy
| | - Claudia Commisso
- Department of Radiology, University Hospital of Parma, Parma, Italy
| | - Antonio Crucitti
- General and Minimally Invasive Surgery Unit, Cristo Re Hospital and Catholic University, Rome, Italy
| | - Nicola De'Angelis
- Unit of Minimally Invasive and Robotic Digestive Surgery, Regional General Hospital F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - Gian Luigi De'Angelis
- Department of Medicine and Surgery, Gastroenterology and Endoscopy Unit, University of Parma, Parma, Italy
| | | | - Belinda De Simone
- Department of General and Metabolic Surgery, Poissy and Saint Germain en Laye Hospitals, Poissy, France
| | | | - Giorgio Ercolani
- General and Oncologic Surgery, Morgagni-Pierantoni Hospital, AUSL Romagna, Forlì, Italy
| | - Gustavo P Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, SP, Brazil
| | | | - Federica Gaiani
- Department of Medicine and Surgery, Gastroenterology and Endoscopy Unit, University of Parma, Parma, Italy
| | | | | | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ari K Leppaniemi
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Andrea Loffredo
- UOC Chirurgia Generale - AOU san Giovanni di Dio e Ruggi d'Aragona, Università di Salerno, Salerno, Italy
| | - Tiziana Meschi
- Department of Medicine and Surgery, University of Parma Geriatric-Rehabilitation Department, Parma University Hospital, Parma, Italy
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, Denver, USA
| | | | | | - Dario Parini
- Santa Maria della Misericordia Hospital, Rovigo, Italy
| | - Adolfo Pisanu
- Department of Emergency Surgery, Cagliari University Hospital "D. Casula", Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy
| | - Gilberto Poggioli
- Surgery of the Alimentary Tract, Sant'Orsola Hospital, Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Andrea Polistena
- Dipartimento di Chirurgia Pietro Valdoni Policlinico Umberto I, Sapienza Università degli Studi di Roma, Rome, Italy
| | - Alessandro Puzziello
- UOC Chirurgia Generale - AOU san Giovanni di Dio e Ruggi d'Aragona, Università di Salerno, Salerno, Italy
| | - Fabio Rondelli
- SC Chirurgia Generale e Specialità Chirurgiche Azienda Ospedaliera Santa Maria, Università degli Studi di Perugia, Terni, Italy
| | | | | | - Michael E Sugrue
- Letterkenny University Hospital and CPM sEUBP Interreg Project, Letterkenny, Ireland
| | | | - Marco Vacante
- Department of General Surgery and Medical - Surgical Specialties, University of Catania, Catania, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Justin Davies
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge, UK
| | - Fausto Catena
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
| |
Collapse
|
|
5
|
Transanale Resektionsverfahren – heutiger Stellenwert. Chirurg 2020; 91:853-859. [DOI: 10.1007/s00104-020-01186-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
|
6
|
Marinello FG, Curell A, Tapiolas I, Pellino G, Vallribera F, Espin E. Systematic review of functional outcomes and quality of life after transanal endoscopic microsurgery and transanal minimally invasive surgery: a word of caution. Int J Colorectal Dis 2020; 35:51-67. [PMID: 31761962 DOI: 10.1007/s00384-019-03439-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE The introduction of transanal endoscopic or minimally invasive surgery has allowed organ preservation for rectal tumors with good oncological results. Data on functional and quality-of-life (QoL) outcomes are scarce and controversial. This systematic review sought to synthesize fecal continence, QoL, and manometric outcomes after transanal endoscopic microsurgery (TEM) or transanal minimally invasive surgery (TAMIS). METHODS A systematic review of the literature including Medline, Embase, and the Cochrane Library databases was conducted searching for articles reporting on functional outcomes after TEM or TAMIS between January 1995 and June 2018. The evaluated outcome parameters were pre- and postoperative fecal continence (primary endpoint), QoL, and manometric results. Data were extracted using the same scales and measurement units as from the original study. RESULTS A total of 29 studies comprising 1297 patients were included. Fecal continence outcomes were evaluated in 23 (79%) studies with a wide variety of assessment tools and divergent results. Ten studies (34%) analyzed QoL changes, and manometric variables were assessed in 15 studies (51%). Most studies reported some deterioration in manometric scores without major QoL impairment. Due to the heterogeneity of the data, it was not possible to perform any pooled analysis or meta-analysis. CONCLUSIONS These techniques do not seem to affect continence by themselves except in minor cases. The possibility of worsened function after TEM and TAMIS should not be underestimated. There is a need to homogenize or standardize functional and manometric outcomes assessment after TEM or TAMIS.
Collapse
Affiliation(s)
- Franco G Marinello
- Colorectal Unit - Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Anna Curell
- Colorectal Unit - Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ingrid Tapiolas
- Colorectal Unit - Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Gianluca Pellino
- Colorectal Unit - Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Francesc Vallribera
- Colorectal Unit - Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Eloy Espin
- Colorectal Unit - Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| |
Collapse
|
|
7
|
Endoscopic closure of iatrogenic colon perforation using dual-channel endoscope with an endoloop and clips: methods and feasibility data (with videos). Surg Endosc 2019; 33:1342-1348. [PMID: 30604267 DOI: 10.1007/s00464-018-06616-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 12/03/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Colon perforation is the most serious complication associated with colonoscopic procedures. We performed a novel purse-string suture technique to close the iatrogenic colonic perforation using dual-channel endoscope with an endoloop and clips. METHODS Iatrogenic colon perforations developed during diagnostic colonoscopy referred to a tertiary hospital over 10 years were considered for this endoscopic closure. An endoloop was inserted through the left channel of the endoscope and placed around the defect. The first clip was placed at the proximal site of the defect through the other channel of the endoscope, and the endoloop was anchored on the mucosa around the defect. Then, subsequent clips were placed next to previous clips and the endoloop was fixed. After the defect was encircled by the endoloop and clips, the rim of the opening was approximated by fastening the endoloop with a purse-string technique. RESULTS A total of 8 patients were admitted to our hospital because of iatrogenic colon perforations during diagnostic colonoscopy. Of these, 2 underwent laparoscopic surgery and 6 underwent endoscopic closure by this novel purse-string suture technique. The estimated diameters of the perforations were 20 mm. All cases were successfully treated in the endoscopy unit without sedation or general anesthesia, and recovered without any complication or subsequent operation. Abdominal pain had nearly resolved within 3 days after the procedure in all patients, and only mild peritonitis was observed. CONCLUSIONS Iatrogenic colon perforation can be treated with a purse-string suture technique using dual-channel endoscope with an endoloop and clips. This technique can be useful for relatively large colon perforations associated with diagnostic colonoscopy.
Collapse
|
|
8
|
Biviano I, Balla A, Badiali D, Quaresima S, D'Ambrosio G, Lezoche E, Corazziari E, Paganini AM. Anal function after endoluminal locoregional resection by transanal endoscopic microsurgery and radiotherapy for rectal cancer. Colorectal Dis 2017; 19:O177-O185. [PMID: 28304143 DOI: 10.1111/codi.13656] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 12/29/2016] [Indexed: 12/16/2022]
Abstract
AIM In patients with rectal cancer, surgery and chemoradiotherapy may affect anal sphincter function. Few studies have evaluated anorectal function after neoadjuvant chemoradiotherapy (n-CRT) and/or transanal endoscopic microsurgery (TEM). The aim of this study was to evaluate the effects of n-CRT and TEM on anorectal function. METHOD Thirty-seven patients with rectal cancer underwent anorectal manometry and Wexner scoring for faecal incontinence at baseline, after n-CRT (cT2-T3N0 cancer) and at 4 and 12 months after surgery. Water-perfused manometry measured anal tone at rest and during squeezing, rectal sensitivity and compliance. Twenty-seven and 10 patients, respectively, underwent TEM without (Group A) or with n-CRT (Group B). RESULTS In Group A, anal resting pressure decreased from 68 ± 23 to 54 ± 26 mmHg at 4 months (P = 0.04) and improved 12 months after surgery (60 ± 30 mmHg). The Wexner score showed a significant increase in gas incontinence (59%), soiling (44%) and urgency (37%) rates at 4 months, followed by clinical improvement at 1 year (41%, 26% and 18%, respectively). In group B, anal resting pressure decreased from 65 ± 23 to 50 ± 18 mmHg at 4 months but remained stable at 12 months (44 ± 11 mmHg, P = 0.02 vs preoperative values - no significant difference compared with evaluation at 4 months). Gas incontinence, soiling and urgency were observed in 50%, 50%, 25% and in 38%, 12% and 12% of cases, respectively, 4 and 12 months after treatment. CONCLUSION TEM does not significantly affect anal function. Instead, n-CRT does affect anal function but without causing major anal incontinence.
Collapse
Affiliation(s)
- I Biviano
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - A Balla
- Department of General Surgery and Surgical Specialties 'Paride Stefanini', Sapienza University of Rome, Rome, Italy
| | - D Badiali
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - S Quaresima
- Department of General Surgery and Surgical Specialties 'Paride Stefanini', Sapienza University of Rome, Rome, Italy
| | - G D'Ambrosio
- Department of General Surgery and Surgical Specialties 'Paride Stefanini', Sapienza University of Rome, Rome, Italy
| | - E Lezoche
- Department of General Surgery and Surgical Specialties 'Paride Stefanini', Sapienza University of Rome, Rome, Italy
| | - E Corazziari
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - A M Paganini
- Department of General Surgery and Surgical Specialties 'Paride Stefanini', Sapienza University of Rome, Rome, Italy
| |
Collapse
|
|
9
|
Liu LG, Yan XB, Shan ZZ, Yan LL, Jiang CY, Zhou J, Tian Y, Jin ZM. Anorectal functional outcome following laparoscopic low anterior resection for rectal cancer. Mol Clin Oncol 2017; 6:613-621. [PMID: 28413679 DOI: 10.3892/mco.2017.1183] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 01/23/2017] [Indexed: 01/01/2023] Open
Abstract
Low anterior resection (LAR) with total mesorectal excision has been considered a standard treatment for patients with rectal cancer. However, the functional outcome and life quality of laparoscopic LAR (LLAR) in Chinese patients remain unclear. A cohort of 51 Chinese patients (22 men and 29 women) who had undergone LLAR was included in this study. Anorectal manometry combined with the Wexner scores questionnaire were applied to assess functional outcome preoperatively (1 week) and postoperatively (at 3, 6 and 9 months). The validated Chinese versions of the European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-CR38 questionnaires were also used to assess the patients' quality of life at the indicated time points. The results demonstrated that the manometric parameters exhibited a temporary decrease at 3 months postoperatively, but a gradual increase at 6 and 9 months, while the Wexner scores exhibited an opposite trend. Furthermore, patients with high anastomoses had significantly higher manometric parameters, a lower frequency of incontinence and lower Wexner scores compared with those with low anastomoses at 9 months (all P<0.05). For the entire cohort, quality of life at 3 months postoperatively was worse compared with the preoperative level, but returned to normal by 9 months. Patients with high anastomoses exhibited significantly better role, emotional and social function, had a better body image and sexual function, fewer problems with defecation and lower frequency of diarrhea, as well as fewer chemotherapy-related side effects at 6 months postoperatively when compared with the low anastomosis group (all P<0.05). In conclusion, LLAR is generally acceptable for Chinese patients with rectal cancer, particularly for those with middle or high rectal cancer, in terms of functional outcome and quality of life.
Collapse
Affiliation(s)
- Li-Guo Liu
- Department of Surgery, Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai 200233, P.R. China
| | - Xue-Bing Yan
- Department of Surgery, Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai 200233, P.R. China
| | - Ze-Zhi Shan
- Department of Surgery, Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai 200233, P.R. China
| | - Lei-Lei Yan
- Department of Surgery, Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai 200233, P.R. China
| | - Chun-Yu Jiang
- Department of Radiology, Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai 200233, P.R. China
| | - Jia Zhou
- Department of Radiology, Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai 200233, P.R. China
| | - Yuan Tian
- Department of Surgery, Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai 200233, P.R. China
| | - Zhi-Ming Jin
- Department of Surgery, Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai 200233, P.R. China
| |
Collapse
|
|
10
|
Current Controversies in Transanal Surgery for Rectal Cancer. Surg Laparosc Endosc Percutan Tech 2016; 26:431-438. [DOI: 10.1097/sle.0000000000000357] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
|
11
|
Mora López L, Serra-Aracil X, Navarro Soto S. Sphincter lesions observed on ultrasound after transanal endoscopic surgery. World J Gastroenterol 2015; 21:13160-13165. [PMID: 26674666 PMCID: PMC4674735 DOI: 10.3748/wjg.v21.i46.13160] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 05/29/2015] [Accepted: 08/31/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess the morphological impact of transanal endoscopic surgery on the sphincter apparatus using the modified Starck classification.
METHODS: A prospective, observational study of 118 consecutive patients undergoing Transanal Endoscopic Operation/Transanal Endoscopic Microsurgery (TEO/TEM) from March 2013 to May 2014 was performed. All the patients underwent an endoanal ultrasound prior to surgery and one and four months postoperatively in order to measure sphincter width, identify sphincter defects and to quantify them in terms of the level, depth and size of the affected anal canal. To assess the lesions, we used the “modified” Starck classification, which incorporates the variable “sphincter fragmentation”. The results were correlated with the Wexner incontinence questionnaire.
RESULTS: Of the 118 patients, twelve (sphincter lesions) were excluded. The results of the 106 patients were as follows after one month: 31 (29.2%) lesions found on ultrasound after one month, median overall Starck score of 4 (range 3-6); 10 (9.4%) defects in the internal anal sphincter (IAS) and 3 (2.8%) in the external anal sphincter (EAS); 17 patients (16%) had fragmentation of the sphincter apparatus with both sphincters affected in one case. At four months: 7 (6.6%) defects, all in the IAS, overall median Starck score of 4 (range 3-6). Mean IAS widths were 3.5 mm (SD 1.14) preoperatively, 4.38 mm (SD 2.1) one month postoperatively and 4.03 mm (SD 1.46) four months postoperatively. The only statistically significant difference in sphincter width in the IAS measurements was between preoperatively and one month postoperatively. No incontinence was reported, even in cases of ultrasound abnormalities.
CONCLUSION: TEO/TEM may produce ultrasound abnormalities but this is not accompanied by clinical changes in continence. The modified Starck classification is useful for describing and managing these disorders.
Collapse
|
|
12
|
Abstract
Transanal endoscopic microsurgery (TEM) was developed by Professor Gerhard Buess 30 years ago at the dawn of minimally invasive surgery. TEM utilizes a closed proctoscopic system whereby endoluminal surgery is accomplished with high-definition magnification, constant CO2 insufflation, and long-shafted instruments. The end result is a more precise excision and closure compared to conventional instrumentation. Virtually any benign lesion can be addressed with this technology; however, proper patient selection is paramount when using it for cancer.
Collapse
|
|
13
|
Abstract
BACKGROUND The concept of natural orifice transluminal endoscopic surgery (NOTES) has stimulated the development of various "incisionless" procedures. One of the most popular is the transanal approach for rectal lesions. The aims of this study were to report how we standardized NOTES technique for transanal mesorectal excision without abdominal assistance, discuss the difficulties and surgical outcomes of this technique and report its feasibility in a small group of selected patients. METHODS Three consecutive female patients underwent transanal NOTES rectal resection without transabdominal laparoscopic assistance for rectal lesions. Functional results were assessed with the Fecal Incontinence Quality of Life scale and the Wexner score. RESULTS The technical steps are described in details and complemented with a video. All procedures were completed without transabdominal laparoscopic help. The mesorectal plane was entirely dissected without any disruption, and distal and circumferential margins were tumor-free. No major complications were observed. Functional results show a significant impairment after surgery with improvement at 6 months to levels near those of the preoperative period. CONCLUSIONS The performance and publication of NOTES procedures are subject to much discussion. Despite the small number of patients, this procedure appears feasible and can be accomplished maintaining fecal continence and respecting oncologic principles.
Collapse
|
|
14
|
Kim SJ, Choi BJ, Lee SC. A novel single-port laparoscopic operation for colorectal cancer with transanal specimen extraction: a comparative study. BMC Surg 2015; 15:10. [PMID: 25633605 PMCID: PMC4328051 DOI: 10.1186/1471-2482-15-10] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 11/28/2014] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Extension of a single incision for the purpose of specimen extraction in single-port laparoscopic surgery (SPLS) can undermine the merits of SPLS, either by hurting cosmesis or by increasing wound morbidity. METHODS We retrospectively analyzed the clinical outcomes of patients undergoing SPLS sigmoidectomy, either with transanal specimen extraction (TASE, n = 15) or transumbilical specimen extraction (TUSE, n = 68), for colorectal cancer between March 2009 and March 2013. The inclusion criterion was a tumor diameter of ≤ 5 cm. The median follow-up was 93 months (range 13 - 149). RESULTS Most of intraoperative and postoperative variables were comparable between the two groups, except for lengthening of operation time in TASE (287 ± 87 min vs. 226 ± 78 min, P = 0.011). TUSE did not lengthen the duration of postoperative recovery, hospital stay, or pain, or increase the incidence of postoperative complications. Whereas TUSE showed 8.8% (6/68) of wound-related complications, TASE did not show wound-related complications during follow-up period (P = 0.586). CONCLUSION With the exception of a prolonged operation time, TASE showed equivalent surgical outcomes as TUSE in SPLS sigmoidectomy. Thus, the implement of TASE is expected to provide one way of reducing wound-related complications in SPLS in patients with a tumor diameter of ≤5 cm.
Collapse
Affiliation(s)
- Say-June Kim
- Department of Surgery, Daejeon St. Mary's Hospital, The Catholic University of Korea, Daeheung-dong 520-2, Daejeon, Jung-gu, Republic of Korea.
| | - Byung-Jo Choi
- Department of Surgery, Daejeon St. Mary's Hospital, The Catholic University of Korea, Daeheung-dong 520-2, Daejeon, Jung-gu, Republic of Korea.
| | - Sang Chul Lee
- Department of Surgery, Daejeon St. Mary's Hospital, The Catholic University of Korea, Daeheung-dong 520-2, Daejeon, Jung-gu, Republic of Korea.
| |
Collapse
|
|
15
|
Morino M, Risio M, Bach S, Beets-Tan R, Bujko K, Panis Y, Quirke P, Rembacken B, Rullier E, Saito Y, Young-Fadok T, Allaix ME. Early rectal cancer: the European Association for Endoscopic Surgery (EAES) clinical consensus conference. Surg Endosc 2015; 29:755-73. [DOI: 10.1007/s00464-015-4067-3] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 01/07/2015] [Indexed: 12/13/2022]
|
|
16
|
Oncological outcomes of local excision compared with radical surgery after neoadjuvant chemoradiotherapy for rectal cancer: a systematic review and meta-analysis. Int J Colorectal Dis 2015; 30:19-29. [PMID: 25367179 DOI: 10.1007/s00384-014-2045-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/21/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND Low rectal cancer is conventionally managed with neoadjuvant chemoradiotherapy (CRT) followed by radical surgery (RS). In patients who refuse a stoma or are unfit for RS, an alternative approach may be the use of pre-op CRT and local excision (LE) where tumours are responsive. The aim of this systematic review is to determine whether differences exist in local recurrence (LR), overall survival (OS) and disease-free (DFS) survival between patients treated with CRT + LE and CRT + RS. METHODS A literature search was performed using MEDLINE/PubMed/Ovid databases and Google Scholar between 1946 and 2013. Studies comparing outcome following LE and RS post-CRT were included. A pooled analysis was carried out using the Mantel-Haenszel statistical (random effects) model to identify differences in LR, OS and DFS between CRT + LE and CRT + RS. RESULTS Eight studies were suitable for pooled analyses of LR whereas five and four studies were analysed for OS and DFS, respectively. When RS was used as the reference group, LR rate was higher in the LE group. However, this was non-significant (odds ratio (OR) 1.29, confidence interval (CI) 0.72-2.31, p = 0.40). Similarly, no difference was observed in 10-year OS (OR 0.96, CI 0.38-2.43, p = 0.93) or 5-year DFS (OR 1.04, CI 0.61-1.76, p = 0.89). There was evidence of publication bias in studies used for DFS. Subgroup analysis of above outcomes in T3/any N stage cancers showed no difference in LE versus RS. CONCLUSION In the current evidence synthesis, there was no statistical difference in the LR, OS and DFS rates observed between patients treated with LE and RS for rectal cancer post-CRT. LE post-CRT may represent a viable alternative to RS for some patients wishing to avoid RS. However, further randomised studies are required to confirm these results.
Collapse
|
|
17
|
Emhoff IA, Lee GC, Sylla P. Future directions in surgery for colorectal cancer: the evolving role of transanal endoscopic surgery. COLORECTAL CANCER 2014. [DOI: 10.2217/crc.14.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
SUMMARY The morbidity associated with radical surgery for rectal cancer has launched a revolution in increasingly less-invasive methods of resection, including a recent resurgence in transanal endoscopic surgical approaches. The next evolution in transanal surgery for rectal cancer is natural orifice translumenal endoscopic surgery (NOTES). To date, 14 series of transanal NOTES total mesorectal excision (TME) for rectal cancer have been published (n = 76). Overall, the intraoperative and postoperative complication rates of 8 and 28%, respectively, compare favorably to those expected from laparoscopic and open TME. Short-term follow-up after NOTES TME has yielded no cancer recurrence in average-risk patients. High-risk patients have cancer recurrence rates similar to those after laparoscopic TME. Overall, these early data support transanal NOTES TME as a safe and viable alternative to conventional TME. Advances in instrumentation, surgical expertise and neoadjuvant treatment may expand current indications for NOTES even further.
Collapse
Affiliation(s)
- Isha Ann Emhoff
- Department of Surgery, Division of Gastrointestinal Surgery, Massachusetts General Hospital, 15 Parkman Street, Wang 460, Boston, MA 02114, USA
| | - Grace Clara Lee
- Department of Surgery, Division of Gastrointestinal Surgery, Massachusetts General Hospital, 15 Parkman Street, Wang 460, Boston, MA 02114, USA
| | - Patricia Sylla
- Department of Surgery, Division of Gastrointestinal Surgery, Massachusetts General Hospital, 15 Parkman Street, Wang 460, Boston, MA 02114, USA
| |
Collapse
|
|
18
|
Walensi M, Käser SA, Theodorou P, Bassotti G, Cathomas G, Maurer CA. Transanal endoscopic microsurgery (TEM) facilitated by video-assistance and anal insertion of a single-incision laparoscopic surgery (SILS(®))-port: preliminary experience. World J Surg 2014; 38:505-511. [PMID: 24101024 DOI: 10.1007/s00268-013-2264-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Transanal endoscopic microsurgery (TEM) is an established method for the resection of benign and early malignant rectal lesions. Very recently, TEM via an anally inserted single incision laparoscopic surgery (SILS(®))-port has been proposed to overcome remaining obstacles of the classical TEM equipment. METHODS Nine patients with a total of 12 benign or early stage malignant rectal polyps were operated using the SILS(®)-port for TEM. Patients' and polyps' characteristics, perioperative and postoperative complications, as well as operating and hospitalization time were recorded. RESULTS All 12 polyps (ten low-grade adenoma, one high-grade adenoma, one pT2 carcinoma [preoperatively staged as T1]) were resected. Local full-thickness bowel wall resection was performed for three lesions and submucosal resection for nine lesions. Median operating time was 64 (range 30-180) min. No conversion to laparoscopic or open techniques was necessary. The median maximum diameter of the specimen was 25 (range 3-60) mm, fragmentation of polyps was avoidable in 11 of 12 (92 %) lesions, and resection margins were histologically clear in 11 of 12 (92 %) polyps. Only one patient, in whom three lesions were resected, experienced a complication as postoperative hemorrhage. No mortality occurred. Median hospitalization time was four (range 1-14) days. CONCLUSIONS SILS(®)-TEM is a feasible and safe method, providing numerous advantages in application, handling, and economy compared with the classical TEM technique. SILS(®)-TEM might become a promising alternative to classical TEM. Randomized, controlled trials comparing safety and efficacy of both instrumental settings will be needed in the future.
Collapse
Affiliation(s)
- Mikolaj Walensi
- Department of Surgery, Hospital of Liestal, Affiliated with the University of Basel, Rheinstrasse 26, 4410, Liestal, Switzerland,
| | | | | | | | | | | |
Collapse
|
|
19
|
Gornicki A, Richter P, Polkowski W, Szczepkowski M, Pietrzak L, Kepka L, Rutkowski A, Bujko K. Anorectal and sexual functions after preoperative radiotherapy and full-thickness local excision of rectal cancer. Eur J Surg Oncol 2013; 40:723-30. [PMID: 24332947 DOI: 10.1016/j.ejso.2013.11.010] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Revised: 10/16/2013] [Accepted: 11/04/2013] [Indexed: 01/19/2023] Open
Abstract
AIMS Local excision with preoperative radiotherapy may be considered as alternative management to abdominal surgery alone for small cT2-3N0 tumours. However, little is known about anorectal and sexual functions after local excision with preoperative radiotherapy. Evaluation of this issue was a secondary aim of our previously published prospective multicentre study. METHODS Functional evaluation was based on a questionnaire completed by 44 of 64 eligible disease-free patients treated with preoperative radiotherapy and local excision. Additionally, ex post, these results were confronted with those recorded retrospectively in the control group treated with anterior resection alone (N = 38). RESULTS In the preoperative radiotherapy and local excision group, the median number of bowel movements was two per day, incontinence of flatus occurred in 51% of patients, incontinence of loose stool in 46%, clustering of stools in 59%, and urgency in 49%; these symptoms occurred often or very often in 11%-21% of patients. Thirty-eight per cent of patients claimed that their quality of life was affected by anorectal dysfunction. Nineteen per cent of men and 20% of women claimed that the treatment negatively influenced their sexual life. The anorectal functions in the preoperative radiotherapy and local excision group were not much different from that observed in the anterior resection alone group. CONCLUSIONS Our study suggests that anorectal functions after preoperative radiotherapy and local excision may be worse than expected and not much different from that recorded after anterior resection alone. It is possible that radiotherapy compromises the functional effects achieved by local excision.
Collapse
Affiliation(s)
- A Gornicki
- Department of Surgery, Praski Hospital, Warsaw, Poland
| | - P Richter
- Department of Surgery, Jagiellonian Medical University College, Krakow, Poland
| | - W Polkowski
- Department of Surgical Oncology, Medical University, Lublin, Poland
| | - M Szczepkowski
- Department of Rehabilitation, Jozef Pilsudski University of Physical Education, Warsaw, Poland
| | - L Pietrzak
- Department of Radiotherapy, Maria Sklodowska-Curie Memorial Cancer Centre, Warsaw, Poland
| | - L Kepka
- Department of Radiotherapy, Maria Sklodowska-Curie Memorial Cancer Centre, Warsaw, Poland
| | - A Rutkowski
- Surgical Division of Department of Gastrointestinal Oncology, Maria Sklodowska-Curie Memorial Cancer Centre, Warsaw, Poland
| | - K Bujko
- Department of Radiotherapy, Maria Sklodowska-Curie Memorial Cancer Centre, Warsaw, Poland.
| |
Collapse
|
|
20
|
Gavilanes Calvo C, Manuel Palazuelos JC, Alonso Martín J, Castillo Diego J, Martín Parra I, Gómez Ruiz M, Gómez Fleitas M. [Transanal endoscopic operations for rectal tumours]. Cir Esp 2013; 92:38-43. [PMID: 24169437 DOI: 10.1016/j.ciresp.2013.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Revised: 02/04/2013] [Accepted: 02/05/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND Transanal endoscopic operation (TEO) may be the technique of choice for the treatment of rectal lesions, both benign and selected malignant lesions, with similar survival rates to conventional surgery but with lower morbidity. METHODS In this article we present a series of 70 patients operated on with this procedure (TEO) in our center. The indications were benign rectal lesions and malignant lesions at early stages (T1) 86%. The surgical procedure was performed with the the transanal endoscopic operation platform (TEO; Karl Storz, Tüttlingen, Germany) and ultrasonic scalpel (Harmonic scalpel, Ethicon Endo-surgery,…). RESULTS The indication in 43 patients was a benign lesion (adenoma), in the other 27 the diagnosis was adenocarcinoma. After the resection, 61% of the series had a malignant lesion in the pathology report: 13 patients of the 43 with a benign lesion initially had a malignant lesion in the pathology report. Postoperative morbidity was 36%, Clavien III (5,7%). 3 patients (4%) needed emergency surgery. All of the benign lesions were completely excised, but 7 malignant lesions had resection margin involvement The median follow-up time was 26,4 months (range, 1-71 months), the overall recurrence for benign tumors was 9%, 8% for malignant pT1 and 12,5% for malignant pT2. Early salvage surgery was performed on 8 patients. CONCLUSIONS TEO allows us to excise benign rectal lesions that could not be excised with a conventional approach (endoscopic or transanal resection) with a low morbidity rate. TEO can be used for malignant rectal tumors in early stages (pT1) with pathological confirmation.
Collapse
Affiliation(s)
- Carlos Gavilanes Calvo
- Servicio de Cirugía General, Hospital Universitario Marqués de Valdecilla, Santander, España
| | | | - Joaquín Alonso Martín
- Unidad Colorrectal, Servicio de Cirugía General, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - Julio Castillo Diego
- Unidad Colorrectal, Servicio de Cirugía General, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - Ignacio Martín Parra
- Unidad Colorrectal, Servicio de Cirugía General, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - Marcos Gómez Ruiz
- Unidad Colorrectal, Servicio de Cirugía General, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - Manuel Gómez Fleitas
- Unidad Colorrectal, Servicio de Cirugía General, Hospital Universitario Marqués de Valdecilla, Santander, España; Cátedra de Cirugía General, Universidad de Cantabria, Santander, España
| |
Collapse
|
|
21
|
Demura Y, Ishikawa N, Hirano Y, Inaki N, Matsunoki A, Watanabe G. Transrectal robotic natural orifice translumenal endoscopic surgery (NOTES) applied to intestinal anastomosis in a porcine intestine model. Surg Endosc 2013; 27:4693-701. [DOI: 10.1007/s00464-013-3117-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 07/17/2013] [Indexed: 12/13/2022]
|
|
22
|
Léonard D, Remue C, Kartheuser A. The transanal endoscopic microsurgery procedure: standards and extended indications. Dig Dis 2012. [PMID: 23207938 DOI: 10.1159/000342033] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Transanal endoscopic microsurgery (TEM) was developed in the early 1980s as a minimally invasive technique allowing the resection of benign rectal adenomas. For this indication, TEM was reported to be safe and effective and even exceeded the results compared to classical local excision. Unsurprisingly, the indication expanded to small rectal cancer. There is still much debate, though, whether it is oncologically safe to perform TEM for rectal cancer. Much has been published about the need for proper patient selection, i.e. patients presenting a low-risk T1 rectal cancer seem to be the most adequate subgroup for this technique. Nevertheless, TEM remains controversial concerning high-risk T1 rectal adenocarcinomas and deeper infiltrating tumors. Several retrospective case series and a small prospective study suggest that radiochemotherapy before local excision reduces recurrence to a level comparable with classic radical surgery (total mesorectal excision). However, these studies are collectively limited, and prospective data from larger multicenter trials are awaited. Reports about functional results after TEM have shown that the procedure has no permanent impact on anorectal function. Even if transient anal resting pressure weakening has been repeatedly described, patients do not suffer from any long-term functional sequelae. Nor do they complain of quality of life impairment.
Collapse
Affiliation(s)
- Daniel Léonard
- Colorectal Surgery Unit, Department of Abdominal Surgery and Transplantation, Université catholique de Louvain, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | | | | |
Collapse
|
|
23
|
|
|
24
|
Zhang HW, Han XD, Wang Y, Zhang P, Jin ZM. Anorectal functional outcome after repeated transanal endoscopic microsurgery. World J Gastroenterol 2012; 18:5807-11. [PMID: 23155324 PMCID: PMC3484352 DOI: 10.3748/wjg.v18.i40.5807] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Revised: 06/27/2012] [Accepted: 07/09/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the status of anorectal function after repeated transanal endoscopic microsurgery (TEM).
METHODS: Twenty-one patients undergoing subtotal colectomy with ileorectal anastomosis were included. There were more than 5 large (> 1 cm) polyps in the remaining rectum (range: 6-20 cm from the anal edge). All patients, 19 with villous adenomas and 2 with low-grade adenocarcinomas, underwent TEM with submucosal endoscopic excision at least twice between 2005 and 2011. Anorectal manometry and a questionnaire about incontinence were carried out at week 1 before operation, and at weeks 2 and 3 and 6 mo after the last operation. Anal resting pressure, maximum squeeze pressure, maximum tolerable volume (MTV) and rectoanal inhibitory reflexes (RAIR) were recorded. The integrity and thickness of the internal anal sphincter (IAS) and external anal sphincter (EAS) were also evaluated by endoanal ultrasonography. We determined the physical and mental health status with SF-36 score to assess the effect of multiple TEM on patient quality of life (QoL).
RESULTS: All patients answered the questionnaire. Apart from negative RAIR in 4 patients, all of the anorectal manometric values in the 21 patients were normal before operation. Mean anal resting pressure decreased from 38 ± 5 mmHg to 19 ± 3 mmHg (38 ± 5 mmHg vs 19 ± 3 mmHg, P = 0.000) and MTV from 165 ± 19 mL to 60 ± 11 mL (165 ± 19 mL vs 60 ± 11 mL, P = 0.000) at month 3 after surgery. Anal resting pressure and MTV were 37 ± 5 mmHg (38 ± 5 mmHg vs 37 ± 5 mmHg, P = 0.057) and 159 ± 19 mL (165 ± 19 mL vs 159 ± 19 mL, P = 0.071), respectively, at month 6 after TEM. Maximal squeeze pressure decreased from 171 ± 19 mmHg to 62 ± 12 mmHg (171 ± 19 mmHg vs 62 ± 12 mmHg, P = 0.000) at week 2 after operation, and returned to normal values by postoperative month 3 (171 ± 19 vs 166 ± 18, P = 0.051). RAIR were absent in 4 patients preoperatively and in 12 (χ2 = 4.947, P = 0.026) patients at month 3 after surgery. RAIR was absent only in 5 patients at postoperative month 6 (χ2 = 0.141, P = 0.707). Endosonography demonstrated that IAS disruption occurred in 8 patients, and 6 patients had temporary incontinence to flatus that was normalized by postoperative month 3. IAS thickness decreased from 1.9 ± 0.6 mm preoperatively to 1.3 ± 0.4 mm (1.9 ± 0.6 mm vs 1.3 ± 0.4 mm, P = 0.000) at postoperative month 3 and increased to 1.8 ± 0.5 mm (1.9 ± 0.6 mm vs 1.8 ± 0.5 mm, P = 0.239) at postoperative month 6. EAS thickness decreased from 3.7 ± 0.6 mm preoperatively to 3.5 ± 0.3 mm (3.7 ± 0.6 mm vs 3.5 ± 0.3 mm, P = 0.510) at month 3 and then increased to 3.6 ± 0.4 mm (3.7 ± 0.6 mm vs 3.6 ± 0.4 mm, P = 0.123) at month 6 after operation. Most patients had frequent stools per day and relatively high Wexner scores in a short time period. While actual fecal incontinence was exceptional, episodes of soiling were reported by 3 patients. With regard to the QoL, the physical and mental health status scores (SF-36) were 56.1 and 46.2 (50 in the general population), respectively.
CONCLUSION: The anorectal function after repeated TEM is preserved. Multiple TEM procedures are useful for resection of multi-polyps in the remaining rectum.
Collapse
|
|
25
|
Abstract
BACKGROUND Rectal dissection using a conventional multiport laparoscopic approach involves risks due to technical difficulties, particularly in patients with a low tumor, a narrow pelvis, or obesity. OBJECTIVE We describe a technique of transanal endoscopic low and middle rectal dissection with subsequent coloanal anastomosis via single-port laparoscopy, with the aim of reducing technical problems, increasing safety, and improving cosmesis after resection of rectal cancer. DESIGN AND SETTING This was an observational study conducted in a large, tertiary care cancer center in France. PATIENTS Consecutive patients with rectal adenocarcinoma requiring total mesorectal excision with a coloanal anastomosis were evaluated for eligibility to undergo the procedure. Patients were selected if they had 1 or more of the following risk factors: narrow pelvis, a voluminous prostate, or obesity. INTERVENTION After an anal mucosectomy, the rectal wall was circumferentially transected above the external sphincter and a transanal trocar was introduced. The dissection of the mesorectum was completely performed via endoscopy up to the Douglas rectovesical pouch. A single port was inserted at the future site of the transient ileostomy, and a left colectomy and a lymphadenectomy were performed. The upper rectum dissection enabled joining the transanal rectal plane of dissection. Then the splenic flexure was completely mobilized and the specimen was extracted through the site of the future ileostomy. OUTCOME MEASURES Operative time, blood loss, duration of hospital stay, and histopathologic variables (margins, number of harvested lymph nodes, grade of the mesorectal fascia dissection) were recorded, and the quality of the surgical plane was assessed. The Cleveland Clinic Florida (Wexner) fecal incontinence questionnaire was administered after ileostomy closure. RESULTS Four consecutive male patients with rectal cancer in a narrow pelvis were treated with this new approach. No conversion (by laparotomy or multiport laparoscopy) was necessary. The pathologic variables were satisfactory and the Wexner scores indicated no severe incontinence after ileostomy closure. The postoperative follow-up was uneventful except for an anastomotic fistula which developed in 1 patient and was treated without reoperation. LIMITATIONS The study was limited by the small number of patients and the fact that no women and no obese patients were included. CONCLUSIONS Rectal resection via the transanal approach combined with single-port laparoscopic assistance may be easier and safer than the traditional approach, especially in male patients who have a narrow pelvis. More data are needed in order to draw conclusions concerning oncologic results and before selecting the most appropriate indications for this technique.
Collapse
|
|
26
|
Diana M, Wall J, Costantino F, D'agostino J, Leroy J, Marescaux J. Transanal extraction of the specimen during laparoscopic colectomy. Colorectal Dis 2011; 13 Suppl 7:23-27. [PMID: 22098513 DOI: 10.1111/j.1463-1318.2011.02774.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
AIM To assess the current state of the art of transanal specimen extraction in colonic resections. METHOD A systematic literature search was conducted including the terms 'transrectal or transanal specimen extraction', 'Natural Orifice Specimen Extraction' and 'laparoscopic colectomy' for the period from 1955 to May 2011. Exclusion criteria were abdomino-perineal resections, pull-through technique, experimental studies and paediatric population. RESULTS Nineteen studies met the inclusion criteria, representing 154 patients. The overall postoperative complication rate was 10%. The risks of peritoneal contamination and sphincter dysfunction were evaluated by a single study of each. CONCLUSION Transanal extraction is a feasible option to minimize incisions in colorectal surgery.
Collapse
Affiliation(s)
- M Diana
- Department of Surgery, IRCAD/EITS, Hôpitaux Universitaires, Strasbourg, France
| | | | | | | | | | | |
Collapse
|
|
27
|
Abstract
Transanal endoscopic video-assisted excision of benign and malignant rectal lesions with pneumorectal distension appears to optimize the visual field and avert several of the pitfalls commonly associated with transanal endoscopic microsurgery. Background: Transanal endoscopic microsurgery is a safe and efficacious surgical approach for local excision of benign adenomas and early-stage rectal cancer. However, utilization of the technique has been limited due to the unavailability of high-priced specialized instrumentation at many institutions and the technically demanding training required. To avoid these obstacles, we have explored an alternative approach called Transanal Endoscopic Video-Assisted excision, which combines the merits of single-port access and local transanal excision. Methods: A disposable single-incision port is inserted into the anal canal for transanal access. The port contains 3 cannulae for introducing instrumentation into the rectal lumen, and a supplementary cannula for carbon dioxide insufflation. Pneumorectum results in rectal distention and optimizes the visual field during the procedure. Standard laparoscopic instrumentation is utilized for visualization and transanal excision of rectal pathologies. Conclusions: Transanal endoscopic video-assisted excision is an innovative approach to local excision of benign and malignant rectal lesions. The approach averts several of the pitfalls commonly experienced with transanal endoscopic microsurgery. Continued investigation and development of this novel modality will be important in establishing its role in minimally invasive surgery.
Collapse
Affiliation(s)
- Madhu Ragupathi
- Division of Minimally Invasive Colon and Rectal Surgery, Department of Surgery, University of Texas Medical School at Houston, Houston, Texas, USA
| | | |
Collapse
|
|
28
|
Allaix ME, Rebecchi F, Giaccone C, Mistrangelo M, Morino M. Long-term functional results and quality of life after transanal endoscopic microsurgery. Br J Surg 2011; 98:1635-43. [PMID: 21713758 DOI: 10.1002/bjs.7584] [Citation(s) in RCA: 113] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND Of the few studies that have investigated quality-of-life (QoL) outcomes after transanal endoscopic microsurgery (TEM), the majority have reported only short-term follow-up data. This study assessed long-term clinical and instrumental outcomes (QoL, sexual, urinary and sphincter function) after TEM for extraperitoneal rectal cancer. METHODS Preoperative and postoperative anorectal function was assessed in consecutive patients with benign rectal lesions or early rectal cancer, based on clinical scores and anorectal manometry. RESULTS Between January 2000 and July 2005, 93 patients undergoing TEM completed the 60-month study protocol. The mean Wexner continence score increased from baseline at 3 months, began to decline within 12 months, and had returned to the preoperative value at 60 months. Urgency was reported by 65·0, 30·0 and 5 per cent of patients at 3, 12 and 60 months respectively (P < 0·050). A significant improvement was noted in various clinical and QoL scores at 12 and 60 months. Postoperative manometry values at 3 months were significantly lower than at baseline (P < 0·050), but had returned to preoperative values at 12 months. Tumour size of 4 cm or above was the only factor that significantly (P = 0·008) affected the rectal sensitivity threshold, the urge to defaecate threshold and the maximum tolerated volume at 3 months after TEM. CONCLUSION TEM had no long-term effect on anorectal function or QoL. Lower anal resting pressure at early follow-up was not associated with defaecation problems in patients who were continent before surgery.
Collapse
Affiliation(s)
- M E Allaix
- Department of Digestive Surgery and Centre for Minimally Invasive Surgery, University of Turin, 14 Corso Achille Mario Dogliotti, 10126 Turin, Italy
| | | | | | | | | |
Collapse
|