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Ghareeb WM, Patricia S, Draz EN, Al Bastaki S, Hassan A, Ghanem A, Shokri I, Madbouly K, Emile SH, Shawki S. Artificial intelligence-assisted decision making: Prediction of optimal level of distal mesorectal margin during transanal total mesorectal excision (taTME) using deep neural network modeling. J Visc Surg 2024; 161:244-249. [PMID: 38964939 DOI: 10.1016/j.jviscsurg.2024.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2024]
Abstract
BACKGROUND With steep posterior anorectal angulation, transanal total mesorectal excision (taTME) may have a risk of dissection in the wrong plane or starting higher up, resulting in leaving distal mesorectum behind. Although the distal mesorectal margin can be assessed by preoperative MRI, it needs skilled radiologist and high-definition image for accurate evaluation. This study developed a deep neural network (DNN) to predict the optimal level of distal mesorectal margin. METHODS A total of 182 pelvic MRI images extracted from the cancer image archive (TCIA) database were included. A DNN was developed using gender, the degree of anterior and posterior anorectal angles as input variables while the difference between anterior and posterior mesorectal distances from anal verge was selected as a target. The predictability power was assessed by regression values (R) which is the correlation between the predicted outputs and actual targets. RESULTS The anterior angle was an obtuse angle while the posterior angle varied from acute to obtuse with mean angle difference 35.5°±14.6. The mean difference between the anterior and posterior mesorectal end distances was 18.6±6.6mm. The developed DNN had a very close correlation with the target during training, validation, and testing (R=0.99, 0.81, and 0.89, P<0.001). The predicted level of distal mesorectal margin was closely correlated with the actual optimal level (R=0.91, P<0.001). CONCLUSIONS Artificial intelligence can assist in either making or confirming the preoperative decisions. Furthermore, the developed model can alert the surgeons for this potential risk and the necessity of re-positioning the proctectomy incision.
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Affiliation(s)
- Waleed M Ghareeb
- Gastrointestinal Surgery Unit, Department of Surgery, Faculty of Medicine, Suez Canal University hospital, Egypt.
| | - Sylla Patricia
- Division of Colon and Rectal Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Eman N Draz
- Department of Human Anatomy and Embryology, Faculty of Medicine, Suez Canal University, Egypt
| | - Sara Al Bastaki
- Department of General and Colorectal Surgery, Mediclinic City Hospital, Abu-Dhabi, United Arab Emirates
| | - Ahmed Hassan
- Gastrointestinal Surgery Unit, Department of Surgery, Faculty of Medicine, Suez Canal University hospital, Egypt
| | - Ahmed Ghanem
- Gastrointestinal Surgery Unit, Department of Surgery, Faculty of Medicine, Suez Canal University hospital, Egypt
| | - Ibrahim Shokri
- Radiology department, Faculty of Medicine, Suez Canal University, Egypt
| | - Khaled Madbouly
- Colorectal Surgery Unit, Alexandria University, Faculty of Medicine, Egypt; Colorectal Surgery Unit, Cleveland Clinic, Abu-Dhabi, United Arab Emirates
| | - Sameh H Emile
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospital, Egypt; Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Sherief Shawki
- Department of colon and rectal Surgery, Mayo Rochester, MN, USA
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Uehara K, Ogura A, Murata Y, Sando M, Mukai T, Aiba T, Yamamura T, Nakamura M. Current status of transanal total mesorectal excision for rectal cancer and the expanding indications of the transanal approach for extended pelvic surgeries. Dig Endosc 2023; 35:243-254. [PMID: 36342054 DOI: 10.1111/den.14464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 11/04/2022] [Indexed: 11/09/2022]
Abstract
Transanal total mesorectal excision (taTME) has been rapidly accepted as a promising surgical approach to the distal rectum. The benefits include ease of access to the bottom of the deep pelvis linearly over a short distance in order to easily visualize the important anatomy. Furthermore, the distal resection margins can be secured under direct vision. Additionally, a two-team approach combining taTME with a transabdominal approach could decrease the operative time and conversion rate. Although taTME was expected to become more rapidly popularized worldwide, enthusiasm for it has stalled due to unfamiliar intraoperative complications, a lack of oncologic evidence from randomized trials, and the widespread use of robotic surgery. While international registries have reported favorable short- and medium-term outcomes from taTME, a Norwegian national study reported a high local recurrence rate of 9.5%. The characteristics of the recurrences included rapid, multifocal growth in the pelvis, which was quite different from recurrences following traditional transabdominal TME; thus, the Norwegian Colorectal Cancer Group reached a consensus for a temporary moratorium on the performance of taTME. To ensure acceptable baseline quality and patient safety, taTME should be performed by well-trained colorectal surgeons. Although the appropriate indications for taTME remain controversial, the transanal approach is extremely important as a means of goal setting in difficult TME cases and as an aid to the transabdominal approach in various types of extended pelvic surgeries. The benefits in transanal lateral lymph node dissection and pelvic exenteration are presented herein.
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Affiliation(s)
- Kay Uehara
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Atsushi Ogura
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Yuki Murata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Masanori Sando
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Toshiki Mukai
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Toshisada Aiba
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Takeshi Yamamura
- Department of Gastroenterology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Masanao Nakamura
- Department of Gastroenterology, Nagoya University Graduate School of Medicine, Aichi, Japan
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Ghareeb WM, Wang X, Zhao X, Xie M, Emile SH, Shawki S, Chi P. The "terminal line": a novel sign for the identification of distal mesorectum end during TME for rectal cancer. Gastroenterol Rep (Oxf) 2022; 10:goac050. [PMID: 36157329 PMCID: PMC9492152 DOI: 10.1093/gastro/goac050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 05/15/2022] [Accepted: 07/07/2022] [Indexed: 12/02/2022] Open
Abstract
Background Although the clinical importance of complete, intact total mesorectal excision (TME) is the widely accepted standard for decreasing local recurrence of rectal cancer, the residual mesorectum still represents a significant component of resection margin involvement. This study aimed to use a visible intraoperative sign to detect the distal mesorectal end to ensure complete inclusion of the mesorectum and avoid unnecessary over-dissection. Methods The distal mesorectum end was investigated retrospectively through a review of 124 operative videos at the Union Hospital of Fujian Medical University (Fujian, China) and Cleveland Clinic (Ohio, USA) by two independent surgeons who were blinded to each other. Furthermore, 28 cadavers and 44 post-operative specimens were prospectively examined by hematoxylin and eosin (H&E) staining and Masson's staining to validate and confirm the findings of the retrospective part. Univariate and multivariate analyses were carried out to detect the independent factors that can affect the visualization of the distal mesorectal end. Results The terminal line (TL) is the distal mesorectal end of the transabdominal and transanal TME (taTME) and appears as a remarkable pearly white fascial structure extending posteriorly from 2 to 10 o'clock. Histopathological examination revealed that the fascia propria of the rectum merges with the presacral fascia at the TL, beyond which the mesorectum ends, with no further downward extension. In the retrospective observation, the TL was seen in 56.6% of transabdominal TME and 56.0% of taTME operations. Surgical approach and tumor distance from the anal verge were the independent variables that directly influenced the detection of the TL (P = 0.03 and P = 0.01). Conclusion The TL is a visible sign where the transabdominal TME should end and the taTME should begin. Recognition of the mesorectal end may impact the certainty of complete mesorectum inclusion. Further clinical trials are needed to confirm the preliminary findings.
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Affiliation(s)
- Waleed M Ghareeb
- Department of Colon and Rectal Surgery, Union Hospital of Fujian Medical University, Fuzhou, Fujian, P. R. China.,Department of Surgery, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Xiaojie Wang
- Department of Colon and Rectal Surgery, Union Hospital of Fujian Medical University, Fuzhou, Fujian, P. R. China
| | - Xiaozhen Zhao
- Laboratory of Clinical Applied Anatomy, Fujian Medical University, Fuzhou, Fujian, P. R. China
| | - Meirong Xie
- Basic Medical College, Fujian Medical University, Fuzhou, Fujian, P. R. China
| | - Sameh H Emile
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA.,Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura, Egypt
| | - Sherief Shawki
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Pan Chi
- Department of Colon and Rectal Surgery, Union Hospital of Fujian Medical University, Fuzhou, Fujian, P. R. China
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Antoun A, Al Rashid F, Alhassan N, Gomez-Garibello C, Fiore JF, Feldman LS, Lee L, Mueller CL. Development of a formative feedback tool for transanal total mesorectal excision. Surg Endosc 2022; 36:6705-6711. [PMID: 34982229 DOI: 10.1007/s00464-021-08943-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 12/06/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Transanal total mesorectal excision (TaTME) is a novel procedure in the treatment of rectal cancer. Current training models for TaTME suggest a period of proctored cases, but no structured feedback tool exists to guide operators during the learning phase. The objective of this study therefore was to develop a formative feedback tool for the critical steps of the transanal portion of TaTME. METHODS A two-round Delphi study by TaTME experts was conducted to determine the items to be included in the formative feedback tool. Participants rated each step from a prepared list using a Likert scale from 1 (Not relevant) to 5 (Very relevant) with the option to suggest additional steps. Responses to the first round were presented in the second round, where participants rated the revised list of steps. Consensus was defined as > 80% of participants rating the step as 4 or 5 (out of 5). Items were combined when appropriate to avoid redundancy. Rating anchors describing performance (on a 5-point scale) were then developed for each step. The final tool was recirculated and participants rated the finished product on its feasibility and usefulness. RESULTS Twenty-six TaTME experts were contacted for participation. Fifteen experts (58%) participated in the first round of the study, and eleven (42%) participated in the second round. The majority (14, 93%) had completed fellowship training in colorectal surgery. The first round of the Delphi study contained 34 items, and 32 items met inclusion criteria after the second round. Redundant items were combined into 15 items that comprised the final tool. Out of eight respondents to the feasibility survey, all believed the feedback tool enhances the feedback of learners and would use it for training purposes if available. CONCLUSION This work describes the development of a novel consensus-based formative feedback tool specific to TaTME.
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Affiliation(s)
- Alen Antoun
- Department of Surgery, McGill University Health Centre and the Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1650 Cedar Ave, L8-505, Montreal, QC, H3G 1A4, Canada
| | - Faisal Al Rashid
- Department of Surgery, McGill University Health Centre and the Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1650 Cedar Ave, L8-505, Montreal, QC, H3G 1A4, Canada
| | - Noura Alhassan
- Department of Surgery, McGill University Health Centre and the Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1650 Cedar Ave, L8-505, Montreal, QC, H3G 1A4, Canada
- Department of Surgery, King Saud University, Riyadh, Saudi Arabia
| | | | - Julio F Fiore
- Department of Surgery, McGill University Health Centre and the Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1650 Cedar Ave, L8-505, Montreal, QC, H3G 1A4, Canada
| | - Liane S Feldman
- Department of Surgery, McGill University Health Centre and the Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1650 Cedar Ave, L8-505, Montreal, QC, H3G 1A4, Canada
| | - Lawrence Lee
- Department of Surgery, McGill University Health Centre and the Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1650 Cedar Ave, L8-505, Montreal, QC, H3G 1A4, Canada
| | - Carmen L Mueller
- Department of Surgery, McGill University Health Centre and the Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1650 Cedar Ave, L8-505, Montreal, QC, H3G 1A4, Canada.
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Naghawi H, Chau J, Madani A, Kaneva P, Monson J, Mueller C, Lee L. Development and evaluation of a virtual knowledge assessment tool for transanal total mesorectal excision. Tech Coloproctol 2022; 26:551-560. [PMID: 35503143 DOI: 10.1007/s10151-022-02621-0] [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: 09/15/2021] [Accepted: 04/10/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Transanal total mesorectal excision (TATME) is difficult to learn and can result in serious complications. Current paradigms for assessing performance and competency may be insufficient. This study aims to develop and provide preliminary validity evidence for a TATME virtual assessment tool (TATME-VAT) to assess the cognitive skills necessary to safely complete TATME dissection. METHODS Participants from North America, Europe, Japan and China completed the test via an interactive online platform between 11/2019 and 05/2020. They were grouped into expert, experienced and novice surgeons depending on the number of independently performed TATMEs. TATME-VAT is a 24-item web-based assessment evaluating advanced cognitive skills, designed according to a blueprint from consensus guidelines. Eight items were multiple choice questions. Sixteen items required making annotations on still frames of TATME videos (VCT) and were scored using a validated algorithm derived from experts' responses. Annotation (range 0-100), multiple choice (range 0-100), and overall scores (sum of annotation and multiple-choice scores, normalized to μ = 50 and σ = 10) were reported. RESULTS There were significant differences between the expert, experienced, and novice groups for the annotation (p < 0.001), multiple-choice (p < 0.001), and overall scores (p < 0.001). The annotation (p = 0.439) and overall (p = 0.152) scores were similar between the experienced and novice groups. Annotation scores were higher in participants with 51 or more vs. 30-50 vs. less than 30 cases. Scores were also lower in users with a self-reported recent complication vs. those without. CONCLUSIONS This study describes the development of an interactive video-based virtual assessment tool for TATME dissection and provides initial validity evidence for its use.
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Affiliation(s)
- Hamzeh Naghawi
- The Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University Health Center, Montreal, QC, Canada
| | - Johnny Chau
- The Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University Health Center, Montreal, QC, Canada
| | - Amin Madani
- The University Health Network - Toronto General Hospital, Toronto, ON, Canada
| | - Pepa Kaneva
- The Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University Health Center, Montreal, QC, Canada
| | - John Monson
- AdventHealth Medical Group, Orlando, FL, USA
| | - Carmen Mueller
- The Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University Health Center, Montreal, QC, Canada
| | - Lawrence Lee
- The Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University Health Center, Montreal, QC, Canada. .,Colon and Rectal Surgery, Department of Surgery, McGill University Health Centre, 1001 Decarie Boulevard, DS1-3310, Montreal, QC, H4A 3J1, Canada.
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Vannijvel M, Wolthuis AM. Limitations and Concerns with Transanal Total Mesorectal Excision for Rectal Cancer. Clin Colon Rectal Surg 2022; 35:141-145. [PMID: 35237110 PMCID: PMC8885157 DOI: 10.1055/s-0041-1742115] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Transanal total mesorectal excision (TaTME) was developed to overcome the technical challenges of a minimally invasive (ultra-) low anterior resection. This new technique has recently come under careful scrutiny as technical pitfalls were reported, in specific relation to the transanal approach. Patients are at risk for urologic lesions. Moreover, carbon dioxide embolism is a rare but potentially life-threatening complication. The benefit of TaTME from an oncological point of view has neither been clarified. Hypothetically, better visualization of the lower rectum could lead to better dissection and total mesorectal excision (TME) specimens, resulting in better oncologic results. Up until now, retrospective multicenter reports seem to show that short-term oncologic results are not inferior after TaTME as compared with after laparoscopic TME. Alarming reports have however been published from Norway suggesting a high incidence and particular multifocal pattern of early local recurrence. In this article, a balanced overview is given of the most important technical pitfalls and oncological concerns arising with this new procedure.
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Affiliation(s)
- M. Vannijvel
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Albert M. Wolthuis
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium,Address for correspondence Albert M. Wolthuis, MD, PhD Department of Abdominal Surgery, University Hospital LeuvenHerestraat 49, 3000 LeuvenBelgium
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Grieco M, Elmore U, Vignali A, Caristo ME, Persiani R. Surgical Training for Transanal Total Mesorectal Excision in a Live Animal Model: A Preliminary Experience. J Laparoendosc Adv Surg Tech A 2022; 32:866-870. [PMID: 35148492 DOI: 10.1089/lap.2021.0845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: In this preliminary experience, the feasibility and effectiveness of surgical training with an animal model for transanal total mesorectal excision (TaTME) were evaluated. Methods: The training was conducted in two experimental animal laboratories in Italy authorized by the Italian Ministry of Health, using female Danish Landrace pigs under the supervision of surgeons with extensive experience in TaTME, animal laboratory training and cadaver laboratory training. The procedure was divided into separate steps, and all the participants were guided step-by-step throughout the entirety of the procedure. Results: During all the editions of the animal laboratory, all the procedures were completed with no major damage to the anatomical structures or intraoperative death of the animals. Live animal tissue is very similar to human tissue, helping trainees improve their tactile feedback. The bleeding effect improved the value of the training and taught the participants how to address this complication. The lack of mesorectal tissue in pigs compared with humans was the main difference. Animal laboratories should not be considered alternatives to cadaver laboratories but as complementary training activities due to their effectiveness and lower costs. Conclusions: Surgical training in animal models for TaTME seems to be effective and could be an opportunity to improve training alongside the use of a cadaver laboratory and proctoring.
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Affiliation(s)
- Michele Grieco
- Department of General Surgery, Fondazione Policlinico Universitario "A. Gemelli"-IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Ugo Elmore
- Department of Gastrointestinal Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Andrea Vignali
- Department of Gastrointestinal Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria Emiliana Caristo
- Fondazione Policlinico Universitario "A. Gemelli"-IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Roberto Persiani
- Department of General Surgery, Fondazione Policlinico Universitario "A. Gemelli"-IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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Stitzenberg KB. Advances in Rectal Cancer Surgery. Clin Colorectal Cancer 2022; 21:55-62. [DOI: 10.1016/j.clcc.2022.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 01/18/2022] [Accepted: 01/20/2022] [Indexed: 12/16/2022]
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Oshio H, Oshima Y, Yunome G, Okazaki S, Kawamura I, Ashitomi Y, Musha H, Kawai M, Motoi F. Transanal total mesorectal excision and transabdominal robotic surgery for rectal cancer: A retrospective study. Ann Med Surg (Lond) 2021; 70:102902. [PMID: 34691436 PMCID: PMC8519803 DOI: 10.1016/j.amsu.2021.102902] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 09/28/2021] [Accepted: 09/28/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Transabdominal robotic surgery and transanal total mesorectal excision (TaTME) are newly introduced strategies for rectal cancer. These procedures might have many advantages in rectal cancer treatment in terms of improving oncological and functional outcomes, especially in cases involving advanced cancer or technical difficulty. In the present study, we aimed to clarify the advantages and disadvantages of transabdominal robotic surgery and laparoscopic TaTME as a hybrid surgery for rectal cancer. MATERIALS AND METHODS We retrospectively evaluated six patients who underwent hybrid surgery for rectal cancer from August 2018 to April 2020. Both clinical and pathological outcomes were assessed. RESULTS Two patients showed circumferential margin involvement both before and after neoadjuvant therapy. Three patients were planned to undergo hybrid surgery with intersphincteric resection because of a narrow pelvis. One patient was planned to undergo hybrid surgery for a giant tumor of >10 cm. The median length of hospitalization was 17 days. No patients required conversion to an open procedure. All patients underwent formation of defunctioning ileostomies. Two patients had a stapled anastomosis and four had a hand-sewn coloanal anastomosis. Complications included one case of anastomotic leakage, which was managed conservatively with ultrasound- and computed tomography-guided drainage and antibiotics. Histological analysis revealed that all specimens had a negative radial margin and distal margin. The median number of lymph nodes harvested was 17.5. Two patients showed extensive lymph node metastases, including lateral node metastasis. CONCLUSION Hybrid surgery was performed safely and may improve oncological outcomes for rectal cancer. This technique has many potential benefits and would be alternative option in multimodal strategies for rectal cancer.
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Affiliation(s)
- Hiroshi Oshio
- Department of Surgery I, Yamagata University Hospital, 2-2-2 Iidanishi, Yamagata, Yamagata Prefecture, 990-9585, Japan
- Department of Surgery, Sendai Medical Center, 2-11-12 Miyagino, Miyagino-ku, Sendai, Miyagi Prefecture, 983-8520, Japan
| | - Yukiko Oshima
- Department of Surgery, Sendai Medical Center, 2-11-12 Miyagino, Miyagino-ku, Sendai, Miyagi Prefecture, 983-8520, Japan
| | - Gen Yunome
- Department of Surgery, Sendai Medical Center, 2-11-12 Miyagino, Miyagino-ku, Sendai, Miyagi Prefecture, 983-8520, Japan
| | - Shinji Okazaki
- Department of Surgery I, Yamagata University Hospital, 2-2-2 Iidanishi, Yamagata, Yamagata Prefecture, 990-9585, Japan
| | - Ichiro Kawamura
- Department of Surgery I, Yamagata University Hospital, 2-2-2 Iidanishi, Yamagata, Yamagata Prefecture, 990-9585, Japan
| | - Yuya Ashitomi
- Department of Surgery I, Yamagata University Hospital, 2-2-2 Iidanishi, Yamagata, Yamagata Prefecture, 990-9585, Japan
| | - Hiroaki Musha
- Department of Surgery I, Yamagata University Hospital, 2-2-2 Iidanishi, Yamagata, Yamagata Prefecture, 990-9585, Japan
| | - Masaaki Kawai
- Department of Surgery I, Yamagata University Hospital, 2-2-2 Iidanishi, Yamagata, Yamagata Prefecture, 990-9585, Japan
| | - Fuyuhiko Motoi
- Department of Surgery I, Yamagata University Hospital, 2-2-2 Iidanishi, Yamagata, Yamagata Prefecture, 990-9585, Japan
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Transperineal minimally invasive abdominoperineal resection for low rectal cancer: standardized technique and clinical outcomes. Surg Endosc 2021; 35:7236-7245. [PMID: 34254186 DOI: 10.1007/s00464-021-08633-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 07/05/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Despite the increasing utilization of transanal total mesorectal excision as a promising approach for low rectal cancer, the feasibility and safety of transperineal minimally invasive abdominoperineal resection (tp-APR) remain unclear. METHODS In total, 25 patients who underwent tp-APR between April 2017 and May 2020 (tp-APR group) and 27 patients who underwent conventional laparoscopic APR between May 2009 and September 2016 (lap-APR group) for low rectal cancer were enrolled in this retrospective study. Clinical outcomes were compared between the groups before and after propensity score matching. The primary outcome was the incidence of the overall postoperative complications with Clavien-Dindo grade II or above. Standardized technique of tp-APR was also demonstrated. RESULTS On comparison, operative time, intraoperative blood loss, and overall postoperative complications with Clavien-Dindo grade II or above were significantly less in the tp-APR group both before and after propensity score matching. The rates of urinary disturbance and perineal wound infection were significantly less in the tp-APR group after matching. Further, postoperative hospital stay was significantly shorter in the tp-APR group both before and after matching. However, pathological outcomes did not differ between the groups before and after matching. There has been no local recurrence in the tp-APR group with a median follow-up period of 18 months. CONCLUSION Standardized tp-APR for low rectal cancer is feasible and seems superior to conventional laparoscopic APR in terms of short-term outcomes. Further larger-scale studies with a longer follow-up period are required to evaluate oncological outcomes.
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Wang J, Liu X, Hu B, Gao Y, Chen J, Li J. Development and validation of an MRI-based radiomic nomogram to distinguish between good and poor responders in patients with locally advanced rectal cancer undergoing neoadjuvant chemoradiotherapy. Abdom Radiol (NY) 2021; 46:1805-1815. [PMID: 33151359 DOI: 10.1007/s00261-020-02846-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 10/25/2020] [Accepted: 10/29/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE In the clinical management of patients with locally advanced rectal cancer (LARC), the early identification of poor and good responders after neoadjuvant chemoradiotherapy (N-CRT) is essential. Therefore, we developed and validated predictive models including MRI findings from the structured report template, clinical and radiomics parameters to differentiate between poor and good responders in patients with locally advanced rectal cancer who underwent neoadjuvant chemoradiotherapy. METHODS Preoperative multiparametric MRI from 183 patients with locally advanced rectal cancer (122 in the training cohort, 61 in the validation cohort) was included in this retrospective study. After preprocessing, radiomic features were extracted and two methods of feature selection was applied to reduce the number of radiomics features. Logistic regression (LR) and random forest (RF) machine learning classifiers were trained to identify good responders from poor responders. Multivariable logistic regression analysis was used to incorporate the radiomic signature and clinical risk factors into a nomogram. Classifier performance was evaluated using the area under the curve (AUC), accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). RESULTS For the differentiation of poor and good responders, the radiomics model with an LR classifier achieved AUCs of 0.869 and 0.842 for the training and validation cohorts, respectively. The nomogram showed the highest reproducibility and prognostic ability in the training and validation cohorts, with AUCs of 0.923 (95% confidence interval, 0.872-0.975) and 0.898 (0.819-0.978), respectively. Additionally, the nomogram achieved significant risk stratification of patients in respect to progression free survival (PFS). CONCLUSIONS The nomogram accurately differentiated good and poor responders in patients with LARC undergoing N-CRT, and showed significant performance for predicting PFS.
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Affiliation(s)
- Jia Wang
- Department of Ultrasound, Qingdao Women and Children Hospital, Qingdao, Shandong, China
| | - Xuejun Liu
- Department of Radiology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, Shandong, China
| | - Bin Hu
- Department of Radiology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, Shandong, China
| | - Yuanxiang Gao
- Department of Radiology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, Shandong, China
| | - Jingjing Chen
- Department of Radiology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, Shandong, China
| | - Jie Li
- Department of Radiology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, Shandong, China.
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12
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Grieco M, Tirelli F, Agnes A, Santocchi P, Biondi A, Persiani R. High-pressure CO 2 insufflation is a risk factor for postoperative ileus in patients undergoing TaTME. Updates Surg 2021; 73:2181-2187. [PMID: 33811314 DOI: 10.1007/s13304-021-01043-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 03/24/2021] [Indexed: 11/26/2022]
Abstract
The aim of this study is to evaluate the influence of high-pressure CO2 insufflation during TaTME on the occurrence of postoperative ileus. All patients undergoing elective transanal total mesorectal excision (TaTME) between April 2015 and March 2019 were included in a prospective database. Eligible patients were adults with mid and low-level rectal cancer undergoing elective TaTME with colorectal anastomosis and diverting ileostomy, following a standardized ERAS pathway. Patients were divided into a low-pressure (LP) group, where surgery was performed with an intrabdominal CO2 pressure of 12 mmHg, and a high-pressure (HP) group, where the intrabdominal pressure reached 15 mmHg of CO2 once the two surgical fields were connected. Of 98 patients undergoing TaTME in the observed period, 74 met the inclusion criteria and were included in this study. There was no significant difference in postoperative complications between the LP and HP groups, except for postoperative ileus, which occurred in seven patients (13.2%) in the LP group and seven patients (33.3%) in the HP group (p value 0.046). The logistic multivariate analysis showed that a high intraabdominal CO2 pressure (OR 7040, 95% CI 1591-31,164, p value 0.01) and male sex (OR 10,343, 95% CI 1078-99,256, p value 0.043) were significantly associated with postoperative ileus after TaTME. Intraabdominal CO2 pressure should be carefully set, as it may represent a risk factor for postoperative ileus in patients undergoing TaTME.
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Affiliation(s)
- Michele Grieco
- General Surgery Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma-Università Cattolica del Sacro Cuore, L.go A. Gemelli 8, 00168, Rome, Italy.
| | - Flavio Tirelli
- General Surgery Department, Fondazione Policlinico Universitario A Gemelli IRCCS Roma, L.go A. Gemelli 8, 00168, Rome, Italy
| | - Annamaria Agnes
- General Surgery Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma-Università Cattolica del Sacro Cuore, L.go A. Gemelli 8, 00168, Rome, Italy
| | - Pietro Santocchi
- General Surgery Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma-Università Cattolica del Sacro Cuore, L.go A. Gemelli 8, 00168, Rome, Italy
| | - Alberto Biondi
- General Surgery Department, Fondazione Policlinico Universitario A Gemelli IRCCS Roma, L.go A. Gemelli 8, 00168, Rome, Italy
| | - Roberto Persiani
- General Surgery Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma-Università Cattolica del Sacro Cuore, L.go A. Gemelli 8, 00168, Rome, Italy
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13
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Multicenter investigation of bowel evacuation function after transanal total mesorectal excision for mid-low rectal cancer. Int J Colorectal Dis 2021; 36:725-734. [PMID: 33392665 DOI: 10.1007/s00384-020-03824-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/16/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE To determine the effect of transanal total mesorectal excision (taTME) procedure on the postoperative bowel evacuation function of patients with low rectal cancer. METHODS Bowel evacuation function was investigated in 316 patients with rectal cancer after taTME in 18 hospitals in China. Low anterior resection syndrome (LARS) score, Wexner score, and EORTC QLQ-C30 were used for functional evaluation. The association between perioperative risk factors and LARS score was determined by univariate and multivariate analyses. RESULTS The prevalence rate of no LARS, minor LARS, and major LARS in patients after taTME was 39.9%, 28.2%, and 31.9%, respectively. The two most frequently reported symptoms of LARS after taTME were bowel clustering (72.8%) and fecal urgency (63.3%). Patients with major LARS had significantly higher Wexner score and worse global health status and financial difficulties according to the EORTC QLQ-C30 questionnaire than those without major LARS. Preoperative chemoradiotherapy was an independent risk factor of major LARS occurrence after taTME (OR: 3.503, P = 0.044); existing preoperative constipation (OR: 0.082, P = 0.040) and manual anastomosis (OR: 4.536, P = 0.021) were favorable factors affecting bowel evacuatory function within 12 months after taTME, but for patients whose follow-up time was longer than 12 months, postoperative chemoradiotherapy (OR: 8.790, P = 0.001) and defunctioning stoma (OR: 3.962, P = 0.010) were independent risk factors. CONCLUSIONS The bowel evacuation function after taTME is acceptable. Perioperative chemoradiotherapy, anastomotic method, and preoperative constipation are factors associated with bowel dysfunction after taTME.
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14
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Keller DS, de Lacy FB, Hompes R. Education and Training in Transanal Endoscopic Surgery and Transanal Total Mesorectal Excision. Clin Colon Rectal Surg 2021; 34:163-171. [PMID: 33814998 DOI: 10.1055/s-0040-1718682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
There is a paradigm shift in surgical training, and new tool and technology are being used to facilitate mastery of the content and technical skills. The transanal procedures for rectal cancer-transanal endoscopic surgery (TES) and transanal total mesorectal excision (TaTME)-have a distinct learning curve for competence in the procedures, and require special training for familiarity with the "bottom-up" anatomy, procedural risks, and managing complex cases. These procedures have been models for structured education and training, using multimodal tools, to ensure safe implementation of TES and TaTME into clinical practice. The goal of this work was to review the current state of surgical education, the introduction and learning curve of the TES and TaTME procedures, and the established and future models for education of the transanal procedures for rectal cancer.
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Affiliation(s)
- Deborah S Keller
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - F Borja de Lacy
- Department of Gastrointestinal Surgery, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Roel Hompes
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherland
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15
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Re-exploring the pelvic neuroanatomy from a new perspective and a potential guidance for TaTME: a "bottom-up" approach. Updates Surg 2021; 73:503-512. [PMID: 33534125 DOI: 10.1007/s13304-020-00968-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 12/27/2020] [Indexed: 12/15/2022]
Abstract
Neuro-anatomy of the perineum has gained renewed attention due to its significance in the transanal procedures for rectal cancer (eg TaTME). Surgeons embarking on this technique must have sophisticated knowledge and a precise anatomical understanding of the perineum before proceeding with this reversed rectal approach. We report anatomical observations deriving from a relevant experience in the colorectal surgery field. The collective multicenter experience of the present study is clinically relevant and based on the rectal and transanal resections performed in colorectal centers of excellence from Greece, UK, and Italy over the last 10 years (2011-2020). From the original anatomical and intraoperative observations derived from collective cases operated by this multicenter group of colorectal surgical centers in three European countries, data were retrieved and analyzed in collaboration with specialist researchers of human anatomy and interpreted for their clinical significance and potential use for preoperative planning and intraoperative guidance during TaTME. This descriptive article demonstrates in detail the neurogenic pathways encountered in the perineum and pelvic cavity during transanal procedures. Specific anatomical and topographic implications are also included serving as a guide for colorectal surgeons to perform a nerve-sparing procedure. transanal approach for rectal excision offers new insights into the complex pelvic and perineal neuroanatomy while the procedure itself remains a challenge for surgeons. Preoperative anatomical planning and 3D reconstruction may help in anticipating technical difficulties, resulting in more precise surgical dissections and decreased postoperative complications.
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16
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Martín-Pérez B, Dar R, Bislenghi G, Stijns J, Grégoir T, Wolthuis AM, D Hoore A. Transanal Minimally Invasive Proctectomy With Two-Stage Turnbull-Cutait Pull-Through Coloanal Anastomosis for Iatrogenic Rectourethral Fistulas. Dis Colon Rectum 2021; 64:e26-e29. [PMID: 33394768 DOI: 10.1097/dcr.0000000000001850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Rectourethral fistula is an uncommon pathology, usually iatrogenic, occurring as a complication of surgical or ablative treatments for prostate or rectal cancer. Among other surgical techniques, restorative ultralow rectal anterior resection may be an option of last resort to achieve fistula closure avoiding the need for a permanent stoma. This article aims to describe a transanal minimally invasive-assisted Turnbull-Cutait technique for radiated rectourethral fistulas with a complementary video. TECHNIQUE Turnbull-Cutait pull-through with delayed coloanal anastomosis technique with a proctectomy by transanal minimally invasive surgery and loop ileostomy was performed in 3 patients who developed delayed rectourethral fistula after prostate cancer treatment. Ileostomy was reversed after fistula closure confirmation. RESULTS The first patient had brachytherapy with no surgery. The second patient had radical prostatectomy and adjuvant radiotherapy, developing the fistula after a pelvic abscess drained transrectally. The third patient underwent prostatectomy and brachytherapy, developing the fistula after transanal endoscopic microsurgery resection of a rectal villous polyp. Surgical intervention and postoperative recovery was uneventful. Fistula closure was confirmed in the 3 cases, and all ileostomies were closed without further recurrence at follow-up. CONCLUSIONS Transanal minimally invasive proctectomy-assisted Turnbull-Cutait procedure for the treatment of rectourethral fistula is a new combination of already existing techniques, enabling the creation of safe colorectal anastomosis in high-risk cases. Given the difficulty obtaining healing with sphincter preservation in cases of postradiation rectourethral fistula, this technique aids in fistula closure and restoration of the intestinal continuity, and potentially represents an added resource in the surgical armamentarium for this challenging pathology.
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Affiliation(s)
- Beatriz Martín-Pérez
- Department of Abdominal Surgery, University Hospitals Gasthuisberg, Leuven, Belgium
| | - Ron Dar
- Emek Medical Center, Afula, Israel
| | - Gabriele Bislenghi
- Department of Abdominal Surgery, University Hospitals Gasthuisberg, Leuven, Belgium
| | - Jasper Stijns
- Department of Abdominal Surgery, University Hospitals Gasthuisberg, Leuven, Belgium
| | - Tine Grégoir
- Department of Abdominal Surgery, University Hospitals Gasthuisberg, Leuven, Belgium
| | - Albert M Wolthuis
- Department of Abdominal Surgery, University Hospitals Gasthuisberg, Leuven, Belgium
| | - André D Hoore
- Department of Abdominal Surgery, University Hospitals Gasthuisberg, Leuven, Belgium
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17
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Shen JM, Zhao JY, Ye T, Gong LF, Wang HP, Chen WJ, Cai YK. Transanal minimally invasive surgery vs endoscopic mucosal resection for rectal benign tumors and rectal carcinoids: A retrospective analysis. World J Clin Cases 2020; 8:4311-4319. [PMID: 33083390 PMCID: PMC7559669 DOI: 10.12998/wjcc.v8.i19.4311] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 07/01/2020] [Accepted: 08/29/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Transanal minimally invasive surgery (TAMIS) is a good choice for resection of rectal neoplasms. Endoscopic mucosal resection (EMR) is also widely used in the treatment of benign rectal tumors such as rectal polyps and rectal adenomas. However, no studies have compared the outcome of TAMIS and EMR.
AIM To compare the short-term outcomes after TAMIS and EMR for rectal carcinoid and benign tumors (including rectal polyps and adenomas).
METHODS From January 2014 to January 2019, 44 patients who received TAMIS and 53 patients who received EMR at The Fifth People’s Hospital of Shanghai were selected. Primary outcomes (surgical-related) were operating time, blood loss, length of postoperative hospital stay, rate of resection margin involvement and lesion fragmentation rate. The secondary outcomes were complications such as hemorrhage, urinary retention, postoperative infection and reoperation.
RESULTS No significant differences were observed in terms of blood loss (12.48 ± 8.00 mL for TAMIS vs 11.45 ± 7.82 mL for EMR, P = 0.527) and length of postoperative hospital stay (3.50 ± 1.87 d for TAMIS vs 2.72 ± 1.98 d for EMR, P = 0.065) between the two groups. Operating time was significantly shorter for EMR compared with TAMIS (21.19 ± 9.49 min vs 49.95 ± 15.28 min, P = 0.001). The lesion fragmentation rate in the EMR group was 22.6% (12/53) and was significantly higher than that (0%, 0/44) in the TAMIS group (P = 0.001). TAMIS was associated with a higher urinary retention rate (13.6%, 6/44 vs 1.9%, 1/53 P = 0.026) and lower hemorrhage rate (0%, 0/44 vs 18.9%, 10/53 P = 0.002). A significantly higher reoperation rate was observed in the EMR group (9.4%, 5/53 vs 0%, 0/44 P = 0.036).
CONCLUSION Compared with EMR, TAMIS can remove lesions more completely with effective hemostasis and lower postoperative hemorrhage and reoperation rates. TAMIS is a better choice for the treatment of rectal carcinoids.
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Affiliation(s)
- Jia-Men Shen
- Department of General Surgery, Shanghai Fifth People’s Hospital, Fudan University, Shanghai 200240, China
| | - Jia-Ying Zhao
- Department of General Surgery, Shanghai Fifth People’s Hospital, Fudan University, Shanghai 200240, China
| | - Tao Ye
- Department of General Surgery, Shanghai Fifth People’s Hospital, Fudan University, Shanghai 200240, China
| | - Li-Feng Gong
- Department of General Surgery, Shanghai Fifth People’s Hospital, Fudan University, Shanghai 200240, China
| | - Hui-Peng Wang
- Department of General Surgery, Shanghai Fifth People’s Hospital, Fudan University, Shanghai 200240, China
| | - Wen-Jie Chen
- Department of General Surgery, Shanghai Fifth People’s Hospital, Fudan University, Shanghai 200240, China
| | - Yuan-Kun Cai
- Department of General Surgery, Shanghai Fifth People’s Hospital, Fudan University, Shanghai 200240, China
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18
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Al-Taher M, Knapen B, Barberio M, Felli E, Gioux S, Bouvy ND, Stassen LPS, Marescaux J, Diana M. Near infrared fluorescence imaging of the urethra: a systematic review of the literature. MINIM INVASIV THER 2020; 31:342-349. [PMID: 33000653 DOI: 10.1080/13645706.2020.1826974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Urethral injury is a dreaded complication during laparoscopic, perineal and transanal surgery and is mainly a result of a failed visualization of the urethra. The aim of this systematic review is to provide an overview of the available literature on the near-infrared fluorescence (NIRF) imaging technique using contrast agents for the intra-operative visualization of the urethra. MATERIAL AND METHODS A systematic review of the literature was conducted including studies on NIRF imaging using contrast agents to visualize the urethra. All studies describing a NIRF imaging technique and demonstrating visual findings of the urethra were included. RESULTS Five studies were identified. Four studies examined indocyanine green, one of which also studied the IRDye® 800BK agent and one examined the CP-IRT dye. All studies showed that the NIRF imaging technique was feasible for an early identification of the urethra. No complications related to NIRF imaging were reported. CONCLUSION We conclude that the use of a NIRF imaging technique is feasible and that it can contribute to prevent iatrogenic injury to the urethra. However, based on the limited available data, no solid conclusion can yet be drawn and further translation to the clinical practice is necessary.
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Affiliation(s)
- Mahdi Al-Taher
- Institute of Image-Guided Surgery, IHU-Strasbourg, Strasbourg, France.,Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Bob Knapen
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Manuel Barberio
- Institute of Image-Guided Surgery, IHU-Strasbourg, Strasbourg, France
| | - Eric Felli
- Institute of Image-Guided Surgery, IHU-Strasbourg, Strasbourg, France
| | - Sylvain Gioux
- Institute of Image-Guided Surgery, IHU-Strasbourg, Strasbourg, France.,Photonics Instrumentation for Health, ICUBE Laboratory, Strasbourg, France
| | - Nicole D Bouvy
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Laurents P S Stassen
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jacques Marescaux
- Research Institute Against Cancer of the Digestive System, IRCAD, Strasbourg, France
| | - Michele Diana
- Institute of Image-Guided Surgery, IHU-Strasbourg, Strasbourg, France.,Photonics Instrumentation for Health, ICUBE Laboratory, Strasbourg, France.,Research Institute Against Cancer of the Digestive System, IRCAD, Strasbourg, France
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19
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A comparative cost analysis of transanal and laparoscopic total mesorectal excision for rectal cancer. Updates Surg 2020; 73:85-91. [PMID: 32929690 DOI: 10.1007/s13304-020-00879-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 08/30/2020] [Indexed: 02/07/2023]
Abstract
Despite proven clinical benefits in the short term, technical difficulties limit utilization of laparoscopy in rectal cancer surgery (RCS). Transanal Total Mesorectal Excision (taTME) overcomes many technical limitations of laparoscopic RCS. However, the costs of this procedure have not been addressed yet. Our goal was to perform a comparative cost analysis of taTME and laparoscopic TME (lapTME). Consecutive patients undergoing curative TME between 1 February 2014 and 31 October 2018 were selected from a prospectively maintained database and stratified, according to the type of procedure, into taTME and lapTME groups. Patient demographics, tumour characteristics, operative parameters, and short-term outcomes were analyzed. The main outcome measure was intraoperative costs of the two procedures. Secondary outcomes were short-term outcome and the utilization of hospital resources to manage the postoperative course. Hundred and fifty-two patients with rectal cancer (66 lapTME, 86 taTME) were included in the study. Surgical supplies required for taTME procedure exceeded the cost of lapTME of 754,54 €. The duration of surgery was not significantly different between the two approaches (266 ± 92.85 vs 271 ± 83.63, p = 0.50). Short-term outcomes were comparable including postoperative complication rate (17 vs 20%, p = 0.68), reintervention rate, and length of stay. There was no difference in hospital resources utilization to manage postoperative course including blood test, diagnostics, consultations, and medications. TaTME has higher intraoperative costs in terms of supplies with respect to lapTME. Short-term outcomes and hospital resources to manage postoperative course are comparable.
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20
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Lu YJ, Chen CH, Lin EK, Wu SY. Neoadjuvant concurrent chemoradiotherapy followed by transanal total mesorectal excision assisted by single-port laparoscopic surgery for low-lying rectal adenocarcinoma: a single center study. World J Surg Oncol 2020; 18:198. [PMID: 32782005 PMCID: PMC7422550 DOI: 10.1186/s12957-020-01980-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 07/31/2020] [Indexed: 11/10/2022] Open
Abstract
Purpose To assess the feasibility and short-term outcomes of neoadjuvant chemoradiotherapy (CCRT) followed by transanal total mesorectal excision assisted by single-port laparoscopic surgery (TaTME-SPLS) for low-lying rectal adenocarcinoma. Methods and materials A total of 23 patients with clinical stage II-III low-lying (from anal verge 0-8 cm) rectal adenocarcinoma who underwent neoadjuvant CCRT followed by TaTME-SPLS consecutively from December 2015 to December 2018, were enrolled into our study. Chi-squared testing and Student’s t testing were used to make parametric comparisons, and Fisher’s exact test or the Mann–Whitney U test were used to make nonparametric comparisons. Results Conversion rate in patients who underwent neoadjuvant CCRT followed by TaTME-SPLS was only 4%. The mean operation time was 366 min and the inter-sphincter resection (ISR) was done for 14 patients (60%). The mean number of lymph nodes harvested was 15. There was no surgical mortality, but the 30-day morbidity rate was 21% (5 patients were Clavien-Dindo I-II). Pathological complete response was 21.74% with 100% organ preservation and 100% clear distal margin after neoadjuvant CCRT followed by TaTME-SPLS. Conclusion TaTME-SPLS would be highly successful in lymph node negative and low T stage of low-lying rectal cancer patients who had pathological complete remission or high percentage of partial remission after neoadjuvant CCRT.
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Affiliation(s)
- Yen-Jung Lu
- Department of Colorectal Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Chien-Hsin Chen
- Department of Colorectal Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - En-Kwang Lin
- Department of Colorectal Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Szu-Yuan Wu
- Department of Food Nutrition and Health Biotechnology, College of Medical and Health Science, Asia University, Taichung, Taiwan. .,Division of Radiation Oncology, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, No. 83, Nanchang St., Luodong Township, Yilan County, 265, Taiwan. .,Big Data Center, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan, Taiwan. .,Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taichung, Taiwan. .,Cancer Center, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan, Taiwan. .,School of Dentistry, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan.
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21
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Bokey L, Zhang M, Fingerhut A, Dent OF, Chapuis PH. Trans-anal total mesorectal excision - reflections on the introduction of a new procedure. Colorectal Dis 2020; 22:739-744. [PMID: 32533809 DOI: 10.1111/codi.15190] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 04/24/2020] [Indexed: 02/08/2023]
Affiliation(s)
- L Bokey
- Department of Colorectal Surgery and Department of Surgery, Liverpool Hospital, Liverpool, New South Wales, Australia.,School of Medicine, Western Sydney University, Penrith, New South Wales, Australia
| | - M Zhang
- Department of Anatomy, University of Otago, Otago, New Zealand
| | - A Fingerhut
- Department of Surgery, Medical University of Graz, Graz, Austria.,Department of General Surgery, Shanghai Minimally Invasive Surgery Centre, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - O F Dent
- School of Medicine, Western Sydney University, Penrith, New South Wales, Australia
| | - P H Chapuis
- School of Medicine, Western Sydney University, Penrith, New South Wales, Australia
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22
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Chau JK, Bilgic E, Hada T, Trepanier M, Naghawi H, Kaneva P, Mueller C, Lee L. Development and validation of a transanal endoscopic rectal purse string simulator. Tech Coloproctol 2020; 24:863-871. [PMID: 32504373 DOI: 10.1007/s10151-020-02251-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 05/25/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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 ± 1.4 min vs 9.0 ± 4.8 min, 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). CONCLUSIONS A transanal endoscopic purse string simulator was constructed and preliminary testing has shown variable performance based on prior laparoscopic suturing experience.
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Affiliation(s)
- J K Chau
- Department of Surgery, Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1001 Decarie Boulevard, DS1-3310, Montreal, QC, H4A 3J1, Canada.,Department of Surgery, Centre for Colon and Rectal Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - E Bilgic
- Department of Surgery, Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1001 Decarie Boulevard, DS1-3310, Montreal, QC, H4A 3J1, Canada.,Steinberg Centre for Simulation and Interactive Learning, McGill University, Montreal, QC, Canada
| | - T Hada
- Department of Surgery, Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1001 Decarie Boulevard, DS1-3310, Montreal, QC, H4A 3J1, Canada
| | - M Trepanier
- Department of Surgery, Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1001 Decarie Boulevard, DS1-3310, Montreal, QC, H4A 3J1, Canada
| | - H Naghawi
- Department of Surgery, Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1001 Decarie Boulevard, DS1-3310, Montreal, QC, H4A 3J1, Canada
| | - P Kaneva
- Department of Surgery, Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1001 Decarie Boulevard, DS1-3310, Montreal, QC, H4A 3J1, Canada
| | - C Mueller
- Department of Surgery, Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1001 Decarie Boulevard, DS1-3310, Montreal, QC, H4A 3J1, Canada
| | - L Lee
- Department of Surgery, Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 1001 Decarie Boulevard, DS1-3310, Montreal, QC, H4A 3J1, Canada. .,Department of Surgery, Centre for Colon and Rectal Surgery, McGill University Health Centre, Montreal, QC, Canada.
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23
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Kitaguchi D, Takeshita N, Matsuzaki H, Hasegawa H, Honda R, Teramura K, Oda T, Ito M. Computer-assisted real-time automatic prostate segmentation during TaTME: a single-center feasibility study. Surg Endosc 2020; 35:2493-2499. [PMID: 32430531 DOI: 10.1007/s00464-020-07659-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 05/15/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND Urethral injuries (UIs) are significant complications pertaining to transanal total mesorectal excision (TaTME). It is important for surgeons to identify the prostate during TaTME to prevent UI occurrence; intraoperative image navigation could be considered useful in this regard. This study aims at developing a deep learning model for real-time automatic prostate segmentation based on intraoperative video during TaTME. The proposed model's performance has been evaluated. METHODS This was a single-institution retrospective feasibility study. Semantic segmentation of the prostate area was performed using a convolutional neural network (CNN)-based approach. DeepLab v3 plus was utilized as the CNN model for the semantic segmentation task. The Dice coefficient (DC), which is calculated based on the overlapping area between the ground truth and predicted area, was utilized as an evaluation metric for the proposed model. RESULTS Five hundred prostate images were randomly extracted from 17 TaTME videos, and the prostate area was manually annotated on each image. Fivefold cross-validation tests were performed, and as observed, the average DC value equaled 0.71 ± 0.04, the maximum value being 0.77. Additionally, the model operated at 11 fps, which provides acceptable real-time performance. CONCLUSIONS To the best of the authors' knowledge, this is the first effort toward realization of computer-assisted TaTME, and results obtained in this study suggest that the proposed deep learning model can be utilized for real-time automatic prostate segmentation. In future endeavors, the accuracy and performance of the proposed model will be improved to enable its use in practical applications, and its capability to reduce UI risks during TaTME will be verified.
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Affiliation(s)
- Daichi Kitaguchi
- Surgical Device Innovation Office, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.,Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.,Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Nobuyoshi Takeshita
- Surgical Device Innovation Office, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan. .,Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
| | - Hiroki Matsuzaki
- Surgical Device Innovation Office, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Hiro Hasegawa
- Surgical Device Innovation Office, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.,Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Ryoya Honda
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Koichi Teramura
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Tatsuya Oda
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Masaaki Ito
- Surgical Device Innovation Office, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan. .,Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
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Izquierdo KM, Salem JF, Cha E, Unal E, Marks JH. Transanal Surgery: A History of taTME Ancestry. Clin Colon Rectal Surg 2020; 33:128-133. [PMID: 32351335 PMCID: PMC7188499 DOI: 10.1055/s-0039-1698395] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Transanal total mesorectal excision (taTME) is the culmination of major developments in rectal cancer management and minimally invasive surgery. This surgical breakthrough holds great promise and excitement for the care of the rectal cancer patient. We would be remiss in discussing taTME to not acknowledge the role of transanal abdominal transanal proctosigmoidectomy, transanal endoluminal microsurgery, laparoscopy, and natural orifice transluminal endoscopic surgery that got us to this modern day explosion of the taTME approach. In this article, we detail and explain the convergence of these disparate experiences, how they culminated in the development of the taTME, and explore future directions in this field.
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Affiliation(s)
- Kevin M. Izquierdo
- Division of Colorectal Surgery, Lankenau Medical Center, Wynnewood, Pennsylvania
| | - Jean F. Salem
- Division of Colorectal Surgery, Lankenau Medical Center, Wynnewood, Pennsylvania
| | - Esther Cha
- Department of Surgery, MedStar Union Memorial Hospital, Baltimore, Maryland
| | - Ece Unal
- Division of Colorectal Surgery, Lankenau Medical Center, Wynnewood, Pennsylvania
| | - John H. Marks
- Division of Colorectal Surgery, Lankenau Medical Center, Wynnewood, Pennsylvania
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Abstract
The role of transanal total mesorectal excision (taTME) in minimally invasive proctectomy, especially rectal cancer surgery, is increasing. There has been exponential growth in uptake from the initial in vivo case in 2010 to the present day. Early adopters of taTME are well within the mature portions of their learning curve, but there are a significant number of novice taTME surgeons. We have overviewed the critical aspects of patient selection, operating room set-up, and necessary equipment. In particular, we recommend that a one-team approach is used for the early cases, and ideally with an experienced proctor. The important technical pearls that will aid the novice taTME surgeon were also described.
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Affiliation(s)
| | - Lawrence Lee
- McGill University Health Centre, Montreal, Canada
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Atallah S. Anatomical Considerations and Procedure-Specific Aspects Important in Preventing Operative Morbidity during Transanal Total Mesorectal Excision. Clin Colon Rectal Surg 2020; 33:157-167. [PMID: 32351339 DOI: 10.1055/s-0040-1701604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
As transanal total mesorectal excision (taTME) becomes increasingly utilized, its technical challenges and potential pitfalls have become more clearly appreciated. This chapter explores the differences in how anatomy presents itself from the taTME vantage point as compared with traditional approaches to taTME, and how special problems unique to taTME pose a new set of operative challenges. Morbidity related, specifically, to the technique of taTME is also delineated with particular focus on male urethral injury.
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Affiliation(s)
- Sam Atallah
- Department of Colorectal Surgery, Florida Hospital, Orlando, Florida
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Abstract
Minimally invasive techniques continue to transform the field of colorectal surgery. Because traditional surgical approaches for rectal cancer are associated with significant mortality and morbidity, developing less invasive approaches to this disease is paramount. Natural orifice transluminal endoscopic surgery (NOTES), commonly known as "no incision surgery," represents the ultimate minimally invasive approach to disease. Although transgastric and transvaginal approaches for NOTES surgery were the initially explored, a transrectal approach for colorectal disease is intuitive given that it makes use of the resected organ for transluminal access. Furthermore, the transanal approach allows for improved, precise visualization of the presacral mesorectal plane compared with an abdominal viewpoint, particularly in the narrow, male pelvis. Finally, experience with existing transanal platforms that have been used for decades for local excision of rectal disease made the development of a transanal approach to total mesorectal excision (TME) feasible. Here, we will review the evolution of minimally invasive and transanal surgical techniques that allowed for the development of transanal TME and its introduction into clinical practice.
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Affiliation(s)
- Heather Carmichael
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Patricia Sylla
- Icahn School Medicine at Mount Sinai, New York, New York
- Division of Colon and Rectal Surgery, Department of Surgery, Mount Sinai Hospital, New York, New York
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28
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Soares AS, Chand M. Future Directions. Clin Colon Rectal Surg 2020; 33:180-186. [PMID: 32368200 PMCID: PMC7192688 DOI: 10.1055/s-0039-3402781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Transanal total mesorectal excision (taTME) is a novel technique that has evolved over the years to address the challenges of low rectal cancer surgery by applying the principles and benefits of laparoscopic surgery to more historic transanal techniques. It has been popularized through its use in rectal cancer, but the transanal approach is slowly being expanded to tackle different clinical scenarios including benign conditions such as inflammatory bowel disease and endometriosis. For all of these new indications, it is the desire to access and begin the dissection in native tissue beyond the pathology which makes this approach applicable to other diseases where anatomy can be challenging. Training pathways to safely introduce taTME in a standardized manner are being developed and implemented in a bid to ensure adequate training to all the surgeons using this technique and thus minimize complications and patient morbidity. The future directions of this promising technique include the use of image and optical technological enhancement to aid navigation, the use of pneumorectum stabilization, and perhaps the use of fluorescence as a safety improvement. Developments have come also from the field of robotics. After a demonstration of feasibility in cadaver models, a growing experience has been gathered in the robotic approach to taTME, covered in the last part of this chapter.
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Affiliation(s)
- António S. Soares
- Department of Surgery and Interventional Sciences, GENIE Centre, University College London, University College London Hospitals, NHS Trust, London, UK
| | - Manish Chand
- Department of Surgery and Interventional Sciences, GENIE Centre, University College London, University College London Hospitals, NHS Trust, London, UK
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Use of a Lighted Stent by Near-Infrared Observation to Identify the Urethra During Transanal Total Mesorectal Excision. Dis Colon Rectum 2020; 63:256-257. [PMID: 31914117 DOI: 10.1097/dcr.0000000000001479] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Han JG, Wang ZJ, Wei GH, Zhai ZW, Zhao BC. Trans-perineal minimally invasive approach during extralevator abdominoperineal excision for advanced low rectal cancer: A retrospective cohort study. Asian J Surg 2020; 43:819-825. [PMID: 31982269 DOI: 10.1016/j.asjsur.2019.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 07/16/2019] [Accepted: 11/08/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND This study is to evaluate trans-perineal minimally invasive approach for extralevator abdominoperineal excision (TP-ELAPE) in a synchronous lithotomy position for locally advanced low rectal cancer. METHODS Between May 2013 and February 2016, 14 patients with locally advanced low rectal cancer underwent TP-ELAPE for the perineal phase of extralevator abdominoperineal excision, and 18 patients underwent conventional ELAPE. RESULTS There was no positive circumferential resection margin in both groups. Patients who received TP-ELAPE had similar bowel perforation rate (7.1% vs. 5.6%, p = 1.000), longer transperineal operative time (100 vs. 40 min, p < 0.001) and higher surgical difficulty visual analog scale (VAS) scores (6 vs. 2, p < 0.001), while had shorter total procedure time (215 vs. 260 min, p = 0.015), lower VAS pain scores on day 1 postoperatively (5 vs. 6.5, p = 0.049), shorter postoperative anus exhausting time (22 h vs 28 h, p = 0.006), and shorter postoperative hospital stay (11.5 d vs 13.5d, p = 0.028) compared with patients who received conventional ELAPE. There was no local recurrence with median follow-up time of 53 months in the TP-ELAPE group and 51 months in the conventional ELAPE group. There were no differences for disease-free survival (p = 0.835) and overall survival (p = 0.829) between groups. CONCLUSIONS TP-ELAPE approach in the synchronous lithotomy position might be a feasible approach for low rectal cancer, while ensuring a radical and safe surgical procedure.
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Affiliation(s)
- Jia Gang Han
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Zhen Jun Wang
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China.
| | - Guang Hui Wei
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Zhi Wei Zhai
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Bao Cheng Zhao
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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31
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Waters PS, Peacock O, Larach T, Lee JD, McCormick JJ, Chander S, Heriot AG, Warrier SK. Utilization of a Transanal TME Platform to Enable a Distal TME Dissection En Bloc with Presacral Fascia and Pelvic Sidewall with Intraoperative Radiotherapy Delivery in a Locally Advanced Rectal Cancer: Advanced Application of taTME. J Laparoendosc Adv Surg Tech A 2019; 30:53-57. [PMID: 31721637 DOI: 10.1089/lap.2019.0576] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Introduction: The safe introduction of transanal total mesorectal excision (taTME) has been documented by the Australasian group previously. The most important prognostic indicator for rectal cancer is the ability to achieve a clear resection margin. By utilizing false planes for taTME surgery, the endopelvic fascia and or presacral fascia can be resected en bloc. Technique: This case highlights the utilization of a taTME platform to perform a distal taTME with presacral fascial stripping and a lateral pelvic sidewall transanal-assisted dissection in a 53-year-old otherwise healthy woman with a mid-rectal tumor. Radiologically the tumor was staged as a T3c/T4 rectal cancer with an N1c deposit extending beyond mesorectal fascia abutting the left piriformis muscle. An extramural venous invasion positive tumor was evident with a positive circumferential resection margin at 4 o' clock. In addition, the taTME platform was used to allow transanal intraoperative radiotherapy (IORT) delivery to the sacrum. An R0 resection was achieved and the patient recovered well without incident. Results: Total operative time was 250 minutes with the patient being discharged on day 7 postoperatively without complication. Macroscopic evaluation revealed a grade III mesorectal excision with en bloc removal of presacral fascia. On microscopic evaluation, revealed a T3N1b tumor with 2 of 14 positive lymph nodes (0/5 pelvic sidewall nodes). Conclusion: The case highlights a novel application of taTME and is to the authors' best knowledge the first described use of a transanal platform to deliver intraoperative radiation therapy in the literature.
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Affiliation(s)
- Peadar S Waters
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Oliver Peacock
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Tomas Larach
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Jordan D Lee
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Jacob J McCormick
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Sarat Chander
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Alexander G Heriot
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Satish K Warrier
- Colorectal Surgery Unit, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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Hardon SF, van Kasteren RJ, Dankelman J, Bonjer HJ, Tuynman JB, Horeman T. The value of force and torque measurements in transanal total mesorectal excision (TaTME). Tech Coloproctol 2019; 23:843-852. [PMID: 31432333 PMCID: PMC6791959 DOI: 10.1007/s10151-019-02057-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 07/31/2019] [Indexed: 12/16/2022]
Abstract
Background Transanal total mesorectal excision (TaTME) is associated with a relatively long learning curve. Force, motion, and time parameters are increasingly used for objective assessment of skills to enhance laparoscopic training efficacy. The aim of this study was to identify relevant metrics for accurate skill assessment in more complex transanal purse-string suturing. Methods A box trainer was designed for TaTME and equipped with two custom made multi-DOF force/torque sensors. These sensors measured the applied forces in the axial direction of the instruments (Fz), instrument load orientation expressed in torque (Mx and My) on the entrance port, and the full tissue interaction force (Fft) at the intestine fixation point. In a construct validity study, novices for TaTME performed a purse-string suture to investigate which parameters can be used best to identify meaningful events during tissue manipulation and instrument handling. Results Significant differences exist between pre- and post-training assessment for the mean axial force at the entrance port Fz (p = 0.01), mean torque in the entrance port Mx (p = 0.03) and mean force on the intestine during suturing Fft (p = 0.05). Furthermore, force levels during suturing exceed safety threshold values, potentially leading to dangerous complications such as rupture of the rectum. Conclusions Forces and torque measured at the entrance port, and the tissue interaction force signatures provide detailed insight into instrument handling, instrument loading, and tissue handling during purse-string suturing in a TaTME training setup. This newly developed training setup for single-port laparoscopy that enables objective feedback has the potential to enhance surgical training in TaTME.
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Affiliation(s)
- S F Hardon
- Department of Surgery, Amsterdam UMC-VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands.
- Department of BioMechanical Engineering, Delft University of Technology, Delft, The Netherlands.
| | - R J van Kasteren
- Department of BioMechanical Engineering, Delft University of Technology, Delft, The Netherlands
| | - J Dankelman
- Department of BioMechanical Engineering, Delft University of Technology, Delft, The Netherlands
| | - H J Bonjer
- Department of Surgery, Amsterdam UMC-VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - J B Tuynman
- Department of Surgery, Amsterdam UMC-VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - T Horeman
- Department of BioMechanical Engineering, Delft University of Technology, Delft, The Netherlands
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Abstract
The proximity of the colon and rectum to the organs of the urologic system virtually ensures that iatrogenic urologic injuries become a distinct possibility during complex colorectal surgical procedures. An intimate knowledge of urogenital anatomy as well as strategies for identification and repair of potential injuries is of paramount importance. Attention is mandated when operating within the narrow confines of the pelvis, as this is where these structures are most at risk. The ureters are at highest risk of injury, followed by the bladder and urethra. The nature of these injuries encompasses both functional and mechanical morbidities. Patient factors, including prior pelvic surgery, radiation, inflammatory bowel disease, infectious processes, and urogenital abnormalities all increase the risk of injury. As colorectal surgeons encounter an increasing number of patients with the above risk factors, it is important to be familiar with the various urologic injury patterns, their diagnosis, and appropriate management.
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Affiliation(s)
- Marco Ferrara
- Department of Colon and Rectal Surgery, Ochsner Medical Center, New Orleans, Louisiana
| | - Brian R. Kann
- Department of Colon and Rectal Surgery, Ochsner Medical Center, New Orleans, Louisiana
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34
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Current Trends in the Management of Low Rectal Tumors: Transanal Total Mesorectal Excision. CURRENT COLORECTAL CANCER REPORTS 2019. [DOI: 10.1007/s11888-019-00434-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Teoh B, Waters PS, Peacock O, Smart P, Reid K, Rajkumar A, Heriot AG, Warrier SK. Utilising taTME and robotics to reduce R1 risk in locally advanced rectal cancer with rectovaginal and cervical involvement. Tech Coloproctol 2019; 23:387-390. [PMID: 30778783 DOI: 10.1007/s10151-019-01941-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 01/31/2019] [Indexed: 02/08/2023]
Affiliation(s)
- B Teoh
- Division of Cancer Surgery, Victorian Comprehensive Cancer Centre, Melbourne, Australia
| | - P S Waters
- Division of Cancer Surgery, Victorian Comprehensive Cancer Centre, Melbourne, Australia
| | - O Peacock
- Division of Cancer Surgery, Victorian Comprehensive Cancer Centre, Melbourne, Australia
| | - P Smart
- Epworth Freemasons Hospital, Melbourne, Australia
| | - K Reid
- Epworth Freemasons Hospital, Melbourne, Australia
| | - A Rajkumar
- Epworth Freemasons Hospital, Melbourne, Australia
| | - A G Heriot
- Division of Cancer Surgery, Victorian Comprehensive Cancer Centre, Melbourne, Australia
- Epworth Freemasons Hospital, Melbourne, Australia
| | - S K Warrier
- Division of Cancer Surgery, Victorian Comprehensive Cancer Centre, Melbourne, Australia.
- Epworth Freemasons Hospital, Melbourne, Australia.
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC, 3000, Australia.
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Current Surgical Strategies in the Management of Rectal Cancer. CURRENT COLORECTAL CANCER REPORTS 2019. [DOI: 10.1007/s11888-019-00428-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Caycedo-Marulanda A, Jiang HY, Kohtakangas EL. Outcomes of a Single Surgeon-Based Transanal-Total Mesorectal Excision (TATME) for Rectal Cancer. J Gastrointest Cancer 2019; 49:455-462. [PMID: 28702861 DOI: 10.1007/s12029-017-9989-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Several studies have shown the transanal total mesorectal excision (TATME) is emerging as a safe and effective technique for proctectomy. The majority of these studies to date, however, is based on procedures done in centers with teams of two surgeons working simultaneously. Few were performed by single-surgeon teams with sizeable case load. The objective of our study was to identify the feasibility and safety of a single-surgeon TATME. METHODS Chart review of prospectively collected data on 27 patients who underwent TATME at our institution from June 2015 to September 2016 were included in this study. Indications for TATME included mid and low rectal cancers. Only patients who underwent surgery for neoplastic lesions were included in the study. Outcomes assessed included mesorectal integrity, margin status, operative time, complications, morbidity, LOS, and 30-day readmission. RESULTS A total of 27 cases were available for inclusion. A single surgeon performed all procedures. The average BMI was 27.2 ± 1.3 kg/m2. The average tumor distance from anal verge was 6.8 ± 0.6 cm. The median operative time was 283 min. No intraoperative complications, including injuries and conversions, occurred. Circumferential resection margin (CRM) and distal resection margin (DRM) were R0 in 96 and 100% of patients, respectively. Mesorectal integrity was "Complete" in 67% and "Near complete" in 33% of patients. There were no incomplete specimens. The total lymph node (LN) harvest was 26 ± 2. The average LOS was 4 days for 75% of all patients. There were no mortalities. The overall morbidity was 33% (9/27). There were 4/27 anastomotic leaks, one required a laparoscopic ileostomy, one had laparoscopic drainage of an abscess, and the other two were endoscopically washed and trans-rectal drains inserted. CONCLUSION TATME performed by a one-surgeon team is oncologically adequate, and it is safe and feasible. Morbidities are comparable with existing literature data from two-surgeon teams. In addition, resection margins, mesorectal integrity, and LN harvests are also comparable or superior to some of the existing studies.
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Affiliation(s)
- Antonio Caycedo-Marulanda
- Department of Surgery, Health Sciences North, Sudbury, ON, Canada.
- Faculty of Medicine, Northern Ontario School of Medicine, 410-65 Larch Street, Sudbury, ON, P3E1B8, Canada.
| | - Henry Y Jiang
- Department of Surgery, Health Sciences North, Sudbury, ON, Canada
- Faculty of Medicine, Northern Ontario School of Medicine, 410-65 Larch Street, Sudbury, ON, P3E1B8, Canada
| | - Erica L Kohtakangas
- Department of Surgery, Health Sciences North, Sudbury, ON, Canada
- Faculty of Medicine, Northern Ontario School of Medicine, 410-65 Larch Street, Sudbury, ON, P3E1B8, Canada
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Metwally IH, Coello PC, Romero JA, Kotb SZ, Hegazy MA, Elnahas W, Noguera JF. Transanal Total Mesorectal Excision for Rectal Cancer: Short Term Outcomes from Two Centers. J Laparoendosc Adv Surg Tech A 2018; 28:1476-1482. [DOI: 10.1089/lap.2018.0083] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Affiliation(s)
- Islam H. Metwally
- Surgical Oncology Unit, Oncology Center Mansoura University (OCMU), Mansoura, Egypt
| | - Pablo C. Coello
- Department of General and Digestive Surgery, Complejo Hospital Universitario A Coruña (CHUAC), La Coruña, Spain
| | - José A. Romero
- Department of General and Digestive Surgery, Complejo Hospital Universitario A Coruña (CHUAC), La Coruña, Spain
| | - Sherif Z. Kotb
- Surgical Oncology Unit, Oncology Center Mansoura University (OCMU), Mansoura, Egypt
| | - Mohamed A.F. Hegazy
- Surgical Oncology Unit, Oncology Center Mansoura University (OCMU), Mansoura, Egypt
| | - Waleed Elnahas
- Surgical Oncology Unit, Oncology Center Mansoura University (OCMU), Mansoura, Egypt
| | - José F. Noguera
- Department of General and Digestive Surgery, Complejo Hospital Universitario A Coruña (CHUAC), La Coruña, Spain
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Abstract
Treatment of locally advanced rectal cancer is evolving through surgical innovation and paradigm shifts in neoadjuvant treatment. Whereas local recurrence was a significant concern before the systematic implementation of neoadjuvant chemoradiation therapy and surgery according to total mesorectal excision principles, distant relapse remains a major drawback. Hence, efforts in recent years have focused on delivering preoperative chemotherapy regimens to overcome compliance issues with adjuvant administration. In parallel, new surgical techniques, including transanal video-assisted total mesorectal excision and robot-assisted surgery, emerged to face the challenge to navigate in the deep and narrow spaces of the pelvis. Furthermore, patients experiencing a complete response after neoadjuvant treatment might even escape surgery within a close surveillance strategy. This novel "watch and wait" concept has gained interest to improve quality of life in highly selected patients. This review summarizes recent evidence and controversies and provides an overview on timely and innovative aspects in the treatment of locally advanced rectal cancer.
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Affiliation(s)
- Fabian Grass
- Department of Surgery, Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Kellie Mathis
- Department of Surgery, Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
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40
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Aiba T, Uehara K, Mukai T, Hattori N, Nakayama G, Nagino M. Transanal extended rectal surgery with lateral pelvic lymph node dissection. Tech Coloproctol 2018; 22:893-894. [PMID: 30483903 DOI: 10.1007/s10151-018-1891-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 11/19/2018] [Indexed: 10/27/2022]
Affiliation(s)
- T Aiba
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Aichi, Japan
| | - K Uehara
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Aichi, Japan.
| | - T Mukai
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Aichi, Japan
| | - N Hattori
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - G Nakayama
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - M Nagino
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Aichi, Japan
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Evaluation of anatomical landmarks for transanal total mesorectal excision based on MRI. Asian J Surg 2018; 42:667-673. [PMID: 30420154 DOI: 10.1016/j.asjsur.2018.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 10/08/2018] [Accepted: 10/19/2018] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Transanal total mesorectal excision (taTME) is a novel sphincter-preserving procedure for low rectal cancer. This "bottom to up" approach is unfamiliar to colorectal surgeons and the crucial anatomical landmarks also remain unclear. METHODS Two hundred and five cases of pelvic magnetic resonance imaging (MRI) from 2015 to 2016 were reviewed. Curvature of posterior mesorectal fascia, distal mesorectal angle, length of posterior mesorectal fascia, main structures around the mesorectum were measured and analyzed. The landmarks identified on MRI were verified in taTME procedures of five rectal cancer patients. RESULTS The most of acute angles of posterior mesorectal fascia located at the joint of anococcygeal ligament-coccyx. Degree of distal mesorectal angle was independently correlated with gender and degree of angle of anococcygeal ligament-coccyx. Candidate landmarks evaluated by MRI with verification during taTME procedures included: anterior: seminal vesicle for male while cervix for female. And peritoneal reflection was a substitute landmark when cervix was hardly confirmed in operation; posterior: the joint of anococcygeal ligament-coccyx. The area between the joint of anococcygeal ligament-coccyx and S3S4 was a "transitional zone", the level of S3S4 could be the as the terminal landmark of transanal posterior dissection during taTME. CONCLUSIONS Preoperative MRI geometrical measurement of mesorectum might play an important role in evaluating the difficulty of taTME procedure before operation, as well as standardizing landmarks during taTME procedure.
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Westwood DA, Cuda TJ, Hamilton AER, Clark D, Stevenson ARL. Transanal total mesorectal excision for rectal cancer: state of the art. Tech Coloproctol 2018; 22:649-655. [PMID: 30255213 DOI: 10.1007/s10151-018-1844-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 09/01/2018] [Indexed: 12/13/2022]
Abstract
Achieving a high-quality total mesorectal excision (TME) resection specimen is a central tenet of curative rectal cancer management. However, operating at the caudal extremity of the pelvis is inherently challenging and a number of patient- and tumour-related factors may increase the risk of obtaining a poor TME specimen and positive resection margins. Transanal TME (TaTME) is an advanced surgical technique developed to overcome the limitations in pelvic exposure and instrumentation of transabdominal surgery. This up-to-date narrative review describes the evolution of TME surgery, the indications for TaTME, current published outcomes, its limitations and future developments.
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Affiliation(s)
- David A Westwood
- Colorectal Unit, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Brisbane, QLD, Australia.
| | - Tahleesa J Cuda
- Colorectal Unit, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Brisbane, QLD, Australia
| | - A E Ricardo Hamilton
- Colorectal Unit, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Brisbane, QLD, Australia
| | - David Clark
- Colorectal Unit, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Brisbane, QLD, Australia.,Holy Spirit Northside Private Hospital, Brisbane, QLD, Australia
| | - Andrew R L Stevenson
- Colorectal Unit, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Brisbane, QLD, Australia.,Holy Spirit Northside Private Hospital, Brisbane, QLD, Australia
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Surgical Techniques for Identification of the Prostate Gland Using the Autonomic Nerve as a Landmark During Transanal Total Mesorectal Excision: Secure Dissection of the Male Rectourethral Muscle. Dis Colon Rectum 2018; 61:999-1000. [PMID: 29944578 DOI: 10.1097/dcr.0000000000001138] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Caycedo-Marulanda A, Chadi S, Patel S, Knol J, Wexner SD. Is a transanal total mesorectal excision programme feasible in a single-team setting? Colorectal Dis 2018; 20:571-573. [PMID: 29963774 DOI: 10.1111/codi.14243] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 04/16/2018] [Indexed: 01/08/2023]
Affiliation(s)
- A Caycedo-Marulanda
- Department of Surgery, Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | - S Chadi
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - S Patel
- Department of Surgery, Queens University Kingston, Ontario, Canada
| | - J Knol
- Department of Surgery, Jessa Hospital, Hasselt, Belgium
| | - S D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, USA
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45
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Purse-string rupture: pitfalls of transanal total mesorectal excision (Cecil approach). Tech Coloproctol 2018; 22:393-394. [PMID: 29796756 DOI: 10.1007/s10151-018-1797-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 05/04/2018] [Indexed: 01/28/2023]
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46
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Fan JKM, Liu J, Liu Z, Chen K, Zhang G, Yang X, Chan FSY, Lo CM. Application of transanal endoscopic operation device in laparoscopic assisted transanal total mesorectal excision for the treatment of ultra-low rectal carcinoma. SURGICAL PRACTICE 2018. [DOI: 10.1111/1744-1633.12304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Joe King-Man Fan
- Department of Surgery; The University of Hong Kong, Hong Kong Special Administrative Region; Shenzhen China
- Department of Surgery; The University of Hong Kong-Shenzhen Hospital; Shenzhen China
| | - Jianwen Liu
- Department of Surgery; The University of Hong Kong-Shenzhen Hospital; Shenzhen China
| | - Zhonghui Liu
- Department of Surgery; The University of Hong Kong-Shenzhen Hospital; Shenzhen China
| | - Kejin Chen
- Department of Surgery; The University of Hong Kong-Shenzhen Hospital; Shenzhen China
| | - Guixi Zhang
- Department of Surgery; The University of Hong Kong-Shenzhen Hospital; Shenzhen China
| | - Xuefei Yang
- Department of Surgery; The University of Hong Kong-Shenzhen Hospital; Shenzhen China
| | - Fion Siu-Yin Chan
- Department of Surgery; The University of Hong Kong, Hong Kong Special Administrative Region; Shenzhen China
- Department of Surgery; The University of Hong Kong-Shenzhen Hospital; Shenzhen China
| | - Chung-Mau Lo
- Department of Surgery; The University of Hong Kong, Hong Kong Special Administrative Region; Shenzhen China
- Department of Surgery; The University of Hong Kong-Shenzhen Hospital; Shenzhen China
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Okada T, Kawada K, Nakamura T, Okamura R, Hida K, Takai A, Matsuda S, Sakai Y. A cadaveric demonstration of visualization of the urethra using a lighted stent during transanal intersphincteric resection. Int Cancer Conf J 2018; 7:77-80. [PMID: 31149519 DOI: 10.1007/s13691-018-0319-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 02/20/2018] [Indexed: 12/25/2022] Open
Abstract
Urethral injury is one of the crucial intraoperative complications during transanal total mesorectal excision (taTME) for male patients with low rectal cancer. Urethral injury can occur during the anterior dissection around the inferior lobe of the prostate and the membranous urethra. A tool to visualize the urethra around this area would be useful to avoid urethral injury. We report a cadaveric demonstration of visualization of the urethra using a lighted stent during transanal intersphincteric resection. The lighted stent (InfraVision Ureteral Kit, Stryker) was placed through the irrigation channel of a clear three-way urinary catheter. After the anterior dissection, the visibility of the lighted stent was investigated under the three laparoscopic light conditions: (1) normal intensity; (2) low intensity; and (3) turned-off. In the proper dissection plane that led to preservation of the urethra, the lighted stent was hardly visible under the normal-intensity condition, but it was clearly visible under the turned-off condition. In the improper dissection plane that led to urethral injury, the lighted stent was clearly visible under both the normal-intensity and the turned-off conditions. Visualization of the urethra using the lighted stent under the turned-off condition of the laparoscopic light can be useful to avoid inadvertent urethral injury during the anterior dissection of male taTME. Clear visibility of the lighted stent under the normal-intensity condition can indicate that the dissection plane is too close to the urethra.
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Affiliation(s)
- Tomoaki Okada
- 1Department of Surgery, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo, Kyoto, 606-8507 Japan
| | - Kenji Kawada
- 1Department of Surgery, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo, Kyoto, 606-8507 Japan
| | - Tatsuro Nakamura
- 1Department of Surgery, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo, Kyoto, 606-8507 Japan
| | - Ryosuke Okamura
- 1Department of Surgery, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo, Kyoto, 606-8507 Japan
| | - Koya Hida
- 1Department of Surgery, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo, Kyoto, 606-8507 Japan
| | - Akihiro Takai
- 2Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Seiji Matsuda
- 3Department of Anatomy and Embryology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Yoshiharu Sakai
- 1Department of Surgery, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo, Kyoto, 606-8507 Japan
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Barnes TG, Volpi D, Cunningham C, Vojnovic B, Hompes R. Improved urethral fluorescence during low rectal surgery: a new dye and a new method. Tech Coloproctol 2018; 22:115-119. [PMID: 29460054 PMCID: PMC5846816 DOI: 10.1007/s10151-018-1757-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 01/06/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND The aim of this study was to demonstrate highlighting of the urethra during surgery through the use of two different methods: a new near-infrared fluorophore IRDye800BK, and indocyanine green (ICG) mixed with silicone. METHODS Male cadavers from the department of anatomy at the University of Oxford were used to visualise the urethra during near-infrared fluorescence excitation. To assess IRDye800BK, a perineal incision was utilised after infiltrating the urethra directly with an IRDye800BK solution mixed with Instillagel. ICG-silicone was assessed when the urethra was purposely exposed as part of a simulated transanal total mesorectal dissection. ICG was previously mixed with ethanol and silicone and left to set in a Foley catheter. Fluorescence was visualised using an in-house manufactured fluorescence-enabled laparoscopic system. RESULTS IRDye800BK demonstrated excellent penetration and visualisation of the urethra under fluorescence at an estimated tissue depth of 2 cm. An ICG-silicone catheter demonstrated excellent fluorescence without leaving any residual solution behind in the urethra after its removal. CONCLUSIONS The newly described ICG-silicone method opens up the possibility of new technologies in this area of fluorescence guided surgery. IRDye800BK is a promising alternative to ICG in visualising the urethra using fluorescence imaging. Its greater depth of penetration may allow earlier detection of the urethra during surgery and prevent wrong plane surgery sooner.
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Affiliation(s)
- T G Barnes
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, University of Oxford, Level 6, Headley Way, Headington, Oxford, OX3 9DS, UK.
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - D Volpi
- Department of Oncology, CR-UK/MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, UK
| | - C Cunningham
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - B Vojnovic
- Department of Oncology, CR-UK/MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, UK
| | - R Hompes
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Sahnan K, Pellino G, Adegbola SO, Tozer PJ, Chandrasinghe P, Miskovic D, Hompes R, Warusavitarne J, Lung PFC. Development of a model of three-dimensional imaging for the preoperative planning of TaTME. Tech Coloproctol 2017; 22:59-63. [PMID: 29188460 PMCID: PMC5829114 DOI: 10.1007/s10151-017-1724-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 09/30/2017] [Indexed: 12/12/2022]
Affiliation(s)
- K Sahnan
- Department of Colorectal Surgery, St Mark's Hospital and Academic Institute, Imperial College University of London, Watford Road, Harrow, Middlesex, HA13UJ, UK.
- Department of Surgery and Cancer, Imperial College, St Mary's Hospital, London, UK.
| | - G Pellino
- Department of Colorectal Surgery, St Mark's Hospital and Academic Institute, Imperial College University of London, Watford Road, Harrow, Middlesex, HA13UJ, UK
- Department of Medical, Surgical, Neurological, Metabolic and Ageing Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - S O Adegbola
- Department of Colorectal Surgery, St Mark's Hospital and Academic Institute, Imperial College University of London, Watford Road, Harrow, Middlesex, HA13UJ, UK
- Department of Surgery and Cancer, Imperial College, St Mary's Hospital, London, UK
| | - P J Tozer
- Department of Colorectal Surgery, St Mark's Hospital and Academic Institute, Imperial College University of London, Watford Road, Harrow, Middlesex, HA13UJ, UK
- Department of Surgery and Cancer, Imperial College, St Mary's Hospital, London, UK
| | - P Chandrasinghe
- Department of Colorectal Surgery, St Mark's Hospital and Academic Institute, Imperial College University of London, Watford Road, Harrow, Middlesex, HA13UJ, UK
- Department of Surgery, University of Kelaniya, Kelaniya, Sri Lanka
| | - D Miskovic
- Department of Colorectal Surgery, St Mark's Hospital and Academic Institute, Imperial College University of London, Watford Road, Harrow, Middlesex, HA13UJ, UK
- Department of Surgery and Cancer, Imperial College, St Mary's Hospital, London, UK
| | - R Hompes
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - J Warusavitarne
- Department of Colorectal Surgery, St Mark's Hospital and Academic Institute, Imperial College University of London, Watford Road, Harrow, Middlesex, HA13UJ, UK
- Department of Surgery and Cancer, Imperial College, St Mary's Hospital, London, UK
| | - P F C Lung
- Department of Colorectal Surgery, St Mark's Hospital and Academic Institute, Imperial College University of London, Watford Road, Harrow, Middlesex, HA13UJ, UK
- Department of Surgery and Cancer, Imperial College, St Mary's Hospital, London, UK
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50
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Initial experience with taTME in patients undergoing laparoscopic restorative proctocolectomy for familial adenomatous polyposis. Tech Coloproctol 2017; 21:971-974. [PMID: 29168141 DOI: 10.1007/s10151-017-1730-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 09/17/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Transanal total mesorectal excision (taTME) is a minimally invasive technique which was developed to overcome the difficulties associated with the "top-down" pelvic dissection by enabling a "bottom-up" dissection in patients with mid- and low rectal cancer. While this technique was primarily designed to manage tumors in the mid- and lower rectum, its spectrum of indications has been broadened to include benign colorectal pathologies. The aim of the present study was to assess our initial experience with taTME in patients undergoing restorative proctocolectomy for familial adenomatous polyposis (FAP). METHODS All consecutive patients (undergoing prophylactic restorative proctocolectomy with IPAA for FAP using taTME between April and October 2016 at our institution) were included in the study. RESULTS There were 8 patients (6 females and 2 males). The median age was 19.5 years (range 16-31 years). In all cases, surgery was successfully completed using with taTME. No perioperative complications were recorded. A median of 5 bowel movements (range 4-6 bowel movements) with intermittent anti-diarrheal medication was recorded in all cases. CONCLUSIONS Our initial experience with 8 consecutive cases suggests taTME is safe and effective in patients undergoing prophylactic restorative proctocolectomy with IPAA for FAP.
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