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Kouladouros K, Baral J. Transanal endoscopic microsurgical submucosal dissection (TEM-ESD) for rectal adenomas: a retrospective cohort study of 145 consecutive cases. Langenbecks Arch Surg 2022; 407:2423-2430. [PMID: 35652960 DOI: 10.1007/s00423-022-02562-0] [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: 01/17/2022] [Accepted: 05/18/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE Transanal endoscopic microsurgery (TEM) and endoscopic submucosal dissection (ESD) are currently the two most popular methods for resecting large rectal adenomas en bloc. However, damage to the mesorectum in the case of TEM, plus the technical challenges and long procedure times of flexible ESD, are major disadvantages of these procedures. Transanal endoscopic microsurgical submucosal dissection (TEM-ESD) is a new technique, combining the ergonomic features of TEM with the minimally invasive approach of ESD. The aim of our study was to assess the feasibility and safety of TEM-ESD for resection of large rectal adenomas. METHODS We retrospectively analyzed all TEM-ESD procedures performed in Karlsruhe Municipal Hospital between 2012 and 2019, isolated all cases of adenomas, and analyzed the perioperative and follow-up data of the patients. RESULTS We identified 145 cases matching our criteria. The median size of the lesions was 4.2 cm, and the median operating time was 45 min. The en bloc resection rate was 100%, and the complete en bloc resection rate was 78.6%. The overall morbidity rate was 6.9%. In a median follow-up period of 24 months, there was a local recurrence in 4.8% of the cases. CONCLUSIONS TEM-ESD is a safe and feasible therapeutic option for resecting large rectal adenomas, offering high en bloc resection and low recurrence rates combined with short operating time and low morbidity. TRIAL REGISTRATION NUMBER (CLINICALTRIALS.GOV): NCT04870931.
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Affiliation(s)
- Konstantinos Kouladouros
- Central Interdisciplinary Endoscopy Department, Department of Surgery, Mannheim University Hospital, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
- Surgery Department, Karlsruhe Municipal Hospital, Moltkestrasse 90, 76133, Karlsruhe, Germany.
| | - Jörg Baral
- Central Interdisciplinary Endoscopy Department, Department of Surgery, Mannheim University Hospital, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
- Surgery Department, Karlsruhe Municipal Hospital, Moltkestrasse 90, 76133, Karlsruhe, Germany
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2
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Kim MJ, Lee TG. Transanal minimally invasive surgery using laparoscopic instruments of the rectum: A review. World J Gastrointest Surg 2021; 13:1149-1165. [PMID: 34754384 PMCID: PMC8554714 DOI: 10.4240/wjgs.v13.i10.1149] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 07/18/2021] [Accepted: 09/16/2021] [Indexed: 02/06/2023] Open
Abstract
Transanal minimally invasive surgery (TAMIS) was first described in 2010 as an alternative to transanal endoscopic microsurgery (TEM). The TAMIS technique can be access to the proximal and mid-rectum for resection of benign and early-stage malignant rectal lesions and also used for noncurative intent surgery of more advanced lesions in patients who are not candidates for radical surgery. TAMIS has a shorter learning curve, reduced device setup time, flexibility in instrument use, and versatility in application than TEM. Also, TAMIS shows similar results in a view of the operation time, conversion rate, reoperation rate, and complication to TEM. For these reasons, TAMIS is an easily accessible, technically feasible, and cost-effective alternative to TEM. Overall, TAMIS has enabled the performance of high-quality local excision of rectal lesions by many colorectal surgeons. As TAMIS becomes more broadly utilized such as pelvic abscess drainage, rectal stenosis, and treatment of anastomotic dehiscence, the acquisition of appropriate training must be ensured, and the continued assessment and assurance of outcome must be maintained.
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Affiliation(s)
- Myung Jo Kim
- Department of Surgery, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju 28644, South Korea
| | - Taek-Gu Lee
- Department of Surgery, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju 28644, South Korea
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3
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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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Abstract
Transluminal surgery, also known as natural orifices endoluminal surgery, can be considered the most minimally invasive approach of gaining access to an organ. Although some approaches, such as transgastric or transvaginal cholecystectomy, have remained experimental, peroral endoscopic myotomy to treat achalasia and transanal total mesorectal excision to treat low rectal cancer have become accepted, safe, and feasible approaches by trained surgeons for selected patients. This article recapitulates the development of transluminal surgery from its experimental beginnings to the validated procedure it has become today.
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Affiliation(s)
- Antonio M Lacy
- Department of Gastrointestinal Surgery, ICMDM, IDIBAPS, CIBEREHD, AIS Channel, Hospital Clínic, Universitat de Barcelona, Villarroel 170, 08036 Barcelona, Spain.
| | - Fransisco Borja De Lacy
- Department of Gastrointestinal Surgery, ICMDM, IDIBAPS, CIBEREHD, AIS Channel, Hospital Clínic, Universitat de Barcelona, Villarroel 170, 08036 Barcelona, Spain
| | - Silvia Valverde
- Department of Gastrointestinal Surgery, ICMDM, IDIBAPS, CIBEREHD, AIS Channel, Hospital Clínic, Universitat de Barcelona, Villarroel 170, 08036 Barcelona, Spain
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5
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Menahem B, Alves A, Morello R, Lubrano J. Should the rectal defect be closed following transanal local excision of rectal tumors? A systematic review and meta-analysis. Tech Coloproctol 2017; 21:929-936. [PMID: 29134387 DOI: 10.1007/s10151-017-1714-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 09/25/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Transanal local excision (TLE) has become the treatment of choice for benign and early-stage selected malignant tumors. However, closure of the rectal wall defect remains a controversial point and the available literature still remains unclear. Our aim was to determine through a systematic review of the literature and a meta-analysis of relevant studies whether or not the wall defect following TLE of rectal tumors should be closed. METHODS Medline and the Cochrane Trials Register were searched for trials published up to December 2016 comparing open versus closed management of the surgical rectal defect after TLE of rectal tumors. Meta-analysis was performed using Review Manager 5.0. RESULTS Four studies were analyzed, yielding 489 patients (317 in the closed group and 182 in the open group). Meta-analysis showed no significant difference between the closed and open groups regarding the overall morbidity rate (OR 1.26; 95% CI 0.32-4.91; p = 0.74), postoperative local infection rate (OR 0.62; 95% CI 0.23-1.62; p = 0.33), postoperative bleeding rate (OR 0.83; 95% CI 0.29-1.77; p = 0.63), and postoperative reintervention rate (OR 2.21; 95% CI 0.52-9.47; p = 0.29). CONCLUSIONS This review and meta-analysis suggest that there is no difference between closure or non-closure of wall defects after TLE.
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Affiliation(s)
- B Menahem
- Department of Digestive Surgery, Caen University Hospital, Avenue de la Côte de Nacre, 14032, Caen Cedex, France.
- UMR, French National Institute for Health and Medical Research U1086 Cancer and Prevention, The François Baclesse Center, Caen, France.
- UFR of Medicine, Caen, France.
| | - A Alves
- Department of Digestive Surgery, Caen University Hospital, Avenue de la Côte de Nacre, 14032, Caen Cedex, France
- UMR, French National Institute for Health and Medical Research U1086 Cancer and Prevention, The François Baclesse Center, Caen, France
- UFR of Medicine, Caen, France
| | - R Morello
- Department of Digestive Surgery, Caen University Hospital, Avenue de la Côte de Nacre, 14032, Caen Cedex, France
- UFR of Medicine, Caen, France
- Department of Clinical Research and Biostatistics, Caen University Hospital, Caen, France
| | - J Lubrano
- Department of Digestive Surgery, Caen University Hospital, Avenue de la Côte de Nacre, 14032, Caen Cedex, France
- UMR, French National Institute for Health and Medical Research U1086 Cancer and Prevention, The François Baclesse Center, Caen, France
- UFR of Medicine, Caen, France
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deBeche-Adams T, Hassan I, Haggerty S, Stefanidis D. Transanal Minimally Invasive Surgery (TAMIS): a clinical spotlight review. Surg Endosc 2017; 31:3791-3800. [DOI: 10.1007/s00464-017-5636-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 06/03/2017] [Indexed: 02/07/2023]
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Quaresima S, Balla A, Franceschilli L, La Torre M, Iafrate C, Shalaby M, Di Lorenzo N, Sileri P. Transanal Minimally Invasive Surgery for Rectal Lesions. JSLS 2017; 20:JSLS.2016.00032. [PMID: 27547025 PMCID: PMC4978546 DOI: 10.4293/jsls.2016.00032] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background and Objectives: Transanal minimally invasive surgery (TAMIS) has emerged as an alternative to transanal endoscopic microsurgery (TEM). The authors report their experience with TAMIS for the treatment of mid and high rectal tumors. Methods: From November 2011 through May 2016, 31 patients (21 females, 68%), with a median age of 65 years who underwent single-port TAMIS were prospectively enrolled. Mean distance from the anal verge of the rectal tumors was 9.5 cm. Seventeen patients presented with T1 cancer, 10 with large adenoma, 2 with gastrointestinal stromal tumor (GIST) and 2 with carcinoid tumor. Data concerning demographics, operative procedure and pathologic results were analyzed. Results: TAMIS was successfully completed in all cases. In 4 (13%) TAMIS was converted to standard Park's transanal technique. Median postoperative stay was 3 days. The overall complication rate was 9.6%, including 1 urinary tract infection, 1 subcutaneous emphysema, and 1 hemorrhoidal thrombosis. TAMIS allowed an R0 resection in 96.8% of cases (30/31 cases) and a single case of local recurrence after a large adenoma resection was encountered. Conclusion: TAMIS is a safe technique, with a short learning curve for laparoscopic surgeons already proficient in single-port procedures, and provides effective oncological outcomes compared to other techniques.
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Affiliation(s)
- Silvia Quaresima
- Department of General Surgery; University of Rome "Tor Vergata," Rome, Italy
| | - Andrea Balla
- Department of General Surgery; University of Rome "Tor Vergata," Rome, Italy
| | - Luana Franceschilli
- Department of General Surgery; University of Rome "Tor Vergata," Rome, Italy
| | - Marco La Torre
- Department of General Surgery; University of Rome "Tor Vergata," Rome, Italy
| | - Corrado Iafrate
- Department of General Surgery; University of Rome "Tor Vergata," Rome, Italy
| | - Mostafa Shalaby
- Department of General Surgery; University of Rome "Tor Vergata," Rome, Italy
| | - Nicola Di Lorenzo
- Department of General Surgery; University of Rome "Tor Vergata," Rome, Italy
| | - Pierpaolo Sileri
- Department of General Surgery; University of Rome "Tor Vergata," Rome, Italy
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8
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Aytac E, Gorgun E, Costedio MM, Stocchi L, Remzi FH, Kessler H. Impact of tumor location on lymph node metastasis in T1 colorectal cancer. Langenbecks Arch Surg 2016; 401:627-32. [PMID: 27270724 DOI: 10.1007/s00423-016-1452-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 05/20/2016] [Indexed: 12/12/2022]
Abstract
PURPOSE Data evaluating the risk of lymph node metastasis depending upon the location of the primary tumor are limited in patients with T1 colorectal cancer. We aimed to evaluate the impact of tumor location on lymph node metastasis in T1 colorectal cancer. METHODS Patients who underwent an oncologic resection with curative intent for T1 adenocarcinoma of the colon and rectum between January 1997 and October 2014 were assessed. Exclusion criteria were distant organ metastases, previous or concurrent cancer, past history of surgical or medical cancer treatment, preoperative chemoradiation, and patients with inflammatory bowel disease or polyposis syndromes. RESULTS Out of 232 (56 % male) patients fulfilling the study criteria, 24 (10 %) had lymph node metastasis. Age (65 vs 61 years, p = 0.1), gender (55 vs 63 % male, p = 0.5), tumor size (2 vs 2 cm, p = 0.49), and lymphovascular invasion (5 vs 8 %, p = 0.46) were not associated with lymph node metastasis. While there was no statistical significance (p = 0.2), lymph node positivity was higher in rectal cancer (14 %, n = 11/79) compared to colon cancer (9 %, n = 13/153). CONCLUSIONS Although it was not statistically significant, lymph node positivity varies based on tumor location of T1 colorectal adenocarcinoma regardless of fundamental tumor characteristics including size, differentiation, and lymphovascular invasion.
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Affiliation(s)
- Erman Aytac
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH, 44195, USA
| | - Emre Gorgun
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH, 44195, USA
| | - Meagan M Costedio
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH, 44195, USA
| | - Luca Stocchi
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH, 44195, USA
| | - Feza H Remzi
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH, 44195, USA
| | - Hermann Kessler
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH, 44195, USA.
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9
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Noura S, Ohue M, Miyoshi N, Yasui M. Transanal minimally invasive surgery (TAMIS) with a GelPOINT ® Path for lower rectal cancer as an alternative to transanal endoscopic microsurgery (TEM). Mol Clin Oncol 2016; 5:148-152. [PMID: 27330788 DOI: 10.3892/mco.2016.893] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 04/26/2016] [Indexed: 12/15/2022] Open
Abstract
Transanal endoscopic microsurgery (TEM) is a minimally invasive technique. However, TEM has not yet achieved widespread use. Recently, transanal minimally invasive surgery (TAMIS) using single-port surgery devices has been reported. In the present study, TAMIS using a GelPOINT® Path was performed in six patients with lower rectal cancer. A complete full-thickness excision was performed in all cases. The patient characteristics, operative techniques and operative outcomes were evaluated. The mean age of the patients was 63.0 years (range: 48-76). The mean operating time and blood loss were 86 min (range: 55-110) and 5 ml (range 0-10), respectively. There were no instances of morbidity or mortality. Additional transabdominal rectal resection was not performed, and adjuvant chemoradiotherapy was performed in all cases. The mean Wexner score was 0.6 (range: 0-3; n=5) at 6 months, and 0 (range: 0; n=4) at 12 months. TAMIS using a GelPOINT® Path was revealed to be easy and safe to perform. Although only a small number of cases were treated, the anal function following surgery was shown to be favorable, and the operation was demonstrated to be sufficiently feasible. Based on these results, TAMIS may, in time, assume a major role in the resection of large adenomas and early rectal cancers.
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Affiliation(s)
- Shingo Noura
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka 537-8511, Japan; Department of Surgery, Osaka Rosai Hospital, Sakai, Osaka 591-8025, Japan
| | - Masayuki Ohue
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka 537-8511, Japan
| | - Norikatsu Miyoshi
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka 537-8511, Japan
| | - Masayoshi Yasui
- Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka 537-8511, Japan
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10
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Dapri G, Grozdev K, Guta D, Cadière GB. Down-to-up transanal rectal resection with total mesorectal excision assisted by single-incision laparoscopy - a video vignette. Colorectal Dis 2016; 18:517-8. [PMID: 26880275 DOI: 10.1111/codi.13298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 12/22/2015] [Indexed: 02/08/2023]
Affiliation(s)
- G Dapri
- Department of Gastrointestinal Surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, 322 Rue Haute, 1000, Brussels, Belgium.
| | - K Grozdev
- Department of Gastrointestinal Surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, 322 Rue Haute, 1000, Brussels, Belgium
| | - D Guta
- Department of Gastrointestinal Surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, 322 Rue Haute, 1000, Brussels, Belgium
| | - G-B Cadière
- Department of Gastrointestinal Surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, 322 Rue Haute, 1000, Brussels, Belgium
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11
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Keller DS, Tahilramani RN, Flores-Gonzalez JR, Mahmood A, Haas EM. Transanal Minimally Invasive Surgery: Review of Indications and Outcomes from 75 Consecutive Patients. J Am Coll Surg 2016; 222:814-22. [PMID: 27016903 DOI: 10.1016/j.jamcollsurg.2016.02.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Revised: 01/11/2016] [Accepted: 02/02/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Transanal minimally invasive surgery (TAMIS) is an advanced local excision platform that helps overcome technical limitations and morbidity associated with other resection methods. Our goal was to review the indications and outcomes of TAMIS in a large series. STUDY DESIGN A review of a prospective database identified patients who underwent TAMIS from 2010 to 2014. Demographic, perioperative, short-term outcomes, and recurrence data were analyzed. RESULTS There were 75 patients with 76 lesions analyzed. Mean age was 64.0 years (SD 11.6 years) and mean BMI was 27.4 kg/m(2) (SD 4.7 kg/m(2)). Median American Society of Anesthesiologists (ASA) score was 2 (range 1 to 4). There were 59 benign (77.3%) and 17 malignant (22.7%) lesions: 6 pT0, 6 pT1, 4 pT2, and 1 pT3. Median lesion distance from the anal verge was 10 cm (range 6 to 16 cm). Mean operative time was 76.0 minutes (SD 36.1 minutes). Three patients had intraperitoneal entry; all were closed transanally, but 2 had temporary diverting ileostomies fashioned to ensure healing. Median length of stay was 1 day (range 0 to 6). One patient had a fragmented lesion (1.3%). Five patients had positive margins: 2 in palliative pT2 resections, and 3 in pT1, pT2, and gastrointestinal stromal tumor (GIST) patients. They were managed with radical resection (pT1 and pT2 lesions) and surveillance/medical oncology (GIST). Postoperatively, 3 patients had complications (bleeding, rectal stricture, and recto-vaginal fistula), and all were managed nonoperatively. After median follow-up of 39.5 months (range 10.5 to 65.3 months), 1 pT1 patient with negative margins developed a local recurrence and underwent salvage APR. CONCLUSIONS Transanal minimally invasive surgery is a viable option for excision of benign or early stage rectal masses, with mid-term oncologic outcomes comparable to those of radical resection. Further, TAMIS minimizes the morbidity and can allow more patients to benefit from the minimally invasive approach.
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Affiliation(s)
- Deborah S Keller
- Colorectal Surgical Associates LLP, LTD, Houston, TX; Department of Surgery, Houston Methodist Hospital, Houston, TX
| | - Reena N Tahilramani
- Colorectal Surgical Associates LLP, LTD, Houston, TX; Minimally Invasive Colon and Rectal Surgery, The University of Texas Medical School at Houston, Houston, TX
| | | | - Ali Mahmood
- Colorectal Surgical Associates LLP, LTD, Houston, TX; Minimally Invasive Colon and Rectal Surgery, The University of Texas Medical School at Houston, Houston, TX; Department of Surgery, Houston Methodist Hospital, Houston, TX
| | - Eric M Haas
- Colorectal Surgical Associates LLP, LTD, Houston, TX; Minimally Invasive Colon and Rectal Surgery, The University of Texas Medical School at Houston, Houston, TX; Department of Surgery, Houston Methodist Hospital, Houston, TX.
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12
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Keller DS, Haas EM. Transanal Minimally Invasive Surgery: State of the Art. J Gastrointest Surg 2016; 20:463-9. [PMID: 26608195 DOI: 10.1007/s11605-015-3036-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 11/17/2015] [Indexed: 01/31/2023]
Abstract
The treatment for rectal cancer and benign rectal lesions continues to progress in the arena of minimally invasive surgery. While surgical excision of the primary mass remains essential for eradication of disease, there has been a paradigm shift towards less invasive resection methods. Local excision is increasing in popularity for its low morbidity and excellent functional results in select patients. Transanal minimally invasive surgery (TAMIS) is a new technology developed to elevate the practice of local excision to state-of-the-art resection. The goal of this article is to evaluate the history, short-term outcomes, and evolution of the TAMIS technique for excision of benign and malignant rectal neoplasia.
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Affiliation(s)
- D S Keller
- Colorectal Surgical Associates, Houston, TX, USA
- Division of Colon and Rectal Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - E M Haas
- Colorectal Surgical Associates, Houston, TX, USA.
- Division of Minimally Invasive Colorectal Surgery, Department of Surgery, University of Texas Medical School at Houston, 7900 Fannin, Suite 2700, Houston, TX, 77054, USA.
- Division of Colon and Rectal Surgery, Houston Methodist Hospital, Houston, TX, USA.
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13
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Karakayali FY, Tezcaner T, Moray G. Anorectal function and outcomes after transanal minimally invasive surgery for rectal tumors. J Minim Access Surg 2015; 11:257-62. [PMID: 26622116 PMCID: PMC4640025 DOI: 10.4103/0972-9941.152094] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND: Transanal endoscopic microsurgery is a minimally invasive technique that allows full-thickness resection and suture closure of the defect for large rectal adenomas, selected low-risk rectal cancers, or small cancers in patients who have a high risk for major surgery. Our aim, in the given prospective study was to report our initial clinical experience with TAMIS, and to evaluate its effects on postoperative anorectal functions. MATERIALS AND METHODS: In 10 patients treated with TAMIS for benign and malignant rectal tumors, preoperative and postoperative anorectal function was evaluated with anorectal manometry and Cleveland Clinic Incontinence Score. RESULTS: The mean distance of the tumors from the anal verge was 5.6 cm, and mean tumor diameter was 2.6 cm. All resection margins were tumor free. There was no difference in preoperative and 3-week postoperative anorectalmanometry findings; only mean minimum rectal sensory volume was lower at 3 weeks after surgery. The Cleveland Clinic Incontinence Score was normal in all patients except one which resolved by 6 weeks after surgery.The mean postoperative follow-up was 28 weeks without any recurrences. CONCLUSION: Transanal minimally invasive surgery is a safe and effective procedure for treatment of rectal tumors and can be performed without impairing anorectal functions.
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Affiliation(s)
- Feza Y Karakayali
- Department of General Surgery, Baskent University, School of Medicine, Ankara, Turkey
| | - Tugan Tezcaner
- Department of General Surgery, Baskent University, School of Medicine, Ankara, Turkey
| | - Gokhan Moray
- Department of General Surgery, Baskent University, School of Medicine, Ankara, Turkey
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14
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Molina G, Bordeianou L, Shellito P, Sylla P. Transanal endoscopic resection with peritoneal entry: a word of caution. Surg Endosc 2015; 30:1816-25. [PMID: 26264697 DOI: 10.1007/s00464-015-4452-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 07/13/2015] [Indexed: 12/30/2022]
Abstract
BACKGROUND Peritoneal entry during transanal endoscopic microsurgery (TEM) can usually be managed transanally with full-thickness suture closure by experienced operators. The preliminary safety of transanal minimally invasive surgery (TAMIS) has been demonstrated, but the reported experience with upper rectal tumors is limited. The incidence and management of peritoneal entry during transanal endoscopic surgery across various platforms have not been previously evaluated. METHODS Retrospective analysis of a prospectively maintained database of all transanal endoscopic resections performed at a single institution between January 2008 and December 2014 was conducted. Cases with and without peritoneal entry were evaluated with respect to transanal platform used, surgical indication, size, location and distance from the anal verge, and incidence of postoperative complications. RESULTS A total of 78 transanal endoscopic procedures were performed on 76 patients using the rigid transanal endoscopic operation (TEO, 65.4 %), TEM (26.9 %), and TAMIS platform (7.7 %). The most common surgical indication included endoscopically unresectable adenomas (50 %). The average distance of lesions from the anal verge (AV) was 9.6 cm (range 4-20 cm). Peritoneal entry occurred in 22 cases (28.2 %). Platform used (TAMIS vs. rigid, p < 0.05), mean distance from the AV (p < 0.0001), location along the rectum (p = 0.01), and mean specimen size (p = 0.01) were associated with a higher likelihood of peritoneal entry. All rectal defects associated with peritoneal entry were successfully closed transanally except for two (TEM and TEO) cases that required conversion to laparoscopic low anterior resection and laparoscopic Hartmann's, respectively. There were four TAMIS cases that required conversion to TEO platforms. CONCLUSION In this high-risk TEM, TEO, and TAMIS series (one-third of rectal lesions located in the upper rectum), 91 % of all peritoneal entries were managed transanally without increased morbidity. TAMIS for upper rectal lesions was associated with a high risk of complicated peritoneal entry requiring conversion to a rigid platform.
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Affiliation(s)
- George Molina
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | | | - Paul Shellito
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Patricia Sylla
- Department of Surgery, Mount Sinai Hospital, 5 East 98th Street Box 1249, New York, NY, 10029, USA.
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Hahnloser D, Cantero R, Salgado G, Dindo D, Rega D, Delrio P. Transanal minimal invasive surgery for rectal lesions: should the defect be closed? Colorectal Dis 2015; 17:397-402. [PMID: 25512176 DOI: 10.1111/codi.12866] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 09/20/2014] [Indexed: 02/08/2023]
Abstract
AIM Transanal minimal invasive surgery (TAMIS) of rectal lesions is increasingly being used, but the technique is not yet standardized. The aims of this study were to evaluate peri-operative complications and long-term functional outcome of the technique and to analyse whether or not the rectal defect needs to be closed. METHOD Consecutive patients undergoing TAMIS using the SILS port (Covidien) and standard laparoscopic instruments were studied. RESULTS Seventy-five patients (68% male) of mean age 67 (± 15) years underwent single-port transanal surgery at three different centres for 37 benign lesions and 38 low-risk cancers located at a mean of 6.4 ± 2.3 cm from the anal verge. The median operating time was 77 (25-245) min including a median time for resection of 36 (15-75) min and for closure of the rectal defect of 38 (9-105) min. The defect was closed in 53% using interrupted (75%) or a running suture (25%). Intra-operative complications occurred in six (8%) patients and postoperative morbidity was 19% with only one patient requiring reoperation for Grade IIIb local infection. There was no difference in the incidence of complications whether the rectal defect was closed or left open. Patients were discharged after 3.4 (1-21) days. At a median follow-up of 12.8 (2-29) months, the continence was normal (Vaizey score of 1.5; 0-16). CONCLUSION Transanal rectal resection can be safely and efficiently performed by means of a SILS port and standard laparoscopic instruments. The rectal defect may be left open and at 1 year continence is not compromised.
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Affiliation(s)
- D Hahnloser
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Zurich, Switzerland; Department of Visceral Surgery, University Hospital Lausanne, Lausanne, Switzerland
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Burke JP, Albert M. Transanal minimally invasive surgery (TAMIS): Pros and cons of this evolving procedure. SEMINARS IN COLON AND RECTAL SURGERY 2015. [DOI: 10.1053/j.scrs.2014.10.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Campbell ML, Vadas KJ, Rasheid SH, Marcet JE, Sanchez JE. A reproducible ex vivo model for transanal minimally invasive surgery. JSLS 2014; 18:62-5. [PMID: 24680145 PMCID: PMC3939344 DOI: 10.4293/108680813x13693422518911] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
The authors conclude that transanal laparoendoscopic procedures to excise rectal tumors can be successfully reproduced in an ex vivo porcine anorectal model. Background: Rectal tumors can be excised through a number of minimally invasive transanal techniques including transanal excision, transanal endoscopic microsurgery, and transanal minimally invasive surgery (TAMIS). Specialty training is often required to master the nuances of these approaches. This study aimed to create a reproducible transanal excision training model that is suited for laparoendoscopic techniques. Methods: Frozen porcine rectum and anus with intact perianal skin were commercially obtained. Thawed specimens were then cut to approximately 20 cm in length. The proximal end of the rectum was then everted and suction applied to the mucosa to create pseudopolyps of various sizes (sessile and pedunculated). Larger pedunculated lesions were made by tying the base of the pseudopolyps with 5–0 monofilament sutures to gather more tissue. Methylene blue dye was injected submucosally into the lesions to simulate tattoos. The proximal rectum was then closed with sutures. The model was suspended in a trainer box by clamping the distal end in a ringed clamp and the proximal end to the box. Transanal excisions using TAMIS were then performed. The procedures were done by trained community colorectal surgeons attending courses on transanal minimally invasive surgery. Results: Both partial- and full-thickness excisions of sessile and pedunculated rectal lesions were successfully performed during simulated TAMIS by trained community surgeons learning this laparoendoscopic technique. Conclusion: Transanal laparoendoscopic procedures to excise rectal tumors can be successfully and reproducibly performed in an ex vivo porcine anorectal model.
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Affiliation(s)
- Michael Larone Campbell
- Department of Surgery, Division of Colon and Rectal Surgery, University of South Florida, Tampa, FL 33606, USA.
| | - Kimberly J Vadas
- Center for Advanced Medical Learning and Simulation, University of South Florida, Tampa, FL, USA
| | - Sowsan H Rasheid
- Department of Surgery, Division of Colon and Rectal Surgery, University of South Florida, Tampa, FL, USA
| | - Jorge E Marcet
- Department of Surgery, Division of Colon and Rectal Surgery, University of South Florida, Tampa, FL, USA
| | - Jaime E Sanchez
- Department of Surgery, Division of Colon and Rectal Surgery, University of South Florida, Tampa, FL, USA
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18
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New surgical approach of retrorectal cystic hamartoma using transanal minimally invasive surgery (TAMIS). JOURNAL OF COLOPROCTOLOGY 2014. [DOI: 10.1016/j.jcol.2014.08.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Martin-Perez B, Andrade-Ribeiro GD, Hunter L, Atallah S. A systematic review of transanal minimally invasive surgery (TAMIS) from 2010 to 2013. Tech Coloproctol 2014; 18:775-88. [PMID: 24848524 DOI: 10.1007/s10151-014-1148-6] [Citation(s) in RCA: 155] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Accepted: 04/10/2014] [Indexed: 12/13/2022]
Abstract
Transanal minimally invasive surgery (TAMIS) was introduced as an alternative to transanal endoscopic microsurgery in 2010. Over the past 4 years, considerable international experience has been gained with this approach. Most published reports focus on TAMIS for local excision of rectal neoplasia, but there are other important applications such as transanal mesorectal excision for rectal cancer. This comprehensive review details the progress with TAMIS since its inception. Robotic transanal surgery is a natural evolution of TAMIS still in its early infancy, which is also reviewed. A comprehensive search of PubMed, EMBASE, the Cochrane Library, and Web of Knowledge was performed. Since the inception of TAMIS in 2009, 33 retrospective studies and case reports, and 3 abstracts have been published on TAMIS for local excision of rectal neoplasms, which represents a combined n = 390 TAMIS procedures performed worldwide using eight different types of TAMIS platforms. A total of 152 lesions were excised for benign disease including adenomas and high-grade dysplasias (39 %), 209 for malignancy for carcinomas in situ and adenocarcinomas (53.5 %). Twenty-nine (7.5 %) of TAMIS resections were for other pathology, of which the majority (23/29) were neuroendocrine lesions. The remaining resections were for mucocele, gastrointestinal stromal tumor, melanoma, and fibrosis. Robotic-TAMIS has also been reported, however, data are extremely limited as there are only 7 case reports (combined n = 11) in the published literature. Success with Robotic-TAMIS has been demonstrated with various patient positions and by use of a special glove port. Transanal total mesorectal excision using the TAMIS platform has also been demonstrated is several small series, and the feasibility of performing pure transanal total mesorectal excision has also been reported. Combined, n = 78 cases of transanal total mesorectal excision have been performed using TAMIS. The advantages of TAMIS-assisted transanal total mesorectal excision are discussed.
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Abstract
Transanal minimally invasive surgery (TAMIS) was introduced as an alternative to transanal endoscopic microsurgery in 2010. Over the past 4 years, considerable international experience has been gained with this approach. Most published reports focus on TAMIS for local excision of rectal neoplasia, but there are other important applications such as transanal mesorectal excision for rectal cancer. This comprehensive review details the progress with TAMIS since its inception. Robotic transanal surgery is a natural evolution of TAMIS still in its early infancy, which is also reviewed. A comprehensive search of PubMed, EMBASE, the Cochrane Library, and Web of Knowledge was performed. Since the inception of TAMIS in 2009, 33 retrospective studies and case reports, and 3 abstracts have been published on TAMIS for local excision of rectal neoplasms, which represents a combined n = 390 TAMIS procedures performed worldwide using eight different types of TAMIS platforms. A total of 152 lesions were excised for benign disease including adenomas and high-grade dysplasias (39 %), 209 for malignancy for carcinomas in situ and adenocarcinomas (53.5 %). Twenty-nine (7.5 %) of TAMIS resections were for other pathology, of which the majority (23/29) were neuroendocrine lesions. The remaining resections were for mucocele, gastrointestinal stromal tumor, melanoma, and fibrosis. Robotic-TAMIS has also been reported, however, data are extremely limited as there are only 7 case reports (combined n = 11) in the published literature. Success with Robotic-TAMIS has been demonstrated with various patient positions and by use of a special glove port. Transanal total mesorectal excision using the TAMIS platform has also been demonstrated is several small series, and the feasibility of performing pure transanal total mesorectal excision has also been reported. Combined, n = 78 cases of transanal total mesorectal excision have been performed using TAMIS. The advantages of TAMIS-assisted transanal total mesorectal excision are discussed.
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McLemore EC, Weston LA, Coker AM, Jacobsen GR, Talamini MA, Horgan S, Ramamoorthy SL. Transanal minimally invasive surgery for benign and malignant rectal neoplasia. Am J Surg 2014; 208:372-81. [PMID: 24832238 DOI: 10.1016/j.amjsurg.2014.01.006] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 12/27/2013] [Accepted: 01/05/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND Transanal minimally invasive surgery (TAMIS), an alternative technique to transanal endoscopic microsurgery, was developed in 2009. Herein, we describe our initial experience using TAMIS for benign and malignant rectal neoplasia. METHODS This is an institutional review board approved, retrospective case series report. RESULTS TAMIS was performed in 32 patients for rectal adenoma (13), adenocarcinoma (16), and carcinoid (3). There were 14 women, with mean age 62 ± 15 years and body mass index 28 ± 5 kg/m(2). Lesion size ranged from .5 to 8.5 cm, distance from the dentate line 1 to 11 cm, and circumference of the lesion 10% to 100%. The mean operative time was 123 ± 62 minutes. Mean hospital length of stay was 2.5 ± 2 days. Complications included urinary tract infection (1), Clostridium difficile diarrhea (1), atrial fibrillation (1), rectal stenosis (1), and rectal bleeding (1). CONCLUSION TAMIS using a disposable transanal access platform is a safe and effective method to remove rectal lesions in this case series.
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Affiliation(s)
| | - Lynn A Weston
- Department of Surgery, Scripps Health Systems, San Diego, CA, USA
| | - Alisa M Coker
- Department of Surgery, University of California, San Diego, CA, USA
| | - Garth R Jacobsen
- Department of Surgery, University of California, San Diego, CA, USA
| | - Mark A Talamini
- Department of Surgery, University of California, San Diego, CA, USA
| | - Santiago Horgan
- Department of Surgery, University of California, San Diego, CA, USA
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Walensi M, Käser SA, Theodorou P, Bassotti G, Cathomas G, Maurer CA. Transanal endoscopic microsurgery (TEM) facilitated by video-assistance and anal insertion of a single-incision laparoscopic surgery (SILS(®))-port: preliminary experience. World J Surg 2014; 38:505-511. [PMID: 24101024 DOI: 10.1007/s00268-013-2264-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Transanal endoscopic microsurgery (TEM) is an established method for the resection of benign and early malignant rectal lesions. Very recently, TEM via an anally inserted single incision laparoscopic surgery (SILS(®))-port has been proposed to overcome remaining obstacles of the classical TEM equipment. METHODS Nine patients with a total of 12 benign or early stage malignant rectal polyps were operated using the SILS(®)-port for TEM. Patients' and polyps' characteristics, perioperative and postoperative complications, as well as operating and hospitalization time were recorded. RESULTS All 12 polyps (ten low-grade adenoma, one high-grade adenoma, one pT2 carcinoma [preoperatively staged as T1]) were resected. Local full-thickness bowel wall resection was performed for three lesions and submucosal resection for nine lesions. Median operating time was 64 (range 30-180) min. No conversion to laparoscopic or open techniques was necessary. The median maximum diameter of the specimen was 25 (range 3-60) mm, fragmentation of polyps was avoidable in 11 of 12 (92 %) lesions, and resection margins were histologically clear in 11 of 12 (92 %) polyps. Only one patient, in whom three lesions were resected, experienced a complication as postoperative hemorrhage. No mortality occurred. Median hospitalization time was four (range 1-14) days. CONCLUSIONS SILS(®)-TEM is a feasible and safe method, providing numerous advantages in application, handling, and economy compared with the classical TEM technique. SILS(®)-TEM might become a promising alternative to classical TEM. Randomized, controlled trials comparing safety and efficacy of both instrumental settings will be needed in the future.
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Affiliation(s)
- Mikolaj Walensi
- Department of Surgery, Hospital of Liestal, Affiliated with the University of Basel, Rheinstrasse 26, 4410, Liestal, Switzerland,
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Gorgun IE, Aytac E, Costedio MM, Erem HH, Valente MA, Stocchi L. Transanal endoscopic surgery using a single access port: a practical tool in the surgeon's toybox. Surg Endosc 2013; 28:1034-8. [PMID: 24178864 DOI: 10.1007/s00464-013-3267-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2013] [Accepted: 10/06/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Large polyps and early carcinomas of the rectum may be excised with transanal endoscopic surgery (TES). Single-port techniques are emerging in the field of colorectal surgery and have been adapted to many colorectal procedures so far. In this article, we aimed to present our initial experience with TES using a single access port with its technical details. PATIENTS AND METHODS Patients undergoing TES using a single access port between July 2010 and January 2013 were included in the study. Patient demographics, operative technique, and both operative and postoperative outcomes were evaluated and presented. RESULTS A total of 12 patients (ten males) were included in our study. The median age was 63.5 years (50-84), median American Society of Anesthesiologists (ASA) score was 3 (2-4), and median body mass index was 28.8 kg/m(2) (17.4-55.6). Median operating time was 79 min (43-261). Histopathological diagnoses were as follows: tubulovillous adenoma (n = 6), tubular adenoma (n = 4), adenocarcinoma (n = 1), and neuroendocrine tumor (n = 1). Five patients were sent home on the day of surgery and the median postoperative hospital stay was 1 day (0-38). Median estimated blood loss was 22.5 ml (5-150). A transient urinary retention was developed in one patient postoperatively, and two patients had postoperative bleeding. The first of these patients with a long history of anticoagulant usage had rectal bleeding 13 days after surgery, which was successfully managed with medical treatment. The second patient was morbidly obese, had multiple comorbidities, and had rectal bleeding on postoperative day 7 which was managed with local epinephrine injection. He suffered unrelated cardiac death on postoperative day 38. CONCLUSIONS TES is safe and feasible when using a single port and in the standard laparoscopic setting. The single-port technique may play a major role in the widespread utilization of TES as a treatment for large adenomas and early rectal cancers.
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Abstract
BACKGROUND Transanal endoscopic microsurgery is a minimally invasive approach reserved for the resection of selected rectal tumors. However, this approach is technically demanding. Although robotic technology may overcome the limitations of this approach, the system can be difficult to dock, especially in the lithotomy position. OBJECTIVE The study aim is thus to report the technical details of robotic transanal endoscopic microsurgery with the use of a lateral approach. DESIGN AND SETTINGS This study is a prospective evaluation of robotic transanal endoscopic microsurgery in a single tertiary institution, under a protocol approved by our local ethics committee. INTERVENTION Patients underwent a routine mechanical bowel preparation and were placed in the left or right lateral position according to the tumor location. A circular anal dilatator was used together with the glove port technique. The robotic system was then docked over the hip. A 30° optic and 2 articulated instruments were used with an additional assistant trocar. The tumor excision was realized with an atraumatic grasper and an articulated cautery hook, and the defect was closed with barbed continuous stiches in each case. MAIN OUTCOME MEASURE The primary outcome was the safety and feasibility of the procedure. RESULTS Three patients underwent a robotic transanal endoscopic microsurgery with the use of the lateral approach. Mean operative time was 110 minutes, including 20 minutes for the docking of the robot. There was 1 intraoperative complication (a pneumoperitoneum without intraabdominal lesion) and no postoperative complications. Mean hospital stay was 3 days. Margins were negative in all the cases. LIMITATIONS The study was limited by the small number of patients. CONCLUSION Robotic transanal endoscopic microsurgery with use of the lateral approach is feasible and may facilitate the local resection of small lesions of the mid and lower rectum. It might assume an important place in sphincter-preserving surgery, especially for selected and early rectal cancer (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A114).
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Transanal single-port microsurgery for rectal tumors: minimal invasive surgery under spinal anesthesia. Surg Endosc 2013; 28:271-80. [PMID: 24061623 DOI: 10.1007/s00464-013-3184-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Accepted: 08/07/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Transanal minimally invasive surgery (TAMIS) for rectal tumors has been introduced as an alternative approach to transanal endoscopic microsurgery (TEM). TEM has some limitations, such as the need for special equipment, expensive cost, and steep learning curve. In this study, we address the technical feasibility of TAMIS under spinal anesthesia and its short-term postoperative outcomes. METHODS From July 2011 to September 2012, 25 consecutive patients with middle or upper third rectal masses underwent TAMIS. Tumors were located 6-17 cm from the anal verge. After spinal anesthesia, a single-incision laparoscopic surgery port was inserted into the anal canal. With this access, conventional laparoscopic instruments, including a grasper and monopolar electrocautery and suction device, were used to perform the transanal excision. A hook-type monopolar electrocautery or harmonic scalpel was used for dissection. The defect of the rectum was closed by interrupted sutures. Data concerning demographics, details of operative procedure, postoperative pain, and pathologic results were collected prospectively. To evaluate anal sphincter injury, an endoanal ultrasonography and fecal incontinence severity index survey were performed at 3-6 months after the operation. RESULTS Of the 25 patients, nine had adenocarcinomas, nine had neuroendocrine tumors, three had tubular adenomas with high-grade dysplasia, three had tubular adenomas, one had a tubulovillous adenoma, and one had a gastrointestinal stromal tumor. The median distance from the tumor mass to the anal verge was 9.0 (range 6-17) cm. The median operative time was 45.0 (range 20-120) min. All patients received TAMIS without conversion to laparoscopic resection. There were no intraoperative complications or postoperative morbidity. The median postoperative hospital stay was 3.0 (range 2-7) days. No sphincter injury was detected by endoanal ultrasonography. CONCLUSIONS TAMIS under spinal anesthesia is a safe and feasible technique for resection of middle and upper rectal masses. Spinal anesthesia is adequate for this procedure.
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Arezzo A, Arolfo S, Cravero F, Migliore M, Allaix ME, Morino M. Which treatment for large rectal adenoma? Preoperative assessment and therapeutic strategy. MINIM INVASIV THER 2013; 23:21-7. [PMID: 23992387 DOI: 10.3109/13645706.2013.833117] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
In the present review the authors discuss the standard ways of preoperative work-up for a suspected large rectal non-invasive lesion, comparing East and West different attitudes both in staging and treatment. Looking at the literature and analyzing recent personal data, neither pit-pattern classification, nor EUS, nor biopsy histology, nor lifting sign verification, nor digital examination allow a specificity of more than three fourth of such cases. The authors disquisition about which optimal treatment excludes a role for EMR for the impossibility to obtain a single en-bloc specimen, minimum requirement for a correct lateral and vertical margin assessment. For the same reason ESD should be preferred, although a recent meta-analysis of the literature defined that one fourth of patients undergoing ESD for a preoperatively assessed non-invasive large rectal lesion fail to receive an R0 en-bloc resection. This forces about 10% of patients treated by flexible endoscopy to undergo abdominal surgery, which is about fourfold higher than TEM. While awaiting further implementation of modern technologies both to improve staging and to reduce invasiveness, a full-thickness excision of the rectal wall by TEM still represents the standard treatment even for suspected benign diseases.
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Affiliation(s)
- Alberto Arezzo
- Department of Surgical Sciences, University of Torino , Torino , Italy
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Rimonda R, Arezzo A, Morino M. Reply to: doi: 10.1007/s00464-013-3111-4: TEM or TAMIS: what is the future of transanal endoscopic surgery? Surg Endosc 2013; 28:1376-7. [PMID: 23982651 DOI: 10.1007/s00464-013-3148-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Accepted: 07/24/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Roberto Rimonda
- Department of Surgery, ASLCN1, Mondovì (CN) Hospital, 12084, Mondovì, Italy,
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TransAnal Minimally Invasive Surgery (TAMIS) with SILS™ port versus Transanal Endoscopic Microsurgery (TEM): a comparative experimental study. Surg Endosc 2013; 27:3762-8. [PMID: 23636523 DOI: 10.1007/s00464-013-2962-z] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 04/02/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND TransAnal Minimally Invasive Surgery (TAMIS) has been proposed as an alternative to Transanal Endoscopic Microsurgery (TEM) for resection of benign polyps and early cancers of rectum. Since clinical application has begun in the absence of any experimental validation, we assessed its feasibility and efficacy ex vivo in a pilot study. METHODS In a dedicated trainer box for transanal procedures, 10 surgeons with no experience in transanal surgery were asked to perform a dissection/suture task using both TAMIS and TEM in randomly allocated order. Surgeons were asked to dissect two identically drawn lesions of ~3 cm in larger diameter. Precision of dissection was assessed using a quantitative photographic method, while the time needed for dissection and suturing was considered a measure of quantitative evaluation. Each participant expressed a subjective opinion regarding difficulty with dissection, difficulty with suturing, vision quality, and conflict between instruments on a scale from 1 to 5. RESULTS No difference was observed between the two techniques regarding the accuracy of dissection as the margin was interrupted along 4.1 % of the circumference in the TEM group compared with 2.48 % in the SILS group (P = 0.271). Dissection and suturing were significantly quicker in the TEM group [04:30 vs. 06:35 min (P = 0.049) and 14:34 versus 19:18 min (P = 0.003)]. In three cases in the SILS group, completing the suture was not considered possible, and the procedures were terminated by TEM. Subjective evaluation revealed a better appreciation of TEM in all proposed comparisons: dissection (2.6 vs. 3.5, P = 0.004), suturing difficulty (3.1 vs. 4.6, P < 0.001), quality of vision (2.3 vs. 2.8, P = 0.18), and instrument conflicts (3.1 vs. 4.0, P = 0.054). CONCLUSIONS In the ex vivo setting, both techniques were comparable for achieving a good dissection, although TAMIS failed to prove effective in suturing the rectal wall. Moreover, TEM was significantly quicker despite the small groups and was better appreciated by the surgeons.
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Abstract
Transanal use of laparoscopic instrumentation has been described in several case reports as an alternative to transanal endoscopic microsurgery (TEM). Both of these techniques have significant technical limitations due to anatomical constrictions. Robotic technology with articulating instruments has been effectively used in many areas with anatomic limitations similar to the intraluminal use within the rectum. We present the technique of a full-thickness transanal resection of a rectal polyp with endorectal suturing using a robotic platform. Larger case series and trials are needed to compare outcome and cost with TEM. Alternative robotic platforms and instrumentation may be further developed for different and more advanced indications of transanal access surgery.
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Affiliation(s)
- Ovunc Bardakcioglu
- Colon & Rectal Surgery, Saint Louis University, 3635 Vista Avenue, Desloge Towers, 3rd Floor, St. Louis, MO 63110, USA.
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Kang J, Lee KY. Current status of robotic rectal cancer surgery. COLORECTAL CANCER 2012. [DOI: 10.2217/crc.12.60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
SUMMARY After the introduction of robotic surgery for rectal cancer, the safety and feasibility of robotic rectal cancer surgery was demonstrated. However, early comparative studies between laparoscopic and robotic surgery did not show a significant postoperative benefit. Recently, it was reported that robotic rectal surgery showed better postoperative outcomes than laparoscopic surgery with regard to postoperative recovery, pain and function preservation. In addition, robotic transanal specimen extraction was safely performed while maintaining a lower level of postoperative pain and recovery time. All of these findings should be validated with well-designed comparative studies. As robotic technology advances and continues to be studied, the use of robotic surgical systems will become more common among colorectal surgeons.
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Affiliation(s)
- Jeonghyun Kang
- Department of Surgery, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 135-720, Korea
| | - Kang Young Lee
- Department of Surgery, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 135-720, Korea
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[Transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS)]. Cir Esp 2012; 90:418-20. [PMID: 22809543 DOI: 10.1016/j.ciresp.2012.04.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Revised: 03/23/2012] [Accepted: 04/08/2012] [Indexed: 11/20/2022]
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Ragupathi M, Vande Maele D, Nieto J, Pickron TB, Haas EM. Transanal endoscopic video-assisted (TEVA) excision. Surg Endosc 2012; 26:3528-35. [PMID: 22729706 DOI: 10.1007/s00464-012-2399-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2012] [Accepted: 05/15/2012] [Indexed: 12/14/2022]
Abstract
BACKGROUND Transanal endoscopic video-assisted (TEVA) excision represents an alternative approach for the surgical treatment of middle and upper rectal lesions not amenable to colonoscopic removal. Utilizing principles of single-incision laparoscopic surgery, this novel minimally invasive approach optimizes access for safe and complete removal of these lesions without the need for a formal rectal resection. We describe our technique and early outcomes with TEVA excision. METHODS Between March 2010 and September 2011, TEVA excision was performed for patients presenting for management of rectal lesions not amenable to colonoscopic or standard transanal removal. Patients were selected if they presented with benign disease or superficial adenocarcinoma, and the proximal extent of the lesion extended beyond 8 cm from the anal verge. Demographic, intraoperative, and postoperative data were assessed. A SILS™ port was placed in the anal canal for access in all cases. Standard laparoscopic instruments were utilized for visualization, full-thickness transanal excision, and primary closure. RESULTS Twenty patients (50% male) with a mean age of 64.6 ± 10.9 years, mean body mass index of 28.2 ± 4.9 kg/m(2), and median American Society of Anesthesiologist score of 2 underwent TEVA excision. Fourteen patients (70%) presented with benign disease and six patients (30%) presented with malignant disease. The mean size of the lesions was 3.0 ± 1.4 cm, and the mean distance from the anal verge was 10.6 ± 2.4 cm. All excisions were successfully completed with a mean operative time of 79.8 ± 25.1 (range, 45-135) min. The mean length of hospital stay was 1.1 ± 0.7 (range, 0-3) days. CONCLUSIONS TEVA excision is a safe and feasible approach for local excision of rectal lesions not otherwise amenable to standard techniques. Continued investigation and development will be important to establish its role in minimally invasive colorectal surgery.
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Glove port technique for transanal endoscopic microsurgery. Int J Surg Oncol 2012; 2012:383025. [PMID: 22701788 PMCID: PMC3371758 DOI: 10.1155/2012/383025] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Accepted: 04/17/2012] [Indexed: 02/06/2023] Open
Abstract
Introduction. Despite initial enthusiasm, the use of transanal endoscopic microsurgery (TEM) is still quite limited at present because of the expense of highly specialized equipment and the complexity of the learning curve. Furthermore, some authors report a relevant, although temporary, effect on anorectal function because of the considerable anal dilatation which can even produce a rupture of the internal anal sphincter. The “glove TEM” proposes itself as an alternative to traditional TEM that could settle these problems. Materials and Methods. The technique is accurately described together with the necessary equipment to perform it. Between 2011 and 2012, we operated eight patients with this technique for rectal adenomas or early carcinomas achieving R0 resection in all cases and reporting no early or late complications during the first five months of followup. Discussion. This technique offers multiple advantages compared to the original TEM. (i) It allows the use of all available laparoscopic instruments. (ii) It gives a great manoeuvrability of the instruments in contrast to rigid rectoscope systems. (iii) Given the limited length of the device, it permits to operate on tumors closer to the dentate line. (iv) It is less traumatic to the anal sphincter. It is definitively much cheaper. Conclusions. We believe that this new technique is easy to perform, cost-effective, and less traumatic to the anal sphincter compared to traditional TEM.
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