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1.
D. F. Altomare A. Picciariello R. Memeo M. Fanelli R. Digennaro N. Chetta M. De Fazio 《Techniques in coloproctology》2018,22(4):289-294
Background
Obstructed defecation syndrome (ODS), most commonly found in females, can be treated by a transanal or abdominal approach with good success rate. Nevertheless, patients may experience de novo or persisting pelvic floor dysfunctions after surgery. The aim of this study was to compare the functional outcome of stapled transanal rectal resection (STARR) and ventral rectopexy (VRP) in a series of ODS patients.Methods
Forty-nine female patients who had surgery for ODS between 2006 and 2016 were retrospectively evaluated: 28 (median age 60 years, IQR 54–69 years) had VRP and 21 (median age 58 years, IQR 51–66 years) had STARR. ODS was scored with the ODS score while the overall pelvic floor function was assessed with the three axial perineal evaluation (TAPE) score. Quality-of-life was evaluated by the patient assessment of constipation quality-of-life (PAC-Qol) questionnaire administered preoperatively and after 1 year of follow-up.Results
The preoperative median ODS score and TAPE score were comparable in both groups. After a median follow-up of 12 months (range 12–18 months), the median ODS score was 12 (range 10–20) in the STARR group and 9 (range 3–15) in the VRP one (p?=?0.02), while the median TAPE score was 70.5 (IQR 60.6–77.3) in the former and 76.8 (IQR 70.2–89.7) in the latter (p?=?0.01). Postoperatively the physical domain of the PAC-QoL score had a median value of 2.74 (IQR 1.7–3.75) in the STARR group compared to 1.5 (IQR 1–2.5) in the VRP group (p?=?0.03). No major complications were recorded in either group.Conclusions
VRP and STARR can improve defecation in patients with ODS with minimal complications, but the overall pelvic wellness evaluated by the TAPE score improves significantly only after VRP, suggesting a better performance of VRP than STARR when overall pelvic floor function is concerned.2.
Luis Miguel Jimenez-Gomez Eloy Espin-Basany Marc Marti-Gallostra Jose Luis Sanchez-Garcia Francesc Vallribera-Valls Manuel Armengol-Carrasco 《International journal of colorectal disease》2016,31(4):813-823
Background
Low anterior resection syndrome (LARS) is frequent following sphincter-sparing procedures for rectal cancer.Objective
This study aims to assess surgeons’ awareness of LARS.Design
This was a survey study.Settings
Members of the American Society of Colon and Rectal Surgeons (ASCRS), the Spanish Association of Surgeons (AEC), and the Spanish Society of Coloproctology (AECP).Participants
Three hundred thirty-four surgeons from the ASCRS and 150 from the Spanish Societies completed a 23-item electronic questionnaire.Main outcome measures
Surgeons’ opinions regarding different aspects of LARS.Results
The proportion of rectal cancer patients undergoing sphincter-sparing operations ranged between 71 and 90 %. Low anterior resection with end-to-end anastomosis was the most frequently cited procedure after mesorectal excision. More than 80 % of participants were recognized to be moderately or extremely aware of the condition, but regarding the method used to assess LARS, the majority relied on clinical manifestations. Around 35 % of surgeons considered that severe LARS developed in less than 40 % of patients. The most important factor related to defecatory function impairment in the surgeons’ opinion was the distance from the anal margin to anastomosis. Other factors thought to be involved were anastomotic leakage, preoperative radiation therapy, age, and postoperative radiotherapy, with similar percentages in the two groups of surgeons. Lifestyle changes and dietary measures associated with or without drug treatment was the modality of choice. The experience with transanal irrigation or sacral nerve stimulation was limited. It was considered that <30 % of patients chronically suffer from severe LARS with significant quality of life impairment.Limitations
The limitations of this study are the international mix and expert status of the specialists.Conclusions
The probability of patients suffering from LARS was underestimated despite reporting good knowledge of the syndrome. Validated methods for the assessment of LARS were rarely used. Deficient awareness regarding risk factors for LARS was documented. Knowledge of therapeutic options was also limited.3.
G. Naldini B. Fabiani C. Menconi I. Giani G. Toniolo D. Mascagni J. Martellucci 《Techniques in coloproctology》2018,22(1):53-58
Background
In recent years, stapled transanal resection (STARR) has been adopted worldwide with convincing short-term results. However, due to the high recurrence rate and some major complications after STARR, there is still controversy about when the procedure is indicated. The aim of this study was to assess the safety, efficacy and feasibility of STARR performed with a new dedicated device for tailored transanal stapled surgery.Methods
All the consecutive patients affected by obstructed defecation syndrome (ODS) due to rectocele or/and rectal intussusception, who underwent STARR with the TST STARR-Plus stapler, were included in a prospective study. Pain, Cleveland Clinic Score for Constipation (CCCS) and incontinence, patient satisfaction, number of hemostatic stitches, operative time, hospital stay and perioperative complications were recorded. Postoperative complications and recurrence were also reported.Results
Forty-five consecutive patients (median age 50; range 24–79) were included in the study. Median resected volume was 15 cm3 (range 12–19 cm3) with a median height of surgical specimen of 5.6 cm (range 4.5–10 cm). The mean CCCS decreased from 17.26 (± 3.77) to 5.42 (± 2.78) postoperatively (p < 0.001). Patient satisfaction grade was excellent in 14 patients (31.1%), good in 25 (55.5%), sufficient in three (6.7%) and poor in three patients (6.7%). No major complications occurred. Five patients (11%) reported urgency after 30 days and two patients (4%) after 12 months. The Cleveland Clinic Incontinence score did not significantly change. At a median follow-up of 23 months (range 12–30 months), only three patients (6.7%) reported recurrent symptoms of obstructed defecation comparable to those reported at baseline.Conclusions
TST STARR-Plus seems to be safe and effective for the treatment of ODS due to rectocele and rectal intussusception, and technical improvement could reduce the risk of some complications. However, careful patient selection is still the best means of preventing complications.4.
Background
Urethral injury is one of the major risks in transanal total mesorectal excision (TaTME). To provide surgeons with experience in and management of potential critical surgical scenarios, urethral and prostate injuries were intentionally created during a body donor workshop under standardized training conditions.Methods
We conducted a 2-day structured TaTME body donor training workshop. The theoretical module included lectures on topographic anatomy, clinical evidence, and surgical technique and pitfalls. Practical modules started with an interactive demonstration of crucial landmarks for the transanal approach using predissected formalin-fixed specimens. Next, surgical teams underwent proctored surgical training that implemented the key steps of TaTME on simulators and four male body donors. Strategies to avoid urethral damage involved intentional dissection and injury of the urethra and prostate, with subsequent demonstration of these lesions.Results
After emphasizing the critical anatomical landmarks, the proctored surgical teams performed TaTME successfully without any urethral lesions. To demonstrate worst-case scenarios, two major pitfalls associated with TaTME, i.e., urethral injury and mobilization of the prostate, were simulated. These deliberate injuries proved to be critical learning experiences for all participants.Conclusion
Appraisal of crucial anatomical landmarks and deliberate implementation of urethral/prostatic injury scenarios in preclinical TaTME training workshops is an effective way to teach surgeons how to avoid those injuries in patients. Structured and supervised training should be offered to all surgeons prior to implementing TaTME procedures in order to acquire skills necessary to address the delicate structures at risk during transanal approach.5.
Purpose of Review
Ultrasound is the most widely used imaging modality in the assessment of male voiding dysfunction. The lower urinary tract can be in imaged by transabdominal, transrectal, and transperineal approaches.Recent Findings
There is an emerging role of transperineal ultrasound in pelvic floor physiotherapy and also in the evaluation of male sling, especially in failed sling cases.Summary
Common applications of ultrasound in lower urinary tract (LUT) dysfunction include measurement of post-void residual volume, prostate size, bladder wall thickness, and intravesical protrusion of the prostate (IPP). IPP measurement by transabdominal ultrasound of the bladder base is the most established non-invasive imaging parameter in the diagnosis of bladder outlet obstruction (BOO).6.
P. Wilhelm S. Axt P. Storz S. Wenz S. Müller A. Kirschniak 《Techniques in coloproctology》2016,20(5):273-278
Background
Natural orifice transluminal endoscopic surgery (NOTES) has seen considerable new developments in its evolution to a platform for rectal and sigmoid resection, but to date no true single NOTES procedure has been convincing. This study investigates the safety and feasibility of a further developed transanal NOTES platform for single-access NOTES rectosigmoid resection.Methods
Ten large female pigs, mean weight 99.3 kg [standard deviation (SD) 7 kg, range 85.1–112.6 kg], underwent transanal rectosigmoid resection. Five animals were included in an acute study group with immediate postoperative euthanization. A second group included five animals in a survival study. Transanal rectosigmoid resections were performed with an elongated and curved transanal endoscopic operation (TEO) device. Coloanal anastomosis was performed using the transanal circular stapler technique. Survival follow-up was at 7 and 28 days via colonoscopy under sedation.Results
Single-access NOTES transanal rectosigmoid resection with coloanal anastomosis was performed in nine out of ten female pigs. Mean length of rectosigmoid specimens exteriorized was 18.7 cm (SD 2.9 cm, range 14–23 cm). Mean operating time was 124 min (SD 35.7 min, range 70–166 min). Within the survival group, no complications occurred during the monitoring phase. In one case, there was ascites and colitis at necropsy as well as fibrosis at the anastomosis site.Conclusions
Pure transanal rectosigmoid resection is a feasible procedure. The approach via a single transanal access is demanding but viable with the elongated and curved TEO device. The newly developed scope offers an excellent view of the area cephalad to the promontory.7.
Purpose
Transanal surgery remains both an innovative approach to rectal pathology and a demonstrated technical challenge. Improved technology using a single-port system robotic platform (SPS) offers a promising option for this surgery.Methods
SPS robotic system was utilized to perform submucosal, full-thickness and cylindrical excision on four cadavers. Operative performance and surgeon fatigue were measured.Results
On all types of resections, the SPS system performed well. There were no piecemeal or fragmented resections. Closure was judged to be good to excellent in all cases. Surgeon assessment of setup and performance of the SPS was excellent in all cases.Conclusions
SPS robotic transanal surgery represents an exciting new option for transanal surgery.8.
Purpose
Sparing the extrinsic autonomic innervation of the internal anal sphincter during total mesorectal excision is important for the preservation of anal sphincter function. This study electrophysiologically confirmed the topography of the internal anal sphincter nerve supply during laparoscopic-assisted transanal minimally invasive surgery for total mesorectal excision.Methods
This prospective study was conducted at two large multispecialty referral centers. Six patients (five males and one female) aged between 45 and 65 years with low rectal cancer (≤5 cm from the anal verge) were enrolled. Surgery was performed under electric stimulation of the pelvic autonomic nerves with observation of the electromyographic signals of the internal anal sphincter.Results
The minimally invasive transanal surgical approach enabled advantageous visualization of the pelvic autonomic nerves in all patients. In particular, extrinsic innervation to the internal anal sphincter near the levator muscle was consciously spared under electrophysiological confirmation. The evoked absolute electromyographic amplitudes of the internal anal sphincter during transanal minimally invasive surgery were significantly lower than the initial results of the laparoscopic approach [3.7 μV (interquartile range 2.4; 5.7) vs. 4.3 μV (interquartile range 3.1; 8.6); p?=?0.002]. Five key zones of risk for pelvic autonomic nerve damage were identified. No complications occurred.Conclusions
The electromyographic results of this preliminary study indicate advantages for sparing the internal anal sphincter innervation during transanal minimally invasive mesorectal dissection considering the specific in situ neuroanatomical topography.9.
Aim
Up to 80% of patients after low anterior resection, experience (low) anterior resection syndrome (ARS/LARS). However, there is no standard treatment option currently available. This systemic review aims to summarize treatment possibilities for LARS after surgical treatment of rectal cancer in the medical literature.Methods
Embase, PubMed, and the Cochrane Library were searched using the terms anterior resection syndrome, low anterior resection, colorectal/rectal/rectum, surgery/operation, pelvic floor rehabilitation, biofeedback, transanal irrigation, sacral nerve stimulation, and tibial nerve stimulation. All English language articles presenting original patient data regarding treatment and outcome of LARS were included. We focused on the effects of different treatment modalities for LARS. The Jadad score was used to assess the methodological quality of trials. The quality scale ranges from 0 to 5 points, with a score ≤?2 indicating a low quality report, and a score of ≥?3 indicating a high quality report.Results
Twenty-one of 160 studies met the inclusion criteria, of which 8 were reporting sacral nerve stimulation, 6 were designed to determine pelvic floor rehabilitation, 3 studies evaluated the effect of transanal irrigation, 2—percutaneous tibial nerve stimulation, and the rest of the studies assessed probiotics and 5-HT3 receptor antagonists for LARS in patients who had undergone rectal resection. All except one study were poor quality reports according to the Jadad score.Conclusions
LARS treatment still carries difficulties because of a lack of well-conducted, randomized multicenter trials. Well-performed randomized controlled trials are needed.10.
Matthias Kraemer Werner Paulus David Kara Saskia Mankewitz Stephanie Rozsnoki 《International journal of colorectal disease》2016,31(12):1855-1861
Purpose
Internal rectal prolapse is common and correlates with age. It causes a plug-like physical obstruction and is a major cause of defecation disorder. The progressive distortion of the prolapsing rectum likely causes secondary defects in the rectal wall, which may exacerbate rectal dysfunction. We undertook a prospective observational study to detect and quantify the neurologic and histopathologic changes in the rectal wall.Methods
We examined dorsal and ventral rectal wall specimens from consecutive patients with internal rectal prolapse undergoing stapled transanal rectal resection (STARR). We subjected specimens to histopathologic and neuropathologic assessment, including immunohistochemistry. We also recorded patients’ clinical and demographic characteristics and sought correlations between these and the pathologic findings.Results
We examined 100 specimens. The severity of rectal prolapse and the extent of descent of the perineum correlated significantly with age. Concomitant hemorrhoidal prolapse was noted in all male patients and in 79 % of female patients. Muscular and neuronal defects were detected in 94 and 90 % of the specimens, respectively. Only four specimens (4 %) were free of significant structural defects.Conclusion
Rectal prolapse traumatizes the rectum causing neuromuscular defects. The tissue trauma is due to shearing forces and ischemia caused by the intussusception. This initiates a self-reinforcing vicious circle of physical and functional obstruction, further impairing rectal evacuation and causing constipation and incontinence. The correlation between extent of prolapse and age suggests that internal rectal prolapse can be considered a degenerative disorder. Neural and motor defects in the wall of the rectum caused by rectal prolapse are likely irreversible.11.
Purpose
A perineal approach to treating rectal prolapse is ideal for frail patients. Recently, internal rectal redundancy has been successfully treated with transanal resection using the Contour® Transtar? stapler. This technique has been modified to the perineal stapled prolapse resection. The surgical technique and the preliminary results of the new procedure for external rectal prolapse are presented.Methods
Patients not suited for transabdominal treatment were included prospectively for perineal stapled prolapse resection in two colorectal centers. Feasibility, complications, and reinterventions were assessed.Results
In 14 of 15 patients, perineal stapled prolapse resection was performed without complications in a median operating time of 33 (range, 22–52) minutes. One procedure was changed to an Altemeier because of a staple line disruption. Two patients required reintervention as a result of postoperative hemorrhage. No other severe complications occurred. At follow-up, all patients were well and showed no early recurrence of prolapse.Conclusions
Perineal stapled prolapse resection is a new surgical procedure for external rectal prolapse, which is easy and quick to perform. Functional results and long-term recurrence rate must be investigated further.12.
Background
This study was designed to evaluate the outcomes of patients who underwent various laparoscopic colorectal procedures with natural orifice specimen extraction (NOSE) at our institute over a 20-year period. Specifically, the study aimed to investigate whether transanal and transvaginal approaches are safe and effective alternatives for extracting the specimen during laparoscopic colorectal surgeries.Methods
We analyzed a prospectively designed database of a consecutive series of patients who underwent various laparoscopic colorectal surgeries for different rectal pathologies between April 1991 and May 2011 at the Texas Endosurgery Institute. The selection criteria for the NOSE approach were based on disease entities, site and size of tumors, and distance of colorectal lesions from the anal verge.Results
A total of 303 patients underwent laparoscopic colorectal procedures with the NOSE approach for specimen extraction, including 277 transanal and 26 transvaginal extractions. The operative time for procedures with transanal specimen extraction was 164.7 ± 47.5 min, the estimated blood loss was 87.5 ± 46.7 ml, and the rate of postoperative complications was 3.6 %. For laparoscopic right hemicolectomy with transvaginal specimen extraction, the operative time was 159 ± 27.1 min and the estimated blood loss was 83.5 ± 14.4 ml. Intraoperatively, transvaginal extraction was associated with 2 complications (7.7 %); however, this procedure was not associated with any postoperative complications. The length of hospital stay was 6.9 ± 2.8 and 5.5 ± 2.5 days for patients who underwent transanal extraction and transvaginal extraction, respectively.Conclusions
Both transanal and transvaginal specimen extractions in laparoscopic colorectal surgeries are safe and effective approaches with comparable postoperative complication rates. In comparison with transanal specimen extraction, transvaginal extraction is more complicated due to the anatomy of the pouch of Douglas. The transvaginal approach thus needs more effective extraction devices for preventing injury to adjacent organs, especially the sigmoid colon and rectum.13.
Purpose
Sparing the extrinsic autonomic innervation of the internal anal sphincter during total mesorectal excision is important for the preservation of anal sphincter function. This study electrophysiologically confirmed the topography of the internal anal sphincter nerve supply during laparoscopicassisted transanal minimally invasive surgery for total mesorectal excision.Methods
This prospective study was conducted at two large multispecialty referral centers. Six patients (five males and one female) aged between 45 and 65 years with low rectal cancer (≤5 cm from the anal verge) were enrolled. Surgery was performed under electric stimulation of the pelvic autonomic nerves with observation of the electromyographic signals of the internal anal sphincter.Results
The minimally invasive transanal surgical approach enabled advantageous visualization of the pelvic autonomic nerves in all patients. In particular, extrinsic innervation to the internal anal sphincter near the levator muscle was consciously spared under electrophysiological confirmation. The evoked absolute electromyographic amplitudes of the internal anal sphincter during transanal minimally invasive surgery were significantly lower than the initial results of the laparoscopic approach (3.7 μV (interquartile range 2.4; 5.7) vs. 4.3 μV (interquartile range 3.1; 8.6); p = 0.002). Five key zones of risk for pelvic autonomic nerve damage were identified. No complications occurred.Conclusions
The electromyographic results of this preliminary study indicate advantages for sparing the internal anal sphincter innervation during transanal minimally invasive mesorectal dissection considering the specific in situ neuroanatomical topography.14.
Aim
To investigate the long-term success after transanal open hemorrhoidopexy after a follow-up period of at least 8 yearsMethods
All patients were operated on at our office. Of 148 patients who underwent surgery more than 8 years ago, 110 were reached and were able to complete a questionnaire.Results
There were no perioperative complications. The follow-up period was at least 97 months (median 123.4 months). Surgical indications were symptomatic second- or third-degree hemorrhoids. The most common symptoms were bleeding (n?=?89) and foreign body sensation (n?=?50). Immediately postoperatively, the symptoms were significantly improved or completely disappeared in 80 patients (72.7%). At the time of follow-up, 71 patients (64.5%) had no complaints and 38 patients (34.5%) had complaints. Ninety-six patients (87.3%) indicated that they would choose transanal open hemorrhoidopexy again, while 12 patients (10.9%) would not do so. In 25 patients (22.7%) another operation had been performed, in 14 of them a new hemorrhoidopexy.Conclusion
After more than 8 years of follow-up, two-thirds of patients were symptom-free. Twenty-five patients (22.7%) underwent further surgery. Transanal open hemorrhoidopexy is a safe operation with encouraging long-term results and should be included in the treatment algorithm for symptomatic hemorrhoidal disease.15.
H. Meillat C. de Chaisemartin F. Poizat E. Bories R. Fara J. R. Delpero B. Lelong 《Techniques in coloproctology》2017,21(1):43-51
Background
Surgery for low rectal cancer remains a challenge when a standard laparoscopic approach is used. Transanal endoscopic total mesorectal excision (TME) has been shown to be feasible and to be associated with a low conversion rate. Combining the transanal and transabdominal single-port approaches (with an abdominal single port implanted in the future stoma and extraction site) could allow TME with minimal wound trauma, low morbidity, and faster recovery. The aim of the current study was to assess the short- and mid-term results of this technique.Methods
We conducted a prospective single-centre study of consecutive patients presenting with low rectal cancer requiring a conservative proctectomy with a manual coloanal anastomosis between January 2012 and April 2015.Results
During the study period, 41 patients were recruited. Conversion to open surgery was required in only one patient (2.4%). The median operating time was 358.5 min (range 300–600 min). Partial intersphincteric resection was necessary for 15 patients (36.6%). The specimens were mostly extracted via the abdominal access (n = 34) without wound complications. The mean number of lymph nodes harvested was 12.7 (range 6–24 lymph nodes). Specimens were graded as complete (n = 31) or nearly complete (n = 10) in all of the patients, and the circumferential resection margin positivity was 4.9%. Intraoperative morbidity rate was 4.9%, and the 30-day morbidity rate was 24.4% (n = 10). Sixty per cent (n = 6) of the patients with 30-day morbidity were Dindo I–II. At a median follow-up of 29 months, overall and disease-free survival rates were 97.5 and 80.5%, respectively. The stoma-free survival rate was 95.1%.Conclusions
Combining an endoscopic transanal TME and a single laparoscopic ileostomy-site proctectomy is a promising minimally invasive approach for the treatment of low rectal cancer.16.
A. Michalopoulos V. N. Papadopoulos S. Panidis S. Apostolidis Α. Mekras V. Duros A. Ioannidis G. Stavrou G. Basdanis 《Techniques in coloproctology》2011,15(1):25-28
Purpose
Rectal prolapse is uncommon; however, the true incidence is unknown because of underreporting, especially in the elderly population. Full-thickness rectal prolapse, mucosal prolapse and internal prolapse are three different clinical entities, which are often combined and constitute rectal prolapse. The aim of the study is to present our experience in the surgical management of rectal prolapse.Methods
In a 6-year period (2004–2010), 27 patients were surgically treated for rectal prolapse. The majority of patients were women (25 women, two men) and their mean age was 72.36 years. The operations performed were two Delorme’s procedures, five STARR (Stapled TransAnal Rectal Resection), 14 Wells procedures, two Wells combined with Thiersch, one Altemeier, one sigmoid resection combined with Wells and two Thiersch.Results
An emergency sigmoidostomy was performed on a patient after Wells operation due to obstructive ileus. One death occurred on the 5th postoperative day due to pulmonary embolism. Two recurrences observed 8 months postoperatively, one in a patient after STARR operation and one in a patient after Thiersch technique. The great majority of patients are completely relieved of symptoms.Conclusions
The application of different modalities in the treatment of rectal prolapse is attributed to the fact that cause, degree of prolapse and symptoms, vary from one patient to another. Successful approach depends on many factors, including the status of a patient’s anal sphincter muscle before surgery, whether the prolapse is internal or external and the overall condition of the patient.17.
Transanal endoscopic microsurgery for giant benign rectal tumours: is large size a contraindication?
Purpose
The purpose of this study is to look at our early postoperative results, recurrence rates and need for further radical surgery in treating large (> 5 cm) rectal tumours by transanal endoscopic microsurgery (TEM).Methods
Patients who underwent TEM for rectal tumours greater than 5 cm were included. Tumour diameter was determined based on fresh specimen measurements. We recorded the demographics, operative details, final pathology, length of hospital stay, complications and recurrence rates.Results
Mean tumour size was 5.9 ± 1.5 cm. 68.4% of tumours (13/19) were in the middle part of the rectum. Three patients (15.8%) developed postoperative complications: two had postoperative bleeding (10.5%), one had wound dehiscence (5.3%). Three patients had involved margins (15.8%). After a median follow up of 25.2 months, there were two recurrences (10.5%). One patient developed rectal cancer 6 years after removal of rectal adenoma.Conclusion
TEM is feasible and safe for the treatment of giant benign rectal tumours. It may be an alternative method for proctectomy in selected patients.18.
K. Zaghiyan J. Warusavitarne A. Spinelli P. Chandrasinghe F. Di Candido P. Fleshner 《Techniques in coloproctology》2018,22(11):867-873
Purpose
Initial reports of transanal ileal pouch-anal anastomosis (taIPAA) suggest safety and feasibility compared with transabdominal IPAA. The purpose of this study was to evaluate differences in technique and results of taIPAA in three centers performing taIPAA across two continents.Methods
Prospective IPAA registries from three institutions in the US and Europe were queried for patients undergoing taIPAA. Demographic, preoperative, intraoperative, and postoperative data were compiled into a single database and evaluated.Results
Sixty-two patients (median age 38 years; range 16–68 years, 43 (69%) male) underwent taIPAA in the three centers (USA 24, UK 23, Italy 15). Most patients had had a subtotal colectomy before taIPAA [n?=?55 (89%)]. Median surgical time was 266 min (range 180–576 min) and blood loss 100 ml (range 10–500 ml). Technical variations across the three institutions included proctectomy plane of dissection (intramesorectal or total mesorectal excision plane), specimen extraction site (future ileostomy site vs. anus), ileo-anal anastomosis technique (stapled vs. hand sewn) and use of fluorescence angiography. Despite technical differences, anastomotic leak rates (5/62; 8%) and overall complications (18/62; 29%) were acceptable across the three centers.Conclusions
This is the first collaborative report showing safety and feasibility of taIPAA. Despite technical variations, outcomes are similar across centers. A large multi-institutional, international IPAA collaborative is needed to compare technical factors and outcomes.19.
A. O. Rasulov Z. Z. Mamedli S. S. Gordeyev N. A. Kozlov H. E. Dzhumabaev 《Techniques in coloproctology》2016,20(4):227-234
Background
Transanal total mesorectal excision (taTME) has potential benefits of better visual control, especially in male patients with a high body mass index and low rectal cancer. However, this method has not yet been validated in clinical trials. The aim of this study was to compare the short-term outcomes of transanal and laparoscopic (lap) TME.Methods
From October 2013 to January 2015, consecutive patients undergoing transanal or laparoscopic TME for biopsy-proven mrT1-4aN0-2M0 rectal cancer were included in a prospective database. Patients with Eastern Cooperative Oncology Group performance status 2 and higher and patients undergoing partial mesorectal excision were excluded. This analysis focused on short-term surgical outcomes.Results
From October 2013 to January 2015, 22 taTME procedures and 23 laparoscopic TME procedures were performed. Patient characteristics were comparable between groups, but more patients in the taTME group underwent neoadjuvant (chemo) radiotherapy (87 vs. 48 %, p = 0.006). Median operative time was 320 min in the taTME group and 305 min in the lapTME group. There was one conversion in each group, but the transanal procedure was converted to laparoscopic resection. Transanal specimen extraction was performed in 86 versus 48 % patients in taTME and lapTME groups accordingly (p = 0.021). There was no post-operative mortality and post-operative morbidity in the taTME and lapTME groups was similar (27 vs. 26 %). One patient in the taTME group had positive circumferential resection margins. Oncologic results from resected specimens were comparable.Conclusions
Our initial experience demonstrates comparable short-term results for taTME and lap TME. Further investigation is necessary to assess long-term functional and oncologic outcomes.20.