Transanal minimally-invasive surgery (TAMIS): experience with no closure of the rectal defect

Background: In transanalminimally-invasive surgery (TAMIS), the closure of the rectal defect is controversial, and endoluminal suture is one of the most challenging aspects. The goal of the present study is to evaluate the short- andmedium-term complications of a consecutive series of patients with extraperitoneal rectal injuries who underwent TAMIS without closure of the rectal defect. Materials and Methods: A prospective, longitudinal, descriptive study conducted between August 2013 and July 2019 in which all patients with extraperitoneal rectal lesions, who were operated on using the TAMIS technique, were consecutively included. The lesions were: benign lesions ≥ 3 cm; neuroendocrine tumors ≤ 2 cm; adenocarcinomas in stage T1N0; and adenocarcinomas in stage T2N0, with high surgical risk, or with the patients reluctant to undergo radical surgery, and others with doubts about complete remission after the neoadjuvant therapy. Bleeding, infectious complications, rectal stenosis, perforations, and death were evaluated. Results: A total of 35 patients were treated using TAMIS without closure of the defect. The average size of the lesionswas of 3.68±2.1 cm(95% confidence interval [95%CI]: 0.7cmto 9 cm), their average distance from the anal margin was of 5.7±1.48cm, and the average operative time was of 39.2±20.5 minutes, with a minimum postoperative follow-up of 1 year. As for the pathologies, they were: 15 adenomas; 3 carcinoid tumors; and 17 adenocarcinomas. In all cases, the rectal defect was left open. The overall morbidity was of 14.2%. Two patients (grade II in the Clavien-Dindo classification) were readmitted for pain treatment, and three patients (grade III in the Clavien-Dindo classification) were assisted due to postoperative bleeding, one of whom required reoperation. Conclusion: The TAMIS technique without closure of the rectal defect yields good results, and present a high feasibility and low complication rate. (AU)

Robotic transanal surgery: initial experience in a developing country / Cirugía robótica transanal: experiencia inicial en un país en vías de desarrollo

Background: Transanal minimally invasive surgery (TAMIS) is a surgical technique used for the excision of rectal neoplasia that gained popularity during the last decade. Due to the technical difficulty (non-articulated instruments, reduced workspace) and the long learning curve associated with this technique, the use of robotic platforms to improve resection results has been suggested and reported, at the same time that the learning curve decreases and the procedure is facilitated. Materials and Methods: From March 2017 to December 2019, all patients with rectal lesions eligible for TAMIS were offered the possibility to receive a robotic TAMIS (RTAMIS). We used a transanal GelPoint Path (Applied Medical Inc., Santa Margarita, CA, USA) in the anal canal to be able to do the Da Vinci Si (Intuitive Surgical, Sunnyvale, CA, USA) robotic platform docking, which we used to perform the excision of the rectal lesion as well as the resection site defect. Results: Five patients between 34 and 79 years of age underwent R-TAMIS. The mean distance to the anal verge was 8.8 cm. There were no conversions. The mean surgery time was 85 minutes, and the mean docking time was 6.6minutes. Conclusions: Robotic TAMIS is a feasible alternative to TAMIS, with a faster learning curve for experienced surgeons in transanal surgery and better ergonomics. Further studies are needed to assess the cost-benefit relationship. (AU)

Introdução: A cirurgia transanal minimamente invasiva (TAMIS, na sigla em inglês) é uma técnica que se tornou popular na última década para a excisão local de neoplasias no reto. Devido à dificuldade técnica (instrumentos não articulados, espaço de trabalho reduzido) e à longa curva de aprendizado representada por essa técnica, o uso de plataformas robóticas para melhorar os resultados da ressecção tem sido sugerido e relatado, aomesmo tempo emque a curva de aprendizado diminui e o procedimento é facilitado. Materiais e Métodos: De março de 2017 a dezembro de 2019, foi oferecida aos pacientes comlesões retais candidatos aoTAMIS a possibilidade de ressecção transanal robótica (R-TAMIS). Foi utilizada uma porta de acesso transanal GelPoint Path (Applied Medical Inc. Santa Margarita, CA, EUA), que foi introduzida no canal anal para posteriormente criar pneumoperitônio e realizar o acoplamento do sistema robótico Da Vinci Si (Intuitive Surgical, Sunnyvale, CA, EUA) para realizar a ressecção e o fechamento do defeito por robótica. Resultados: Cinco pacientes entre 79 e 34 anos foram submetidos à R-TAMIS. A distânciamédia àmargemanal foi de 8,8 cm. Não houve conversões. O tempo cirúrgico médio foi de 85 minutos, e o tempo médio de acoplamento foi de 6,6 minutos. Conclusões: A R-TAMIS é uma alternativa à TAMIS convencional, com menor curva de aprendizado para cirurgiões experientes em cirurgia transanalminimamente invasiva e melhor ergonomia para ressecção e fechamento. Outros estudos são necessários para avaliar a relação custo-benefício. (AU)

Robotic transanal ressection for rectal tumor: a description of the technique / Ressecção transanal robótica para tumor retal: uma descrição da técnica

ABSTRACT Introduction: Robotic transanal surgery (RTS) is the analog of TAMIS and represents a new focus for the advancement of transanal platforms robotic transanal surgery is sometimes referred to as robotic TAMIS. Though limited to only a few centers world-wide, experience with robotic transanal surgery has been encouraging. Most research with robotic transanal surgery has concentrated on local excision of rectal neoplasia, although more complex procedures such as transanal proctectomy are possible using the robotic approach. This article reports the surgical technique of R-TAMIS performed in the Brazilian National Cancer Institute (INCA, Rio de Janeiro). Methods: 71-year-old, female with cardiologic disease (heart failure), with a 1.5 cm rectal neoplasm at 4 cm from the anal verge in the right anterolateral position. Biopsy revealed neuroendocrine tumor. A compete colonoscopy revealed no evidence of synchronous lesions. Work-up included 3D endorectal ultrasonography and magnetic resonance imaging, which demonstrated the lesion to be uT1uN0. The patient was counseled about surgical options − local excision versus low anterior resection. Due to the cardiologic condition, the patient was elected to proceed with local excision with robotic transanal surgery. Conclusion: Robotic TAMIS is a safe and effective operative procedure for high selected cases of rectal neoplasm. It enhances surgeon ergonomics and facilitates tumor removal and suture in the transanal approach.

RESUMO Introdução: A cirurgia transanal robótica (RTS,Robotic Transanal Surgery) é análoga da TAMIS (cirurgia minimamente invasiva transanal) e representa um novo foco para o avanço das plataformas transanais. A cirurgia transanal robótica é algumas vezes chamada de TAMIS robótica. Embora limitada a apenas alguns centros em todo o mundo, a experiência com a cirurgia transanal robótica tem sido encorajadora. A maioria das pesquisas com cirurgia transanal robótica tem se concentrado na excisão local da neoplasia retal, embora procedimentos mais complexos, como a proctectomia transanal, sejam possíveis utilizando a abordagem robótica. Este artigo relata a técnica cirúrgica de R-TAMIS realizada no Instituto Nacional do Câncer (INCA, Rio de Janeiro). Métodos: paciente de 71 anos, sexo feminino, com doença cardiológica (insuficiência cardíaca), com neoplasia retal de 1,5 cm a 4 cm da borda anal em posição anterolateral direita. A biópsia revelou tumor neuroendócrino. Uma colonoscopia completa não revelou evidências de lesões sincrônicas. A investigação incluiu ultrassonografia endorretal em 3D e ressonância magnética, que demonstrou que a lesão era uT1uN0. A paciente foi aconselhada sobre as opções cirúrgicas - excisão localversus ressecção anterior baixa. Devido à condição cardiológica, optou-se por proceder à excisão local com cirurgia transanal robótica. Conclusão: A TAMIS robótica é um procedimento cirúrgico seguro e eficaz para casos altamente selecionados de neoplasia retal. Ela melhora a ergonomia do cirurgião e facilita a remoção do tumor e a sutura na abordagem transanal.

A rectal gastrointestinal stromal tumor - a plea for neoadjuvant imatinib and TAMIS / Tumor estromal gastrointestinal no reto - um caso de uso de imatinibe neoadjuvante e TAMIS

Abstract Here we describe an infrequent case of gastrointestinal stromal tumor of the rectum in a 57 year-old man with spindle cell neoplasm probably gastrointestinal stromal tumor and CT scan showed tumor from the anterior rectal wall and offered abdominoperineal resection for the same. The patient was started on imatinib and had a significant reduction in symptoms. The patient was reassessed with the CT scan, which showed a reduction in tumor size and Transanal minimally invasive surgery was planned for the patient. Use of imatinib prior to surgical resection to attain the reduced size of the tumor within the limit of resection is an attractive approach. Since tumor development can happen rapidly again after substantial tumor shrinkage, the best time to operate depending on resectability and the maximum therapeutic outcome remains divisive.

Resumo No presente estudo, os autores descrevem um caso raro de tumor estromal gastrointestinal no reto em um homem de 57 anos que se apresentou com neoplasia de células fusiformes, com provável tumor estromal gastrointestinal. A tomografia computadorizada demonstrou tumor na parede anterior do reto e foi sugerida sua ressecção abdominoperineal. O paciente iniciou tratamento com imatinibe e apresentou uma redução significativa nos sintomas. O paciente foi reavaliado por tomografia computadorizada, que evidenciou redução do tamanho do tumor; portanto, foi indicada cirurgia transanal minimamente invasiva. O tumor era ressecável e foi necessário um extenso acompanhamento para romper o órgão, de forma a alcançar a ressecção máxima; caso contrário, o tumor estromal gastrointestinal também seria irressecável. O uso de imatinibe antes da ressecção cirúrgica para reduzir o tamanho do tumor dentro do limite de ressecção é uma abordagem interessante. Como o tumor pode se crescer rapidamente após ser substancialmente reduzido, a literatura ainda apresenta controvérsias quanto ao melhor momento para operar e quanto ao melhor desfecho terapêutico.

Cirugía mínimamente invasiva transanal (TAMIS): técnica y resultados de la experiencia inicial / Transanal minimally invasive surgery (TAMIS): technique and results of initial experience

Resumen Antecedentes: la cirugía transanal endoscópica es un abordaje mínimamente invasivo recientemente descrito, que provee una exposición superior y permite el acceso a las lesiones del recto en toda su extensión. Además, provee un riesgo menor de compromiso de los márgenes de resección, menores tasas de recurrencia y una menor morbimortalidad en comparación con la escisión transanal convencional o las remociones endoscópicas. Objetivos: se pretende describir la experiencia inicial y los resultados con la cirugía transanal mínimamente invasiva (transanal minimally invasive surgery, TAMIS) en términos de resecciones completas y posibles complicaciones relacionadas con el procedimiento. Materiales y métodos: esta una serie de casos con un seguimiento prospectivo de los pacientes con TAMIS. Se analizaron los resultados de 27 pacientes intervenidos en varios centros de Medellín, Colombia, entre enero de 2012 y diciembre de 2016, realizados con cirugía laparoscópica monopuerto (single-port laparoscopic surgery, SILS) (21 casos) o el GelPOINT® Path (6 casos), junto con el apoyo de la óptica del laparoscopio (16 pacientes) y del endoscopio flexible (11 pacientes). Resultados: se realizaron 27 TAMIS en el mismo número de pacientes, 10 mujeres (37 %) y 17 hombres fueron evaluados. Se realizó un seguimiento a los pacientes durante aproximadamente 12 meses, en promedio 32 meses. La edad promedio fue de 68 años (52-83 años). El tamaño promedio del tumor fue de 5,3 cm (2-9 cm) y la distancia promedio desde el margen anal fue de 7 cm (5-9 cm) Las complicaciones posoperatorias se dieron en 6 casos (22 %) Una perforación rectal se corrigió por vía laparoscópica en el mismo acto quirúrgico y otra por la misma vía transanal. Una estenosis rectal se manejó con dilatación digital, y hubo un caso de sangrado rectal menor, uno de retención urinaria y un paciente presentó un cáncer rectal avanzado a los tres meses de la resección con margen microscópico positivo (4 %). No hubo reingresos. La mortalidad por la intervención fue nula. La patología operatoria reportó la presencia de adenoma de bajo grado en 3 casos (11 %), de alto grado en 11 (41 %), adenocarcinoma in situ en 6 (22 %), tumor neuroendocrino en 5 pacientes (18 %), 1 caso de fibrosis cicatricial (4 %) y 1 de leiomioma (4 %). Limitaciones: los resultados no son extrapolables a la población general debido al poco número de intervenciones y la ejecución limitada a solo dos autores. Conclusiones: en nuestra experiencia inicial, TAMIS es un procedimiento mínimamente invasivo con una baja morbilidad posoperatoria, es curativa para lesiones benignas y para pacientes seleccionados con cáncer temprano.

Abstract Background: Transanal endoscopic surgery, a recently described minimally invasive approach, provides superior exposure and access to the entirety of rectal lesions and has lower risks of compromising resection margins, lower recurrence rates and lower morbidity and mortality than do conventional transanal excision and endoscopic removals. Objectives: The aim of this study is to describe our initial experience and with minimally invasive transanal surgery (TAMIS) and its results in terms of complete resections and complications possibly related to the procedure. Materials and methods: This is a series of TAMIS cases with prospective follow-ups. We analyzed the results of 27 patients who underwent the procedure at several centers in Medellín, Colombia, between January 2012 and December 2016. Twenty patients had Single Incision Laparoscopic Surgery while the GelPOINT path transanal access platform was used for the other six patients. Laparoscope optics provide support for 16 procedures while the more recently introduced flexible endoscope supported eleven procedures. Results: Twenty-seven TAMIS procedures were performed and evaluated. Ten patients were women (37%), and 17 were men. On average, patients were followed up for 32 months, but none less than 12 months. Average patient age was 68 years (52 to 83 years). The average tumor size was 5.3 cm (2 to 9 cm) and the average distance from the anal margin was 7 cm (5 to 9 cm). Postoperative complications occurred in six cases (22%). In one case, a rectal perforation was corrected laparoscopically during the procedure. Another perforation was corrected by the same transanal route. A rectal stenosis was managed with digital dilatation, there was one case of minor rectal bleeding, one case of urinary retention and one patient developed advanced rectal cancer with a positive microscopic margin (4%) three months after resection. There were no readmissions. There were no deaths due to the intervention. Pathology reported low grade adenomas in three cases (11%), high grade adenomas in 11 cases (41%), in-situ adenocarcinoma in six cases (22%), neuroendocrine tumors in five cases (19%), and one case each of cicatricial fibrosis (4%) and leiomyoma (4%). Limitations: The results cannot be extrapolated to the general population because of the limited number of interventions and performance of procedures by only two authors. Conclusions: Our initial experience shows TAMIS to be a minimally invasive procedure with low postoperative morbidity which is curative for benign lesions and for selected patients with early cancer.

TAMIS: ¿Un nuevo estándar para el tratamiento de los pólipos de recto? Revisión de la bibliografía y reporte de nuestra experiencia / TAMIS: A new standard for the treatment of rectal polyps? Literature review and report our experience

La morbilidad y alteración de la calidad de vida asociadas a la resección anterior del recto y amputación abdominoperineal determinaron un gran interés en el desarrollo del abordaje transanal. En los últimos años se ha visto un marcado desarrollo tecnológico en los dispositivos disponible para este abordaje. La cirugía por vía transanal ofrece ventajas en cuanto a sus resultados y complicaciones cuando se la compara a la cirugía por vía abdominal. La cirugía transanal mini-invasiva surge como una alternativa de abordaje videoendoscópico del recto. La resección local por cirugía endoscópica para los pólipos grandes de recto se ha convertido en un nuevo estándar de tratamiento en la mayoría de los centros, obteniendo piezas no fragmentadas con una alta tasa de márgenes negativos. En el presente estudio realizamos una revisión sobre la aplicación de TAMIS (TransAnal Minimally Invasive Surgery) al tratamiento de los pólipos de recto. (AU)

A great interest has developed in implementing trans anal minimally invasive surgery for the treatment of rectal adenomas and early rectal tumors. It present advantages when compare to radical surgery and peace meal endoscopic resections. TAMIS delivers non-fragmented specimens with clear resection margin in the majority of the cases. Such good technical results are mirrored with a low recurrence rate when evaluating rectal adenomas. This is a review of the application of TAMIS for the treatment of rectal adenomas. (AU)

Resección de GIST rectal mediante cirugía transanal mínimamente invasiva (TAMIS) tras neoadyuvancia con imatinib / Resection of a rectal gastrointestinal stromal tumour by transanal minimally invasive surgery (TAMIS) after neoadjuvant treatment with Imatinib

Resumen El tratamiento primario de elección para los pacientes con una tumoración GIST localizada es la extirpación quirúrgica completa con márgenes microscópicos negativos. Sin embargo, en un espacio tan reducido como el de la pelvis, la resección completa de una tumo-ración rectal grande es difícil y necesita en ocasiones una amputación abdomino-perienal. En nuestro caso, con la finalidad de reducir el tamaño del tumor y la morbilidad asociada a procedimientos quirúrgicos más agresivos se introdujo el tratamiento con imatinib, con intención neoadyuvante monitorizando la respuesta mediante ecoendoscopia. La respuesta obtenida, rediciendo el volumen tumoral, modificó la estrategia quirúrgica inicial y fue posible conseguir una resección satisfactoria mediante cirugía transanal mínimamente invasiva (TAMIS), preservando los esfínteres anales y soslayando la morbilidad genitourinaria asociada a la excisión mesorectal.

Abstract The primary treatment of choice for patients with a localised gastro-intestinal stromal tumour (GIST) is complete surgical excision with negative microscopic margins. However, in a space as small as that of the pelvis, complete resection of a large rectal tumour is difficult, and sometimes requires an abdominoperineal amputation. In order to reduce the size of the tumour, as well as the morbidity associated with more aggressive surgical procedures, neoadjuvant treatment with Imatinib was introduced in this case, with the response being monitored by of endoscopic ultrasound. The response obtained by reducing the tumour volume modified the strategy, making it possible to obtain a satisfactory resection using transanal minimally invasive surgery (TAMIS), preserving the anal sphincters and avoiding the genitourinary morbidity associated with the mesorectal excision.

Retroperitoneal abscess after transanal minimally invasive surgery: case report and review of literature / Abscesso retroperitoneal após cirurgia de ressecção transanal minimamente invasiva: relato de caso clínico e revisão a literatura médica

ABSTRACT Abscesses are a rare complication of transanal minimally invasive surgery and transanal endoscopic micro surgery. Reported cases have been in the rectal and pre-sacral areas and have been managed with either antibiotics alone or in conjunction with laparotomy and diverting colostomy. We report a case of a large retroperitoneal abscess following a Transanal minimally invasive surgery full thickness rectal polyp excision. The patient was successfully managed conservatively with antibiotics and a percutaneous drain. Retroperitoneal infection should be included in a differential diagnosis following a Transanal minimally invasive surgery procedure as the presentation can be insidious and timely intervention is needed to prevent further morbidity.

RESUMO Os abscessos são uma complicação rara da cirurgia de ressecção transanal minimamente invasiva (TAMIS) e da micro cirurgia endoscópica transanal (TEMS). Os casos notificados foram nas áreas rectal e pré-sacral e foram administrados com antibióticos isoladamente ou em conjunto com laparotomia e desvio de colostomia. Relatamos um caso de grande abscesso retroperitoneal após uma excisão de pólipo retal de espessura total TAMIS. O paciente foi tratado com sucesso com a administração de antibióticos e drenagem percutânea. Para prevenir mais morbidade é necessária incluir a infecção retroperitoneal no diagnostico diferencial após um procedimento TAMIS onde a apresentação pode ser insidiosa e a intervenção atempada.

TAMIS with partial excision of mesorectum and primary closure of rectal wound using vloc / TAMIS com excisão parcial do mesorreto e fechamento primário da ferida retal usando vloc

Background: Transanal Minimally Invasive Surgery has proven to be a viable alternative in the treatment of rectal tumors; however, rectal wound closure can be challenging. We describe our experience with this procedure using the vloc suture device. Resume: Eight successful Transanal Minimally Invasive Surgery with primary wound closure using vloc were performed in 5 men, 62 years mean age; all cases had pre-operative diagnosis of adenoma with high-grade dysplasia. The surgical anatomic-pathologic results showed 6 adenomas with high-grade dysplasia and 2 well differentiated adenocarcinomas, limited to the upper third of the submucosa (pT1SM1) without lymphatic or vascular invasion. All lesions were resected with negative margins. No patient reported during follow-up rectal pain, fecal incontinence or bleeding. Conclusion: The use of vloc in rectal wound closure during Transanal Minimally Invasive Surgery is secure and facilitates the procedure. (AU).

Tema: Cirurgia Minimamente Invasiva Transanal (TAMIS) tem provado ser uma alternativa viável para o tratamento de tumores do reto, porém o fechamento da ferida rectal pode ser desafiadante. Nós descrevemos nossa experiência com este procedimento utilizando o dispositivo de sutura vloc. Resumo: Oito TAMIS foram realizados com sucesso com o fechamento primário da ferida usando vloc, cinco homens, com idade média de 62 anos, todos os casos tiveram diagnóstico pré-operatório de adenoma com displasia de alto grau. Os resultados anátomo-patológicos pós-operatório demonstraram: 6 adenomas com displasia de alto grau e 2 adenocarcinomas bem diferenciados, limitado ao terço superior da submucosa (pT1SM1), sem invasão linfática ou vascular. Todas as lesões foram ressecados com margens negativas. Nenhum paciente relatou durante o seguimento dor rectal, incontinência fecal ou sangramento. Conclusão: O uso de vloc no fechamento da ferida retal durante TAMIS é seguro e facilita o procedimento. (AU).

Resección de tumoración rectal mediante cirugía transanal mínimamente invasiva (TAMIS) / Rectal tumor resected by transanal minimally invasive surgery (TAMIS)

La microcirugía endoscópica transanal (TEM, por sus siglas en inglés) es una técnica que se ha desarrollado desde los años 80 y tiene múltiples indicaciones. La cirugía transanal mínimamente invasiva (TAMIS, por sus siglas en inglés) se ha introducido como un enfoque alternativo al TEM, con las mismas indicaciones y algunas ventajas. Se reporta aquí el primer caso en Costa Rica de TAMIS, practicada exitosamente en un paciente de 85 años con una tumoración rectal de 4 cm de diámetro.

Transanal Endoscopic Microsurgery (TEM, for its acronym in English) is a technique developed in the 80s, which has many uses. Transanal Minimally Invasive Surgery (TAMIS, for its acronym in English) has been introduced as an alternative approach to TEM, with the same indications and some advantages. The case of an 85-yearold male with a 4 cm in diameter rectal tumor successfully resected by TAMIS is herein reported, which is the first case treated in this manner in Costa Rica.

Cirugía transanal por puerto único para la resección local de lesiones de recto / Single port transanal excision for local treatment of rectal lesions

Background: Since 2009, transanal minimally invasive surgery (TAMIS) is increasingly used as an alternative to local excision and transanal microscopic excision (TEM) for rectal lesions located in the mid and superior third. The clinical benefits of the technique are being evaluated. Aim: To establish the feasibility, quality of excision and short term results of single port transanal excision for rectal lesions. Patients and Methods: Analysis of a prospective series of patients subjected to single port transanal excision. Patients had benign or malignant lesions located in the mid or superior third of the rectum. Those with a diagnosis of adenocarcinoma were excluded. Results: The transanal resection using the SILS Port® was completed in 11 patients aged 21 to 86 years (eight women). The American Society of Anesthesiologists (ASA) classification of patients was two and their body mass index was 24 +/- 3.1 kg/m². The lesion distance from the anal margin ranged from 5 to 10 cm. The surgical time was 47 min and hospital stay was 2.8 days. One patient was converted to conventional transanal surgery and two patients had self-limited episode of hematochezia. Conclusions: TAMIS is a feasible technique and with promising results in selected patients.

Introducción: Desde el año 2009, la cirugía transanal mínimamente invasiva (TAMIS) ha sido utilizada de forma creciente como una alternativa a la excisión local y la resección transanal microscópica (TEM) de lesiones de tercio medio y superior del recto. A pesar de su aceptación, los beneficios clínicos han sido parcialmente validados y se encuentran en etapa de evaluación. Objetivos: Establecer la factibilidad, calidad de resección y resultados a corto plazo del uso del sistema de puerto único en la resección transanal en lesiones de recto. Pacientes y Métodos: Análisis retrospectivo de una serie prospectiva y consecutiva de pacientes sometidos a resección transanal utilizando un dispositivo de puerto único. Los pacientes eran portadores de lesiones benignas y/o malignas de recto medio o superior, excluyendo aquellos con diagnóstico de adenocarcinoma. Resultados: Se completó la resección transanal por SILS Port® en 11 pacientes, 8 de ellos de sexo femenino. Edad media fue de 61,6 años (21-86). La clasificación de ASA fue de 2 e IMC de 24 +/- 3,1 kg/m². La distancia de las lesiones desde el margen anal fue de 7,2 cm (5-10). Tiempo quirúrgico fue de 47,2 min. La estadía hospitalaria fue de 2,8 días. Presentamos una conversión a cirugía transanal convencional y dos rectorragias postoperatorias autolimitadas. Conclusiones: TAMIS se ha convertido en una técnica factible y con resultados prometedores en un grupo de pacientes bien seleccionados. De los nuevos horizontes que ha entregado la cirugía de puerto único, nace esta nueva aplicación para el abordaje transanal, representando una nueva frontera en la cirugía rectal.

Transanal minimally invasive surgery (TAMIS) for local excision of selected rectal neoplasms: efficacy and outcomes in the first 11 patients / Cirurgia trans-anal minimamente invasiva (CTAMI) para excisão local de neoplasias retais selecionadas: eficácia e desfechos nos primeiros 11 pacientes

Disposable single-port surgery devices have been used for transanal minimally invasive surgery (TAMIS) with benefits, when compared to local resection and transanal endoscopic microsurgery (TEM). Objective: To show outcomes and details of the technique. Method: A series of patients with indication for local resection of rectal tumors were submitted to surgery using the TAMIS platform. Results: Eleven patients have been submitted to TAMIS. Distance from anal verge was from 1.5 to 8 cm and maximum tumor diameter was 6 cm. Initial diagnosis of adenoma was the most frequent indication for resection. One partial dehiscence was the only complication seen. Minimal setup time, low cost and the possibility of using regular laparoscopic instruments make TAMIS a good option for transanal resection. The results of this technique are encouraging, concerning the feasibility, maneuverability, upfront cost, setup time, resectability and complication rate. Because of its simplicity and similarity with conventional laparoscopic surgery, it can be learned easily. Although at the present time the appropriate use of local excision is still under debate, TAMIS is a technique that still expects a lot of growing and much remains to be learned. (AU)

Dispositivos cirúrgicos de porta única descartáveis têm sido utilizados para a Cirurgia Trans-anal Minimamente Invasiva (CTAMI) com benefícios, quando comparados com ressecção local e microcirurgia endoscópica trans-anal (MET). Objetivo: Apresentar os desfechos e detalhes da técnica. Método: Uma série de pacientes com indicação para ressecção local de tumores retais foi tratada cirurgicamente pela plataforma CTAMI. Resultados: Onze pacientes foram tratados por CTAMI. A distância a contar da margem anal variou de 1,5 até 8 cm, e o diâmetro máximo do tumor foi 6 cm. Um diagnóstico inicial de adenoma foi a indicação mais frequente para a ressecção. A única complicação ocorrida foi uma deiscência parcial. Mínimo tempo para preparação, baixo custo e a possibilidade do uso de instrumentos laparoscópicos convencionais fazem de CTAMI uma boa opção para a ressecção trans-anal. Os resultados dessa técnica são animadores, no que diz respeito à exeqüibilidade, manobrabilidade, custos iniciais, tempo de preparação, ressectabilidade e percentual de complicações. Graças à sua simplicidade e semelhança com a cirurgia laparoscópica convencional, CTAMI tem uma fácil curva de aprendizado. Embora atualmente ainda seja motivo de discussão o uso apropriado da excisão local, CTAMI é uma técnica que ainda provavelmente ainda crescerá muito–e há muito a ser aprendido. (AU)

Resección de lesión neoplásica rectal mediante cirugía transanal mínimamente invasiva-técnica de TAMIS / Rectal neoplasm lesion resected by Transanal Minimally Invasive Surgery – TAMIS technique

We present a clinical case with a stage T1 rectal neoplasm lesion; resection was performed with transanal minimally invasive surgery-TAMIS procedure without complications. Anatomical pathology results showed invasion of the muscular layer, i.e. stage T2. The TAMIS technique, recently described by the coloproctology group of Orlando Hospital (USA), consists of using a single port device to generate a pneumorectum and resect the rectal lesion by means of regular laparoscopic tools. It has low morbidity and has gained general acceptance basically because the use of standard laparoscopic instrumentation, which reduces costs, allows one-block resections, without fragmentation of the surgical specimen and the learning curve not that long. The indication of local resection in cases of rectal cancer is still for T1 lesions, without nodal involvement and without histological factors leading to poor prognosis. Local relapse in these cases is acceptable and conservation of the rectum ensures good life quality for patients. Incorrect staging once the sample has been analyzed is indication of radical surgery and does not affect the prognosis.

Se presenta un caso clínico de una lesión neoplásica rectal etapificada como T1 la cual fue resecada con cirugía transanal mínimamente invasiva (transanal minimally invasive surgery-TAMIS) sin complicaciones. La anatomía patológica evidenció invasión hasta la túnica muscular, es decir T2. La técnica TAMIS, descrita recientemente por el grupo de coloproctología del Hospital de Orlando (EE.UU.), consiste en utilizar un dispositivo de puerto único para generar un neumorrecto y resecar la lesión rectal mediante instrumentos de laparoscopía tradicional. Tiene baja morbilidad y ha ganado aceptación principalmente por utilizar instrumental laparoscópico estándar, lo que disminuye el costo, permite resecciones transmurales, en bloque, sin fragmentar la pieza operatoria y su curva de aprendizaje no es larga. La indicación de resección local en cáncer de recto sigue siendo lesiones T1, sin compromiso nodal y sin factores de mal pronóstico histológico. La recidiva local en estos casos es aceptable y la conservación del recto permite una buena calidad de vida de los pacientes. La incorrecta etapificación una vez analizada la pieza operatoria es indicación de cirugía radical y no afecta el pronóstico.

Transanal minimally invasive surgery with single-port (TAMIS) for the management of rectal neoplasms: a pilot study

Transanal endoscopic microsurgery (TEM) has been used since the 1980's for the treatment of selected rectal cancers, with clear benefits regarding morbidity and mortality, and good oncological outcomes when compared to radical surgery and conventional local resections. The high cost of equipment and the need for long learning curve did not allow the spread of the technique. The aim of this study was to describe the technical characteristics and outcomes of 4 patients operated by this technique, 3 with histologically confirmed adenomas and 1 carcinoid rectal tumor, with no recurrence after an average -follow-up of 12 months. The use of single port devices for transanal surgery is a safe method with good oncological results and allows a faster learning curve, by the similarity with conventional laparoscopic procedures and the availability of devices commonly used in laparoscopy. (AU)

A microcirurgia endoscópica transanal (TEM) é usada desde a década de 80 para o tratamento de neoplasias retais selecionadas, com claros benefícios relacionados à mortalidade e morbidade, e com bons resultados oncológicos, em comparação à cirurgia radical e a ressecções locais convencionais. O custo alto de equipamento de TEM e a necessidade de uma curva de aprendizagem longa ainda não permitiram a propagação da técnica. O objetivo deste estudo foi descrever a técnica cirúrgica e os desfechos oncológicos em 4 pacientes operados por esta técnica, 3 com diagnóstico final de adenomas e 1 de tumor carcinoide, sem recorrência após seguimento médio de 12 meses. A utilização de dispositivos de portal único para a cirurgia transanal é um método seguro e com bons resultados oncológicos, permitindo uma curva de aprendizado mais rápida pela semelhança com os procedimentos laparoscópicos convencionais e pela disponibilidade de dispositivos comumente utilizados em laparoscopia. (AU)

Uso del dispositivo SILS™ en cirugía transanal mínimamente invasiva para el manejo de lesiones benignas de recto / Using the device SILS ™ Transanal minimally invasive surgery for the management of benign rectal

Minimally invasive transanal microsurgery was described in 2009. It allows the excision polyps or small malignant lesions. We report a 73 years old female consulting for hematochezia. A sessile polyp located 9 cm above the anal margin was discovered during a colonoscopy that corresponded to a villous adenoma. The polyp was excised transanally, using a SILS* port for transanal endoscopic microsurgery.

La cirugía transanal mínimamente invasiva fue descrita inicialmente en el año 2009 como un abordaje híbrido para lograr la resección endoluminal de lesiones rectales, surgiendo como una alternativa más económica al uso del TEM (Transanal endoscopic microsurgery). La resección transanal de pólipos, así como de pequeñas lesiones malignas rectales con instrumentos laparoscópicos y de puerto único, utiliza la tecnología desarrollada inicialmente para procedimientos desde un orificio natural como es el recto. Nuestra intención es presentar la técnica quirúrgica, así como su aplicación en la resección de lesiones benignas como malignas del recto no realizables a través de una resección transanal convencional.