Transanal Total Mesorectal Excision for Rectal Cancer: Outcomes after 140 Patients.

BACKGROUND: The anatomic difficulties that we have to deal with in open surgery for rectal cancer have not been overcome with the laparoscopic approach. In the search for a solution, a change of concept arose: approaching the rectum from below. The main objectives of this study were to show the potential advantages of the hybrid transabdominal-transanal total mesorectal excision (taTME). This approach may improve quality of the mesorectal specimens. Second, proctectomy can be technically easier and more safely performed "down to up," which would result in shorter surgical times, lower conversion rates, and less morbidity. STUDY DESIGN: A prospective series of hybrid taTME was conducted from October 2011 to November 2014. RESULTS: During the study period, 140 procedures were performed. Mean operative time was 166 minutes. There were no conversions or intraoperative complications. Macroscopic quality assessment of the resected specimen was complete in 97.1% and nearly complete in 2.1%. Thirty-day morbidity was minor (Clavien-Dindo I + II) in 24.2% and major (Clavien-Dindo III + IV) in 10 %. No patient died within the first 30 days postsurgery (Clavien-Dindo V). The mean follow-up was 15 months, with a 2.3% local recurrence rate and a 7.6% rate of systemic recurrence. CONCLUSIONS: Pathologic analysis showed a very good macroscopic quality of TME specimens, which is the most important prognostic factor in rectal cancer. Intraoperative outcomes regarding conversion, surgical times, and intraoperative complications are very satisfactory. Short-term morbidity and oncologic outcomes are as good as in other laparoscopic TME series.

Minimal invasive surgery: NOSE and NOTES in ulcerative colitis.

BACKGROUND: In patients with ulcerative colitis (UC), laparoscopic pelvic dissection for IPAA is not always straightforward: often, a hand-assistance incision is used to complete the proctectomy, lengthening operative times. Hybrid NOSE and NOTES are emerging as an alternative approach to conventional laparoscopy. We believe that UC patients could benefit from this new hybrid approach in three ways: by easing the proctectomy as performed down to up, avoiding additional incisions and decreasing surgical times. We present the short-term outcomes of our series. METHODS: All patients with UC who required IPAA were enrolled in a single-arm prospective study (July 2011 to March 2014). A three-step procedure was performed. The first step: laparoscopic colectomy (with transanal removal of the colon) and temporary ileostomy. The second step: "down-to-up" proctectomy (with transanal removal of the rectum) and IPAA with a covering ileostomy. We combined simultaneously transanal and laparoscopic approach. The third step: ileostomy closure. Functional outcomes were assessed 3 months after third step. RESULTS: Eighteen patients were enrolled. Two patients are waiting to complete the second stage, and 16 underwent all surgical steps. Twelve have been evaluated with functional scores. For the first step, the mean operative time was 162.2 min (SD 40.5) and 170 min (SD 50.1) for the second one. The median hospital stay was 6 days (IQR 5-14.75) for the first step and 5.5 (IQR 5-9.75) for the second one. No major complications occurred. Twenty-four-hour defecation frequency was 5.5 per day (SD 1.7), 0.5 per night. Seventy-five percentage of patients may retain stools for more than 30 min; the mean value of Oresland score was 4.7 and Wexner score 1.4. CONCLUSIONS: This is a safe and feasible technique to treat UC patients with good short-term outcomes. Long-term outcomes and controlled trials are needed.

Transanal total mesorectal excision in rectal cancer: short-term outcomes in comparison with laparoscopic surgery.

OBJECTIVE: The aim of this study was to compare short-term results obtained with transanal total mesorectal excision (TME) and laparoscopic surgery. BACKGROUND: Transanal TME appears as an alternative in the treatment of rectal cancer and other rectal disease. Natural orifices transluminal endoscopic surgery using the rectum as access in colorectal surgery is intuitively better suited than other access routes. METHODS: All consecutive patients with middle or low rectal cancer submitted to surgery were included into a prospective cohort and treated by transanal TME assisted by laparoscopy. They were compared with a retrospective cohort of consecutive patients of identical characteristics treated by laparoscopic TME in the immediate chronological period. RESULTS: Thirty-seven patients were included in both study groups. No differences were observed between them with respect to baseline characteristics, thus emphasizing the comparability of both cohorts. Surgical time was higher in the laparoscopy group (252 ± 50 minutes) than in the transanal group (215 ± 60 minutes) (P < 0.01). Moreover, coloanal anastomosis was performed less frequently (16% vs 43%, respectively; P = 0.01) and distal margin was lower (1.8 ± 1.2 mm vs 2.7 ± 1.7 mm, respectively; P = 0.05) in the laparoscopy group than in the transanal one. Although there was no significant difference in 30-day postoperative complication rate (laparoscopy, 51% vs transanal, 32%; P = 0.16), early readmissions were more frequent in the laparoscopy group than in the transanal one (22% vs 6%, respectively; P = 0.03). CONCLUSIONS: Evaluation of short-term outcomes demonstrated that transanal TME is a feasible and safe technique associated with a shorter surgical time and a lower early readmission rate.

Transanal natural orifice transluminal endoscopic surgery (NOTES) rectal resection: "down-to-up" total mesorectal excision (TME)--short-term outcomes in the first 20 cases.

BACKGROUND: The transanal minilaparoscopy-assisted natural orifice transluminal endoscopic surgery (NOTES) approach holds significant promise as a safe and less morbid alternative to conventional low anterior rectal resection. Previous reports have shown satisfactory short-term oncologic results. We evaluated the safety and short-term outcomes in rectal cancer subjects who underwent transanal minilaparoscopy-assisted natural orifice surgery total mesorectal excision (TME) rectal resection. METHODS: Twenty selected patients with rectal cancer were enrolled onto a prospective study of minilaparoscopy-assisted natural orifice surgery TME rectal resection. The study endpoints were safety of access (intra- or postoperative morbidity) and adequacy of oncological resection criteria; intact TME; distal and circumferential margins; and number of lymph nodes retrieved. RESULTS: All procedures were successfully completed with the transanal NOTES and minilaparoscopy technique. The mean age was 65 ± 10 years; 55% of patients were male; the mean body mass index was 25.3 ± 3.8 kg/m(2). Thirty-five percent of tumors were in the distal rectum, 50% in midrectum, and 15% in proximal rectum. Coloanal anastomoses were hand sewn in 65% and stapled in 35%. Mean operative time was 235 ± 56 min. There were no procedure-related complications. Pathologic analysis demonstrated negative distal and circumferential margins in all patients. An average of 15.9 ± 4.3 lymph nodes were retrieved. The mesorectal fascia was intact in all the specimens. CONCLUSIONS: This study demonstrates that transanal NOTES with minilaparoscopic assistance in the hands of a specialized team is safe; meets the oncologic requirements for high-quality rectal cancer surgery; and may offer advantages over pure laparoscopic approaches for visualizing and dissecting out the distal mesorectum. Minilaparoscopic assistance allows one to compensate for the limitations of current NOTES instrumentation to ensure the safety and adequacy of oncologic resection in these difficult cases. Careful patient selection, a specialized team, and long-term outcome evaluation are critical before this procedure can be considered for routine clinical use.