Flexible robotic transanal resection of rectal polyps - A case series.

BACKGROUND: Flexible systems in robotic transanal surgery (RTA) are a proposed solution to the challenges of transanal minimally invasive surgery (TAMIS). RTA was performed with the Medrobotics Flex® Robotics System to determine its safety and feasibility. METHODS: Medrobotics Flex® Robotics System was used for transanal resection of benign rectal polyps by a single surgeon in a tertiary centre, and cases retrospectively reviewed. RESULTS: Five patients underwent flexible RTA, average age was 67 years. Polyps were between 5 and 12 o'clock, mean distance of 8.3 cm from the anal verge. Average operating time was 143 min. There was no peri-operative or 30-day morbidity or mortality. Histopathology included tubulovillous adenoma (TVA), and one hyperplastic polyp, all were clear of the surgical margin. CONCLUSION: This is the first case series using Medrobotics Flex® Robotics System for RTA in a tertiary Australian public hospital. Flexible RTA is safe and feasible for the resection of benign rectal polyps.

Advances in Rectal Cancer Surgery.

Surgical resection is the cornerstone of curative intent therapy for rectal cancer. The introduction of the concept of total mesorectal excision (TME) led to significant decreases in local recurrence. However, TME carries substantial morbidity. The advent of transanal endoscopic techniques, such as transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS), has allowed patients with early-stage disease to be managed with local excision and avoid the morbidity of TME. Advances in surgery such as laparoscopy, robotic surgery, and transanal approaches have also broadened the options for achieving TME. However, there is significant debate within the literature regarding the optimal approach and oncologic outcomes of these modalities.

Transanal minimally invasive surgery using laparoscopic instruments of the rectum: A review.

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.

Massive Retroperitoneal and Subcutaneous Emphysema after Transanal Excision of Rectal Cancer.

Transanal excision (TAE) is considered a safe, alternative approach for patients with early stage of rectal cancer. Complications associated with TAE are rare, such as bleeding, perforation, incontinence, and rectal stricture. Subcutaneous emphysema is early complication of laparoscopic surgery, common during upper gastrointestinal and gynecological surgery. We report a case of retroperitoneal and subcutaneous emphysema emerging after TAE of rectal tumor. The patient presented with changed bowel habits. Colonoscopy with pathology reports, ultrasound, and magnetic resonance imaging showed an adenocarcinoma in the rectum at a 5 cm from the anus and did not reveal signs of invasive growth, pathologic lymph nodes, or systemic metastases. After surgery patient complained about abdominal pain and severe subcutaneous emphysema. Computed tomography showed retroperitoneal emphysema with no signs of rectal wall defect. He received antibiotics and was kept hospitalized with a solid diet and the retroperitoneal air disappeared on the thoracic X-ray. Patients who remain clinically stable or steadily improving without signs if peritonitis can be managed conservatively. Only in case of ineffectiveness of conservative therapy, undergo surgery.

Early salvage total mesorectal excision (sTME) after organ preservation failure in rectal cancer does not worsen postoperative outcomes compared to primary TME: systematic review and meta-analysis.

IMPORTANCE: While oncological outcomes of early salvage total mesorectal excision (sTME) after local excision (LE) have been well studied, the impact of LE before TME on postoperative outcomes remains unclear. We aimed to compare early sTME with a primary TME for rectal cancer. METHODS: Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines with the random-effects model were adopted using Review Manager Version 5.3 for pooled estimates. RESULTS: We retrieved eleven relevant articles including 1728 patients (350 patients in the sTME group and 1438 patients in the TME group). There was no significant difference between the two groups in terms of mortality (OR = 0.90, 95%CI [0.21 to 3.77], p = 0.88), morbidity (OR = 1.19, 95%CI [0.59 to 2.38], p = 0.63), conversion to open surgery (OR = 1.34, 95%CI [0.61 to 2.94], p = 0.47), anastomotic leak (OR = 1.38, 95%CI [0.50 to 3.83], p = 0.53), hospital stay (MD = 0.23 day, 95%CI [- 1.63 to 2.10], p < 0.81), diverting stoma rate (OR = 0.69, 95%CI [0.44 to 1.09], p = 0.11), abdominoperineal resection rate (OR = 1.47, 95%CI [0.91 to 2.37], p = 0.11), local recurrence (OR = 0.94, 95%CI [0.44 to 2.04], p = 0.88), and distant recurrence (OR = 0.88, 95%CI [0.52 to 1.48], p = 0.62). sTME was associated with significantly longer operative time (MD = 25.62 min, 95%CI[11.92 to 39.32], p < 0.001) lower number of harvested lymph nodes (MD = - 2.25 lymph node, 95%CI [- 3.86 to - 0.65], p = 0.006), and higher proportion of incomplete TME (OR = 0.25, 95%CI [0.11 to 0.61], p = 0.002). CONCLUSIONS: sTME is not associated with increased postoperative morbidity, mortality, or local recurrence. However, the operative times are longer and yield a poor specimen quality.

The impact of transanal local excision of early rectal cancer on completion rectal resection without neoadjuvant chemoradiotherapy: a systematic review.

BACKGROUND: The impact of transanal local excision (TAE) of early rectal cancer (ERC) on subsequent completion rectal resection (CRR) for unfavorable histology or margin involvement is unclear. The aim of this study was to provide a comprehensive review of the literature on the impact of TAE on CRR in patients without neoadjuvant chemoradiotherapy (CRT). METHODS: We performed a systematic review of the literature up to March 2020. Medline and Cochrane libraries were searched for studies reporting outcomes of CRR after TAE for ERC. We excluded patients who had neoadjuvant CRT and endoscopic local excision. Surgical, functional, pathological and oncological outcomes were assessed. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. RESULTS: Sixteen studies involving 353 patients were included. Pathology following TAE was as follows T0 = 2 (0.5%); T1 = 154 (44.7%); T2 = 142 (41.2%); T3 = 43 (12.5%); Tx = 3 (0.8%); T not reported = 9. Fifty-three percent were > T1. Abdominoperineal resection (APR) was performed in 80 (23.2%) patients. Postoperative major morbidity and mortality occurred in 22 (11.4%) and 3 (1.1%), patients, respectively. An incomplete mesorectal fascia resulting in defects of the mesorectum was reported in 30 (24.6%) cases. Thirteen (12%) patients developed recurrence: 8 (3.1%) local, 19 (7.3%) distant, 4 (1.5%) local and distant. The 5-year cancer-specific survival was 92%. Only 1 study assessed anal function reporting no continence disorders in 11 patients. In the meta-analysis, CRR after TAE showed an increased APR rate (OR 5.25; 95% CI 1.27-21.8; p 0.020) and incomplete mesorectum rate (OR 3.48; 95% CI 1.32-9.19; p 0.010) compared to primary total mesorectal excision (TME). Two case matched studies reported no difference in recurrence rate and disease free survival respectively. CONCLUSIONS: The data are incomplete and of low quality. There was a tendency towards an increased risk of APR and poor specimen quality. It is necessary to improve the accuracy of preoperative staging of malignant rectal tumors in patients scheduled for TAE.

“Watch and wait“ strategy in the treatment of patients with rectal carcinoma.

Innovative treatment strategies which do not involve oncosurgical radical rectal resection have been explored within the last decades in the management of patients with rectal carcinoma. Resection of the rectum with total mesorectal excision is burdened not only with significant postoperative morbidity, but also with symptoms of bowel, urinary and sexual dysfunctions, which can significantly affect patients quality of life. The aim of these alternative strategies is to preserve the anatomy and function of the rectum (so called organ preservation approach). This approach includes three innovative strategies: “watch and wait” strategy, neoadjuvant radiochemotherapy completed with transanal rectal carcinoma excision (or excision of the scar remaining after neoadjuvant therapy) and neoadjuvant radiochemotherapy of an early rectal carcinoma. So far, evidence supporting the organ preservation approach is highly insufficient in the available literature. There are no clear indication criteria for these strategies, no unequivocal criteria for complete clinical response detection and vague recommendations regarding an optimal neoadjuvant regimen or patients follow-up. Organ preservation approach is therefore considered to be an experimental treatment strategy, which should be offered only to patients within clinical trials with a high-quality design and very careful long-term follow-up. Patients considered for “watch and wait” must be informed properly about the benefits and drawbacks of the strategy including the risk of rectal carcinoma recurrence in 30% of the patients.

Rectal Lipoma in an Elderly Male: A Case Report.

Lipomas of the gastrointestinal tract are uncommon, benign non-epithelial tumors detected incidentally during surgery or endoscopy. Rectal lipomas are extremely rare. Patients may be asymptomatic or present with rectal bleeding, constipation, tenesmus and signs of intestinal obstruction. Preoperative diagnosis is challenging. Management consists of simple observation, endoscopic or laparoscopic removal, and open surgery. We present a case of an elderly male admitted to the Department of Surgery of a general hospital in Crete, complaining of a protruding rectal mass during defecation. CT raised the diagnostic suspicion. The mass was removed by trans-anal excision. Histopathology of the resected specimen confirmed the diagnosis. The patient had an uneventful postoperative course and was discharged home at the second postoperative day.

Management of low rectal gastrointestinal stromal tumor with neoadjuvant therapy and transanal excision: a rare case report and review of the literature.

BACKGROUND: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. However, rectal GISTs represent only 5% of this category. We report a case of a rectal GIST treated with local excision after neoadjuvant therapy. CASE PRESENTATION: A 41-year-old male patient presented with anal bleeding. Colonoscopy revealed a mass located 5 cm from the anal verge. Histological examination showed a GIST with immunohistochemical positivity for CD117 and CD34. Transanal local excision was performed after neoadjuvant therapy. CONCLUSION: Neoadjuvant immunotherapy for GISTs with unfavorable localization may facilitate local excision and avoid complications of more demanding operations.

Robotic transanal microsurgery for high early rectal neoplasia (T0-T1, N0 lesions), case series of 10 patients.

PURPOSE/BACKGROUND: In 2017, an estimated 39 910 people will receive a new diagnosis of rectal cancer. Current surgical guidelines limit transanal excision of early rectal neoplasia to 8 cm from the anal verge. We report that R0 resection of higher rectal cancers is possible using transanal robotic microsurgery. METHODS/INTERVENTIONS: Ten cases of robotic assisted transanal surgery for early stage disease (T0-T1, N0) between 2013 and 2016 were reviewed. RESULTS/OUTCOMES: All cases were diagnosed preoperatively with colonoscopy, and the average distance from the anal verge was 11.1 cm. The average operative time was 167 minutes, and the average blood loss was 37.5 cc. Four cases required intraoperative conversion; one conversion required robotic abdominal access to repair a proctotomy. All margins were histologically negative, and 6-month follow-up showed no recurrences. CONCLUSION/DISCUSSION: Transanal robotic surgery may provide the colorectal surgeon a method to address rectal lesions farther from the anal verge.

Does previous transanal excision for early rectal cancer impair surgical outcomes and pathologic findings of completion total mesorectal excision? Results of a systematic review of the literature.

BACKGROUND: Transanal excision (TAE) is increasingly used in the treatment of early rectal cancer because of lower rate of both postoperative complications and postsurgical functional disorders as compared with total mesorectal excision (TME) OBJECTIVE: To compare in a meta-analysis surgical outcomes and pathologic findings between patients who underwent TAE followed by completion proctectomy with TME (TAE group) for early rectal cancer with unfavorable histology or incomplete resection, and those who underwent primary TME (TME group). METHODS: The Medline and Cochrane Trials Register databases were searched for studies comparing short-term outcomes between patients who underwent TAE followed by completion TME versus primary TME. Studies published until December 2016 were included. The meta-analysis was performed using Review Manager 5.0 (Cochrane Collaboration, Oxford, UK). RESULTS: Meta-analysis showed that completion TME after TAE was significantly associated with increased reintervention rate (OR=4.28; 95% CI, 1.10-16.76; P≤0.04) and incomplete mesorectal excision rate (OR=5.74; 95% CI, 2.24-14.75; P≤0.0003), as compared with primary TME. However there both abdominoperineal amputation and circumferential margin invasion rates were comparable between TAE and TME groups. CONCLUSIONS: This meta-analysis suggests that previous TAE impaired significantly surgical outcomes and pathologic findings of completion TME as compared with primary TME. First transanal approach during completion TME might be evaluated in order to decrease technical difficulties.

A case of local recurrence of T1 rectal cancer 10 years after transanal excision.

We report a case of a patient with T1 rectal cancer, which recurred locally after 10 years from the primary operation. A 78-year-old woman was diagnosed with rectal cancer. Transanal excision (TAE) was performed in December 2006. The pathological findings revealed stage I rectal cancer [tub2>muc, pSM (2,510 µm), ly0, v0, pHM0, pVM0]. Because she did not opt for additional treatment, she received follow-up examination. After approximately 10 years from the primary operation, she presented to her physician, complaining of melena, and she was referred to our hospital again in November 2016. She was diagnosed with recurrent rectal cancer. Laparoscopic abdominoperineal resection was performed in December 2016. Pathological findings revealed stage IIIB rectal cancer (tub2>muc, pA, pN1). The reported postoperative local recurrence rate for T1 rectal cancer after TAE is high, but local recurrence after years from the primary operation is rare. In high-risk cases, local recurrence may be observed even after 10 years from the primary operation. Long-term and close postoperative follow-up is important to detect local recurrence early.

Systematic review and meta-analysis of local resection or transanal endoscopic microsurgery versus radical resection in stage i rectal cancer: A real standard?

Current guidelines recommend radical resection for stage I rectal cancer. However, since screening programs are being installed, an increasing number of cancers are being detected in early stages. Endoscopic resection is often performed at the time of diagnosis. This systematic review was undertaken to review the evidence on endoscopic approach vs. radical resection for stage I rectal cancer. Recommendations were issued based on the GRADE methodology and risk stratification used in clinical practice. A systematic search (until March 2015) identified 2 meta-analyses and 1 additional randomized trial. For the primary outcomes (overall survival, disease-free survival, local recurrence-free survival and metastasis-free survival) no evidence could be found on the superiority of local or radical resection. Secondary outcomes (blood loss, hospital stay, operative time, number of permanent stomas and perioperative deaths) were in favour of local resection. The authors strongly recommend radical resection for T2 rectal cancer, but consider 'en bloc' local resection sufficient for pT1 sm1 rectal cancers when confirmed pathologically. Discussion by a multidisciplinary team and adequate surveillance remain mandatory.

Anal Melanoma in an Elderly Woman Masquerading as Hemorrhoid.

Anal melanoma is a rare and aggressive neoplasm of the anal canal seen in the elderly population in the six or seventh decade of their lives. Presentation is usually nonspecific and diagnosis is often delayed or missed initially. The management is surgical and prognosis is poor. Here we present a case of anal melanoma in an elderly patient masquerading as hemorrhoid.

Significance of defect closure following transanal local full-thickness excision of rectal malignant tumors.

Transanal excision (TAE) for rectal tumors is increasingly applied and it is generally recommended that the defect following full-thickness excision should be closed. The aim of this study was to compare the complications and anal function following TAE between cases where the defect was closed and those where it was not. A total of 43 consecutive rectal malignant tumor patients eligible for TAE were investigated. Regarding anorectal function, incontinence was assessed using the Wexner score. The defect of the rectum was closed in 21 of the 43 patients. There were no significant differences between the two groups regarding gender, distance from the anal verge, tumor size, diagnosis and tumor site. There was a significantly higher number of postoperative complications of all grades and ≥Clavien-Dindo grade IIIa in the closure group (P=0.02 and 0.04, respectively). Regarding the Wexner score, there was no significant difference between the two groups (P=0.24). Compared with the closure group, the non-closure group had significantly fewer postoperative complications of all grades and ≥Clavien-Dindo grade IIIa. Moreover, there was no significant difference regarding the anorectal function between the two groups. Thus, suturing the rectal defect is not necessarily recommended following TAE.

Surgical management of rectal carcinoids: trends and outcomes from the Surveillance, Epidemiology, and End Results database (1988 to 2012).

BACKGROUND: Local excision of small (<10 mm) rectal carcinoids is a standard treatment. Actual patterns of care and outcomes are understudied because of the rarity of this tumor. METHODS: Surveillance, Epidemiology, and End Results database (1988 to 2012) was interrogated for rectal carcinoid patients. Chi-square testing and Kaplan-Meier survival analysis were used to compare survival outcomes. RESULTS: Of all, 11,329 patients were identified-9,605 with only localized disease. The majority (77%) underwent local excision only. Full rectal resection was performed more frequently for tumors greater than 10 mm (11.7% to 12.2%) than for tumors less than 10 mm (4.5% to 4.9%, P < .001), and for higher T stage (T1: 4.0%, T2: 11.4%, T3/4:30.4%, P < .001). Nonoperative management was more common after year 2000 (11.2% to 13.7%) than prior (7.4% to 8.5%, P < .001). Cancer-specific survival improved across time periods but did not differ between nonoperative, local excision, or surgical resection. CONCLUSIONS: Nonexcisional management of small, localized rectal carcinoids is becoming more common and may offer equivalent survival to excision or resection.

Transanal Approach to Rectal Polyps and Cancer.

A transanal approach to rectal polyp and cancer excision is often an appropriate alternative to conventional rectal resection, and has a lower associated morbidity. There has been a steady evolution in the techniques of transanal surgery over the past 30 years. It started with traditional transanal excision and was revolutionized by introduction of transanal endoscopic microsurgery in early 1980s. Introduction of transanal minimally invasive surgery made it more accessible to surgeons around the world. Now robotic platforms are being tried in certain institutions. Concerns have been raised about recurrence rates of cancers with transanal approach and success of subsequent salvage operations.

Transanal Minimally Invasive Surgery: State of the Art.

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.