Ann Surg Treat Res.  2019 Mar;96(3):123-130. 10.4174/astr.2019.96.3.123.

Feasibility of transanal total mesorectal excision in cases with challenging patient and tumor characteristics

Affiliations
  • 1Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea. jayoh@ncc.re.kr

Abstract

PURPOSE
To assess the feasibility of transanal total mesorectal excision in difficult cases including obese patients or patients with bulky tumors or threatened mesorectal fascias.
METHODS
We performed laparoscopy-assisted transanal total mesorectal excision in patients with biopsy-proven rectal adenocarcinoma located 3-12 cm from the anal verge as part of a prospective, single arm, pilot trial. The primary endpoint was resection quality and circumferential resection margin involvement. Secondary endpoints included the number of harvested lymph nodes and 30-day postoperative complications.
RESULTS
A total of 12 patients (9 men and 3 women) were enrolled: one obese patient, 7 with large tumors and 8 with threatened mesorectal fascias (4 patients had multiple indications). Tumors were located a median of 5.5 cm from the anal verge, and all patients received preoperative chemoradiotherapy. Median operating time was 191 minutes, and there were no intraoperative complications. One patient needed conversion to open surgery for ureterocystostomy after en bloc resection. Complete or near-complete excision and negative circumferential resection margins were achieved in all cases. The median number of harvested lymph nodes was 15.5. There was no postoperative mortality and 3 cases of postoperative morbidity (1 postoperative ileus, 1 wound problem near the stoma site, and 1 anastomotic dehiscence).
CONCLUSION
This pilot study showed that transanal total mesorectal excision is also feasible in difficult laparoscopic cases such as in obese patients or those with bulky tumors or tumors threatening the mesorectal fascia. Additional larger studies are needed.

Keyword

Laparoscopy; Rectal neoplasms; Transanal endoscopic surgery

MeSH Terms

Adenocarcinoma
Arm
Chemoradiotherapy
Conversion to Open Surgery
Fascia
Humans
Ileus
Intraoperative Complications
Laparoscopy
Lymph Nodes
Male
Mortality
Pilot Projects
Postoperative Complications
Prospective Studies
Rectal Neoplasms
Transanal Endoscopic Surgery
Wounds and Injuries

Cited by  1 articles

Short- and mid-term outcomes of transanal versus laparoscopic total mesorectal excision for low rectal cancer: a meta-analysis
Jingqing Ren, Huixing Luo, Shaojie Liu, Bailin Wang, Fan Wu
Ann Surg Treat Res. 2021;100(2):86-99.    doi: 10.4174/astr.2021.100.2.86.


Reference

1. Martling AL, Holm T, Rutqvist LE, Moran BJ, Heald RJ, Cedemark B. Effect of a surgical training programme on outcome of rectal cancer in the County of Stockholm. Stockholm Colorectal Cancer Study Group, Basingstoke Bowel Cancer Research Project. Lancet. 2000; 356:93–96. PMID: 10963244.
2. Clinical Outcomes, Nelson H, Sargent DJ, Wieand HS, Fleshman J, Anvari M, et al. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med. 2004; 350:2050–2059. PMID: 15141043.
Article
3. Jeong SY, Park JW, Nam BH, Kim S, Kang SB, Lim SB, et al. Open versus laparoscopic surgery for mid-rectal or low-rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): survival outcomes of an open-label, non-inferiority, randomised controlled trial. Lancet Oncol. 2014; 15:767–774. PMID: 24837215.
Article
4. Kang SB, Park JW, Jeong SY, Nam BH, Choi HS, Kim DW, et al. Open versus laparoscopic surgery for mid or low rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): short-term outcomes of an open-label randomised controlled trial. Lancet Oncol. 2010; 11:637–645. PMID: 20610322.
Article
5. van der, Haglind E, Cuesta MA, Furst A, Lacy AM, Hop WC, et al. Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol. 2013; 14:210–218. PMID: 23395398.
6. Thorpe H, Jayne DG, Guillou PJ, Quirke P, Copeland J, Brown JM, et al. Patient factors influencing conversion from laparoscopically assisted to open surgery for colorectal cancer. Br J Surg. 2008; 95:199–205. PMID: 17696215.
Article
7. Allaix ME, Furnee EJ, Mistrangelo M, Arezzo A, Morino M. Conversion of laparoscopic colorectal resection for cancer: what is the impact on short-term outcomes and survival? World J Gastroenterol. 2016; 22:8304–8313. PMID: 27729737.
Article
8. Funahashi K, Koike J, Teramoto T, Saito N, Shiokawa H, Kurihara A, et al. Transanal rectal dissection: a procedure to assist achievement of laparoscopic total mesorectal excision for bulky tumor in the narrow pelvis. Am J Surg. 2009; 197:e46–e50.
Article
9. Rouanet P, Mourregot A, Azar CC, Carrere S, Gutowski M, Quenet F, et al. Transanal endoscopic proctectomy: an innovative procedure for difficult resection of rectal tumors in men with narrow pelvis. Dis Colon Rectum. 2013; 56:408–415. PMID: 23478607.
10. Dumont F, Goere D, Honore C, Elias D. Transanal endoscopic total mesorectal excision combined with single-port laparoscopy. Dis Colon Rectum. 2012; 55:996–1001. PMID: 22874608.
Article
11. Sylla P, Rattner DW, Delgado S, Lacy AM. NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance. Surg Endosc. 2010; 24:1205–1210. PMID: 20186432.
Article
12. Emhoff IA, Lee GC, Sylla P. Transanal colorectal resection using natural orifice translumenal endoscopic surgery (NOTES). Dig Endosc. 2014; 26(Suppl 1):29–42. PMID: 24033375.
Article
13. Sohn DK, Jeong SY, Park JW, Kim JS, Hwang JH, Kim DW, et al. Comparative study of NOTES rectosigmoidectomy in a swine model: E-NOTES vs. P-NOTES. Endoscopy. 2011; 43:526–532. PMID: 21425040.
Article
14. Kim T, Sohn DK, Park JW, Park CH, Moon SH, Chang HJ, et al. Transanal rectosigmoidectomy using a single port in a Swine model. Surg Innov. 2013; 20:225–229. PMID: 22751619.
Article
15. Oh JH, Park SC, Kim MJ, Park BK, Hyun JH, Chang HJ, et al. Feasibility of transanal endoscopic total mesorectal excision for rectal cancer: results of a pilot study. Ann Surg Treat Res. 2016; 91:187–194. PMID: 27757396.
Article
16. Quirke P, Durdey P, Dixon MF, Williams NS. Local recurrence of rectal adenocarcinoma due to inadequate surgical resection. Histopathological study of lateral tumour spread and surgical excision. Lancet. 1986; 2:996–999. PMID: 2430152.
17. Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009; 250:187–196. PMID: 19638912.
18. Jayne D, Pigazzi A, Marshall H, Croft J, Corrigan N, Copeland J, et al. Effect of robotic-assisted vs conventional laparoscopic surgery on risk of conversion to open laparotomy among patients undergoing resection for rectal cancer: the ROLARR randomized clinical trial. JAMA. 2017; 318:1569–1580. PMID: 29067426.
19. de Lacy AM, Rattner DW, Adelsdorfer C, Tasende MM, Fernandez M, Delgado S, et al. Transanal natural orifice transluminal endoscopic surgery (NOTES) rectal resection: “down-to-up” total mesorectal excision (TME)--short-term outcomes in the first 20 cases. Surg Endosc. 2013; 27:3165–3172. PMID: 23519489.
Article
20. Wolthuis AM, de Buck van Overstraeten A, D'Hoore A. Dynamic article: transanal rectal excision: a pilot study. Dis Colon Rectum. 2014; 57:105–109. PMID: 24316953.
21. Penna M, Hompes R, Arnold S, Wynn G, Austin R, Warusavitarne J, et al. Transanal total mesorectal excision: international registry results of the first 720 cases. Ann Surg. 2017; 266:111–117. PMID: 27735827.
22. Deijen CL, Velthuis S, Tsai A, Mavroveli S, de Lange-de Klerk ES, Sietses C, et al. COLOR III: a multicentre randomised clinical trial comparing transanal TME versus laparoscopic TME for mid and low rectal cancer. Surg Endosc. 2016; 30:3210–3215. PMID: 26537907.
Article
23. Park JW, Lim SW, Choi HS, Jeong SY, Oh JH, Lim SB. The impact of obesity on outcomes of laparoscopic surgery for colorectal cancer in Asians. Surg Endosc. 2010; 24:1679–1685. PMID: 20039065.
Article
24. McLemore EC, Harnsberger CR, Broderick RC, Leland H, Sylla P, Coker AM, et al. Transanal total mesorectal excision (taTME) for rectal cancer: a training pathway. Surg Endosc. 2016; 30:4130–4135. PMID: 26659246.
Article
25. Francis N, Penna M, Mackenzie H, Carter F, Hompes R. International TaTME Educational Collaborative Group. Consensus on structured training curriculum for transanal total mesorectal excision (TaTME). Surg Endosc. 2017; 31:2711–2719. PMID: 28462478.
Article
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