Should the rectal defect be sutured following TEMS/TAMIS carried out for neoplastic rectal lesions? A meta-analysis

Abstract

Introduction Management of the rectal defect following transanal endoscopic microsurgery (TEMS) or minimally invasive surgery (TAMIS) carried out for excision of neoplasm in the lower rectum is controversial. We aimed to extract evidence by carrying out a meta-analysis to compare the peri- and postoperative outcomes following rectal neoplasm excision carried out by TEMS and/or TAMIS, whereby the defect is either sutured or left open. Methods A literature search of Ovid MEDLINE and EMBASE was performed. Full-text comparative studies published until November 2019, in English and of adult patients, whereby TEMS or TAMIS was undertaken for rectal neoplasms were included. The main outcome measures were postoperative bleeding, infection, operative time and hospital stay. Findings Three studies (one randomised controlled trial and two comparative case series) yielded 555 cases (283 in the sutured group and 272 in the open group). The incidence of postoperative bleeding was higher and statistically significant (p = 0.006) where the rectal defect was left open following excision of the neoplasm (19/272, 6.99% vs 6/283, 2.12%). There was no statistical difference between the sutured and open groups regarding infection (p = 0.27; (10/283, 3.53% vs 5/272, 1.84%, respectively), operative time (p = 0.15) or length of stay (p = 0.67). Conclusion Suturing the rectal defect following excision of rectal neoplasm by TEMS/TAMIS reduces the incidence of postoperative bleeding in comparison to leaving the defect open. However, suturing makes the procedure slightly longer but there was no statistical difference between both groups when postoperative infection and length of hospital stay were compared.

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

“…Reoperation was performed due to bleeding, rectal perforation, residual cancer, pelvic abscess, and nonhealing wound. Khan et al [ 46 ] reported closure of the rectal defect, which accounts for a major part of the operating time. It has also been reported that defect closure reduces the risk of re-bleeding, but has no effect on postoperative infection and hospital stay[ 46 ].…”

Transanal minimal invasive surgery (TAMIS): safety and feasibility for the resection of benign and malignant lesions of the rectum

“…Closing the defect resulted in significantly decreased rate of post-operative bleeding as compared to leaving the defect open. However, there was no statistical difference in postoperative infection, operative time and length of hospital stay between the two groups (14). In our series, we routinely closed all the defects.…”

Management of early rectal cancer; current surgical options and future direction

“…For lesions with any suspicion of malignancy, a full thickness resection should be performed with transmural dissection up to the mesorectal fat. Following lesion excision, closure of the rectal wall defect is warranted for cases where there has been inadvertent intra-peritoneal entry or where there has been a planned dissection above the peritoneal reflection for proximal lesions[ 39 ]. For resections below the peritoneal reflection there is a lack of consensus on whether the defect should be closed and it is largely dependent on surgeon preference.…”

“…A meta-analysis conducted by Khan et al [ 39 ] in 2020 assessed outcomes of TEM/TAMIS in cases where the defect was sutured ( n = 283) in comparison to cases where it was left open ( n = 272). Authors found no statistically significant differences in rates of post-operative infection, length of hospital stay or duration of procedure; although there was a trend towards longer operations in the defect closure group.…”