The new approach to the rectal cancer: ‘down-to-up’ double endolaparoscopic pelvic access. Preliminary evaluation of outcomes

Abstract

Laparoscopic access in low anterior rectal resection is widely adopted, performing an 'up-to-down' dissection. The aim of this study is to present and analyze the outcomes of a novel surgical 'down-to-up' total mesorectal excision technique that could obviate to the well-known issues of the standard treatment. 18 suitable patients underwent double endolaparoscopic pelvic access (DEPA) 'down-to-up' technique. DEPA TME was completed in all patients, with intact mesorectum. Mean operative time was 365 min (range 280-510 min). The morbidity rate was 22%, including three radiologically detected leakage (grade A) and one pelvic abscess, requiring only a conservative management. Mortality rate at 30 and 90 days was 0%. Resection margins were negative in all patients. A median of 11 nodes (range 5-19) was retrieved per specimen. Mean length of hospital stay was 9 days (range 7-19 days). Patients were followed for an average of 14 months (range 0-42 months), with no recurrence. Despite exiguous patient's sample in this pilot study, transanal endoscopic TME with laparoscopic assistance seems to be feasible and safe, and is a promising alternative to open and laparoscopic TME. However, a conspicuous functional and oncologic long-term evaluation is required, before the widespread adoption could be recommended.

Functional results and quality of life after transanal total mesorectal excision

“…In one study 6 patients completed the Wexner incontinence score one week and 6 months after surgery [38] : mean score only slightly deteriorated from 0 to 3 at 6 months after surgery and 4 months after stoma closure. A similar mean Wexner score value of 3.3 was reported by Borreca et al [36] with no patient complaining of urgency symptoms. A worse anorectal function was reported by Rouanet et al [37] who studied 30 patients with advanced or recurrent low rectal tumor with complex anatomical (male gender, high BMI, fatty mesorectum), or tumor characteristics (bulky anterior tumor, narrow radial margin).…”

“…Three employed the Wexner Incontinence score [36][37][38] , while Atallah et al [39] examined 20 patients with a telephone survey 8 weeks after ileosto-my closure: most patients stated they had less than one accident per day, and one patient reported lifestylelimiting incontinence that did not improve 12 months post-resection. In three of the studies incontinence symptoms were only evaluated after surgery [36,37,39] . In one study 6 patients completed the Wexner incontinence score one week and 6 months after surgery [38] : mean score only slightly deteriorated from 0 to 3 at 6 months after surgery and 4 months after stoma closure.…”