Transanal minimally invasive rectal resection for deep endometriosis: a promising technique

Vlek, Stijn L.; Lier, M.C.I.; Koedam, T. W. A.; Melgers, Ingeborg; Dekker, Joost; Bonjer, Jaap; Mijatovic, Velja; Tuynman, Jurriaan B.

doi:10.1111/codi.13569

Cited by 9 publications

(6 citation statements)

References 24 publications

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“…Also, it allows an exact transection of the rectum at the top of the anal canal, leaving no rectal mucosa behind, and avoids multiple stapler firings and cross-stapling. Further benign indications include complex fistulae [ 59 , 60 ], anastomotic complications (stenosis or leakage) [ 61 – 63 ], completion proctectomy [ 64 – 66 ], deep pelvic endometriosis [ 67 ], and reversal of Hartmann [ 68 ].…”

Section: Discussionmentioning

confidence: 99%

St.Gallen consensus on safe implementation of transanal total mesorectal excision

et al. 2017

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Background The management of rectal cancer has evolved over the years, including the recent rise of Transanal Total Mesorectal Excision (TaTME). TaTME addresses the limitations created by the bony confines of the pelvis, bulky tumours, and fatty mesorectum, particularly for low rectal cancers. However, guidance is required to ensure safe implementation and to avoid the pitfalls and potential major morbidity encountered by the early adopters of TaTME. We report a broad international consensus statement, which provides a basis for optimal clinical practice. Methods Forty international experts were invited to participate based on clinical and academic achievements. The consensus statements were developed using Delphi methodology incorporating three successive rounds. Consensus was defined as agreement by 80% or more of the experts. Results A total of 37 colorectal surgeons from 20 countries and 5 continents (Europe, Asia, North and South America, Australasia) contributed to the consensus. Participation to the iterative Delphi rounds was 100%. An expert radiologist, pathologist, and medical oncologist provided recommendations to maximize relevance to current practice. Consensus was obtained on all seven different chapters: patient selection and surgical indication, perioperative management, patient positioning and operating room set up, surgical technique, devices and instruments, pelvic anatomy, TaTME training, and outcomes analysis. Conclusions This multidisciplinary consensus statement achieved more than 80% approval and can thus be graded as strong recommendation, yet acknowledging the current lack of high level evidence. It provides the best possible guidance for safe implementation and practice of Transanal Total Mesorectal Excision.

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Section: Discussionmentioning

confidence: 99%

St.Gallen consensus on safe implementation of transanal total mesorectal excision

et al. 2017

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“…In more difficult pelvic surgery cases, including redooperations and patients with adhesions due to endometriosis, TaTME has already shown promising results [18,19]. Since completion TME is associated with higher morbidity, poorer specimen quality, and less favorable oncological outcome compared to primary TME, the transanal approach could improve the accuracy of the TME dissection.…”

Section: Discussionmentioning

confidence: 99%

Short-term outcomes of transanal completion total mesorectal excision (cTaTME) for rectal cancer: a case-matched analysis

et al. 2018

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Background Local excision of early rectal tumors as a rectal preserving treatment is gaining popularity, especially since bowel cancer screening programs result in a shift towards the diagnosis of early stage rectal cancers. However, unfavorable histological features predicting high risk for recurrence within the "big biopsy" may mandate completion total mesorectal excision (cTME). Completion surgery is associated with higher morbidity, poorer specimen quality, and less favorable oncological outcomes compared to primary TME. Transanal approach potentially improves outcome of completion surgery for rectal cancer. The aim of this study was to compare radical completion surgery after local excision for rectal cancer by the transanal approach (cTaTME) with conventional abdominal approach (cTME). Methods All consecutive patients who underwent cTaTME for rectal cancer between 2012 and 2017 were case-matched with cTME patients, according to gender, tumor height, preoperative radiotherapy, and tumor stage. Surgical, pathological, and short-term postoperative outcomes were evaluated. Results In total, 25 patients underwent completion TaTME and were matched with 25 patients after cTME. Median time from local excision to completion surgery was 9 weeks in both groups. In the cTaTME and cTME groups, perforation of the rectum occurred in 4 and 28% of patients, respectively (p = 0.049), leading to poor specimen quality in these patients. Number of harvested lymph nodes was higher after cTaTME (median 15; range 7-47) than after cTME (median 10; range 0-17). No significant difference was found in end colostomy rate between the two groups. Major 30-day morbidity (Clavien-Dindo≥ III) was 20 and 32%, respectively (p = 0.321). Hospital stay was significantly longer after cTME. Conclusion TaTME after full-thickness excision is a promising technique with a significantly lower risk of perforation of the rectum and better specimen quality compared to conventional completion TME.Keywords TAMIS · TaTME · Completion · Rectal surgery · Outcomes Early rectal cancer is increasingly treated with transanal minimal invasive surgery (TAMIS). With the implementation of population screening programs for colorectal cancer and longer life expectancy, the incidence of elderly patients being diagnosed with early rectal cancer increases. Rectal preserving therapy is appealing for these patients as radical rectal surgery has been correlated with higher colostomy rate, higher morbidity, and poorer functional outcomes [1][2][3][4][5][6][7][8]. Commonly used platforms for full-thickness local excision include transanal endoscopic microsurgery (TEM), transanal endoscopic operations (TEO) and the GelPoint® Path port which offer a safe and curative therapy when performed for large rectal adenomas and low-risk T1 carcinoma, including tumors smaller than 3 centimeters in size,

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“…Proposed benefits from the transanal approach in this context are avoiding damage to ureter and vagina, better nerve preservation, less conversions, and less permanent colostomies. 17 The feasibility of this technique has already been demonstrated with early reports showing promising results. In the first published series of transanal approach to endometriosis surgery, 5 cases of transanal approach were compared with 6 cases of conventional low anterior resection.…”

Section: Rectovaginal Endometriosismentioning

confidence: 96%

“…Rectovaginal endometriosis presents particular difficulties in surgical access due to the obliteration of normal anatomical spaces like the pouch of Douglas. 17 High perioperative morbidities (40-50%) 18 are associated with colorectal resection in this context, with a high risk of damaging neighboring structures. Surgical intervention is reserved for failure of conservative management, extensive deep endometriosis in the rectum, and significant decrease in health-related quality of life.…”

Section: Rectovaginal Endometriosismentioning

confidence: 99%

Future Directions

Soares

Chand

2020

Clinics in Colon and Rectal Surgery

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Transanal total mesorectal excision (taTME) is a novel technique that has evolved over the years to address the challenges of low rectal cancer surgery by applying the principles and benefits of laparoscopic surgery to more historic transanal techniques. It has been popularized through its use in rectal cancer, but the transanal approach is slowly being expanded to tackle different clinical scenarios including benign conditions such as inflammatory bowel disease and endometriosis. For all of these new indications, it is the desire to access and begin the dissection in native tissue beyond the pathology which makes this approach applicable to other diseases where anatomy can be challenging. Training pathways to safely introduce taTME in a standardized manner are being developed and implemented in a bid to ensure adequate training to all the surgeons using this technique and thus minimize complications and patient morbidity. The future directions of this promising technique include the use of image and optical technological enhancement to aid navigation, the use of pneumorectum stabilization, and perhaps the use of fluorescence as a safety improvement. Developments have come also from the field of robotics. After a demonstration of feasibility in cadaver models, a growing experience has been gathered in the robotic approach to taTME, covered in the last part of this chapter.

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Transanal minimally invasive rectal resection for deep endometriosis: a promising technique

Cited by 9 publications

References 24 publications

St.Gallen consensus on safe implementation of transanal total mesorectal excision

St.Gallen consensus on safe implementation of transanal total mesorectal excision

Short-term outcomes of transanal completion total mesorectal excision (cTaTME) for rectal cancer: a case-matched analysis

Future Directions

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