Long-term outcomes by a transanal approach to total mesorectal excision for rectal cancer.

BACKGROUND: The challenge of performing a good total mesorectal excision (TME) dissection, particularly in the distal 1/3 of the rectum, has spurred interest in new techniques. Robotic surgery is advocated by some, and more recently, a "new" approach, the transanal total mesorectal excision, has been popularized to address this problem. While great interest in this technique exists, little long-term outcome data are available. We have been utilizing a transanal abdominal transanal approach to TME in order to facilitate the distal dissection, and here, we provide our long-term outcomes using this approach in the management of rectal cancer. METHODS: From a prospectively maintained rectal cancer database, we identified 373 consecutive rectal cancers treated with sphincter preservation surgery through a combined transanal and abdominal approach to TME. Perioperative, pathological, and oncologic outcomes were analyzed. RESULTS: Three hundred and seventy-three patients with rectal cancer underwent a transanally initiated TME with mean follow-up of 5.5 years. 91% of cancers were in the distal rectum. 68.9% were men and 53.2% of cancers were tethered or fixed on presentation. 97.7% received neoadjuvant radiotherapy (mean 5405 cGy, 5-fluorouracil based); average time from completion of neoadjuvant therapy to surgery was 11 weeks. 180 and 193 patients underwent completion of their operation through open and laparoscopic abdominal approaches. 96% of TME specimens were complete/near complete, 94% had a negative circumferential resection margin, and 98.6% had a negative distal margin. Perioperative morbidity and mortality rates were 13.4 and 0.3%. Overall local recurrence (LR), DM, and Kaplan-Meier 5-year actuarial survival were 7.4, 19.5, and 90%, respectively. CONCLUSION: This is the first report of long-term data using a transanal approach to TME supporting this approach for rectal cancer. Our data with 5-year follow-up show that adequate distal and circumferential margins with very good-quality TME specimens, and a low risk for LR with excellent overall survival can be achieved using this technique. Our long-term results support the promising reports of early experiences in the literature.

Quality of Life and Functional Outcome After Transanal Abdominal Transanal Proctectomy for Low Rectal Cancer.

BACKGROUND: Transanal abdominal transanal proctectomy is a sphincter-preserving procedure designed to avoid colostomy in patients with cancer in the distal third of the rectum. Oncologic outcomes of this procedure have been established. However, data regarding patient satisfaction and quality of life are scant. OBJECTIVE: The purpose of this study was to evaluate the quality of life and functional outcomes of patients after transanal abdominal transanal proctectomy. DESIGN: This is a cross-sectional study. SETTINGS: The study was conducted at a tertiary referral colorectal center. PATIENTS: Patients who underwent transanal abdominal transanal proctectomy were included and surveyed using the Fecal Incontinence Quality of Life Scale, the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30, the Quality of Life Questionnaire CR38 module, and a questionnaire designed by the authors to assess satisfaction with quality of life. MAIN OUTCOME MEASURES: Quality of life, functional outcomes, and patient satisfaction were measured and compared by age, tumor level, and stage of the disease. RESULTS: A total of 133 surveys were mailed, and 90 patients responded and were included in the study. Patient quality of life was not significantly different after surgery. Patients with more proximal tumors had better lifestyle, physical, and emotional scores. Older patients performed better on multiple levels, including coping, emotional, body image, future perspective, and digestive. Stage of disease had no impact on quality of life. Compared with reference values, patients who underwent transanal abdominal transanal proctectomy performed better on most of the components. All of patients preferred transanal abdominal transanal proctectomy over having a stoma based on their current anal sphincter function, and >97% of patients preferred transanal abdominal transanal proctectomy based on their current quality of life, sexual function, and level of activities. LIMITATIONS: This study is limited by the lack of a comparison group and a potential selection bias. CONCLUSIONS: Satisfaction with quality of life and functional outcomes is high after transanal abdominal transanal proctectomy. Older patients and those with more proximal tumors performed better. This patient population clearly preferred a sphincter-preserving option for treatment of their rectal cancer.

True NOTES TME resection with splenic flexure release, high ligation of IMA, and side-to-end hand-sewn coloanal anastomosis.

INTRODUCTION: Natural orifice transluminal endoscopic surgery (NOTES) represents the ultimate expression of minimally invasive surgery. We have developed and present here an initial feasibility and safety study of transanal total mesorectal excision (TME) with splenic flexure release, high ligation of the IMA and IMV, and side-to-end coloanal anastomosis with temporary diverting ileostomy for rectal cancer. METHODS: A program of full NOTES TME resection with release of the splenic flexure, high ligation of the IMA/IMV, with side-to-end coloanal anastomosis was performed transanally from December 2013 to July 2014. Demographics, preoperative, perioperative, and postoperative data were prospectively obtained. Operative components were broken into TME, colonic mobilization, splenic flexure release, IMA/IMV transection, transanal extraction of specimen, and coloanal anastomosis for analysis of performance completion. RESULTS: There were 3 women and 1 man on whom we operated. Mean age was 56 (46-65). Mean BMI was 26 (23.8-30.2). The operation was completed entirely transanally in 2 patients. Transanal component completion of the operation was as follows: TME in 3/4; colonic mobilization in 4/4; splenic flexure release in 3/4; IMA/IMV transection in 3/4; transanal specimen extraction in 4/4; coloanal anastomosis in 4/4. Abdominal time for completion of component parts was: splenic flexure release 4:53 (min:s), IMA/IMV 19:43, completion of TME 13:41. Mean EBL was 194 cc (25-500). Aside from stoma site, there were no abdominal incisions. There were no mortalities. Mesorectum was intact in all 4 patients and with negative circumferential and distal margins. CONCLUSION: This experience supports the feasibility and safety of a true NOTES TME. The critical anatomic views demonstrated on video affirm the potential of this approach for distal rectal cancer. Colorectal surgery represents the most logical application for NOTES. While highly promising, a great deal of work remains to develop the technique and applicability of NOTES colorectal surgery.

Single-port laparoscopic colorectal surgery shows equivalent or better outcomes to standard laparoscopic surgery: results of a 190-patient, 7-criterion case-match study.

INTRODUCTION: Single-port (SP) surgery has been characterized as having limited applicability regarding procedure, disease, and patient characteristics. There is a question if SP procedures offer disadvantages or advantages to multiport (MP) colorectal surgery. We hypothesize that SP is equivalent to MP and is a safe alternative in the full spectrum of colorectal disease and procedures. METHODS: A case-matched analysis of a prospectively maintained database to compare perioperative outcomes in SP versus MP was performed. Criteria included age, gender, BMI, previous abdominal surgery, previous XRT, disease process, and procedure. 95 exact matches for all 7 criteria were found between 159 SP and 1,617 MP cases. Perioperative outcomes, surgical technique, morbidity, mortality, local recurrence, and 5-year survival were analyzed. RESULTS: There was lower mean EBL in SP but no difference in transfusion requirement. OR time for SP left colectomy was shorter, with a trend to shorter OR times found in all procedures. 99 % SP and 98 % MP had no intra-operative complications. Conversion to open was equivalent (0/1). Mean largest incision was smaller for SP. There were no differences in return of bowel function or length of hospital stay. There were no mortalities. There were no differences in perioperative morbidity, local recurrence, distant metastasis, or overall 5-year survival. CONCLUSIONS: SP is a safe alternative to MP colorectal surgery across the full array of procedures in equivalent patients. This study demonstrates SP has less blood loss, smaller incisions, is quicker in left colectomy, and tends to be quicker across all procedures. Conversion and morbidity rates are equivalent to MP, without compromise in quality of surgical technique. While proper training is essential, concerns regarding the inability to use SP laparoscopic colorectal surgery safely are unfounded in nearly exactly matched patients. These issues will require further study as SP laparoscopic colorectal surgery is practiced more widely.

Quality of life and fecal incontinence after transanal endoscopic microsurgery for benign and malignant rectal lesions.

BACKGROUND: Transanal endoscopic microsurgery (TEM) is a minimally invasive treatment used to excise a variety of rectal lesions. Potential overstretching of the sphincter's musculature due to dilation of the anal canal to allow placement of a 40-mm-wide scope combined with partial resection of the rectum and subsequent loss of rectal volume creates a concern regarding anorectal function postoperatively. Data regarding patient satisfaction with anorectal function and quality of life after TEM are scant. This report presents data on patient satisfaction gathered during a period of 10 years. METHODS: A prospectively maintained database of patients undergoing TEM from 1997 to 2007 was queried to identify patients to survey using the Fecal Incontinence Quality of Life Scale questionnaire, the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) questionnaire version 3, and a questionnaire designed by the authors to assess satisfaction with quality of life. From a group of 86 patients, 57 (66 %) responded to the questionnaires. Patient satisfaction outcomes were determined by age, preoperative diagnosis, tumor level in the rectum, excision method, and radiation treatment. RESULTS: Most of the patients (94.7 %) preferred TEM to having a stoma. Age (p = 0.03) and nature of the lesion (p = 0.03) were the only factors that affected coping. Depression was affected only by the presence of malignancy (p = 0.001). Excision method was the only factor that significantly influenced overall lifestyle (p = 0.002). Neither tumor level (p = 0.8) nor radiation therapy (p = 0.9) affected patient satisfaction with lifestyle after TEM. The presence of malignancy (p = 0.004) and full-thickness excision (p = 0.02) were related to more problems with fecal incontinence. CONCLUSION: Satisfaction with fecal continence generally is high after TEM. Tumor level, size of tumor, and radiation therapy do not affect the level of satisfaction after TEM. Younger age and benign nature of the lesion help patients to cope better with lifestyle changes and reduce depression. Patients with submucosal excision have a significantly higher level of satisfaction.