摘要
Introduction: Transanal Endoscopic Microsurgery (TEM) is a minimally invasive method for management of different proctologic conditions. Despite widespread use of this method, it is not used widely in Iran. This report is about to describe the application of TEM in managing different proctologic conditions in a tertiary colorectal referral center in Iran regarding methods and complications. Methods: All of the patients' documents such as procedure, method, early postop complications and further operations were actively reviewed and the data were entered in to the database. Results: Since 2012 till the end of 2020 chart review was done and 150 cases of TEM operation were found. The most frequent procedure that was done was resection procedure. Using different energy devices during surgery or suturing versus not suturing the defect were not associated with complication. There was a case of in hospital mortality and one case delayed perianal fistula following TEM. Measurement of lesion distance from anal verge was not significantly different using TEM or colonoscopy. Villous adenomas detected in colonoscopy were mostly associated with malignancy. In evaluated resected lesions most of cases had free base and distance from anal verge or using different energy devices were not associated with obtaining free base. Conclusion: TEM is a safe minimal invasive procedure with acceptable complications that could be helped in managing different proctologic conditions and the results of reviewing our patients revealed the same results that is reported from other colorectal centers. (AU)
Subject(s)
Humans , Male , Female , Adolescent , Adult , Middle Aged , Aged , Aged, 80 and over , Transanal Endoscopic Surgery/methods , Postoperative Complications , Colonoscopy摘要
Objective: To methodically assess the clinical effectiveness and safety of robot-assisted total rectal mesenteric resection (RTME), laparoscopic-assisted total rectal mesenteric resection (laTME), and transanal total rectal mesenteric resection (taTME). Methods: A computer search was conducted on PubMed, Embase, Cochrane Library, and Ovid databases to identify English-language reports published between January 2017 and January 2022 that compared the clinical efficacy of the three surgical procedures of RTME, laTME, and taTME. The quality of the studies was evaluated using the NOS and JADAD scales for retrospective cohort studies and randomized controlled trials, respectively. Direct meta-analysis and reticulated meta-analysis were performed using Review Manager software and R software, respectively. Results: Twenty-nine publications comprising 8,339 patients with rectal cancer were ultimately included. The direct meta-analysis indicated that the length of hospital stay was longer after RTME than after taTME, whereas according to the reticulated meta-analysis the length of hospital stay was shorter after taTME than after laTME (MD=-0.86, 95%CI: -1.70 to -0.096, P=0.036). Moreover, the incidence of anastomotic leak was lower after taTME than after RTME (OR=0.60, 95%CI: 0.39 to 0.91, P=0.018). The incidence of intestinal obstruction was also lower after taTME than after RTME (OR=0.55, 95%CI: 0.31 to 0.94, P=0.037). All of these differences were statistically significant (all P<0.05). There were no statistically significant differences between the three surgical procedures regarding the number of lymph nodes cleared, length of the inferior rectal margin, or rate of positive circumferential margins (all P>0.05). An inconsistency test using nodal analysis revealed no statistically significant differences between the results of direct and indirect comparisons of the six outcome indicators (all P>0.05). Furthermore, we detected no significant overall inconsistency between direct and indirect evidence. Conclusion: taTME has advantages over RTME and laTME, in terms of radical and surgical short-term outcomes in patients with rectal cancer.
Subject(s)
Humans , Robotics , Robotic Surgical Procedures/adverse effects , Network Meta-Analysis , Retrospective Studies , Postoperative Complications/etiology , Transanal Endoscopic Surgery/methods , Rectum/surgery , Rectal Neoplasms/pathology , Laparoscopy/methods , Treatment Outcome摘要
Transanal total mesorectal resection (taTME) has come a long way since it was first used in the clinic in 2010.The learning curve of this procedure is long due to different surgical approaches, different perspectives and different anatomical positions. Many surgeons experience complications during this procedure. Although the advantages and problems of this procedure have been reported in much literature, the anatomy and operation methods of taTME introduced in literatures and training centers are too complicated, which makes many surgeons encounter difficulties in carrying out taTME surgery. According to the author's experience in learning and carrying out this operation, spatial expansion process of ultralow rectal cancer was divided into three stages. At each stage, according to different pulling forces, three different schemes of triangular stability mechanics model were adopted for separation. From point to line, from line to plane, the model can protect the safety of peripheral blood vessels and nerves while ensuring total mesorectal excision . This model simplifies the complex surgical process and is convenient for beginners to master taTME surgical separation skills.
Subject(s)
Humans , Rectum/surgery , Laparoscopy/methods , Transanal Endoscopic Surgery/methods , Rectal Neoplasms/surgery , Proctectomy/methods , Postoperative Complications , Treatment Outcome摘要
Although transanal endoscopic surgery has been developed for more than 40 years, it remains relatively unknown to most domestic colleagues. In 2019, the Chinese Society of Transanal Total Mesorectal Excision (CSTa) and the Chinese Society of Colon and Rectal Surgeons (CSCRS) organized domestic experts to write and publish the "Chinese Expert Consensus on Transanal Endoscopic Surgery (2019 Edition)", which elaborated on the definition, surgical methods, indications, contraindications, basic principles, key issues and complications of transanal endoscopic surgery, and provided a certain theoretical foundation for the development of transanal endoscopic surgery in China. In the past four years, the scope of application of transanal endoscopic techniques has been expanded, and many prospective and retrospective clinical research have provided more evidence-based medical evidence. Therefore, the Chinese Society of Transanal Total Mesorectal Excision (CSTa) once again organized domestic experts to write the "Expert Consensus and Operation Guidelines for Transanal Endoscopic Surgery in China (2023 Edition)", updating the expert consensus opinions on the definition, indications, complications and learning curve of transanal endoscopic surgery and adding operation guidelines. The aim is to promote the standardized practices in transanal endoscopic surgery and facilitate a shorter learning curve for surgeons.
Subject(s)
Humans , Rectum/surgery , Rectal Neoplasms/surgery , Consensus , Prospective Studies , Retrospective Studies , Transanal Endoscopic Surgery/methods摘要
Contexte et objectif. Les variétés histologiques de tumeurs du septum nasal sont peu documentées dans les pays d'Afrique. La présenté étude avait pour objectif de décrire les variétés histologiques de tumeurs septales bénignes. Méthodes. C'était une analyse rétrospective de dossiers des patients admis pour tumeurs septales bénignes, entre janvier 1998 et aout 2021 ; à l'hôpital Dr Dorban en Algérie. Les variables d'intérêt englobaient les données cliniques et histopathologiques. Résultats. En 23 ans, seulement trente dossiers de tumeurs bénignes du septum nasal ont été colligés. Leur âge moyen était de 36,2 ans avec les extrêmes entre 13 et 70 ans avec une prédominance du sexe féminin (63,3 %). Les tumeurs vasculaires étaient prépondérantes (83,3 %) en particulier les hémangiomes capillaires (92 %) suivies des variétés épithéliales (13,3%) et un seul adénome pléomorphe septal. L'évolution clinique était émaillée par 3 récidives pour les hémangiomes, et absence de récidive pour l'adénome pléomorphe après 120 mois de recul. Trois autres cas étaient perdus. Conclusion: Les tumeurs bénignes du septum nasal sont rares et diversifiées sur le plan histologique. A coté des formes classiques et communes (hémangiomes, papillomes, adénomes), il existe des variétés rares et qui nécessitent une étude spécifique et une expertise dédiée.
Subject(s)
Transanal Endoscopic Surgery , Nasal Septum , Papilloma , Nose Neoplasms , Hemangioma , Neoplasms摘要
to describe the epidemiological and clinical aspects, to evaluate the surgical result and to identify the prognostic factors for the success of septoplasty. Methods: It was a retrospective study including 250 patients operated on for a septoplasty collected over a 6-yearperiod. The evaluation of our results was made using 2 tools: NOSE scale and the visual satisfaction scale. Results: In our series, there was a male predominance with a sex ratio of 1.4. The mean age of the patients was 32.7 years. The medical history was dominated by allergic rhinitis in 38.4% of cases. Nasal trauma was noted in 45.2% of cases. A subjective quantification of respiratory discomfort by the NOSE score made it possible to divide them into 3 groups:Group 1: Severe ON: 65.2% of cases; Group 2: Moderate ON: 31.6% of cases; Group 3: Mild ON: 3.2% of cases. Our analytical study of the epidemiological and clinical factors that may influence the functional results showed that: Severe or moderate overall discomfort, severe ON (NOSE scale> 50) or moderate (NOSE scale between 26 and 50), DS classified zone I, II, III according to the Cottle classification, a quasi-obstructive deviation were considered as a predictor of the success of septoplasty. Conclusion: Several factors can influence the results of a septoplasty that must be considered before any surgical indication.
Subject(s)
Humans , Transanal Endoscopic Surgery , Nasal Cavity , General Surgery , Nasal Septal Perforation摘要
Objective: Choanal atresia (CA) is a rare congenital malformation caused by the obliteration of the posterior choanae by an atretic plate. The aim of our study is to describe the diagnosis and management modalities of CA and to determine the factors associated with recurrence. Materials and methods: This is a retrospective study based on the medical records of patients with CA managed in our department in the period between 2002 and 2021. We studied the clinical features and management modalities of each patient. For patients who developed a recurrence, we determined the factors associated with recurrence based on a bivariate analysis. Results: We studied the medical records of 26 patients with either a bilateral (n=8) or a unilateral (n=16) form of CA. The median age at surgery was two days for bilateral forms and 5 years and 4 months for unilateral forms. At computed tomography scan, CA was mixed (n=20), bony (n=4) or membranous (n=2). All patients underwent intranasal endoscopic surgical treatment using cold instruments alone in membranous forms and combined to the drilling of the atretic plate in bony and mixed forms. The surgical management included the resection of the posterior part of the vomer bone and the placement of nasal stents in 10 and 16 patients respectively. We recorded 6 cases of recurrence requiring a surgical re-intervention. The presence of associated cranio-facial malformations was the only factor associated with recurrence (p=0,001). Conclusion: Choanal atresia diagnosis was based on nasal endoscopy and CT scan. Surgical treatment using transnasal endoscopic approach was an effective and safe technique. Associated local malformations was a factor associated with re-stenosis
Subject(s)
Humans , Choanal Atresia , Transanal Endoscopic Surgery , Recurrence , Case Management , Diagnosis摘要
La escisión mesorrectal transanal (TaTME: transanal total mesorectal escision) es la última de una larga lista de desarrollos técnicos y tecnológicos para el tratamiento del cáncer de recto medio y bajo. Incluso para los cirujanos colorrectales experimentados, lograr una escisión mesorrectal total (emt) de calidad en cirugía oncológica no siempre es sencillo, por la dificultad de obtener un adecuado acceso a la pelvis. Los estudios realizados han mostrado resultados comparables al abordaje laparoscópico, con tasas elevadas de escisiones mesorrectales completas y bajo porcentaje de margen circunferencial radial (CRM: circumferential radial margin) y distal positivos, con un adecuado número de ganglios resecados. Como toda técnica nueva, su implementación puede traer consecuencias no intencionales. La complejidad del abordaje, la dificultad en la identificación de nuevos repères y planos anatómicos, ha llevado a complicaciones graves como la lesión uretral o la siembra tumoral pelviana. Por ello, la comunidad quirúrgica ha retrasado la implementación masiva de la técnica y desarrollado estrategias de enseñanza y monitorización de este procedimiento para su realización en centros de alto volumen. El objetivo de esta publicación es presentar el primer caso de TaTME en un centro docente universitario y difundir en nuestra comunidad científica el fundamento de la técnica, sus indicaciones, describir los principales pasos técnicos, complicaciones, resultados oncológicos y funcionales.
Transanal total mesorectal excision (TaTME) is the last of a long list of technical and technological developments for treatment of middle and low rectal cancer. Even for skilled colorectal surgeons, achieving a good quality total mesorectal excision (TME) in oncology surgery is not always simple, due to the difficulty of obtaining optimal access to the pelvis. So far, studies have shown similar results to laparoscopic surgery, with high rates of complete mesorectal excisions and low rate of circumferential radial margin (CRM) and distal margin with an appropriate number of resected lymph nodes. Like every new technique, its implementation can bring unwanted consequences. The complexity of the approach, the difficulty in the identification of new landmarks and anatomic planes, has led to serious complications such as urethral injury or tumoral seeding. This has made slowdown the massive implementation of the technique among the surgical community, addressing the need of developing training programs and mentoring of this procedure that belongs to high volume centers. The aim of this publication is to present the first case of TaTME in a teaching tertiary center and spread, in our scientific community, the principles of the technique, its indications, main technical steps, complications and functional and oncologic results.
A excisão mesorretal transanal (TaTME: transanal total mesorectal escision) é o mais recente de uma longa linha de desenvolvimentos técnicos e tecnológicos para o tratamento do câncer retal inferior e médio. Mesmo para cirurgiões colorretais experientes, nem sempre é fácil obter uma excisão total do mesorreto (EMT) de qualidade em cirurgia de câncer, devido à dificuldade de obter acesso adequado à pelve. Os estudos realizados mostraram resultados comparáveis ââà abordagem laparoscópica, com altas taxas de excisões completas do mesorreto e baixo percentual de margem radial circunferencial positiva (CRM: circumferential radial margin) e distal, com número adequado de linfonodos ressecados. Como qualquer nova técnica, sua implementação pode ter consequências não intencionais. A complexidade da abordagem, a dificuldade em identificar novos repères e planos anatômicos, levou a complicações graves, como lesão uretral ou semeadura de tumor pélvico. Por esse motivo, a comunidade cirúrgica atrasou a implementação massiva da técnica e desenvolveu estratégias de ensino e acompanhamento desse procedimento para sua realização em centros de alto volume. O objetivo desta publicação é apresentar o primeiro caso de TaTME em um centro de ensino universitário e divulgar em nossa comunidade científica as bases da técnica, suas indicações, descrever as principais etapas técnicas, complicações, resultados oncológicos e funcionais.
Subject(s)
Humans , Female , Aged , Rectal Neoplasms/surgery , Adenocarcinoma/surgery , Transanal Endoscopic Surgery/methods , Treatment Outcome摘要
Abstract Idiopathic scoliosis is a three-dimensional spinal deformity with axial rotation and lateral inclination with an angle greater than 10º per the Cobb method. The approach to idiopathic scoliosis can be conservative or surgical, depending on the degree of angulation, musculoskeletal development, and age of the child or adolescent. It also depends on the functional impairment resulting from the condition. This study aimed to analyze the impact of video-assisted thoracoscopic surgery in idiopathic scoliosis management. This systematic literature review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol, and its PROSPERO registration number is CRD42022351466. Studies queries occurred from August to September 2022 in the bibliographic databases MEDLINE, The Cochrane Library, and Web of Science. The video-assisted thoracoscopic surgery is a minimally invasive alternative to thoracotomy with significant evolution in recent years. Its main advantages include lower blood loss during the procedure, shorter hospital stays, and improved post-surgical esthetics. Authors mentioned its disadvantages as greater complexity and technological requirement, longer surgical time, and the need for careful selection of the patients per vertebral deviation degree. The use of analgesic and anti-inflammatory drugs was not significantly different between traditional procedures (thoracotomy) and thoracoscopic surgery.
Resumo A escoliose idiopática é caracterizada por um quadro de deformidade tridimensional da coluna vertebral com rotação axial e inclinação lateral com angulação maior que 10º segundo o Método de Cobb. Sua abordagem pode se dar de maneira conservadora ou cirúrgica, a depender do grau de angulação, desenvolvimento osteomuscular e idade da criança ou adolescente acometido, ou ainda, a depender do comprometimento funcional advindo da condição. O objetivo deste estudo foi analisar o impacto da videotoracoscopia na abordagem da escoliose idiopática. Trata-se de uma revisão sistemática de literatura, construída conforme protocolo Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) e registrada no PROSPERO sob número CRD42022351466. A busca por estudos foi realizada entre agosto de 2022 e setembro do mesmo ano, em bancos de dados bibliográficos incluindo MEDLINE, The Cochrane Library e Web of Science. A técnica é uma alternativa minimamente invasiva à toracotomia que apresentou grande evolução nos últimos anos. Destacam-se como principais vantagens a menor perda sanguínea durante procedimento, menor tempo de internação e melhora da estética pós-cirúrgica. Uma das desvantagens citadas pelos autores é a maior complexidade e exigência tecnológica, maior tempo cirúrgico e necessidade de seleção criteriosa dos pacientes, conforme graus de desvio vertebral. O uso de analgésicos e anti-inflamatórios não teve diferença significativa entre os procedimentos tradicionais (toracotomia) ou videotoracoscopia.
Subject(s)
Humans , Scoliosis/surgery , Thoracoscopy , Transanal Endoscopic Surgery摘要
Introduction: The optimal rectal cancer care is achieved by a multidisciplinary approach, with a high-quality surgical resection, with complete mesorectal excision and adequate margins. New approaches like the transanal total mesorectal excision (TaTME) aim to achieve these goals, maximizing the sphincter preservation ratio, with good oncologic and functional results. This report describes a way to implement TaTME without a proctor, presents the first case series of this approach in a center experienced in rectal cancer, and compares the results with those of the international literature. Methods: We performed a retrospective study of the first 10 consecutive patients submitted to TaTME for rectal cancer at our institution. The primary outcomes were postoperative complications, pathological specimen quality and local recurrence rate. The results and performance were compared with the outcomes of a known structured program with proctorship and with the largest meta-analysis on this topic. Results: All patients had locally advanced cancer; therefore, all underwent neoadjuvant therapy. A total of 30% had postoperative complications, without mortality or re-admissions. In comparison with the structured training program referred, no differences were found in postoperative complications and reintervention rates, resulting in a similar quality of resection. Comparing these results with those of the largest meta-analysis on the subject, no differences in the postoperative complication rates were found, and very similar outcomes regarding anastomotic leaks and oncological quality of resection were registered. Conclusion: The results of this study validate the safety and effectiveness of our pathway regarding the implementation of the TaTME approach, highlighting the fact that it should be done in a center with proficiency in minimally invasive rectal surgery. (AU)
Subject(s)
Humans , Male , Female , Middle Aged , Aged , Rectal Neoplasms/surgery , Transanal Endoscopic Surgery/methods , Postoperative Period , Recurrence , Treatment Outcome , Operative Time , Neoplasm Staging摘要
Objective: To compare the short-term and long-term outcomes between transanal total mesorectal excision (taTME) and laparoscopic total mesorectal excision (laTME) for mid-to-low rectal cancer and to evaluate the learning curve of taTME. Methods: This study was a retrospective cohort study. Firstly, consecutive patients undergoing total mesorectal excision who were registered in the prospective established database of Division of Colorectal Diseases, Department of General Surgery, Peking Union Medical College Hospital during July 2014 to June 2020 were recruited. The enrolled patients were divided into taTME and laTME group. The demographic data, clinical characteristics, neoadjuvant treatment, intraoperative and postoperative complications, pathological results and follow-up data were extracted from the database. The primary endpoint was the incidence of anastomotic leakage and the secondary endpoints included the 3-year disease-free survival (DFS) and the 3-year local recurrence rate. Independent t-test for comparison between groups of normally distributed measures; skewed measures were expressed as M (range). Categorical variables were expressed as examples (%) and the χ(2) or Fisher exact probability was used for comparison between groups. When comparing the incidence of anastomotic leakage, 5 variables including sex, BMI, clinical stage evaluated by MRI, distance from tumor to anal margin evaluated by MRI, and whether receiving neoadjuvant treatment were balanced by propensity score matching (PSM) to adjust confounders. Kaplan-Meier curve and Log-rank test were used to compare the DFS of two groups. Cox proportional hazard model was used to analyze and determine the independent risk factors affecting the DFS of patients with mid-low rectal cancer. Secondly, the data of consecutive patients undergoing taTME performed by the same surgical team (the trananal procedures were performed by the same main surgeon) from February 2017 to March 2021 were separately extracted and analyzed. The multidimensional cumulative sum (CUSUM) control chart was used to draw the learning curve of taTME. The outcomes of 'mature' taTME cases through learning curve were compared with laTME cases and the independent risk factors of DFS of 'mature' cases were also analyzed. Results: Two hundred and forty-three patients were eventually enrolled, including 182 undergoing laTME and 61 undergoing taTME. After PSM, both fifty-two patients were in laTME group and taTME group respectively, and patients of these two groups had comparable characteristics in sex, age, BMI, clinical tumor stage, distance from tumor to anal margin by MRI, mesorectal fasciae (MRF) and extramural vascular invasion (EMVI) by MRI and proportion of receiving neoadjuvant treatment. After PSM, as compared to laTME group, taTME group showed significantly longer operation time [(198.4±58.3) min vs. (147.9±47.3) min, t=-4.321, P<0.001], higher ratio of blood loss >100 ml during surgery [17.3% (9/52) vs. 0, P=0.003], higher incidence of anastomotic leakage [26.9% (14/52) vs. 3.8% (2/52), χ(2)=10.636, P=0.001] and higher morbidity of overall postoperative complications [55.8%(29/52) vs. 19.2% (10/52), χ(2)=14.810, P<0.001]. Total harvested lymph nodes and circumferential resection margin involvement were comparable between two groups (both P>0.05). The median follow-up for the whole group was 24 (1 to 72) months, with 4 cases lost, giving a follow-up rate of 98.4% (239/243). The laTME group had significantly better 3-year DFS than taTME group (83.9% vs. 73.0%, P=0.019), while the 3-year local recurrence rate was similar in two groups (1.7% vs. 3.6%, P=0.420). Multivariate analysis showed that and taTME surgery (HR=3.202, 95%CI: 1.592-6.441, P=0.001) the postoperative pathological staging of UICC stage II (HR=13.862, 95%CI:1.810-106.150, P=0.011), stage III (HR=8.705, 95%CI: 1.104-68.670, P=0.040) were independent risk factors for 3-year DFS. Analysis of taTME learning curve revealed that surgeons would cross over the learning stage after performing 28 cases. To compare the two groups excluding the cases within the learning stage, there was no significant difference between two groups after PSM no matter in the incidence of anastomotic leakage [taTME: 6.7%(1/15); laTME: 5.3% (2/38), P=1.000] or overall complications [taTME: 33.3%(5/15), laTME: 26.3%(10/38), P=0.737]. The taTME was still an independent risk factor of 3-year DFS only analyzing patients crossing over the learning stage (HR=5.351, 95%CI:1.666-17.192, P=0.005), and whether crossing over the learning stage was not the independent risk factor of 3-year DFS for mid-low rectal cancer patients undergoing taTME (HR=0.954, 95%CI:0.227-4.017, P=0.949). Conclusions: Compared with conventional laTME, taTME may increase the risk of anastomotic leakage and compromise the oncological outcomes. Performing taTME within the learning stage may significantly increase the risk of postoperative anastomotic leakage.
Subject(s)
Humans , Anastomotic Leak/etiology , Laparoscopy/methods , Postoperative Complications/epidemiology , Prognosis , Prospective Studies , Rectal Neoplasms/pathology , Rectum/surgery , Retrospective Studies , Transanal Endoscopic Surgery/methods , Treatment Outcome摘要
Thanks to the new surgical approach, transanal total mesorectal excision (taTME) has a better operative field exposure than laparoscopic-assisted total mesorectal excision (laTME), especially for male patients with obesity, pelvic stenosis or prostate hypertrophy. Nevertheless, whether the urogenital function and quality of life after taTME are better as compared to laTME requires further study. According to the existing studies, taTME and laTME are not significantly different in symptoms of the urology system for male patients, but some large sample clinical studies show that the incidence of urethral mechanical injury after taTME is higher. Unfortunately, there is no elaboration on that for females. The sexual function of male patients after taTME and laTME is both impaired. The sexual function of male patients will be relieved to different degrees over time, but there is no significant difference. Compared with laTME, taTME shows advantages in the sexual function for female patients. There is no significant difference in short-term urogenital system function between taTME and laTME at present. As a new surgical approach, the impact on urogenital system function after taTME is acceptable. However, whether there is a significant difference in urogenital function between taTME and laTME needs further research. In addition, functional results still need comprehensive evaluation, and preoperative baseline evaluation also needs to be enhanced. The functional evaluation for male and female should be carried out separately rather than confused. Questionnaire for evaluation of functional results also needs to be verified.
Subject(s)
Female , Humans , Male , Laparoscopy/methods , Operative Time , Postoperative Complications/epidemiology , Quality of Life , Rectal Neoplasms/surgery , Rectum/surgery , Transanal Endoscopic Surgery/methods , Treatment Outcome摘要
Background: In transanalminimally-invasive surgery (TAMIS), the closure of the rectal defect is controversial, and endoluminal suture is one of the most challenging aspects. The goal of the present study is to evaluate the short- andmedium-term complications of a consecutive series of patients with extraperitoneal rectal injuries who underwent TAMIS without closure of the rectal defect. Materials and Methods: A prospective, longitudinal, descriptive study conducted between August 2013 and July 2019 in which all patients with extraperitoneal rectal lesions, who were operated on using the TAMIS technique, were consecutively included. The lesions were: benign lesions ≥ 3 cm; neuroendocrine tumors ≤ 2 cm; adenocarcinomas in stage T1N0; and adenocarcinomas in stage T2N0, with high surgical risk, or with the patients reluctant to undergo radical surgery, and others with doubts about complete remission after the neoadjuvant therapy. Bleeding, infectious complications, rectal stenosis, perforations, and death were evaluated. Results: A total of 35 patients were treated using TAMIS without closure of the defect. The average size of the lesionswas of 3.68±2.1 cm(95% confidence interval [95%CI]: 0.7cmto 9 cm), their average distance from the anal margin was of 5.7±1.48cm, and the average operative time was of 39.2±20.5 minutes, with a minimum postoperative follow-up of 1 year. As for the pathologies, they were: 15 adenomas; 3 carcinoid tumors; and 17 adenocarcinomas. In all cases, the rectal defect was left open. The overall morbidity was of 14.2%. Two patients (grade II in the Clavien-Dindo classification) were readmitted for pain treatment, and three patients (grade III in the Clavien-Dindo classification) were assisted due to postoperative bleeding, one of whom required reoperation. Conclusion: The TAMIS technique without closure of the rectal defect yields good results, and present a high feasibility and low complication rate. (AU)
Subject(s)
Humans , Male , Female , Adult , Middle Aged , Aged , Aged, 80 and over , Anal Canal/surgery , Transanal Endoscopic Surgery , Anal Canal/injuries摘要
Abstract Objective Transanal hemorrhoidal artery ligation with mucopexy (ligation anopexy [LA]) and open hemorrhoidectomy (OH) can both be performed under local anesthesia. The aim of the present study was to analyze the impact and the cost-effectiveness of performing these techniques in an ambulatory setting of an Italian academic center on the postoperative outcome. Methods A series of 122 consecutive patients with grades II and III hemorrhoidal disease undergoing ambulatory surgical treatment of hemorrhoids in 2015 to 2018 (group A) was comparedwith 122 patients operated at the same institution in the same period (group H) in a hospital setting. The primary outcome was the number of days required to return to work/daily activities. Secondary outcomes included postoperative pain and complications, costeffectiveness, patient satisfaction, and recurrence at 12 months. In group A, all the procedures were performed under local anesthesia with early discharge. In group H, the procedureswere performed under general or loco-regional anesthesia with hospital admission. Results The mean number of days required to return to work/daily activities was 8.4 ± 4.8 days in group A, compared with 12.5 ± 3 days in group H (p<0.001). The visual analog scale (VAS) pain score at 1 week, 2 and 3 weeks, and 1 month after surgery was lower for patients undergoing LA in the ambulatory setting (p<0.01). We observedmore postoperative complications in hospitalized (12.5%) than in ambulatory patients (7.5%) (p<0.001). The total mean direct costs per patient were significantly lower in the ambulatory setting versus the hospital stay group (351.3 versus 1,746 euros). Conclusion Implementing ambulatory surgery for hemorrhoids is feasible, safe, and cost-effective.
Resumo Objetivo A ligação transanal da artéria hemorroidária com mucopexia e a hemorroidectomia aberta (HA) podem ser realizadas em anestesia local. O objetivo do presente estudo foi analisar o impacto no resultado pós-operatório e a relação custo-eficácia da realização destas técnicas em ambiente ambulatorial de um centro acadêmico italiano no desfecho pós-operatório. Métodos Uma série de 122 pacientes consecutivos com patologia hemorroidária de graus II e III submetidos a cirurgia de hemorroidas em regime ambulatório de 2015 a 2018 (grupo A) foi comparada com 122 pacientes operados na mesma instituição no mesmo período (grupo H) por hospitalização. O desfecho primário foi o número de dias necessários para regressar ao trabalho/atividades diárias. Os desfechos secundários incluíram dor e complicações pós-operatórias, custo-eficácia, satisfação do paciente, e recidiva aos 12 meses. No grupo A, todos os procedimentos foram realizados em anestesia local. No grupo H, os procedimentos foram realizados em anestesia geral ou loco-regional. Resultados A espera média para o regresso ao trabalho foi de 8,4 ± 4,8 dias no grupo A em comparação com 12,5 ± 3 dias no grupo H (p<0,001). A pontuação na escala visual analógica (EVA) da dor 1 semana, 2 e 3 semanas, e 1 mês após a cirurgia foi mais baixa para os pacientes submetidos a cirurgia de ligadura com anopexia em ambiente ambulatorial (p<0,01). Observamosmais complicações pós-operatórias empacientes hospitalizados (12,5%) do que em pacientes ambulatórios (7,5%) (p<0,001). Os custos diretosmédios totais por paciente foram mais baixos em ambiente ambulatório do que no grupo de hospitalização (351,3 contra 1.746 euros). Conclusão A implementação da cirurgia ambulatória para hemorroidas é possível, segura e rentável.
Subject(s)
Humans , Male , Female , Adult , Hospital Charges/statistics & numerical data , Costs and Cost Analysis , Hemorrhoidectomy/methods , Transanal Endoscopic Surgery/economics , Treatment Outcome , Hemorrhoids/economics摘要
In recent years, transanal total mesorectal excision (taTME) has been a hot spot in the field of colorectal surgery. Compared with the traditional laparoscopic technique, taTME has potential advantages in the treatment of rectal diseases. However, the procedural safety and effectiveness of taTME need further verification. In order to ensure the safe and standardized implementation of this procedure, the European Society of Coloproctology, together with 14 international academic organizations related to colorectal surgery and minimally invasive surgery, has developed the international expert consensus guidance on indications, implementation and quality measures for taTME. This paper introduces the background of the international consensus guidance, and interprets its core contents, including the surgical indications (complex pelvic conditions, malignant and benign rectal diseases), surgical quality and outcome evaluation, structured training, and expert center. It is expected to provide reference and guidance for Chinese colorectal surgery colleagues performing taTME.
Subject(s)
Humans , Consensus , Laparoscopy , Quality Indicators, Health Care , Rectal Neoplasms/surgery , Rectum/surgery , Transanal Endoscopic Surgery摘要
The difficulty of transanal total mesorectal excision (TME) is to find the correct dissection plane of perirectal space. As a complex new surgical procedure, the fascial anatomic landmarks of transanal approach operation are more likely to be ignored. It is often found that dissection plane is false after the secondary injury occurs during the operation, which results in the damage of pelvic autonomic nerves. Meanwhile, the mesorectum is easily damaged if the dissection plane is too close to the rectum. Thus, the safety of oncologic outcomes could be limited by difficulty achieving adequate TME quality. The promotion and development of the theory of perirectal fascial anatomy provides a new thought for researchers to design a precise approach for transanal endoscopic surgery. Transanal total mesorectal excision based on fascial anatomy offers a solution to identify the transanal anatomic landmarks precisely and achieves pelvic autonomic nerve preservation. In this paper, the authors focus on the surgical experience of transanal total mesorectal excision based on the theory of perirectal fascial anatomy, and discuss the feature of perirectal fascial anatomy dissection and technique of pelvic autonomic nerve preservation during transanal approach operation.
Subject(s)
Humans , Autonomic Pathways/surgery , Proctectomy , Rectal Neoplasms/surgery , Rectum/surgery , Transanal Endoscopic Surgery摘要
Transanal total mesorectal excision (taTME) is one of the hotspots in colorectal surgery in recent years. Although most studies confirm that taTME is safe and feasible, some studies still showed that the morbidity of complication and local recurrence rate of taTME were higher than traditional laparoscopic surgery. This article reviews and analyzes the short-term and long-term outcomes of taTME and the related progress of postoperative function. The results showed that there were no significant differences in the main short-term and long-term efficacy between taTME and traditional laparoscopic TME, but taTME had potential advantages in postoperative functional recovery. The results of case study after passing the learning curve suggested that taTME had better short-term and long-term efficacy. Moreover, with the maturity of taTME technology, transanal endoscopic surgery has gradually shown its advantages in the treatment of complex pelvic diseases. In the future, the application of single-port robot will further promote the development of natural orifice transluminal endoscopic colorectal surgery.
Subject(s)
Humans , Neoplasm Recurrence, Local , Proctectomy , Rectal Neoplasms/surgery , Rectum/surgery , Transanal Endoscopic Surgery摘要
As a novel surgical technique, taTME has developed rapidly in recent years. TaTME inevitably attracts some skepticism on safety, efficacy, and indication. First, the controversies over taTME are mainly reflected on the safety and effectiveness of taTME. On one hand, the increase of surgical complications, such as urethral injury, CO2 embolism, anastomotic leakage and pelvic infection, has raised concerns about the safety of taTME. Second, the poor quality of taTME specimens, the increased local recurrence rate and the impaired anal function after taTME, also make people question the effectiveness of taTME. Third, there are more or less controversies in the selection of taTME cases, surgical procedures and cost-effectiveness. However, it can not be denied that taTME has a promising future in view of both surgical theory and clinical practice. Furthermore, taTME is a relatively safe and effective supplementary surgical procedure, especially for patients with low rectal cancer. We should attach more importance to structured training for beginners and conduct high-quality clinical studies in the future development of taTME in China, so as to ensure the safe implementation of taTME and obtain high-level evidence-based medicine evidence, and then standardize the clinical practice of taTME.
Subject(s)
Humans , Neoplasm Recurrence, Local , Proctectomy , Rectal Neoplasms/surgery , Rectum/surgery , Transanal Endoscopic Surgery摘要
ABSTRACT Introduction: Robotic transanal surgery (RTS) is the analog of TAMIS and represents a new focus for the advancement of transanal platforms robotic transanal surgery is sometimes referred to as robotic TAMIS. Though limited to only a few centers world-wide, experience with robotic transanal surgery has been encouraging. Most research with robotic transanal surgery has concentrated on local excision of rectal neoplasia, although more complex procedures such as transanal proctectomy are possible using the robotic approach. This article reports the surgical technique of R-TAMIS performed in the Brazilian National Cancer Institute (INCA, Rio de Janeiro). Methods: 71-year-old, female with cardiologic disease (heart failure), with a 1.5 cm rectal neoplasm at 4 cm from the anal verge in the right anterolateral position. Biopsy revealed neuroendocrine tumor. A compete colonoscopy revealed no evidence of synchronous lesions. Work-up included 3D endorectal ultrasonography and magnetic resonance imaging, which demonstrated the lesion to be uT1uN0. The patient was counseled about surgical options − local excision versus low anterior resection. Due to the cardiologic condition, the patient was elected to proceed with local excision with robotic transanal surgery. Conclusion: Robotic TAMIS is a safe and effective operative procedure for high selected cases of rectal neoplasm. It enhances surgeon ergonomics and facilitates tumor removal and suture in the transanal approach.
RESUMO Introdução: A cirurgia transanal robótica (RTS,Robotic Transanal Surgery) é análoga da TAMIS (cirurgia minimamente invasiva transanal) e representa um novo foco para o avanço das plataformas transanais. A cirurgia transanal robótica é algumas vezes chamada de TAMIS robótica. Embora limitada a apenas alguns centros em todo o mundo, a experiência com a cirurgia transanal robótica tem sido encorajadora. A maioria das pesquisas com cirurgia transanal robótica tem se concentrado na excisão local da neoplasia retal, embora procedimentos mais complexos, como a proctectomia transanal, sejam possíveis utilizando a abordagem robótica. Este artigo relata a técnica cirúrgica de R-TAMIS realizada no Instituto Nacional do Câncer (INCA, Rio de Janeiro). Métodos: paciente de 71 anos, sexo feminino, com doença cardiológica (insuficiência cardíaca), com neoplasia retal de 1,5 cm a 4 cm da borda anal em posição anterolateral direita. A biópsia revelou tumor neuroendócrino. Uma colonoscopia completa não revelou evidências de lesões sincrônicas. A investigação incluiu ultrassonografia endorretal em 3D e ressonância magnética, que demonstrou que a lesão era uT1uN0. A paciente foi aconselhada sobre as opções cirúrgicas - excisão localversus ressecção anterior baixa. Devido à condição cardiológica, optou-se por proceder à excisão local com cirurgia transanal robótica. Conclusão: A TAMIS robótica é um procedimento cirúrgico seguro e eficaz para casos altamente selecionados de neoplasia retal. Ela melhora a ergonomia do cirurgião e facilita a remoção do tumor e a sutura na abordagem transanal.
Subject(s)
Humans , Female , Aged , Rectal Neoplasms/surgery , Carcinoma, Neuroendocrine/surgery , Robotic Surgical Procedures/methods , Transanal Endoscopic Surgery/methods摘要
Abstract Up to 80 % of the rectal injuries reported in US trauma centers occur secondary to firearm injuries. Rectal gunshot wounds are associated with significant morbidity and mortality. Diverse surgical approaches and techniques have been described; however, controversy persists regarding the best management for these complex injuries. Nowadays, no single approach has proven to provide optimal results when dealing with these injuries. We present a case of a young male that suffered a combined (intra-extraperitoneal) gun shot gun to the rectus and the use of a transanal platform to repair it.
Resumo Até 80 % das lesões retais relatadas nos centros de trauma dos EUA ocorrem secundariamente às lesões por armas de fogo. Ferimentos retais por arma de fogo estão associados a significativa morbimortalidade. Foram descritas diversas abordagens e técnicas cirúrgicas; no entanto, ainda há controvérsias quanto qual é o melhor tratamento para essas lesões complexas. Atualmente, nenhuma abordagem isolada provou ótimos resultados ao lidar com essas lesões. Apresentamos um caso de um jovem do sexo masculino que sofreu um ferimento de pistola combinada (intra-extraperitoneal) no reto e o uso de uma plataforma transanal para repará-la.