Prognostic factors for local recurrence in patients with rectal cancer submitted to neoadjuvant chemoradiotherapy and total mesorectal excision.

Prognostic factors for local recurrence in patients with rectal cancer submitted to neoadjuvant chemoradiotherapy and total mesorectal excision. BACKGROUND: The standard curative treatment for locally advanced rectal cancer of the middle and lower thirds is long-course chemoradiotherapy followed by total mesorectal excision. PURPOSE: To evaluate the prognostic factors associated with local recurrence in patients with rectal cancer submitted to neoadjuvant chemoradiotherapy and total mesorectal excision. METHODS: Retrospective study including patients with rectal cancer T3-4N0M0 or T (any)N + M0 located within 10 cm from the anal border, or patients with T2N0M0 located within 5 cm, treated by long course chemoradiotherapy followed by total mesorectal excision with curative intent. Clinical, demographic, radiologic, surgical, and anatomopathological data were collected. Local recurrence was estimated using the Kaplan-Meier function, and risk was estimated according to each characteristic using univariate and multivariate analyses. RESULTS: 270 patients were included, 57.8% male and mean age 61.7 (30‒88) years. At initial staging, 6.7% of patients were stage I, 21.5% stage II, and 71.8% stage III. Open surgery was performed in 65.2%, with sphincter preservation in 78.1%. Mortality within 30 postoperative days was 0.7%. After 49.4 (0.5‒86.1) months of median follow-up, overall and local recurrences were 26.3% and 5.9%. On multivariate analyses, local recurrence was associated with involvement of the mesorectal fascia on restaging MRI (HR = 9.11, p = 0.001) and with pathologic involvement of radial surgical margin (HR = 8.19, p < 0.001). CONCLUSION: Local recurrence of rectal cancer treated with long-course chemoradiation and total mesorectal excision is low and is associated with pathologic involvement of the radial surgical margin and can be predicted on restaging MRI.

Prognostic factors for local recurrence in patients with rectal cancer submitted to neoadjuvant chemoradiotherapy and total mesorectal excision

Abstract Prognostic factors for local recurrence in patients with rectal cancer submitted to neoadjuvant chemoradiotherapy and total mesorectal excision. Background: The standard curative treatment for locally advanced rectal cancer of the middle and lower thirds is long-course chemoradiotherapy followed by total mesorectal excision. Purpose: To evaluate the prognostic factors associated with local recurrence in patients with rectal cancer submitted to neoadjuvant chemoradiotherapy and total mesorectal excision. Methods: Retrospective study including patients with rectal cancer T3-4N0M0 or T (any)N + M0 located within 10 cm from the anal border, or patients with T2N0M0 located within 5 cm, treated by long course chemoradio-therapy followed by total mesorectal excision with curative intent. Clinical, demographic, radiologic, surgical, and anatomopathological data were collected. Local recurrence was estimated using the Kaplan-Meier function, and risk was estimated according to each characteristic using univariate and multivariate analyses. Results: 270 patients were included, 57.8% male and mean age 61.7 (30‒88) years. At initial staging, 6.7% of patients were stage I, 21.5% stage II, and 71.8% stage III. Open surgery was performed in 65.2%, with sphincter preservation in 78.1%. Mortality within 30 postoperative days was 0.7%. After 49.4 (0.5‒86.1) months of median follow-up, overall and local recurrences were 26.3% and 5.9%. On multivariate analyses, local recurrence was associated with involvement of the mesorectal fascia on restaging MRI (HR = 9.11, p = 0.001) and with pathologic involvement of radial surgical margin (HR = 8.19, p < 0.001). Conclusion: Local recurrence of rectal cancer treated with long-course chemoradiation and total mesorectal excision is low and is associated with pathologic involvement of the radial surgical margin and can be predicted on restaging MRI.

Câncer de reto: qual a melhor técnica para excisão total do mesorreto laparoscópica ou robótica? / Rectum cancer: which is the best technique for total excision of the mesorectum laparoscopic or robotic?

Introdução: As operações laparoscópicas, assistidas por robô e a abertas são técnicas cirúrgicas comumente utilizadas na vida diária. A viabilidade e os resultados em curto e longo prazos dos procedimentos laparoscópicos e robóticos têm sido amplamente relatados. Objetivos: Comparar os dados clínicos e oncológicos da cirurgia assistida por robô e laparoscópica no câncer retal. Métodos: Foram pesquisados o Pubmed/Medline, Embase, e Cochrane Library para artigos relevantes publicados até 2021. Estudos baseados na comparabilidade entre operação assistida por robô e laparoscópica para câncer retal foram designados. Os parâmetros analisados incluíram tempo operatório, conversão para procedimento aberto, perda estimada de sangue, tempo de recuperação da função intestinal, tempo de internação, vazamento da anastomose e complicações pós-operatórias. Resultados: Operação assistida por robô foi associada com maior tempo operatório (342 vs.192 min na cirurgia laparoscópica, p<0,001), menor conversão para procedimento aberto, menor tempo de internação hospitalar e recuperação mais rápida da função intestinal, menores complicações pós-operatórias de forma significativa (p=0,041). A perda estimada de sangue, a taxa de vazamento da anastomose e os resultados oncológicos, incluindo o número de linfonodos extraídos, não mostraram diferenças significativas entre os grupos. Conclusão: A cirurgia assistida por robô para câncer retal mostrou maior tempo operatório, menor conversão, taxas de recuperação da função intestinal mais rápidas e menor permanência no hospital. Seus resultados oncológicos forram semelhantes à cirurgia laparoscópica.

Introduction: Laparoscopic surgery, robot-assisted surgery and open surgery are the most commonly used surgical techniques in daily living. The feasibility and short- and long-term results of laparoscopic and robotic procedures have been widely reported. Objectives: To compare the clinical and oncological results of robot-assisted and laparoscopic surgery for rectal cancer. Methods: PubMed/Medline, Embase, The Cochrane Library were searched for relevant articles published until 2021. Studies based on comparability between robot-assisted and laparoscopic surgery for rectal cancer were designed. The parameters analyzed included operative time, conversion to open surgery, estimated blood loss, bowel function recovery time, length of hospital stay, anastomosis leak, and postoperative complications. Results: The robot-assisted surgery group was associated with longer operative time (342 vs. 192 min in laparoscopic surgery,p <0.001), lower conversion to open surgery, shorter length of hospital stay, faster bowel function recovery and lower postoperative complications significantly (p=0.041). Estimated blood loss, anastomosis leak rate, and oncological outcomes including the number of lymph nodes extracted showed no significant differences between groups. Conclusion: Robot-assisted surgery for rectal cancer showed longer operative time, lower conversion, faster bowel function recovery rates, shorter hospital stay, and similar oncological outcomes compared to laparoscopic surgery.

Primer caso de escisión mesorrectal total transanal (TaTME) para el tratamiento del cáncer de recto medio en un centro docente universitario: descripción de la técnica / First case of transanal total mesorectal excision (TaTME) for middle rectal cancer in a teaching tertiary center: technical aspects / Primeiro caso de excisão total do mesorreto transanal (TaTME) para tratamento de câncer de reto meio em um centro universitário de ensino: aspectos tecnicos

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 ​​à 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.

Scarless two-stage delayed coloanal anastomosis: a technique description

Introduction: In current clinical practice, immediate coloanal anastomosis (ICA) remains the standard technique for restoring the gastrointestinal tract following coloproctectomy for low rectal cancer. This anastomosis still requires a temporary diverting stoma to decrease the postoperative morbidity, which remains significantly high. As an alternative, some authors have proposed a two-stage delayed coloanal anastomosis (TS-DCA). This article reports on the surgical technique of TS-DCA. Methods: The case described is of a 53-year-old woman, without any particular history, in whom colonoscopy motivated by rectal bleeding revealed an adenocarcinoma of the low rectum. Magnetic resonance imaging showed a tumor ~ 1 cm above the puborectalis muscle, graded cT3N +. The extension workup was negative. Seven weeks after chemoradiotherapy, a coloproctectomy with total mesorectal excision (TME) was performed. A TS-DCA was chosen to restore the digestive tract. Conclusion: Two-stage delayed coloanal anastomosis is a safe and effective alternative for restoring the digestive tract after proctectomy for low rectal cancer. Recent data seem to show a clear advantage of this technique in terms of morbidity. (AU)

Exposure of the Middle Rectal Artery and Lateral Ligament of the Rectum Following the Gate Approach during Total Mesorectal Excision.

Controversial surgical anatomical landmarks in the deep pelvis can be visualized and identified using current technologies. Performing the gate approach technique during deep lateral dissection for total mesorectal excision facilitates visualization of the pelvic neurovascular structures following simple dissection steps to preserve the pelvic autonomic nerves and avoid accidental vascular injuries. Here, we discuss laparoscopic exposure of an infrequent disposition of the middle rectal artery anterior to the lateral ligament of the rectum while performing the gate approach.

Quality indicators of transanal total mesorectal excision (TaTME) for rectal cancer

Introduction: Transanal total mesorectal excision (TaTME) has revolutionized the surgical techniques for lower-third rectal cancer. The aim of the present study was to analyze the outcomes of quality indicators of TaTME for rectal cancer compared with laparoscopic TME (LaTME). Methods: A cohort prospective study with 50 (14 female and 36male) patients, with a mean age of 67 (range: 55.75 to 75.25) years, who underwent surgery for rectal cancer. In total, 20 patients underwent TaTME, and 30, LaTME. Every TaTME procedure was performed by experienced colorectal surgeons. The sample was divided into two groups (TaTME and LaTME), and the quality indicators of the surgery for rectal cancer were analyzed. Results: There were no statistically significant differences regarding the patients and the main characteristics of the tumor (age, gender, American Society of Anesthesiologists [ASA] score, body mass index [BMI], tumoral stage, neoadjuvant therapy, and distance from the tumor to the external anal margin) between the two groups. The rates of: postoperativemorbidity (TaTME: 35%; LaTME: 30%; p=0.763);mortality (0%); anastomotic leak (TaTME: 10%; LaTME: 13%; p=0.722); wound infection (TaTME: 0%; LaTME: 3.3%; p=0.409); reoperation (TaTME: 5%; LaTME: 6.6%; p=0.808); and readmission (TaTME: 5%; LaTME: 0%; p=0.400), as well as the length of the hospital stay (TaTME: 13.5 days; LaTME: 11 days; p=0.538), were similar in both groups. There were no statistically significant differences in the rates of positive circumferential resection margin (TaTME: 5%; LaTME: 3.3%; p=0.989) and positive distal resection margin (TaTME: 0%; LaTME: 3.3%; p=0.400), the completeness of the TME (TaTME: 100%; LaTME: 100%), and the number of lymph nodes harvested (TaTME: 15; LaTME: 15.5; p=0.882) between two groups. Conclusion: Transanal total mesorectal excision is a safe and feasible surgical procedure for middle/lower-third rectal cancer. (AU)

Electro-thermal bipolar vessel sealing versus clipping of the inferior mesenteric vessels during minimally invasive proctectomy.

INTRODUCTION: The introduction of new energy vessel sealing devices in minimally invasive proctectomy led to better hemostatic effect, less blood loss, and shorter operating time. At present, the available evidence from literature about the use of electro-thermal bipolar vessel sealers (EBVS) in laparoscopic rectal cancer surgery is weak where most studies are retrospective with non-homogenous patient groups. METHODS: This is a retrospective cohort study where 40 rectal cancer patients operated by laparoscopic TME or laparoscopic assisted transanal total mesorectal excision were classified in two groups according to approach of inferior mesenteric vessels ligation (EBVS versus Clipping). RESULTS: The operative time was significantly longer and the blood loss was significantly more in the EBVS group. However, hospital stay, time to oral, time to starting stoma function, and number of retrieved lymph nodes were not significantly affected by the method of vascular control. CONCLUSION: Both methods for control of vascular pedicle during minimally invasive rectal cancer surgery are safe, as such it is at the discretion of the operating surgeon to which method to use. Prospective well-designed trials are awaited to provide stronger evidence.

ANTECEDENTES: La introducción de nuevos dispositivos de sellado de vasos energéticos en la proctectomía mínimamente invasiva condujo a un mejor efecto hemostático, una menor pérdida de sangre y un tiempo de operación más corto. Actualmente, la evidencia disponible en la literatura sobre el uso de EBVS (electro-thermal bipolar vessel sealers) en cirugía laparoscópica de cáncer rectal es débil, pues la mayoría de los estudios son retrospectivos con grupos de pacientes no homogéneos. MÉTODO: Estudio de cohorte retrospectivo con 40 pacientes con cáncer rectal operados por escisión mesorrectal total laparoscópica o asistida por laparoscopia, clasificados en dos grupos según el enfoque de la ligadura de los vasos mesentéricos inferiores (EBVS vs. recorte). RESULTADOS: El tiempo operatorio fue significativamente mayor y la pérdida de sangre fue significativamente mayor en el grupo EBVS. Sin embargo, el método de control vascular no afectó significativamente el tiempo de hospitalización, el tiempo hasta el inicio de la función del estoma ni el número de ganglios linfáticos recuperados. CONCLUSIÓN: Ambos métodos para el control del pedículo vascular durante la cirugía de cáncer rectal mínimamente invasiva son seguros, por lo que queda a discreción del cirujano el método a utilizar. Se esperan ensayos prospectivos bien diseñados para proporcionar pruebas más sólidas.

TransAnal Total Mesorectal Excision (TaTME) in Peru: Case series.

INTRODUCTION: Describe and demonstrate the feasibility and safety of TaTME in short term outcomes in the Instituto Nacional de Enfermedades Neoplásicas (INEN) in Peru. MATERIALS AND METHODS: Case series with retrospective and prospective data collection of patients with middle and inferior rectal cancer who underwent TaTME between January 2015 and March 2020. Patients and tumor characteristics, operative details, postoperative complications and pathological results were analyzed. RESULTS: Nineteen patients were included. The median age was 56 years old (range 40-69). Ten were female. The median distance from the anal verge was 4 cm (range 3-6) and 17 cases were located in the inferior rectum. Eleven patients with clinical stage III. Thirteen (68.4%) patients received neoadjuvant treatment. There was no conversion to open surgery reported. Ten (52.6%) cases had intersphincteric resection and 18 (94.7%) had primary coloanal anastomosis, 13 (72.2%) of them with hand-sewn. All patients had a diversion with ileostomy. The median operative time was 330 min (range 270-480). Median postoperative hospital stay of 5 days (range 3-18). The overall rate of postoperative complication was 21.1%, two cases (10.5%) had anastomotic leakage and mortality was present in one (5.3%) patient. 94.5% had an optimal TME specimen, only one case (5.3%) had positive circumferential resection margin and positive distal margin. The median tumor size in the specimen was 4 cm (range 2-11) and nine (47.4%) patients had ypT3 on pathology. CONCLUSION: TaTME is a safe and feasible technique with good pathological results.

Using taTME to maintain restorative options in locally advanced rectal cancer: A technical note.

BACKGROUND: The safe adoption of transanal total mesorectal excision (taTME) has occurred in Australasia as previously reported by the current authors. Planes beyond TME can be utilised in more advanced cases to achieve negative margins during transanal dissection. METHODS: In this article we describe how taTME is used to perform an en-bloc partial vaginectomy and aid restore intestinal and vaginal continuity in a young female with a locally advanced rectal cancer and posterior vaginal wall involvement in the pre-treatment magnetic resonance imaging. RESULTS: The transanal technique allowed the surgeons to remove a disc of vagina, ensure organ preservation and control the main R1 risk point. An R0 resection was achieved. CONCLUSION: This technical note highlights that in experienced hands, taTME may be safely implemented to maintain restorative options in locally advanced rectal cancer requiring resection beyond the total mesorectal excision plane.

Tansanal total mesorectal excision (TaTME): systematization and mediated results in 10 patients / Excisão total do mesorreto por via transanal (TaTME): sistematização e resultados mediatos em dez pacientes

Abstract Background: Transanal total mesorectal excision is a surgical technique for minimally invasive resection of the rectum and perirectal tissues. It is indicated for patients with medial and distal rectum cancer confined to the mesorectal envelope. This study describes a series of patients undergoing transanal total mesorectal excision. Methods: Ten patients were selected to undergo transanal total mesorectal excision using the SILS-Port® platform. All patients included here had middle or low rectal cancer. Abdominal access for proximal colon mobilization was performed by laparoscopy in all cases. As a rule, in 9 of the 10 cases, the surgical specimen was removed transanally. Result:s During a 41-month period, 10 patients underwent transanal total mesorectal excision based on curative intent. The first indication for transanal total mesorectum excision was medial and distal rectal cancer, locally invasive and confined to the mesortal envelope. The median age of patients with rectal cancer at the time of surgery was 61 years (mean 59.4 years, range 22-78 years), with 80% (8) female and 20% (2) male. The median surgical time was 305' (mean 314', range 260-420'). The median postoperative length of stay was five days (average of 7.3 days, interval of 3-23 days). There was no postoperative mortality. Surgical complications included postoperative ileus (n = 1), bladder paresis (n = 1), and ileostomy stenosis (n = 1). All patients had negative surgical margins for neoplasia and more than 12 resected lymph nodes. The tumors were between 1 and 9 cm from the anal margin. Conclusion: Total transanal mesorectal excision has been shown to be a viable method for oncologic resection of locally advanced rectal cancer with curative intent.

Resumo Contexto: A excisão total do mesorreto por via transanal é uma aborgadem crânio-caudal para a realização de ressecção minimamente invasiva do reto e tecidos perirretais em monobloco. É adequada para pacientes com câncer de reto médio e distal confinados ao envelope mesorretal. Aqui relatamos uma série de pacientes submetidos à excisão total do mesorreto por via transanal. Métodos: Dez pacientes foram selecionados para serem submetidos à excisão total do mesorreto por via transanal utilizando a plataforma SILS-Port®. Todos os pacientes eram portadores de câncer retal de localização extraperitoneal. O acesso abdominal para mobilização do cólon proximal, em todos os casos, foi realizado por laparoscopia. Como regra, a retirada do espécime cirúrgico, em nove casos, ocorreu por via transanal. Resultados: Durante um período de 41 meses, 10 pacientes foram submetidos à excisão total do mesorreto por via transanal com intenção curativa. A indicação primária para excisão total do mesorreto transanal foi o câncer de reto médio e distal, localmente invasor, mas confinado ao envelope mesorretal. A mediana de idade dos pacientes com câncer de reto no momento da cirurgia foi de 61 anos (média de 59,4 anos, faixa de 22-78 anos), sendo 80% (8) do sexo feminino e 20% (2) do sexo masculino. A mediana do tempo cirúrgico foi de 305' (média de 314', intervalo de 260-420'). A mediana do tempo de permanência pós-operatória foi de cinco dias (média de 7,3 dias, intervalo de 3-23 dias). Não houve mortalidade pós-operatória. As complicações cirúrgicas incluíram íleo paralítico (n = 1), paresia vesical (n = 1) e estenose de ileostomia (n = 1). Todos os pacientes tiveram margens cirúrgicas negativas para neoplasia e mais de 12 linfonodos ressecados. Os tumores distavam de 1 a 9 cm da margem anal. Conclusão: A excisão total do mesorreto transanal demonstrou-se um método viável para a ressecção oncológica de câncer de reto localmente avançado com intenção curativa.

Resección anterior del recto ultrabaja laparoscópica con anastomosis coloanal en cáncer del recto bajo / Laparoscopic Ultralow Anterior Rectal Resection with Coloanal Anastomosis in Low Rectum Cancer

RESUMEN Introducción: La resección anterior del recto ultrabaja laparoscópica con anastomosis coloanal evita la realización una colostomía definitiva. Objetivo: Determinar las indicaciones, describir la técnica quirúrgica y mostrar los resultados a largo plazo obtenidos en la realización de este proceder en el tratamiento del cáncer del recto bajo. Método: Se realizó un estudio observacional descriptivo y prospectivo de 53 pacientes con cáncer del recto bajo en el período comprendido entre octubre 2007 y noviembre 2018 en el Centro Nacional de Cirugía de Mínimo Acceso. Todas las resecciones fueron llevadas a cabo por un grupo dedicado a la cirugía colorrectal, en todos los casos se realizó la excisión total del mesorrecto. Resultados: Se operaron mediante esta técnica 53 pacientes, 30 masculinos y 23 femeninos con un promedio de edad de 57 años (rango 23-81) y de ellos 42 (79,2 por ciento) después de terapia neoadyuvante. El promedio de tiempo quirúrgico fue de 195 min (rango 90-360) y las pérdidas hemáticas estimadas, de 72 mL. La incidencia de morbilidad mayor fue de 16,9 por ciento (9/53) y la media de estadía hospitalaria de 6,3 días. La media del periodo de seguimiento fue de 40 meses (rango 1-132) con una recidiva local de 9,4 por ciento (5/53) y una supervivencia global a los 5 años de 80,3 por ciento. Conclusiones: La resección anterior del recto ultrabaja laparoscópica con anastomosis coloanal es una técnica segura con excelentes resultados en cuanto a recidiva local y supervivencia global(AU)

ABSTRACT Introduction: Laparoscopic ultralow anterior rectal resection with coloanal anastomosis prevents the performance of a definitive colostomy. Objective: To determine the indications, describe the surgical technique and show the long-term outcome of performing this procedure in the treatment of cancer of the lower rectum. Method: A descriptive and prospective observational study of 53 patients with low rectal cancer was carried out in the period between October 2007 and November 2018, at the National Center for Minimum Access Surgery. All resections were carried out by a group dedicated to colorectal surgery. In all cases, the total mesorectal excision was performed. Results: 53 patients (30 males and 23 females), with an average age of 57 years (range 23-81) and 42 (79.2 percent) after neoadjuvant therapy were operated using this technique. The average surgical time was 195 min (range 90-360) and the estimated blood loss was 72 mL. The incidence of major morbidity was 16.9 percent (9/53) and the average hospital stay was 6.3 days. The mean follow-up period was 40 months (range 1-132), with a local relapse of 9.4 percent (5/53) and a 5-year overall survival of 80.3 percent. Conclusions: Laparoscopic ultralow anterior resection of the rectum with coloanal anastomosis is a safe technique with excellent outcomes in terms of local relapse and overall survival(AU)

A combination treatment of transanal total mesorectal excision and Turnbull-Cutait abdominoperineal pull-through procedure for a low rectal cancer

ABSTRACT Surgical treatment for low rectal cancer has changed dramatically during the preceding several decades, and the optimal surgical approach remains incompletely developed. Transanal total mesorectal excision is likely the most promising approach for the dissection of the distal part of the mesorectum in a manner that allows for a technically easy and oncologically safe operation. Long after it was first described, the Turnbull-Cutait abdominoperineal pull-through procedure has recently been reintroduced in surgical practice for the treatment of patients with complex anorectal conditions. The current report describes a case of distal rectal cancer involving successful surgical treatment with a combination of the two aforementioned methods and patient discharge without a diverting stoma.

RESUMO tratamento cirúrgico para o câncer de reto baixo mudou drásticamente durante as últimas décadas, mas uma abordagem cirúrgica de excelência ainda continua incompletamente desenvolvida. A excisão total do mesorreto por via transanal parece ser a abordagem mais promissora para a dissecção da parte distal do mesorreto de forma a assegurar uma cirurgia oncológicamente segura com uma técnica simples. Muito depois de sua descrição, o pull-through abdominoperineal de Turnbull-Cutait tem sido reintroduzido na prática cirúrgica para o tratamento de pacientes com enfermidades anorretais complexas. Este relato descreve um caso de câncer de reto baixo que se beneficiou de um tratamento cirúrgico bem sucedido a partir da combinação das duas técnicas supracitadas com o paciente recebendo alta hospitalar sem ostomia de proteção.

Recent advances in the management of rectal cancer: No surgery, minimal surgery or minimally invasive surgery.

Over the last decade, with the acceptance of the need for improvements in the outcome of patients affected with rectal cancer, there has been a significant increase in the literature regarding treatment options available to patients affected by this disease. That treatment related decisions should be made at a high volume multidisciplinary tumor board, after pre-operative rectal magnetic resonance imaging and the importance of total mesorectal excision (TME) are accepted standard of care. More controversial is the emerging role for watchful waiting rather than radical surgery in complete pathologic responders, which may be appropriate in 20% of patients. Patients with early T1 rectal cancers and favorable pathologic features can be cured with local excision only, with transanal minimal invasive surgery (TAMIS) because of its versatility and almost universal availability of the necessary equipment and skillset in the average laparoscopic surgeon, emerging as the leading option. Recent trials have raised concerns about the oncologic outcomes of the standard "top-down" TME hence transanal TME (TaTME "bottom-up") approach has gained popularity as an alternative. The challenges are many, with a dearth of evidence of the oncologic superiority in the long-term for any given option. However, this review highlights recent advances in the role of chemoradiation only for complete pathologic responders, TAMIS for highly selected early rectal cancer patients and TaTME as options to improve cure rates whilst maintaining quality of life in these patients, while we await the results of further definitive trials being currently conducted.

Transcolonic Perirectal NOTES Access (PNA): A feasibility study with survival in swine model

ABSTRACT Transrectal access still has some unsolved issues such as spatial orientation, infection, access and site closure. This study presents a simple technique to perform transcolonic access with survival in a swine model series. A new technique for NOTES perirectal access to perform retroperitoneoscopy, peritoneoscopy, liver and lymphnode biopsies was performed in 6 pigs, using Totally NOTES technique. The specimens were extracted transanally. The flexible endoscope was inserted through a posterior transmural incision and the retrorectal space. Cultures of bacteria were documented for the retroperitoneal space and intra abdominal cavity after 14 days. Rectal site was closed using non-absorbable sutures. There was no bowel cleansing, nor preoperative fasting. The procedures were performed in 6 pigs through transcolonic natural orifice access using available endoscopic flexible instruments. All animals survived 14 days without complications, and cultures were negative. Histopathologic examination of the rectal closure site showed adequate healing of suture line and no micro abscesses. The results of feasibility and safety of experimental Transcolonic NOTES potentially brings new frontiers and future wider applications for minimally invasive surgery. The treatment of colorectal, abdominal and retroperitoneal diseases through a flexible Perirectal NOTES Access (PNA) is a promising new approach.

The circumferential resection margins status: A comparison of robotic, laparoscopic and open total mesorectal excision for mid and low rectal cancer.

INTRODUCTION: Minimally invasive surgery for rectal cancer (RC) is now widely performed via the laparoscopic approach, but robotic-assisted surgery may overcome some limitations of laparoscopy in RC treatment. We compared the rate of positive circumferential margins between robotic, laparoscopic and open total mesorectal excision (TME) for RC in our institution. METHODS: Mid and low rectal adenocarcinoma patients consecutively submitted to robotic surgery were compared to laparoscopic and open approach. From our prospective database, 59 patients underwent robotic-assisted rectal surgery from 2012 to 2015 (RTME group) were compared to our historical control group comprising 200 open TME (OTME group) and 41 laparoscopic TME (LTME group) approaches from July 2008 to February 2012. Primary endpoint was to compare the rate of involved circumferential resection margins (CRM) and the mean CRM between the three groups. Secondary endpoint was to compare the mean number of resected lymph nodes between the three groups. RESULTS: CRM involvement was demonstrated in 20 patients (15.5%) in OTME, 4 (16%) in LTME and 9 (16.4%) in the RTME (p = 0.988). The mean CRM in OTME, LTME and RTME were respectively 0.6 cm (0-2.7), 0.7 cm (0-2.0) and 0.6 cm (0-2.0) (p = 0.960). Overall mean LN harvest was 14 (0-56); 16 (0-52) in OTME, 13 (1-56) in LTME and 10 (0-45) in RTME (p = 0.156). CONCLUSION: Our results suggest that robotic TME has the same oncological short-term results when compared to the open and laparoscopic technique, and it could be safely offered for the treatment of mid and low rectal cancer.

The quest for precision in transanal total mesorectal excision.

Transanal total mesorectal excision (TME) is an emerging minimally invasive approach to rectal cancer, with encouraging preliminary results. However, the new surgical anatomy of the bottom-up approach complicates surgical understanding and increases the risks of inadvertent injuries to crucial anatomical structures, including nerves. Key elements to improve the safety and stimulate interest in such a complex technique might be robotics and image guidance, to enhance the level of precision. In this editorial, some of the technologies that could be used for precision TME are outlined, in light of the experience of our Institute for Image-Guided Surgery.

Mesorectal pathologic assessment in two grades predicts accurately recurrence, positive circumferential margin, and correlates with survival.

BACKGROUND AND OBJECTIVES: We aimed to determine the prognostic value of the mesorectum quality assessed in a two-grade system compared with a classic system. METHODS: Consecutive patients undergoing surgery for rectal cancer were included (n = 103). Mesorectum was assessed into three grades (classic system: complete, nearly complete, incomplete) and compared with a two-grade system (adequate, inadequate). RESULTS: Mesorectum was complete in 62 (60.25%) patients, nearly complete in 21, and incomplete in 20. Reassessment showed adequate mesorectum in 83 (80.5%) patients and inadequate in 20. A R0 resection was achieved in 90.4% of adequate mesorectum and in 65% of inadequate mesorectum (P = 0.006). Recurrence was present in 18% of adequate mesorectum patients as compared with 50% of inadequate mesorectum (P = 0.003). The classic system failed to accurately predict the 5-year survival rate between complete (78.9%) and nearly complete (86.2%) categories (P = 0.235); whereas a two grading system showed a 5-year survival rate of 80.8% for adequate versus 39.3% for inadequate (P = 0.034). CONCLUSION: High recurrence occurred in inadecuate mesorectum patients and was correlated with R1/R2 resections, positive margins, and decreased survival. We propose a simplified classification of mesorectum that correlates with survival and overall recurrence.

[Laparoscopic versus open surgery for colorectal cancer. A comparative study]. / Estudio comparativo entre cirugía laparoscópica y cirugía abierta en cáncer colorrectal.

BACKGROUND: Laparoscopic surgery for colorectal cancer is currently accepted and widespread worldwide. However, according tol the surgical experience on this approach, surgical and short-term oncologic results may vary. Studies comparing laparoscopic vs. open surgery in our population are scarce. OBJECTIVE: To determine the superiority of the laparoscopic vs. open technique for colorectal cancer surgery. METHODS: This retrospective and comparative study collected data from patients operated on for colorectal cancer between 1999 and 2011 at the Angeles Lomas Hospital, Mexico. RESULTS: A total of 82 patients were included in this study; 47 were operated through an open approach and 35 laparoscopically. Mean operative time was significantly lower in the open approach group (p= 0.008). There were no significant difference between both techniques for intraoperative bleeding (p= 0.3980), number of lymph nodes (p= 0.27), time to initiate oral feeding (p= 0.31), hospital stay (p= 0.12), and postoperative pain (p= 0.19). Procedure-related complications rate and type were not significantly different in both groups (p= 0.44). Patients operated laparoscopically required significantly less analgesic drugs (p= 0.04) and less need for epidural postoperative analgesia (p= 0.01). CONCLUSIONS: Laparoscopic approach is as safe as the traditional open approach for colorectal cancer. Early oncological and surgical results confirm its suitability according to this indication.

Antecedentes: la cirugía laparoscópica para tratar pacientes con cáncer colorrectal ha sido ampliamente aceptada y difundida en todo el mundo. Sin embargo, dependiendo de la experiencia en este abordaje los resultados quirúrgicos y oncológicos a corto plazo pueden variar. En nuestra población existen pocos estudios que comparan los resultados de esta técnica con los de la cirugía abierta. Objetivos: determinar la superioridad de la técnica laparoscópica o abierta en cirugía de cáncer colorrectal. Material y métodos: estudio retrospectivo y comparativo de pacientes operados con técnica abierta o laparoscópica por cáncer de colon y recto entre 1999 y 2011 en nuestro centro. Resultados: se incluyeron 47 pacientes intervenidos de manera convencional y 35 por laparoscopia. El tiempo operatorio fue menor en el grupo de cirugía abierta (p= 0.008). No se encontraron diferencias en: sangrado intraoperatorio (p= 0.3980), número de ganglios resecados (p= 0.27), inicio de la vía oral (p= 0.31), tiempo de estancia hospitalaria (p= 0.12), y dolor referido por el paciente (p= 0.19). En el grupo de cirugía laparoscópica se requirieron menos dosis de analgésicos (p= 0.04) y menor necesidad de catéter epidural para analgesia postoperatoria (p= 0.01). Las tasas de morbilidad (p= 0.44) y mortalidad (p= 0.39) fueron similares en ambos grupos. Conclusiones: la cirugía laparoscópica es equiparable a la técnica abierta en cuanto a estándares oncológicos y resultados técnicos. Este trabajo demuestra que en nuestro hospital la cirugía laparoscópica en pacientes con cáncer de colon y recto es tan segura como la cirugía abierta.

"Down-to-Up" transanal NOTES Total mesorectal excision for rectal cancer: Preliminary series of 9 patients.

BACKGROUND: Applications for natural orifice translumenal endoscopic surgery (NOTES) to access the abdominal cavity have increased in recent years. Despite potential advantages of transanal and transcolonic NOTES for colorectal pathology, it has not been widely applied in the clinical setting. This study describes a series of nine patients for whom we performed transanal retrograde ("Down-to-Up") total mesorectal excision for rectal cancer. MATERIALS AND METHODS: Under IRB approval, informed consent was obtained from each patient with rectal adenocarcinoma. Rectosigmoidectomy with total mesorectal excision was performed using low rectal translumenal access to the mesorectal fascia and subsequent dissection in a retrograde fashion. This was achieved using either a single port device or flexible colonoscope with endoscopic instrumentation and laparoscopic assistance. This was followed by transanal extraction of the specimen and hand-sewn anastomosis. RESULTS: Mean operative time was 311 min. Mean hospital stay was 7.56 days. Complications occurred in two patients, and consisted of one anastomotic leakage with reoperation and one intraoperative conversion to open surgery because of impossibility to dissect the specimen. TME specimen integrity was adequate in six patients. CONCLUSION: This series suggests that a retrograde mesorectal dissection via a NOTES technique is feasible in patients with rectal adenocarcinoma. This technique may act as a complimentary part of operative treatment for rectal cancer alongside other minimally invasive strategies. Long-term follow up will be needed to assess oncological results.