How to Learn a Complex Endoscopic Procedure: Knots in Transanal Endoscopic Surgery: Different Skill Among Surgeons.

PURPOSE: The intrarectal suture is considered a high technically complex procedure. The study's objectives were to assess the feasibility of making an intrarectal knot, through an in vitro study and assessing whether the video tutorial facilitates learning. MATERIALS AND METHODS: A detailed description of the technique. A comparative observational cross-sectional study in surgeons with no previous experience in intrarectal knots. RESULTS: Twenty-one of these 32 participants passed the intrarectal knot test without video tutorial (T1) (65.6%), and 26 (81.2%) after the video tutorial (T2) (P=0.26). The mean time taken to tie the knot fell from 74 seconds (SD=46) in T1 to 41 seconds (SD=41) in T2 (P<0.001). At T1, 26 participants (81.3%) described the technique as difficult, but only 7 (21.9%) at T2 (P<0.001). CONCLUSIONS: Performing the intrarectal knot suture is feasible. Despite the technical difficulty, the video tutorial is sufficient for surgeons to learn the technique.

T1 Rectal Adenocarcinoma: a Different Way to Measure Tumoral Invasion Based on the Healthy Residual Submucosa with Its Prognosis and Therapeutic Implications.

BACKGROUND: Surgical treatment of early rectal cancer T1 is either local excision or total mesorectal excision. The choice of surgery is based on the risk of metastatic lymph node involvement. The most important factor to consider is the degree of submucosal invasion. We present a different way to measure tumoral invasion derived from the measurement of the healthy residual submucosa with its prognosis and therapeutic implications METHODS: Observational study of tumor submucosal invasion in patients undergoing transanal endoscopic microsurgery was conducted. Parameters evaluated are submucosal invasion, measuring the healthy residual submucosa at the point of maximum invasion; macroscopic morphology of the tumor; presence of muscularis mucosa, muscularis propria, and measurement of submucosa in the tumor area and the healthy area. The classification proposed is compared with the ones previously published. RESULTS: Eighty consecutive patients diagnosed with T1 rectal cancer underwent transanal endoscopic microsurgery. Seventeen tumors (21.3%) were polypoid. En bloc resection was achieved in 77 (96.3%). The muscularis mucosa was present in 28 (35%), and the muscularis propria in 77 (96.3%) (p < 0.001). The healthy residual submucosa in the tumor area measured 2,343 ± 1,869 µm. Agreement was moderate with the Kikuchi classification (kappa 0.58) and very good with the Kudo classification (kappa 0.87). CONCLUSIONS: We describe a method for measuring submucosal invasion in T1 rectal cancer which does not depend on the morphology of the lesion or on the presence of the muscularis mucosa. It can be applied to all T1 classifications of the digestive tract in which the muscularis propria is present.

Transanal Endoscopic Microsurgery: An Alternative Perineal Approach to Treat Rectal Prolapse: A Video Vignette.

PURPOSE: Laparoscopic ventral rectopexy is the most favored surgical treatment for rectal prolapse. Perineal approaches are recommended for frail patients and those with major comorbidities, and in young men to avoid genitourinary disorders. There are very few descriptions in the literature of transanal endoscopic surgery to treat complete rectal prolapse. The aim of this article is to describe our experience with this technique. PATIENTS AND METHODS: Patients undergoing transanal endoscopic surgery for rectal prolapse repair between 2010 and 2019 were recruited for the study. Preoperative, surgical, and postoperative variables were recorded. Surgical technique, 30-day morbidity and follow-up are described. RESULTS: Five patients have been included. The postoperative period was uneventful and all patients were discharged in 48 hours without complications. All showed improved symptoms at 1-year control, and none presented recurrence in a mean follow-up period of 6 years. CONCLUSIONS: The transanal endoscopic procedure allows improved endoscopic vision, and the reconstruction is performed transpelvically by fixing the anastomosis suture to the pelvic wall to prevent recurrence. Therefore, we think it is a valid alternative to other perineal procedures in patients in whom abdominal surgery is contraindicated.

Minimal invasive surgery for left colectomy adapted to the COVID-19 pandemic: laparoscopic intracorporeal resection and anastomosis, a 'don't touch the bowel' technique.

AIM: The COVID-19 pandemic has forced surgeons to adapt their standard procedures. The modifications introduced are designed to favour minimally invasive surgery. The positive results obtained with intracorporeal resection and anastomosis in the right colon and rectum prompt us to adapt these procedures to the left colon. We describe a 'don't touch the bowel' technique and outline the benefits to patients of the use of less surgically aggressive techniques and also to surgeons in terms of the lower emission of aerosols that might transmit the COVID-19 infection. METHODS: This was an observational study of intracorporeal resection and anastomosis in left colectomy. We describe the technical details of intracorporeal resection, end-to-end stapled anastomosis and extraction of the specimen through mini-laparotomy in the ideal location. RESULTS: We present preliminary results of 17 patients with left-sided colonic pathologies, 15 neoplasia and two diverticular disease, who underwent four left hemicolectomies, six sigmoidectomies and seven high anterior resections. Median operating time was 186 min (range 120-280). No patient required conversion to extracorporeal laparoscopy or open surgery. Median hospital stay was 4.7 days (range 3-12 days). There was one case of anastomotic leak managed with conservative treatment. CONCLUSION: Intracorporeal resection and end-to-end anastomosis with the possibility of extraction of the specimen by a mini-laparotomy in the ideal location may present benefits and also adapts well to the conditions imposed by the COVID-19 pandemic. Future comparative studies are needed to demonstrate these benefits with respect to extracorporeal anastomosis.

Management of intra- and postoperative complications during TEM/TAMIS procedures: a systematic review.

INTRODUCTION: Transanal endoscopic microsurgery (TEM) is a safe procedure and the rates of intra- and postoperative complications are low. The information in the literature on the management of these complications is limited, and so their importance may be either under- or overestimated (which may in turn lead to under- or overtreatment). The present article reviews the most relevant series of TEM procedures and their complications and describes various approaches to their management. EVIDENCE ACQUISITION: A systematic review of the literature, including TEM series of more than 150 cases each. We analyzed the population characteristics, surgical variables and intraoperative and postoperative complications. EVIDENCE SYNTHESIS: A total of 1043 records were found. After review, 1031 were excluded. The review therefore includes 12 independent cohorts of TEM procedures with a total of 4395 patients. The rate of perforation into the peritoneal cavity was 5.1%, and conversion to abdominal approach was required in 0.8% of cases. The most frequent complications were acute urinary retention (AUR, 4.9%) and rectal bleeding (2.2%). Less common complications included abscesses (0.99%) and rectovaginal fistula (0.62%). Mortality rates were low, with a mean value of 0.29%. CONCLUSIONS: Awareness and knowledge of TEM complications and their management can play an important role in their treatment and patient safety. Here, we present a review of the most important TEM series and their complication rates and describe various approaches to their management.

Urinary catheter in colorectal surgery: current practices and improvements in order to allow prompt removal. A cross-sectional study.

BACKGROUND: Despite the publication of the guidelines for enhanced recovery after surgery (ERAS), attitudes to urinary catheter (UC) management vary widely in colorectal surgery. The aim of the present study was to define current practices in UC management in colorectal surgery. METHODS: Cross-sectional observational study carried out in March-April 2019, based on the responses to a survey administered to public hospitals in Catalonia. Respondents were asked about their observance of ERAS programs, the percentage of laparoscopic procedures performed, and the time of UC withdrawal in surgery of the colon and rectum. RESULTS: Forty-three of 45 hospitals contacted eventually responded (95.6%). As two hospitals reported that they did not perform colorectal surgery, the study is based on the results from 41 centers. Thirty-five (85.4%) reported following ERAS programs; 30 (73.2%) have coloproctology units, and 39 (95.1%) perform more than 70% of colorectal surgeries by laparoscopy. In colon surgery, 27 (65.9%) remove the UC at 24 h, and 12 (29.3%) on day 2 or day 3. In rectal surgery, 17 (58.6%) remove the UC on day 2-3. CONCLUSIONS: Management of UC in colon and rectal surgery varies widely. There is clearly room for improvement in UC management, but needs to be thoroughly assessed in randomized multicenter studies.