Oncological Outcomes of Transanal Endoscopic Surgery for the Surgical Management of T2 and T3 Rectal Cancer.

BACKGROUND: Transanal endoscopic surgery is an organ-sparing treatment for early rectal cancer. Patients with advanced lesions are recommended for total mesorectal excision. However, some patients have prohibitive comorbidities or refuse major surgery. OBJECTIVE: To assess the cancer outcomes of patients with T2 or T3 rectal cancers who received transanal endoscopic surgery as their sole surgical treatment. DESIGN: This study used a prospectively maintained database. SETTING: A tertiary hospital in Canada. PATIENTS: Patients who underwent transanal endoscopic surgery for pathology-confirmed T2 or T3 rectal adenocarcinomas from 2007-2020 were included. MAIN OUTCOME MEASURES: Disease-free survival and overall survival, stratified by tumor stage and reason for transanal endoscopic surgery. RESULTS: Among the included 132 patients (T2, n = 96; T3, n = 36), average follow-up was 22 months. Twenty-eight decline oncologic resection, whereas 104 had preclusive comorbidities. Fifteen patients (11.4%) had disease recurrence (4 local, 11 metastatic). Three-year disease-free survival was 86.5% (95% CI, 77.1-95.9) for T2 and 67.9% (95% CI, 46.3-89.5) for T3 tumors. Mean disease-free survival was longer for T2 (75.0 mo; 95% CI, 67.8-82.1) compared to T3 cancers (50 mo; 95% CI, 37.7-62.3; p = 0.037). Three-year disease-free survival for patients who declined radical excision was 84.0% (95% CI, 67.1-100) versus 80.7% (95% CI, 69.7-91.7) in patients too comorbid for surgery. Three-year overall survival rate was 84.9% (95% CI, 73.9-95.9) for T2 and 49.0% (95% CI, 26.7-71.3) for T3 tumors. Patients who declined radical resection had similar 3-year overall survival (89.7%; 95% CI, 76.2-100) compared to patients who were unable to undergo excision because of medical comorbidities (98.1%; 95% CI, 95.6-100). LIMITATIONS: Small sample, single institution, and surgeon experience. CONCLUSIONS: Oncologic outcomes are compromised in patients treated by transanal endoscopic surgery for T2 and T3 rectal cancer. Transanal endoscopic surgery remains an option for informed patients who prefer to avoid radical resection. See Video Abstract at http://links.lww.com/DCR/C200 . RESULTADOS ONCOLGICOS DE LA CIRUGA ENDOSCPICA TRANSANAL PARA EL MANEJO QUIRRGICO DEL CNCER DE RECTO T Y T: ANTECEDENTES:La cirugía endoscópica transanal es un tratamiento de conservación de órganos para el cáncer de recto en estadio temprano. A los pacisentes con lesiones avanzadas se les recomienda la escisión total del mesorrecto. Sin embargo, algunos pacientes tienen comorbilidades prohibitivas o rechazan una cirugía mayor.OBJETIVO:Evaluar los resultados del cáncer de pacientes con cáncer de recto T2 o T3 que recibieron cirugía endoscópica transanal como único tratamiento quirúrgico.DISEÑO:Este estudio utilizó una base de datos mantenida prospectivamente.ENTORNO CLINICO:Un hospital terciario en CanadáPACIENTES:Aquellos que se sometieron a cirugía endoscópica transanal por adenocarcinomas rectales T2 o T3 confirmados por patología de 2007-2020. Se excluyeron los pacientes cuya cirugía se realizó por recurrencia del cáncer o posteriormente fueron sometidos a resección radical.PRINCIPALES MEDIDAS DE VALORACIÓN:Supervivencia libre de enfermedad y supervivencia global, estratificada por estadio del tumor y motivo de la cirugía endoscópica transanal.RESULTADOS:Se incluyeron 132 pacientes (T2, n = 96; T3, n = 36). El seguimiento medio fue de 22 meses (DE ± 23,4). 104 pacientes tenían comorbilidades significativas, mientras que 28 rechazaron la resección oncológica. Quince pacientes (11,4%) tuvieron recurrencia de la enfermedad (4 locales, 11 metastásicos). La supervivencia libre de enfermedad a los tres años para los tumores T2 fue del 86,5 % (IC del 95%: 77,1-95,9) y del 67,9% (IC del 95%: 46,3-89,5) para los tumores T3. La supervivencia libre de enfermedad media fue más prolongada para los cánceres T2 (75,0 meses, IC del 95%: 67,8 a 82,1) en comparación con los cánceres T3 (50 meses, IC del 95%: 37,7 a 62,3, p = 0,037). La supervivencia sin enfermedad a los tres años para los pacientes que rechazaron la escisión mesorrectal total fue del 84,0% (IC del 95%: 67,1-100), mientras que los pacientes con demasiada comorbilidad médica para la cirugía tuvieron una supervivencia sin enfermedad a los tres años del 80,7% (IC del 95%: 69.7-91.7). La supervivencia general a los tres años fue del 84,9% (IC del 95%: 73,9 a 95,9) para los tumores T2 y del 49,0% (IC del 95%: 26,7 a 71,3) para los tumores T3. Los pacientes que rechazaron la resección radical tuvieron una supervivencia general similar a los tres años (89,7%, IC del 95%: 76,2-100), en comparación con los pacientes que no pudieron someterse a una escisión mesorrectal total debido a comorbilidades médicas (98,1%, IC del 95%: 95,6-100).LIMITACIONES:Muestra pequeña, institución única, experiencia del cirujano.CONCLUSIONES:Los resultados oncológicos están comprometidos en pacientes tratados con cirugía endoscópica transanal por cáncer de recto T2 y T3. Sin embargo, la cirugía endoscópica transanal sigue siendo una opción para pacientes informados que prefieren evitar la resección radical. Consulte Video Resumen en http://links.lww.com/DCR/C200 . (Traducción-Dr. Ingrid Melo ).

Quality indicators for operative reporting in transanal endoscopic surgery.

Transanal endoscopic surgery (TES) platforms have become quite popular. Many surgeons across the country have begun excising rectal lesions using these platforms; however, the perioperative decision-making surrounding these excisions can be quite variable. To facilitate care between providers, it would be helpful to standardize the way TES is reported. Synoptic operative reports have previously been established as an effective and efficient communication tool. For patients with rectal cancer, synoptic reports are required for pathology, radiology and major oncologic resections, but never previously for TES. We used a Delphi process including 15 stakeholders from across Canada to develop a TES synoptic report. Participants submitted items according to 6 categories: team characteristics, patient demographics, preoperative work-up, lesion characteristics, procedure details and postoperative details. Twenty-six surgeon-entered and 41 auto-populated items reached final inclusion. This will allow generation of a synoptic reporting template to improve perioperative communication for these patients.

Preoperative stoma site marking for fecal diversions (ileostomy and colostomy): position statement of the Canadian Society of Colon and Rectal Surgeons and Nurses Specialized in Wound, Ostomy and Continence Canada.

BACKGROUND: Every year, about 13 000 Canadians undergo an ostomy procedure, which requires stoma site marking to create a well-constructed stoma and prevent stoma-related complications. The Canadian Society of Colon and Rectal Surgeons (CSCRS) and Nurses Specialized in Wound, Ostomy and Continence Canada (NSWOCC) created a position statement to provide evidence-based guidance and techniques for stoma site selection. METHODS: A task force was formed comprising 20 health care professionals (7 colorectal surgeons from the CSCRS and 13 nurses from NSWOCC) with representation from across Canada. A literature review was performed, with the following databases searched from January 2009 to April 2019: MEDLINE, Embase, Cochrane, PubMed, CINAHL and Google Scholar. After the abstracts were screened, 6 task force members created a draft version of the position statement from the articles retained after full-text review. The draft was submitted to the entire task force for comments, and the ensuing modifications were incorporated. Peer reviewers were then recruited from the CSCRS and NSWOCC; a summary of their comments was reviewed by the task force, and modifications were incorporated to produce the final document. RESULTS: The literature search identified 272 papers, of which 58 were reviewed after duplicates were excluded. After full-text review, 18 papers were included to guide the position statement. From these papers, we created a series of 17 steps for stoma site marking. Four general principles were found to be important for stoma site marking: obtain informed consent, identify important patient factors and landmarks, assess the abdomen and mark the most appropriate location. A 1-page enabler document and video were created as teaching aids and to help with dissemination of the information. CONCLUSION: This position statement, associated enabler document and video provide evidence-based guidance for stoma site marking in both emergency and elective settings, and should be used by surgeons and nurses specialized in wound, ostomy and continence to identify optimal stoma sites preoperatively.

Effect of rater training on the reliability of technical skill assessments: a randomized controlled trial.

BACKGROUND: Rater training improves the reliability of observational assessment tools but has not been well studied for technical skills. This study assessed whether rater training could improve the reliability of technical skill assessment. METHODS: Academic and community surgeons in Royal College of Physicians and Surgeons of Canada surgical subspecialties were randomly allocated to either rater training (7-minute video incorporating frame-of-reference training elements) or no training. Participants then assessed trainees performing a suturing and knot-tying task using 3 assessment tools: a visual analogue scale, a task-specific checklist and a modified version of the Objective Structured Assessment of Technical Skill global rating scale (GRS). We measured interrater reliability (IRR) using intraclass correlation type 2. RESULTS: There were 24 surgeons in the training group and 23 in the no-training group. Mean assessment tool scores were not significantly different between the 2 groups. The training group had higher IRR than the no-training group on the visual analogue scale (0.71 v. 0.46), task-specific checklist (0.46 v. 0.33) and GRS (0.71 v. 0.61). However, confidence intervals were wide and overlapping for all 3 tools. CONCLUSION: For education purposes, the reliability of the visual analogue scale and GRS would be considered "good" for the training group but "moderate" for the no-training group. However, a significant difference in IRR was not shown, and reliability remained below the desired level of 0.8 for high-stakes testing. Training did not significantly improve assessment tool reliability. Although rater training may represent a way to improve reliability, further study is needed to determine effective training methods.

CONTEXTE: La formation des évaluateurs améliore la fiabilité des outils d'évaluation observationnels, mais n'a pas été rigoureusement étudiée au plan des habiletés techniques. Cette étude a tenté de vérifier si la formation des évaluateurs permettait d'améliorer la fiabilité de l'évaluation des habiletés techniques. MÉTHODES: On a assigné des chirurgiens universitaires et communautaires appartenant aux surspécialités chirurgicales du Collège royal des médecins et chirurgiens du Canada, soit à une formation des évaluateurs (vidéo de 7 minutes comprenant des éléments de formation afférents au cadre de référence), soit à l'absence de formation. les participants ont ensuite évalué des stagiaires qui effectuaient tâches, telles sutures et nœuds, à l'aide de trois outils d'évaluation : échelle analogique visuelle, liste de vérification spécifique à la tâche et version modifiée de l'échelle d'appréciation globale (ÉAG) de l'Objective Structured Assessment of Technical Skill. Nous avons mesuré la fiabilité interévaluateurs (FIÉ) à l'aide de la corrélation intraclasse de type 2. RÉSULTATS: Il y avait 24 chirurgiens dans le groupe soumis à la formation et 23 dans le groupe non soumis à la formation. Les scores moyens des outils d'évaluation n'ont pas été significativement différents entre les deux groupes. Le groupe soumis à la formation a présenté une FIÉ plus élevée que l'autre groupe à l'échelle analogique visuelle (0,71 c. 0,46), à la liste de vérification spécifique à la tâche (0,46 c. 0,33) et à l'ÉAG (0,71 c. 0,61). Par contre, les intervalles de confiance étaient larges et se recoupaient pour les trois outils. CONCLUSION: Aux fins de la formation, la fiabilité de l'échelle analogique visuelle et de l'ÉAG serait considérée «.bonne.¼ pour le groupe soumis à la formation, mais «.modérée.¼ pour le groupe non soumis à la formation. On n'a toutefois pas démontré de différence significative quant à la FIÉ et la fiabilité est demeurée inférieure au niveau souhaité de 0,8 pour les tests importants. La formation n'a pas significativement amélioré la fiabilité de l'outil d'évaluation. Même si la formation des évaluateurs représente potentiellement une façon d'améliorer la fiabilité, il faudra approfondir la recherche pour déterminer quelles méthodes de formation sont efficaces.

Synoptic Operative Reporting: Documentation of Quality of Care Data for Rectal Cancer Surgery.

Operative reports can be used to evaluate quality of care indicators in surgical patients. This study evaluated documentation of preoperative and intraoperative quality of care indicators for rectal cancer surgery in synoptic reports and traditional dictated reports. Two surgeons independently reviewed 40 prospectively collected synoptic operative reports from rectal cancer cases and a case-matched historical cohort of 40 dictated reports. Rectal cancer-specific quality measures were scored in both report groups using two separate, previously validated checklists. Synoptic reports had significantly higher overall scores on both checklists 1 (mean adjusted score ± SD 76 ± 4 vs 41 ± 19, P < 0.01) and 2 (54 ± 3 vs 24 ± 11, P < 0.01; maximum score of 100 for both checklists). Synoptic reports scored significantly higher in reporting preoperative and intraoperative care indicators. Data were extracted quickly from synoptic reports (mean 3:46 vs 6:21, minutes:seconds to complete checklists, P < 0.05). Synoptic reports are associated with accurate documentation of quality of care data for rectal cancer surgery. Refining the synoptic templates used will further enhance the collection of quality indicators and reporting in complex oncologic procedures.

The impact of rater training on the psychometric properties of standardized surgical skill assessment tools.

INTRODUCTION: Competency-based frameworks are common in surgical training. However, the optimal use of standardized technical assessments is not well defined. We investigated the effect of rater training (RT) on the reliability and validity of four assessment tools. MATERIALS AND METHODS: Forty-Seven surgeons were randomized to RT (N = 24) and no training (N = 23) groups. A task-specific checklist, pass-fail, visual analog, and OSATS global rating scale (GRS) were used to assess trainee knot-tying and suturing tasks. Delayed assessment was performed two weeks later. Internal consistency, intra/inter-rater reliability, and construct validity were measured. RESULTS: The GRS had superior reliability and validity compared to the other tools regardless of training. No significant differences between training groups was found. However, the RT group trended to improved reliability for all tools at both assessments. CONCLUSIONS: RT did not lead to significant improvements in skills assessments. Standardized assessments (OSATS GRS) are preferred due to their superior reliability and validity over other methods. Despite findings, we believe more effective training methods or repeated sessions may be required for sustained and significant effects.