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Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Disclosure
  8. References

Background

Laparoscopic resection of colorectal cancers is a safe alternative to open surgery. The conversion rate to open surgery remains fairly constant but is associated with increased morbidity. A new approach to the surgical excision of rectal cancer is transanal total mesorectal excision (TME), in which the rectum is mobilized peranally using endoscopic instruments. This feasibility study describes initial results with transanal TME.

Methods

Between June and August 2012, five consecutive unselected patients with rectal carcinoma underwent surgical excision of rectal tumours by means of transanal TME.

Results

Transanal endoscopic dissection of the complete rectum was possible in all patients. Histopathological examination confirmed clear surgical margins and an intact mesorectal fascia in all patients. One patient developed a presacral abscess. Median duration of operation was 175 (range 160–194) min.

Conclusion

Transanal TME using the down-to-up principle is feasible. Whether the oncological and clinical results are comparable with those of standard laparoscopic or open TME has yet to be proven.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Disclosure
  8. References

In recent years the aim has been to reduce the impact of surgical trauma. The next logical step for laparoscopic surgery may be natural orifice transluminal endoscopic surgery (NOTES). However, progress has been slow owing to technical problems in performing these procedures safely[1, 2].

By avoiding transabdominal incisions and their related complications, NOTES procedures can, in theory, have a number of potential advantages over the conventional laparoscopic approach for rectal cancer, which is a safe alternative to open surgery[3]. In more technically demanding cases such as patients with bulky tumours, distal rectal tumours and in the narrow male pelvis, conversion remains necessary possibly resulting in increased morbidity[4].

Rectal cancer is invariably approached transabdominally, beginning at the proximal rectum: top-to-bottom total mesorectal excision (TME). Recently, the authors have used a new transanal TME approach to mobilize the rectum transanally by using a single port and endoscopic instruments. Beginning distal to the tumour and working upwards (down-to-up principle), this approach for rectal cancer gives new options in difficult cases and may reduce the need for conversion[5]. This article describes the feasibility of applying this new transanal TME technique to an unselected group of patients.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Disclosure
  8. References

This feasibility study started in June 2012 after the Vrije Universiteit Medical Centre ethics committee had approved the study protocol. The data monitoring committee included an independent pathologist and a gastroenterologist. The specimens were assessed according to protocol.

Patients with histologically proven mid-rectal T2 or T3 adenocarcinomas were included in the study. Patients with a previous history of abdominal surgery were excluded. The preoperative assessment included magnetic resonance imaging for local staging, and computed tomography (CT) of the thorax and abdomen for distant metastasis. The minimum distance from the tumour to the anal verge was 5 cm.

All patients were treated according to the Dutch guidelines for the treatment of rectal cancer. Patients with T2–3 N0-1 tumours underwent preoperative radiotherapy with a total dose of 25 Gy and a daily dose of 5 Gy; surgery was performed in the week following cessation of radiotherapy. Patients with T2–3 N2 tumours underwent chemoradiotherapy with a total dose of 50 Gy and a daily dose of 2 Gy combined with 5-fluorouracil. In this situation, surgery was performed 6 weeks after the end of the neoadjuvant treatment.

Patients received mechanical bowel preparation before surgery with Moviprep® (Norgine, Amsterdam, The Netherlands), an epidural for postoperative pain control and prophylactic antibiotics according to protocol. Patients were treated according to enhanced recovery after surgery guidelines.

Patients were placed in the lithotomy position with both arms parallel to the body. The procedure started with the transanal phase. A Scott retractor (Lone star Medical Products, Houston, Texas, USA) facilitated the full-thickness circumferential resection. The distance to the dentate line depended on the distance from the tumour to the anal verge. A minimum margin of 2 cm distal to the tumour was used. After full-thickness resection, the rectal stump was closed with a purse-string suture to prevent spillage of tumour cells and bacteria. After closure of the rectal stump the cavity was rinsed with povidone–iodine solution as a cytocidal agent.

A single–incision laparoscopic surgery (SILS™) port (Covidien, Mansfield, Massachusetts, USA) was introduced into the anus without prior dilatation. It was not necessary to suture the port to the perineal skin. A pneumoperirectum was created with carbon dioxide at a pressure of 15 mmHg. A 30° 5-mm endoscope was positioned on the right side. An atraumatic grasper and a LigaSure® device (Covidien) were introduced on the left side (Fig. 1). By gently pushing against the tissue starting on the dorsal side, the avascular presacral plane was developed (Fig. 2). According to TME principles, the plane of dissection was first extended posteriorly, then anteriorly and then laterally. After circumferential mobilization of the rectum, the peritoneal reflection was exposed and opened, thereby entering the peritoneal cavity (Fig. 3).

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Figure 1. Set-up during transanal phase

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Figure 2. Transanal view showing complete mobilization of the dorsal total mesorectal excision plane

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Figure 3. Transanal view showing opening of the peritoneal reflection and dissection of the lateral total mesorectal excision plane

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A second SILS™ port was introduced at the previously marked future ileostomy site in the right lower abdomen. Pneumoperitoneum was established with a pressure of 14 mmHg. The descending colon and sigmoid were mobilized from medial to lateral using the single-incision laparoscopic surgery technique described previously[6]. The inferior mesenteric vessels were transected using the LigaSure® device after identification of the left ureter. To avoid rotation of the colon, the rectosigmoid was exteriorized transanally under direct visualization by using the camera in the abdominal port. Anal retrieval of the specimen was performed under the protection of an Alexis® wound protector (Applied Medical, Rancho Santa Margarita, California, USA) to avoid any wound contamination by bacteria or tumour cells. After dividing the sigmoid, a transverse coloplasty was made. A hand-sutured coloanal anastomosis was created for the first two patients, whereas a stapled anastomosis was formed in the last three patients using a EEA™ haemorrhoid stapler (Covidien) with 4·8-mm staples. Finally, a loop ileostomy was created after removing the SILS™ port.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Disclosure
  8. References

Five consecutive unselected patients with rectal adenocarcinomas were treated with the transanal TME technique between June 2012 and August 2012. The demographic and clinical characteristics of the patients are summarized in Table 1. Transanal endoscopic dissection of the complete rectum was possible in all patients and the peritoneal reflection was opened, thereby entering the abdominal cavity. Complete mobilization of the sigmoid was possible using the SILS™ port at the ileostomy site in four patients. In one patient the mesentery of the sigmoid was too bulky and two extra 5-mm trocars were used for complete mobilization. The median duration of operation was 175 (range 160–194) min.

Table 1. Tumour pathology and perioperative outcomes
PatientAge (years)SexDistance to anal verge (cm)Tumour stage (MRI)Neoadjuvant therapyDuration of operation (min)ComplicationsHistologyNo. of lymphnodes harvested
  1. MRI, magnetic resonance imaging; ypT and N, tumour and node histology after neoadjuvant therapy; 5-FU, 5-fluorouracil.

170F5T3 N05 × 5 Gy170ypT3 N012
266M5T3 N225 × 2 Gy + 5-FU160ypT0 N017
379M8T3 N05 × 5 Gy175PneumoniaypT2 N011
463F5T3 N05 × 5 Gy192Presacral abscessypT3 N112
569M7T2 N05 × 5 Gy194ypT2 N015

One patient developed extreme perioperative pneumatosis of the retroperitoneum and mesentery of the small bowel, making laparoscopic mobilization of the sigmoid difficult. There were no perioperative complications in the other four patients. On the fifth day after surgery the patient with pneumatosis developed a small bowel ileus that resolved with conservative measures. This patient, who had severe chronic obstructive pulmonary disease, also developed pneumonia necessitating treatment with antibiotics. One patient developed a presacral abscess that was treated by repeat laparoscopic drainage; CT did not reveal any anastomotic leakage.

Histopathological examination of the resected specimens confirmed clear surgical margins, both circumferential and distal, in all patients. The mesorectal fascia remained intact in all patients. The median number of lymph nodes harvested was 12 (range 11–17).

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Disclosure
  8. References

Conversions to open surgery during laparoscopic TME for rectal carcinoma are sometimes unavoidable for technical reasons. These include bulky tumours and a narrow male pelvis, both of which can make dissection of the tumour impossible distally. Another limitation of the laparoscopic approach for mid-rectal tumours is achieving an acceptable clear distal resection margin. It is often difficult to determine the margin after the placement of laparoscopic staplers, and this may result in an insufficient surgical margin and inadequate oncological clearance. It may therefore be necessary to change the surgical strategy to reduce further the number of inadequate resections and potential conversions.

Using a conventional laparoscopic technique, the rectum is always mobilized transabdominally. In theory, rectal carcinomas could also be approached from below through the anal canal (down-to-up approach). This combination of both abdominal and transanal approaches is not new and has already been described. Both Ramos[7] and Watanabe and colleagues[8] described a laparoscopic ultralow anterior resection combining transanal dissection with transabdominal mobilization of the rectosigmoid for low rectal cancer. However, the transanal part was limited to an intersphinteric dissection or a coloanal pull-through with handsewn anastomosis. An important advantage of this technique was that a sufficient distal margin could be obtained under direct vision.

In 2009, Zorron and colleagues[5] described a new approach, the perirectal NOTES access, with down-to-up TME. They reported their initial experience with transanal mobilization of the whole rectum[5]. Two different techniques were described. The first entailed use of a colonoscope and the second use of a transanally placed SILS™ port and standard laparoscopic instruments. Preliminary data showed that it was possible to perform an oncologically successful resection in a selected group of patients.

Other authors have described comparable techniques. Sylla and co-workers[9] described transanal dissection using a transanal endoscopic microsurgery (TEM) proctoscope. After closure of the rectum with a purse-string suture, the rectum was dissected circumferentially. The rectal dissection was done with TEM instruments and a harmonic scalpel. After complete mobilization of the rectum, the peritoneal reflection was opened. The abdominal part was performed with 2-mm needle ports and mini-instruments. The vascular pedicle was divided with an endostapler introduced transanally. After creation of a transverse coloplasty, a handsewn anastomosis was formed.

Tuech et al.[10] published a case report using a similar technique. However, they applied two single-port trocars. The first was introduced transanally and the second at the future ileostomy site. Their procedure is comparable to the technique used in five patients in the present feasibility study. This approach was used in an unselected group of patients with mid-rectal cancer treated previously with neoadjuvant therapy. In all patients, the whole rectum was mobilized without perioperative complications. The surgical TME plane was clearly visible and developed without any problems. One patient developed pneumatosis of the mesentery of the small bowel and sigmoid, which complicated the laparoscopic mobilization of the sigmoid loop.

The transanal route for NOTES-type procedures has always been considered the least likely to be successful because of the high bacterial load in the rectum and the fear of infection. In this feasibility study, one patient developed a presacral abscess, without proven anastomotic leakage on CT, that was treated by laparoscopic drain placement. All surgical margins were clear and all specimens had an intact mesorectal fascia. Finally, the number of lymph nodes harvested was within guidelines.

Transanal TME involving the down-to-up principle is feasible. Whether the oncological and postoperative results of this new technique are comparable with those of standard laparoscopic or open TME has yet to be proven. This new approach could be useful in ensuring a clear distal resection margin, thus reducing the number of conversions.

Disclosure

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Disclosure
  8. References

The authors declare no conflict of interest.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Disclosure
  8. References
  • 1
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  • 2
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  • 3
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  • 5
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  • 8
    Watanabe M, Teramoto T, Hasegawa H, Kitajima M. Laparoscopic ultralow anterior resection combined with per anum intersphincteric rectal dissection for lower rectal cancer. Dis Colon Rectum 2000; 43(Suppl): S94S97.
  • 9
    Sylla P, Rattner DW, Delgado S, Lacy AM. NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance. Surg Endosc 2010; 24: 12051210.
  • 10
    Tuech JJ, Bridoux V, Kianifard B, Schwarz L, Tsilividis B, Huet E, et al. Natural orifice total mesorectal excision using transanal port and laparoscopic assistance. Eur J Surg Oncol 2011; 37: 334335.