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Transanal natural orifice transluminal endoscopic surgery (NOTES) rectal resection: “down-to-up” total mesorectal excision (TME)—short-term outcomes in the first 20 cases

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Abstract

Background

The transanal minilaparoscopy-assisted natural orifice transluminal endoscopic surgery (NOTES) approach holds significant promise as a safe and less morbid alternative to conventional low anterior rectal resection. Previous reports have shown satisfactory short-term oncologic results. We evaluated the safety and short-term outcomes in rectal cancer subjects who underwent transanal minilaparoscopy-assisted natural orifice surgery total mesorectal excision (TME) rectal resection.

Methods

Twenty selected patients with rectal cancer were enrolled onto a prospective study of minilaparoscopy-assisted natural orifice surgery TME rectal resection. The study endpoints were safety of access (intra- or postoperative morbidity) and adequacy of oncological resection criteria; intact TME; distal and circumferential margins; and number of lymph nodes retrieved.

Results

All procedures were successfully completed with the transanal NOTES and minilaparoscopy technique. The mean age was 65 ± 10 years; 55 % of patients were male; the mean body mass index was 25.3 ± 3.8 kg/m2. Thirty-five percent of tumors were in the distal rectum, 50 % in midrectum, and 15 % in proximal rectum. Coloanal anastomoses were hand sewn in 65 % and stapled in 35 %. Mean operative time was 235 ± 56 min. There were no procedure-related complications. Pathologic analysis demonstrated negative distal and circumferential margins in all patients. An average of 15.9 ± 4.3 lymph nodes were retrieved. The mesorectal fascia was intact in all the specimens.

Conclusions

This study demonstrates that transanal NOTES with minilaparoscopic assistance in the hands of a specialized team is safe; meets the oncologic requirements for high-quality rectal cancer surgery; and may offer advantages over pure laparoscopic approaches for visualizing and dissecting out the distal mesorectum. Minilaparoscopic assistance allows one to compensate for the limitations of current NOTES instrumentation to ensure the safety and adequacy of oncologic resection in these difficult cases. Careful patient selection, a specialized team, and long-term outcome evaluation are critical before this procedure can be considered for routine clinical use.

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References

  1. Kalloo AN, Singh VK, Jagannath SB, Niiyama H, Hill SL, Vaughn CA, Magee CA, Kantsevoy S (2004) Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity. Gastrointest Endosc 60:114–117

    Article  PubMed  Google Scholar 

  2. Rao GV (2006) Transgastric appendectomy results and follow-up (SAGES Transgastric Surgery panel). Presented at the SAGES meeting, 2006

  3. Lehmann KS, Ritz JP, Wibmer A, Gellert K, Zornig C, Burghardt J, Büsing M, Runkel N, Kohlhaw K, Albrecht R, Kirchner TG, Arlt G, Mall JW, Butters M, Bulian DR, Bretschneider J, Holmer C, Buhr HJ (2010) The German registry for natural orifice translumenal endoscopic surgery: report of the first 551 patients. Ann Surg 252:263–270

    Article  PubMed  Google Scholar 

  4. Rattner D, Kalloo A; ASGE/SAGES Working Group (2006) ASGE/SAGES Working Group on Natural Orifice Translumenal Endoscopic Surgery. October 2005. Surg Endosc 20:329–333

    Google Scholar 

  5. Lacy AM, Delgado S, Rojas OA, Almenara R, Blasi A, Llach J (2008) MA-NOS radical sigmoidectomy: report of a transvaginal resection in the human. Surg Endosc 22:1717–1723

    Article  PubMed  Google Scholar 

  6. Targarona EM, Gomez C, Rovira R, Pernas JC, Balague C, Guarner-Argente C, Sainz S, Trias M (2009) NOTES-assisted transvaginal splenectomy: the next step in the minimally invasive approach to the spleen. Surg Innov 16:218–222

    Article  PubMed  Google Scholar 

  7. Lacy AM, Delgado S, Rojas OA, Ibarzabal A, Fernandez-Esparrach G, Taura P (2009) Hybrid vaginal MA-NOS sleeve gastrectomy: technical note on the procedure in a patient. Surg Endosc 23(5):1130–1137

    Article  PubMed  Google Scholar 

  8. Whiteford MH, Denk PM, Swamstrom LL (2007) Feasibility of radical sigmoid colectomy performed as natural orifice translumenal endoscopic surgery (NOTES) using transanal endoscopic microsurgery. Surg Endosc 21:1870–1874

    Article  PubMed  CAS  Google Scholar 

  9. Sylla P, Willingham FF, Sohn DK, Gee D, Brugge WR, Rattner DW (2008) NOTES rectosigmoid resection using transanal endoscopic microsurgery (TEM) with transgastric endoscopic assistance: a pilot study in swine. J Gastrointest Surg 12:1717–1723

    Article  PubMed  Google Scholar 

  10. Sylla P, Rattner DW, Delgado S, Lacy AM (2010) NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance. Surg Endosc 24:1205–1210

    Article  PubMed  Google Scholar 

  11. Lacy AM, Saavedra-Perez D, Bravo R, Adelsdorfer C, Aceituno M, Balust J (2012) Minilaparoscopy-assisted natural orifice total colectomy: technical report of a minilaparoscopy-assisted transrectal resection. Surg Endosc 26(7):2080–2085

    Article  PubMed  Google Scholar 

  12. Lacy AM, Adelsdorfer C, Delgado S, Sylla P, Rattner DW (2013) Minilaparoscopy-assisted transrectal low anterior resection (LAR): a preliminary study. Surg Endosc 27:339–346

    Article  PubMed  Google Scholar 

  13. Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213

    Article  PubMed  Google Scholar 

  14. Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, de Santibañes E, Pekolj J, Slankamenac K, Bassi C, Graf R, Vonlanthen R, Padbury R, Cameron JL, Makuuchi M (2009) The Clavien-Dindo classification of surgical complications. Five-year experience. Ann Surg 250:187–196

    Article  Google Scholar 

  15. Pearl JP, Marks JM, Ponsky JL (2008) Hybrid surgery: combined laparoscopy and natural orifice surgery. Gastrointest Endosc Clin N Am 18:325–332

    Article  PubMed  Google Scholar 

  16. Horgan S, Cullen JP, Talamini MA, Mintz Y, Ferreres A, Jacobsen GR, Sandler B, Bosia J, Savides T, Easter DW, Savu MK, Ramamoorthy SL, Whitcomb E, Agarwal S, Lukacz E, Dominguez G, Ferraina P (2009) Natural orifice surgery: initial clinical experience. Surg Endosc 23:1512–1518

    Article  PubMed  Google Scholar 

  17. Lacy AM, García-Valdecasas JC, Delgado S, Castells A, Taurá P, Piqué J, Visa J (2002) Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomised trial. Lancet 359:2224–2229

    Article  PubMed  Google Scholar 

  18. Lacy AM, Delgado S, Castells A, Prins HA, Arroyo V, Ibarzabal A, Piqué JM (2008) The long-term results of a randomised clinical trial of laparoscopy assisted versus open surgery for colon cancer. Ann Surg 248:1–7

    Article  PubMed  Google Scholar 

  19. Nagtegaal ID, Quirke P (2008) What is the role for the circumferential margin in the modern treatment of rectal cancer? J Clin Oncol 26:303–312

    Article  PubMed  Google Scholar 

  20. Birbeck KF, Macklin CP, Tiffin NJ, Parsons W, Dixon MF, Mapstone NP, Abbott CR, Scott N, Finan PJ, Johnston D, Quirke P (2002) Rates of circumferential resection margin involvement vary between surgeons and predict outcomes in rectal cancer surgery. Ann Surg 235:449–457

    Article  PubMed  Google Scholar 

  21. Clinical Outcomes of Surgical Therapy Study Group (2004) A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 350:2050–2059

    Article  Google Scholar 

  22. Guillou PJ, Quirke P, Thorpe H, Walker J, Jayne DG, Smith AM, Heath RM, Brown JM; MRC CLASICC Trial Group (2005) Short-term endpoints of conventional versus laparoscopic assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre randomised controlled trial. Lancet 365:1718–1726

    Google Scholar 

  23. Aziz O, Constantinides V, Tekkis PP, Athanasiou T, Purkayastha S, Paraskeva P, Darzi AW, Heriot AG (2006) Laparoscopic versus open surgery for rectal cancer: a meta-analysis. Ann Surg Oncol 13:413–424

    Article  PubMed  Google Scholar 

  24. Laurent C, Leblanc F, Wütrich P, Scheffler M, Rullier E (2009) Laparoscopic versus open surgery for rectal cancer. Long-term oncologic results. Ann Surg 250:54–61

    Google Scholar 

  25. Delgado S, Momblan D, Salvador L, Bravo R, Castells A, Ibarzabal A, Pique JM, Lacy AM (2004) Laparoscopic-assisted approach in rectal cancer patients: lessons learned from 200 patients. Surg Endosc 18:1457–1462

    Article  PubMed  CAS  Google Scholar 

  26. Lujan J, Valero G, Hernández Q, Sánchez A, Frutos MD, Parrilla P (2009) Randomized clinical trial comparing laparoscopic and open surgery in patients with rectal cancer. Br J Surg 96:982–989

    Article  PubMed  CAS  Google Scholar 

  27. Strohlein MA, Grutzner KU, Jauch KW, Heiss MM (2008) Comparison of laparoscopic vs. open access surgery in patients with rectal cancer: a prospective analysis. Dis Colon Rectum 51:385–391

    Article  PubMed  Google Scholar 

  28. Lelong B, Bege T, Esterni B, Guiramand J, Turrini O, Moutardier V, Magnin V, Monges G, Pernoud N, Blache JL, Giovannini M, Delpero JR (2007) Short-term outcome after laparoscopic or open restorative mesorectal excision for rectal cancer: a comparative cohort study. Dis Colon Rectum 50:176–183

    Article  PubMed  Google Scholar 

  29. Kuroyanagi H, Oya M, Ueno M, Fujimoto Y, Yamaguchi T, Muto T (2008) Standardized technique of laparoscopic intracorporeal rectal transection and anastomosis for low anterior resection. Surg Endosc 22:557–561

    Article  PubMed  Google Scholar 

  30. Fukunaga Y, Higashino M, Tanimura S, Takemura M, Fujiwara Y, Osugi H (2008) New technique for rectal division in laparoscopic anterior resection (with video). World J Surg 32:2095–2100

    Article  PubMed  Google Scholar 

  31. Wang HS, Lin JK, Yang SH, Jiang JK, Chen WS, Lin TC (2003) Prospective study of the functional results of transanal endoscopic microsurgery. Hepatogastroenterology 50(53):1376–1380

    PubMed  Google Scholar 

  32. Kennedy ML, Lubowski DZ, King DW (2002) Transanal endoscopic microsurgery excision: is anorectal function compromised? Dis Colon Rectum 45(5):601–604

    Article  PubMed  CAS  Google Scholar 

  33. Shah J, Buckley D, Frisby J, Darzi A (2003) Depth cue reliance in surgeons and medical students. Surg Endosc 17:1472–1474

    Article  PubMed  CAS  Google Scholar 

  34. Peeters KC, Tollenaar RA, Marijnen CA, Klein Kranenbarg E, Steup WH, Wiggers T, Rutten HJ, van de Velde CJ; Dutch Colorectal Cancer Group (2005) Risk factors for anastomotic failure after total mesorectal excision of rectal cancer. Br J Surg 92:211–216

    Google Scholar 

  35. Kim JS, Cho SY, Min BS, Kim NK (2009) Risk factors for anastomotic leakage after laparoscopic intracorporeal colorectal anastomosis with a double stapling technique. J Am Coll Surg 209:694–701

    Article  PubMed  Google Scholar 

  36. Ito M, Sugito M, Kobayashi A, Nishizawa Y, Tsunoda Y, Saito N (2008) Relationship between multiple numbers of stapler firings during rectal division and anastomotic leakage after laparoscopic rectal resection. Int J Colorectal Dis 23:703–707

    Article  PubMed  Google Scholar 

  37. Kuroyanagi H, Oya M, Ueno M, Fujimoto Y, Yamaguchi T, Muto T (2008) Standardized technique of laparoscopic intracorporeal rectal transection and anastomosis for low anterior resection. Surg Endosc 22:557–561

    Article  PubMed  Google Scholar 

  38. Fukunaga Y, Higashino M, Tanimura S, Takemura M, Fujiwara Y, Osugi H (2008) New technique for rectal division in laparoscopic anterior resection (with video). World J Surg 32:2095–2100

    Article  PubMed  Google Scholar 

  39. Akiyoshi T, Ueno M, Fukunaga Y, Nagayama S, Fujimoto Y, Konishi T, Kuroyanagi H, Yamaguchi T (2011) Incidence of and risk factors for anastomotic leakage after laparoscopic anterior resection with intracorporeal rectal transection and double-stapling technique anastomosis for rectal cancer. Am J Surg 202(3):259–264

    Article  PubMed  Google Scholar 

  40. Matthiessen P, Hallbook O, Rutegård J, Simert G, Sjödhal R (2007) Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial. Ann Surg 246:207–214

    Article  PubMed  Google Scholar 

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Disclosures

Dr. Antonio M. Lacy is a consultant for Covidien and for Olympus Medical. Dr. Patricia Sylla has received an honorarium from Genzyme for consulting and an honorarium from Applied Medical for teaching. Dr. Rattner is a consultant for Olympus. Drs. Cedric Adelsdorfer, Marta M. Tasende, María Fernández, Salvadora Delgado, and Graciella Martínez-Palli have no conflicts of interest or financial ties to disclose.

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Authors and Affiliations

  1. Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases (ICMDM), Hospital Clínic, IDIBAPS, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Centro Esther Koplowitz, University of Barcelona, Barcelona, Spain

    Antonio M. de Lacy, Cedric Adelsdorfer, Marta M. Tasende, María Fernández & Salvadora Delgado

  2. Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    David W. Rattner & Patricia Sylla

  3. Department of Anesthesiology, Hospital Clinic, Barcelona, Spain

    Graciela Martínez-Palli

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  1. Antonio M. de Lacy
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Correspondence to Antonio M. de Lacy.

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de Lacy, A.M., Rattner, D.W., Adelsdorfer, C. et al. Transanal natural orifice transluminal endoscopic surgery (NOTES) rectal resection: “down-to-up” total mesorectal excision (TME)—short-term outcomes in the first 20 cases. Surg Endosc 27, 3165–3172 (2013). https://doi.org/10.1007/s00464-013-2872-0

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