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

Abstract

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.

Natural orifice transluminal endoscopic surgery for colorectal cancer

“…As in the present series, other reports4, 5, 6, 7, 8, 9, 10, 11 24, 25 have described the absence of intra‐abdominal infection.…”

“…Since the first transgastric liver biopsy by Kalloo and colleagues1, there has been continued interest in natural orifice transluminal endoscopic surgery (NOTES)2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14. For colorectal cancer, most operations have been hybrid procedures4, 5, 6, 7, 8, 9, 10 with few reports11, 12, 13, 14 confined to NOTES alone.…”

“…For colorectal cancer, most operations have been hybrid procedures4, 5, 6, 7, 8, 9, 10 with few reports11, 12, 13, 14 confined to NOTES alone. In colorectal cancer surgery, potential benefits of NOTES might include less pain, avoidance of incisional infection, shorter hospital stay, better cosmesis and high‐quality oncological resection by transanal total mesorectal excision (TME)4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14.…”

Current methods in the treatment of rectal cancer

“…С течением времени появились сообщения о новых гибких платформах [39]: Endorec Trocar (Aspide, France), GelPOINT Path Transanal Access Platform (Applied Medical, Inc. Rancho Santa Margarita, CA, USA), Triport, (Olympus), SILS Port (Covidien, Mansfield, MA, USA) и др. В литературе встречают-ся также сведения о применении в качестве транс-анальных платформ колоноскопов [40] и самодель-ных (перчаточный порт) устройств [41].…”

Low rectal cancer: Sphincter preserving techniques-selection of patients, techniques and outcomes

“…Results from four studies [7,11,12,115] , addressed positive CRM in 10 out of 136 patients (7.3%), while all studies, except two [103,113] , reported a mean number of retrieved lymphnodes equal to or greater to 12.…”