w w w . j c o l . o r g . b r
Journal
of
Coloproctology
Technical
Note
Transanal
Endoscopic
Proctectomy:
a
new
approach
to
the
total
excision
of
the
mesorectum
夽
Carlos
Ramon
Silveira
Mendes
a,b,c,∗,
Luciano
Santana
de
Miranda
Ferreira
a,c,
Ricardo
Aguiar
Sapucaia
a,c,
Meyline
Andrade
Lima
a,c,
Eduardo
Costa
Cobas
a,c,
Sergio
Eduardo
Alonso
Araujo
c,d,eaServiceofColoproctology,HospitalSantaIzabel,SantaCasadeMisericórdiadaBahia,Salvador,BA,Brazil
bResidencePrograminColoproctology,HospitalGeralRobertoSantos,Salvador,BA,Brazil
cSociedadeBrasileiradeColoproctologia,Brazil
dDepartmentofGastroenterology,MedicineSchool,UniversidadedeSãoPaulo(USP),SãoPaulo,SP,Brazil
eServiceofColonandRectumSurgery,HospitaldasClínicas,MedicineSchool,UniversidadedeSãoPaulo(USP),SãoPaulo,SP,Brazil
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Articlehistory:
Received9March2015 Accepted8June2015 Availableonline2July2015
Keywords:
Minimallyinvasivesurgery Rectalcancer
Transanalendoscopicmicrosurgery Proctectomy
a
b
s
t
r
a
c
t
Introduction:Colorectalcancerisaseriouspublichealthproblem.In1982,Healdmanaged toreducemortalitybystandardizingthetotalexcisionofmesorectum.Theuseoftransanal endoscopicmicrosurgeryhasemergedtoallowresectionofrectaltumorsasaminimally invasivemethod.WiththeassociationofTransanalEndoscopicOperationwithtotalexcision ofmesorectum,itwaspossibletodevelopanewapproachfortotalexcisionofmesorectum.
Surgicaltechnique:TheprocedureisstartedbytheperinealtimewithTransanalEndoscopic Operationdevice;introductionofTransanalEndoscopicOperationsystem follows,with exposureofthelesionwithacircumferentialincisionatadistancebetween2and4cmfrom distaltumormarginaftermakingapursestringsuturetoclosetherectalstump.Then, dis-sectioniscarriedoutbytheposteriorportionuntilreachingthepresacralavascularfascia, completingthemesorectalcircumferentialdissectionuntiltheperitonealreflection.After thisstep,alaparoscopicprocedureisperformedwiththeuseofthreetrocars,with mobi-lizationofsplenicflexureandligationoftheinferiormesentericartery,aswellasconfection ofaprotectiveileostomy.Then,transanalremovalofthesurgicalspecimenisperformed, andtheproceduregoesonwithacoloanalanastomosis.
©2015SociedadeBrasileiradeColoproctologia.PublishedbyElsevierEditoraLtda.All rightsreserved.
夽
ThisworkwasconductedatHospitalSantaIzabel,SantaCasadeMisericórdiadaBahia,Salvador,BA,Brazil.
∗ Correspondingauthorat:ResidencePrograminColoproctology,HospitalGeralRobertoSantos,Salvador,BA,Brazil.
E-mail:[email protected](C.R.S.Mendes).
http://dx.doi.org/10.1016/j.jcol.2015.06.003
Protectomia
Endoscopica
Transanal
(TaETM):
Uma
nova
abordagem
para
excisão
total
do
mesoreto
Palavras-chave:
Cirurgiaminimamenteinvasiva Cancerdereto
Microcirurgiaendoscópica transanal
Protectomia
r
e
s
u
m
o
Introduc¸ão: Ocâncercolorretaléumserioproblemadesaúdepublica.Em1982,Heald con-seguiureduziramortalidadecomapadronizac¸ãodaexcisãototaldomesoreto.Ousoda Microcirurgiaendoscópicatransanalsurgiuparaproporcionarressecc¸õesdetumoresde retocomométodominimamenteinvasivo.Comaassociac¸ãodoTEOaETMfoipossível desenvolverumanovaabordagemparaETM.
Técnicacirúrgica: OprocedimentoéiniciadopelotempoperinealcomoaparelhodeTEO. EmseguidaosistemaTEOéintroduzido,comexposic¸ãodalesãopormeiodeumaincisão circunferencialacercade2a4cmdamargemdistaldotumorapósaconfecc¸ãodesutura embolsacomfechamentodocotoretal.Emseguida,faz-sedissecc¸ãopelaporc¸ãoposterior atéafásciaavascularpré-sacral,completandoadissecc¸ãocircunferencialdomesorretoaté atingirareflexãoperitoneal.Apósessaetapa,faz-selaparoscópicacomutilizac¸ãodetrês trocateres,commobilizac¸ãodoânguloesplênicoeligaduradaartériamesentéricainferior, etambémaconfecc¸ãodeumaileostomiaprotetora.Oespécimecirúrgicoéretiradopela viatransanal,eoprocedimentotemcontinuidadecomumaanastomosecoloanal.
©2015SociedadeBrasileiradeColoproctologia.PublicadoporElsevierEditoraLtda. Todososdireitosreservados.
Introduction
Colorectal cancer(CRC)is aserious healthproblem world-wide.Itisknownthat 25%ofCRCcasesarelocatedinthe rectum.1,2
In1982,Healdet al.proposed astandardizationoftotal excision of mesorectum (TEM), whose initial results were surprisingintermsoflocalrecurrence.3 Through standard-izationofthe technique,theseauthors managed toreduce localrecurrencetolessthan10%andincreasetheoverall sur-vivalfor80%.Thetransabdominal-transanal(TATA)technique describedbyMarks4,5improvedthequalityoflifeforpatients whowould besubmittedtoabdominoperineal amputation, enablingitsrealizationbylaparoscopy.
The transanal endoscopic microsurgery (TEM) was introduced in 1983 by G. Buess as a minimally invasive technique for the resection of adenomas and early rectal carcinomas.6–9
Using TATA technique, performing abdominal time by laparoscopy and perineal time with Transanal Endo-scopicOperation (TEO;Storz,Tuttlingen,Germany) system, TransanalEndoscopicProctectomy(TAEP)wasestablished.
ThequalityofTEMwithlymphnoderesectioninpursuit ofasingleobjectivewhichistheROresection,haspromoting thesearchfornewtacticsandtechniques.Obesepatientswith narrowpelviswithafattymesorectumwhichhasafibrosis planemainlywithabigprostatehavehinderedtheresection bylaparoscopy.
TAEPemergedasanalternativefordifficultcasesofrectal adenocarcinoma.
Thisisatechniquethatisperformedbytransanalroute; init,onecircumferentialrectalincisionwithdissectionofthe wholerectumtogetherwiththemesorectumtothe abdomi-nalcavityiscarriedout.Theabdominalperiodisdeveloped
bylaparoscopytoreleasethesplenicflexureandbyinferior mesentericarteryandveinligature.
Surgical
technique
InFebruary2014,oneofthefirstcasesinBrazilofTAEPfor treatmentofrectaltumorwasconductedatHospitalSanta Izabel,Salvador–Bahia.Preoperatively,thepatientfilledand signedafreeandinformedconsentformandwasinstructed regardingtheprocedure.
Toperformtheproctectomy,somepreoperativemeasures were implemented, for example, mechanical bowel prepa-rationandprophylacticantibiotictherapyduringanesthetic induction.
Followinggeneralanesthesia,thepatientisplacedin litho-tomyposition.
Fig.1–Closingofrectallumen.
additiontomakingaprotectiveileostomy.Thesurgical speci-menisremoved(Fig.2)bytransanalroute,andtheprocedure goesonwithamanualcoloanalanastomosis(Figs.3and4).
Experimental
and
cadaveric
models
TheTATAresectiontechniquewasfirstdescribedbyMarks,as analternativetoabdominoperinealresectionwithpermanent colostomyinpatientswithlowrectalcancer.In2010,Marks describedhisexperiencewithTATA laparoscopically, repor-tingacaseseriesof79patientswithnoperioperativemortality
Fig.2–Removalofthesurgicalspecimen.
Fig.3–Coloanalanastomosis.
andlowconversion(2.5%)andrecurrence(2.5%)rates.4With theadventofnaturalorificeendoscopicsurgery(NOTES)and withtheuseofminimallyinvasivetechniquesfortransanal tumorresection(TEM),thetechniquehasbeenrefined.
Fromthatmomenton,ademonstrationofsafetyand appli-cabilityofTAEPstartedoff,withthehelpofstudiesinpigsand humancorpses.10–14
In2010,Patricia10publishedherexperienceinpigsusing therectoscopetoperformTEM.
In 2013, McLemore held TAEP using minimally invasive transanalsurgery(TAMIS)inaseriesof5humancorpses(all male),withasurgicaltimeof200(128–249)min.Inthe peri-analtime,thisauthorusedGelPOINT-Path;intheabdominal
access,theauthorusedaGelPOINTintheregionofthemaking ofileostomyandanaccessory5-mmtrocarintheleftinguinal region(siteofpelvicdrainage).Asacomplication,aninjuryto thespleniccapsuleoccurredduringsurgery.15–18
Inthesameyear,Telenetal.19publishedthelargestseries incadavers,with32casesandmeanoperativetimeof5.1h. Inallspecimens,itwaspossibletoresecttheintactrectum.
Withtheadventofrobotics,newstudieshavebeen pub-lished, with robot use for access to the perineal time, in associationwithasingle-portaldevice.Thefirstreportofthis modelwaspublishedbyAtallah;thisauthorconductedfour daysofexperiments,showingthattheuseoftherobotis fea-sibleandsafe;however,thecostofitsuseisstillveryhigh.20,21
Clinical
series
Thefirstreport ofTAEP withtheuse ofTEOplatform was describedin2010byPatriciaetal.22Thepatientwasawoman of76years withadenocarcinomaofthe rectumT2N2. The patientunderwentaTAEPwithsurgicaltimeof4hand30min. Abdominalaccesswasperformedthroughthreeportals(one 10-mmportalintheumbilicalregion,one5-mmportalinthe rightflank,andone2-mmportalintheleftinguinalregion). Coloanalmanualanastomosiswasperformed,andthe spec-imenwasremovedbytransanalroute;aprotectiveileostomy wasmade.
Thepost-surgicalresultsrevealedthatthepatientwaswith aT1N0adenocarcinomawith23disease-freelymphnodes.
In2012,thefirstseriesofcasesinhumanswaspublished, with a total of 5 patients (3 males). The mean operative timewas 175(160–194)min, thepatients hadstageII orIII adenocarcinoma.Therewasoneintraoperativecomplication (pneumo-retroperitoneum)that made it difficultthe surgi-caltechnique.Postoperatively,oneprolongedileuscaseand anothercaseofpelvicabscess(whichwasexternallydrained) werereported.
In2013,Lacypublishedhisseriesof20patientswithmean BMIof25.3and withadenomaandrectaladenocarcinoma. The operative time was 234 (150–325)min. There were no intraoperativecomplications. Postoperatively,acaseof uri-naryretention,andalsoprolongedileus,wasreported;and onepatientrequiredreadmissionduetoseveredehydration.
Thelargest series inhumans wasreported byRouanet, with30cases.Allpatientsweremale.Thecriteriaforuseof TAEPtechniquewere:adenocarcinomacarrier, presentinga thickmesorectum,orhighbodymassindex(BMI),ortumor fibrosis,or a narrow pelvis(bi-tuberal distance <10cm, bi-ischialdistance<12cm). Themean operativetimewas304 (170–432)min.Intheearlyseries,twocasesofurethralinjury andacaseofthromboembolismwerereported.Subsequently, severe sepsis and one case of intestinal obstruction were diagnosed.TheQuirkeclassificationwasusedtoanalyzethe mesorectum,andallpatientswereclassifiedasgrade3.
Discussion
Duringlaparoscopy,when TEM,recommended byHeald, is carriedout,insomecasesthesurgeonhasstruggledtogetan
upstandingspecimenwithoutcausingharmtothe mesorec-tum.
Thesedifficultiesarisemainlyinmalepatientsandalsoin obesepatients.
Rouanat11 after usingTAEP, advocatedsomeindications for its proper execution: being an adenocarcinoma carrier, andtomeetoneofthefollowingcriteria:thickmesorectum, highBMI,tumorfibrosis,anarrowpelvis(bi-tuberaldistance <10cm,bi-ischialdistance<12cm).
Withthesecriteria,aupstandingpieceofmesorectumwas obtained.Thissuggeststhatthissurgicalapproachisthebest forthesecases.
Today,forthisprocedurethereareseveralwaystoa peri-nealapproachwithTEOandTAMIS.23,24Inthesestudies,their authors provedthattheuseoftheseveraltoolsequipment foundinthemarkettocarryoutTAMISisviable,andthisis truealsofortheequipmentforTEO.
Thelaparoscopicabdominaltimehasproventobe straight-forward; one needs only to do the ligation of the inferior mesentericvessels,besidestherelease ofthesplenicangle ofthecolon;tothisend,onecanresorttominilaparoscopy,to singleportaltechnique,oreventomultiportals.The complica-tionssofarencounteredwereminor,andallofthemcouldbe resolved.Themostcommoncomplicationwasurethralinjury, especiallyintheinitialphaseoftheprocedures,becauseofthe difficultyinrecognizinganewdissectionplane.
Whenexaminingthesurgicalspecimen,itwaspossibleto obtain awholesomepieceinallcases,asrecommendedby Heald.
Newtechnologies areemerging;and whentheyare well applied,shouldbeusedforthebesttreatmentofthepatient. And new studies are emerging,and newexperiences have beentried,thusresultingingreatercertaintyinthe applica-tionofTAEPtechniques.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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