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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 3  |  Issue : 2  |  Page : 35-37

Transanal minimally invasive surgery short- and mid-term outcomes


Department of General and Laparoscopic Surgery, Sir Ganga Ram Hospital, New Delhi, India

Date of Submission27-Jan-2020
Date of Acceptance11-Jul-2020
Date of Web Publication28-Apr-2021

Correspondence Address:
Dr. Mohammad Taha Mustafa Sheikh
18/1, Ground Floor, West Patel Nagar, New Delhi - 110 008
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCS.IJCS_11_20

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  Abstract 

Introduction: Transanal minimally invasive surgery (TAMIS) is a very efficient and safe technique for the management of rectal lesions that are large or not amenable to colonoscopic removal. Both benign and malignant lesions can be excised with higher rates of specimen nonfragmentation and margin negativity. Introduced in 2010 by Atallah it has undergone tremendous growth with respect to indications and instrumentation. We present our short- and mid-term experience in this novel technique. Materials and Methods: A retrospective study from September 2016 (when the first TAMIS case was done in our institution) up to February 2020 was carried out. Case records were analyzed and their outpatient follow-up was traced. Results: A total of 20 patients had undergone TAMIS from September 2016 to February 2020. The most common indication for undergoing TAMIS was rectal adenomas in 6 (30%) patients. This was followed by rectal carcinomas in situ or carcinoma suspected in a previously biopsied polyp in 4 (20%) patients. Hyperplastic polyps constituted 4 (20%) of the TAMIS procedures. We also had two patients with juvenile polyposis. There was no specimen fragmentation in any of the specimens. Only one patient had a positive margin and underwent low anterior resection. The final biopsy showed no residual tumor. There were no procedure-related complications. The average hospital stay was 24 h. All procures were done under general anesthesia. Our longest follow-up is 40 months. The mean follow-up was of 16.1 months. There has been no procedure-related complication. None of our patients have recurrence. Conclusion: TAMIS is a safe and effective technique for the management of benign and early rectal cancer lesions of the rectum. Our short- and mid-term outcomes are encouraging to continue using this technique for our patients.

Keywords: Adenoma, tis (carcinoma in situ), transanal endoscopic microsurgery, transanal minimally invasive surgery


How to cite this article:
Sheikh MT. Transanal minimally invasive surgery short- and mid-term outcomes. Indian J Colo-Rectal Surg 2020;3:35-7

How to cite this URL:
Sheikh MT. Transanal minimally invasive surgery short- and mid-term outcomes. Indian J Colo-Rectal Surg [serial online] 2020 [cited 2021 May 16];3:35-7. Available from: https://www.ijcrsonweb.org/text.asp?2020/3/2/35/314973


  Introduction Top


Transanal minimally surgery is a novel and elegant technique for the management of mid and upper rectal lesions. It provides a better visualization and completeness of resected margins compared to traditional open methods of transanal excision. First described by Atallah in 2010, it has gained rapid popularity among colorectal surgeons across the world.[1] A large number of studies have been published to evaluate and extend the indications of this technique. Transanal minimally invasive surgery (TAMIS) results in more cases of completeness of surgical margin negativity and less fragmentation of specimens.[2]

TAMIS is similar in its indications to transanal endoscopic microsurgery (TEM) described by Buess et al. from Germany in 1984.[3] Although described, nearly three decades earlier TEM could not gain wide acceptance and popularity like TAMIS. The primary reason was a rigid platform and the need for a specialized instrumentation. TAMIS's development was in parallel with the development of single-incision laparoscopic surgery (SILS). The port initially used by Atallah was a SILS port.[1]

We have been doing TAMIS since the fall of 2016.[4],[5] We continue to do TAMIS till present. We present our experience and outcomes over the past 40 months.


  Materials and Methods Top


All patients who underwent TAMIS from September 2016 to February 2020 were included in this study. Case records were examined which extended over a period of 40 months. The author keeps a separate copy of minimally invasive transanal procedures. Outpatient records were analyzed for follow-up of the patients. Patients' follow-up was done by both clinical examination and flexible sigmoidoscopy. TAMIS was performed using both SILS port and GelPoint Path. Conventional laparoscopic instruments like L-hook with monopolar cautery and atraumatic bowel graspers were used. The technical aspects of the procedure are described elsewhere.[4],[5]


  Results Top


A total of 20 patients had undergone TAMIS from September 2016 to February 2020 [Table 1]. The most common indication for undergoing TAMIS was rectal adenoma with or without dysplasia in 6 patients (30%). This was followed by rectal carcinomas in situ or carcinoma suspected in a previously biopsied polyp in 4 patients (20%). Hyperplastic polyps constituted 4 (20%) of the TAMIS procedures. We also had 2 (10%) patients with juvenile polyposis. The average age of patients was 45.4 years, while the youngest patient was 14-year-old male and the oldest 88-year-old female [Table 2]. The average time taken to do TAMIS was 42 min from scoring of lesions till suturing of the rectal wall defect. The shortest time was 30 min with the longest 90 min.
Table 1: Transanal minimally invasive surgery operations done at our institution

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Table 2: Demography of transanal minimally invasive surgery patients

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Patients who had adenomas underwent full-thickness excision with suturing of the rectal wall defect with 3-0 braided absorbable briaded suture in a running fashion.

Four patients underwent full-thickness excision after they had been diagnosed with carcinoma in situ. There was no specimen fragmentation and three of four had negative margins. One patient had tumor extending up to one of the resected margins. Due to her suspicion of nodal involvement, she underwent Lap low anterior resection (LAR) with coloanal pull through. Her final biopsy showed no tumor and none of the 14 lymph nodes removed had any tumor. She has completed 18 months of follow-up and her ileostomy has been reversed. She is disease free.

A 44-year-old male presented with mid rectal stricture following treatment of his prolapse by a quack which was done several years back. TAMIS was done – stricture was identified and a stirctureplasty was done. This patient underwent Hegar dilations twice and he has no stricture now. He has completed 28 months of follow-up.

In a 58-year-old lady with rectal bleeding, repeated biopsies were inconclusive. TAMIS was performed and her final biopsy showed mucinous adenocarcinoma.

TAMIS was also found a useful technique in a 52-year-old male where the internal opening was very high and could not be traced with a naked eye examination. TAMIS was used to locate and thread the internal opening and a seton was placed. A 88-year-old lady with obstructing right colon cancer with large rectal adenoma was referred by our gastroenterologist. She underwent laparoscopic right hemicolectomy followed by TAMIS. Both the procedures together took 3 h to perform. She tolerated both the procedures well. She went home on the 5th postoperative day on a normal diet. She has completed 4 months of follow-up.

Our longest follow-up is of 40 months. There has been no recurrence in our series so far.

Our smallest size of the rectal lesion was 1 cm and the largest 6 cm. Although we have done TAMIS in circumferential lesions, but most of these were scattered close to each other and a submucosal resection was done (juvenile polyposis). There were 11 males and 9 female patients in our series.


  Discussion Top


TAMIS was first done by Atallah in 2010, but he published his results in 2010.[1] Since then, it has gained rapid popularity in North America as well as outside.[6],[7] A large number of studies have shown the safety and efficacy of TAMIS.[1],[2],[7] Its indications and contraindications are the same as that of TEM.[1] Conventionally, it has been recommended to be applied to lesions <3 cm in size and occupying <30% of the rectal circumference.[8],[9] However, lesions occupying more than 40% of the rectal circumference and sleeve resections for circumferential rectal lesions have been reported with good results.[6],[10] As the experience of the surgeons is increasing, the indications are being pushed further.[10] TAMIS results in less specimen fragmentation and less margin positivity.[7] We have been doing TAMIS for more than 3 years now.[4],[5] Our indications have encompassed all range of rectal pathologies such as adenomas, polyps with dysplasias, hyperplastic polyps, rectal strictures, high anal fistula, and diagnostic biopsies. TAMIS is well tolerated in all age groups. Our youngest patient was 14 years old and our oldest patient was 88 years old. There has been no procedure associated with morbidity or mortality. We had no cases of specimen fragmentation or peritoneal entry. Only one patient had a margin-positive specimen in whom subsequent resection showed no residual cancer. We have not seen any recurrence in our series. We did not do any frozen sections. Margins were clearly marked and sent to pathology personally by the operating surgeon. In suspicions cases of cancer a full work up to rule out higher T stage of cancer or lymph node involvement was done. This included a pelvic magnetic resonance imaging and computed tomography scan of the chest, abdomen, and pelvis.[4],[5] Patients were counseled and explained that if there was upstaging of cancer, then a full resection shall be needed. The average distance from the anal verge was 7.4 cm.


  Conclusion Top


TAMIS is a safe and effective technique for the management of benign and early rectal cancer lesions of the rectum. Our mid-term outcomes are encouraging to continue using this technique for our patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Atallah S, Albert M, Larach S. Transanal minimally invasive surgery: A giant leap forward. Surg Endosc 2010;24:2200-5.  Back to cited text no. 1
    
2.
Lee L, Burke JP, de Beche-Adams T, Nassif G, Martin-Perez B, Monson JR, et al. Transanal Minimally Invasive Surgery for Local Excision of Benign and Malignant Rectal Neoplasia: Outcomes From 200 Consecutive Cases With Midterm Follow Up. Ann Surg 2018;267:910-6.  Back to cited text no. 2
    
3.
Buess G, Hutterer F, Thesis J, Bobel M, Isselhard W, Pichlmaier H. A system for a tranasanal endoscopic rectum operation. Chir Z Alee Geb Oper Medizen 1984;55:677-80.  Back to cited text no. 3
    
4.
Bamburle P, Sheikh MT, Mittal T, Dey A, Kumar A, Kanuri H, et al. Trans anal minimally invasive surgery initial experience. Curr Med Res Practice 2019;9:196-200.  Back to cited text no. 4
    
5.
Sheikh MT. Trans anal minimally invasive surgery. How I do it? Indian J Colorectal Surg 2019;2:3-5.  Back to cited text no. 5
    
6.
Atallah S, Albert M, Debeche-Adams T, Larach S. Transanal minimally invasive surgery (TAMIS): Applications beyond local excision. Tech Coloproctol 2013;17:239-43.  Back to cited text no. 6
    
7.
Clancy C, Burke JP, Albert MR, O'Connell PR, Winter DC. Transanal endoscopic microsurgery versus standard transanal excision for the removal of rectal neoplasms: A systematic review and meta-analysis. Dis Colon Rectum 2015;58:254-61.  Back to cited text no. 7
    
8.
National Comprehensive Cancer Network. Rectal Cancer (Version 6.2018). Available from: https://www.nccn.org/professionals/physician_gls/pdf/rectal.pdf. [Last accessed on 2020 Jun 20].  Back to cited text no. 8
    
9.
Monson JR, Weiser MR, Buie WD, Chang GJ, Rafferty JF, Buie WD, et al. Practice parameters for the management of rectal cancer (revised). Dis Colon Rectum 2013;56:535-50.  Back to cited text no. 9
    
10.
Arezzo A, Arolfo S, Allaix ME, Bullano A, Miegge A, Marola S, et al. Transanal endoscopic microsurgery for giant circumferential rectal adenomas. Colorectal Dis 2016;18:897-902.  Back to cited text no. 10
    



 
 
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