Published online Jun 15, 2018. doi: 10.4251/wjgo.v10.i6.137
Peer-review started: March 12, 2018
First decision: April 10, 2018
Revised: April 26, 2018
Accepted: May 30, 2018
Article in press: May 30, 2018
Published online: June 15, 2018
Local excision is regarded as the standard treatment for mid-low rectal neoplasia, including benign tumors and early-stage malignancy. Due to the disadvantages in exposure, high quality of local excision could not be well guaranteed, though trans-anal endoscopic microsurgery (TEM) could merely provide solutions in certain conditions. Therefore, it is essential to call for another technique to fill the gap in-between. Recently, trans-anal minimally invasive surgery (TAMIS) has been introduced as an alternative choice for rectal lesions.
TAMIS surgery was reported by literature with relatively small amount of cases, however, there has been no published data on TAMIS surgery on the Chinese population. The safety and feasibility of TAMIS is still lack of evidence.
This study was designed to investigate the utility of TAMIS technique with both favorable and unfavorable factors.
TAMIS surgery was done by a standard laparoscopic platform (SILS Port). Patients’ characteristics, surgery duration, pathological diagnosis and post-operative complications (Clavien-Dindo classification) were collected.
The research findings, their contributions to the research in this field, and the problems that remain to be solved should be described in detail. Among 25 patients enrolled, 10 (40%) patients were male, with the mean age of the patients 51.8 and the mean body mass index 23.9 kg/m2. Mean diameter of the lesions was 1.1 cm (range from 0.5 to 2 cm) and the mean distance to anal verge was 8.4 cm (range from 5 to 10 cm). 3 (12%) patients was diagnosed benign lesions (adenomas), 22 (88%) were malignancies (16 with neuroendocrine tumors (NETs) and 6 with adenocarcinoma (5 patients pT1, and 1 pT3). Positive resection margin (less than 1 mm) was revealed in 5 patients and lymph-vascular invasion was seen in 1 patient. Eighteen (72%) TAMIS surgeries were performed in the Lloyd-Davies position, with the rest in jackknife position. The mean duration of was 61.3 min (ranger from 25 to 105 min), with mean blood loss 8.2 mL (range from 5 to 20 mL) and no conversion to laparoscopic surgery. No operative mortality or serious complication (over grade 3 by Clavien-Dindo grading system), and the mean length of hospital stay was 2.7 d post-operatively. A laparoscopic surgeon would be proficient to perform TAMIS surgery with around 10 cases.
TAMIS could be safe and feasible technique to early stage rectal neoplasia. Laparoscopic surgeons would be proficient for TAMIS with approximately 10 cases. TAMIS might provide an alternative method with conventional laparoscopic apparatus, compared with TEM. This study demonstrated the first piece of evidence of peri-operative data and short-term outcome in patients treated with TAMIS in Chinese tertiary hospital. TAMIS is a safe method treating early stage rectal neoplasia. Surgical position might have a significant effect on the positivity of resection margin, and Lloyds-Davies position might not be appropriate for anterior lesions. TAMIS could offer full-thickness resection and minimal sphincter injury. TAMIS might be an alternative choice for patients with early stage rectal neoplasia.
TAMIS could be feasible by utilizing laparoscopic apparatus. For lesion located anteriorly, it might be better with jackknife position. It might be essential to know the rate of positivity concerning resection margin with larger number of cases prospectively; and it worth a try to use TAMIS in down-stage rectal cancer patients underwent neoadjuvant chemoradiation for re-staging and curative intent. A prospective clinical trial might be a good choice.