Application of transanal endoscopic operation device in laparoscopic assisted transanal total mesorectal excision for the treatment of ultra-low rectal carcinoma

Abstract BackgroundTo evaluate the use of laparoscopic-assisted transanal, total mesorectal excision (ta-TME) in men with difficult pelvic anatomy in an attempt to optimize anal sphincteric preservation, determine the completeness of TME, and determine postoperative morbidity and mortality.MethodsTwenty male patients（laparoscopic-assisted transanal total mesorectal excision, A group）with difficult pelvic anatomy (narrow pelvis) who were diagnosed as rectal cancer underwent a Ta-TME surgery from January 2017 to January 2018 at Peking University Cancer Hospital. We matched these 20 patients with 2 other groups of patients who underwent either a laparoscopic transabdominal TME （LA group）or an open transabdominal TME（OP group）according to age, sex, BMI, distance of tumor from the anal verge, and diameter of the tumor. All 3 groups of patients had undergone preoperative neoadjuvant chemoradiation therapy. The efficacy and safety of Ta-TME were evaluated according to operative time, blood loss, postoperative hospital stay, and postoperative complications. Outcomes of Ta-TME were evaluated by comparing the rate of a positive circumferential resection margin, the integrity of the TME, and the rate of sphincter preservation among the 3 groups. We also analyzed whether operative time could be shortened using a laparoscopically assisted Ta-TME through optimizing the surgical procedure.ResultsWhen comparing Ta-TME（TA group）, laparoscopic transabdominal TME(LA group), and open transabdominal TME（OP group, the respective mean blood loss(100mL, 100mL, 100mL, p=0.335),postoperative hospital stay(9 days,9 days,7 days),number of harvested lymph nodes(7, 6, 7,), positive circumferential resection margin rate(0%, 0%, 5%), rate of pathologic complete response(5%,10%,10%,), and integrity of TME showed no statistical differences across groups (p>0.5 for all). In contrast, there were significant differences in operation time(302 min, 253 min, 135 min),rate preservation of the anal sphincter(100%, 30%, 45%,), and the creation of a protective diverting ileostomy(100%, 30%, 45%, p<0.05 for all).ConclusionThe rate of anal sphincter preservation in the Ta-TME group was considerably greater than the other groups, but the safety of the operation did not differ among the 3 groups. The Ta-TME required a diverting ileostomy in all cases, and the total operation time for Ta-TME was greater than that of laparoscopic and open transabdominal TME. We believe that experience and appropriate procedure of the steps of the Ta-TME may lead to a decrease in the operation time.

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Wasmuth HH, Færden AE, Myklebust TÅ, et al (2020) Transanal total mesorectal excision for rectal cancer has been suspended in Norway. Br J Surg 107:121–30

Côlon & Rectum ◽

10.3166/cer-2020-0146 ◽

2020 ◽

Vol 14 (3) ◽

pp. 155-158

Author(s):

M. Aubert ◽

Y. Panis

Keyword(s):

Rectal Cancer ◽

Total Mesorectal Excision ◽

Cancer Du Rectum ◽

Prise En Charge ◽

Transanal Total Mesorectal Excision ◽

Mesorectal Excision ◽

Récidive Locale ◽

Kaplan Meier ◽

Cancers Colorectaux ◽

Technique Chirurgicale

Contexte : L’exérèse totale du mésorectum par voie transanale (TaTME) pour la prise en charge du cancer du rectum est récemment apparue comme alternative à l’exérèse totale du mésorectum par voie abdominale. Cependant, certaines inquiétudes à propos des résultats oncologiques de cette technique chirurgicale ont émergé. Le but de cette étude était d’évaluer le taux de récidives locales après TaTME. Les objectifs secondaires s’intéressaient à la mortalité postopératoire, au taux de fistule anastomotique et au taux de stomie définitive. Méthodes : Les données de tous les patients opérés par TaTME ont été rapportées et comparées aux données issues des registres nationaux norvégiens de cancers colorectaux (NCCR) et de chirurgie gastro-intestinale (NoRGast). Les taux de récidive locale étaient estimés selon Kaplan-Meier. Résultats : En Norvège, 157 patients ont été opérés par TaTME pour un cancer du rectum entre octobre 2014 et octobre 2018. Trois des sept centres hospitaliers participants ont abandonné la réalisation de cette intervention après cinq procédures. Le taux de récidive locale était de 12 sur 157 patients (7,6 %) ; huit récidives locales étaient multifocales ou étendues. Le taux de récidive locale après un suivi de à 2,4 ans était estimé à 11,6 % (IC 95 % : [6,6‒19,9]) après TaTME contre 2,4 % (IC 95 % : [1,4‒4,4]) dans le registre NCCR (p < 0,001). Le hasard ratio était estimé à 6,71 (IC 95 % : [2,94‒15,32]). Le taux de fistule anastomotique nécessitant une réintervention était de 8,4 % dans le groupe TaTME contre 4,5 % dans le registre NoRGast (p = 0,047). Cinquante-six patients (35,7 %) étaient porteurs d’une stomie à la fin du suivi, dont 39 (24,8 %) étaient définitives. Conclusion : Le taux de fistule anastomotique était plus élevé après TaTME en comparaison aux données des registres nationaux norvégiens. Le taux de récidive locale ainsi que les caractéristiques de cette récidive après TaTME étaient défavorables.

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Deep learning-based automatic surgical step recognition in intraoperative videos for transanal total mesorectal excision

Surgical Endoscopy ◽

10.1007/s00464-021-08381-6 ◽

2021 ◽

Author(s):

Daichi Kitaguchi ◽

Nobuyoshi Takeshita ◽

Hiroki Matsuzaki ◽

Hiro Hasegawa ◽

Takahiro Igaki ◽

...

Keyword(s):

Deep Learning ◽

Total Mesorectal Excision ◽

Rectal Wall ◽

Learning Model ◽

Video Indexing ◽

Video Data ◽

Transanal Total Mesorectal Excision ◽

Mesorectal Excision ◽

Purse String ◽

Deep Learning Model

Abstract Background Dividing a surgical procedure into a sequence of identifiable and meaningful steps facilitates intraoperative video data acquisition and storage. These efforts are especially valuable for technically challenging procedures that require intraoperative video analysis, such as transanal total mesorectal excision (TaTME); however, manual video indexing is time-consuming. Thus, in this study, we constructed an annotated video dataset for TaTME with surgical step information and evaluated the performance of a deep learning model in recognizing the surgical steps in TaTME. Methods This was a single-institutional retrospective feasibility study. All TaTME intraoperative videos were divided into frames. Each frame was manually annotated as one of the following major steps: (1) purse-string closure; (2) full thickness transection of the rectal wall; (3) down-to-up dissection; (4) dissection after rendezvous; and (5) purse-string suture for stapled anastomosis. Steps 3 and 4 were each further classified into four sub-steps, specifically, for dissection of the anterior, posterior, right, and left planes. A convolutional neural network-based deep learning model, Xception, was utilized for the surgical step classification task. Results Our dataset containing 50 TaTME videos was randomly divided into two subsets for training and testing with 40 and 10 videos, respectively. The overall accuracy obtained for all classification steps was 93.2%. By contrast, when sub-step classification was included in the performance analysis, a mean accuracy (± standard deviation) of 78% (± 5%), with a maximum accuracy of 85%, was obtained. Conclusions To the best of our knowledge, this is the first study based on automatic surgical step classification for TaTME. Our deep learning model self-learned and recognized the classification steps in TaTME videos with high accuracy after training. Thus, our model can be applied to a system for intraoperative guidance or for postoperative video indexing and analysis in TaTME procedures.

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