Preoperative Diagnostic Uncertainty in T2–T3 Rectal Adenomas and T1–T2 Adenocarcinomas and a Therapeutic Dilemma: Transanal Endoscopic Surgery, or Total Mesorectal Excision?

Background: Endorectal ultrasound and rectal magnetic resonance are sometimes unable to differentiate between stages T2 and T3 in rectal adenomas that are possible adenocarcinomas, or between stages T1 and T2 in rectal adenocarcinomas. These cases of diagnostic uncertainty raise a therapeutic dilemma: transanal endoscopic surgery (TES) or total mesorectal excision (TME)? Methods: An observational study of a cohort of 803 patients who underwent TES from 2004 to 2021. Patients operated on for adenoma (group I) and low-grade T1 adenocarcinoma (group II) were included. The variables related to uncertain diagnosis, and to the definitive pathological diagnosis of adenocarcinoma stage higher than T1, were analyzed. Results: A total of 638 patients were included. Group I comprised 529 patients, 113 (21.4%) with uncertain diagnosis. Seventeen (15%) eventually had a pathological diagnosis of adenocarcinoma higher than T1. However, the variable diagnostic uncertainty was a risk factor for adenocarcinoma above T1 (OR 2.3, 95% CI 1.1–4.7). Group II included 109 patients, eight with uncertain diagnosis (7.3%). Two patients presented a definitive pathological diagnosis of adenocarcinoma above T1. Conclusions: On the strength of these data, we recommend TES as the initial indication in cases of diagnostic uncertainty. Multicenter studies with larger samples for both groups should now be performed to further assess this strategy of initiating treatment with TES.

ASSESSMENT OF TECHNICAL ABILITIES IN ENDOSCOPIC SURGERY SIMULATED BY MEDICINE STUDENTS

INTRODUCTION Simulation training has become a widely accepted educational tool for the development of technical skills in endoscopic surgery. The objective of this work was to evaluate bachelors who hold a Degree in Medicine in the execution of exercises carried out in both physical and virtual simulations. MATERIAL AND METHODS The descriptive study was carried out among 400 students (266 women and 134 men) in their third year of medicine studies between 2016 and 2019. The practises consisted of 11 hours of teaching, made of theory introduction, and exercise work in groups of 15-20 students on 4 workstations: LapSim, Pelvitrainer, Transanal Endoscopic Surgery (singleport) and Flexible Endoscopy. The execution time per individual exercise and in pairs is collected. RESULTS Individual exercises: the average execution time was: 277.0±117.8 sg, LapSim: 158.8± 66.44 sg and Pelvitrainer: 123.6±82.7sg. Couple exercises: the average execution time in Transanal Endoscopic Surgery was: 79.4±51.9 sg and Flexible Endoscopy: 53.56±34.4 sg. The analysis by gender showed that men performed better in LapSim with an average of 141.4 sg ± 52.2 in respect to women, 167.8 sg ± 71.1 (p < 0.05). In the rest of the exercises, no significant differences were shown. CONCLUSIONS Conducting simulated practises or studies for further development in the Degree is feasible, with objective evaluations of the skills acquired. The possibility of interacting in a controlled environment and with immediate feedback has made it possible to identify baseline differences by gender only in virtual simulation.

Education and Training in Transanal Endoscopic Surgery and Transanal Total Mesorectal Excision

There is a paradigm shift in surgical training, and new tool and technology are being used to facilitate mastery of the content and technical skills. The transanal procedures for rectal cancer—transanal endoscopic surgery (TES) and transanal total mesorectal excision (TaTME)—have a distinct learning curve for competence in the procedures, and require special training for familiarity with the “bottom-up” anatomy, procedural risks, and managing complex cases. These procedures have been models for structured education and training, using multimodal tools, to ensure safe implementation of TES and TaTME into clinical practice. The goal of this work was to review the current state of surgical education, the introduction and learning curve of the TES and TaTME procedures, and the established and future models for education of the transanal procedures for rectal cancer.

Current Challenges for Education and Training in Transanal Surgery

Transanal endoscopic microsurgery (TEM) is a technique that was introduced in the 1980s for improved exposure to upper rectal polyps. This technique, though initially difficult to master due to new skill acquisition for surgeons, has spared many patients proctectomy. There are many benign indications for transanal endoscopic surgery which has led to in vivo operating room training with fewer undesirable effects to the patient. With the explosion of laparoscopic technology this transanal technique is no longer limited to intraluminal pathology, but is now being used to remove the entire rectum. In transanal total mesorectal excision (taTME), benign indications are less common, translating to potentially more severe oncologic patient consequences during the early phase of adoption. For this reason, strict training criteria consensus guidelines have been developed by the experts in taTME. The current consensus statements agree that training surgeons should have performed a minimum of 10 laparoscopic TME procedures and should have some experience with transanal surgery. Surgeons need to attend a formal training course and should start clinically on benign or early malignant pathology without threated circumferential resection margins. Surgeons also need to have their first cases proctored until deemed proficient by the proctor and monitor their morbidity, oncologic, and functional outcomes prospectively.

Rectovaginal Fistula With Double Vagina and Anastomotic Stenosis: A Case Report Following Rectal Cancer Surgery

Rectovaginal fistula (RVF) occurs as a result of abnormal epithelialized connections between the rectum and vagina. Rectal cancer surgery remains the major cause of RVF. Here, we report a rare postoperative complication in which a patient with a double uterine and vagina received RVF following rectal cancer surgery. The patient received radiotherapy and developed rectal anastomotic stenosis leading to scar hyperplasia around the fistula, making repair difficult. Complex RVF is prone to release, which despite the multitude of procedures and treatments reported, optimal strategies remain controversial. Our previous studies showed how the use of rectal mucosal advancement flap (RMAF) with transanal endoscopic surgery (TES) can repair mid-low RVF. We successfully repaired RVF and rectal anastomotic stenosis with staging TES in this complex case. This highlights the safety and utility of TES treatment for complex RVF. Further studies are now required to confirm its effectiveness.