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Transanal minimally invasive surgery an option for certain rectal cancer patients

JAMA Surgery
Reuters Health - 27/11/2020 - In carefully selected rectal cancer patients, transanal minimally invasive surgery (TAMIS) is an option when local excision (LE) will likely be curative, researchers say.

Dr. Sam Atallah and Dr. Sergio Larach, colon and rectal surgeons in private practice in Orlando, reviewed the literature and wrote an overview of TAMIS, a method to locally excise premalignant and select malignant rectal lesions with curative intent. Among the key points, as reported in JAMA Surgery:

- TAMIS was developed in 2009 as an alternative to traditional LE techniques, such as the Parks transanal excision (TAE); transanal endoscopic microsurgery (TEM) preceded TAMIS and was developed in 1984.

- TAMIS outcomes seem to be comparable to those achieved with TEM; results from a multi-institutional analysis of 428 patients who underwent either TEM or TAMIS for LE showed a cumulative five-year disease-free survival of 80%(TAMIS) versus 78% (TEM), with no difference in the incidence of peritoneal violation (3% vs. 3%) and postoperative morbidity (11% vs. 9%).

- Both TAMIS and TEM result in high-quality LE, but TAMIS may enable surgeons with an established minimally invasive surgery background to quickly gain proficiency.

- TAMIS is an option for the LE of any sessile or pedunculated premalignant neoplasms not amenable to endoscopic retrieval, as well as select, invasive cancers.

- Most TAMIS operations for LE can be done on an ambulatory basis.

- Because benign rectal neoplasms can harbor an invasive component, the majority of rectal neoplasia - with certain exceptions - should be managed by full-thickness excision via a surgical approach using TAMIS or similar techniques.

- Lack of awareness among primary care physicians and gastroenterologists regarding the availability of TAMIS-experienced surgeons in their area probably represents the most important barrier to broader implementation of TAMIS.

- TAMIS requires expertise in rectal surgery, a strong minimally invasive surgery skill set, and careful case selection.

- Robotic TAMIS is in the early stages of development, but with further technological advances, may further improve excision quality.

Dr. Atallah did not respond to requests for a comment, but two colorectal cancer surgeons commented in emails to Reuters Health.

Dr. Jeffrey Farma, Chief of the Division of General Surgery at Fox Chase Cancer Center in Philadelphia said, "There is a learning curve for the technique and depending on the location of the lesion, (surgeons) may or may not be able to use this technique."

"TAMIS must be used in the appropriate context and patient selection is key," he noted. "Some patients who may have large polyps, premalignant rectal cancer, rare rectal tumors (GIST, carcinoid) or scars after neoadjuvant therapy for rectal cancer are potentially eligible for this procedure."

"Even though it is a less invasive procedure, there are still potential risks of infection, perforation, or injury to other structures," he said. "At our institution, we selectively use this procedure in the correct clinical context."

Dr. Marcos Szomstein, a colorectal surgeon at Miami Cancer Institute, noted, "An issue that doesn't seem to be mentioned in the review is that all TAMIS patients need to be under general anesthesia so the pneumorectum needed for the technique can be achieved. A significant number of conventional transanal excisions could be done with sedation and local, which could be more attractive for some patients."

"The instruments used for this procedure are the same as for laparoscopy procedures, which keeps the cost down compared to TEM," he said. "But at the same time, these tools, besides the camera, are all straight stiff instruments, which sometimes makes working in such a small cavity very difficult."

"The last part of the procedure is closure of the defect, which requires advanced laparoscopic suturing skills that not every laparoscopy surgeon has," he added. "There is definitely a learning curve even for good laparoscopic surgeons to master this technique."

By Marilynn Larkin

SOURCE: https://bit.ly/3lfeGZy JAMA Surgery, online November 18, 2020.


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