Pure NOTES Total Mesorectal Excision (TME) for Patients with Rectal NeoplasiaIs it possible to go all the way up from the anus?


Introduction: Pure Natural Orifice Transluminal Endoscopic Surgery (NOTES) has rare applications in routine abdominal surgery. Starting on 2009, we have developed a transanal, NOTES-inspired approach to TME (NOTESTME) in patients with rectal neoplasia. The aim was to further reduce or even avoid the abdominal wall invasiveness of laparoscopy in patients with rectal cancer. Eventually, this approach could reduce post-operative pain, decrease overall morbidity, preserve the abdominal wall, and enhance cosmesis.

Technique and Procedures: NOTESTME was attempted in 39 patients with mid or low rectal neoplasia. Additional criteria included ASA status I to III and the absence of prior major abdominal surgery.

Results: NOTESTME was completed without abdominal assistance in 15 patients (38.1 %).  Conversion to laparotomy occurred in 4 patients. (10.3 %).

In patients who had pure NOTESTME, mean operative time was 295 minutes (range, 195-540). NOTESTME was sphincter preserving with coloanal anastomosis in 11 patients (73.3 %) with (8 patients) or without (3 patients) diverting stoma. Four patients had NOTESTME with Miles procedure (26.7 %). Mortality rate was 0 %. Post-operative complication rate was 13.3 % (2 pelvic collections, 1 intestinal obstruction). No anastomotic leakage occurred. Resection was complete in all 15 patients. An average of 18 nodes were retrieved (range, 12-81). Mean length of hospital stay was 10.4 days (range, 4-29). One patient (6.7 %) was reoperated for pelvic collection.

Conclusions: NOTESTME was found to be safe and feasible in this series of selected patients with mid or low rectal cancer. The short-term mortality and morbidity results seemed to be acceptable with no compromise in the oncological quality of resection occurred as based on the histological analysis of the specimen. Longer term analysis is required.

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