Stanadardization of the Approach to Transanal NOTES Total Mesorectal Excision (TME) in Patients with Rectal Cancer: Is Anatomy better preserved?

Elie K Chouillard, MD, PhD, Elias Chahine, MD, Sylvia Quarisima, MD, Beatrice Vinson Bonnet, MD, Agathe Regnier, MD, Silviu Bors, MD. Paris Poissy Medical Center

Background: Natural Orifice Transluminal Endoscopic Surgery (NOTES) and single-incision laparoscopy are emerging, minimally invasive techniques. Total mesorectal excision (TME), the gold standard treatment for patients with resectable distal rectal tumors, is usually performed in an “up-to-down” approach, either laparoscopically or via open techniques. We already reported a NOTES, transanal, “down-to-up” variant of TME (NOTES TME) (Group A). The aim of the present study was to assess the short term results of NOTES TME as compared to standard, “up-to-down” laparoscopic TME (S TME) in patients with rectal cancer (Group B).

Methods: All patients had distal rectal neoplasia (i.e., distal edge of the tumor lower than the pouch of Douglas, between 0 and 12 cm from the dentate line). Additional inclusion criteria consisted of an ASA status ≤ III and the absence of previous abdominal surgery. Compared parameters included operative identification of the sacral nerves (photos), short term outcome, and histologic assessment of the specimen.

Results: Group A comprised 18 patients (4 men and 14 women) and Group B 14 patients (5 men and 9 women), respectively. TME was completed in all patients. Mean operative time was 245 minutes (range= 155-440 min) in Group A and 275 minutes (range= 180-400 min) in Group B, respectively. Sacral nerves were formally identified in 14 patients in Group A and in only 4 patients in Group B (p<0.05). No leak occurred and the mortality rate was 0%, in both groups. Resection margins were negative in all patients.

A comparative analysis of the operative specimens was performed in both groups. A median of 17 lymph nodes (range, 12-31) was retrieved per specimen in Group A and 12 (range, 8-19) in Group B, respectively (p<0.05). Circumferential margins were comparable in both groups. However, the lower third of the mesorectum as assessed on the operative specimen was significantly thicker in patients with group A (p<0.05). Mean length of hospital stay was comparable in both groups. 30-day morbidity rate was comparable in both groups (p<0.05).

Conclusion: NOTES TME was feasible and safe in this series of patients with mid- or low rectal tumors. Moreover, as compared to the S TME, the NOTES TME seems to offer more advantages including clearer definition of anatomy and better preservation of the lower mesorectum.

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