Authors’ note: This article reports our application of the latest international rectal cancer procedure “NOTES transanal total rectal mesorectal resection” to treat a male rectal cancer case on May 21, 2010, probably because of the innovative nature of this procedure. The author gave a free speech at the 12th National Conference on Laparoscopic and Endoscopic Surgery of the Chinese Medical Association held in Suzhou on August 27, 2010. The significance of this procedure is discussed in the article, so we will not repeat it here.
NOTES transanal endoscopic total rectal mesorectal resection for rectal cancer
Chen Yuanguang, Hu Ming, Lei Jian, Chen Jiacheng, Li Juanyun, Department of General Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
Department of Gastrointestinal Surgery, The First Affiliated Hospital of Guangzhou Medical University
No.151 Yanjiang Road, Guangzhou 510120, China
Email [email protected]
Abstract
Background and objectives Total rectal mesenteric resection has become the worldwide gold standard for rectal cancer surgery, which is traditionally performed via the anterior abdominal wall, either open or laparoscopically. transanal natural lumpectomy of the rectum and sigmoid colon has been studied since 2007. transanal endoscopic resection was first reported internationally in May 2010 for a female rectal cancer patient following the principle of total rectal mesenteric resection. This article reports for the first time the application of this new procedure in a male rectal cancer patient with combined left-sided free kidney in May 2010.
The tumor diameter was reduced from 3 cm to 1.5 cm after neoadjuvant chemotherapy, and the operation was initially divided into two groups: the proposed abdominal group was divided from the upper rectum and sigmoid colon, its mesentery and submesenteric vessels with the assistance of transabdominal laparoscopy, and the anal group was free from the rectal mesentery. However, the submesenteric vessels could not be found in the abdominal group because of the interference of the left pelvic wandering kidney, and then the surgeon in charge of the anal group completed the two groups alternately. After transection of the rectal wall under the PPH anoscope, the operator completed the above operation in the abdominal group first, and then performed the operation in the anal group, separating the rectal mesentery upward through the homemade lumbar proctoscope according to the TME principle until entering the abdominal cavity through the anterior sacral space. After entering the abdominal cavity, the separation of the anterior part of the pelvic floor peritoneum was difficult because of the obstruction of the seminal vesicle gland, i.e., it was performed laparoscopically through the anterior abdominal wall. After confirming that the length of the sigmoid colon was free enough, the rectum and sigmoid colon were dragged out via anorectoscope, and the sigmoid colon was cut off and anastomosed with an anastomosis between the rectum and sigmoid colon.
The operation time was 4 hours and 50 minutes, and the rectal mesentery was completely resected and 25 lymph nodes were detected, among which 5 lower rectal mesenteric lymph nodes were positive and the distal margins of the rectum and its mesentery were negative, and the final pathological stage was pT3N2. The patient recovered well after the operation, and oral enteral nutrition was started on the second day, and semi-fluid diet and normal diet were started on the fifth and eighth days, respectively. No anastomotic leak or infection occurred, and defecation function was near normal after the seventh day.
Conclusions Natural lumen surgery with transanal endoscopic total rectal mesenteric resection is feasible and safe, and laparoscopic assistance helps to overcome the difficulty of separation caused by the seminal vesicle gland and the free kidney .
Keywords natural lumen surgery, total rectal mesenteric resection, laparoscopy, rectal cancer, free kidney, transanal
NOTES Transanal Endoscopic Total Mesorectal Excision For Rectal Cancer
Yuanguan Chen,Ming Hu,Jian Lei,Jiacheng Chen,Juanyun Li
Department of Gastrointestinal Surgery, 1st Affiliated Hospital of Guangzhou Medical College
510120,Number 151,Yanjiang Road,Guangzhou City,China
e-mail: [email protected]
Abstract
Background Total mesorectal excision(TME) has become the worldwide gold standard for rectal cancer,its traditional laparotomy or laparoscopic procedure is performed through the anterior abdominal ablation. Since 2007, Natural OrificeTranslumenal Endoscopic Surgery (NOTES) transanal excision has become the worldwide gold standard for rectal cancer, its traditional laparotomy or laparoscopic procedure is performed through the anterior abdominal wall. endoscopic rectosigmoid resection has been studied in human cadavers and porcine models. The first clinical report of a woman patient of NOTES transanal endoscopic rectal resection with TME for rectal cancer using laparoscopic assistance was published in May 2010. We first report the new procedure applied on a man patient with rectal cancer and left ectopic pelvic kidney in May 2010.
Methods The patient was a 47-year-old man with a CT3N0 rectal cancer combined with left ectopic pelvic kidney and pelvic appendix ,the tumor had a diameter of 3 cm before and 1.5 cm after the surgery. The tumor had a diameter of 3 cm before and 1.5 cm after neoadjuvant chemotherapy , his body mass index (BMI) was 22 kg/m2. Transabdominal laparoscopic dissection of the Transabdominal laparoscopic dissection of the rectosigmoid and the inferior mesenteric vessels was planned to be performed synchronously with transanal endoscopic mobilization of mesorectum at first,but searching for the inferior mesenteric vessels was puzzled by ectopic pelvic kidney and it was too difficult for abdominal team to do, then the The rectum was transected through PPH anoscope at first and then the operator who was in charge of transanal procedure finished both transabdominal and transanal dissection in turn. The rectum was transected through PPH anoscope at first and then the above abdominal dissection was finished, the mesorectum was mobilized upwards to peritoneal cavity with the TME After entering the peritoneal cavity from the presacral plane, the forepart of pelvic floor After entering the peritoneal cavity from the presacral plane, the forepart of pelvic floor peritoneum was hindered by the seminal vesicle, and was dissected under transabdominal laparoscope. sigmoid colon had been mobilized, the rectosigmoid was exteriorized transanally, and the specimen was transected transanally followed by staped The length of sigmoid colon had been mobilized, the rectosigmoid was exteriorized transanally, and the specimen was transected transanally followed by staped colorectal anastomosis.
The operative time of was 4 hours and 50 minutes. Mesorectal excision was complete,25 lymph nodes were retrieved from the specimen, and the final The pathology demonstrated pT3N2 with 5 positive nodes of lower mesorectum and negative margins of distal rectum and mesorectum. The patient recovered smoothly . Enteral nutrition ,semi-liquid diet and normal diet was taken respectively on the second, fifth and eighth postoperative day. no anastomotic leakage No anastomotic leakage and infection was encountered, nearly normal defecation came back on the seventh postoperative day.
Conclusions NOTES transanal endoscopic TME in man patient for rectal cancer combined with ectopic pelvic kidney is feasible and safe. The laparoscopic assistance is helpful to overcome difficulties caused by left pelvic ectopic pelvic kidney and seminal vesicle.
Keywords Natural orifice translumenal endoscopic surgery,Total mesorectal excision , Laparoscopy , Rectal cancer, Ectopic pelvic kidney , Transanal
0 Introduction
Total mesorectal excision (TME), first reported by Heald in 1982, is the most important advancement in rectal cancer surgery in recent years and has now become the worldwide gold standard [1-4]. Conventional TME, whether performed openly or laparoscopically, is performed through the anterior abdominal wall and often requires large or small abdominal wall incisions for the separation and removal of the specimen, which can lead to risks and complications such as infection, bleeding, wound pain, and distant hernia formation. To eliminate these incisional complications, since 2007, studies have attempted resection of the rectum and sigmoid colon in a porcine model as well as in human cadavers with Natural OrificeTranslumenal Endoscopic Surgery (NOTES) and found that this method without abdominal incision was feasible and that TME could be done transanally [ The first international report of NOTES transanal endoscopic resection for a female rectal cancer patient following the principles of TME was made in May 2010 [12].
However, to date, no reports of NOTES transanal endoscopic resection according to TME principles in male rectal cancer patients have been reported, so there is no way to know the characteristics of the procedure in male patients. In this paper, we report for the first time the performance of this new procedure in a male patient with rectal cancer. Interestingly, this patient also had a left-sided free kidney.
1 Clinical data and surgical approach
The surgeon had experience in traditional TME, transanal surgery for rectal prolapse and congenital megacolon. Before performing this new procedure, the surgical team performed successful animal experiments using pigs as a model, and hospital approval consent and informed consent from the patient were obtained for the new procedure. In order to avoid potential adverse effects of pelvic free kidney and to shorten the operation time, the preoperative discussion was designed to treat the intra-abdominal rectosigmoid colon and its mesentery as well as the inferior mesenteric vessels laparoscopically through the anterior abdominal wall and the extra-abdominal rectum and its mesentery endoscopically through the anus.
1.1 General clinical data
This 47-year-old male patient with a body mass index of 22 kg/m2 and no previous history of major diseases was found to have a mass in the left anterior wall of the rectum, 5 cm from the anal verge, by anal finger examination and proctoscopy for two weeks due to blood in the stool. After three cycles of neoadjuvant chemotherapy with FOLFORI regimen, the tumor diameter was reduced from 3.5 cm to 1.5 cm. Preoperative pelvic MRI showed that the infiltration in the fatty space next to the rectum was significantly reduced, and there were no obvious enlarged lymph nodes in the mesentery.
1.2 Preoperative preparation
Oral compound polyethylene glycol was administered in the afternoon of the day before surgery for intestinal preparation. Cephalosporin was applied intravenously before the start of surgery to prevent infection. A urinary catheter and central venous catheter were left in place after general anesthesia. The rectum was disinfected with iodine irrigation in the lithotomy position.
1.3 Surgical methods
1.3.1 Trans-anterior abdominal wall laparoscopic observation and exploration
A pneumoperitoneum was established by subumbilical Veress needle puncture with a pressure of 12 mmHg, and then a 10-mm trocar and laparoscope were placed. A 10-mm trocar was placed in the right lower abdomen as the main operation hole, and a 5-mm trocar was placed in the left lower abdomen and suprapubic bone as the secondary operation hole. No liver or other organ metastases were found laparoscopically, and there were no pelvic adhesions, but the left pelvic kidney pushed the sigmoid colon and upper rectum and its mesentery forward and upward to the right, while the appendix was attached to the right wall of the rectum in pelvic position. After the exploration, the abdominal and anal groups started to operate simultaneously, but the abdominal group was unable to overcome the difficulties caused by the free kidney to find the submesenteric vessels after freeing the pelvic appendix. The planned operator in charge of the anal group then alternated between the two groups.
1.3.2 Transanal endoscopic freeing of the rectal mesentery
The PPH anoscope was inserted into the anus and sutured to the perianal skin, and the rectal wall cut line was designed in a V-shape, with the tumor side being 3 cm from the anal verge and the opposite side being 4 cm. After the submucosal injection of melanin to mark the cut line, a purse-string suture was made to close the rectal cavity, and then the rectal wall was cut with the ultrasonic knife in its entirety, and the prostatic rectal space (Figure 1) and the presacral space were entered after the cut without seeing the mesenteric fat. After the rectum was transected, the distal end of the rectum was circumferentially contracted, which hindered the operation. After the rectum was free from the rectal mesentery for about 2 cm, the operation was extremely difficult, and the anoscope was removed and replaced with a homemade waist-shaped proctoscope (patent pending). This proctoscope is 8 cm long, 4 cm in diameter at the center of the waist and 5.5 cm in diameter at the upper end. When used, the anus is dilated and fixed in the center of the waist, and the distal rectum is dilated and fixed outside the upper part of the waist, which no longer hinders operation. From this scope, the separation is performed from below upwards according to the TME principle in the avascular zone between the visceral layers of the pelvic fascia wall, entering the abdominal cavity through the presacral space (Figure 2), taking care not to damage the prostatic seminal glands as well as the presacral vessels. After entering the abdominal cavity, the posterior fall of the seminal vesicle gland fills the anterior half of the proctoscopic field of view, making it difficult to separate the anterior part of the pelvic floor peritoneum, so the lumbar rectoscope is closed with gloves and the anterior part of the pelvic floor peritoneum is cut off by the abdominal operation
Figure 1. Transanal proctoscopic access to the prostatic rectal space
Figure 2. Transanal proctoscopic access to the abdominal cavity through the anterior sacral space
1.3.3 Trans-anal laparoscopic separation of the anterior abdominal wall
Because of the interference of the pelvic wandering kidney, the laparoscopic separation of the abdominal aortic bifurcation, a conventional medial access marker, was not seen. After careful observation, the operator found that the medial mesenteric margins of the rectum and sigmoid colon were still faintly visible, but were only pushed to the right side for several centimeters, i.e., the mesenteric margins were separated from below the right iliac artery along the mesenteric margins from the bottom up to the root The roots of the mesenteric vessels were naked and then clamped under the left colonic artery with an absorbable clip and cut off with an ultrasonic knife. After freeing the rest of the sigmoid mesentery, the mesentery was cut radially to the intestinal wall 5 cm above the ethmo-rectal junction, and then the rectal mesentery was free down to the level of peritoneal reflex and discontinued, and then the anterior part of the pelvic floor peritoneum was cut by laparoscopic operation after the rectal mesentery under the peritoneal reflex had entered the abdominal cavity from the presacral area. The laparoscopic confirmation of the sigmoid colon length was sufficient for anastomosis, and the sigmoid rectal specimen was dragged out of the anus through the proctoscope in a plastic bag.
1.3.4 Colorectal anastomosis
The sigmoid colon was cut at 5 cm above the sigmoid-rectal junction outside the anus, and the proximal end of the anastomotic anvil was placed into the abdomen and reinserted into the PPH anoscope, and a drainage tube was placed in the pelvic floor to lead out from the anal side, and the distal end of the rectum was sutured with a 32-gauge circular anastomosis. An anal tube was placed in the anus for drainage, and the head of the anal tube was placed about 10 cm above the anastomosis. Finally, an anastomotic leak test was performed, and no leak was found.
2 Results
2.1 Intraoperative procedure and what was seen
It is easy to perform full transection of the rectal wall via PPH anoscopy, and also easy to access the prostatic rectal space as well as the presacral space. The distal transection of the rectal wall shrinks into a loop under the anoscope, which initially prevents upward freeing of the rectal mesentery, but can be utilized later to facilitate purse-string suturing. With a lumbar proctoscope, the distal constricted ring of the rectal wall can be expanded outside the scope, thus creating an operating space sufficient for rectal mesenteric evacuation without the need to inflate the TEM platform to create the operating space. Transanal rectal mesenteric freeing can be performed up to the level of peritoneal reflex, where freeing at this level must be done by transabdominal laparoscopy because of the obstruction of the free kidney and seminal vesicle glands. The total operative time was 4 hours and 50 minutes.
2.2 Postoperative pathology and recovery
The pelvic fascia around the rectum was intact except for a 1.5-cm-long fissure near the right vesicoureteral gland (Figure 3). A total of 25 lymph nodes were detected on the specimen, and the final pathology reported that the rectal medium-differentiated adenocarcinoma infiltrated the entire intestinal wall, and 5 of the 8 lymph nodes in the lower mesentery had metastases, and the margins of the intestinal wall and mesentery were negative.
The patient recovered well after surgery, and began to take oral onsite nutrition on the second day, and started semi-liquid and normal diet on the fifth and eighth day, respectively; a small amount of bloody fluid was drained from the paranal drainage tube at the beginning of the postoperative period, and the drainage fluid turned yellow and clear in a few hours, and the amount was small; there was no anastomotic leak or infection, and the anus began to vent and defecate on the third day, and the paranal drainage tube was removed on the fifth day, and the defecation function was nearly normal after one week. The postoperative abdominal wall appearance was satisfactory (Figure 4).
Figure 3 Excised specimen
Figure 4 Postoperative abdominal appearance
3 Discussion
NOTES transanal endoscopic TME expands the indications for NOTES and can achieve both radical treatment of rectal cancer and minimally invasive and cosmetic results without incision of the abdominal wall [5-12]. Like the first female procedure performed by Sylla et al [12], the present case of a male rectal cancer with combined pelvic roaming kidney showed that NOTES transanal TME is also feasible in men, and the satisfactory oncologic results and the absence of anastomotic leakage and infection suggest that it is a safe new procedure.
When freeing the rectal mesentery, the traditional open or laparoscopic TME enters the abdominal cavity through the anterior abdominal wall, starting from the top down near the peritoneal reflex and ending near the distal rectal end, which has a larger operating space and easily identifiable levels; while the NOTES transanal TME is in the opposite order of the traditional TME, with a smaller operating space. Can the ligament be intact? This is the key question related to its feasibility. Consistent with the report in the literature [12], the present case showed easy access to the full transverse rectal wall under trans-PPH anoscopy, as well as to the prostatic rectal space as well as the presacral space, with complete mesenteric resection, tentatively suggesting that NOTES transanal TME is feasible.
Since the first clinical NOTES transgastric resection of the appendix was reported in 2005, studies of transgastric and vaginal procedures have far outnumbered those of transcolonic and anal procedures, mainly because of the possibility of postoperative infection due to fecal contamination of the abdominal cavity in the latter; in the case of NOTES transanal endoscopic rectosigmoid resection, recent studies do not support this possibility of infection [7,12]. Infection did not occur in this case either. The reason for this may be that the occurrence of infection is not only related to bacterial contamination, but also to the degree of contamination and anti-contamination measures. In the case of NOTES rectal resection, adequate preoperative bowel preparation, preoperative intestinal disinfection, closure of the bowel segment above the proximal end from the beginning of surgery, extremely short bowel segment below the distal end close to the body for easy disinfection, and appropriate postoperative pelvic floor drainage can result in a contaminated but infection-free surgical area.
Most of the experiments reported in the literature were performed on female pigs, and the first clinical applications were performed on female patients [6,7,10-12]. The authors had conducted experiments with male pigs before clinical application and found that the posterior fall of the seminal vesicle gland after transanal free rectal mesentery into the abdominal cavity obstructed the visualization and manipulation, and the same phenomenon was found in the clinical application of this case. This difficulty was overcome in this case with the aid of laparoscopic manipulation. Whether there is a better approach such as the application of a flexible mirror remains to be further investigated. In addition, in this case, the combined pelvic wandering kidney could not be located in accordance with the conventional laparoscopic medial approach sign to find the submesenteric vessels, but it was still possible to separate along the faintly visible medial mesenteric margin of the rectosigmoid colon up to the root, and the wide transabdominal laparoscopic field of view facilitated the observation, suggesting that the anomalous anatomy could be resolved by a combination of laparoscopic endoscopic techniques, without being bound to the application of one method such as NOTES alone.
Compared to conventional dissection and laparoscopic TME, TME with NOTES eliminates abdominal incisions and the corresponding complications [5-12]. TME by the transanal route has specific advantages over other routes such as transgastric and vaginal for NOTES. First, the transanal route allows for maximum radicalization while preserving anal function, as it allows the rectum to be cut under direct anoscopic view and, if necessary, a rapid pathological section of the distal rectal cut margin can be performed at the beginning of the procedure to determine the presence or absence of cancer residue. Secondly, the transanal route is the least invasive because other routes to approach the tumor require the passage of normal healthy tissues, while the transanal route passes through the tissues that need to be resected for treatment, and the rectal mesentery under the retroperitoneum can be freed from inflation by the transanal route, which can shorten the operation time if performed simultaneously with the transabdominal operation. Thirdly, the transanal route is the most suitable for the largest number of patients, and there is no gender difference, because this method does not require incision of the vagina and is suitable for both men and women. Fourth, the transanal approach is more economical because the distal end of the suture can be sutured under direct anoscopic view, eliminating the need for the double anastomosis technique and reducing medical costs. Fifth, the method is easy to learn and master, and gastrointestinal surgeons or general surgeons can not only use conventional laparoscopic instruments and techniques they are familiar with, but also learn from similar surgical experiences, such as Parks surgery, transanal local excision of rectal tumors, transanal surgery for rectal prolapse and congenital megacolon, PPH, total laparoscopic TME specimens dragged from the rectum, etc.; whereas the transgastric route and transvaginal route may require relearning of gastroscopic techniques. The transgastric and transvaginal routes may require relearning of gastroscopic techniques or assistance from gynecologists.
Of course, NOTES transanal TME has natural limitations and drawbacks. For example, the prolonged dilatation during the operation must affect the function of the anal canal; if the low tumor is large and the pelvic space is narrow, it must be difficult to free the rectum from the anus upward. In this case, because of the presence of the free kidney, laparoscopic assistance was used via the abdomen, and preoperative chemotherapy succeeded in shrinking the tumor significantly, so it is difficult to judge the above effects. This case is an individual case, and the long-term effects of the tumor treatment in question remain to be seen.
Therefore, in the light of the literature and the success of this case, the new surgical approach of TME with transanal NOTES is feasible and safe, and has more advantages and attractions than other routes of NOTES. Laparoscopic assistance helps to overcome the difficulties of separation caused by the seminal vesicle gland and the wandering kidney. However, the application of this approach for rectal cancer requires more studies to critically assess indications and contraindications and to address some technical and instrumental challenges.
4 REFERENCES
1. Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery–the clue to pelvic recurrence?Br J Surg. 1982;69(10):613-6 [PMID: 6751457]
2. Heald RJ, Ryall RD. Recurrence and survival after total mesorectal excision for rectal cancer. Lancet. 1986;1(8496):1479-82 [ PMID: 2425199]
3. Chen YG, Chen Daojin, Jin Qinwen, Wu Junhui, Qian LY. Total rectal mesenteric resection guided by superior rectal artery infusion of melanoma. World Journal of Chinese Digestion 2003;11(1):117-119
4. Lei J, Chen YG, Lai S. K. Research progress of total rectal mesenteric resection for rectal cancer. Journal of Guangzhou Medical College 2004;14(04):83-87
5.Whiteford MH, Denk PM, Swamstrom LL. Feasibility of radical sigmoid colectomy performed as natural orifice translumenal endoscopic surgery (NOTES) using transanal endoscopic microsurgery. Surg Endosc. 2007; 21:1870C1874 [PMID: 17705068]
6. Sylla P, Willingham FF, Sohn DK, Gee D, Brugge WR, Rattner DW. NOTES rectosigmoid resection using transanal endoscopic microsurgery (TEM) with transgastric endoscopic assistance: a pilot study in swine. J Gastrointest Surg 2008;12(10):1717C1723.[PMID: 18704596]
7. Sylla P, Sohn DK, Cizginer S, Konuk Y, Turner BG, Gee DW,et al. Survival study of NOTES rectosigmoid resection using transanal endoscopic microsurgery with or without transgastric endoscopic assistance in a swine model. Surg Endosc. 2010; 24(8):2022-2030[ PMID: 20174948]
8. Ricardo Zorron. Natural orifice surgery applied for colorectal diseases. World J Gastrointest Surg 2010; 2(2): 35-38
9. Fajardo AD, Hunt SR, Fleshman JW, Mutch MG. Video. transanal single-port low anterior resection in a cadaver model. Surg Endosc. 2010;24(7):1765 [ PMID: 20054571]
10.Trunzo JA, Delaney CP.Natural orifice proctectomy using a transanal endoscopic microsurgical technique in a porcine model. Surg Innov. 2010;17(1):48-52 [PMID: 20097670]
11.Tan KY, Maeda T, Konishi F. Multimedia article. Transanal endoscopic resection of the rectum with high ligation on a swine model–a novel type of natural orifice endoscopic surgery. Dis Colon Rectum. 2009 Dec;52(12):2045-7 [PMID: 19934929].
12. Sylla P, Rattner DW, Delgado S, Lacy AM. NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance.Surg Endosc. 2010;24(5):1205-10. [PMID: 20186432].