Abdomen/surgery* ; Humans ; Laparoscopy/methods* ; Pelvic Floor/surgery* ; Perineum/surgery* ; Proctectomy ; Rectal Neoplasms/surgery*

Transanal total mesorectal resection (taTME) has come a long way since it was first used in the clinic in 2010.The learning curve of this procedure is long due to different surgical approaches, different perspectives and different anatomical positions. Many surgeons experience complications during this procedure. Although the advantages and problems of this procedure have been reported in much literature, the anatomy and operation methods of taTME introduced in literatures and training centers are too complicated, which makes many surgeons encounter difficulties in carrying out taTME surgery. According to the author's experience in learning and carrying out this operation, spatial expansion process of ultralow rectal cancer was divided into three stages. At each stage, according to different pulling forces, three different schemes of triangular stability mechanics model were adopted for separation. From point to line, from line to plane, the model can protect the safety of peripheral blood vessels and nerves while ensuring total mesorectal excision . This model simplifies the complex surgical process and is convenient for beginners to master taTME surgical separation skills.
Humans ; Rectum/surgery* ; Laparoscopy/methods* ; Transanal Endoscopic Surgery/methods* ; Rectal Neoplasms/surgery* ; Proctectomy/methods* ; Postoperative Complications ; Treatment Outcome

Objective: To summarize short-term postoperative complications of transanal total mesorectal excision (taTME) in the treatment of middle-low rectal cancer. Methods: A descriptive case series of cases was constructed. Clinical data of consecutive 83 patients with mid-low rectal cancer who received taTME treatment from November 2016 to April 2021 at Department of General Surgery of Beijing Friendship Hospital, Capital Medical University were collected. Among 83 patients, 58 (69.9%) were males, with a mean age of (61.4±11.8) years; 42 (50.6%) were low rectal cancer, 41 (49.4%) were middle rectal cancer. Short-term postoperative complication was defined as complication occurring within 30 days after operation. The complication was graded according to the Clavien-Dindo classification. At the same time, the morbidity of short-term postoperative complication in the first 40 patients and that in the last 43 patients were compared to understand the differences before and after passing the taTME learning curve. Results: Two patients (2.5%) were converted to laparotomy ; 78 (94.0%) completed anastomosis.While 5 (6.0%) underwent permanent stoma. The total operation time of transabdominal+ transanal procedure was (246.9±85.0) minutes, and the median intraoperative blood loss was 100 (IQR: 100) ml. Seventy-five cases (75 /78, 96.2%) underwent defunctioning stoma, including 74 cases of diverting ileostomy, 1 case of diverting transverse colostomy and 3 cases without stoma. The morbidity of complication within 30 days after operation was 38.6% (32/83), and the morbidity of complication after discharge was 8.4% (7/83). Minor complications accounted for 31.3% (26/83) and major complications accounted for 7.2% (6/83). No patient died within 30 days after operation. The incidence of anastomotic leakage was 15.4% (12/78). Eight patients (9.6%) were hospitalized again due to complications after discharge. The median postoperative hospital stay was 7 (IQR: 3) days. All the patients with minor (I-II) complications received conservative treatment. One patient with grade C anastomotic leakage was transferred to intensive care unit and received a second operation due to sepsis and multiple organ dysfunction. Two patients with paralytic ileus (Clavien-Dindo IIIa) underwent endoscopic ileus catheter placement. There were 3 patients with Clavien-Dindo III or above respiratory complications, including 1 patient with pleural effusion and ultrasound-guided puncture, 2 patients with respiratory failure who were improved and discharged after anti-infection and symptomatic treatment. One patient underwent emergency ureteral stent implantation due to urinary infection (Clavien-Dindo IIIb). The morbidity of postoperative complication in the first 40 cases was 50.0% (20/40), and that in the latter 43 cases decreased significantly (27.9%, 12/43), whose difference was statistically significant (χ(2)=4.270, P=0.039). Conclusions: The procedure of taTME has an acceptable morbidity of short-term postoperative complication in the treatment of mid-low rectal cancer. The accumulation of surgical experience plays an important role in reducing the morbidity of postoperative complication.
Aged ; Anal Canal/surgery* ; Anastomotic Leak/etiology* ; Female ; Humans ; Male ; Middle Aged ; Operative Time ; Proctectomy/methods* ; Rectal Neoplasms/surgery*

Objective: To examine the patterning cropped and shaped mesh repair for perineal hernia after abdominoperineal excision (APE) in rectal cancer. Methods: The clinical data of 8 patients with perineal hernia after APE who accepted surgical treatment in the Department of Hepatopancreatobiliary and Hernia Surgery, the First Affiliated Hospital of Fujian Medical University from March 2017 to December 2022 were retrospectively reviewed. There were 3 males and 5 females, aged (67.6±7.2) years (range: 56 to 76 years). Eight patients developed a perineal mass at (11.3±2.9) months (range: 5 to 13 months) after APE. After surgical separation of adhesion and exposing the pelvic floor defect, a 15 cm×20 cm anti-adhesion mesh was fashioned as a three-dimensional pocket shape to fit the pelvic defect, then fixed to the promontory or sacrum and sutured to the pelvic sidewalls and the anterior peritoneum, while two side slender slings were tailored in front of the mesh and fixed on the pectineal ligament. Results: The repair of their perineal hernias went well, with an operating time of (240.6±48.8) minutes (range: 155 to 300 minutes). Five patients underwent laparotomy, 3 patients tried laparoscopic surgery first and then transferred to laparotomy combined with the perineal approach. Intraoperative bowel injury was observed in 3 patients. All patients did not have an intestinal fistula, bleeding occurred. No reoperation was performed and their preoperative symptoms improved significantly. The postoperative hospital stay was (13.5±2.9) days (range: 7 to 17 days) and two patients had postoperative ileus, which improved after conservative treatment. Two patients had a postoperative perineal hernia sac effusion, one of them underwent placement of a tube to puncture the hernia sac effusion due to infection, and continued irrigation and drainage. The postoperative follow-up was (34.8±14.0) months (range: 13 to 48 months), and 1 patient developed recurrence in the seventh postoperative month, no further surgery was performed. Conclusions: Surgical repair of the perineal hernia after APE can be preferred transabdominal approach, routine application of laparoscopy is not recommended, combined abdominoperineal approach can be considered if necessary. The perineal hernia after APE can be repaired safely and effectively using the described technique of patterning cropped and shaped mesh repair.
Male ; Female ; Humans ; Animals ; Herniorrhaphy/methods* ; Surgical Mesh ; Retrospective Studies ; Hernia, Abdominal/surgery* ; Hernia ; Rectal Neoplasms/surgery* ; Proctectomy ; Laparoscopy ; Perineum/surgery* ; Postoperative Complications ; Incisional Hernia/surgery* ; Hominidae

OBJECTIVE: To investigate the surgical efficacy and prognostic factors of T3NxM0 middle-low rectal cancer without neoadjuvant therapy. METHODS: Clinical data of patients with middle-low rectal cancer undergoing TME surgery with T3NxM0 confirmed by postoperative pathology at Colorectal Surgery Department of Changhai Hospital from January 2008 to December 2010 were analyzed retrospectively. INCLUSION CRITERIA: (1)no preoperative neoadjuvant chemoradiotherapy (nCRT); (2) complete preoperative evaluation, including medical history, preoperative colonoscopy or digital examination, blood tumor marker examination, and imaging examination; (3) distance between tumor lower margin and anal verge was ≤ 10 cm; (4) negative circumferential resection margin (CRM-). Finally, a total of 331 patients were included in this study. According to the number of metastatic lymph node confirmed by postoperative pathology, the patients were divided into N0 group without regional lymph node metastasis (190 cases) and N+ group with regional lymph node metastasis (141 cases). The perioperative conditions, local recurrence, distant metastasis and prognostic factors were analyzed. RESULTS: Compared to N0 group in the perioperative data, N+ group had higher ratio of tumor deposit [29.8%(42/141) vs. 0, χ²=64.821, P<0.001] and vascular invasion [7.1%(10/141) vs. 0.5%(1/190),χ²=10.860, P<0.001]. There were no significant differences in tumor diameter, number of lymph nodes detected, positive nerve invasion, degree of tumor differentiation, morbidity of postoperative complication and postoperative adjuvant chemotherapy rate between the two groups (all P>0.05). The median follow-up period was 73.4 months. The merged 5-year local recurrence rate was 2.7%(9/331), 5-year distant metastasis rate was 23.3% (77/331), 5-year disease-free survival (DFS) rate was 73.4%, and 5-year overall survival (OS) rate was 77.2%. Multivariate analysis showed that lymph node metastasis (HR=3.120, 95%CI: 1.918 to 5.075, P<0.001), nerve invasion (HR=0.345, 95%CI: 0.156 to 0.760, P=0.008) and vascular invasion (HR=0.428, 95%CI: 0.189 to 0.972, P=0.043) were independent risk factors for DFS in patients with T3NxM0 rectal cancer after operation. Preoperative carcinoembryonic antigen level (HR=1.858, 95%CI:1.121 to 3.079, P=0.016), lymph node metastasis (HR=3.320, 95%CI: 1.985 to 5.553, P<0.001) and nerve invasion (HR=0.339, 95%CI: 0.156 to 0.738, P=0.006) were independent risk factors for OS in patients with T3NxM0 rectal cancer after operation. CONCLUSIONS Optimal local control rate of middle-low rectal cancer patients with T3NxM0 and CRM- can be achieved by standard TME surgery alone. For patients with preoperative elevated blood carcinoembryonic antigen level, regional lymph node metastasis, or neurovascular invasion confirmed by pathology after surgery, adjuvant chemoradiotherapy should be actively applied after surgery to improve prognosis.
Humans ; Lymph Node Excision ; Lymph Nodes ; pathology ; surgery ; Lymphatic Metastasis ; Mesocolon ; surgery ; Neoadjuvant Therapy ; Neoplasm Staging ; Proctectomy ; methods ; Prognosis ; Rectal Neoplasms ; pathology ; surgery ; Retrospective Studies