Matthew R. Albert

Transanal minimally invasive surgery (TAMIS) for local excision of benign neoplasms and early-stage rectal cancer: efficacy and outcomes in the first 50 patients.

BACKGROUND: Since its inception in 2009, transanal minimally invasive surgery has been used increasingly in the United States and internationally as an alternative to local excision and transanal endoscopic microsurgery for local excision of neoplasms in the distal and mid rectum. Despite its increasing acceptance, the clinical benefits of transanal minimally invasive surgery have not yet been validated. OBJECTIVE: The aim of this study is to assess the adequacy of transanal minimally invasive surgery for the local excision of benign and malignant lesions of the rectum. DESIGN: This is a retrospective analysis of consecutive patients who underwent transanal minimally invasive surgery for local excision of neoplasms at a single institution. SETTINGS: The study was conducted by a single group of colorectal surgeons at a tertiary referral center. PATIENTS: Eligible patients with early-stage rectal cancer and benign neoplasms were offered transanal minimally invasive surgery as a means for local excision. Data from these patients were collected prospectively in a registry. MAIN OUTCOME MEASURES: The primary outcome measures included the feasibility of transanal minimally invasive surgery for local excision, resection quality, and short-term clinical results. RESULTS: Fifty patients underwent transanal minimally invasive surgery between July 2009 and December 2011. Twenty-five benign neoplasms, 23 malignant lesions, and 2 neuroendocrine tumors were excised. All lesions were excised using transanal minimally invasive surgery without conversion to an alternate transanal platform. The average length of stay was 0.6 days (range, 0–6), and 68% of patients were discharged on the day of surgery. The average distance from the anal verge was 8.1 cm (range, 3–14 cm). All lesions were excised completely with only 2 fragmented specimens (4%). All specimens were removed with grossly negative margins, although 3 (6%) were found to have microscopically positive margins on final pathology. There were 2 recurrences (4%) at 6- and 18-month follow-up. Early complications occurred in 3 patients (6%). No long-term complications were observed at a median follow-up of 20 months. LIMITATIONS: The study was limited by its retrospective nature and midterm follow-up. CONCLUSIONS: Transanal minimally invasive surgery is an advanced transanal platform that provides a safe and effective method for resecting benign neoplasms, as well as carefully selected, early-stage malignancies of the mid and distal rectum.

Transanal minimally invasive surgery for total mesorectal excision (TAMIS–TME): a stepwise description of the surgical technique with video demonstration

Transanal minimally invasive surgery (TAMIS), which can provide high-quality local excision for rectal neoplasia, has emerged as an important alternative to transanal endoscopic microsurgery. The role of TAMIS beyond local excision has also been explored, and it has been shown that this platform can be used for complete rectal resection with total mesorectal excision (TME). The stepwise approach to TAMIS for TME is described and illustrated in video format.

Robotic transanal minimally invasive surgery in a cadaveric model

The technique of TransAnal Minimally Invasive Surgery (TAMIS) was pioneered in 2009 as a hybrid approach to endoluminal resections of appropriately selected rectal lesions. There are, however, limitations to performing this type of resection. Robotic TAMIS is a novel, experimental technique and in this study was performed in a cadaveric model at a surgical education center. Various tasks were carried out using robotic TAMIS, including full-thickness sharp and cautery excision of rectal wall, as well as intra-luminal suturing of the surgical defect. It was found that for the da Vinci–trained surgeon, these tasks were simple to perform and accomplished with greater precision when compared to standard TAMIS. Our initial results indicate that robotic TAMIS overcomes the limitations of standard TAMIS and that it is a feasible platform for transanal surgery. The cost, however, of performing robotic TAMIS may limit its application to special cases in which standard TAMIS or transanal endoscopic microsurgery resections may prove difficult. Further study is necessary to validate these preliminary findings before robotic TAMIS is performed on live patients.

Robotic-assisted transanal surgery for total mesorectal excision (RATS-TME): a description of a novel surgical approach with video demonstration

A new era has emerged in rectal cancer surgery—transanal total mesorectal excision (TME). Various platforms have been used to facilitate this novel approach, including transanal minimally invasive surgery (TAMIS) and transanal endoscopic microsurgery. We have previously reported the use of TAMIS-TME. This is a report of the first human case of robotic-assisted transanal surgery for TME.

Transanal minimally invasive surgery (TAMIS): applications beyond local excision.

Transanal minimally invasive surgery (TAMIS) is a new technique for the local excision of rectal neoplasia. This platform employs ordinary laparoscopic instruments to achieve high-quality local excision. The TAMIS platform, however, is quite versatile. Described here are applications of TAMIS beyond local excision, ranging from repair of a rectourethral fistula to reverse proctectomy.

Excision of a rectal neoplasm using robotic transanal surgery (RTS): a description of the technique

The approach to local excision of benign and early-stage, well-selected neoplasms of the rectum continues to evolve. We demonstrate here that local excision of a rectal neoplasm using the da Vinci Robotic Surgical System can be successfully performed. To our knowledge, this is the first time robotic transanal surgery (RTS) has been used in this manner.

Transanal Total Mesorectal Excision for Rectal Cancer: early outcomes in 50 consecutive patients

Minimally invasive approaches to proctectomy for rectal cancer have not been widely adopted due to inherent technical challenges. A modification of traditional transabdominal mobilization, termed transanal total mesorectal excision (TaTME), has the potential to improve access to the distal rectum. The aim of the current study is to assess outcomes following TaTME for rectal cancer.

Transanal minimally invasive surgery (TAMIS) versus transanal endoscopic microsurgery (TEM): Is one better than the other?

We read with interest the recent publication by Rimonda et al. [1] comparing transanal minimally invasive surgery (TAMIS) using a SILS Port (Covidien, Mansfield, MA) with the more traditional transanal platform, transanal endoscopic microsurgery (TEM), for local excision of rectal neoplasms. We congratulate them for their effort to provide the first comparative study of the two platforms. However, an unexplained disparity exists between the findings of this small ex vivo study (n = 10) and the data obtained from multiple clinical series on TAMIS referenced by the authors (combined n = 109). The first report of using a multichannel port transanally was published by our group in this journal on 21 February 2010, and this approach was named TAMIS [2]. Subsequently, other investigators reported their experience with various multichannel ports [3–6]. In each of these publications, however, the conclusion was the same: this new approach for transanal surgery is feasible and safe, with encouraging clinical results. In these studies, no significant difficulty was reported. Instead, investigators typically pointed to the elegant simplicity of TAMIS as one of its principal advantages, which contradicts the findings in this comparative trial. These other clinical data thereby validate TAMIS, and this, in fact, has led to United States Food and Drug Administration (FDA) approval of two multichannel ports for use with TAMIS (SILS Port by Covidien, and GelPOINT Path Transanal Access Platform by Applied Medical, Inc., Rancho Santa Margarita, CA). Using their ex vivo comparative model, the authors concluded that TEM has a significant advantage, particularly with closure of the surgical defect, and emphasized that this was more technically challenging when performed with the TAMIS platform. They cite this difficulty as a key reason why TEM was preferred over TAMIS by the surgeons (neither of whom was experienced with either platform). But the comparison represents a limited construct and does not account for surgeon skill level, training, or experience. Nor does it account for the various types of TAMIS platforms available or the accessory devices commonly used by TAMIS surgeons, such as automated suturing and knot-forming devices. These devices aid significantly with the more technically demanding part of TAMIS, namely, closure of the surgical defect after local excision has been completed. Such automated devices, readily available from industry, are tools commonly used by seasoned TAMIS surgeons. These devices allow for rapid and accurate closure of rectal wall defects and have resulted in excellent outcomes. The TAMIS platform allows surgeons to translate familiar laparoscopic skills to transanal surgery, which is expected to result in rapid acquisition of the skill necessary for competency. Despite this advantage, the authors found the TAMIS approach to be difficult. Perhaps difficulty, however, should not be the litmus test of a new technique. Traditionally, safety and efficacy are considered more relevant parameters. A more durable method for validating TAMIS is to compare clinical outcomes obtained using this platform with those obtained using TEM. In the largest series to date on TAMIS for local excision of rectal neoplasia (n = 50), the rate of locoregional recurrence and tumor fragmentation was found to be comparable with those reported for TEM, and no appreciable difference in morbidity was S. B. Atallah (&) M. R. Albert Center for Colon and Rectal Surgery, Florida Hospital, Orlando, FL, USA e-mail: atallah@post.harvard.edu

Transanal minimally invasive surgery (TAMIS): a technique that can be used for retrograde proctectomy.

Diseases of the Colon & ReCtum Volume 56: 7 (2013) transanal minimally invasive surgery (tamis) has emerged as an advanced transanal platform for local excision of rectal neoplasia. this platform has also been shown to be suitable for applications beyond local excision. this video (see Video, supplemental Digital Content 1, http://links.lww.com/DCR/a111) demonstrates the technique and approach to performing a tamis proctectomy in a retrograde fashion in a patient who has had a previous subtotal colectomy for ulcerative colitis, and who does not wish to proceed with a restorative ileal pouch-anal procedure.

Uptake of Transanal Total Mesorectal Excision in North America: Initial Assessment of a Structured Training Program and the Experience of Delegate Surgeons.

BACKGROUND: Transanal total mesorectal excision is a new approach to curative-intent rectal cancer surgery. Training and surgeon experience with this approach has not been assessed previously in America. OBJECTIVE: The purpose of this study was to characterize a structured training program and to determine the experience of delegate surgeons. DESIGN: Data were assimilated from an anonymous, online survey delivered to attendees on course completion. Data on surgeon performance during hands-on cadaveric dissection were collected prospectively. SETTINGS: This study was conducted at a single tertiary colorectal surgery referral center, and cadaveric hands-on training was conducted at a specialized surgeon education center. MAIN OUTCOME MEASURES: The main outcome measurement was the use of the course and surgeon experience posttraining. RESULTS: During a 12-month period, eight 2-day transanal total mesorectal excision courses were conducted. Eighty-one colorectal surgeons successfully completed the course. During cadaveric dissection, 71% achieved a complete (Quirke 3) specimen; 26% were near complete (Quirke 2), and 3% were incomplete (Quirke 1). A total of 9.1% demonstrated dissection in the incorrect plane, whereas 4.5% created major injury to the rectum or surrounding structures, excluding the prostate. Thirty eight (46.9%) of 81 surgeon delegates responded to an online survey. Of survey respondents, 94.6% believed training should be required before performing transanal total mesorectal excision. Posttraining, 94.3% of surgeon delegates planned to use transanal total mesorectal excision for distal-third rectal cancers, 74.3% for middle-third cancers, and 8.6% for proximal-third cancers. The most significant complication reported was urethral injury; 5 were reported by the subset of survey respondents who had performed this operation postcourse. LIMITATIONS: The study was limited by inherent reporting bias, including observer and recall biases. CONCLUSIONS: Although this structured training program for transanal total mesorectal excision was found to be useful by the majority of respondents, the risk of iatrogenic injury after training remains high, suggesting that this training pedagogy alone is insufficient. See Video Abstract at http://links.lww.com/DCR/A335.