Real-time in vivo distal margin selection using confocal laser endomicroscopy in transanal total mesorectal excision for rectal cancer

BACKGROUND Transanal total mesorectal excision(TaTME)allows patients with ultralow rectal cancer to be treated with sphincter-saving surgery.However,accurate delineation of the distal resection margin(DRM),which is essential to achieve R0 resection for low rectal cancer in TaTME,is technically demanding.AIM To assess the feasibility of optical biopsy using probe-based confocal laser endomicroscopy(pCLE)to select the DRM during TaTME for low rectal cancer.METHODS A total of 43 consecutive patients who were diagnosed with low rectal cancer and scheduled for TaTME were prospectively enrolled from January 2019 to January 2021.pCLE was used to determine the distal edge of the tumor as well as the DRM during surgery.The final pathological report was used as the gold standard.The diagnostic accuracy of pCLE examination was calculated.RESULTS A total of 86 pCLE videos of 43 patients were included in the analyses.The sensitivity,specificity and accuracy of real-time pCLE examination were 90.00%[95%confidence interval(CI):76.34%-97.21%],86.96%(95%CI:73.74%-95.06%)and 88.37%(95%CI:79.65%-94.28%),respectively.The accuracy of blinded pCLE reinterpretation was 86.05%(95%CI:76.89%-92.58%).Furthermore,our results show satisfactory interobserver agreement(κ=0.767,standard error=0.069)for the detection of cancer tissue by pCLE.There were no positive DRMs(≤1 mm)in this study.The median DRM was 7 mm[interquartile range(IQR)=5-10 mm].The median Wexner score was 5(IQR=3-6)at 6 mo after stoma closure.CONCLUSION Real-time in vivo pCLE examination is feasible and safe for selecting the DRM during TaTME for low rectal cancer(clinical trial registration number:NCT04016948).

Role of minimally invasive surgery for rectal cancer

Rectal cancer is one of the most common malignancies worldwide.Surgical resection for rectal cancer usually requires a proctectomy with respective lymphadenectomy(total mesorectal excision).This has traditionally been performed transabdominally through an open incision.Over the last thirty years,minimally invasive surgery platforms have rapidly evolved with the goal to accomplish the same quality rectal resection through a less invasive approach.There are currently three resective modalities that complement the traditional open operation:(1)Laparoscopic surgery;(2)Robotic surgery;and(3)Transanal total mesorectal excision.In addition,there are several platforms to carry out transluminal local excisions(without lymphadenectomy).Evidence on the various modalities is of mixed to moderate quality.It is unreasonable to expect a randomized comparison of all options in a single trial.This review aims at reviewing in detail the various techniques in regard to intra-/perioperative benchmarks,recovery and complications,oncological and functional outcomes.

经自然腔道取标本手术(NOSES)治疗结直肠癌的国际共识

近年来,经自然腔道取标本手术(NOSES)治疗结直肠癌已引起了广泛关注。NOSES应用于结直肠手术的潜在优势包括减轻术后疼痛,减少伤口并发症,减少对术后镇痛的需求,加快肠道功能的恢复,缩短住院时间,更好的美容效果,以及给患者带来了更佳的心理状态。尽管NOSES的手术创伤显著减轻,然而该技术也存在一些潜在问题。尤其随着这项新技术的兴起,人们对其无菌的把控、肿瘤学结果和病例选择等问题表示出关切。因此,迫切需要一部操作指南来规范NOSES手术在结直肠癌中的开展。经过国际NOSES联盟全体成员的三轮讨论,最终形成了该部共识。这一共识有助于NOSES在全球范围内的长远发展。

对比经肛全直肠系膜切除术与腹腔镜全直肠系膜切除术:一项多中心III期随机临床试验(TaLaR试验)方案

背景:全直肠系膜切除术是直肠癌治疗的标准手术方法。经肛全直肠系膜切除术(taTME)是治疗低位直肠癌的新术式。既往研究表明,与腹腔镜全直肠系膜切除术(lapTME)相比,taTME应用于低位直肠癌患者可提供更高质量的手术标本,但其长期肿瘤学结果仍需进一步观察。因此,我们设计了这个非劣效性临床试验(TaLaR试验),比较taTME与lapTME治疗直肠癌的短期和长期结果。方法/设计:TaLaR试验是一项多中心III期随机对照试验。研究对象为经磁共振成像、直肠指检或结肠镜检查被诊断为位于腹膜反折以下的直肠癌,若肿瘤分期≤cT3N2直接手术,若>cT3N2则先行新辅助治疗。通过计算,本研究需纳入1,114例患者(每组557例)。纳入病例随机分配到taTME或lapTME组。本研究的主要终点是3年无病生存率(DFS)和5年总生存率(OS)。次要终点包括手术标本质量、围手术期结果、骨盆和肛门功能以及生活质量。讨论:我们认为,TaLaR试验将阐明taTME是否可以达到与lapTME相似的肿瘤学结果,以及是否可改善直肠癌患者的手术标本质量及恢复情况。