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A scoring system to predict complex transanal endoscopic surgery

  • X. Serra-AracilEmail author
  • P. Rebasa-Cladera
  • L. Mora-Lopez
  • A. Pallisera-Lloveras
  • S. Serra-Pla
  • S. Navarro-Soto
Article

Abstract

Background

Since the introduction of screening for colorectal cancer, the use of transanal endoscopic surgery (TEM) has become increasingly popular. However, the technical difficulty of this surgery varies widely. The few studies of learning curve in TEM have produced very disparate results. The aim of this study is to distinguish between straightforward and complex procedures, in order to refer more difficult cases to centers with greater experience.

Method

Observational study with prospective data collection and retrospective analysis was carried out between June 2004 and January 2019. All TEMs performed on rectal tumors were included. The complexity of the procedure was defined according to the weighted mean surgical time for each surgeon. A predictive model of complexity was established, with a score higher than 5 indicating a complex lesion.

Results

During the study period, 773 TEMs were performed, 708 of which met the study’s inclusion criteria. One hundred and three tumors were defined as complex. Predictors of complexity were as follows: male sex (OR: 1.78, 95% CI 1.1–2.9, score: 1), tumor size > 5 cm (OR: 5.1, 95% CI 3.2–8.2, score: 4), TEM for recurrence (OR: 6.3, 95% CI 2.3–16.7, score: 5), and distance from the upper margin of the tumor to the anal verge > 15 cm (OR: 1.6, 95% CI 0.96–2.7, score: 1).

Conclusions

Rather than establishing the learning curve merely in terms of the number of TEM procedures performed, it is important to consider the surgical difficulty of the interventions. To this end, it is essential to differentiate simple TEMs from the complex ones.

Keywords

Learning curve Transanal endoscopic surgery TEM TEO 

Notes

Acknowledgments

We thank the rest of the members of the Coloproctology Unit for applying the study protocol. We thank Cristina Gomez Vigo for correcting the manuscript and Michael Maudsley for helping with English. All authors contributed to the design and writing of the paper.

Author contributions

All authors agree to the submission of the paper.

Compliance with ethical standards

Disclosures

Xavier Serra-Aracil X, Pere Rebasa, Laura Mora-López, Anna Pallisera, Sheila Serra-Pla, and Salvador Navarro-Soto have no conflicts of interest or financial ties to disclose.

References

  1. 1.
    Buess G, Hutterer F, Theiss J, Böbel M, Isselhard W, Pichlmaier H (1984) A system for a transanal endoscopic rectum operation. Chirurg 55:677–680PubMedGoogle Scholar
  2. 2.
    Rocha JJ, Feres O (2008) Transanal endoscopic operation: a new proposal. Acta Cir Bras 23(Suppl 1):93–104CrossRefGoogle Scholar
  3. 3.
    Atallah S, Albert M, Larach S (2010) Transanal minimally invasive surgery: a giant leap forward. Surg Endosc 24:2200–2205.  https://doi.org/10.1007/s00464-010-0927-z CrossRefPubMedGoogle Scholar
  4. 4.
    Barendse RM, Dijkgraaf MG, Rolf UR, Bijnen AB, Consten EC, Hoff C, Dekker E, Fockens P, Bemelman WA, de Graaf EJ (2013) Colorectal surgeons’ learning curve of transanal endoscopic microsurgery. Surg Endosc 27:3591–3602.  https://doi.org/10.1007/s00464-013-2931-6 CrossRefPubMedGoogle Scholar
  5. 5.
    Maya A, Vorenberg A, Oviedo M, da Silva G, Wexner SD, Sands D (2014) Learning curve for transanal endoscopic microsurgery: a single-center experience. Surg Endosc 28:1407–1412.  https://doi.org/10.1007/s00464-013-3341-5 CrossRefPubMedGoogle Scholar
  6. 6.
    Helewa RM, Rajaee AN, Raiche I, Williams L, Paquin-Gobeil M, Boushey RP, Moloo H (2016) The implementation of a transanal endoscopic microsurgery programme: initial experience with surgical performance. Colorectal Dis 18:1057–1062.  https://doi.org/10.1111/codi.13333 CrossRefPubMedGoogle Scholar
  7. 7.
    Koebrugge B, Bosscha K, Ernst MF (2009) Transanal endoscopic microsurgery for local excision of rectal lesions: is there a learning curve? Dig Surg 26:372–377.  https://doi.org/10.1159/000257228 CrossRefPubMedGoogle Scholar
  8. 8.
    Serra-Aracil X, Labró-Ciurans M, Rebasa-Cladera P, Mora-López L, Pallisera-Lloveras A, Serra-Pla S, Gracia-Roman R, Navarro-Soto S (2018) Morbidity after transanal endoscopic surgery. Risk factors for postoperative complications in a one-day surgery program. Surg Endosc Other Interv Tech.  https://doi.org/10.1007/s00464-018-6432-5 CrossRefGoogle Scholar
  9. 9.
    Serra-Aracil X, Mora-Lopez L, Alcantara-Moral M, Caro-Tarrago A, Gomez-Diaz CJ, Navarro-Soto S (2014) Transanal endoscopic surgery in rectal cancer. World J Gastroenterol 20:11538–11545.  https://doi.org/10.3748/wjg.v20.i33.11538 CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Serra-Aracil X, Mora-Lopez L, Alcantara-Moral M, Corredera-Cantarin C, Gomez-Diaz C, Navarro-Soto S (2014) Atypical indications for transanal endoscòpic microsurgery to avoid major surgery. Tech Coloproctol 18:157–164.  https://doi.org/10.1007/s10151-013-1040-9 CrossRefPubMedGoogle Scholar
  11. 11.
    Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213CrossRefGoogle Scholar
  12. 12.
    Slankamenac K, Graf R, Barkun J, Puhan MA, Clavien PA (2013) The comprehensive complication index: a novel continuous scale to measure surgical morbidity. Ann Surg 258:1–7CrossRefGoogle Scholar
  13. 13.
    Kim CW, Kim WR, Kim HY, Kang J, Hur H, Min BS, Baik SH, Lee KY, Kim NK (2015) Learning curve for single-incision laparoscopic anterior resection for sigmoid colon cancer. J Am Coll Surg 221:397–403.  https://doi.org/10.1016/j.jamcollsurg.2015.02.016 CrossRefPubMedGoogle Scholar
  14. 14.
    Serra-Aracil X, Gràcia R, Mora-López L, Serra-Pla S, Pallisera-Lloveras A, Labró M, Navarro-Soto S (2019) How to deal with rectal lesions more than 15 cm from the anal verge through transanal endoscopic microsurgery. Am J Surg 217:53–58.  https://doi.org/10.1016/j.amjsurg.2018.04.014 CrossRefPubMedGoogle Scholar
  15. 15.
    Lev-Chelouche D, Margel D, Goldman G, Rabau MJ (2000) Transanal endoscopic microsurgery: experience with 75 rectal neoplasms. Dis Colon Rectum 43:662–667 discussion 667–668 CrossRefGoogle Scholar
  16. 16.
    Serra-Aracil X, Pallisera-Lloveras A, Mora-Lopez L, Rebasa P, Serra-Pla S, Navarro S (2019) Perforation in the peritoneal cavity during transanal endoscopic microsurgery for rectal tumors: a real surgical complication with a challenging prognosis? Surg Endosc 33:1870–1879.  https://doi.org/10.1007/s00464-018-6466-8 CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Unidad de Coloproctología, Servicio de Cirugía General y del Ap. DigestivoParc Tauli Hospital Universitari. Institut d’investigació i innovació Parc Tauli I3PT, Universitat Autonoma de BarcelonaSabadellSpain

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