title: Transanal endoscopic proctectomy: an innovative procedure for difficult resection of rectal tumors in men with narrow pelvis.
abstract: BACKGROUND
  In rectal surgery, some situations can be critical, such as anterior topography of locally advanced low tumors with a positive predictive radial margin, especially in a narrow pelvis of men who are obese. Transanal proctectomy is a new laparoscopic technique that uses the transanal endoscopic microsurgery device.
  
  
  OBJECTIVE
  The aim of this study is to evaluate the technical feasibility of laparoscopic transanal proctectomy in patients with unfavorable features.
  
  
  METHODS
  This is a single-center, prospective analysis of selected patients with rectal cancer operated on from January 2009 to June 2011.
  
  
  METHODS
  Intraoperative details and short-term postoperative outcome were described.
  
  
  RESULTS
  Thirty men with advanced or recurrent low rectal tumors associated with unfavorable anatomical and/or tumor characteristics underwent a sphincter-sparing transanal endoscopic proctectomy. Twenty-nine patients had received preoperative treatment. We report a 6% conversion rate, no postoperative mortality, and a 30% morbidity rate. At the beginning of our experience, a urethral injury was diagnosed in 2 patients and easily sutured intraoperatively, without postoperative after-effect. The mesorectal resection was graded as "good" in all patients. R0 resection was achieved in 26 patients (87%). The short-term stoma closure rate was 85%. After a median follow-up of 21 months, 4 patients experienced locoregional recurrence alone. Overall survival rates at 12 and 24 months were 96.6% (95% CI, 78.0-99.5) and 80.5% (95% CI, 53.0-92.9). Relapse-free survival rates at 12 and 24 months were 93.3% (95% CI, 75.9-98.3) and 88.9% (95% CI, 69.0-96.3).
  
  
  CONCLUSIONS
  Although the transanal endoscopic proctectomy was performed by trained surgeons, we report a slight increase in early postoperative morbidity and relatively poor early outcome. There was a clear selection bias related to the study cohort exclusively composed of high-risk patients, but we need to be cautious before generalizing this technique.
  
  
  CONCLUSIONS
  The transanal endoscopic proctectomy is a feasible alternative surgical option to conventional laparoscopy for radical rectal resection in selected cases with unfavorable characteristics. Further investigations with larger cohorts are required to validate its safety and to clarify its best indication.
authors.affiliation: Surgical Oncology Department, Val d'Aurelle Montpellier Cancer Institute, Montpellier, France. Philippe.Rouanet@montpellier.unicancer.fr
authors.forename: Philippe
authors.initials: P
authors.lastname: Rouanet
authors.forename: Anne
authors.initials: A
authors.lastname: Mourregot
authors.forename: Chebl Christian
authors.initials: CC
authors.lastname: Azar
authors.forename: Sébastien
authors.initials: S
authors.lastname: Carrere
authors.forename: Marian
authors.initials: M
authors.lastname: Gutowski
authors.forename: François
authors.initials: F
authors.lastname: Quenet
authors.forename: Bernard
authors.initials: B
authors.lastname: Saint-Aubert
authors.forename: Pierre-Emmanuel
authors.initials: PE
authors.lastname: Colombo
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001003:Anal Canal / Q000601:surgery*; D000714:Anastomosis, Surgical; D002277:Carcinoma / Q000401:mortality / Q000601:surgery; D039021:Colonic Pouches; D018572:Disease-Free Survival; D006801:Humans; D007081:Ileostomy; D008197:Lymph Node Excision; D008297:Male; D008875:Middle Aged; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods*; D011183:Postoperative Complications; D011446:Prospective Studies; D012004:Rectal Neoplasms / Q000401:mortality / Q000601:surgery*