In “The role of TAMIS (transanal minimally invasive surgery) in the management of advanced rectal cancer—one shared story of three exceptional cases,” the authors aim to raise awareness for the use of TAMIS in patients with advanced rectal cancer, when the gold standard of treatment (total mesorectal excision, TME) is either not feasible or refused by the patient. The results of the above mentioned paper encourage the consideration of TAMIS in certain clinical scenarios.Citation1
In the United States, colorectal cancer is estimated to have the third highest mortality rate among all types of cancers for women, and the second highest mortality rate among all types of cancers for men in 2017. Furthermore, colorectal cancer is one of the more common forms of cancer in the United States.Citation2 Approximately 135,430 new cases of colorectal cancer are estimated for 2017.Citation2 The incidence of rectal cancer in men and women under the age of 50 has been increasing at an alarming rate of 2.1% per year from 1992 through 2012.Citation3 It is especially important to offer treatments with positive clinical outcomes that also consider quality of life in younger patients. Multiple studies have shown that this minimally invasive approach can preserve both fecal continence and allow for a higher quality of life.Citation4,Citation5
Research on minimally invasive procedures for rectal cancer is desirable since studies analyzing large sample populations with significant conclusions are lacking. TME is known to have various complications such as wound infections, fistulas, leaks, bleeding, and extensive postoperative morbidity and mortality, so an alternative solution could be very valuable, both to patients as well as to hospitals.Citation1
In agreement with the authors, we believe the TAMIS approach could offer significant benefits. If the surgeon is already familiar with conventional laparoscopic instruments, there is a shortened learning curve (approximately 20 cases) when analyzing time spent in the operating room.Citation6,Citation10 While this might lead a surgeon to think that TAMIS will provide better results based on a wider range of maneuverability and the possibility of better resection than the traditional TME, more research focused on TAMIS is needed.Citation6,Citation7
Of the three case studies, it is important to highlight the fact that the TAMIS approach was not the primary procedure recommended for two of the patients. In fact, TME was recommended; however, both patients were unwilling to accept a permanent colostomy. Even physicians who are familiar with TAMIS may prefer to conduct TME, as it is considered the standard of care. Additionally, not all patients who undergo TME will have a permanent colostomy.
The patient in case three also declined a permanent colostomy, and underwent TAMIS as a palliative procedure due to extensive comorbidities. Unfortunately, it was not possible to evaluate the success of the procedure, since the patient expired 3 weeks after surgery due to a pulmonary embolism after deciding to discontinue anticoagulation treatment. Even so, the use of TAMIS may have a larger role as a palliative procedure, since recovery is faster and easier when compared to TME, which may cause more severe complications.
One potential drawback of this case series is the role of neoadjuvant chemotherapy as a confounding factor. Studies show that in patients who have a complete response to chemotherapy, surgery does not add any benefit in terms of prognosis, however, not every patient responds well.Citation8 In fact, the complete response to chemotherapy in T2 and T3 lesions is relatively rare, between 10 and 44% of patients have a complete response.Citation1 Furthermore, there are reports demonstrating that TAMIS can be used as a safe procedure for patients with locally advanced rectal cancer that have good responses to preoperative chemo-radiation therapy.Citation1,Citation9
In an age where cost-effective health care is becoming more and more relevant, it would be interesting to see a comparative analysis of the costs between patients who have undergone TAMIS and TME. As it has been documented, TAMIS patients typically have a shorter length of stay compared to TME patients, thus saving money and resources while providing patients with a better quality of life.Citation1,Citation6
In conclusion, we believe this study will generate more interest in the use of TAMIS in locally advanced cancers in patients who were not candidates for TME, since two of these cases demonstrated positive results. Like the authors noted, the use of TAMIS would benefit from a randomized study with a much larger research population to draw significant conclusions. Finally, it would also be interesting to see a study documenting the instances and outcomes in which a TME with a permanent colostomy was conducted after using TAMIS, indicating that TAMIS might not have been appropriate.
Declaration of interest statement
The authors report no conflict of interest.
References
- The role of TAMIS (transanal minimally invasive surgery) in the management of advanced rectal cancer – one shared story of three exceptional cases. Journal of Investigative Surgery. ( In Press).
- Siegel RL, Miller KD, Jemal A. Cancer Statistics, 2017. CA Cancer J Clin. 2017;67(1):7–30. doi:10.3322/caac.21387.
- Ahnen DJ, Wade SW, Jones WF, et al. The increasing incidence of young-onset colorectal cancer: a call to action. Mayo Clin Proc. 2014;89(2):216–24. doi:10.1016/j.mayocp.2013.09.006.
- Karakayali FY, Tezcaner T, Moray G. Anorectal function and outcomes after transanal minimally invasive surgery for rectal tumors. J Minim Access Surg. 2015;11(4):257–62. doi:10.4103/0972-9941.152094.
- Verseveld M, Barendse RM, Gosselink MP, et al. Transanal minimally invasive surgery: impact on quality of life and functional outcome. Surg Endosc. 2016;30(3):1184–7. doi:10.1007/s00464-015-4326-3.
- Kirkner R. TAMIS for rectal cancer holds its own vs. TEM. ACS Surgery News [Internet]. 2016 12/29/2017. Available from: https://www.mdedge.com/acssurgerynews/article/106724/colon-and-rectal/tamis-rectal-cancer-holds-its-own-vs-tem.
- Albert MR, Atallah SB, deBeche-Adams TC, et al. Transanal minimally invasive surgery (TAMIS) for local excision of benign neoplasms and early-stage rectal cancer: efficacy and outcomes in the first 50 patients. Dis Colon Rectum. 2013;56(3):301–7. doi:10.1097/DCR.0b013e31827ca313.
- Fiorica F, Trovo M, Anania G, et al. Is It Possible a Conservative Approach After Radiochemotherapy in Locally Advanced Rectal Cancer (LARC)? A Systematic Review of the Literature and Meta-analysis. J Gastrointest Cancer. 2017:1–11. doi:10.1007/s12029-017-0041-8. PMID: 29273921.
- Lee BC, Oh S, Lim SB, et al. Transanal Minimally-Invasive Surgery for Treating Patients With Regressed Rectal Cancer After Preoperative Chemoradiotherapy. Ann Coloproctol. 2017;33(2):52–6. doi:10.3393/ac.2017.33.2.52.
- Schoonyoung H, Quinteros F, Martin-Perez B, et al. Defining the learning curve for Transanal Minimally Invasive Surgery (TAMIS). Society of American Gastrointestinal and Endoscopic Surgeons – SAGES Abstrasct Archives. 2014.