The Feasibility and Safety of No-scar Transanal Total Mesorectal Excision for Rectal Cancer

Sponsor

Sun Yat-sen University (Other)

Overall Status

Completed

CT.gov ID

NCT02236884

Collaborator

(none)

Enrollment

Location

Arm

Duration (Months)

Patients Per Site Per Month

Study Details

Study Description

Brief Summary

During the past three years, a revolutionized radical surgical approach for rectal cancer ("down to up TME " approach or "transanal TME (TaTME)"approach, which is opposite to the conventional approach) has emerged and it is a concept that combines natural orifice transluminal endoscopic surgery(NOTES) and total mesorectal excision(TME) with curative intent. The feasibility, safety and reproducibility of it were first demonstrated in swine survival experiments and subsequently in human cadaver series, and then it was successfully applied to human patients in few centers around the world, most of which were performed with assistance of laparoscopy, namely hybrid transanal TME. In addition, pure-NOTES without conventional laparoscopic assistance (no scar) has also been demonstrated, though the cases were more limited. In the initial stage, our group has successfully performed this no-scar transanal TME in a series of human cadavers with satisfactory outcome. Hence the investigators conduct this study, looking to see if this pure transanal NOTES investigational procedure is a safe and effective approach to radically remove rectal cancer of the mid and lower rectum and meanwhile, if it can reduce pain, gain faster recovery and better function and life quality when gaining the best cosmetic effect.

Condition or Disease	Intervention/Treatment	Phase
Rectal Cancer Surgery	Procedure: no-scar transanal total mesorectal excision(TME)	Phase 1/Phase 2

Detailed Description

Transanal total mesorectal excision (TaTME) is a novel development in the field of colorectal surgery which combines the mini-invasive concept of natural orifice transluminal endoscopic surgery(NOTES), the technique of single-port laparoscopic surgery and the principle of total mesorectal excision with curative intent for treating rectal cancer. Based on the platform of either transanal endoscopic microsurgery(TEM) or transanal minimally invasive surgery (TAMIS), it is an innovative way of retrograde TME dissection from bottom to up with or without laparoscopic assistance. It is supposed to facilitate distal rectal mobilization, thus achieving precise and sufficient distal margin and to reduced need for multiple stapler firings in transecting the rectum, consequently decreasing anastomotic leakage rates which is especially important for obese male patients with a narrow pelvis where exposure to the distal rectum from the abdominal approach can prove difficult. It could also protect neurovascular bundle with better visualization and exposure and has the advantage of better function and avoiding sacrificing sphincter. After a series of preclinical trail of animal and cadaver, it has been successfully applied to humans and successional reports have proved its feasibility and safety. However, the majority of published series is hybrid NOTES, which need the assistance of conventional laparoscopic surgery from above to bottom and abdominal incision, scar, pain and incision related complications such as wound infection, abscess, hernia and implanted incisional tumors cannot be necessary avoided. It is also worried that the cost will increased since two groups of surgical equipment are needed(the abdominal and perineal) and more surgical staff are required if the two team operate at the same time(two-team approach). Up to date, as far as we have known, the pure transanal TME NOTES without any laparoscopic assistance has also been successfully performed in human patients though the cases are rare. The investigators of our center have also successfully performed pure-NOTES rectal resection in human cadavers in the past few months, and are confident to move this forward to conduct this pilot study to evaluate the feasibility and safety of this surgery in rectal cancer patients.

Study Design

Study Type:

Interventional

Actual Enrollment :

20 participants

Allocation:

N/A

Intervention Model:

Single Group Assignment

Masking:

None (Open Label)

Primary Purpose:

Treatment

Official Title:

A Pilot Study of the Feasibility and Safety of No-scar Transanal Total Mesorectal Excision for Rectal Cancer Without Conventional Laparoscopic Assistance

Study Start Date :

Sep 1, 2014

Actual Primary Completion Date :

Dec 1, 2015

Actual Study Completion Date :

Jun 1, 2016

Arms and Interventions

Arm	Intervention/Treatment
Experimental: no-scar transanal TME no-scar transanal total mesorectal excision(TME) of rectal cancer	Procedure: no-scar transanal total mesorectal excision(TME) Other Names: Pure NOTES transanal TME TaTME TAMIS TME single-port transanal TME

Arm

Intervention/Treatment

Experimental: no-scar transanal TME

no-scar transanal total mesorectal excision(TME) of rectal cancer

Procedure: no-scar transanal total mesorectal excision(TME)

Other Names:

Pure NOTES transanal TME

TaTME

TAMIS TME

single-port transanal TME

Outcome Measures

Primary Outcome Measures

Composite mesure of prioperative feasibility and safety [one-year]
To evaluate the feasibility and safety by operative time, estimated blood loss, intraoperative complications, convert to Hybrid NOTES or open surgery, pathological outcome including Total Mesorectal Excision (TME) quality, the lymph nodes harvested, and specimen length, circumferential margin, etc. and postoperative complications graded according to Clavien-Dindo, reoperation rate, 30-day mortality, 30-day readmission

Secondary Outcome Measures

composite measure of life quality [1-3 year]
To evaluate bladder function, anal function, sexual function and life quality by incontinence score, EORTC QLQ C30 and EORTC QLQ CR38, etc
Composite mesure of postoperative outcome [one-year]
To evaluate the postoperative outcome by length of hospital stay after operation, the time of first flatus, the time of recover to flow diet, postoperative pain by VAS, analgesic use ,etc
Composite mesure of oncological outcome [1-3 year]
3-year disease free survival (DFS), 3-year local recurrence rate, 3-year distal metastasis rate, 3-year overall survival (cancer related or non-cancer related)

Eligibility Criteria

Criteria

Ages Eligible for Study:

18 Years to 70 Years

Sexes Eligible for Study:

All

Accepts Healthy Volunteers:

Inclusion Criteria:

Biopsy-proven adenocarcinoma of the rectum
No previous abdominal surgery, no distant metastasis or synchronous colon cancer
BMI≤ 35kg/m2
Clinical staging (T1 or T2 or T3) with N1-2M0
Patients of rectal adenocarcinoma with T3N0 or N (+) received preoperative concurrent chemoradiotherapy (CCRT) as neoadjuvant therapy
Rectal cancer located 4-12 cm from the anal verge
The diameter of primary tumor should <6cm
Patients must have an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1
American Society of Anesthesiology (ASA) classⅠ to Ⅲ lesions
After the evaluation of Multi-disciplinary team (MDT)
Written informed consent

Exclusion Criteria:

T4 tumor that invade the external sphincter or levator ani muscle or neighbor organs
Recurrent rectal cancer
Distant metastasis
Obstructing rectal cancer
Synchronous colon cancer
Pregnant or breast-feeding women
Fecal incontinence
History of prior colorectal cancer
History of inflammatory bowel disease
Other malignancies diagnosed within the previous year
Mental illness
Any evidence of active infection
History of bleeding diathesis or coagulopathy
Impaired renal or hepatic function that could not tolerate surgery