A.M. LACY transanal colo-rectal endoscopic surgery (TACRES)

Hello?

Hi, I'm from Rome, welcome, and on behalf of Professor Palazzini, welcome to the Rome conference.

Can you hear me?

Yes, perfect.

Okay, so you are going to give a lecture?

Yes, I have the lecture.

Okay, you can start whatever you want.

Okay, everything is connected?

Yes.

Okay, I have a...

Thank you very much for your kind invitation.

I think it's important for us. I'm sorry not to be there. I prefer to be there, but sometimes it's, you know, due to the time we are very busy, we have to do something because we are organizing a meeting, you know, yes, tomorrow.

tomorrow. My talk is related with, I think it's a new name, it's TACRIS. TACRIS means

Transanal Colorectal Endoscopic Surgery. At the beginning it's TATME, and TATME is related

only with rectal cancer. Now we are doing different procedures transanally that include

inflammatory bowel disease, include hormone reversal, high rectal sigmoid cancer, another

possible complication that was the reason I wanted to remember you know

sometimes because each L is very close to France and let me let me say

something about we have to remember you know what's happening in in Paris it's

an extra in a city with extraordinary citizens and I think all we have to be

with them. My second slide is related with, because probably it's not related with the

topic about colorectal surgery, but tomorrow we have a meeting with Phil Schauer, it's

a live congress, and I think it could be useful if some of you is interested in to be connected

with us, it's approximately a live congress, three hours time, and that is the video that

demonstrated that we wanted to do in these live comments immediately finish the videos

you know some seconds we will start with the topic we wanted to discuss the reality of uh

who and what and why by gastric bypass i don't know in the hospitals but in at least in spain

many people is now doing this liposuction i think this liposuction is the next step

about the banding, and I think you know that the best procedure is probably not related

with a very restricted procedure like this little objective.

Okay, thank you all of you, and you are invited to be connected with us tomorrow.

Talking about colorectal surgery nowadays, I think it's important evolution of surgery

is coming from open surgery to laparoscopy, and maybe, who knows, in the future is a combined

buying open laparoscopy natural orifices or why not robotic surgery it depends on many things one

of the important thing is the health economics you know we are not like Italy you are a very

healthy country however we have a lot of employment and that is the reason because

sometimes it's cheaper to have a human being done on robotic in colorectal surgery there are many

different way to treat from nose, laparoscopy, open, robotics, TEM, TAMIS

notes is very complicated but we have to remember and coming back to the history

in the history in 1991 is long time ago Moises Jacobs I thought was a Cuban

surgeon who works in Florida but he's not true he's a Liban from

from Lebanon and he started and he published the first paper related with

minimally invasive surgery in a laparoscopic right colectomy for cancer

but immediately for three years later the group from from Netherlands published

an incredible paper in Lancet and that is only 12 cases they have they had

three porcine metastases and immediately was a perfect excuse to stop cancer and laparoscopy.

If you go to the to the nowadays you know from 1991 first laparoscopic colectomy now 2015 my

first question to you to the audience is why colorectal cancer and laparoscopy we don't have

a global uptake. It's similar to the trans-anon approach, you know, because it's an explosion

in Europe. However, in the United States, I think in my knowledge, it's less than 150 procedures

performing until now. But be careful. You say, don't worry about that. You know, tell Houston

we have a problem, but we wanted to keep the car. That I think is important because it's a recent

paper is an editorial by probably one of the most important guys in not only in

the United States in the world talking about colorectal surgery and he says the

professor Steve Steve works but he wrote you know it's a green light given for

laparoscopic surgery for a right on cancer and now we wanted to change but

again if you go to the literature that for me the only good real good paper

recently published about the call to trial in New England Journal of Medicine

comparing open and laparoscopic approach in rectal cancer. If you go to the

positive circumferential radial margin or not, if you compare laparoscopy in

open, there are better results in laparoscopy with 9% CRM positive versus 22% in

open approach I'm surprised about those data and many people in favor to the

laparoscopy said that is really important and the reason is because we

improve visualization of the lower pelvis let me make a very provocative

sentence in my life I didn't see any life procedure well done by laparoscopy

in rectal cancer if you go now to the middle rectum you know that the numbers

is the opposite side is the contrary because if they have positive serum and in middle rectum

10% in laparoscopy versus 3% in open you know maybe some of you can explain to me because I

don't understand the results maybe one of the skews is because you are using the APR the

MICE procedure in open approach and that could be like they do you know like a cone dissection

they do better by laparoscopy than open however that is the numbers and that is

a reality at least in many hospitals in Europe and sometimes abroad to Europe in

minimally versus surgery colorectal talking about rectal section is not out

you have visual superiority it's too much related with the individual skill

of the surgeon and the hospitals and there are advantages in minimally

And if there's a surgery, like morbidity and mortality, return to normal activity, etc.

However, you know, talking about the truth is too difficult.

I think it's very difficult.

People are still discussing about, you know, the pelvic, it's a male pelvis, it's an obese patient,

the obesity in Europe is increasing the numbers, male is 50% of the population,

More than 60% of them in the majority of the studies are males with rectal cancer.

People are talking about closed rectal stem.

You know how many...

Sorry.

Hello.

Professor Lassi, can you hear me?

Yeah.

Yes.

I am very sorry, and we apologize, but we lost the connection.

From when you were talking about the color to study that was recently published.

Yes.

Okay.

can you can you sorry can you go back thank you very much yeah i try to repeat okay you know but

probably probably in a shorter time you say this paper is talking about you know you know comparing

in the new england laparoscopy an open approach in rectal cancer if you go to the numbers the

lower rectum the c the the positive margin as were positive in nine percent in laparoscopy

versus 22% in open you know that means probably because you have improved visualization you know

in the lower part pelvis by laparoscope maybe you can do better surgery however I'm not agree on

that because in the same paper you go to the middle rectum you have 10% positive in middle

rectum in laparoscopy versus 3% in open and I you know I told you I'm very provocative

sentence, probably you will not agree with me, is I never saw in my life a life congress,

a life surgery, well done by laparoscopy of rectal cancer. And that you have to compare

because the reality is 3% in open approach, positive margin versus 22% in lower rectum.

maybe they are including, and I know that, APR or MICE procedure.

If you go to the laparoscopic rectal section by minimally invasive,

it's no doubt we have visual superiority,

too much related with the skill of the surgeons,

the advantages of the minimally invasive surgery

like mobility and mortality, return to normal activity.

However, it's too difficult.

People are still talking about pelvic, male pelvis,

obesity, the obesity, you know, the numbers are increasing in Europe.

Closed rectal stand by stapling pharynx, I don't understand why we need to use two,

even three or four cartridges, 4.5 centimeters, when at the beginning by open approach

we use always a 30 millimeters of stapler to close the rectum.

Something is not going well.

The curvation rate in the majority that we experience is approximately between 5-10% in non-experience is more than 20%.

And it's no doubt that oncological resection and asthmatic leak is absolutely 100% related to the quality of mesorectin.

Maybe a solution to do, not only in rectal surgery, in many procedures,

procedures, that is the reason because we include colorectal surgery and a valid alternative

is to use a trans-anal approach.

That is a short video clip because we have to remember again, we decided to use because

we use in two teams this approach and we have to remember the sensual approach, the stupid

dentist who killed this beautiful lab. I think that is the evolution of the this approach. You

have the quality of the image in the left side is absolutely worse than now. You will see talking

about the stable platforms. Cecil's approach is no doubt for us is mandatory to do this approach

roads with two teams is safe, quicker, and better in oncological point of view.

With the new equipment of the in-sufflation, you have a stable cavity.

Actually, the case of looking here is a patient with ulcerative colitis with an IBD,

and we decided exactly where you are cutting the rectum.

That is a big mistake.

take you leave open you know the pull string to close the rectum there is no doubt you can do it

you can close again by trying to find the right plane that is wrong that is wrong also and that

is right you know that is a good plane you see the you know described by professor hill

the angel's hair is a very easy operation i mean i think it's easier than normal

laparoscopy or even an open approach. But if you commit a mistake and you are not

dissecting absolutely 360 degrees, you know the rectum goes to the right side of the

patient, that could be more difficult. There are some tricks you have to know

because if not you commit a mistake like this, you can dissect the prostate and

there are some cases they describe it with a urethral injury.

The pre-sacral vessels, in this case, you know, it's a mistake again, but this is very

easy, sometimes very complicated if you are going from the abdomen.

With this approach, you can treat your complications, the intraperitoneal complications, better.

We are doing the Bruce Twin because, as I said, we are using this approach in high rectum,

like this.

and I don't know why, it's much better to do anti-cloak rights.

Other type of anastomosis, you can combine the laparoscopic approach

and the transanal approach to make J-pouches, to make J-colonic pouches,

to make many things, as you can see here in this movie.

You see the new staples is much better for the donors.

Another possible is complication.

That is a patient previously operated with a normal signal ectomy,

There's a bleeding, the endoscopist tried to treat with clips, with adrenaline, etc.

At the end we decided to come back to the operating room, introduce, you can see it's more than 50 cm from the anus,

and we put a simple stitch, and that's it. It's absolutely better and cheaper.

I hope you're convinced with these images.

you know now we have more than 250 but in this case I present 226 cases the

majority of course is in 191 rectal cancer 20 ulcerative colitis and reduce

like I presented here that is the you know is demographics you know 60% are

are male. BMI is coming from 18 to 30. Now we operate a case with 43 BMI. You know, the

classification anesthesiology is a normal thing and previous surgery, more than 25%

of the patients. The majority of them are in the mid and low rectum, but as I said,

we're including also the high rectum. We use it, you know, the T-states, the majority of

them are by MRI and neoadjuvant therapy in mid and rectal cancer in 60% of our serians.

In surgery, we made it a total mesoregulation in 75%, partially in the high rectum in 25%,

anastomosis in the majority of them is stapled, and diverticulostoma, unfortunately,

we are using too much, but you can see here that the numbers of conversion from the first case

now is zero percent and that is the same experience the majority of centers in

Europe they are doing in terms of the time you know that many of time the

meantime now is 150 minutes I think it's quite good for rectal cancer but when

you are using one team is the mean is 211 when we decided after the you know

the 40 cases with one team we decided to do in two teams now you know the mean time is approximately

two hours and that is i think it's very good but now at the moment you can do a procedure even in

less than one hour at least in 25 of our patients if you go to the to the to the time the first 50

was 202 minutes and the last 50 is less than two hours by this approach in terms

of the of the of the follow-up you know we have the discharge medium six days we

have that is the specimen pathology that is quite important but probably more

important for you is the quality of the mesorectum in more than 95 percent of

the cases is a complete misorectum and CRM positive in less than 7% and the distant margin

is better than open on laparoscopic approach. In terms of complication, unfortunately we

have 8% of anastomotic leak is still a problem and readmission rate is less than 10% and

and mortality is zero in these areas, I think is important.

In the follow-up, now we have, you know, a short follow-up,

but approximately with a mean of two years, the recurrence is free, is more than 90%.

Local recurrence is less than 3%, and systemic recurrence less than 7%.

Survival, you know, is still alive, almost 98%.

And there are four cases, three cancer-related deaths, one not.

And you can see here the Kaplan-Meyer curve with, I think, very promising results in terms of the survival.

If you compare with the literature, there are not many papers published in the literature with a long series.

The majority is less than 50 cases.

Probably it's anecdotical, but there are many of them that are increasing the numbers.

and we recently published 140 cases in the Journal of the American College of Surgeons

with, I think, quite good results comparing with the literature.

In our technique, our essentials are resection circumferentially and progressively.

The device required for us is important to see in 3D, at least the transplant approach,

using insufflator trochanter barbers because you have a stable platform and a smoke evacuation.

recreation. We are not using rigid device in the platform. I think it's better for the

sphincter of the patients. And it's no doubt we are starting saying, you know, very patient

with this, it's very important to work in symptomatic TOT teams, you know, with safer

surgery for the patient and to reduce the operative time he's trying to to

demonstrate now in the innovation of surgery innovation in everything you

know I think the transformation is not talking about one surgeon ego I I think

we are in the era of we we working together with the teams and that is the

way to do it in take-home messages you know total misdirection decision decision

is still the gold standard.

Introduction of laparoscopy is very good for those patients.

Probably, you know, it's probably better than open approach.

Try to reduce abdominal trauma.

We have to remember Maurice Franklin a long, long time ago

talking about extraction about the specimen through the anus.

The new bottom-up approach is no doubt

is a trans-anal total mesoregulation and TACRIS.

and the evolution and short-term outcomes demonstrated that this approach,

the Cecil approach is feasible, is a safe technique with shorter surgical time

and lower early remission rate.

And we need to find, to do, to make a randomized trial,

the COLOR3 trial comparing laparoscopy and transplant approach

and maybe the future, the combined approaches and technology could be the robotics.

Now I want to invite you for the winter meeting in December 2018.

And the same channel is we will have a patient with a diagnosis,

from the diagnosis to the last treatment and follow-up.

We have an incredible people invited, Lynn Jones by Radio Oncology,

you know and we do a live surgery and at the same time we have phil kirke and mariana berger

you know making the pathology outage into the operating room we discuss about what is the

possibility of treating those patients what is the genetic cancer and i think we have to

let me say one of the most important people of course not all you know in a three hours

live lectures trying to demonstrate that could be a good approach. My last slide is something

very important, you know, to remember. Probably, I don't know exactly who is this guy, Albert

Einstein. I think he's not, you know, he's quite a smart guy. And if I didn't explain

to you, if you can explain it simply, you don't understand it well enough. If you don't

understand my you know my talk my approach let me say i apologize for it thank you very much indeed

thank you very much for your great presentation and for your great data from

your experience and also thank you very much for the taking home message

we will try to be connected on December 18 and the idea of we approach in laparoscopic surgery

it's a great challenge for the future thank you so much okay also on behalf of professor palazzini

we really like to thank you very much for being here in rome and you have any other

presentation yes only one thing the next time please invite me to a very good pasta in Rome

okay thank you very much okay ciao bye bye ciao hope to see you soon bye bye ciao ciao bye bye