July 2024 – Colorectal surgery

Editorial

Professor Jacques Marescaux
President and Founder of IRCAD

Interview of the month

Advances in colorectal surgery in France and around the world.

Prof. Patricia Sylla
Colorectal Surgeon and Chief of Colon and Rectal Surgery, Mount Sinai Health System, New York City

Past-President of the American Society of Gastrointestinal and Endoscopic Surgeons (SAGES), Professor of Surgery, Patricia Sylla heads the Colon and Rectal Surgery Division of the Mount Sinai Health System Hospitals in the United States. A specialist in minimally invasive surgery, particularly colorectal and bariatric surgery, she is internationally renowned for her expertise in the transanal endoscopic treatment of rectal cancer.

Professor Patricia Sylla, your involvement with IRCAD is closely tied to the development of the NOTES program. Could you tell us more about how this began?

Professor Patricia Sylla: At the end of my residency, I received a prize from SAGES, which enabled me to take a course at IRCAD. At the time, I was conducting experimental work on transanal access in rectal surgery and was very interested in the NOTES program developed by IRCAD, which had resulted in the first scarless cholecystectomy in 2007. Professor Jacques Marescaux’s team was a leader in the field, with a real vision of the place and benefits of this type of surgery. Joel Leroy and Silvana Perretta, who worked extensively on the transvaginal and transgastric routes, were very interested in my profile and my knowledge of the transanal route.

I learned a great deal from my experience at IRCAD, and fruitful exchanges with the institute have never ceased. After returning to the United States, I maintained contact with Professor Marescaux’s teams, organizing research in Strasbourg and New York, including numerous experimental cases on cadavers to advance the technique. With Silvana Perretta, more specialized in the gastric route, we compared our practices and considered how we could combine the transgastric and transanal routes. Our work on this new type of surgery led us to engage with manufacturers to improve the available equipment. Collaboration with IRCAD has been extremely fruitful throughout the NOTES program.

Can you describe the transrectal approach to rectal cancer treatment?

Transrectal treatment of rectal cancer involves passing through the natural opening in the anus to resect (remove) the cancer. The extent of resection depends on the size and nature of the cancer. The rectum’s mucosa comprises several layers: mucosa, submucosa, and muscle. If the cancer is in the superficial layer, it can be easily removed without incising the rectal wall. If it has invaded other layers, the tumor must be removed beyond the superficial layer, often requiring lymph node removal, necessitating a more complex dissection. The transrectal route allows direct, minimally invasive access to the tumor.

Can you describe the benefits of transanal colorectal cancer surgery?

The most significant advantage of this technique is its facilitation of rectal tumor resection, particularly for cancers located very low. The lower the cancer, the more challenging the surgery, as advancing towards the tumor without seeing it is difficult, especially in men with narrow pelvises and obese individuals. Laparoscopic or robotic surgery in these patients is often converted to open surgery for safety.

Additionally, when the cancer is a few centimeters from the anus, laparoscopic or robotic approaches do not always allow for anus preservation, resulting in a permanent colostomy. The transanal approach avoids these pitfalls by reversing the order of surgical progression: starting from the anus and working up to the tumor, visible immediately on 4K HD monitoring screens, enabling precise resection with fewer conversions to open surgery (less than 5% compared to 10-20% for laparoscopic surgery) and avoiding anal sphincter removal. This approach allows patients to maintain bowel transit, with necessary lifestyle adaptations. Most patients, particularly younger ones (35-55), prefer to avoid mutilating surgery. However, we are seeing more young patients.

What lifestyle adjustments are necessary after rectal surgery to preserve the anal sphincter?

Although the anal sphincter is preserved, it is weakened by the surgical procedure. Pre-surgery, patients must be prepared psychologically, understanding the changes in their daily life. Post-operation, various measures enable a normal life without leakage risk:

• Low-residue diet
• Pelvic muscle strengthening
• Medication
• Learning to self-wash daily with saline solution to control stool output

What were the stages in the development of transanal endoscopic surgery up to its routine use? And how many teams perform this surgery worldwide?

The technique’s development was subject to regulatory constraints. Techniques are developed not for their own sake but to overcome the limitations of other approaches, proving their non-inferiority or benefits through clinical studies and refining indications for the greatest benefits. In colorectal cancer surgery, this assessment is challenging and time-consuming due to long-term result evaluations. Today, the benefits are established. However, this complex surgery requires extensive training, inaccessible to all surgeons. Training is crucial, and IRCAD has played a decisive role. Currently, too few teams worldwide are trained in this technique, highlighting the need for advanced training for patient benefit.

About IRCAD

Founded in 1994 by Professor Jacques Marescaux, IRCAD is dedicated to training and research in minimally invasive surgery. The Strasbourg-based institute is internationally renowned for its excellent training courses, both face-to-face (nearly 8,800 surgeons trained annually in Strasbourg) and virtual, through the Websurg online university, which has over 470,000 members worldwide.

For more information, please visit https://www.ircad.com

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