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Technique to Prevent Painful Surgery May Have Role in Pediatrics

Researcher from Mt. Sinai Says First Case Showed A Child Able To Return To Normal Activity Sooner

New York— A group of surgeons, experts in colorectal and minimally invasive surgery (MIS), are investigating a surgical technique called Transanal Endoscopic Surgery or TES to evaluate its potential role in the management of retrorectal tumors in the pediatric population. The results could offer children less painful surgeries in the future.

TES has been evolving over the past few decades, moving toward a more tailored approach in the treatment of rectal tumors. Recently, the standard surgical approach has been investigated on young adults and even more recently on children. Led through a course by Dr. Patricia Sylla, pediatric surgeons agreed that not only could the technique offer younger patients alternatives to major surgery, but also it would result in less pain because it eliminates the need for painful incisions, a procedure that is widely used today. “As we were having great success in TES with young adults, I received a call from an expert pediatric surgeon who wanted to see whether or not this particular procedure would work in a 12 year-old patient who was eager to avoid painful surgery,” says Sylla, an associate professor of surgery, division of colorectal Surgery, Mount Sinai Hospital. “He decided to use this approach in that particular case.”

According to both surgeons, the operation was a success. “The typical surgery for these tumors in children requires removing the tailbone, which is painful and aggressive,” said Dr. David Rothstein, associate professor, Department of Surgery; Pediatric Surgeon, Women and Children’s Hospital of Buffalo. “This patient’s tumor was lodged between her bone and rectum, a difficult space for any surgeon to operate.“ Afterward, Sylla proposed teaching a course for SLS, the medical society for minimally invasive surgeons, to further explore the potential of this approach in pediatric patients. As a result of the course’s success, SLS will present an award for her ingenuity and foresight, this August at MIS Week, their annual conference. “In the right patient with the right indications Dr. Sylla’s technique really helps the patient, says Dr. Paul Wetter, chairman of SLS. “TES is a less painful procedure that reduces the morbidity of rectal surgery, so it is a logical solution in complex surgery for children.”

Transanal Endoscopic Surgery or TES removes rectal tumors using endoscopic access. The procedure is performed under general anesthesia and involves positioning the patient either supine, or in the lateral or “prone” position. Because no skin incisions are needed, the procedure is reportedly less painful.

Instead of the traditional approach of removing the tumor through the coccyx, with TES the tumor is removed through the rectum. Sylla warns that although the first case in pediatrics was successful, it needs more study, “This technique needs more evaluation and pediatric surgeons need to be trained before we can begin to offer it to children worldwide. But I am thrilled that the feedback has been so positive from pediatric surgeons.” TES (transanal endoscopic surgery) is also referred to TEM (transanal endoscopic microsurgery), TEO (transanal endoscopic operation) or TAMIS (transanal minimally invasive surgery), based on which commercial platform is used. These techniques have been increasingly used in the surgical treatment of benign rectal tumors and early rectal cancer. According to research, the conditions they treat can be burdened by significant morbidity. Compared with standard abdominal surgery, TES offers the advantages of an incisionless surgical approach; however, this approach is not suited for the treatment of advanced rectal cancer.

The TES approach may be applicable to selected pediatric patients with retrorectal tumors, such as children with benign retrorectal tumors based on preoperative studies,” says Gustavo Stringel, professor of surgery and pediatrics at New York Medical College.   “Overall, the consensus is that the TES approach holds value within pediatric surgery.”

The majority of retrorectal tumors are congenital development cysts including epidermoid, dermoid, duplication and tailgut cysts. Most retrorectal tumors are benign and resected using en-bloc coccygectomy or via a transabdominal approach, with or without proctectomy. The current standard of care is accompanied with a small but non-negligible risk of infection, incisional pain, longer hospital stay and prolonged recovery. Conversely, several case reports have described the success of TES to resect benign presacral lesions in adults. Suggested benefits of this minimally invasive transanal approach include exceptional endoscopic exposure to the retrorectal space, shorter length of stay and hospital recovery time, and minimal pain and excellent cosmesis.

“The feedback on the course and the Nicholson Center, where the course was held, was excellent,” says Jay Redan, immediate past president of SLS and a general surgeon at Florida Hospital. “We also agreed that this procedure should be performed by pediatric surgeons with colorectal surgery experience, trained in this technique, and with an appropriate level of experience operating on retrorectal tumors.”

The course, “Transanal Endoscopic Surgery Applied to Retrorectal Tumors: Hand-on Training Course for Pediatric Surgeons,” was held at the Florida Hospital Nicholson Center in Orlando, Florida on December 11, 2015. It was designed by SLS to provide a comprehensive review of TES, as well as provide attendants with hands-on training in the technique. More importantly, the course aimed to determine if this approach is applicable and feasible in pediatrics patients with retrorectal tumors. Five pediatrics surgeons from Boston, Columbus, Pittsburgh, and Buffalo were invited to attend the course, each having been selected based on their extensive experience in colorectal surgery and MIS and all considered experts in their field. The attendants had little to no prior training or experience with TES.

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