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Page 10 of 13 Jahansouz et al. Mini-invasive Surg 2021;5:1 I http://dx.doi.org/10.20517/2574-1225.2020.82

were evaluated with the FISI questionnaire, and quality of life was evaluated with the EuroQol EQ-5D/
EG-VAS and Fecal Incontinence Quality of Life (FIQL) scores. Mean FISI did not significantly change
pre-resection to six months post-resection. Prior to surgery, 13 patients had abnormal FISI scores, while
11 had normal scores. Fifteen patients were continent following surgery, while 5 patients had minor
deterioration. These 5 patients also had tumors that were larger and at a shorter distance from the dentate
line. FIQL score trended towards improvement following resection and was significantly improved in the
area of “coping behavior”. EQ-VAS scores were significantly higher following resection, consistent with an
improvement in quality of life, while there was no change in the EQ-5D score, suggesting no change from
a social perspective. Overall, the authors concluded that quality of life is generally improved following
resection and is equal to the general population at 6 months post-resection.

[47]
Karakayali et al. evaluated anorectal function in 10 patients undergoing TAMIS for benign neoplasia or
low-risk T1 rectal adenocarcinoma. All procedures were performed in lithotomy, the SILS port was used
for transanal access, and all defects were closed. Follow-up consisted of digital rectal examination at 1 week
and proctoscopy at 3 weeks following surgery. Anorectal manometry was performed prior to and at 3 weeks
following surgery. Mean distance of tumor from anal verge was 5.6 cm (3-10 cm). Mean operative time was
98.8 min. All patients had R0 resections. There were no complications through a mean follow-up period of
27 weeks. Patients were evaluated for function by the Cleveland Clinic Incontinence Score questionnaire.
All patients were continent prior to surgery with a score of 0. At 3 weeks postoperative, only one patient
complained of incontinence to flatus and fecal urgency for a score of 3. This resolved by 6 weeks following
surgery. All 9 other patients had scores of 0. Anorectal manometry prior to surgery was normal for all
patients. At postoperative week 3, there were no significant differences seen in mean resting anal pressure,
maximum squeeze pressure, or squeeze endurance. However, minimum rectal sensory volume was
significantly reduced from 37±8.23 preoperatively to 24 ± 5.15 following surgery (P = 0.004). There were
no changes in rectoanal inhibitory reflex or sphincter reflex contractions. Thus, the authors concluded that
conventional TAMIS is safe without impairment of anorectal function.

LEARNING CURVE
[48]
The learning curve for conventional TAMIS appears reasonable and attainable [27,48,49] . Lee et al.
performed at cumulative summation (CUSUM) analysis to determine the number of cases required to
reach proficiency. Overall, 254 TAMIS procedures were included with an R1 resection rate of 7%. CUSUM
[49]
analysis reported that an acceptable R1 rate was achieved between 14 and 24 cases. Clermonts et al.
identified a learning curve between 18 to 31 procedures to reach proficiency. They also pointed out that
with the establishment of standardized protocols and proctorship a shorter learning curve with fewer
cases (6 to 10) may be achieved. Chen et al. reached a similar conclusion, with a minimum of 10 cases
[27]
required for proficiency. A learning curve has not been established for the robotic platform. In comparison
to TEM, our group has evaluated the TEM learning curve, performed by the senior author in 23 patients .
[50]
A CUSUM analysis was conducted taking into account the size of lesion and the operating time. The rate of
excision was extrapolated. The CUSUM curve stabilized following the four-case mark, after which the rate
of excision declined indicating the surmounting of the learning curve.

CONCLUSION
A decade following its introduction, TAMIS appears to be a safe, cost-effective and clinically appropriate
approach to the treatment of benign and early malignant (T1) rectal neoplasia with low-risk features. It
overcomes several of the limitations of TEM, while matching its efficacy and advantages over resection by
traditional TAE. Most importantly, it has an acceptable rate of achieving R0 resection with a low rate of
disease recurrence, while maintaining a low rate of morbidity. Oncologic outcomes are not affected should
disease recur. The majority of patients are now undergoing TAMIS as an outpatient procedure and many
are spared the morbidity associated with TME.