The surgery is intended to be less and less invasive, less painful, with as little scarring as possible and the fastest recovery for the patient. It is in this sense that in 2005 the “NOTES” surgery (Natural Orifice Transluminal Endoscopic Surgery) was established worldwide, which allowed surgeons to access the internal cavities of the body through orifices such as: the mouth, the anus , the vagina, without any external incision. Everything happens inside the body. Leaving almost no wound, limiting the risk of infection and reduced convalescence time.
Heiress of this minimally invasive technique, Dr Patricia Sylla saw further: resecting deep cancers of the rectum or lower colon by a so-called “surgery”.transanal“. Nothing shameful in going through the anus to remove lesions, polyps or cancerous tumors to avoid the large abdominal incision box and thus preserve your rectal functions and the surrounding organs taking into account the high precision of this mini technique invasive. Time for the interview!
Why Doctor: Why can we call you an expert in minimally invasive colorectal cancer surgery?
Dr Patricia Sylla: I did two specializations in colorectal surgery in New York and then in surgery “minimally invasive”, where I developed my repertoire a little with the bariatric and the esophagus, the higher part. I moved with my family to Boston where I practiced for almost nine years. It was a very special time because I was completely immersed in natural surgery, I was part of the first trials in terms of minimally invasive natural reflux access through the vagina. My interest was to do it from the rectum. I was really intrigued by this approach because we had always had problems with pain associated with traditional colorectal surgery, because even if it is laparoscopic or robotic, there are still incisions. There is always an extraction site with a risk of infection and therefore recovery difficulties. And so, I was really very intrigued by the idea of being able to access the rectum transanally.
“We had the first case in the world in Spain in 2009”
Were you one of the first to bring this rectal ablation technique to the USA?
Yes, we did the world’s first case in Spain in 2009. I spent almost 9 years training surgeons around the world. And so, Ircad was a huge collaborator in the process because they were very involved. Then I brought this technique to New York and continued. We did a multicenter clinical study that was just published last year. We demonstrated the effectiveness and safety of the procedure on patients across eleven centers in the United States. This had already been validated in Europe and Asia, but in the United States it was more complex.
When did Ircad come into your life and what were your points of convergence?
At the very beginning, I had incredible luck when I was still training in my specialty. I received a Travel Fellowship Award, they offered a course at Ircad, and so I chose to come at the end of my training. I was already in the laboratory developing the experimental method focused on anus access, and Jacques Marescaux and his team were very interested. They worked a little more on the transgastric oral route and a lot on the transvaginal route. They did the first case of course, but the rectal… they weren’t too involved in that, so we started working a little bit together on that. It was the first time I tested the concept of transanal surgery and they were the first people in the world who saw it and encouraged me to develop this procedure.
This is the magical part of this procedure! For the patient, especially for cancer which is very low.
What is the advantage of the transanal technique in the context of rectal cancer, for example?
The most important benefit, especially for rectal cancer, is the fact that this technique facilitates resection of the rectum without having to automatically and systematically remove the anus. This is the magical part of this procedure! Especially for cancer which is very low. Traditionally: the lower the cancer, the more difficult the surgery is because you really have to go deep into the anatomy, especially in men who have a very narrow pelvis and the obese. Which makes the surgery much more complex and as a result we see a lot of conversions.”open”, that is to say that surgeons start with the laparoscopic or robotic approach in a safe manner. And, because of the difficulty of accessing the tumor, they end up giving up. In this scenario, they finish their intervention with the classic abdominal incision. Or in the worst case, when the cancer is really very low, that is to say when you can feel it with your finger and they can’t go down, they say to the patient: “I can’t “I can’t save the anus muscle, I have to remove everything.” It’s the “APR (Abdominoperineal Resection)”, and that’s catastrophic.
Why is abdominoperineal resection (APR) a disaster scenario?
Because the anus which is tube-shaped is removed, and the rectum too. The colon, which is higher, is cut, then taken out through the skin to make a pouch. Instead of having an anus, there is nothing! They colloquially call it the “barbie butt“, that’s to say “a barbie’s butt”. And when we look at the details, usually it’s because the tumors were 4 or 5 centimeters from the anus. So, when the cancers are very, very low, it becomes more and more complicated to resect everything without compromising the quality of the surgery. Especially since it’s cancer, we can’t take any risks. We can’t damage the rectum because otherwise the cancer will come back. So, most surgeons are traditional: “I don’t take any risks, I remove everything, so we are sure that we cure the patient permanently.”
We can begin the dissection in a very precise way, we are no longer guessing.
And finally, what does the transanal procedure change?
With the transanal procedure, the biggest advantage is that for the lowest cancers, we start from the bottom, we see the cancer, it’s in front of us, everything is enlarged because we are on 5K HD screens or 4K and we can start the dissection very precisely, we are no longer guessing. The resection will be done at the site of the cancer with perhaps some tissue around it. We start the dissection, then we go through the muscle, we go up and we join the part at the top. So in fact we combine the dissection from above and from below but it makes the dissection easier, it makes it easier because I do the most complex part while the other surgeon from above does it. stop when it gets hard, I go in from below and when we’re finished, we bring the colon back from above to reconnect it to the anus. So everything is done internally and we take the rectum out from below. And the connection is made with the stapler or with sutures in the traditional way. A suture and then the tissues are sewn together. This is the concept of transanal.
What drives you in your specialty? What is your daily driving force in this discipline which is not easy? ?
The most satisfying part is the gratitude from the patients. Of course there are always complications, and we need to re-educate them regarding changes in defecatory function. NOTWe monitored them for 5 years for oncological reasons and we ended up becoming very close with these patients. I am a surgeon, I love operating but I really like the relationship with my patients, especially cancer patients. These are very special relationships that keep me going. I encourage my patients to use groups on social networks to support cancer patients with defecatory dysfunctions which have more than a hundred members around the world who connect with each other, exchange their experiences, their solutions to live better.
And the second thing that motivates me is seeing all this technological development, endoluminal techniques, advanced endoscopies, and innovative instruments that allow us to avoid complex and disfiguring abdominal surgery.
Check out our digital video work,
only an account creation is required to access it.
