In Episode 2 of our Colorectal Cutting Edge series, Miguel Cunha interviews Professor Antonino Spinelli about TTSS, a new anastomotic technique.

Antonino Spinelli is the General Secretary of the European Society of Coloproctology, Director of the Colon and Rectal Surgery division and Professor of Surgery at Humanitas, Rozzano Milano, Italy. He is an associated editor on several journals. He is dedicated to the development of innovative techniques in minimally invasive colorectal surgery.

Miguel Cunha: Thank you Professor Antonino for sharing with us you expert view on this exciting subject: TTSS anastomosis technique.

Let me start the interview by saying that your vast experience as a scientific colorectal surgeon is well known and your career is very inspiring. As a young ESCP member, I look at you as an example to follow.

One of the greatest fields of interest among the colorectal surgery community is definitely colorectal and coloanal anastomosis. To introduce this topic to our readers, can you briefly explain this new anastomotic technique?

Antonino Spinelli: TTSS is a strategy to take the best of both worlds:

  1. From traditional TME, the well-established TME dissection, learned by generations of surgeons and proven to be safe, efficacious and equally reliable if performed by open, laparoscopic or robotic
  2. From transanal TME (TaTME), the idea of combining a transanal transection (TT) and a single-stapled (SS) anastomosis, though accounting for key technical differences from TaTME when performing the transection and the anastomosis.

MC: I’ve read with great interest your papers on Colorectal Disease where you describe the technique and give some tips and tricks on it. As two years have now passed, do you have new tips and tricks you want to share with us?

AS: I started to perform a technique similar to TTSS occasionally, and later developed and refined TTSS in January 2018. After 100 cases, I am fully satisfied with this approach and I will soon be presenting my results.

There are a number of tips and tricks to know - the most important one is to complete the dissection from above until the inter-sphincteric level in order to facilitate the purse string for transection, and the subsequent purse string, to smoothly perform the single-stapled, dog ears-free, anastomosis.

MC: What are the main advantages of these technique over others and how do you select the patients that may benefit from it?

AS: The candidates for TTSS are the same as for TME (mid and low rectal tumors) and pouch surgery. As mentioned, the main advantage of the TTSS strategy is that it takes the best of both worlds: the efficacious and reliable TME dissection, and the combination of transanal transection (TT) and a single-stapled (SS) anastomosis from TaTME.

MC: When we talk about colorectal anastomosis, we are almost obligated to talk about dehiscence. This is one of the subjects that most concern a colorectal surgeon. In your impressive paper on the European Journal of surgical Oncology on this subject, you’ve clearly pointed dehiscence as a result of multiple factors. Do you think that this technique can control some of these factors?

AS: I’m very aware of the multifactorial aetiology of anastomotic leak. The related technical factors depend on both transection and anastomosis, which are two key steps of any reconstructive rectal surgery. TTSS allows an even rectal transection performed under visual control, avoiding multiple staple-firings, which have been identified as risks factors for leak. Additionally, the perfect anastomosis ideally is without cross stapling, which is only performed due to a technical issue, but is conceptually not required. The single stapled (SS) anastomosis avoids cross stapling and dog-ears. Whether or not this can reduce leaks remains to be seen.

MC: What other factors could be improved or controlled in the near future?

AS: Significant progress is being made in all the emerging areas investigating anastomotic healing at a molecular level. In fact, the complexity of intestinal homeostasis invokes the need to move from a merely technical level of research towards integrated translational therapeutic strategies to reduce the incidence of leak, and potentially prevent the complication itself.

For example, next generation sequencing technology could lead to a mechanism-based prophylaxis strategy, targeting only those pathogens that can cause anastomotic leak. In fact, thanks to microbial metagenomics, it will be possible to prepare tailored bowel preparations which include nutritional supplements and non-microbiocidal agents.

MC: That brings us to the end of the interview! I would like to thank you for sharing with us your insight and expertise in this area, and I would like to ask you one final question: I started the interview by saying that you have a very inspiring career. Following this thought, can you tell us what your main piece of advice would be to the young 'scientific surgeons' generation interested in colorectal surgery and research?

AS: My message to all the young colleagues is that motivation is everything. Your background is not important, nor is your initial experience or your current CV. What matters is how hungry you are and how strong your determination to learn and improve is.

MC: Thank you so much for sharing your knowledge with us.

Interview by Miguel Cunha

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