Transanal Total Mesorectal Excision for Rectal Cancer: Outcomes after 140 Patients

Transanal Total Mesorectal Excision: A Novel Approach to Rectal Surgery

Less invasive approaches continue to be explored and refined for diseases of the colon and rectum. The current gold standard for the surgical treatment of rectal cancer, total mesorectal excision (TME), is a technically precise yet demanding procedure with outcomes measured by both oncologic and functional outcomes (including bowel, urinary, and sexual). To date, the minimally invasive approach to rectal cancer has not yet been perfected, leaving ample opportunity for rectal surgeons to innovate. Transanal TME has recently emerged as a safe and effective technique for both benign and malignant diseases of the rectum. While widespread acceptance of this surgical approach remains tempered at this time due to lack of long-term oncologic outcome data, short-term outcomes are promising and there is great excitement surrounding the promise of this technique.

Combined transanal total mesorectal excision (taTME) with laparoscopic instruments and abdominal robotic surgery in rectal cancer

Laparoscopic surgery for rectal cancer can be technically challenging. We describe a hybrid technique combining abdominal robotic dissection and transanal total mesorectal excision. This procedure was performed in a 50-year-old man with rectal adenocarcinoma at 5 cm from the dentate lane. Preoperative staging was T2N0M0. Surgery went well without complications, and estimated blood loss was less than 50 mL. Robotic surgical time was 90 min, and total operative time was 160 min. The patient was discharged on postoperative day 3. Pathology analysis revealed an intact mesorectum (TME grade 3) and a T2N0 tumor with negative margins. Hybrid surgery with pelvic robotic dissection and transanal total mesorectal excision was feasible, quick and safe in this patient and may be a method that can be developed further.

Combined robotic transanal total mesorectal excision (R-taTME) and single-site plus one-port (R-SSPO) technique for ultra-low rectal surgery-initial experience with a new operation approach

OBJECTIVE

Robot-assisted rectal surgery is gaining popularity, and robotic single-site surgery is also being explored clinically. We report our initial experience with robotic transanal total mesorectal excision (R-taTME) and radical proctectomy using the robotic single-site plus one-port (R-SSPO) technique for low rectal surgery.

METHODS

Between July 2015 and March 2016, 15 consecutive patients with ultra-low rectal lesions underwent R-taTME followed by radical proctectomy using the R-SSPO technique by a single surgeon. The clinical and pathological results were retrospectively analyzed.

RESULTS

The median operative time was 473 (range, 335-569) min, and the estimated blood loss was 33 (range, 30-50) mL. The median number of lymph nodes harvested was 12 (range, 8-18). The median distal resection margin was 1.4 (range, 0.4-3.5) cm, and all patients had clear circumferential resection margins. We encountered a left ureteric transection intraoperatively in one patient, and another patient required reoperation for postoperative adhesive intestinal obstruction. There was no 30-day mortality.

CONCLUSION

R-taTME followed by radical proctectomy using the R-SSPO technique for patients with low rectal lesions is technically feasible and safe without compromising oncologic outcomes. However, there were considerable limitations and a steep learning curve using current robotic technology.

Re-appraisal and consideration of minimally invasive surgery in colorectal cancer

Throughout history, surgeons have been on a quest to refine the surgical treatment options for their patients and to minimize operative trauma. During the last three decades, there have been tremendous advances in the field of minimally invasive colorectal surgery, with an explosion of different technologies and approaches offered to treat well-known diseases. Laparoscopic surgery has been shown to be equal or superior to open surgery. The boundaries of laparoscopy have been pushed further, in the form of single-incision laparoscopy, natural-orifice transluminal endoscopic surgery and robotics. This paper critically reviews the pathway of development of minimally invasive surgery, and appraises the different minimally invasive colorectal surgical approaches available to date.

Transanal total mesorectal excision (TaTME) for rectal cancer: effects on patient-reported quality of life and functional outcome

Background

Transanal total mesorectal excision (TaTME) has rapidly become an important component of the treatment of rectal cancer surgery. Cohort studies have shown feasibility concerning procedure, specimen quality and morbidity. However, concerns exist about quality of life and ano(neo)rectal function. The aim of this study was to prospectively evaluate quality of life in patients following TaTME for rectal cancer with anastomosis.

Methods

Consecutive patients who underwent restorative TaTME surgery for rectal adenocarcinoma in an academic teaching center with tertiary referral function were evaluated. Validated questionnaires were prospectively collected. Quality of life was assessed by the EuroQol 5D (EQ-5D), European Organization for Research and Treatment of Cancer’s QLQ-C30 and QLQ-CR29 and low anterior resection syndrome (LARS) scale. Outcomes of the questionnaires at 1 and 6 months were compared with preoperative (baseline) values.

Results

Thirty patients after restorative TaTME for rectal cancer were included. Deterioration for all domains was mainly observed at 1 month after surgery compared to baseline, but most outcomes had returned to baseline at 6 months. Social function and anal pain remained significantly worse at 6 months. Major LARS (score >30) was 33% at 6 months after ileostomy closure. No end colostomies were required.

Conclusions

TaTME is associated with acceptable quality of life and functional outcome at 6 months after surgery comparable to published results after conventional laparoscopic low anterior resection.

Hybrid transanal and total mesorectal excision after transanal endoscopic microsurgery for unfavourable early rectal cancer: a report of two cases

Completion total mesorectal excision (TME) is a rare but complex procedure after transanal endoscopic microsurgery for early rectal cancer with unfavourable final histology. Two cases are reported when completion TME was performed after upfront transanal partial mesorectal dissection. Intact non-perforated TME specimens with negative and adequate distal and circumferential margins were created. The quality of both total mesorectal excisions was complete and distal margins were sufficient. We believe that our technique might be a way of approaching completion TME after TEM, especially in cases of low rectal cancer.

Abdomino-endoscopic perineal excision of the rectum for benign and malignant pathology: Technique considerations for true transperineal verus transanal total mesorectal excision endoscopic proctectomy

PURPOSE

Transanal minimally invasive surgery using single port instrumentation is now well described for the performance of total mesorectal excision with restorative colorectal/anal anastomosis most-often in conjunction with transabdominal multiport assistance. While non-restorative abdomino-endoscopic perineal excision of the anorectum is conceptually similar, it has been less detailed in the literature.

METHODS

Consecutive patients undergoing non-restorative ano-proctectomy including a transperineal endoscopic component were analysed. All cases commenced laparoscopically with initial medial to lateral mobilisation of any left colon and upper rectum. The lower anorectal dissection started via an intersphincteric or extrasphincteric incision for benign and malignant pathology, respectively, and following suture closure and circumferential mobilisation of the anorectum, a single port (GelPOINT Path, Applied Medical) was positioned allowing the procedure progress endoscopically in all quadrants up to the cephalad dissection level. Standard laparoscopic instrumentation was used. Specimens were removed perineally.

RESULTS

Of the 13 patients (median age 55 years, median BMI 28.75 kg/m2, median follow-up 17 months, 6 males), ten needed completion proctectomy for ulcerative colitis following prior total colectomy (three with concomitant parastomal hernia repair) while three required abdominoperineal resection for locally advanced rectal cancer following neoadjuvant chemoradiotherapy. Median operative time was 190 min, median post-operative discharge day was 7. Eleven specimens were of high quality. Four patients developed perineal wound complications (one chronic sinus, two abscesses needing drainage) within median 17-month follow-up.

CONCLUSION

Convergence of transabdominal and transanal technology and technique allows accuracy in combination operative performance. Nuanced appreciation of transperineal operative access should allow specified standardisation and innovation.

A two-centre experience of transanal total mesorectal excision

AIM

Transanal total mesorectal excision (TaTME) offers a promising alternative to the standard surgical abdominopelvic approach for rectal cancer. The aim of this study was to report a two-centre experience of this technique, focusing on the short-term and oncological outcome.

METHOD

From May 2013 to May 2015, 40 selected patients with histologically proven rectal adenocarcinoma underwent TaTME in two institutions and were prospectively entered on an online international registry.

RESULTS

Forty patients (80% men, mean body mass index 27.4 kg/m² ) requiring TME underwent TaTME. Procedures included low anterior resection (n = 31), abdominoperineal excision (n = 7) and proctocolectomy (n = 2). A minimally invasive approach was attempted in all cases, with three conversions. The mean operation time was 368 min and 16 patients (40%) had a synchronous abdominal and transanal approach. There was no mortality and 16 postoperative complications occurred, of which 68.8% were minor. The median length of stay was 7.5 (3-92) days. A complete or near-complete TME specimen was delivered in 39 (97.5%) cases with a mean number of 20 lymph nodes harvested. R0 resection was achieved in 38 (95%) patients. After a median follow-up of 10.7 months, there were no local recurrences and six (15%) patients had developed distant metastases.

CONCLUSION

TaTME appears to be feasible, safe and reproducible, without compromising the oncological principles of rectal cancer surgery. It is an attractive option for patients for whom laparoscopy is likely to be particularly difficult. These encouraging results should encourage larger studies with assessment of long-term function and the oncological outcome.

Initial experience of restorative proctocolectomy for ulcerative colitis by transanal total mesorectal rectal excision and single-incision abdominal laparoscopic surgery

AIM

Laparoscopic surgery is well established for colon cancer, with defined benefits. Use of laparoscopy for the performance of restorative proctocolectomy (RPC) with ileoanal anastomosis is more controversial. Technical aspects include difficult dissection of the distal rectum and a potentially increased risk of anastomotic leakage through multiple firings of the stapler. In an attempt to overcome these difficulties we have used the technique of transanal rectal excision to perform the proctectomy. This paper describes the technique, which is combined with an abdominal approach using a single-incision platform (SIP).

METHOD

Data were collected prospectively for consecutive operations between May 2013 and October 2015, including all cases of restorative proctocolectomy with ileoanal pouch anastomosis performed laparoscopically. Only patients having a transanal total mesorectal excision (TaTME) assisted by SIP were included. The indication for RPC was ulcerative colitis (UC) refractory to medical treatment.

RESULTS

The procedure was performed on 16 patients with a median age of 46 (26-70) years. The male:female ratio was 5:3 and the median hospital stay was 6 (3-20) days. The median operation time was 247 (185-470) min and the overall conversion rate to open surgery was 18.7%. The 30-day surgical complication rate was 37.5% (Clavien-Dindo 1 in four patients, 2 in one patient and 3 in one patient). One patient developed anastomotic leakage 2 weeks postoperatively.

CONCLUSION

This initial study has demonstrated the feasibility and safety of TaTME combined with SIP when performing RPC with ileal pouch-anal anastomosis for UC.

Transanal approach for intersphincteric resection of rectal cancer in a patient with a huge prostatic hypertrophy

The gold standard of surgical technique for rectal cancer is total mesorectal excision (TME). Laparoscopic TME has been proven to provide surgical safety and oncological outcomes equivalent to open TME. However, dissection of the lower rectum has some inherent difficulties related to a narrow pelvic space. The challenge of TME in the lower rectum was confirmed by the Colorectal Cancer Laparoscopic or Open Resection (COLOR) II trial showing a 9% positive circumferential margin (CRM) rate in laparoscopic TME and a 22% positive CRM rate in open TME. Recently, transanal TME has attracted intense attention as a promising alternative to laparoscopic TME. In this video article, we show the performance of a transanal approach for intersphincteric resection (ISR) of rectal cancer in a patient with a huge prostatic hypertrophy.

Clinical outcomes and case volume effect of transanal total mesorectal excision for rectal cancer: a systematic review

Transanal total mesorectal excision (TaTME) has been developed to improve quality of TME for patients with mid and low rectal cancer. However, despite enthusiastic uptake and teaching facilities, concern exists for safe introduction. TaTME is a complex procedure and potentially a learning curve will hamper clinical outcome. With this systematic review, we aim to provide data regarding morbidity and safety of TaTME. A systematic literature search was performed in MEDLINE (PubMed), EMBASE (Ovid) and Cochrane Library. Case reports, cohort series and comparative series on TaTME for rectal cancer were included. To evaluate a potential effect of case volume, low-volume centres (n ≤ 30 total volume) were compared with high-volume centres (n > 30 total volume). Thirty-three studies were identified (three case reports, 25 case series, five comparative studies), including 794 patients. Conversion was performed in 3.0% of the procedures. The complication rate was 40.3, and 11.5% were major complications. The quality of the mesorectum was “complete” in 87.6%, and the circumferential resection margin (CRM) was involved in 4.7%. In low- versus high-volume centres, the conversion rate was 4.3 versus 2.7%, and major complication rates were 12.2 versus 10.5%, respectively. TME quality was “complete” in 80.5 versus 89.7%, and CRM involvement was 4.8 and 4.5% in low- versus high-volume centres, respectively. TaTME for mid and low rectal cancer is a promising technique; however, it is associated with considerable morbidity. Safe implementation of the TaTME should include proctoring and quality assurance preferably within a trial setting.

The treatment of all MRI-defined low rectal cancers in a single expert centre over a 5-year period: is there room for improvement?

AIM

Outcomes following treatment for low rectal cancer still remain inferior to those for upper rectal cancer. A clear definition of 'low' rectal cancer is lacking and consensus is more likely using a definition based on MRI criteria. This study aimed to determine disease presentation and treatment outcome of low rectal cancer based on a strict anatomical definition.

METHOD

A low rectal cancer was defined as one with a lower border below the pelvic attachment of the levator muscles on sagittal MRI. One hundred and eighty consecutive patients with tumours defined by this criterion between 2006 and 2011 were identified from a prospectively managed departmental database.

RESULTS

One hundred and eighteen patients (66%) underwent curative resection and 12 (7%) palliative resection. Eleven patients (6%) were entered into a 'watch and wait' (W&W) protocol; 10 others (5%) were not fit to undergo any operation. Some 26 patients (14%) had nonresectable local or metastatic disease. An R0 resection was the most important factor influencing survival after curative surgery. R+ resections occurred in 12% of non-abdominoperineal excisions, 11% of abdominoperineal excisions and 47% of extended resections. Overall survival was similar in the curative resections compared with the W&W patients. In 23 of the 96 (24%) treated with neoadjuvant chemoradiotherapy there was a persistent clinical or a pathological complete response.

CONCLUSION

In curative resections, a clear margin is the most important determinant of survival. In 24% of the patients treated with neoadjuvant chemoradiotherapy, surgery could potentially have been avoided. There is scope for improvement in the treatment of locally advanced rectal cancers.

Laparoscopic colorectal cancer resections in the obese: a systematic review

BACKGROUND

Laparoscopic colorectal cancer operations in obese patients pose technical challenges that may negatively impact oncologic adequacy. A meta-analysis was performed to assess the oncologic outcomes of laparoscopic colorectal cancer resections in obese compared to non-obese patients. Short- and long-term outcomes were assessed secondarily.

METHODS

A systematic literature search was conducted from inception until October 01, 2014. Studies that compared outcomes of laparoscopic colorectal malignant neoplasms in obese and non-obese patients were selected for meta-analysis. Studies that defined obesity as body mass index (BMI) ≥ 30 kg/m² were included. Oncologic, operative, and postoperative outcomes were evaluated. Pooled odds ratios (OR) and weighted mean differences (WMD) with 95 % confidence intervals (CI) were calculated using fixed-effects models. For oncologic and survival outcomes, a subgroup analysis was conducted for rectal cancer and a secondary analysis was conducted for Asian studies that used a BMI cutoff of 25 kg/m².

RESULTS

Thirteen observational studies with a total of 4550 patients were included in the meta-analysis. Lymph node retrieval, distal, and circumferential margins, and 5-year disease-free and overall survival were similar in the obese and non-obese groups. Conversion rate (OR 2.11, 95 % CI 1.58-2.81), postoperative morbidity (OR 1.54, 95 % CI 1.21-1.97), wound infection (OR 2.43, 95 % CI 1.46-4.03), and anastomotic leak (OR 1.65, 95 % CI 1.01-2.71) were all significantly increased in the obese group.

CONCLUSIONS

Laparoscopic colorectal cancer operations in obese patients pose an increased technical challenge as demonstrated by higher conversion rates and higher risk of postoperative complications compared to non-obese patients. Despite these challenges, oncologic adequacy of laparoscopic colorectal cancer resections is comparable in both groups.

Conversions in laparoscopic surgery for rectal cancer

BACKGROUND

Laparoscopic surgery offers patients with rectal cancer short-term benefits and similar survival rates as open surgery. However, selecting patients who are suitable candidates for laparoscopic surgery is essential to prevent intra-operative conversion from laparoscopic to open surgery. Clinical and pathological variables were studied among patients who had converted laparoscopic surgeries within the COLOR II trial to improve patient selection for laparoscopic rectal cancer surgery.

METHODS

Between January 20, 2004, and May 4, 2010, 1044 patients with rectal cancer enrolled in the COLOR II trial and were randomized to either laparoscopic or open surgery. Of 693 patients who had laparoscopic surgery, 114 (16 %) were converted to open surgery. Predictive factors were studied using multivariate analyses, and morbidity and mortality rates were determined.

RESULTS

Factors correlating with conversion were as follows: age above 65 years (OR 1.9; 95 % CI 1.2-3.0: p = 0.003), BMI greater than 25 (OR 2.7; 95 % CI 1.7-4.3: p < 0.001), and tumor location more than 5 cm from the anal verge (OR 0.5; CI 0.3-0.9). Gender was not significantly related to conversion (p = 0.14). In the converted group, blood loss was greater (p < 0.001) and operating time was longer (p = 0.028) compared with the non-converted laparoscopies. Hospital stay did not differ (p = 0.06). Converted procedures were followed by more postoperative complications compared with laparoscopic or open surgery (p = 0.041 and p = 0.042, respectively). Mortality was similar in the laparoscopic and converted groups.

CONCLUSIONS

Age above 65 years, BMI greater than 25, and tumor location between 5 and 15 cm from the anal verge were risk factors for conversion of laparoscopic to open surgery in patients with rectal cancer.

Transanal total mesorectal excision: Myths and reality

Transanal total mesorectal excision (TaTME) is a new and promising approach for the treatment of rectal cancer. Whilst the experience is still limited, there are growing evidences that this approach might overcome the limits of standard low anterior resection. TaTME might help to decrease the conversion rate especially in difficult patients, and to improve the pathological results, while preserving the urogenital function. Evaluation of data from large registries and randomized studies should help to draw firmer conclusions. Beyond these technical considerations, the next challenge seems to be clearly the safe introduction of this approach, motivating the development of dedicated courses.

Transanal total mesorectal excision for rectal cancer: the journey towards a new technique and its current status

INTRODUCTION

The surgical approach to total mesorectal excision (TME) for rectal cancer has undergone a substantial evolution with the adoption of more minimally invasive procedures. Transanal TME (taTME) is the latest advanced technique pioneered to tackle difficult pelvic dissections. Areas covered: The evolution of TME surgery from open to laparoscopic, robotic and transanal techniques was explored in this review. The outcomes to date on the latest approach, taTME, are reviewed and the future direction of rectal cancer surgery proposed. A literature search was performed using Embase, Medline, Web of Science and Cochrane databases for articles published between January 2005 to May 2016 using the keywords 'transanal', 'TME', 'laparoscopy', 'robotics', 'minimally invasive', 'outcomes' and 'training'. Expert commentary: Surgical experience in taTME is growing and randomised controlled trials have been planned and initiated worldwide. However, the learning curve for this procedure remains to be established and a structured training programme is necessary to ensure safe introduction and dissemination of the technique in the clinical setting. Further innovation including stereotactic navigation and more specialised transanal equipment are currently being explored and are likely to enhance the technique further.

Anterior Perineal PlanE for ultra-low Anterior Resection of the rectum (APPEAR) technique: A systematic review

INTRODUCTION

The Anterior Perineal PlanE for ultra-low Anterior Resection of the rectum (APPEAR) technique utilises a perineal incision to facilitate resection of the distal rectum. The aim of this study was to review use of the APPEAR technique, assessing patient selection, indications, complications and outcomes, both oncological and functional.

MATERIALS AND METHODS

A systematic review was carried out to identify studies reporting outcomes following rectal resection via an anterior perineal incision, with no limits on year or language. All studies were included. Quality of studies was assessed using the methodological index for non-randomised studies (MINORS) score.

RESULTS

Thirteen studies were identified from 1985 to 2013. 174 patients (102 male), ranging from 21 to 82 years, underwent surgery at eleven centres in seven countries. Maximum experience at one centre is 60 cases. 9 cases were performed for rectal dysplasia, 141 for rectal cancer; 96 resections were R0 (remaining 45 unstated). 14 cases were carried out laparoscopically. 30-day mortality was 2.3% (4 patients); there were 2 further deaths from systemic recurrence. Permanent stoma rate was 8/155 (5%). The most frequent complication was perineal or vaginal fistulation (26 patients): 6 underwent reoperation; 15 healed with conservative management; 5 required a permanent stoma. Functional outcomes were variably reported; median stool frequency was 3/24hrs with average Wexner scores of 5-5.5.

CONCLUSION

In selected patients the APPEAR technique offers avoidance of permanent colostomy with good oncological outcomes. The majority of studies had short follow up periods and longer-term outcomes will need evaluation.

Technologies, technical steps, and early postoperative results of transanal TME

INTRODUCTION

First described in 1982, TME overcomes most of the concerns regarding adequate local control after anterior rectal resection. TME requires close sharp dissection along the so-called Heald's plane down to the levators, with distal dissection often cumbersome. In recent years, Transanal TME was introduced with the aim to improve distal rectal dissection and quality of mesorectal excision.

MATERIAL AND METHODS

A prospective, non-randomized study, started in 2013, is currently ongoing in two Italian Centers. Study objectives were assessing the safety of TaTME and TME quality. TaTME technique and technologies as performed in these centers and cumulative results at ≤30 postoperative days of the first 102 patients are reported.

RESULTS

Early postoperative morbidity and mortality rates were 33.3% (34 pts, 16 Clavien-Dindo I + II and 18 Clavien-Dindo III + IV + V), and 1.96% (two deaths), respectively. The quality of mesorectal excision according to Quirke was: complete in 97.1% and nearly complete in 2.9% of the cases.

CONCLUSIONS

The results confirm the effectiveness of TaTME, especially regarding the quality of the mesorectal dissection. Open questions regarding standardization, anatomical landmarks, indications, morbidity (with special regard to local infection and sepsis), learning curve and oncological outcomes require further answers from larger studies and RCTs before definitive validation of this procedure.  .

Transanal total mesorectal excision (taTME) for rectal cancer: a systematic review and meta-analysis of oncological and perioperative outcomes compared with laparoscopic total mesorectal excision

Background

Transanal total mesorectal excision (taTME) is an emerging surgical technique for rectal cancer. However, the oncological and perioperative outcomes are controversial when compared with conventional laparoscopic total mesorectal excision (laTME).

Methods

A systematic review and meta-analysis based on Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines was conducted in PubMed, Embase and Cochrane database. All original studies published in English that compared taTME with laTME were included for critical appraisal and meta-analysis. Data synthesis and statistical analysis were carried out using RevMan 5.3 software.

Results

A total of seven studies including 573 patients (taTME group = 270; laTME group = 303) were included in our meta-analysis. Concerning the oncological outcomes, no differences were observed in harvested lymph nodes, distal resection margin (DRM) and positive DRM between the two groups. However, the taTME group showed a higher rate of achievement of complete grading of mesorectal quality (OR = 1.75, 95% CI = 1.02–3.01, P = 0.04), a longer circumferential resection margin (CRM) and less involvement of positive CRM (CRM: WMD = 0.96, 95% CI = 0.60–1.31, P <0.01; positive CRM: OR = 0.39, 95% CI = 0.17–0.86, P = 0.02). Concerning the perioperative outcomes, the results for hospital stay, intraoperative complications and readmission were comparable between the two groups. However, the taTME group showed shorter operation times (WMD = –23.45, 95% CI = –37.43 to –9.46, P <0.01), a lower rate of conversion (OR = 0.29, 95% CI = 0.11–0.81, P = 0.02) and a higher rate of mobilization of the splenic flexure (OR = 2.34, 95% CI = 0.99–5.54, P = 0.05). Although the incidence of anastomotic leakage, ileus and urinary morbidity showed no difference between the groups, a significantly lower rate of overall postoperative complications (OR = 0.65, 95% CI = 0.45–0.95, P = 0.03) was observed in the taTME group.

Conclusions

In comparison with laTME, taTME seems to achieve comparable technical success with acceptable oncologic and perioperative outcomes. However, multicenter randomized controlled trials are required to further evaluate the efficacy and safety of taTME.

Stereotactic navigation for TAMIS-TME

Stereotactic navigation allows for real-time, image-guided surgery, thus providing an augmented working environment for the operator. This technique can be applied to complex minimally invasive surgery for fixed anatomic targets. Transanal minimally invasive surgery represents a new approach to rectal cancer surgery that is technically demanding and introduces the potential for procedure-specific morbidity. Feasibility of stereotactic navigation for TAMIS-TME has been demonstrated, and this could theoretically translate into improved resection quality by improving the surgeon's spatial awareness. The future of minimally invasive surgery as it relates to augmented reality and image-guided surgery is discussed.

Transanal total mesorectal excision: surgical technique description and outcomes

Minimally invasive techniques (MIS) have been evolving quickly in colorectal surgery during the last two decades. Transanal total mesorectal excision (taTME) was developed as a combination of skills acquired from different MIS approaches such as Transanal Endoscopic Microsurgery (TEM), Transanal Minimally Invasive Surgery (TAMIS) and Natural Orifices Transluminal Endoscopic Surgery (NOTES). TaTME allows for a better visualization of surgical planes of dissection and achievement of rectal resection following oncologic principles. We here present the standardized taTME technique in use at the Hospital Clínic de Barcelona and our published outcomes in rectal cancer.

Surgeons' assessment of internal anal sphincter nerve supply during TaTME - inbetween expectations and reality

Background: Intraoperative identification of nerve fibers heading from the inferior rectal plexus (IRP) to the internal anal sphincter (IAS) is challenging. The transanal total mesorectal excision (TaTME) is said to better preserve pelvic autonomic nerves. The aim of this study was to investigate the nerve identification rates during TaTME by transanal visual and electrophysiological assessment.

Material and methods: A total of 52 patients underwent TaTME for malignant conditions. The IRP with its posterior branches to the IAS and the pelvic splanchnic nerves (PSN) were visually assessed in 20 patients (v-TaTME). Electrophysiological nerve identification was performed in 32 patients using electric stimulation under processed electromyography of IAS (e-TaTME).

Results: The indication profile for TaTME was comparable between the v-TaTME and the e-TaTME group. The identification of IRP was more meaningful under electrophysiological assessment than under visual assessment for the left pelvic side (81% vs. 45%, p = 0.008) as well as the right pelvic side (78% vs. 45%, p = 0.016). The identification rates for PSN did not significantly differ between both groups, respectively (81% vs. 75%, p = 0.420 and 84% vs. 70%, p = 0.187).

Conclusions: The transanal approach facilitated visual identification of IAS nerve supply. In combination with electrophysiological nerve assessment the identification rate almost doubled. For further insights functional data are needed.

Transanal total mesorectal excision for rectal cancer: early outcomes in 50 consecutive patients

AIM

Minimally invasive approaches to proctectomy for rectal cancer have not been widely adopted due to inherent technical challenges. A modification of traditional transabdominal mobilization, termed transanal total mesorectal excision (TaTME), has the potential to improve access to the distal rectum. The aim of the current study is to assess outcomes following TaTME for rectal cancer.

METHOD

This is a retrospective analysis of a prospectively maintained database of consecutive patients who underwent TaTME for rectal cancer at a single institution. The study period was from 1 March 2012 to 31 July 2015.

RESULTS

During the study period 50 patients underwent TaTME. The median tumour distance from the anal verge was 4.4 (3.0-5.5) cm. The rate of conversion from a planned minimally invasive approach was 2.2%. The median operative time was 267.0 (227.0-331.0) min. The median lymph node yield was 18.0 (12.0-23.8), the macroscopic quality assessment of the resected specimen was incomplete in 2% and the circumferential resection margin positivity rate was 4%. Intra-operative morbidity occurred in 6% and the 30 day morbidity rate was 36%. The median length of stay was 4.5 (4.0-8.0) days. The median follow-up was 15.1 (7.0-23.2) months; two patients have developed a local recurrence and eight patients have developed distant recurrence.

CONCLUSION

These data suggest that TaTME for rectal cancer is feasible with an acceptable pathological outcome and morbidity profile. Further data on functional and long-term survival outcomes are required.

Current Status of Minimally Invasive Surgery for Rectal Cancer

Recent randomized controlled data have shown possible limitations to laparoscopic treatment of rectal cancer. The retrospective data, used as the basis for designing the trials, and which showed no problems with the technique, are discussed. The design of the randomized trials is discussed relative to the future meta-analysis of the recent data. The implications of the current findings on practice are discussed as surgeons try to adjust their practice to the new findings. The possible next steps for clinical and research innovations are put into perspective as new technology is considered to compensate for newly identified limitations in the laparoscopic treatment of rectal cancer.

Surface Electromyography Reliably Records Electrophysiologically Evoked Internal Anal Sphincter Activity: A More Minimally Invasive Approach for Monitoring Extrinsic Innervation

BACKGROUND

Even in the case of minimally invasive pelvic surgery, sparing of the autonomic nerve supply is a prerequisite for maintaining anal sphincter function. Internal anal sphincter (IAS) innervation could be electrophysiologically identified based on processed electromyographic (EMG) recordings with conventional bipolar needle electrodes (NE). This experimental study aimed for the development of a minimally invasive approach via intra-anal surface EMG for recordings of evoked IAS activity.

METHODS

Six male pigs underwent nerve-sparing low anterior rectal resection. Electric autonomic nerve stimulations were performed under online-processed EMG of the IAS. EMG recordings were simultaneously carried out with conventional bipolar NE as the reference method and newly developed intra-anal surface electrodes (SE) in different designs.

RESULTS

In all experiments, the IAS activity could be continuously visualized via EMG recordings based on NE and SE. The median number of bipolar electric stimulations per animal was 27 (range 5-52). The neurostimulations resulted in significant EMG amplitude increases for both recording types [NE: median 3.0 µV (interquartile range, IQR 2.8-3.5) before stimulation vs. 7.1 µV (IQR 3.9-13.8) during stimulation, p < 0.001; SE: median 3.6 µV (IQR 3.1-4.3) before stimulation vs. 6.8 µV (IQR 4.8-10.3) during stimulation, p < 0.001].

CONCLUSIONS

Intra-anal SE enabled reliable EMG of electrophysiologically evoked IAS activity similar to the conventional recording via NE. The transfer of the method to access platforms for transanal total mesorectal excision or robotics may offer a practical more minimally invasive approach for monitoring extrinsic innervation.

A Systematic Review of Outcomes After Transanal Mesorectal Resection for Rectal Cancer

BACKGROUND

Transanal mesorectal resection has been developed to facilitate minimally invasive proctectomy for rectal cancer.

OBJECTIVE

The purpose of this study was to evaluate the evidence regarding technical parameters, oncological outcomes, morbidity, and mortality after transanal mesorectal resection.

DATA SOURCES

The Cochrane Library, PubMed, and MEDLINE databases were reviewed.

STUDY SELECTION

Systematic review of the literature from January 2005 to September 2015 was used for study selection.

INTERVENTION

Intervention included transanal mesorectal resection for rectal cancer.

MAIN OUTCOME MEASURES

Technical parameters, histological outcomes, morbidity, and mortality were the outcomes measured.

RESULTS

Fifteen predominately retrospective studies involving 449 patients were included (mean age, 64.3 years; 64.1% men). Different platforms were used. The operative mortality rate was 0.4% and the cumulative morbidity rate 35.5%. Circumferential resection margins were clear in 98%, and the resected mesorectum was grade III in 87% of patients. Median follow-up was 14.7 months. There were 4 local recurrences (1.5%) and 12 patients (5.6%) with metastatic disease. No study followed patients long enough to report on 5-year overall and disease-free survival rates. Functional outcome was only reported in 3 studies.

LIMITATIONS

A low number of procedures were performed by expert early adopters. There are no comparative or randomized data included in this study and inconsistent reporting of outcome variables.

CONCLUSIONS

Transanal mesorectal resection for rectal cancer may enhance negative circumferential margin rates with a reasonable safety profile. Contemporary randomized, controlled studies are required before there can be universal recommendation.

Transanal total mesorectal excision in rectal cancer: why, how and when

Down-to-up total mesorectal excision (TME) or transanal TME (taTME) has gained worldwide popularity. taTME is one of the most promising innovations of the last years in the field of gastrointestinal surgery. Due to the better view of the dissection planes even in difficult patients (i.e., narrow pelvis or low rectal cancer), taTME seems to achieve both better TME quality reducing the rate of incomplete TME and lower rates of positive circumferential resection margins. taTME has overall morbidity and anastomotic leak rates comparable with the up-to-down TME. Mid-term results of taTME seems to be comparable with those of the up-to-down approach but definitive conclusions cannot be drawn since the short follow-up and small cohort of patients of the present studies.

Four anastomotic techniques following transanal total mesorectal excision (TaTME)

Transanal total mesorectal excision (TaTME) is a novel approach pioneered to tackle the challenges posed by difficult pelvic dissections in rectal cancer and the restrictions in angulation of currently available laparoscopic staplers. To date, four techniques can be employed in order to create the colorectal/coloanal anastomosis following TaTME. We present a technical note describing these techniques and discuss the risks and benefits of each.

Quality of life in rectal cancer surgery: What do the patient ask?

Rectal cancer surgery has dramatically changed with the introduction of the total mesorectal excision (TME), which has demonstrated to significantly reduce the risk of local recurrence. The combination of TME with radiochemotherapy has led to a reduction of local failure to less than 5%. On the other hand, surgery for rectal cancer is also impaired by the potential for a significant loss in quality of life. This is a new challenge surgeons should think about nowadays: If patients live more, they also want to live better. The fight against cancer cannot only be based on survival, recurrence rate and other oncological endpoints. Patients are also asking for a decent quality of life. Rectal cancer is probably a paradigmatic example: Its treatment is often associated with the loss or severe impairment of faecal function, alteration of body anatomy, urogenital problems and, sometimes, intractable pain. The evolution of laparoscopic colorectal surgery in the last decades is an important example, which emphasizes the importance that themes like scar, recovery, pain and quality of life might play for patients. The attention to quality of life from both patients and surgeons led to several surgical innovations in the treatment of rectal cancer: Sphincter saving procedures, reservoir techniques (pouch and coloplasty) to mitigate postoperative faecal disorders, nerve-sparing techniques to reduce the risk for sexual dysfunction. Even more conservative procedures have been proposed alternatively to the abdominal-perineal resection, like the local excisions or transanal endoscopic microsurgery, till the possibility of a wait and see approach in selected cases after radiation therapy.

Transanal total mesorectal excision (taTME) for rectal cancer: a training pathway

BACKGROUND

With increasing interest in natural orifice surgery, there has been a dramatic evolution of transanal and endoluminal surgical techniques. These techniques began with transanal endoluminal surgical removal of rectal masses and have progressed to transanal radical proctectomy for rectal cancer. The first transanal total mesorectal excision (taTME) was performed in 2009 by Sylla, Rattner, Delgado, and Lacy. The improved visibility and working space associated with the taTME technique is intriguing. This video manuscript outlines the training pathway followed by pioneers in the taTME technique, the process of implementation into clinical practice, and initial case report.

METHODS

A double board-certified colorectal surgeon with expertise in rectal cancer, minimally invasive total mesorectal excision, transanal endoscopic surgery (TES), and intersphincteric dissection, underwent taTME training in male cadaver models. Institutional review board (IRB) approval for a phase I clinical trial was achieved. The entire operative team including surgeons, nurses, and operative staff underwent taTME cadaver training the day prior to the first clinical case. The case was proctored by an expert in taTME.

RESULTS

A 66-year-old male with uT3N1M0 rectal cancer located in the posterior distal rectum, underwent taTME with laparoscopic abdominal assistance, hand sewn coloanal anastomosis, and diverting loop ileostomy. The majority of the TME was performed transanally with laparoscopic assistance for exposure, splenic flexure mobilization, and high ligation of the vascular pedicles. Operative time was 359 min. There were no intraoperative complications. Pathology revealed a ypT2N1 moderately differentiated invasive adenocarcinoma, grade I TME, 1 cm circumferential radial margin, and 2/13 positive lymph nodes.

CONCLUSION

Implementation of taTME into practice can be achieved by surgeons with expertise in minimally invasive TME, TES, pre-clinical taTME training in cadavers, case observation, proctoring, and ongoing mentorship. IRB peer review process and participation in a clinical registry are additional measures that should be employed.

COLOR III: a multicentre randomised clinical trial comparing transanal TME versus laparoscopic TME for mid and low rectal cancer

Introduction

Total mesorectal excision (TME) is an essential component of surgical management of rectal cancer. Both open and laparoscopic TME have been proven to be oncologically safe. However, it remains a challenge to achieve complete TME with clear circumferential resections margin (CRM) with the conventional transabdominal approach, particularly in mid and low rectal tumours. Transanal TME (TaTME) was developed to improve oncological and functional outcomes of patients with mid and low rectal cancer.

Methods

An international, multicentre, superiority, randomised trial was designed to compare TaTME and conventional laparoscopic TME as the surgical treatment of mid and low rectal carcinomas. The primary endpoint is involved CRM. Secondary endpoints include completeness of mesorectum, residual mesorectum, morbidity and mortality, local recurrence, disease-free and overall survival, percentage of sphincter-saving procedures, functional outcome and quality of life. A Quality Assurance Protocol including centralised MRI review, histopathology re-evaluation, standardisation of surgical techniques, and monitoring and assessment of surgical quality will be conducted.

Discussion

The difference in involvement of CRM between the two treatment strategies is thought to be in favour of the TaTME. TaTME is therefore expected to be superior to laparoscopic TME in terms of oncological outcomes in case of mid and low rectal carcinomas.

Urogenital dysfunctions after treatment of rectal cancer

A significant part of rectal cancer survivors will experience urogenital dysfunction induced by the treatment. Significant progress has been made in order to improve the total mesorectal technique through different approaches (open, laparoscopic, robotic, transanal). Rectal cancer surgery is technically difficult notably deep in the pelvis, and therefore the most frequent cause of the postoperative dysfunction is the surgical nerve damage of the autonomic nerves at this level. The main objectives of these efforts were to obtain maximal oncological results and to achieve better functional outcomes including less postoperative urogenital dysfunctions. Our purpose was to build a comprehensive review of the existing literature data regarding this issue from past to present.

Promises and pitfalls of total mesorectal excision: getting the best outcomes

The management of patients with rectal cancer has seen a number of important advances over the past 30 years. The most important of these has been the improvement and standardization of surgical technique. Combined with advances in preoperative imaging, neoadjuvant and adjuvant therapies and expert pathological assessment, widespread adoption of total mesorectal excision has led to improved results for this challenging but eminently curable cancer.