Transanal total mesorectal excision for rectal cancer has been suspended in Norway

Transanal total mesorectal excision for locally advanced rectal cancer following neoadjuvant chemoradiotherapy

PURPOSE

To examine the clinical impact of transanal total mesorectal excision (TaTME) for locally advanced rectal cancer after neoadjuvant chemoradiotherapy (NACRT).

METHODS

This retrospective study included 91 patients undergoing surgery for rectal cancer after NACRT between 2011 and 2022. Among them, 24, 22, and 45 patients underwent open (Open), conventional laparoscopic (Lap), and TaTME surgeries, respectively. We compared their clinical outcomes.

RESULTS

Operative time, blood loss, transfusion, morbidity, and hospital stay were significantly lower in the TaTME group than in the Open or Lap groups. The multivariate regression analyses identified only the TaTME approach as a significant factor for reducing morbidity. Both 3 yrear relapse-free survival (RFS) and local recurrence-free survival (LRFS) were significantly better in the TaTME group than in the Open or Lap groups (3 yr RFS: 94.7%, 80.4%, and 66.7%, and 3 yr LRFS: 100%, 90.5%, and 82.2% for the TaTME, Lap, and Open groups, respectively). Multivariate analyses of potential risk factors for recurrence identified body mass index, combined resection, and pathological stage, but not the TaTME approach, as significant predictors of recurrence.

CONCLUSION

TaTME reduced morbidity significantly in patients with locally advanced rectal cancer undergoing NACRT, compared with open or laparoscopic surgery.

Robotic-assisted colorectal surgery in colorectal cancer management: a narrative review of clinical efficacy and multidisciplinary integration

Colorectal cancer (CRC) remains a formidable global health challenge, ranking among the most prevalent malignancies and a principal contributor to cancer-associated mortality. While traditional open surgery has historically been the cornerstone of CRC treatment, the advent of minimally invasive techniques, particularly robotic-assisted colorectal surgery (RACS), has garnered significant momentum owing to technological advancements in the field. Robotic platforms, exemplified by the da Vinci Surgical System, offer superior three-dimensional visualization, enhanced dexterity, and heightened precision, yielding improved perioperative outcomes, particularly in anatomically intricate regions such as the pelvis. This review provides a critical appraisal of the current landscape of RACS, emphasizing its superiority over conventional open and laparoscopic approaches. The increased control and precision afforded by robotic surgery have been shown to optimize outcomes in complex procedures such as total mesorectal excision, with evidence indicating reduced intraoperative blood loss, shortened hospital stays, and improved functional recovery. Nonetheless, challenges persist, including absence of haptic feedback, prohibitive costs, and steep learning curve associated with robotic systems. Despite these limitations, RACS has demonstrated considerable promise in sphincter-preserving and function-preserving procedures, ultimately enhancing postoperative quality of life. Beyond the surgical field, this review also investigates the integration of robotic surgery within multidisciplinary treatment strategies for CRC, particularly in the context of locally advanced rectal cancer. The combination of robotic techniques with total neoadjuvant therapy and immunotherapy-especially in tumors characterized by mismatch repair deficiency or high microsatellite instability has shown notable clinical efficacy. Furthermore, emerging personalized therapeutic approaches, including immunotherapies and targeted chemotherapeutic agents, emphasize the transformative potential of RACS in delivering superior oncologic outcomes. Looking towards the future, innovations in robotic platforms, including intraoperative imaging, artificial intelligence, and augmented reality, herald new possibilities for further enhancing the precision and efficacy of colorectal surgeries. The standardization of RACS protocols, alongside ongoing training and robust clinical research, will be critical to fully realizing the benefits of these advancements across diverse clinical settings. By incorporating cutting-edge technologies and personalized treatment methods, robotic-assisted surgery is prepared to become a cornerstone in future of CRC management, with the potential to significantly improve both survival outcomes and patient quality of life.

Efficacy and long-term outcomes of abdominoperineal resection using transperineal total mesorectal excision approach for rectal cancer

PURPOSE

Although abdominoperineal resection (APR) is essential for a certain population of patients with low rectal cancer, it is technically difficult and sometimes contains oncological disadvantages. Thus, the use of the transperineal total mesorectal excision (TpTME) approach might overcome such concerns regarding APR.

METHODS

In total, 27 patients who underwent conventional APR (conventional group) and 49 patients who underwent APR using the TpTME approach (TpTME group) for low rectal cancer were included. After propensity score matching, the outcomes of the 25 matched cases were compared between groups.

RESULTS

The operative time was significantly shorter in the TpTME group than in the conventional group (452 vs. 565 min, P = 0.039). Intraoperative blood loss and transfusion rates were also significantly lower in the TpTME group than in the conventional group (25 mL vs. 200 mL, P < 0.001 and 0% vs. 28.0%, P = 0.015, respectively). Although the incidence of postoperative complications did not differ significantly, the postoperative hospital stay was significantly shorter in the TpTME group than in the conventional group (24 vs. 36 days, P = 0.001). The 5 year relapse-free survival rates in the TpTME and conventional groups were 62.0% and 57.6%, respectively (P = 0.648).

CONCLUSION

APR using the TpTME approach for the treatment of low rectal cancer is feasible and can achieve favorable oncological outcomes.

Effects of tumor spillage prevention in laparoscopic radical hysterectomy for early-stage cervical cancer: a propensity score-matched analysis

OBJECTIVE

Minimally invasive radical hysterectomy has a worse prognosis than open surgery, but the reasons for the poor prognosis remain unclear. Tumor spillage occurs when the tumor is exposed to the surgical field and has been suggested to be related to a poor prognosis. This study aimed to compare the prognostic value of tumor spillage in laparoscopic radical hysterectomy and evaluate whether tumor spillage prevention improves oncological safety.

METHODS

We compared the prognosis of patients who underwent laparoscopic radical hysterectomy between December 2014 and November 2021 with or without tumor spillage prevention, including surgeries without prevention and those with failed prevention. Prevention consisted of vaginal cuff formation or closure of the vaginal canal with clips to prevent tumor exposure at the time of colpotomy. The primary endpoint was disease-free survival, which was adjusted using propensity scores to compare patients.

RESULTS

In total, 165 patients received tumor spillage prevention, and 61 did not or failed to receive such prevention. The median follow-up was 4.4 years. Patients who did not undergo prevention or failed prevention had significantly shorter disease-free survival than those who did (hazard ratio [HR]=3.54; 95% confidence interval [CI]=1.23-10.23). The same trend was observed after adjusting for propensity score matching. Patients who did not or failed to receive prevention were more likely to experience local recurrence (HR=4.01; 95% CI=1.13-14.24).

CONCLUSION

Tumor spillage prevention was associated with longer disease-free survival in laparoscopic radical hysterectomy.

Systematic review and meta-analysis comparing robotic total mesorectal excision versus transanal total mesorectal excision for rectal cancer

INTRODUCTION

The best approach for total mesorectal excision (TME) remains controversial. Two recently described approaches are robotic TME (RTME) and transanal TME (TaTME). This systematic review and meta-analysis aimed to compare the outcomes between robotic surgery and TaTME in patients undergoing rectal cancer resection.

METHODS

We structured this systematic review and meta-analysis according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines 2020 and Assessing the Methodological Quality of Systematic Reviews (AMSTAR) guidelines. An electronic search of relevant literature was conducted on 20 May 2023. The protocol was registered in PROSPERO (CRD42023435259).

RESULTS

Eleven eligible nonrandomised studies were included in this study. The study included 2796 patients (RTME = 1800; TaTME = 996). The RTME group had a higher rate of complete TME. However, no significant differences were observed in mortality, morbidity, severe complications, operative time, conversion rate, anastomotic leak, hospital stay, CRM-positive resection margin, distal resection margin, number of harvested lymph nodes, abdominoperineal resection (APR) rate, or local recurrence between the RTME and TaTME groups.

CONCLUSION

The RTME technique may ensure a higher rate of complete TME than TaTME. However, no significant differences were observed in most postoperative outcomes and oncological safety between the RTME and TaTME groups. Evidence does not conclusively favor one technique over the other, highlighting the need for additional randomized controlled trials to better define their roles in rectal cancer surgery.

Metabolic bariatric surgery generates substantial, sustained weight loss and health improvement in a real-world setting

BACKGROUND

To determine if the positive outcomes from clinical trials regarding the safety and efficacy of metabolic bariatric surgery are reproducible at a national level.

METHODS

A longitudinal registry-based observation study with data collected from all persons undergoing metabolic bariatric surgery in Australia from 28 February 2012-31 December 2021 including data from 122,567 index patients who underwent 134,625 completed bariatric procedures.

MAIN OUTCOMES AND MEASURES

Defined adverse outcomes at 90-days (unplanned readmission, intensive care admission and re-operation; death), annual change in weight (percent total body weight loss (TBWL)), diabetes treatment and need for re-operation.

RESULTS

79.0% of participants were female. Mean age on the day of surgery was 44.0 years (SD 11.8; range 12.9-87.9 years) and mean BMI 41.7 kg/m2 (SD 7.6). At 5-years participants who underwent one anastomosis gastric bypass had TBWL 34.88% (SD 8.67%), roux-en-Y gastric bypass 30.73 % (SD 9.47%); sleeve gastrectomy 26.5% (SD 10.5%) and adjustable gastric bands 17.6% (SD 12.1%). At 90-days 3.6% of procedures recorded a defined adverse event. 13,904 (13.6%) primary participants reported being treated for diabetes at baseline. No medication for diabetes was required by 71.6% (follow-up 58%) at 1-year and 61% (follow-up 22%) at 5-years. 13 904 (13.6%) primary participants reported being treated for diabetes at baseline. No medication for diabetes was required by 71.6% (follow-up 58%) at 1-year and 61% (follow-up 22%) at 5-years.

CONCLUSIONS

Metabolic bariatric surgery is safe and induces substantial weight loss with reduced need for diabetes medications in the real-world.

CLINICALTRIALS

GOV ID

NCT03441451.

Short- and long-term impact of the TaTME learning process: a single institutional study

BACKGROUND

Transanal total mesorectal excision (TaTME) is a promising and innovative approach for lower rectal cancer but requires high technical skill and learning process that can affect patient outcomes. We aimed to determine the learning curve of TaTME and then to assess its impact on 5-year oncologic outcomes.

METHODS

Over a 54-month period, 94 patients underwent TaTME by experienced laparoscopic colorectal surgeons at our department. To provide a comprehensive overview of success, we used a composite criterion including the most relevant parameters related to the learning process: the conversion rate to an open procedure, TaTME procedure completion, severe postoperative morbidity, mesorectal integrity on macroscopic evaluation, and microscopic margins. Moving average method and cumulative sum analyses were performed.

RESULTS

The operative time continuously decreased over the entire study period. The success rate stabilised after 14 patients in a parallel and balanced analysis of the two surgeons' experiences. Mesorectal completeness was the most sensitive marker for the TaTME learning process (42.9% vs 71.25%; p = 0.06). The learning process did not significantly affect the postoperative morbidity, conversion rate, or R0 resection. Five-year oncological outcomes were similar between the groups.

CONCLUSION

Even among laparoscopically experienced surgeons, the TaTME learning process influences the oncological quality of the resection but not the postoperative morbidity. Gaining an early command of the surgical anatomy and technical skills and understanding the challenges through specific educational sessions are necessary. The results of this study could help generate a comprehensive training program and define necessary prerequisites for prospective trials.

TRIAL REGISTRATION

This study is registered in our Clinical Research Unit (2016_LELONG_01). Our database is registered in the clinicalTrials.gov registry: Institut Paoli Calmettes Colorectal Cancer Database (NCT02869503).

Utilizing sentiment analysis of X data to document the evolution of colorectal surgical innovations: The case of transanal total mesorectal excision

AIM

The evolution of the utility of medical social media and its global reach has led to a much greater speed of dissemination of medical innovation, such as transanal total mesorectal excision (TaTME). The acceptability and discussions surrounding such innovations can be followed online. Here, we sought to determine if online discussions over time could match known models of innovation evolution using the example of TaTME since its initial description in 2010.

METHODS

Data on using the X hashtag #TaTME were analysed using the social media analytics tool Brandwatch. Trends in mentions, impressions and reach were highlighted over 13 years (1 May 2010 to 31 July 2023). Each mention's sentiment and emotional connotations were analysed using Brandwatch's natural language processing approach.

RESULTS

We identified 18 525 mentions of #TaTME by healthcare professionals, reaching over 30.6 million X users. A Gartner's hype-cycle-like pattern was identified for mention volume and emotional connotation over time. The majority of mentions had a neutral (84%; n = 15 341) or positive connotation (15%, n = 2675). A peak of negatively connotated mentions was identified surrounding the temporary suspension of TaTME in 2019.

CONCLUSION

This study presents a novel method of monitoring online discussions surrounding new surgical innovations by healthcare professionals based on sentiment analysis of public social media data. Mention volume and emotional connotation were the most accurate parameters closely resembling Gartner's hype cycle.

Transanal intersphincteric under direct view in the jackknife position combined with laparoscopic total mesorectal excision for treating ultra-low rectal cancer

Aim

To investigate the effect and clinical advantage of transanal intersphincteric (ISR) under direct view in the jackknife position combined with laparoscopic total mesorectal excision (TME) for treating ultra-low rectal cancer. Additionally, the feasibility of this surgical technique was evaluated.

Method

This was a retrospective, single-center, single-arm pilot study. Ten patients with ultra-low rectal cancer underwent treatment by the same surgical team for direct view transanal ISR combined with laparoscopic TME in the Department of Anorectal Surgery, Huizhou Central People's Hospital between January 2021 and June 2021. The relevant clinical data were collected and analyzed.

Results

All the patients underwent complete mesenteric resection without conversion to laparotomy. The circumferential and distal resection margins (CRM and DRM) were negative. The mean distance between the lower margin of the tumor and the anal margin was 2.8 ± 0.8 cm, and the mean margin of distal resection was 1.2 ± 0.2 cm. TNM pathological stages I, II, III, and IV were observed in 6, 2, 2, and 0 cases, respectively. The median follow-up period was 15 months (interquartile range, 8 months). The mean Wexner and Low Anterior Resection Syndrome scores at 12 months after ileostomy were 8.1 ± 2.1 and 22.4 ± 5.7, respectively.

Conclusion

Transanal ISR under direct view in the jackknife position combined with laparoscopic TME is safe and feasible for the treatment of ultralow rectal cancer.

Functional Outcomes After Transanal Total Mesorectal Excision (taTME) for Rectal Cancer: Results From the Phase II North American Multicenter Prospective Observational Trial

OBJECTIVE

To investigate fecal incontinence and defecatory, urinary, and sexual functional outcomes after transanal total mesorectal excision (taTME).

BACKGROUND

Proctectomy for rectal cancer may result in alterations in defecatory, urinary, and sexual function that persist beyond 12 months. The recent multicenter phase II taTME trial demonstrated the safety of taTME in patients with stage I to III tumors.

METHODS

Prospectively registered self-reported questionnaires were collected from 100 taTME patients. Fecal continence [Fecal Incontinence Quality of Life (FIQL), Wexner], defecatory function [Colorectal Functional Outcome (COREFO)], urinary function (International Prostate Symptom Score), and sexual function (Female Sexual Function Index-female, International Index of Erectile Function-male) were assessed preoperatively (PQ), 3 to 4 months postileostomy closure (FQ1), and 12 to 18 months post-taTME [postoperative questionnaire 2 (FQ2)].

RESULTS

Among 83 patients who responded at all 3 time points, FIQL, Wexner, and COREFO significantly worsened postileostomy closure. Between FQ1 and FQ2, FIQL lifestyle and coping, Wexner, and COREFO incontinence, social impact, frequency, and need for medication significantly improved, while FIQL depression and embarrassment did not change. International Prostate Symptom Score did not change relative to preoperative scores. For females, Female Sexual Function Index declined for desire, orgasm, and satisfaction between PQ and FQ1, and did not improve between FQ1 and FQ2. In males, International Index of Erectile Function declined with no change between FQ1 and FQ2.

CONCLUSIONS

Although taTME resulted in initial decline in defecatory function and fecal continence, most functional domains improved by 12 months after ileostomy closure, without returning to preoperative status. Urinary function was preserved while sexual function declined without improvement by 18 months post-taTME. Our results address patient expectations and inform shared decision-making regarding taTME.

Prediction of postoperative complications following transanal total mesorectal excision in middle and low rectal cancer: development and internal validation of a clinical prediction model

PURPOSE

The objective of this study is to develop a nomogram for the personalized prediction of postoperative complication risks in patients with middle and low rectal cancer who are undergoing transanal total mesorectal excision (taTME). This tool aims to assist clinicians in early identification of high-risk patients and in addressing preoperative risk factors to enhance surgical safety.

METHODS

In this case-control study, 207 patients diagnosed with middle and low rectal cancer and undergoing taTME between February 2018 and November 2023 at The First Affiliated Hospital of Xiamen University were included. Independent risk factors for postoperative complications were analyzed using the Least Absolute Shrinkage and Selection Operator (LASSO) regression and multifactorial logistic regression models. A predictive nomogram was constructed using R Studio.

RESULTS

Among the 207 patients, 57 (27.5%) experienced postoperative complications. The LASSO and multifactorial logistic regression analyses identified operation time (OR = 1.010, P = 0.007), smoking history (OR = 9.693, P < 0.001), anastomotic technique (OR = 0.260, P = 0.004), and ASA score (OR = 9.077, P = 0.051) as significant predictors. These factors were integrated into the nomogram. The model's accuracy was validated through receiver operating characteristic curves, calibration curves, consistency indices, and decision curve analysis.

CONCLUSION

The developed nomogram, incorporating operation time, smoking history, anastomotic technique, and ASA score, effectively forecasts postoperative complication risks in taTME procedures. It is a valuable tool for clinicians to identify patients at heightened risk and initiate timely interventions, ultimately improving patient outcomes.

Dissection layer selection based on an understanding of pelvic fascial anatomy in transanal total mesorectal excision

This study aimed to review the historical transition of rectal cancer surgery and recent evidence regarding transanal total mesorectal excision (TaTME). Additionally, it outlined the anatomical landmarks and technical considerations essential for successful TaTME. Anatomical studies and surgical techniques were analyzed to identify key landmarks and procedural steps crucial for TaTME. TaTME offers improved visibility and maneuverability even in the deep and narrow pelvis and is expected to contribute to tumor radical cure rates. By securing the circumferential resection margin and distal margin while preserving pelvic autonomic nerve function, TaTME holds promise for maintaining postoperative urinary and sexual functions. Key anatomical landmarks include the endopelvic fascia posteriorly, the S4-pelvic splanchnic nerve laterally, and the prostate or posterior vaginal wall anteriorly. Selecting the appropriate dissection layer based on tumor depth and ensuring precise incision of the tendinous arch of the pelvic fascia contributes to successful TaTME outcomes. TaTME represents a significant advancement in rectal cancer surgery, offering improved outcomes through meticulous attention to anatomical detail and precise dissection techniques. Understanding the historical context of rectal cancer surgery alongside recent evidence on TaTME is essential for optimizing patient outcomes and expanding the safe implementation of this innovative approach.

Cytological Analysis of the Surgical Field During Transanal Total Mesorectal Excision for Rectal Cancer: A Prospective Study

BACKGROUND

An unexpectedly large number of patients experienced local recurrence with transanal total mesorectal excision in Norway. This appears to be associated with cancer cell spillage during surgery.

OBJECTIVE

To investigate the surgical field cytology during transanal total mesorectal excision.

DESIGN

This was a prospective cohort study.

SETTINGS

This study was conducted at a single center between June and December 2020.

PATIENTS

Forty patients with rectal cancer underwent transanal total mesorectal excision. After irrigation of the surgical field, the water specimens were cytologically evaluated at 6 representative steps. The first sample was used as an initial control. The second, third, fourth, fifth, and sixth samples were collected after the first pursestring suture, rectotomy, the second pursestring suture, specimen resection, and anastomosis, respectively. The clinicopathological features and intraoperative complications of the patients were reviewed.

MAIN OUTCOME MEASURES

The primary outcome was to evaluate the presence of cancer cells in washing cytological samples.

RESULTS

Of the 40 consecutive patients enrolled in this study, 18 patients underwent neoadjuvant chemoradiotherapy. Incomplete first pursestring suture and rectal perforation were observed in 4 (10.0%) and 3 (7.5%) cases, respectively. In the first sample, 31 patients (77.5%) had malignant cells. Malignant findings were detected in 2 patients (5.0%) from the second to fifth samples. None of the sixth sample exhibited any malignant findings.

LIMITATIONS

This single-center study had a small sample size.

CONCLUSIONS

Cancer cells were initially detected by cytology, but only a few were observed throughout the procedure; however, cancer cells were not detected in the final surgical field. Further follow-up and novel studies are required to obtain clinically significant findings using cytology during transanal total mesorectal excision. See Video Abstract .

ANLISIS CITOLGICO DEL CAMPO QUIRRGICO DURANTE LA ESCISIN TOTAL DEL MESORRECTO TRANSANAL PARA EL CNCER DE RECTO UN ESTUDIO PROSPECTIVO

ANTECEDENTES:Un número inesperadamente grande de pacientes experimentó recurrencia local con la escisión total del mesorrecto transanal en Noruega. Esto parece estar asociado con el derrame de células cancerosas durante la cirugía.OBJETIVO:Investigar la citología del campo quirúrgico durante la escisión total del mesorrecto transanal.DISEÑO:Este fue un estudio de cohorte prospectivo.ENTORNO CLINICO:Este estudio se realizó en un solo centro entre junio y diciembre de 2020.PACIENTES:Cuarenta pacientes con cáncer de recto se sometieron a escisión total del mesorrecto transanal. Después de la irrigación del campo quirúrgico, las muestras de agua se evaluaron citológicamente en seis pasos representativos. La primera muestra se utilizó como control inicial. La segunda, tercera, cuarta, quinta y sexta muestras se recolectaron después de la primera sutura en bolsa de tabaco, la rectotomía, la segunda sutura en bolsa de tabaco, la resección de la muestra y la anastomosis, respectivamente. Se revisaron las características clínico-patológicas y las complicaciones intraoperatorias de los pacientes.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue evaluar la presencia de células cancerosas en el lavado de muestras citológicas.RESULTADOS:De los 40 pacientes consecutivos inscritos en este estudio, 18 pacientes se sometieron a quimiorradioterapia neoadyuvante. Se observaron la primera sutura en bolsa de tabaco incompleta y perforación rectal en cuatro (10,0%) y tres (7,5%) casos, respectivamente. En la primera muestra, 31 (77,5%) pacientes tenían células malignas. Se detectaron hallazgos malignos en dos pacientes (5,0%) de la segunda a la quinta muestra. Ninguno de la sexta muestra demostraron hallazgos malignos.LIMITACIONES:Este estudio unicéntrico tuvo un tamaño de muestra pequeño.CONCLUSIONES:Inicialmente se detectaron células cancerosas mediante citología, pero solo se observaron unas pocas durante todo el procedimiento; sin embargo, no se detectaron células cancerosas en el campo quirúrgico final. Se requieren más seguimientos y estudios novedosos para obtener hallazgos clínicamente significativos mediante citología durante la escisión total del mesorrecto transanal. (Traducción- Dr. Francisco M. Abarca-Rendon ).

Minimally Invasive transCervical oEsophagectomy (MICE) for oesophageal cancer: prospective cohort study (IDEAL stage 2A)

BACKGROUND

Minimally invasive transcervical oesophagectomy is a surgical technique that offers radical oesophagectomy without the need for transthoracic access. The aim of this study was to evaluate the safety and feasibility of the minimally invasive transcervical oesophagectomy procedure and to report the refinement of this technique in a Western cohort.

METHODS

A single-centre prospective cohort study was designed as an IDEAL stage 2A study. Patients with oesophageal cancer (cT1b-4a N0-3 M0) who were scheduled for oesophagectomy with curative intent were eligible for inclusion in the study. The main outcome parameter was the postoperative pulmonary complication rate and the secondary outcomes were the anastomotic leakage, recurrent laryngeal nerve palsy, and R0 resection rates, as well as the lymph node yield.

RESULTS

In total, 75 patients underwent minimally invasive transcervical oesophagectomy between January 2021 and November 2023. Several modifications to the surgical technique were registered, evaluated, and implemented in the context of IDEAL stage 2A. A total of 12 patients (16%) had postoperative pulmonary complications, including pneumonia (4 patients) and pleural effusion with drainage or aspiration (8 patients). Recurrent laryngeal nerve palsy was observed in 33 of 75 patients (44%), with recovery in 30 of 33 patients (91%). A total of 5 of 75 patients (7%) had anastomotic leakage. The median number of resected lymph nodes was 29 (interquartile range 22-37) and the R0 resection rate was 96% (72 patients).

CONCLUSION

Introducing minimally invasive transcervical oesophagectomy for oesophageal cancer in a Dutch institution is associated with a low rate of postoperative pulmonary complications and a high rate of temporary recurrent laryngeal nerve palsy.

Oncologic outcomes following transanal total mesorectal excision: the United States experience

AIM

The benefits and short-term outcomes of transanal total mesorectal excision (taTME) for rectal cancer have been demonstrated previously, but questions remain regarding the oncologic outcomes following this challenging procedure. The purpose of this study was to analyze the oncologic outcomes following taTME at high-volume centers in the USA.

METHODS

This was a multicenter, retrospective observational study of 8 tertiary care centers. All consecutive taTME cases for primary rectal cancer performed between 2011 and 2020 were included. Clinical, histopathologic, and oncologic data were analyzed. Primary endpoints were rate of local recurrence, distal recurrence, 3-year disease recurrence, and 3-year overall survival. Secondary endpoints included perioperative complications and TME specimen quality.

RESULTS

A total of 391 patients were included in the study. The median age was 57 years (IQR: 49, 66), 68% of patients were male, and the median BMI was 27.4 (IQR: 24.1, 31.0). TME specimen was complete or near complete in 94.5% of cases and the rates of positive circumferential radial margin and distal resection margin were 2.0% and 0.3%, respectively. Median follow-up time was 30.7 months as calculated using reverse-KM estimator (CI 28.1-33.8) and there were 9 cases (2.5%) of local recurrence not accounting for competing risk. The 3-year estimated rate of disease recurrence was 19% (CI 15-25%) and the 3-year estimated overall survival was 90% (CI 87-94%).

CONCLUSION

This large multicenter study confirms the oncologic safety and perioperative benefits of taTME for rectal cancer when performed by experienced surgeons at experienced referral centers.

Changes to circulating tumor cells in the central vein during laparoscopic versus transanal endoscopic surgeries for rectal cancer: can surgical approach make a difference?

Background

The oncological safety of transanal total mesorectal excision (taTME) remains uncertain, and its special surgical approach may contribute to tumor cell dissemination. Thus, we conducted a study to investigate the impact of surgical approach on circulating tumor cell (CTC) counts and phenotypes in rectal cancer.

Methods

This is a prospective randomized controlled study (ClinicalTrials: NCT05109130). The patients were randomized to either the taTME (n = 49) or laparoscopic TME (laTME) (n = 48) groups. Blood samples were collected from the central vein to measure CTC counts and phenotypes at three time points: preoperative (t1), immediately post-tumor removal (t2), and one week post-surgery (t3). The effect of surgical procedure on CTCs at each time point was analyzed, with the primary endpoint being the change in CTC counts from t1 to t3 for each surgical approach. This study adheres to Consolidated Standards of Reporting Trials Guidelines.

Results

The baseline clinicopathologic characteristics of the laTME and taTME groups were balanced. The change in CTC count from t1 to t3 was 1.81 ± 5.66 in the laTME group and 2.18 ± 5.53 in the taTME group. The taTME surgery was non-inferior to laTME in terms of changing CTC counts (mean difference [MD]: -0.371; 95% confidence interval [CI]: -2.626 to 1.883, upper-sided 95% CI of 1.883 < 2, non-inferiority boundary value). Compared with that at t1, the CTC count at t2 did not change significantly. However, higher CTC counts were detected at t3 than at t2 in the taTME (P = 0.032) and laTME (P = 0.003) groups. From t1 to t3, CTC counts significantly increased in both the taTME (P = 0.008) and laTME (P = 0.031) groups. There were no significant differences in CTC phenotype changes between the two groups from t1 to t3.

Conclusions

Compared with laTME, taTME did not affect CTC counts and phenotypes. Our findings indicate that taTME is not inferior to laTME in terms of CTC changes from an oncological perspective.

Total mesorectal excision in MRI-defined low rectal cancer: multicentre study comparing oncological outcomes of robotic, laparoscopic and transanal total mesorectal excision in high-volume centres

BACKGROUND

The routine use of MRI in rectal cancer treatment allows the use of a strict definition for low rectal cancer. This study aimed to compare minimally invasive total mesorectal excision in MRI-defined low rectal cancer in expert laparoscopic, transanal and robotic high-volume centres.

METHODS

All MRI-defined low rectal cancer operated on between 2015 and 2017 in 11 Dutch centres were included. Primary outcomes were: R1 rate, total mesorectal excision quality and 3-year local recurrence and survivals (overall and disease free). Secondary outcomes included conversion rate, complications and whether there was a perioperative change in the preoperative treatment plan.

RESULTS

Of 1071 eligible rectal cancers, 633 patients with low rectal cancer were identified. Quality of the total mesorectal excision specimen (P = 0.337), R1 rate (P = 0.107), conversion (P = 0.344), anastomotic leakage rate (P = 0.942), local recurrence (P = 0.809), overall survival (P = 0.436) and disease-free survival (P = 0.347) were comparable among the centres. The laparoscopic centre group had the highest rate of perioperative change in the preoperative treatment plan (10.4%), compared with robotic expert centres (5.2%) and transanal centres (2.1%), P = 0.004. The main reason for this change was stapling difficulty (43%), followed by low tumour location (29%). Multivariable analysis showed that laparoscopic surgery was the only independent risk factor for a change in the preoperative planned procedure, P = 0.024.

CONCLUSION

Centres with expertise in all three minimally invasive total mesorectal excision techniques can achieve good oncological resection in the treatment of MRI-defined low rectal cancer. However, compared with robotic expert centres and transanal centres, patients treated in laparoscopic centres have an increased risk of a change in the preoperative intended procedure due to technical limitations.

A systematic review and meta-analysis of oncological outcomes with transanal total mesorectal excision for rectal cancer

AIM

Transanal total mesorectal (taTME) excision is a method used to assist in the radical removal of the rectum. By adopting the concept of natural orifice surgery, it offers potential benefits over conventional techniques. Early enthusiasm for this strategy led to its rapid and widespread adoption. The imposing of a local moratorium was precipitated by the discovery in Norway of an uncommon multifocal pattern of locoregional recurrence. The aim of this systematic review and meta-analysis was to determine the incidence of local recurrence after taTME for rectal cancer.

METHOD

Conforming to the Cochrane Handbook for Systematic Reviews of Interventions and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines checklist, a systematic review and meta-analysis was conducted. This included case series and comparative studies between taTME and preferentially laparoscopic procedures published between 2010 and 2021.

RESULTS

There were a total of 1175 studies retrieved. After removal and screening for quality and relevance, the final analysis contained 40 studies. The local recurrence rate following taTME was 3.4% (95% CI 2.9%-3.9%, I2 = 0%) in 4987 patients with follow-up durations ranging from 0.7 to 5.5 years. Compared with laparoscopic TME, local recurrence was not statistically different for the taTME group (p = 0.076); however, it was less probable (OR = 0.51, 95% CI 0.24-1.09, I2 = 0%). Systemic recurrence and circumferential resection margin status were secondary outcomes; however, the differences were not statistically significant.

CONCLUSION

Our data suggest that the local recurrence for regular laparoscopic and transanal TME surgeries may be comparable, suggesting that taTME can be performed without influencing locoregional oncological outcomes in patients treated at specialized institutions and who have been cautiously selected.

Local Recurrence-Free Survival After TaTME: A Canadian Institutional Experience

BACKGROUND

Transanal total mesorectal excision is a novel surgical treatment for mid to low rectal cancers. Norwegian population data have raised concerns about local recurrence in patients treated with transanal total mesorectal excision.

OBJECTIVE

This study aimed to analyze local recurrence and disease-free survival in patients treated by transanal total mesorectal excision for rectal cancer at a high-volume tertiary center.

DESIGN

This retrospective study used a prospectively maintained institutional transanal total mesorectal excision database. Patient demographics, treatment, and outcomes data were analyzed. Local recurrence, disease-free survival, and overall survival were analyzed using Kaplan-Meier analysis.

SETTINGS

The study was conducted at a single academic institution in Vancouver, Canada.

PATIENTS

All patients treated by transanal total mesorectal excision for rectal adenocarcinoma between 2014 and 2022 were included.

MAIN OUTCOME MEASURES

The primary outcome was local recurrence-free survival.

RESULTS

Between 2014 and 2022, 306 patients were treated by transanal total mesorectal excision at St. Paul's Hospital. Of these, 279 patients met the inclusion criteria. The mean age was 62 years (SD ± 12.3), and 66.7% of patients were men. Restorative resection was achieved in 97.5% of patients, with a conversion rate from laparoscopic to open surgery of 6.8%. The composite optimal pathological outcome was 93.9%. The median follow-up was 26 months (interquartile range, 12-47), and 82.8% of patients achieved reestablishment of GI continuity to date. The overall local recurrence rate was 4.7% (n = 13). The estimated 2-year local recurrence-free survival rate was 95.0% (95% CI, 92-98) and the estimated 5-year local recurrence-free survival rate was 94.5% (95% CI, 91-98).

LIMITATIONS

Limitations include the retrospective nature of the study and the generalizability of a Canadian population.

CONCLUSIONS

Recent European data have challenged the presumed oncologic safety of transanal total mesorectal excision. Although the learning curve for this procedure is challenging and poor outcomes are associated with low volume, this high-volume single-center study confirms acceptable oncologic outcomes consistent with the current standard. See Video Abstract .

SOBREVIDA SIN RECIDIVA DESPUS DE TATME EXPERIENCIA INSTITUCIONAL CANADIENSE

ANTECEDENTES:La excisión total del mesorecto por vía transanal es un tratamiento quirúrgico novedoso para los cánceres de recto medio a bajo. Estudios sobre la población noruega han generado preocupación debido a la recidiva local en pacientes tratados con excisión total del mesorecto por vía transanal.OBJETIVO:Nuestra finalidad fué de analizar la recidiva local y la sobrevida libre de enfermedad en pacientes tratados mediante la excisión total del mesorecto por vía transanal, debido a un cáncer de recto en un centro terciario de alto volúmen.DISEÑO:El presente estudio retrospectivo, utiliza una base de datos institucional sobre la excisión total del mesorecto por vía transanal mantenida prospectivamente. Se analizaron los datos demográficos, de tratamiento y los resultados de los pacientes sometidos a la técnica mencionada. La recidiva local, la sobrevida libre de enfermedad y la sobrevida global se analizaron mediante el modelo de Kaplan-Meier.AJUSTES:El estudio se llevó a cabo en una sola institución académica en Vancouver, Canadá.PARTICIPANTES:Se incluyeron todos los pacientes tratados mediante excisión total del mesorecto por vía transanal causado por adenocarcinomas de recto entre 2014 y 2022.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue la sobrevida libre de recidiva local.RESULTADOS:Entre 2014 y 2022, 306 pacientes fueron tratados mediante la excisión total del mesorecto por vía transanal en el Hospital St. Paul. De estos, 279 pacientes cumplieron los criterios de inclusión. La edad media fue de 62 años (DE ± 12,3) y el 66,7% de los pacientes eran varones. La resección restauradora se logró en el 97,5% de los pacientes con una tasa de conversión de cirugía laparoscópica en laparotomía del 6,8%. El resultado patológico óptimo combinado fué del 93,9%. La mediana de seguimiento fue de 26 meses (rango intercuartil 12-47) y el 82,8% logró el restablecimiento de la continuidad gastrointestinal hasta la fecha. La tasa global de recidiva local fué del 4,7% (n = 13). La sobrevida libre de recidiva local estimada a los 2 años fué del 95,0% (IC del 95%: 92-98) y del 94,5% a los 5 años (IC del 95%: 91-98).LIMITACIONES:Las limitaciones incluyen la naturaleza retrospectiva del estudio y la generalización de una población canadiense.CONCLUSIONES:Datos europeos recientes han cuestionado la supuesta seguridad oncológica de la excisión total del mesorecto por vía transanal. Si bien la curva de aprendizaje de este procedimiento es muy desafiante y los malos resultados se asocian con un volumen bajo, el presente estudio, unicéntrico de gran volumen confirma los resultados oncológicos aceptables consistentes con el estándar actual. (Traducción-Dr. Xavier Delgadillo ).

Local Recurrence of Rectal Cancer After Transanal Total Mesorectal Excision and Risk Factors: A Nationwide Multicenter Cohort Study in Japan

Objective

To investigate the oncological outcomes after transanal total mesorectal excision (TaTME) for rectal cancer and risk factors for local recurrence (LR).

Background

A high LR rate with a multifocal pattern early after TaTME has been reported in Norway and the Netherlands, causing controversy over the oncological safety of this technique.

Methods

Twenty-six member institutions of the Japan Society of Laparoscopic Colorectal Surgery participated in this retrospective cohort study. A total of 706 patients with primary rectal cancer who underwent TaTME between January 2012 and December 2019 were included for analysis. The primary endpoint was the cumulative 3-year LR rate.

Results

A total of 253 patients had clinical stage III disease (35.8%) and 91 (12.9%) had stage IV. Intersphincteric resection was performed in 318 patients (45.0%) and abdominoperineal resection in 193 (27.3%). There was 1 urethral injury (0.1%). A positive resection margin (R1) was seen in 42 patients (5.9%). Median follow-up was 3.42 years, and the 2- and 3-year cumulative LR rates were 4.95% (95% confidence interval: 3.50-6.75) and 6.82% (95% confidence interval: 5.08-8.89), respectively. A multifocal pattern was observed in 14 (25%) of 56 patients with LR. Tumor height from the anal verge, pathological T4 disease, pathological stage III/IV, positive perineural invasion, and R1 resection were significant risk factors for LR in multivariable analysis.

Conclusions

In this selected cohort in which intersphincteric resection or abdominoperineal resection was performed in more than half of cases, oncological outcomes were acceptable during a median follow-up of more than 3 years.

Long-term oncological outcomes of transanal versus laparoscopic total mesorectal excision for mid-low rectal cancer: a retrospective analysis of 2502 patients

BACKGROUND

Transanal total mesorectal resection (taTME) has recently emerged as a promising surgical approach for the treatment of mid-low rectal cancer. However, there is limited evidence on the long-term survival outcomes associated with taTME. This retrospective study aimed to compare the overall survival (OS), disease-free survival (DFS), and cancer-specific survival of taTME and laparoscopic TME (laTME) in patients with mid-low rectal cancer.

MATERIALS AND METHODS

From July 2014 to June 2022, a total of 3627 patients were identified from two prospective cohorts: the laparoscopic rectal surgery cohort and the CNTAES cohort. To balance the baseline characteristics between the taTME and laTME groups, propensity score matching (PSM) was performed.

RESULTS

A total of 2502 patients were included in the study. Prior to PSM, the laTME group comprised 1853 patients, while the taTME group comprised 649 patients. The 5-year OS (82.9% vs. 80.4%, P =0.202) and 5-year DFS (74.4% vs. 72.5%, P =0.167) were comparable between the taTME and laTME groups. After PSM, the taTME group showed no statistically significant difference in the 5-year OS (83.1% vs. 79.2%, P =0.101) and 5-year DFS (74.8% vs. 72.1%, P =0.135) compared to the laTME group. Subgroup analysis further suggested that taTME may potentially reduce the risk of death [hazard ratio 0.652; (95% CI, 0.452-0.939)] and disease recurrence [hazard ratio 0.736; (95% CI, 0.562-0.965)] specifically in patients with low rectal cancer.

CONCLUSION

In this study, taTME demonstrated comparable oncologic safety to laTME in patients with mid-low rectal cancer. Moreover, the results indicate that taTME may confer potential survival benefits for patients with low rectal cancer.

Short-term results after robot-assisted surgery for primary rectal cancers requiring beyond total mesorectal excision in multiple compartments

AIM

Rectal cancers requiring beyond total mesorectal excision (bTME) are traditionally operated using an open approach, but the use of minimally invasive robot-assisted procedures is increasing. Introduction of minimal invasive surgery for complex cancer cases could be associated with compromised surgical margins or increased complication rates. Therefore, reporting results both clinical and oncological in large series is important. Since bTME procedure reports are heterogeneous, comparing results is often difficult. In this study, a magnetic resonance imaging (MRI) classification system was used to describe the bTME surgery according to pelvic compartments.

METHODS

Consecutive patients with primary rectal cancer operated with laparoscopic robot-assisted bTME were prospectively included for 2 years. All patients had tumors that threatened the mesorectal fascia, invaded adjacent organs, and/or involved metastatic pelvic lateral lymph nodes. Short-term clinical outcomes and oncological specimen quality were registered. Surgery was classified according to pelvic compartments resected.

RESULTS

Clear resection margins (R0 resection) were achieved in 95 out of 105 patients (90.5%). About 26% had Accordion Severity Grading System of Surgical Complications grade 3-4 complications and 15% required re-operations. About 7% were converted to open surgery. The number of compartments resected ranged from one to the maximum seven, with 83% having two or three compartments resected. All 10 R1 resections occurred in the lateral and posterior compartments.

CONCLUSIONS

The short-term clinical outcomes and oncological specimen quality after robot-assisted bTME surgery were comparable to previously published open bTME surgery. The description of surgical procedures using the Royal Marsden MRI compartment classification was feasible.

Evolution in Laparoscopic Gastrectomy From a Randomized Controlled Trial Through National Clinical Practice

OBJECTIVE

To examine the influence of the LOGICA RCT (randomized controlled trial) upon the practice and outcomes of laparoscopic gastrectomy within the Netherlands.

BACKGROUND

Following RCTs the dissemination of complex interventions has been poorly studied. The LOGICA RCT included 10 Dutch centers and compared laparoscopic to open gastrectomy.

METHODS

Data were obtained from the Dutch Upper Gastrointestinal Cancer Audit (DUCA) on all gastrectomies performed in the Netherlands (2012-2021), and the LOGICA RCT from 2015 to 2018. Multilevel multivariable logistic regression analyses were performed to assess the effect of laparoscopic versus open gastrectomy upon clinical outcomes before, during, and after the LOGICA RCT.

RESULTS

Two hundred eleven patients from the LOGICA RCT (105 open vs 106 laparoscopic) and 4131 patients from the DUCA data set (1884 open vs 2247 laparoscopic) were included. In 2012, laparoscopic gastrectomy was performed in 6% of patients, increasing to 82% in 2021. No significant effect of laparoscopic gastrectomy on postoperative clinical outcomes was observed within the LOGICA RCT. Nationally within DUCA, a shift toward a beneficial effect of laparoscopic gastrectomy upon complications was observed, reaching a significant reduction in overall [adjusted odds ratio (aOR):0.62; 95% CI: 0.46-0.82], severe (aOR: 0.64; 95% CI: 0.46-0.90) and cardiac complications (aOR: 0.51; 95% CI: 0.30-0.89) after the LOGICA trial.

CONCLUSIONS

The wider benefits of the LOGICA trial included the safe dissemination of laparoscopic gastrectomy across the Netherlands. The robust surgical quality assurance program in the design of the LOGICA RCT was crucial to facilitate the national dissemination of the technique following the trial and reducing potential patient harm during surgeons learning curve.

Longitudinal Analysis of Local Recurrence and Survival After Transanal Abdominal Transanal Radical Proctosigmoidectomy for Low Rectal Cancer Treated With Neoadjuvant Chemoradiation Therapy

BACKGROUND

The transanal abdominal transanal radical proctosigmoidectomy was developed in 1984 as a sphincter preservation surgery in patients with low rectal cancers after preoperative radiation therapy. While serving as a catalyst for disruptive sphincter preservation surgery, it continues to be used and evolve. With the controversy over safety and local recurrence in other sphincter-preserving surgery, review of transanal abdominal transanal radical proctosigmoidectomy long-term oncologic outcomes is warranted.

OBJECTIVE

To assess local recurrence and survival after transanal abdominal transanal radical proctosigmoidectomy after neoadjuvant chemoradiation therapy.

DESIGN

Retrospective cohort study of a prospectively maintained database.

SETTINGS

Tertiary rectal cancer referral center.

PATIENTS

Patients with low adenocarcinoma (≤5 cm anorectal ring) receiving neoadjuvant chemoradiation therapy and then transanal abdominal transanal radical proctosigmoidectomy for curative resection between 1998 and 2021.

MAIN OUTCOME MEASURES

Local recurrence rates and overall survival rates.

RESULTS

Of 255 included patients, 67.8% were men (n = 173); the mean age was 58.7 years (SD 11.5) and the mean BMI was 27.1 (SD 5.4), with 50.2% (n = 128) having ASA class II and 49.8% (n = 127) having ASA class III/IV. The mean tumor size was 4.8 cm (SD 1.9), the majority of patients had clinical T3 disease (81.8%; n = 184), and 52.1% had nodal disease (n = 100). The median radiation dose was 5400 cGy, with 73.7% (n = 149) achieving good response and 90.2% (n = 230) receiving minimally invasive surgery. The complete total mesorectal excision rate was 94.3%, and 100% of patients (n = 255) had negative distal margins. The mean number of examined lymph nodes were 13.9 (SD 10.7). After a median follow-up of 55.4 months, 5.1% of patients (n = 13) developed local recurrence at a median time of 29.6 months. The 5-year overall survival was 84.1% (95% CI, 78.8-89.4).

LIMITATIONS

Retrospective review with risk of bias and lack of generalizability.

CONCLUSIONS

In this longitudinal study, the transanal abdominal transanal radical proctosigmoidectomy demonstrated excellent long-term locoregional control and survival in very low rectal cancers. The superior transanal abdominal transanal radical proctosigmoidectomy outcomes are durable over time, warranting expansion of the sphincter-preserving surgery technique. See Video Abstract .

ANLISIS LONGITUDINAL DE LA RECURRENCIA LOCAL Y LA SUPERVIVENCIA DESPUS DE LA PROCTOSIGMOIDECTOMA RADICAL TRANSANAL ABDOMINAL TATA PARA EL CNCER DE RECTO BAJO TRATADO CON QUIMIORRADIACIN NEOADYUVANTE

ANTECEDENTES:La proctosigmoidectomía radical transanal abdominal se desarrolló en 1984 como una cirugía de preservación del esfínter en cánceres de recto bajo después de la radiación preoperatoria. Si bien sirve como catalizador para la cirugía disruptiva de preservación del esfínter, continúa utilizándose y evolucionando. Con la controversia sobre la seguridad y la recurrencia local en otras cirugías que preservan el esfínter, se justifica la revisión de los resultados oncológicos a largo plazo de la proctosigmoidectomía radical transanal abdominal.OBJETIVO:Evaluar localmente después de Proctosigmoidectomía Radical Transanal Abdominal Transanal después de quimiorradiación neoadyuvante.DISEÑO:Estudio de cohorte retrospectivo de una base de datos mantenida de forma prospectiva.AJUSTES:Centro terciario de referencia para el cáncer de recto.PACIENTES:Adenocarcinoma bajo (=/ Collapse

Key Words Collapse

MESH Headings

• Humans
• Male
• Middle Aged
• Female
• Retrospective Studies
• Longitudinal Studies
• Neoadjuvant Therapy
• Rectal Neoplasms/surgery
• Adenocarcinoma/therapy
• Adenocarcinoma/pathology
• Neoplasm Staging

Collapse

Grants Collapse

Affiliation(s)

John H Marks Lankenau Medical Center, Lankenau Institute for Medical Research, Wynnewood, Pennsylvania
Thais Reif de Paula
Hela Saidi
Taylor P Ikner
Henry Schoonyoung
Gerald Marks
Deborah S Keller

Collapse

Is survival after transanal total mesorectal excision (taTME) worse than that after traditional total mesorectal excision? A retrospective propensity score-adjusted cohort study

PURPOSE

Transanal total mesorectal excision (taTME) was developed to provide better vision during resection of the mesorectum. Conflicting results have shown an increase in local recurrence and shorter survival after taTME. This study compared the outcomes of taTME and abdominal (open, laparoscopic, robotic) total mesorectal excision (abTME).

METHODS

Patients who underwent taTME or abTME for stages I-III rectal cancer and who received an anastomosis were included. A retrospective analysis of a prospectively conducted database was performed. The primary endpoints were overall survival (OS), cancer-specific survival (CSS), and disease-free survival (DFS). Risk factors were adjusted by propensity score matching (PSM). The secondary endpoints were local recurrence rates and combined poor pathological outcomes.

RESULTS

From 2012 to 2020, a total of 189 patients underwent taTME, and 119 underwent abTME; patients were followed up for a mean of 54.7 (SD 24.2) and 78.4 (SD 34.8) months, respectively (p < 0.001). The 5-year survival rates after taTME and abTME were not significantly different after PSM: OS: 78.2% vs. 88.6% (p = 0.073), CSS: 87.4% vs. 92.1% (p = 0.359), and DFS: 69.3% vs. 80.9% (p = 0.104), respectively. No difference in the local recurrence rate was observed (taTME, n = 10 (5.3%); abTME, n = 10 (8.4%); p = 0.280). Combined poor pathological outcomes were more frequent after abTME (n = 36, 34.3%) than after taTME (n = 35, 19.6%) (p = 0.006); this difference was nonsignificant according to multivariate analysis (p = 0.404).

CONCLUSION

taTME seems to be a good treatment option for patients with rectal cancer and is unlikely to significantly affect local recurrence or survival. However, further investigations concerning the latter are warranted.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT0496910).

Transanal Total Mesorectal Excision With Delayed Coloanal Anastomosis (TaTME-DCAA) Versus Laparoscopic Total Mesorectal Excision (LTME) and Robotic Total Mesorectal Excision (RTME) for Low Rectal Cancer: A Propensity Score-Matched Analysis of Short-term Outcomes, Bowel Function, and Cost

INTRODUCTION

Total mesorectal excision (TME) with delayed coloanal anastomosis (DCAA) is surgical option for low rectal cancer, replacing conventional immediate coloanal anastomosis (ICAA) with bowel diversion. This study aimed to assess the outcomes of transanal TME (TaTME) with DCAA versus laparoscopic TME (LTME) with ICAA versus robotic TME (RTME) with ICAA.

METHODS

This was a retrospective propensity score-matched analysis of patients who underwent elective TaTME-DCAA between November 2021 and June 2022. Patients were propensity-score matched in a ratio of 1:3 to patients who underwent LTME-ICAA and RTME-ICAA from January 2019 to December 2020. Outcome measures were histopathologic results, postoperative morbidity, function, and inpatient costs.

RESULTS

Twelve patients in the TaTME-DCAA group were compared with 36 patients in the LTME-ICAA and RTME-ICAA groups each after propensity score matching. Histopathologic results and postoperative morbidity rates were statistically similar. Overall stoma-related complication rates in the ICAA groups were 11%. Median total length of hospital stays for TME plus stoma reversal surgery was similar across all techniques (10 vs. 10 vs. 9 days; P =0.532). Despite a significantly shorter duration of follow-up, bowel function after TaTME-DCAA was comparable to that of LTME-ICAA and RTME-ICAA. Overall median inpatient costs of TaTME-DCAA were comparable to LTME-ICAA and significantly cheaper than RTME-ICAA ($31,087 vs. $29,927 vs. $36,750; P =0.002).

CONCLUSIONS

TaTME with DCAA is a feasible and safe technique compared with other minimally invasive methods of TME, while avoiding bowel diversion and stoma-related complications, as well as comparing favorably in terms of overall hospitalization costs.

Evolution of surgical approach to rectal cancer resection: A multinational registry assessment

PURPOSE

Surgical approach to rectal cancer has evolved in recent decades, with introduction of minimally invasive surgery (MIS) techniques and local excision. Since implementation might differ internationally, this study is aimed at evaluating trends in surgical approach to rectal cancer across different countries over the last 10 years and to gain insight into patient, tumour and treatment characteristics.

METHODS

Pseudo-anonymised data of patients undergoing resection for rectal cancer between 2010 and 2019 were extracted from clinical audits in the Netherlands (NL), Sweden (SE), England-Wales (EW) and Australia-New Zealand (AZ).

RESULTS

Ninety-nine thousand five hundred ninety-seven patients were included (38,413 open, 55,155 MIS and 5416 local excision). An overall increase in MIS was observed from 29.9% in 2010 to 72.1% in 2019, with decreasing conversion rates (17.5-9.0%). The MIS proportion was highly variable between countries in the period 2010-2014 (54.4% NL, 45.3% EW, 39.8% AZ, 14.1% SE, P < 0.001), but variation reduced over time (2015-2019 78.8% NL, 66.3% EW, 64.3% AZ, 53.2% SE, P < 0.001). The proportion of local excision for the two periods was highly variable between countries: 4.7% and 11.8% in NL, 3.9% and 7.4% in EW, 4.7% and 4.6% in AZ, 6.0% and 2.9% in SE.

CONCLUSIONS

Application and speed of implementation of MIS were highly variable between countries, but each registry demonstrated a significant increase over time. Local excision revealed inconsistent trends over time.

Inflammatory stress response after transanal vs laparoscopic total mesorectal excision: a cohort study based on the TaLaR trial

BACKGROUND

Transanal total mesorectal excision (taTME) is a novel approach to radical surgery for low rectal cancer; however, it is not clear whether taTME causes a more severe inflammatory stress response than laparoscopic total mesorectal excision (laTME). Therefore, the authors conducted this study to address this question, with the secondary objective of analyzing the predictive effect of inflammatory indexes on postoperative infective complications between laTME and taTME.

METHODS

A total of 545 cases of laTME and 544 cases of taTME from the TaLaR randomized controlled trial were included. Inflammatory stress response was assessed via C-reactive protein (CRP), white blood cell count, neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, lymphocyte-monocyte ratio, and prognostic nutritional index. Inflammatory indexes were measured and calculated preoperatively (t1) and on postoperative days one (t2) and seven (t3). The accuracy of inflammatory indexes as predictor of infective complications was evaluated by areas under the receiver operating characteristic curve.

RESULTS

Preoperative blood parameters were comparable between the two surgical methods. There were no significant differences in CRP, white blood cell count, neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, lymphocyte-monocyte ratio, or prognostic nutritional index between the two surgical methods at any time point ( P >0.05). Among the inflammatory indexes at three time points, CRP on the first postoperative day was the most accurate predictor of infective complications, which is suitable for two surgical methods. The AUC was 0.7671 ( P <0.0001) with a cutoff of 39.84 mg/l, yielding 94% sensitivity and 47% specificity.

CONCLUSIONS

Compared with laTME, taTME surgery has no obvious disadvantage with respect to the postoperative inflammatory stress response. In addition, inflammatory indexes were favorable in predicting infective complications, with the best results for CRP on the first postoperative day. Defining the specific predictors for laTME and taTME is unnecessary.

Feasibility of transanal minimally invasive surgery for total pelvic exenteration for advanced primary and recurrent pelvic malignancies

BACKGROUND

The purpose of this study was to clarify the efficacy and safety of transanal minimally invasive surgery (TAMIS) for total pelvic exenteration (TPE) in advanced primary and recurrent pelvic malignancies.

METHODS

Using a prospectively collected database, we retrospectively analyzed the clinical, surgical, and pathological outcomes of TAMIS for TPE. Surgery was performed between September 2019 and April 2023. The median follow-up period was 22 months (2-45 months).

RESULTS

Fifteen consecutive patients were included in this analysis M:F = 14:1 and median (range) age was 63 (36-74). Their diagnoses were as follows: primary rectal cancer (n = 5; 33%), recurrent rectal cancer (n = 4; 27%), primary anorectal cancer (n = 5; 33%), and gastrointestinal stromal tumor (n = 1; 7%). Bladder-sparing TPE was selected for two patients (13%). In nine of 15 patients (60%) the anal sphincter could be successfully preserved, five patients (33%) required combined resection of the internal iliac vessels, and two (13%) required rectus muscle flap reconstruction. The median operative time was 723 min (561-1082), and the median intraoperative blood loss was 195 ml (30-1520). The Clavien-Dindo classifications of the postoperative complications were as follows: grade 0-2 (n = 11; 73%); 3a (n = 3; 20%); 3b (n = 1; 7%); and ≥ 4 (n = 0; 0%). No cases of conversion to laparotomy or mortality were observed. The pathological results demonstrated that R0 was achieved in 14 patients (93%).

CONCLUSIONS

The short-term outcomes of this initial experience proved that this novel approach is feasible for TPE, with low blood loss, acceptable postoperative complications, and a satisfactory R0 resection rate.

Patient Reported Outcomes following Cancer of the Rectum (PROCaRe): protocol of a prospective multicentre international study

PURPOSE

Rectal cancer surgery presents challenges in achieving good oncological results and preserving functional outcomes. Different surgical approaches, including open, laparoscopic, robotic and transanal techniques, have been employed, but there is a lack of consensus on the optimal approach, particularly in terms of functional results. This study aims to assess bowel function and to compare outcomes of patients that had undergone surgery for mid-low rectal cancer across different surgical approaches.

METHOD

This is an international, multicentre, prospective cohort study. Inclusion criteria are patients diagnosed with rectal cancer below the peritoneal reflection, eligible for different surgical approaches for total mesorectal excision (TME). Data will be collected using validated questionnaires assessing bowel, sexual and urinary function, and quality of life (QOL). Secondary outcomes include short-term postoperative results. Data will be collected at baseline and 6, 12 and 24 months after index surgery or stoma reversal surgery.

CONCLUSION

This study will provide insights into the impact of different approaches for TME on bowel, sexual and urinary function, and overall QOL of patients undergoing rectal cancer surgery. The findings will provide important information to optimise the surgical strategy and to improve patient care in this population.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04936581 (registered 23 June 2021).

Exfoliate cancer cell analysis in rectal cancer surgery: comparison of laparoscopic and transanal total mesorectal excision, a pilot study

PURPOSE

Minimally invasive surgery (MIS) is currently the standard treatment for rectal cancer. However, its limitations include complications and incomplete total mesorectal resection (TME) due to anatomical features and technical difficulties. Transanal TME (TaTME) has been practiced since 2010 to improve this, but there is a risk of local recurrence and intra-abdominal contamination. We aimed to analyze samples obtained through lavage to compare laparoscopic TME (LapTME) and TaTME.

METHODS

From June 2020 to January 2021, 20 patients with rectal cancer undergoing MIS were consecutively and prospectively recruited. Samples were collected at the start of surgery, immediately after TME, and after irrigation. The samples were analyzed for carcinoembryonic antigen (CEA) and cytokeratin 20 (CK20) through a quantitative real-time polymerase chain reaction. The primary outcome was to compare the detected amounts of CEA and CK20 immediately after TME between the surgical methods.

RESULTS

Among the 20 patients, 13 underwent LapTME and 7 underwent TaTME. Tumor location was lower in TaTME (7.3 cm vs. 4.6 cm, P=0.012), and negative mesorectal fascia (MRF) was more in LapTME (76.9% vs. 28.6%, P=0.044). CEA and CK20 levels were high in 3 patients (42.9%) only in TaTME. There was 1 case of T4 with incomplete purse-string suture and 1 case of positive MRF with dissection failure. All patients were followed up for an average of 32.5 months without local recurrence.

CONCLUSION

CEA and CK20 levels were high only in TaTME and were related to tumor factors or intraoperative events. However, whether the detection amount is clinically related to local recurrence remains unclear.

IDEAL Stage 2a/b prospective cohort study of transanal transection and single-stapled anastomosis for rectal cancer

AIM

There are several anastomotic techniques available to facilitate restorative rectal cancer surgery after total mesorectal excision (TME), including double-stapled anastomosis (DST) and handsewn coloanal anastomosis (CAA). However, to date no one technique is superior with regard to anastomotic leakage (AL) or functional outcomes. Transanal transection single-stapled anastomosis (TTSS) aims to overcome some of the technical challenges and offer comparable clinical and functional outcomes to traditional anastomotic techniques. The aim of this study was to explore the role of TTSS in modern rectal cancer surgery and to provide comparative clinical and functional outcome data with DST and CAA.

METHOD

A prospective cohort study was undertaken to assess the safety and clinical and patient-reported outcomes associated with the TTSS procedure. All patients undergoing sphincter-preserving surgery for rectal cancer with an anastomosis performed within 6 cm of the anal verge between January 2016 and April 2021 were prospectively enrolled into this study. Clinical and patient-reported outcome data, including low anterior resection syndrome (LARS) assessment, were collected. The primary endpoint was anastomotic leakage within 30 days.

RESULTS

A total of 275 patients participated in this study, with 70 (25%) patients undergoing a TTSS, 110 (40%) undergoing a DST and 95 (35%) undergoing a CAA. Patients undergoing a CAA had more distal tumours than those having a TTSS or DST, with a median tumour height of 5, 7 and 9 cm (p < 0.001), respectively. We observed a statistically significant reduction in AL in the TTSS group compared with the DST group, with rates of 8.6% versus 20.9% (p = 0.028). There was no difference in LARS scores between patients undergoing TTSS and DST (p = 0.228), while patients with a CAA had worse LARS scores than TTSS patients (p = 0.002).

CONCLUSION

TTSS is a technically safe and feasible anastomotic technique in rectal cancer surgery as an alternative to DST and CAA. Its advantages over DST are a reduced AL rate and, over CAA, improved function. It should therefore be considered as an alternative technique to improve clinical and patient-reported outcomes in restorative rectal cancer surgery.

Multicenter phase II trial of transanal total mesorectal excision for rectal cancer: preliminary results

BACKGROUND

Transanal TME (taTME) combines abdominal and transanal dissection to facilitate sphincter preservation in patients with low rectal tumors. Few phase II/III trials report long-term oncologic and functional results. We report early results from a North American prospective multicenter phase II trial of taTME (NCT03144765).

METHODS

100 patients with stage I-III rectal adenocarcinoma located ≤ 10 cm from the anal verge (AV) were enrolled across 11 centers. Primary and secondary endpoints were TME quality, pathologic outcomes, 30-day and 90-day outcomes, and stoma closure rate. Univariable regression analysis was performed to assess risk factors for incomplete TME and anastomotic complications.

RESULTS

Between September 2017 and April 2022, 70 males and 30 females with median age of 58 (IQR 49-62) years and BMI 27.8 (IQR 23.9-31.8) kg/m2 underwent 2-team taTME for tumors located a median 5.8 (IQR 4.5-7.0) cm from the AV. Neoadjuvant radiotherapy was completed in 69%. Intersphincteric resection was performed in 36% and all patients were diverted. Intraoperative complications occurred in 8% including 3 organ injuries, 2 abdominal and 1 transanal conversion. The 30-day and 90-day morbidity rates were 49% (Clavien-Dindo (CD) ≥ 3 in 28.6%) and 56% (CD ≥ 3 in 30.4% including 1 mortality), respectively. Anastomotic complications were reported in 18% including 10% diagnosed within 30 days. Higher anastomotic risk was noted among males (p = 0.05). At a median follow-up of 5 (IQR 3.1-7.4) months, 98% of stomas were closed. TME grade was complete or near complete in 90%, with positive margins in 2 cases (3%). Risk factors for incomplete TME were ASA ≥ 3 (p = 0.01), increased time between NRT and surgery (p = 0.03), and higher operative blood loss (p = 0.003).

CONCLUSION

When performed at expert centers, 2-team taTME in patients with low rectal tumors is safe with low conversion rates and high stoma closure rate. Mid-term results will further evaluate oncologic and functional outcomes.

Pneumovaginoscopy-assisted radical hysterectomy for early-stage cervical cancer: a novel bidirectional approach for tumor spillage prevention and R0 resection

OBJECTIVE

This study evaluated the feasibility and outcomes of pneumovaginoscopy-assisted radical hysterectomy (PVRH) for cervical cancer up to stage IIA using a bidirectional fascia-oriented and nerve-sparing surgical approach.

METHODS

This retrospective observational cohort study examined the operative outcomes and prognoses of patients who underwent PVRH (n=59) for up to stage IIA cervical cancer. The basic procedure was Kyoto B2 (Viper Type II nerve-sparing) radical hysterectomy and pelvic lymphadenectomy through simultaneous vaginal and abdominal (open or laparoscopic) approaches. In all cases, pneumovaginoscopy (PV) was used to create a vaginal cuff and dissect the paracolpium and paracervical endopelvic fascia to minimize nerve damage.

RESULTS

Thirty-eight (64.4%) patients had stage IB1 cancer. Seven (11.9%) had vaginal invasion (stage IIA1, n=4; IIA2, n=3). The abdominal approach was open in 38 cases and laparoscopic in 21. Adjuvant therapy was administered to 24 patients (41%); one patient received concurrent chemoradiotherapy for gastric-type adenocarcinoma. There were three (6.1%) intraoperative complications (CO2 gas embolism [n=1], sigmoid colon musculosa injury [n=1], and ureteral injury [n=1]) and 8 (14%) postoperative complications (lymphedema with cellulitis [n=4], vaginal cuff dehiscence [n=1], sub-ileus [n=1], symptomatic lymphocyst [n=l], and ureterovaginal fistula [n=1]). The median urination recovery period was 3 days. Microscopic R0 was achieved in all cases. The median follow-up was 44.5 (2-122) months, and no recurrence occurred.

CONCLUSION

PVRH is a new fascia-oriented and nerve-sparing surgery for early-stage cervical cancer. Further, it has favorable operative outcomes and good prognoses, similar to those of adjacent pelvic surgery such as trans-anal total mesorectal excision and radical prostatectomy.

Transanal Total Mesorectal Excision for Rectal Cancer: Toward Standardization of the Surgical Technique

Laparoscopic surgery is widely used for rectal cancer; however, this technique is challenging due to tapering of the mesorectum in the pelvis, and the forward angle of the distal rectum, which renders this part of the rectum less accessible from the abdominal cavity. Hence, concerns regarding its safety and curability have been raised, particularly for inadequate distal and circumferential resection margins. Recently, transanal total mesorectal excision (TaTME), which involves endoscopic total mesorectal excision (TME) retrogradely from the anal side, has attracted attention worldwide as a solution to these problems. TaTME is superior to the conventional laparoscopic approach for rectal cancer in terms of both oncological and functional preservations. However, a shallow learning curve caused by the unfamiliar anatomical view from the anal side can pose challenges. Therefore, an efficient educational system needs to be established. Randomized controlled trials comparing conventional laparoscopic TME with TaTME are ongoing to demonstrate the usefulness of TaTME. This article reviews changes in the surgical treatment of rectal cancer, with a focus on TaTME, and describes the indications, surgical techniques, and training curricula for TaTME.

Transanal total mesorectal excision (TaTME) in rectal cancer treatment within an expert center

The objective of this study was to evaluate treatment outcomes in patients who underwent the TaTME procedure for cancer of the middle and low rectum in an expert center. Prospective analysis of the outcomes of all consecutive patients treated using the TaTME technique for cancer of the middle and distal rectum at the our medical center between March 1, 2015, and March 31, 2022. A total of 128 patients (34 women, 94 men; mean age 66.01 [38-85] years) with cancer of the middle and distal rectum qualified for TaTME. TaTME procedures were performed in 127/128 (99.22%) patients. Complications of surgery were observed in 22/127 (17.32%) patients. Negative proximal and distal margins were confirmed in all 127 patients. Complete (R0) resection of the mesorectum was confirmed in 125/127 (98.43%) and nearly complete (R1) resection was confirmed in 2/127 (1.57%) patients. The average follow-up period was 795 days (296-1522) days. Local recurrence was detected during the follow-up period in 2/127 (1.57%) patients. This study showed that the TaTME procedure is an effective and safe method for the minimally invasive treatment of middle and low rectal cancers, particularly within an expert center setting.

Standardization of rectal cancer surgery and bowel preparation in Austria : A multicenter nationwide survey by the Austrian Society of Surgical Oncology

BACKGROUND

Standardized management of colorectal cancer is crucial for achieving an optimal clinical and oncological outcome. The present nationwide survey was designed to provide data about the surgical management of rectal cancer patients. In addition, we evaluated the standard approach for bowel preparation in all centers in Austria performing elective colorectal surgery.

METHODS

The Austrian Society of Surgical Oncology (ACO["Arbeitsgemeinschaft für chirurgische Onkonlogie"]-ASSO) conducted a multicenter questionnaire-based study comprising 64 hospitals between October 2020 and March 2021.

RESULTS

The median number of low anterior resections performed annually per department was 20 (range 0-73). The highest number was found in Vienna, with a median of 27 operations, whereas Vorarlberg was the state with the lowest median number of 13 resections per year. The laparoscopic approach was the standard technique in 46 (72%) departments, followed by the open approach in 30 (47%), transanal total mesorectal excision (TaTME) in 10 (16%) and robotic surgery in 6 hospitals (9%). Out of 64 hospitals 51 (80%) named a standard for bowel preparation before colorectal resections. No preparation was commonly used for the right colon (33%).

CONCLUSION

Considering the low number of low anterior resections performed in each hospital per year in Austria, defined centers for rectal cancer surgery are still scarce. Many hospitals did not transfer recommended bowel preparation guidelines into clinical practice.

Discordance in Total Mesorectal Excision Specimen Grading in a Prospective Phase 2 Multicenter Rectal Cancer Trial: Are We Overestimating the Quality of Our Resections?

OBJECTIVES

To report the results of a rigorous quality control (QC) process in the grading of total mesorectal excision (TME) specimens during a multicenter prospective phase 2 trial of transanal TME.

BACKGROUND

Grading of TME specimens is based on the macroscopic assessment of the mesorectum and standardized through synoptic pathology reporting. TME grade is a strong predictor of outcomes with incomplete (IC) TME associated with increased rates of local recurrence relative to complete or near complete (NC) TME. Although TME grade serves as an endpoint in most rectal cancer trials, in protocols incorporating centralized review of TME specimens for quality assurance, discordance in grading and the management thereof has not been previously described.

METHODS

A phase 2 prospective transanal TME trial was conducted from 2017 to 2022 across 11 North American centers with TME quality as the primary study endpoint. QC measures included (1) training of site pathologists in TME protocols, (2) blinded grading of de-identified TME specimen photographs by central pathologists, and (3) reconciliation of major discordance before trial reporting. Cohen Kappa statistic was used to assess agreement in grading.

RESULTS

Overall agreement in grading of 100 TME specimens between site and central reviewer was rated as fair, (κ = 0.35; 95% CI: 0.10-0.61; P < 0.0001). Concordance was noted in 54%, with minor and major discordance in 32% and 14% of cases, respectively. Upon reconciliation, 13/14 (93%) major discordances were resolved. Pre versus postreconciliation rates of complete or NC and IC TME are 77%/16% and 7% versus 69%/21% and 10%. Reconciliation resulted in a major upgrade (IC-NC; N = 1) or major downgrade (NC/C-IC, N = 4) in 5 cases overall (5%).

CONCLUSIONS

A 14% rate of major discordance was observed in TME grading between the site and central reviewers. The resolution resulted in a major change in final TME grade in 5% of cases, which suggests that reported rates or TME completeness are likely overestimated in trials. QC through a central review of TME photographs and reconciliation of major discordances is strongly recommended.

Oncological monitoring after transanal total mesorectal excision (TaTME) for rectal neoplasia

BACKGROUND

The surgical treatment of choice for rectal neoplasia is total mesorectal excision (TME). The transanal approach enables a better approach in male and obese patients and/or those with a narrow pelvis and in patients with small tumors. Short-term results are comparable with those for laparoscopy or the open approach, but the medium- and long-term oncological data are sparse. The aim of the present study was to evaluate our early experience with transanal TME (TaTME).

METHODS

This was a retrospective study conducted on patients who underwent TaTME at our center between August 2013 and April 2017 with a follow-up ≥ 3 years. Histopathology, complications, mortality, neoplastic recurrence and disease-free survival were analyzed.

RESULTS

One hundred patients (68 men and 32 women,, median age 66.8 years [range 29.6-91.2 years]) were included. There were 67 T3 cases (67%) with 74 N0 cases (74%), the mesorectal quality was graded optimal for 87.6% and only 2 cases of radial margin involvement were detected (2%). The median follow-up period was 47.6 months (range 11.8-78.9 months). Eighteen cases of recurrence were diagnosed, of which 3 (3%) recurred locally with an average disease-free period of 43.1 months. Overall survival was 80% and mortality due to progression of disease was 13%.

CONCLUSIONS

TaTME is a safe surgical procedure with surgical, anatomopathological and oncological results at 3 years (medium-term) comparable with those for the laparoscopic and open approaches. Better monitoring is required with studies of the long-term functional and quality of life outcomes, i.e., at 5 or 10 years.

Transanal Total Mesorectal Excision for Rectal Cancer

Transanal total mesorectal excision (taTME) is a technique where rectal dissection is begun transanally in a "bottom-up" fashion. This technique facilitates dissection of the most distal part of the rectum and allows the establishment of the distal margin for rectal cancer. TaTME has proven its utility in facilitating low rectal dissection with significantly lower conversion rates and acceptable perioperative, oncological, and functional outcomes. However, taTME remains a challenging technique to learn and adopt. This article describes the technique, indications, and outcomes of taTME in rectal cancer during the last decade.

Transanal total mesorectal excision versus laparoscopic intersphincteric resection for low rectal cancer: a propensity score matching analysis

BACKGROUND

Anus-preserving surgery for low rectal cancer has always been a serious difficulty for surgeons. Transanal total mesorectal excision (TaTME) and laparoscopic intersphincteric resection (ISR) are commonly used Anus-preserving surgeries for low rectal cancer. The aim of this study was to compare the clinical use of two surgical methods.

METHODS

A total of 152 patients with low rectal cancer were treated with taTME in 75 cases and ISR in 77 cases. After propensity score matching, 46 patients in each group were included in the study. Perioperative outcomes, anal function scores (Wexner incontinence score) and quality of life scores (EORTC QLQ C30, EORTC QLQ CR38) at least 1 year after surgery were compared between the two groups.

RESULTS

There were no significant differences between the two groups in terms of surgical outcomes, pathological examination of surgical specimens, postoperative recovery, and postoperative complications, except for patients in the taTME group who had their indwelling catheters removed later. Anal Wexner incontinence score was lower in taTME group than ISR group (P < 0.05). On the EORTC QLQ-C30 scale, the physical function and role function scores in the ISR group were lower than those in the taTME group (P < 0.05), while the fatigue, pain symptoms, and constipation scores in the ISR group were higher than those in the taTME group (P < 0.05). On the EORTC QLQ-CR38 scale, the scores of gastrointestinal symptoms and defecation problems in the ISR group were higher than those in the taTME group (P < 0.05).

CONCLUSION

Compared with ISR surgery, taTME surgery is comparable in terms of surgical safety and short-term efficacy, and has better long-term anal function and quality of life. From the perspective of long-term anal function and quality of life, taTME surgery is a better surgical method for the treatment of low rectal cancer.

Recurrence following transanal total mesorectal excision for rectal cancer: a monocentric retrospective series of technically difficult cases

PURPOSE

Transanal total mesorectal excision (TaTME) has been proposed to overcome surgical difficulties encountered during rectal resection, especially for patients having high body mass index or low rectal cancer. The aim of this study was to evaluate oncologic outcomes following TaTME.

METHODS

This retrospective study included all consecutive patients with rectal cancer who had a TaTME from 2013 to 2019. The main outcome was the incidence of locoregional recurrence by the end of the follow-up period.

RESULTS

Among a total of 81 patients, 96.3% were male, and their mean age was 63±9 years. The mean body mass index was 30.3±5.7 kg/m2, and the median distance from tumor to anal verge was 5.0 cm (interquartile range [IQR], 4.0-6.0 cm). Most patients had a low anterior resection performed (n=80, 98.8%) with a diverting ileostomy (n=64, 79.0%). Distal and circumferential resection margins were positive in 2.5% and 6.2% of patients, respectively. Total mesorectal excision was complete or near complete in 95.1% of patients. A successful resection was achieved in 72 patients (88.9%). After a median follow-up of 27.5 months (IQR, 16.7-48.1 months), 4 patients (4.9%) experienced locoregional recurrence. Anastomotic leaks were observed in 21 patients (25.9%). At the end of the follow-up, 69 patients (85.2%) were stoma-free.

CONCLUSION

TaTME was associated with acceptable oncological outcomes, including low locoregional recurrence rates in selected patients with low rectal cancer. Although associated with a high incidence of postoperative morbidities, the use of TaTME enabled a high rate of successful sphincter-saving procedures in selected patients who posed a technical challenge.

Long-term outcomes after transanal total mesorectal excision for rectal cancer in Denmark: A prospective multicenter study from the late implementation phase

PURPOSE

The aim of this study was to evaluate the long-term surgical and oncological outcomes after transanal total mesorectal excision (TaTME) for rectal cancer during an implementation phase on a national level.

METHOD

This is a retrospective review of prospectively recorded data. Registration was initiated by the Danish Colorectal Cancer Group in order to assess the quality of care during the implementation of TaTME in Denmark. Data from four centers were pooled for simultaneous analysis. Short-term data was available from a prior study, and long-term data regarding recurrences, chemotherapy, and mortality was collected.

RESULTS

From August 2016 to April 2019, 115 TaTME procedures were registered. Patients were predominantly male (n = 85, 74%) with mid-rectal (n = 88, 77%) tumors. The overall local recurrence rate was 7.8% (n = 9) of which six patients also had systemic recurrence. Mean long-term follow-up was 59.4 months, and median time to local recurrence was 24.9 months. Local recurrences occurred predominantly among initial implementation cases. The overall mortality rate was 13% (n = 15). Of the 17 patients with recurrence, 35% (n = 6) died and developed either solely distant recurrence (n = 2, 12%) or in combination with local recurrence (n = 4, 24%).

CONCLUSION

We found acceptable long-term oncological results after TaTME during the implementation phase in Denmark. There was an accumulation of local recurrences in the early phase of the study which emphasizes the importance of thorough training and proctoring when starting the approach.

Innovation in gastrointestinal surgery: the evolution of minimally invasive surgery-a narrative review

Background

Minimally invasive (MI) surgery has revolutionised surgery, becoming the standard of care in many countries around the globe. Observed benefits over traditional open surgery include reduced pain, shorter hospital stay, and decreased recovery time. Gastrointestinal surgery in particular was an early adaptor to both laparoscopic and robotic surgery. Within this review, we provide a comprehensive overview of the evolution of minimally invasive gastrointestinal surgery and a critical outlook on the evidence surrounding its effectiveness and safety.

Methods

A literature review was conducted to identify relevant articles for the topic of this review. The literature search was performed using Medical Subject Heading terms on PubMed. The methodology for evidence synthesis was in line with the four steps for narrative reviews outlined in current literature. The key words used were minimally invasive, robotic, laparoscopic colorectal, colon, rectal surgery.

Conclusion

The introduction of minimally surgery has revolutionised patient care. Despite the evidence supporting this technique in gastrointestinal surgery, several controversies remain. Here we discuss some of them; the lack of high level evidence regarding the oncological outcomes of TaTME and lack of supporting evidence for robotic colorectalrectal surgery and upper GI surgery. These controversies open pathways for future research opportunities with RCTs focusing on comparing robotic to laparoscopic with different primary outcomes including ergonomics and surgeon comfort.

Learning Curve for Transanal Total Mesorectal Excision for Low Rectal Malignancy

BACKGROUND

Although transanal total mesorectal excision (TaTME) is a promising treatment for low rectal cancer, it is considered technically demanding, and the number of cases required to become proficient in TaTME remains unknown. The purpose of this study was to assess the TaTME learning curve based on the total mesorectal excision completion time.

STUDY DESIGN

This retrospective analysis comprised 128 individuals who received TaTME between September 2016 and December 2021. The cumulative sum method was used to generate the learning curve. The duration of the procedure from the beginning to the end of the circumferential rendezvous was used to define the total mesorectal excision completion time.

RESULTS

The learning curve consists of 3 phases: phase I (learning phase: cases 1 to 38), phase II (consolidation phase: cases 39 to 70), and phase III (maturing phase: cases 71 to 128). As the phases varied, both the overall operative time and total mesorectal excision completion time decreased considerably. Through the 3 phases of TaTME, intraoperative adverse events decreased, and in phase III, none occurred. Only 1 instance of local recurrence occurred during phase III, and none occurred during phase I or II.

CONCLUSIONS

After 70 operations, the surgeon could join the mastery phase of TaTME based on the total mesorectal excision completion time. After the mastering phase began, there were no intraoperative negative occurrences. From the beginning, the oncological safety could be guaranteed.

Case report on a rare complication after transanal total mesorectal excision (TaTME) for rectal malignancy vesicorectal fistula

INTRODUCTION AND IMPORTANCE

Transanal Total Mesorectal Excision (TaTME) represents the latest surgical approach in rectal cancer management. We present a rare case of vesicorectal fistula (VRF) following a complication of TaTME surgery.

CASE PRESENTATION

A 67-year-old male underwent a Hartmann's procedure for perforated rectosigmoid cancer in 2019. He was lost to follow-up and re-presented in 2021 with synchronous cancer of the transverse colon and rectum. A two-team surgical approach was utilized: open subtotal colectomy (transabdominal approach) with concurrent excision of rectal stump (TaTME approach). Intraoperatively, an inadvertent bladder injury was identified and repaired. 8 months later, he re-presented with the passage of urine per rectum. Imaging and endoscopy revealed a VRF with cancer recurrence at the rectal stump.

CLINICAL DISCUSSION

VRF is an uncommon complication of TaTME that carries a significant physical and psychological impact on the patient. While shown to be a safe and useful technique, the long-term oncological outcomes of TaTME are still awaited. Unique complications have been reported with TaTME, including gas embolism and injuries to the genitourinary structures, in which the latter caused the eventual VRF formation in our patient.

CONCLUSION

Revisional surgery for recurrent disease is challenging and can result in rare complications, especially in patients with distorted anatomy and when new surgical techniques are utilized. Radiotherapy further causes unpredictable tissue healing quality. The challenge remains for proper patient selection with individualization of surgical approaches, while keeping a close eye on the oncological outcomes of the patient.