Transanal total mesorectal excision for rectal carcinoma: short-term outcomes and experience after 80 cases

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.

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).

Incidence and Risk Factors for Low Anterior Resection Syndrome following Trans-Anal Total Mesorectal Excision

BACKGROUND

Trans-anal total mesorectal excision (Ta-TME) is a novel approach for the resection of rectal cancer. Low anterior resection syndrome (LARS) is a frequent functional disorder that might follow restorative proctectomy. Data regarding bowel function after Ta-TME are scarce. The aim of this study was to evaluate the incidence and risk factors for the development of LARS following Ta-TME.

METHODS

A prospectively maintained database of all patients who underwent Ta-TME for rectal cancer at our institution was reviewed. All patients who were operated on from January 2018 to December 2021 were evaluated. The LARS score questionnaire was used via telephone interviews. Incidence, severity and risk factors for LARS were evaluated.

RESULTS

Eighty-five patients underwent Ta-TME for rectal cancer between January 2018 and December 2021. Thirty-five patients were excluded due to ostomy status, death, local disease recurrence, ileal pouch or lack of compliance. Fifty patients were included in the analysis. LARS was diagnosed in 76% of patients. Anastomosis distance from dentate line was identified as a risk factor for LARS via multivariate analysis (p = 0.042). Neo-adjuvant therapy, hand sewn anastomosis and anastomotic leak did not increase the risk of LARS.

CONCLUSION

LARS is a frequent condition following ta-TME, as it is used for other approaches to low anterior resection. Anastomosis distance from dentate line is an independent risk factor for LARS. In this study neo-adjuvant therapy, hand sewn anastomosis and anastomotic leak did not increase the risk of LARS. Further studies with longer follow-up times are required to better understand the functional outcomes following Ta-TME.

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.

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.

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.

Indocyanine green angiography for lower incidence of anastomotic leakage after transanal total mesorectal excision: a propensity score-matched cohort study

Background

Anastomotic leakage (AL) is the most serious complication that can arise during colorectal surgery. Indocyanine green (ICG) angiography offers an intraoperative assessment of colonic vascular perfusion in real time. We aimed to assess ICG's effects on the AL rate in patients who have undergone transanal total mesorectal excision (TaTME) for rectal cancer.

Methods

This retrospective cohort study was conducted at our center from October 2018 to March 2022 to analyze the clinical data of patients with rectal cancer who have undergone TaTME after propensity score matching (PSM). The primary outcome was the proximal colonic transection line modification and clinical AL rate.

Results

A total of 143 patients in the non-ICG group and 143 patients in the ICG group were included after PSM. The proximal colonic transection line of seven patients in the non-ICG group was modified, while 18 were in the ICG group (4.9% vs. 12.5%, p = 0.023). Twenty-three patients (16.1%) in the non-ICG group and five patients (3.5%) in the ICG group were diagnosed with AL (p < 0.001). The ICG group had a less hospital readmission rate than the non-ICG group (0.7% vs. 7.7%, p = 0.003). The between-group differences in basic line and other outcomes were not significant.

Conclusions

ICG angiography is a safe and feasible method to help surgeons identify potentially poor colonic vascular perfusion and modify the proximal colonic transection line, resulting in a significant reduction in AL and hospital readmission rates.

Laparoscopic natural orifice specimen extraction, a minimally invasive surgical technique for mid-rectal cancers: Retrospective single-center analysis and single-surgeon experience of selected patients

OBJECTIVE

To evaluate the feasibility, safety, and short-term outcomes of middle rectal resection followed by transanal specimen extraction.

METHODS

Forty-four patients with small mid-rectal tumors underwent laparoscopic rectal resection followed by transanal specimen extraction.

RESULTS

The procedure was successful in all patients without intraoperative conversion or additional access. The mean operation time was 182.7 minutes (range, 130-255 minutes), the mean blood loss was 26.5 mL (range, 5-120 mL), the mean postoperative exhaust time was 31.3 hours (range, 16-60 hours), and the mean length of hospital stay was 9.5 days (range, 8-19 days). One patient developed anastomotic leakage, which was treated by intravenous antibiotics and daily pelvic cavity flushes through the abdominal drainage tube. No infection-related complications or anal incontinence were observed. The mean tumor size was 2.1 cm (range, 1.6-3.2 cm), the mean number of harvested lymph nodes was 16.5 (range, 6-31), and the mean follow-up time was 8.5 months (range, 2-16 months). By the last follow-up, no signs of recurrence had been found in any patient.

CONCLUSION

The combination of standard laparoscopic proctectomy and transanal specimen extraction could become a well-established strategy for selected patients.

Comparison of three-year oncological results after restorative low anterior resection, non-restorative low anterior resection and abdominoperineal resection for rectal cancer

INTRODUCTION

Oncological outcome might be influenced by the type of resection in total mesorectal excision (TME) for rectal cancer. The aim was to see if non-restorative LAR would have worse oncological outcome. A comparison was made between non-restorative low anterior resection (NRLAR), restorative low anterior resection (RLAR) and abdominoperineal resection (APR).

MATERIALS AND METHODS

This retrospective cohort included data from patients undergoing TME for rectal cancer between 2015 and 2017 in eleven Dutch hospitals. A comparison was made for each different type of procedure (APR, NRLAR or RLAR). Primary outcome was 3-year overall survival (OS). Secondary outcomes included 3-year disease-free survival (DFS) and 3-year local recurrence (LR) rate.

RESULTS

Of 998 patients 363 underwent APR, 132 NRLAR and 503 RLAR. Three-year OS was worse after NRLAR (78.2%) compared to APR (86.3%) and RLAR (92.2%, p < 0.001). This was confirmed in a multivariable Cox regression analysis (HR 1.85 (1.07, 3.19), p = 0.03). The 3-year DFS was also worse after NRLAR (60.3%), compared to APR (70.5%) and RLAR (80.1%, p < 0.001), HR 2.05 (1.42, 2.97), p < 0.001. The LR rate was 14.6% after NRLAR, 5.2% after APR and 4.8% after RLAR (p = 0.005), HR 3.22 (1.61, 6.47), p < 0.001.

CONCLUSION

NRLAR might be associated with worse 3-year OS, DFS and LR rate compared to RLAR and APR.

Pathologic outcomes of transanal versus laparoscopic total mesorectal excision for rectal cancer: a meta-analysis of 26 studies

PURPOSE

Transanal total mesorectal excision (TaTME) has the potential advantages for patients with low rectal cancer. The objective of this meta-analysis was to identify the pathologic outcomes between the TaTME and laparoscopic total mesorectal excision (LaTME) in rectal cancer.

METHODS

The literature searches were conducted in PubMed, Cochrane Library, and EMBASE with English language restriction. The primary endpoint was circumferential margin (CRM), and the secondary endpoints were distal resection margin (DRM), mesorectal excision quality, and harvested lymph nodes.

RESULTS

Our research identified 1090 articles, and 26 studies met the inclusion criteria for the meta-analysis. The positive CRM was lower in the TaTME than the LaTME (OR = 0.72; 95% CI = 0.53, 0.98; P = 0.04). There was no significant difference in the positive CRM between the TaTME and LaTME published after 2016 (OR = 0.80; 95% CI = 0.57, 1.12; P = 0.19), prospective study (OR = 2.70; 95% CI = 0.51, 14.24; P = 0.24), respective study (OR = 0.76; 95% CI = 0.55, 1.04; P = 0.09), BMI > 26 (OR = 1.00; 95% CI = 0.63, 1.58; P = 0.98), or sample size > 100 (OR = 0.84; 95% CI = 0.57, 1.23; P = 0.38). In addition, there was no significant difference observed between the TaTME and LaTME in terms of DRM, mesorectum incompleteness, and harvested lymph nodes.

CONCLUSIONS

The TaTME is associated with lower positive CRM compared to the LaTME and similar pathologic outcomes including DRM, harvested lymph node, and mesorectal excision quality.

New Frontiers in Management of Early and Advanced Rectal Cancer

It is important to understand advances in treatment options for rectal cancer. We attempt to highlight advances in rectal cancer treatment in the form of a systematic review. Early-stage rectal cancer focuses on minimally invasive endoluminal surgery, with importance placed on patient selection as the driving factor for improved outcomes. To achieve a complete pathologic response, various neoadjuvant chemoradiation regimens have been employed. Short-course radiation therapy, total neoadjuvant chemotherapy, and others provide unique advantages with select patient populations best suited for each. With a clinical complete response, a "watch and wait" non-operative surveillance has been introduced with preliminary equivalency to radical resection. Various modalities for total mesorectal excision, such as robotic or transanal, have advantages and can be utilized in select patient populations. Tumors demonstrating solid organ or peritoneal spread, traditionally defined as unresectable lesions conveying a terminal diagnosis, have recently undergone advances in hepatic and pulmonary metastasectomy. Hepatic and pulmonary metastasectomy has demonstrated clear advantages in 5-year survival over standard chemotherapy. With the peritoneal spread of colorectal cancer, HIPEC with cytoreductive therapy has emerged as the preferred treatment. Understanding the various therapeutic interventions will pave the way for improved patient outcomes.

Defining the learning curve of transanal total mesorectal excision: a systematic review and meta-analysis

BACKGROUND

Transanal total mesorectal excision (taTME) represents a novel approach to rectal dissection. Although many structured training programs have been developed worldwide to assist surgeons in implementing this new technique, the learning curve (LC) of taTME has yet to be conclusively defined. This is particularly important given the concerns regarding the complication profile and oncological safety of taTME. The aim of this review was to provide an up-to-date systematic review and meta-analysis of the LC for taTME, comparing the difference of outcomes between the LC and after learning curve (ALC) groups.

METHODS

An up-to-date systematic review was performed on the available literature between 2010-2020 on PubMed, EMBASE, Medline and Cochrane Library databases. All studies comparing taTME procedures before and after LC were analysed.

RESULTS

Seven retrospective studies of prospectively collected databases were included, comparing 333 (51.0%) patients in the LC group and 320 (49.0%) patients in the ALC group. There was a significantly reduced number of adverse intra-operative events, anastomotic leaks and improved quality of mesorectal excision in the ALC group.

CONCLUSION

This review shows that there is a significant improvement in clinical outcomes between the LC and ALC groups which supports the need for careful mastery and ongoing technical refinement during the LC in taTME. This procedure should be performed on a subset of carefully selected patients in the hands of experienced and well-trained teams dedicated to ongoing audit.

A systematic review and meta-analysis on complications of transanal total mesorectal excision

AIM

Transanal total mesorectal excision (TaTME) is a surgical approach for treating mid to low rectal cancer as well as other colorectal diseases. Since the procedure is difficult to master, perioperative complications of TaTME should be examined precisely, especially during the early implementation phase of this procedure. The primary aim of this review was to determine a pooled morbidity and anastomotic leakage (AL) rate after TaTME surgery, and the secondary aim was to show the completeness of reporting of complications among the included studies, as well as the correlation between completeness and reported incidence of complications.

METHOD

A systematic review of literature was conducted using Medline, Embase and Cochrane databases, searching for observational studies reporting on complications after TaTME. Studies published between 1 January 2010 and 15 October 2019 were included. Meta-analysis on the proportion of morbidity, AL and intraoperative complications was performed.

RESULTS

Forty-one studies (2446 TaTME cases), consisting of 27 noncomparative studies and 14 comparative studies, were included, after screening 1711 possible studies. The pooled rates of overall morbidity and AL were 30.0% (95% CI 26.4%-34.0%) and 6.8% (95% CI 5.2%-8.9%), respectively. Subgroup analysis showed that the morbidity rate in studies that reported 30-day results (35.5%; 95% CI 31.8%-39.4%) was significantly higher than the rate in studies that did not define the follow-up length for complications (23.4%; 95% CI 17.8%-30.1%; p = 0.003). The rates of intraoperative urethral injury, rectal injury, vaginal injury and bladder injury were 0.3% (95% CI 0.1%-1.7%), 0.4% (95% CI 0.1%-2.2%), 0.3% (95% CI 0.1%-0.8%) and 0.3% (95% CI 0.1%-1.7%), respectively.

CONCLUSION

This meta-analysis shows that pooled perioperative complication rates were within acceptable ranges. However, the significant difference in overall morbidity rate between the studies with 30-day results and the studies without a specified follow-up time, indicates a large under-reporting of complications in many studies.

A systematic review and meta-analysis of robotic-assisted transabdominal total mesorectal excision and transanal total mesorectal excision: which approach offers optimal short-term outcomes for mid-to-low rectal adenocarcinoma?

BACKGROUND

Resection of low rectal adenocarcinoma can be challenging in the narrow pelvis of male patients. Transanal total mesorectal excision (TaTME) appears to offer technical advantages for distal rectal tumours, and robotic-assisted transabdominal TME (rTME) was introduced in effort to improve operative precision and ergonomics. However, no study has comprehensively compared these approaches. The aim of the present study was to perform a systematic review of the literature to compare postoperative short-term outcomes in rTME and TaTME.

METHODS

A systematic online search (1974-July 2020) of MEDLINE, Embase, web of science and google scholar was conducted for trials, prospective or retrospective studies involving rTME, or TaTME for rectal cancer. Outcome variables included: hospital stay; operation duration, blood loss; resection margins; proportion of histologically complete resected specimens; lymph nodes; overall complications; anastomotic leak, and 30-day mortality.

RESULTS

Sixty-two articles met the inclusion criteria, including 37 studies (3835 patients) assessing rTME resection, 23 studies (1326 patients) involving TaTME and 2 comparing both (165 patients). Operating time was longer in rTME (309.2 min, 95% CI 285.5-332.8) than in TaTME studies (256.2 min, 95% CI 231.5-280.9) (p = 0.002). rTME resected specimens had a larger distal resection margin (2.62 cm, 95% CI 2.35-2.88) than in TaTME studies (2.10 cm, 95% CI 1.83-2.36) (p = 0.007). Other outcome variables did not significantly differ between the two techniques.

CONCLUSIONS

rTME provides similar pathological and short-term outcomes to TaTME and both are reasonable surgical approaches for patients with mid-to-low rectal cancer. To definitively answer the question of the optimal TME technique, we suggest a prospective trial comparing both techniques assessing long-term survival as a primary outcome.

Robotic rectal resection preserves anorectal function: Systematic review and meta-analysis

BACKGROUND

Improving survival rates in rectal cancer patients has generated a growing interest in functional outcomes after total mesorectal excision (TME). The well-established low anterior resection syndrome (LARS) score assesses postoperative anorectal impairment after TME. Our meta-analysis is the first to compare bowel function after open, laparoscopic, transanal, and robotic TME.

METHODS

All studies reporting functional outcomes after rectal cancer surgery (LARS score) were included, and were compared with a consecutive series of robotic TME (n = 48).

RESULTS

Thirty-two publications were identified, including 5 565 patients. Anorectal function recovered significantly better within one year after robotic TME (3.8 [95%CI -9.709-17.309]) versus laparoscopic TME (26.4 [95%CI 19.524-33.286]), p = 0.006), open TME (26.0 [95%CI 24.338-29.702], p = 0.002) and transanal TME (27.9 [95%CI 22.127-33.669], p = 0.003).

CONCLUSIONS

Robotic TME enables better recovery of anorectal function compared to other techniques. Further prospective, high-quality studies are needed to confirm the benefits of robotic surgery.

Morbidity and costs of diverting ileostomy in transanal total mesorectal excision with primary anastomosis for rectal cancer

BACKGROUND

The role of diverting ileostomy is debated in rectal cancer surgery with primary anastomosis. The aim of this study was to evaluate the associated morbidity and hospital costs of diversion after sphincter saving TaTME surgery.

METHODS

All patients undergoing TaTME with primary anastomosis for rectal cancer between January 2012 and December 2019 in a single centre in the Netherlands were included. Patients with diverting ileostomy creation during primary surgery were compared with those without ileostomy. Outcomes included length of hospital stay, anastomotic leakage rates and total hospital costs at 1 year.

RESULTS

One hundred and one patients were included in the ileostomy group, and 46 patients were in the non-ileostomy group. The number of female patients was 31 (30.7%) in the ileostomy group and 21 (45.7%) in the non-ileostomy group Mean age was 64.5 ± 11.1 years in the ileostomy group and 62.6 ± 10.7 years in the non-ileostomy group The anastomotic leakage rate was 21.7% in the non-ileostomy group and 15.8% in the ileostomy group (p = 0.385). The grade of leakage and number of anastomotic takedowns did not differ between groups. Mean costs at 1 year after surgery was €26,500.13 in the ileostomy group and €16,852.61 in the non-ileostomy group. The main cost driver was longer total length of hospital stay at 1 year (mean 12.4 ± 13.3 days vs 20.6 ± 12.6 days, p = 0.000).

CONCLUSIONS

Morbidity and associated costs after diverting ileostomy are high. The incidence and morbidity of anastomotic leakage was not reduced by creation of an ileostomy. Omission of a diverting ileostomy after TaTME could possibly result in a reduction in treatment associated morbidity and costs.

Statistical, Clinical, Methodological Evaluation of Local Recurrence Following Transanal Total Mesorectal Excision for Rectal Cancer: A Systematic Review

BACKGROUND

A recent Norwegian moratorium challenged the status quo of transanal total mesorectal excision for rectal cancer by reporting increased early multifocal local recurrences.

OBJECTIVE

The aim of this systematic review and meta-analysis was to evaluate the local recurrence rates following transanal total mesorectal excision as well as to assess statistical, clinical, and methodological bias in reports published to date.

DATA SOURCES

The PubMed and MEDLINE (via Ovid) databases were systematically searched.

STUDY SELECTION

Descriptive or comparative studies reporting rates of local recurrence at a median follow-up of 6 months (or more) after transanal total mesorectal excision were included.

INTERVENTIONS

Patients underwent transanal total mesorectal excision.

MAIN OUTCOME MEASURES

Local recurrence was any recurrence located in the pelvic surgery site. The untransformed proportion method of 1-arm meta-analysis was utilized. Untransformed percent proportion with 95% confidence interval was reported. Ad hoc meta-regression with the Omnibus test was utilized to assess risk factors for local recurrence. Among-study heterogeneity was evaluated: statistically by I2 and τ2, clinically by summary tables, and methodologically by a 33-item questionnaire.

RESULTS

Twenty-nine studies totaling 2906 patients were included. The pooled rate of local recurrence was 3.4% (2.7%-4.0%) at an average of 20.1 months with low statistical heterogeneity (I2 = 0%). Meta-regression yielded no correlation between complete total mesorectal excision quality (p = 0.855), circumferential resection margin (p = 0.268), distal margin (p = 0.886), and local recurrence rates. Clinical heterogeneity was substantial. Methodological heterogeneity was linked to the excitement of novelty, loss aversion, reactivity to criticism, indication for transanal total mesorectal excision, nonprobability sampling, circular reasoning, misclassification, inadequate follow-up, reporting bias, conflict of interest, and self-licensing.

LIMITATIONS

The studies included had an observational design and limited sample and follow-up.

CONCLUSION

This systematic review found a pooled rate of local recurrence of 3.4% at 20 months. However, given the substantial clinical and methodological heterogeneity across the studies, the evidence for or against transanal total mesorectal excision is inconclusive at this time.

Transanal mesorectal excision: early outcomes in Australia and New Zealand

BACKGROUND

Transanal total mesorectal excision (taTME) aims to overcome some of the technical challenges faced when operating on mid and low rectal cancers. Specimen quality has been confirmed previously, but recent concerns have been raised about oncological safety. This multicentre prospective study aimed to evaluate the safety of taTME among early adopters in Australia and New Zealand.

METHODS

Data from all consecutive patients who had taTME for rectal cancer from July 2014 to February 2020 at six tertiary referral centres in Australasia were recorded and analysed.

RESULTS

A total of 308 patients of median age of 64 years underwent taTME. Some 75.6 per cent of patients were men, and the median BMI was 26.8 kg/m2. The median distance of tumour from anal verge was 7 cm. Neoadjuvant chemoradiotherapy was administered to 57.8 per cent of patients. The anastomotic leak rate was 8.1 per cent and there was no mortality within 30 days of surgery. Pathological examination found a complete mesorectum in 295 patients (95.8 per cent), a near-complete mesorectum in seven patients (2.3 per cent), and an incomplete mesorectum in six patients (1.9 per cent). The circumferential resection margin and distal resection margin was involved in nine patients (2.9 per cent), and two patients (0.6 per cent) respectively. Over a median follow-up of 22 months, the local recurrence rate was 1.9 per cent and median time to local recurrence was 30.5 months.

CONCLUSION

This study showed that, with appropriate training and supervision, skilled minimally invasive rectal cancer surgeons can perform taTME with similar pathological and oncological results to open and laparoscopic surgery.

Short-term outcomes after transanal total mesorectal excision for rectal cancer in Denmark - a prospective multicentre study

AIM

The aim of this study was to evaluate the short-term surgical and oncological outcomes after transanal total mesorectal excision (TaTME) for rectal cancer during the implementation phase of this procedure in Denmark.

METHOD

This is a retrospective review of prospectively recorded data. Registration was initiated by the Scientific Council of the Danish Colorectal Cancer Group (DCCG.dk) in order to assess the quality of care during the implementation of TaTME. Pre-, intra- and postoperative data including early recurrences were recorded at the operating centres.

RESULTS

From August 2016 to April 2019, 115 TaTME procedures were registered. Patients were predominantly male (74%) with mid-rectal (88%) tumours. The level of surgical complications was comparable to previous nationwide results. Anastomotic leakage occurred in 6/109 (5.5%). One urethral injury occurred. The plane of dissection was mesorectal in 60% of cases, intramesorectal in 28% and muscularis in 12%. Nonmicroradicality was seen in 8% (R1, 6%; R2, 2%). Four local recurrences occurred after a median of 23 months of follow-up. One of these was multifocal.

CONCLUSION

In an implementation phase where patient selection is expected, surgical and oncological results after TaTME were comparable to those of other approaches reported in the literature.

Multicenter investigation of bowel evacuation function after transanal total mesorectal excision for mid-low rectal cancer

PURPOSE

To determine the effect of transanal total mesorectal excision (taTME) procedure on the postoperative bowel evacuation function of patients with low rectal cancer.

METHODS

Bowel evacuation function was investigated in 316 patients with rectal cancer after taTME in 18 hospitals in China. Low anterior resection syndrome (LARS) score, Wexner score, and EORTC QLQ-C30 were used for functional evaluation. The association between perioperative risk factors and LARS score was determined by univariate and multivariate analyses.

RESULTS

The prevalence rate of no LARS, minor LARS, and major LARS in patients after taTME was 39.9%, 28.2%, and 31.9%, respectively. The two most frequently reported symptoms of LARS after taTME were bowel clustering (72.8%) and fecal urgency (63.3%). Patients with major LARS had significantly higher Wexner score and worse global health status and financial difficulties according to the EORTC QLQ-C30 questionnaire than those without major LARS. Preoperative chemoradiotherapy was an independent risk factor of major LARS occurrence after taTME (OR: 3.503, P = 0.044); existing preoperative constipation (OR: 0.082, P = 0.040) and manual anastomosis (OR: 4.536, P = 0.021) were favorable factors affecting bowel evacuatory function within 12 months after taTME, but for patients whose follow-up time was longer than 12 months, postoperative chemoradiotherapy (OR: 8.790, P = 0.001) and defunctioning stoma (OR: 3.962, P = 0.010) were independent risk factors.

CONCLUSIONS

The bowel evacuation function after taTME is acceptable. Perioperative chemoradiotherapy, anastomotic method, and preoperative constipation are factors associated with bowel dysfunction after taTME.

Education and Training in Transanal Endoscopic Surgery and Transanal Total Mesorectal Excision

There is a paradigm shift in surgical training, and new tool and technology are being used to facilitate mastery of the content and technical skills. The transanal procedures for rectal cancer-transanal endoscopic surgery (TES) and transanal total mesorectal excision (TaTME)-have a distinct learning curve for competence in the procedures, and require special training for familiarity with the "bottom-up" anatomy, procedural risks, and managing complex cases. These procedures have been models for structured education and training, using multimodal tools, to ensure safe implementation of TES and TaTME into clinical practice. The goal of this work was to review the current state of surgical education, the introduction and learning curve of the TES and TaTME procedures, and the established and future models for education of the transanal procedures for rectal cancer.

Current Challenges for Education and Training in Transanal Surgery

Transanal endoscopic microsurgery (TEM) is a technique that was introduced in the 1980s for improved exposure to upper rectal polyps. This technique, though initially difficult to master due to new skill acquisition for surgeons, has spared many patients proctectomy. There are many benign indications for transanal endoscopic surgery which has led to in vivo operating room training with fewer undesirable effects to the patient. With the explosion of laparoscopic technology this transanal technique is no longer limited to intraluminal pathology, but is now being used to remove the entire rectum. In transanal total mesorectal excision (taTME), benign indications are less common, translating to potentially more severe oncologic patient consequences during the early phase of adoption. For this reason, strict training criteria consensus guidelines have been developed by the experts in taTME. The current consensus statements agree that training surgeons should have performed a minimum of 10 laparoscopic TME procedures and should have some experience with transanal surgery. Surgeons need to attend a formal training course and should start clinically on benign or early malignant pathology without threated circumferential resection margins. Surgeons also need to have their first cases proctored until deemed proficient by the proctor and monitor their morbidity, oncologic, and functional outcomes prospectively.

Transanal Total Mesorectal Excision: Short-term Outcomes of 1283 Cases from a Nationwide Registry in China

BACKGROUND

Transanal total mesorectal excision is a promising surgical procedure for mid to low rectal cancer.

OBJECTIVE

This study aimed to determine the short-term outcomes of Chinese patients treated with transanal total mesorectal excision.

DESIGN

This was an observational study using data from an online registry system.

SETTING

Study participants were recruited from 40 different centers across 15 provinces in China.

PATIENTS

Patients with either benign or malignant rectal disease who underwent transanal total mesorectal excision procedure and were registered in the Chinese Transanal Total Mesorectal Excision Registry Collaborative from May 2010 to November 2019 were included.

INTERVENTION

Patients underwent transanal total mesorectal excision.

MAIN OUTCOME MEASURES

The primary outcomes measured were the postoperative complications and pathological outcomes.

RESULTS

In total, 1283 patients, comprising 888 men (69.2%) and 395 women (39.8%) with a median age of 61 (22-92) years and a median BMI of 23.6 (14.5-46.3) kg/m2, were analyzed. Among 40 participating centers, the average number of registered cases was 32.1±34.7, and 12 centers (30%) registered >40 cases in the registry. Among 849 patients with rectal cancer who underwent laparoscopic-assisted transanal total mesorectal excision, the conversion rate was 0.5% in the abdominal phase and 1.9% in the perineal phase. Three patients reported urethral injury (0.5%). The postoperative complication rate and the anastomotic leakage incidence were 18.4% and 5.8%. The quality of the total mesorectum excision specimens was found to be complete in 81.9% of patients. In addition, the positive circumferential resection margin rate was 2.8%.

LIMITATIONS

The primary limitation of this registry study was the high percentage of missing data (10.8% overall), and, for some of the analyzed variables, up to 35% of the data was missing. Postoperative complications were not monitored after discharge, resulting in a lower morbidity rate than the 30-day morbidity rate reported in other studies.

CONCLUSIONS

The short-term outcomes of patients who underwent transanal total mesorectal excision procedures in China were acceptable. See Video Abstract at http://links.lww.com/DCR/B414.

EXCISIN TOTAL DEL MESORRECTO POR VA TRANSANAL RESULTADOS A CORTO PLAZO DE CASOS DE UN REGISTRO NACIONAL EN CHINA

ANTECEDENTES:La excisión total del mesorrecto por vía transanal es un procedimiento quirúrgico prometedor para el cáncer de recto medio y bajo.OBJETIVO:Determinar los resultados a corto plazo de los pacientes chinos tratados con escisión mesorrectal total transanal.DISEÑO:Estudio observacional con datos de un sistema de registro en línea.AJUSTE:Los participantes del estudio fueron reclutados en 40 centros diferentes en 15 provincias de China.PACIENTES:Se incluyeron pacientes con enfermedad rectal benigna o maligna que se sometieron a una cirugía de excisión total del mesorrecto por vía transanal y que se registraron en el Registro Colaborativo de Excisión Total del Mesorrecto por vía Transanal en China desde mayo de 2010 hasta noviembre de 2019.INTERVENCIÓN:Excisión total delmesorrecto por vía transanal.PRINCIPALES MEDIDAS DE RESULTADO:Complicaciones postoperatorias y resultados patológicos.RESULTADOS:Fueron analizados un total de 1.283 pacientes, que comprendían 888 hombres (69,2%) y 395 mujeres (39,8%) con una mediana de edad de 61 (22-92) años y una mediana de índice de masa corporal de 23,6 (14,5-46,3) kg / m2. Entre los 40 centros participantes, el promedio de casos registrados fue de 32,1 ± 34,7, y 12 centros (30%) inscribieron > 40 casos en el registro. Entre 849 pacientes con cáncer de recto que se sometieron a excisión total del mesorrecto pééor vía transanal asistida por laparoscopia, la tasa de conversión fue del 0,5% en la fase abdominal y del 1,9% en la fase perineal. Tres pacientes refirieron una lesión uretral (0,5%). La tasa de complicaciones posoperatorias y la incidencia de fuga anastomótica fueron del 18,4% y el 5,8%, respectivamente. La calidad de las muestras de excisión total del mesorrecto se evaluó como completa en el 81,9% de los pacientes. Además, la tasa de margen de resección circunferencial positiva fue del 2,8%.LIMITACIONES:La principal limitación del presente estudio de registros fue el alto porcentaje de datos faltantes (10,8% en general), y para algunas de las variables analizadas, faltaba hasta el 35% de los datos. Las complicaciones postoperatorias no fueron verificadas después del alta, lo que resultó en una tasa de morbilidad más baja que la tasa de morbilidad a 30 días informada en otros estudios.CONCLUSIONES:Los resultados a corto plazo de los pacientes que se sometieron al procedimiento de excisión total del mesorrecto por vía transanal en China fueron aceptables. Consulte Video Resumen en http://links.lww.com/DCR/B414. (Traducción-Dr. Xavier Delgadillo).

Association between urinary function and resected pattern of the autonomic nerve system after transanal total mesorectal excision for rectal cancer

AIM

Transanal total mesorectal excision (TaTME) is expected to improve the quality of total mesorectal excision as well as preserve urinary function. We aimed to study the frequency and risk factors of urinary dysfunction in rectal cancer patients after TaTME. Moreover, we analysed the association between urinary function and resected pattern of the autonomic nerve system (ANS) in TaTME.

METHOD

We retrospectively analysed 231 patients who underwent TaTME at our hospital from 2013 to 2018. Independent risk factors for urinary dysfunction were assessed by multivariate analysis. Urinary dysfunction was defined as a condition that requires urethral catheterisation. We intraoperatively judged and classified the preserved or resected pattern of ANS into four categories.

RESULTS

The rate of urinary dysfunction after TaTME was 12.1% at discharge. Multivariate analysis revealed that beyond TME and ANS resection were the two major independent risk factors for urinary dysfunction. Total ANS preservation had reduced rates of urinary dysfunction, and all patients were free from catheterisation 6 months post-surgery. There was a higher rate of urinary dysfunction in total ANS resection than in partial ANS resection at 6 months post-surgery.

CONCLUSION

This study showed that urinary function after TaTME was associated with resection of the ANS. Furthermore, the rate of urinary dysfunction and recovery time were closely related to the pattern of ANS resection.

Transanal total mesorectal excision outcomes for advanced rectal cancer in a complex surgical population

BACKGROUND

Total mesorectal excision (TME) is the gold standard for oncologic resection in low and mid rectal cancers. However, abdominal approaches to TME can be hampered by poor visibility, inadequate retraction, and distal margin delineation. Transanal TME (taTME) is a promising hybrid technique that was developed to mitigate the difficulties of operating in the low pelvis and to optimize the circumferential resection and distal margins.

METHODS

The objective of this study was to characterize our experience implementing taTME at our institution in a technically challenging patient population. We performed a retrospective review of consecutive patients who underwent taTMEs between November 2013 and May 2019 for rectal cancer at a tertiary community cancer center. Outcome measures included pathologic grading of TME specimen, post-operative complications, and oncologic outcomes.

RESULTS

Forty-four patients with mid and low rectal cancer underwent low anterior resection via taTME. The most common staging modality was rectal MRI which demonstrated T3 or T4 tumors in 89% of our patients prior to neoadjuvant. Eighty-six percent of patients underwent neoadjuvant chemoradiation. The initial cases were performed sequentially as a single team, but we later transitioned to a synchronous, two-team approach. Ninety-one percent of TME grades were complete or near complete. Only one patient (2.3%) had a positive circumferential margin. Six patients developed anastomotic leaks with an overall anastomotic complication rate of 18.2%. Two patients (4.5%) with primary rectal cancer developed local recurrence, one of which developed multifocal local recurrence.

CONCLUSIONS

Using the taTME approach on selected locally advanced low rectal cancers, especially in technically complex irradiated and obese male patients, has yielded comparably safe and effective outcomes to laparoscopic proctectomy.

Trans-anal total mesorectal excision in low rectal cancers: Preliminary oncological results of a comparative study

OBJECTIVE

The management of lower rectal cancers is a therapeutic challenge both from the oncological and functional viewpoints. The aim of this study is to assess the oncological results and postoperative morbidity after transanal total mesorectal excision (TaTME) for low rectal cancer.

MATERIAL AND METHODS

In this monocentric retrospective study, we compared the quality of carcinologic resection and the morbidity-mortality between a group of 20 patients undergoing TaTME and 21 patients treated by abdomino-perineal resection (APR) between 2016 to 2019.

RESULTS

More patients had a positive circumferential resection margin (CRM) (≤1mm) in the APR group (47.6% vs. 5%; P<0.0036). The difference in the rates of grades I-II and III-IV complications (Clavien-Dindo classification) between the two groups was not statistically significant (50% vs. 57.1% and 5% vs. 9.5% in TaTME and APR, respectively; P=0.7579, P=1.00). The median follow-up was longer in the TaTME group (20 months vs. 11 months; P=0.58). The local recurrence rate did not differ between the two groups (5% vs. 4.8%; P=1.00) CONCLUSION: TaTME provides a reliable total mesorectal resection with an acceptable CRM. However, like any new technique, it requires experience and the learning curve is long.

Single incision laparoscopic approach for infected necrotizing pancreatitis: A case report

INTRODUCTION

Approximately 5% of patients with acute pancreatitis develop infected necrotizing pancreatitis, with reported mortality rates up to 32%. Surgical interventions are postponed as long as possible, but if surgical debridement is needed the optimal approach has not been found yet.

CASE PRESENTATION

A 47-year-old male was referred to our tertiary centre with infected necrotizing pancreatitis. Two months after initial presentation and repeated percutaneous drainage, surgical retroperitoneal debridement of the necrotic tissue was performed using a single incision laparoscopic surgery (SILS) port. Postoperatively, percutaneous drainage was performed two more times, but no additional surgical interventions were needed. The patient was discharged one month after the surgical procedure.

DISCUSSION AND CONCLUSION

This is the first report of a minimally invasive technique using a SILS port for debridement of necrotizing pancreatitis. The ability to create a stable pneumo-retroperitoneum leads to optimal visualisation, better haemostasis, more space to operate in, better instrument handling, and better tissue control.

Three-year outcome after transanal versus laparoscopic total mesorectal excision in locally advanced rectal cancer: a multicenter comparative analysis

Background

For patients with mid and distal rectal cancer, robust evidence on long-term outcome and causal treatment effects of transanal total mesorectal excision (TaTME) is lacking. This multicentre retrospective cohort study aimed to assess whether TaTME reduces locoregional recurrence rate compared to laparoscopic total mesorectal excision (LapTME).

Methods

Consecutive patients with rectal cancer within 12 cm from the anal verge and clinical stage II-III were selected from three institutional databases. Outcome after TaTME (Nov 2011 - Feb 2018) was compared to a historical cohort of patients treated with LapTME (Jan 2000 - Feb 2018) using the inverse probability of treatment weights method. The primary endpoint was three-year locoregional recurrence.

Results

A total of 710 patients were analysed, 344 in the TaTME group and 366 in the LapTME group. At 3 years, cumulative locoregional recurrence rates were 3.6% (95% CI, 1.1–6.1) in the TaTME group and 9.6% (95% CI, 6.5–12.7) in the LapTME group (HR = 0.4; 95% CI, 0.23–0.69; p = 0.001). Three-year cumulative disease-free survival rates were 74.3% (95% CI, 68.8–79.8) and 68.6% (95% CI, 63.7–73.5) (HR = 0.82; 95% CI, 0.65–1.02; p = 0.078) and three-year overall survival 87.2% (95% CI, 82.7–91.7) and 82.2% (95% CI, 78.0–86.2) (HR = 0.74; 95% CI, 0.53–1.03; p = 0.077), respectively. In patients who underwent sphincter preservation procedures, TaTME was associated with a significantly better disease-free survival (HR = 0.78; 95% CI, 0.62–0.98; p = 0.033).

Conclusions

These findings suggest that TaTME may improve locoregional recurrence and disease-free survival rates among patients with mid and distal locally advanced rectal cancer.

Canadian taTME expert collaboration (CaTaCO) position statement

INTRODUCTION

Transanal total mesorectal excision (taTME) is a novel approach to surgery for rectal cancer. The technique has gained significant popularity in the surgical community due to the promising ability to overcome technical difficulties related to the access of the distal pelvis. Recently, Norwegian surgeons issued a local moratorium related to potential issues with the safety of the procedure. Early adopters of taTME in Canada have recognized the need to create guidelines for its adoption and supervision. The objective of the statement is to provide expert opinion based on the best available evidence and authors' experience.

METHODS

The procedure has been performed in Canada since 2014 at different institutions. In 2016, the first Canadian taTME congress was held in the city of Toronto, organized by two of the authors. In early 2019, a multicentric collaborative was established [The Canadian taTME expert Collaboration] which aimed at ensuring safe performance and adoption of taTME in Canada. Recently surgeons from 8 major Canadian rectal cancer centers met in the city of Toronto on December 7 of 2019, to discuss and develop a position statement. There in person, meeting was followed by 4 rounds of Delphi methodology.

RESULTS

The generated document focused on the need to ensure a unified approach among rectal cancer surgeons across the country considering its technical complexity and potential morbidity. The position statement addressed four domains: surgical setting, surgeons' requirements, patient selection, and quality assurance.

CONCLUSIONS

Authors agree transanal total mesorectal excision is technically demanding and has a significant risk for morbidity. As of now, there is uncertainty for some of the outcomes. We consider it is possible to safely adopt this operation and obtain adequate results, however for this purpose it is necessary to meet specific requirements in different domains.

Transanal total mesorectal excision the Gold Coast experience: learning curve and comparison to traditional technique

BACKGROUND

Laparoscopic and open techniques in rectal cancer are well-published, however, technical challenges remain for mid to low rectal cancer resections in the narrow pelvis. Transanal total mesorectal excision (taTME) has been pioneered to potentially circumvent these challenges. The aims of this study were to evaluate the learning curve associated with our first cases of taTME as well as compare outcomes to that of conventionally performed rectal resections.

METHODS

This was a single-centre retrospective study with data collated from all elective resections by the colorectal unit from 2015 to 2017. Primary outcome was completeness of total mesorectal excision and secondary outcomes were intra- and post-operative morbidity and mortality.

RESULTS

A total of 43 patients were identified. Of which, 20 underwent taTME. Mesorectal completeness was obtained in only 47.4% in the taTME group compared to 78.3% in the anterior resection group (p = 0.115). 5.9% of patients in our taTME group had positive circumferential resection margin compared to nil in the anterior resection. Conversion rates were greater in the taTME group (15% versus 0%; 0.028). Operative time, length of stay and clavien IV and V complications were greater in the taTME group.

CONCLUSION

This study highlights the difficulty in introducing a novel technique given the learning curve. Our results would expect to improve with increased caseload.

Evolution of Transanal Total Mesorectal Excision

Minimally invasive techniques continue to transform the field of colorectal surgery. Because traditional surgical approaches for rectal cancer are associated with significant mortality and morbidity, developing less invasive approaches to this disease is paramount. Natural orifice transluminal endoscopic surgery (NOTES), commonly known as "no incision surgery," represents the ultimate minimally invasive approach to disease. Although transgastric and transvaginal approaches for NOTES surgery were the initially explored, a transrectal approach for colorectal disease is intuitive given that it makes use of the resected organ for transluminal access. Furthermore, the transanal approach allows for improved, precise visualization of the presacral mesorectal plane compared with an abdominal viewpoint, particularly in the narrow, male pelvis. Finally, experience with existing transanal platforms that have been used for decades for local excision of rectal disease made the development of a transanal approach to total mesorectal excision (TME) feasible. Here, we will review the evolution of minimally invasive and transanal surgical techniques that allowed for the development of transanal TME and its introduction into clinical practice.

Locoregional recurrences after transanal total mesorectal excision of rectal cancer during implementation

Background

Transanal total mesorectal excision (TaTME) has been proposed as an approach in patients with mid and low rectal cancer. The TaTME procedure has been introduced in the Netherlands in a structured training pathway, including proctoring. This study evaluated the local recurrence rate during the implementation phase of TaTME.

Methods

Oncological outcomes of the first ten TaTME procedures in each of 12 participating centres were collected as part of an external audit of procedure implementation. Data collected from a cohort of patients treated over a prolonged period in four centres were also collected to analyse learning curve effects. The primary outcome was the presence of locoregional recurrence.

Results

The implementation cohort of 120 patients had a median follow up of 21·9 months. Short‐term outcomes included a positive circumferential resection margin rate of 5·0 per cent and anastomotic leakage rate of 17 per cent. The overall local recurrence rate in the implementation cohort was 10·0 per cent (12 of 120), with a mean(s.d.) interval to recurrence of 15·2(7·0) months. Multifocal local recurrence was present in eight of 12 patients. In the prolonged cohort (266 patients), the overall recurrence rate was 5·6 per cent (4·0 per cent after excluding the first 10 procedures at each centre).

Conclusion

TaTME was associated with a multifocal local recurrence rate that may be related to suboptimal execution rather than the technique itself. Prolonged proctoring, optimization of the technique to avoid spillage, and quality control is recommended.

Surgical Quality Assurance in COLOR III: Standardization and Competency Assessment in a Randomized Controlled Trial

OBJECTIVE

The aim of this study was to develop an objective and reliable surgical quality assurance system (SQA) for COLOR III, an international multicenter randomized controlled trial (RCT) comparing transanal total mesorectal excision (TaTME) with laparoscopic approach for rectal cancer.

BACKGROUND OF SUMMARY DATA

SQA influences outcome measures in RCTs such as lymph nodes harvest, in-hospital mortality, and locoregional cancer recurrence. However, levels of SQA are variable.

METHOD

Hierarchical task analysis of TaTME was performed. A 4-round Delphi methodology was applied for standardization of TaTME steps. Semistructured interviews were conducted in round 1 to identify key steps and tasks, which were rated as mandatory, optional, or prohibited in rounds 2 to 4 using questionnaires. Competency assessment tool (CAT) was developed and its content validity was examined by expert surgeons. Twenty unedited videos were assessed to test reliability using generalizability theory.

RESULTS

Eighty-three of 101 surgical tasks identified reached 70% agreement (26 mandatory, 56 optional, and 1 prohibited). An operative guide of standardized TaTME was created. CAT is matrix of 9 steps and 4 performance qualities: exposure, execution, adverse event, and end-product. The overall G-coefficient was 0.883. Inter-rater and interitem reliability were 0.883 and 0.986. To enter COLOR III, 2 unedited TaTME and 1 laparoscopic TME videos were submitted and assessed by 2 independent assessors using CAT.

CONCLUSION

We described an iterative approach to develop an objective SQA within multicenter RCT. This approach provided standardization, the development of reliable and valid CAT, and the criteria for trial entry and monitoring surgical performance during the trial.

Is my life going to change?-a review of quality of life after rectal resection

Rectal resection is a common practice for colorectal surgeons. The causes of this procedure are varied. The most frequent is cancer, but also inflammatory bowel disease, endometriosis, and rectovaginal or rectourethral fistulas. The loss of the normal rectal reservoir function, urinary problems, sexual dysfunction or pelvic pain are frequently reported in patients after rectal surgery and these disorders markedly affect the overall quality of life (QoL). In the last decades, rectal surgery has radically changed, with the development of surgical techniques, and it has progressed from abdominoperineal resection (APR) with a permanent colostomy to sphincter-saving procedures. Nowadays, the use of sphincter-preserving surgery has increased, but all these surgical techniques can have important sequels that modify the QoL of the patients. Historically, surgical outcomes, such as complications, survival and recurrences, have been widely studied by surgeons. In the present day, surgical outcomes have improved, rectal cancer recurrence rate has decreased and survival has increased. For these reasons, it has begun to gain importance in aspects of the QoL of patients, such as body image, fecal continence and sexuality or urinary function. Therefore, physicians should know the influence of different techniques and approaches on functional outcomes and QoL, to be able to inform patients of the treatment benefits and risk of postoperative dysfunctions. The aim of our study is to review the current literature to determine to what degree the QoL of patients who underwent a rectal resection decreases, which domains are the most affected and, in addition, to establish the influence of different surgical techniques and approaches on functional outcomes.

An evaluation of trans-anal rectoscopic-assisted minimally invasive surgery (ARAMIS): a new platform for transanal surgery

PURPOSE

The study aimed to evaluate the feasibility and safety of a new trans-anal rectoscopic-assisted minimally invasive surgery (ARAMIS) platform to treat rectal lesions.

METHODS

ARAMIS was first compared with two transanal minimally invasive surgery platforms (SILS Port and GelPOINT Path) on human cadavers. Surgeons with different experience performed running sutures at different distances, at four quadrants, using the three platforms and gave a score to visibility, safety, and maneuverability. ARAMIS was then utilized on patients affected with rectal neoplasia who met the inclusion criteria. Patients and tumor characteristic and results were prospectively collected. The follow-up examinations included proctoscopy at 3, 6, and 12 months.

RESULTS

According to surgeons' scores, ARAMIS improves visibility and safety with respect to other platforms for distances beyond 10 cm. The procedure, which lasted an average of 59 min, was successfully carried out in 14 patients. No intraoperative or postoperative complications were reported. The mean tumor size was 3 cm; they were located a mean of 11 cm from the anal verge. Complete removal of the lesion was possible in 13/14 patients. There was one case of adenoma recurrence at follow-up.

CONCLUSION

Study results showed that ARAMIS, which is equipped with an adjustable rectoscope, can be considered a safe, effective platform for transanal surgery. The rectoscope protects the rectum during the procedure, a particularly important consideration when proximal rectal lesions are being treated. Further clinical studies are warranted to confirm these encouraging results.

Pure transanal total mesorectal excision for rectal cancer: experience with 55 cases

Background

Although the anatomic difficulties of laparoscopic surgery for rectal cancer have been resolved by hybrid transanal total mesorectal excision (h-taTME), a completely incisionless surgical procedure has not yet been developed. This study was performed to explore the efficacy of pure taTME (p-taTME) without laparoscopic assistance as a completely non-invasive surgical procedure for rectal cancer.

Methods

We retrospectively evaluated all patients with rectal cancer who underwent p-taTME between December 2015 and April 2018. Relevant patient characteristics and clinical information including the surgical procedure, specimens, pathological characteristics, and patients’ post-operative state were analysed and the feasibility of p-taTME in patients with rectal cancer was assessed.

Results

Fifty-five patients who had undergone p-taTME were included in this study. They comprised 32 (58.2%) men and 23 (41.8%) women with a mean age of 65.6 ± 10.6 years and mean body mass index of 23.4 ± 3.3 kg/m². The median surgical time was 180.0 (range, 130–360) min and estimated blood loss was 25.0 (range, 15–80) mL. The commonest post-operative complication was varying degrees of faecal incontinence (56.4%). However, such incontinence greatly improved after pelvic-floor-function-rehabilitation exercises and did not seriously affect the patients’ quality of life.

Conclusions

p-taTME is a relatively safe and incisionless procedure for patients with middle and low rectal cancer, especially in those with obesity or a narrow pelvis. However, further studies of the indications and long-term efficacy are needed to verify the suitability of this procedure.

Hybrid abdominal robotic approach with conventional transanal total mesorectal excision (TaTME) for rectal cancer: feasibility and outcomes from a single institution

Total mesorectal excision (TME) is currently recognised as the standard of care for patients with rectal cancer. Complete TME is known to be associated with lower rates of recurrence. Robotic and endoscopic TaTME approaches are reported to offer excellent proximal and distal rectal dissection into the TME plane, however, combining both approaches in a hybrid procedure could potentially optimise visualisation of the dissection plane and confer improved circumferential and distal margin rates. The aim of this study was to analyse the feasibility of a hybrid robotic abdominal approach with conventional TaTME for rectal cancer. Furthermore, pathological and patient outcomes were assessed. A review of prospectively maintained databases was undertaken to assess all patients undergoing robotic TME surgery for rectal tumours from August 2016 to October 2017. Patient demographics, tumour characteristics and outcomes were collated from patient charts and hospital databases. All patients underwent a modified Cecil approach after multidisciplinary team discussion. Eight patients (7 male, 1 female) underwent a combined hybrid approach with a median age of 60 years (range 47-73) and BMI of 29.5 (range 20-39.1) kg/m². Median distance from the anorectal junction (ARJ) was 7.5 (range 4-13) cm. Six patients underwent neoadjuvant treatment with chemoradiotherapy. Patients had a median length of stay (LOS) of 9 (range 4-33) days. There were no intra-operative complications encountered and no patients required a conversion to an open procedure. Complications included one anastomotic leak and one presacral collection. All patients had a complete TME with RO resection with a median number of lymph nodes harvested was 22 (range 6-37) lymph nodes. This hybrid technique is a feasible, practical and operatively favourable approach to rectal cancer surgery with initial pathological outcomes and complication profile equivalent to other approaches.

Transanal total mesorectal excision (taTME) for rectal cancer: beyond the learning curve

BACKGROUND

Transanal total mesorectal excision (taTME) is a surgical approach for low rectal cancer with a learning curve estimated at 40-50 cases. The experience among taTME surgeons beyond their learning curve is limited.

METHODS

A retrospective analysis of all taTME cases performed for rectal cancer at two tertiary care hospitals from 2014 to 2019 was conducted. Transanal surgeons had previously performed > 50 taTME cases. Demographic, perioperative, and short-term outcomes were analyzed.

RESULTS

Among 54 taTME patients, 74.1% were male and 27.8% had a BMI ≥ 30. Tumors were stage I (8), II (13), III (29), and IV (4). Complex cases included 4 local recurrences, 4 prior liver resections, and 2 with prior prostate cancer. Thirty tumors were located ≤ 6 cm from the anal verge. On staging MRI, 12 had a positive predicted circumferential radial margin (+CRM), and 4 had internal anal sphincter involvement (+IAS). Forty-seven patients received neoadjuvant therapy. A 2-team approach was used in 51 patients with laparoscopic (83.3%) or robotic (16.7%) abdominal assistance with a 9.2% conversion rate. Low anterior resection with sphincter salvage was achieved in 87% with 8 patients requiring intersphincteric resection. Anastomoses were hand-sewn in 57.4% and all patients were diverted. Median LOS was 5 days with a 42.6% 30-day morbidity rate and 3 postoperative mortalities (ARDS, pulmonary embolism and pseudomembranous colitis). Complete and near complete TME grade was achieved in 94.4% with a 3.7% rate of +CRM. At a median follow-up of 28 months, local and distant recurrence rates were 3.9% and 17.6%, respectively, with no cancer-related mortality.

CONCLUSION

Indications for taTME at experienced centers have expanded to include complex reoperative cases, local recurrences, metastatic cancer, and tumors with threatened CRM or IAS with evidence of post-treatment tumor regression. In the latter cases, taTME achieves good short-term outcomes and may facilitate R0 resection.

Long-term oncological results after transanal total mesorectal excision for rectal carcinoma

Background

Transanal total mesorectal excision (TaTME) for mid and low rectal cancer has been shown to improve short-term outcomes, mostly due to lower conversion rates and with improved quality of the specimen. However, robust long-term oncological data supporting the encouraging clinical and pathological outcomes are lacking.

Methods

All consecutive patients undergoing TaTME with curative intent for mid or low rectal cancer in two referral centers in The Netherlands between January 2012 and April 2016 with a complete and minimum follow-up of 36 months were included. The primary outcome was local recurrence rate. Secondary outcomes were disease-free survival, overall survival and development of metastasis.

Results

There were 159 consecutive patients. Their mean age was 66.9 (10.2) years and 66.7% of all patients were men. Pathological analysis showed a complete mesorectum in 139 patients (87.4%), nearly complete in 16 (10.1%) and an incomplete mesorectum in 4 (2.5%). There was involvement of the CRM (< 1 mm) in one patient (0.6%) and no patients had involvement of the distal margin (< 5 mm). Final postoperative staging after neoadjuvant therapy was stage 0 in 11 patients (6.9%), stage I in 73 (45.9%), stage II in 31 (19.5%), stage III in 37 (23.3%) and stage IV in 7 (4.4%). The 3-year local recurrence rate was 2.0% and the 5-year local recurrence rate was 4.0%. Median time to local recurrence was 19.2 months. Distant metastases were found in 22 (13.8%) patients and were diagnosed after a median of 6.9 months (range 1.1–50.4) months. Disease-free survival was 92% at 3 years and 81% at 5 years. Overall survival was 83.6% at 3 years and 77.3% at 5 years.

Conclusions

The long-term follow-up of the current cohort confirms the oncological safety and feasibility of TaTME in two high volume referral centers for rectal carcinoma. However, further robust and audited data must confirm current findings before widespread implementation of TaTME.

Transanal total mesorectal excision (TaTME): are we doing it for the right indication? An assessment of the external validity of published online video resources

BACKGROUND

The steep learning curve for safe introduction of transanal total mesorectal excision (TaTME) highlights the need for mentored training reserved for surgeons with expertise in minimally invasive colorectal surgery and transanal surgery. Video-based education in minimally invasive surgery is considered by surgical trainers as a useful teaching aid to maximize learning. This study aims to systematically assess the availability and quality of online TaTME videos.

METHODS

TaTME videos were systematically searched on YouTube.com , Colorectal diseases video channel, WebSurg.com , and AIS channel. Data collected included video characteristics, presence of supplementary educational content, patient details, indication for surgery, different steps of TaTME presented, and surgical outcomes.

RESULTS

Forty-six videos were included with a median of 92 views per month. Nineteen videos (41.3%) reported the age of the participants and 29 patients were male (63%). Body mass index (BMI) was reported in 20 videos (43.5%) with a median of 27 and it indicated obesity (BMI ≥ 30) in 2 cases only. The use of neoadjuvant treatment was reported in 8 cases (17.4%). Eighteen videos (39.1%) reported the distance of the tumor from the anal verge, with a median of 6.4 cm and in 9 out of 18 cases, the tumor distance from the anal verge was 7 cm or higher. Pathological staging was reported in 17 videos (37.0%), with 1 T1, 3 T2, 10 T3, and 3 T4 tumors.

CONCLUSIONS

There is considerable interest in TaTME videos. Lack of consensus on reporting of these videos limits the educational value of these resources, which are missing important patient details and postoperative outcomes.

Evolution of surgery for rectal cancer: Transanal total mesorectal excision～new standard or fad?～

Transanal Total Mesorectal Excision (TaTME) has recently been developed to overcome the difficulties associated with conventional laparoscopic or robotic TME. TaTME has gained popularity and becomes the center of attention among colorectal surgeons globally. The present review aims to update the literature, clarify the current status and perspectives of TaTME. Complete TaTME specimens were obtained in 85-97.1% of the case; the reported circumferential resection margin (CRM) ranged from 1.5% to 8.1%, whereas and distal resection margin (DRM) positive rates ranged from 0% to 3.2%. The conversion rate of TaTME occurred from 0 to 15%, and there was no difference between TaTME and laparoscopic or robotic TME. Intraoperative complications occurred in 5-6% of the case, which compared favorably to laparoscopic TME. The most serious intraoperative complication with this approach was urethral injury, although only small numbers were reported, which was possibly due to under-reporting. Clavien-Dindo I or II postoperative complications occurred in 22-24% of the case, and III or IV in 10-11% of the case, which did not differ between TaTME and laparoscopic or robotic TME. TaTME may be technically easier and more beneficial than laparoscopic, robotic or open TME in male patients with a narrow pelvis; in obese patients with a bulky tumor. At present two randomized controlled trials, COLOR III and GRECCAR, and comparing TaTME with laparoscopic TME are being conducted and their outcomes are awaited. TaTME is a complex procedure, but proved to be feasible, oncologically safe, and effective in difficult cases. Before this new technique is adopted, proper training with Proctor/mentorship is strongly advised. Careful case selection and audit of data are mandatory.

Urethral Injury and Other Urologic Injuries During Transanal Total Mesorectal Excision: An International Collaborative Study

OBJECTIVE

To identify risk factors for urethral and urologic injuries during transanal total mesorectal excision (taTME) and evaluate outcomes.

BACKGROUND

Urethral injury is a rare complication of abdominoperineal resection (APR) that has not been reported during abdominal proctectomy. The Low Rectal Cancer Development Program international taTME registry recently reported a 0.8% incidence, but actual incidence and mechanisms of injury remain largely unknown.

METHODS

A retrospective analysis of taTME cases complicated by urologic injury was conducted. Patient demographics, tumor characteristics, intraoperative details, and outcomes were analyzed, along with surgeons' experience and training in taTME. Surgeons' opinion of contributing factors and best approaches to avoid injuries were evaluated.

RESULTS

Thirty-four urethral, 2 ureteral, and 3 bladder injuries were reported during taTME operations performed over 7 years by 32 surgical teams. Twenty injuries occurred during the teams' first 8 taTME cases ("early experience"), whereas the remainder occurred between the 12th to 101st case. Injuries resulted in a 22% conversion rate and 8% rate of unplanned APR or Hartmann procedure. At median follow-up of 27.6 months (range, 3-85), the urethral repair complication rate was 26% with a 9% rate of failed urethral repair requiring permanent urinary diversion. In patients with successful repair, 18% reported persistent urinary dysfunction.

CONCLUSIONS

Urologic injuries result in substantial morbidity. Our survey indicated that those occurring in surgeons' early experience might best be reduced by implementation of structured taTME training and proctoring, whereas those occurring later relate to case complexity and may be avoided by more stringent case selection.

Evolution of transanal total mesorectal excision according to the IDEAL framework

Tremendous innovations have taken place in surgical procedures, but contrary to drug development, this process has been unregulated in the past. IDEAL promotes a structured framework for the safe implementation and assessment of a new surgical technique or intervention, by describing five stages for evaluating and reporting of innovations: Idea, Development, Exploration, Assessment and Long term. Transanal total mesorectal excision (TaTME) is a relatively new technique in rectal cancer surgery that has attracted huge interest and increasing adoption worldwide. This review article aims to provide an overview of the evolution of TaTME, according to the IDEAL framework, which guides us in the difficult yet exciting process of surgical innovation.

The Role of transanal (Ta) dissection in the management of difficult primary and recurrent rectal cancer

Background

The objective of this study was to review the postoperative and short-term oncological outcomes of our first cohort of patients having had a transanal (Ta) approach for primary or recurrent rectal cancer.

Methods

A retrospective chart review was performed on all cases of Ta dissection occurring between 2013 and 2016. We reviewed data concerning case selection, tumour characteristics, perioperative and postoperative data and final pathology.

Results

A total of 24 males were operated for primary (92% (22/24)) or recurrent rectal cancer (8.3% (2/24)). Four patients (16.7% (4/24)) had a history of previous rectal surgery and two had a history of previous Ta total mesorectal excision (TME). A majority of patients were obese, with 58.3% (14/24) having a body mass index >30. The laparoscopic approach was used in the majority of cases (95.8% (23/24)). Most patients had a low anterior resection (95.8% (23/24)). Sixteen patients received a temporary ileostomy (66.7% (16/24)). Three patients suffered perioperative complications (including colonic ischaemia, rectal perforation and arterial bleeding). Five patients (21.7% (5/23)) had an anastomotic leak treated with Ta drainage in two patients. Final pathology revealed negative margins in 95.8% (23/24). TME was considered complete in 87.5% (21/24) overall and in 95% (21/22) when considering only primary cancer cases.

Conclusion

According to our cohort of selected difficult cases, Ta dissection approach helped achieve complete mesorectal excision in complex primary rectal cancer but also allowed for rectal resection in patients with previous rectal surgery. This technique also helped perform a primary anastomosis in these difficult cases.