Short-term outcomes of transanal completion total mesorectal excision (cTaTME) for rectal cancer: a case-matched analysis

Oncologic safety and technical feasibility of completion transanal total mesorectal excision after local excision; a cohort study from the International TaTME Registry

BACKGROUND

As part of an organ sparing strategy, a surgical local excision may be performed in patients with early-stage rectal cancer or following neoadjuvant (chemo)radiotherapy. In selected cases, a completion total mesorectal excision may be recommended which can be more complex because of the preceding local excision. A transanal approach to perform completion total mesorectal excision may offer an advantage through the better visualization of the surgical field in the distal rectum and less forceful retraction for exposure. However, the oncologic safety and technical feasibility of this approach have yet to be demonstrated in these patients. Therefore, the aim of this study was to evaluate the oncological and technical safety of completion transanal total mesorectal excision following a local excision in patients with rectal cancer.

METHODS

Patients from the prospective International Transanal Total Mesorectal Excision Registry who underwent a surgical local excision prior to completion transanal total mesorectal excision were retrospectively analyzed.

RESULTS

In total, 189 patients were included of which 22% received neoadjuvant radiotherapy. In 94% of the patients, a low anterior resection was performed. A primary anastomosis was constructed in 91% (n = 171/189) of the patients, with the majority also receiving a defunctioning stoma (84%, n = 144/171), of which 69% (n = 100/144) were reversed. Within 30 days, 7% developed an anastomotic leakage. The two-year local recurrence rate was 5% (n = 5/104) with an estimated rate of 3% (95% CI 0-7%). Two-year disease-free survival was 85% (n = 88/104) and overall survival was 95% (n = 99/104).

CONCLUSIONS

Transanal completion total mesorectal excision following local excision for rectal cancer is oncologically safe, with low complication rates and high restorative rates.

Salvageable locoregional recurrence and stoma rate after local excision of pT1-2 rectal cancer - A nationwide cross-sectional cohort study

BACKGROUND

Screening has increased the incidence of early-stage rectal cancer and interest in rectal-preserving treatment strategies. Although guidelines recommend completion total mesorectal excision (cTME) in the presence of histological risk factor(s) after local excision, surgery-related morbidity often deters patients from cTME. Additionally, locoregional recurrences (LR) identified during surveillance may still be salvageable. This study evaluates oncological and surgical outcomes in pT1-2 rectal cancer patients who received local excision with or without additional therapy.

METHODS

A retrospective cross-sectional national cohort study was conducted in 67 Dutch hospitals, including all patients who underwent curative surgical resection for rectal cancer in 2016. Patients with pT1-2 tumours who received surveillance, cTME or adjuvant chemoradiotherapy after local excision were selected. The primary outcome was LR. Secondary endpoints included ostomy rate, disease-free survival (DFS), and overall survival (OS).

RESULTS

Of 3057 patients, 219 underwent local excision, followed by surveillance in 74 % (n = 162), cTME in 23 % (n = 51), and adjuvant (chemo)radiation in 3 % (n = 6). Median follow-up was 46 months (IQR 29-54). Four-year LR rates were 14 % and 4 % after surveillance and cTME, respectively (p = 0.033). In the surveillance group, 16 of 20 patients (80 %) who developed LR were treated with curative intent. cTME resulted in a substantially higher ostomy rate (43 % vs 4 %, p = 0.001). No significant differences were found in 4-year DFS and OS.

CONCLUSION

Despite a LR rate of 14 % after local excision alone, the majority of these recurrences could be treated with curative intent. Additionally, the risk of stoma was 10-fold lower after surveillance compared to cTME.

TRIAL REGISTRATION

ClinicalTrials.gov, identifier: NCT05539417, https://www.

CLINICALTRIALS

gov/ct2/show/NCT05539417.

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.

Completion Total Mesorectal Excision: A Case-Matched Comparison With Primary Resection

Objectives

The aim of this study was to compare the perioperative and oncological results of completion total mesorectal excision (cTME) versus primary total mesorectal excision (pTME).

Background

Early-stage rectal cancer can be treated by local excision alone, which is associated with less surgical morbidity and improved functional outcomes compared with radical surgery. When high-risk histological features are present, cTME is indicated, with possible worse clinical and oncological outcomes compared to pTME.

Methods

This retrospective cohort study included all patients that underwent TME surgery for rectal cancer performed in 11 centers in the Netherlands between 2015 and 2017. After case-matching, we compared cTME with pTME. The primary outcome was major postoperative morbidity. Secondary outcomes included the rate of restorative procedures and 3-year oncological outcomes.

Results

In total 1069 patients were included, of which 35 underwent cTME. After matching (1:2 ratio), 29 cTME and 58 pTME were analyzed. No differences were found for major morbidity (27.6% vs 19.0%; P = 0.28) and abdominoperineal excision rate (31.0% vs 32.8%; P = 0.85) between cTME and pTME, respectively. Local recurrence (3.4% vs 8.6%; P = 0.43), systemic recurrence (3.4% vs 12.1%; P = 0.25), overall survival (93.1% vs 94.8%; P = 0.71), and disease-free survival (89.7% vs 81.0%; P = 0.43) were comparable between cTME and pTME.

Conclusions

cTME is not associated with higher major morbidity, whereas the abdominoperineal excision rate and 3-year oncological outcomes are similar compared to pTME. Local excision as a diagnostic tool followed by completion surgery for early rectal cancer does not compromise outcomes and should still be considered as the treatment of early-stage rectal cancer.

A standardized measurement instrument was recommended for evaluating operator experience in complex healthcare interventions

OBJECTIVE

During development of complex surgical innovations, modifications occur to optimize safety and efficacy. Operators' experiences (how professionals feel undertaking the innovation) drive this process but comprehensive overviews of measures of this concept are lacking. This study identified and appraised measures to assess operators' experience of surgical innovation.

STUDY DESIGN AND SETTING

There were three phases: (1) Literature reviews identified measures of operators' experience and concepts measured were extracted and grouped into domains. (2) Quality appraisal was conducted to assess content validity of identified instruments and was supported by COnsensus-based Standards for the selection of health Measurement Instruments methodology. Self-reported measurement instruments that had underdone formal development were eligible. Content validity was assessed using COnsensus-based Standards for the selection of health Measurement Instruments criteria for good content validity (rated sufficient/insufficient/indeterminate/inconsistent), informed by standards for measurement development and domains identified in phase 1. (3) Instruments determined suitable and of sufficient quality underwent supplemental appraisal in interviews with international multidisciplinary professionals and a focus group.

RESULTS

Literature reviews identified 16 measurement instruments from 243 studies. Most assessed 'psychological' experiences and 'usability'. No instrument was specifically validated for innovative surgery. Three instruments were rated 'sufficient' (Surgery Task Load Index [SURG-TLX]) or 'indeterminate' (Spielberger State-Trait Anxiety Inventory, Imperial Stress Assessment Tool). Twenty professionals were interviewed (seven female; 15 specialties; six countries) and the focus group included 10 participants (four professionals, six researchers). The SURG-TLX was considered the most relevant, comprehensive, and comprehensible instrument.

CONCLUSION

The SURG-TLX is preliminarily recommended to measure operators' experiences of innovation. Further work exploring its role and impact on surgical innovation is required.

Mesentery in Transanal TME

Oncological adequacy in rectal cancer surgery mandates not only a clear distal and circumferential resection margin but also resection of the entire ontogenetic mesorectal package. Incomplete removal of the mesentery is one of the commonest causes of local recurrences. The completeness of the resection is not only determined by tumor and patient related factors but also by the patient-tailored treatment selected by the multidisciplinary team. This is performed in the context of the technical ability and experience of the surgeon to ensure an optimal total mesorectal excision (TME). In TME, popularized by Professor Heald in the early 1980s as a sharp dissection through the avascular embryologic plane, the midline pedicle of tumor and mesorectum is separated from the surrounding, mostly paired structures of the retroperitoneum. Although TME significantly improved the oncological and functional results of rectal cancer surgery, the difficulty of the procedure is still mainly dependent on and determined by the dissection of the most distal part of the rectum and mesorectum. To overcome some of the limitations of working in the narrowest part of the pelvis, robotic and transanal surgery have been shown to improve the access and quality of resection in minimally invasive techniques. Whatever technique is chosen to perform a TME, embryologically derived planes and anatomical points of reference should be identified to guide the surgery. Standardization of the chosen technique, widespread education, and training of surgeons, as well as caseloads per surgeon, are important factors to optimize outcomes. In this article, we discuss the introduction of transanal TME, with emphasis on the mesentery, relevant anatomy, standard procedural steps, and importance of a training pathway.

Completion Total Mesorectal Excision After Transanal Local Excision of Early Rectal Cancer: A Systematic Review and Meta-analysis

BACKGROUND

Completion total mesorectal excision is recommended when local excision of early rectal cancers demonstrates high-risk histopathological features. Concerns regarding the quality of completion resections and the impact on oncological safety remain unanswered.

OBJECTIVE

This study aims to summarize and analyze the outcomes associated with completion surgery and undertake a comparative analysis with primary rectal resections.

DATA SOURCES

Data sources included PubMed, Cochrane library, MEDLINE, and Embase databases up to April 2021.

STUDY SELECTION

All studies reporting any outcome of completion surgery after transanal local excision of an early rectal cancer were selected. Case reports, studies of benign lesions, and studies using flexible endoscopic techniques were not included.

INTERVENTION

The intervention was completion total mesorectal excision after transanal local excision of early rectal cancers.

MAIN OUTCOME MEASURES

Primary outcome measures included histopathological and long-term oncological outcomes of completion total mesorectal excision. Secondary outcome measures included short-term perioperative outcomes.

RESULTS

Twenty-three studies including 646 patients met the eligibility criteria, and 8 studies were included in the meta-analyses. Patients undergoing completion surgery have longer operative times (standardized mean difference, 0.49; 95% CI, 0.23-0.75; p = 0.0002) and higher intraoperative blood loss (standardized mean difference, 0.25; 95% CI, 0.01-0.5; p = 0.04) compared with primary resections, but perioperative morbidity is comparable (risk ratio, 1.26; 95% CI, 0.98-1.62; p = 0.08). Completion surgery is associated with higher rates of incomplete mesorectal specimens (risk ratio, 3.06; 95% CI, 1.41-6.62; p = 0.005) and lower lymph node yields (standardized mean difference, -0.26; 95% CI, -0.47 to 0.06; p = 0.01). Comparative analysis on long-term outcomes is limited, but no evidence of inferior recurrence or survival rates is found.

LIMITATIONS

Only small retrospective cohort and case-control studies are published on this topic, with considerable heterogeneity limiting the effectiveness of meta-analysis.

CONCLUSIONS

This review provides the strongest evidence to date that completion surgery is associated with an inferior histopathological grade of the mesorectum and finds insufficient long-term results to satisfy concerns regarding oncological safety. International collaborative research is required to demonstrate noninferiority.

REGISTRATION NO

CRD42021245101.

Transanal total mesorectal excision for abdominoperineal resection is associated with poor oncological outcomes in rectal cancer patients: A word of caution from a multicentric Canadian cohort study

AIM

The main objective of this study was to compare the oncological outcomes of patients undergoing abdominoperineal resection (APR) versus low anterior resection (LAR) through a transanal total mesorectal excision (taTME) approach.

METHOD

A total of 360 adult patients with a diagnosis of rectal cancer were enrolled at participating centres from the Canadian taTME Expert Collaboration. Forty-three patients received taTME-APR and received 317 taTME-LAR. Demographic, operative, pathological and follow-up data were collected and merged into a single database. Results are presented as hazard ratio (HR) and 95% confidence interval. All analyses were performed in the R environment (v.3.6).

RESULTS

The proportion of patients with a positive circumferential radial margin status was higher in the taTME-APR group than the taTME-LAR group (21% vs. 9%, p = 0.001). Complete TME was achieved in 91% of those undergoing APR compared with 96% of those undergoing LAR (p = 0.25). APR was associated with a greater rate of local recurrence relative to LAR, although it was not significant [crude HR = 3.53 (95% CI 0.92-13.53)]. Circumferential margin positivity was significantly associated with a higher rate of systemic recurrence [crude HR = 3.59 (95% CI 1.38-9.3)].

CONCLUSION

Our results demonstrate inferior outcomes in those undergoing taTME-APR compared with taTME-LAR. The use of this technique for this particular indication needs to be carefully considered.

Transanal Local Excision of Rectal Cancer after Neoadjuvant Chemoradiation: Is There a Place for It or Should Be Avoided at All Costs?

Tumor response to neoadjuvant chemoradiation (nCRT) with tumor downsizing and downstaging has significantly impacted the number of patients considered to be appropriate candidates for transanal local excision (TLE). Some patients may harbor small residual lesions, restricted to the bowel wall. These patients, who exhibit major response ("near-complete") by digital rectal examination, endoscopic assessment, and radiological assessment may be considered for this approach. Although TLE is associated with minimal postoperative morbidity, a few clinical consequences and oncological outcomes must be evaluated in advance and with caution. In the setting of nCRT, a higher risk for clinically relevant wound dehiscences leading to a considerable risk for readmission for pain management has been observed. Worse anorectal function (still better than after total mesorectal excision [TME]), worsening in the quality of TME specimen, and higher rates of abdominal resections (in cases requiring completion TME) have been reported. The exuberant scar observed in the area of TLE also represents a challenging finding during follow-up of these patients. Local excision should be probably restricted for patients with primary tumors located at or below the level of the anorectal ring (magnetic resonance defined). These patients are otherwise candidates for abdominal perineal resections or ultra-low anterior resections with coloanal anastomosis frequently requiring definitive stomas or considerably poor anorectal function.

The role of transanal total mesorectal excision

At inception, transanal total mesorectal excision (TaTME) was hypothesized to be a solution for several problems encountered in pelvic surgery, particularly for distal rectal cancer. The transanal part of the procedure is less hampered by patient related factors such as visceral obesity and a narrow bony pelvis and can thus overcome access and visualization problems encountered with a pure abdominal approach. Clearly, as for any new technique, a learning curve needs to be negotiated, ideally without unacceptable harm to patients. Once in experienced hands, TaTME might overcome challenges found in anatomically challenging rectal cancer patients as well as for other indications. The role of TaTME is not to replace, but rather complement its abdominal counterpart.

Multidisciplinary management of early rectal cancer - The role of surgical local excision in current and future clinical practice

The implementation of bowel cancer screening programs has led to a rise in the incidence of early rectal cancer. The combination of increased incidence and the growing interest in organ-sparing treatment options has led to an amplified importance of local excision techniques in treatment strategies for early rectal cancer. In addition, developments in new technologies of single-port surgery have popularized surgical techniques. Although local treatment of early rectal cancer seems promising, a multidisciplinary approach is necessary and awareness of the oncological robustness is warranted to enable shared decision-making. This review illustrates the position of surgical local excision in the treatment of early rectal cancer and reflects on its role in current and future clinical practice.

Early salvage total mesorectal excision (sTME) after organ preservation failure in rectal cancer does not worsen postoperative outcomes compared to primary TME: systematic review and meta-analysis

IMPORTANCE

While oncological outcomes of early salvage total mesorectal excision (sTME) after local excision (LE) have been well studied, the impact of LE before TME on postoperative outcomes remains unclear. We aimed to compare early sTME with a primary TME for rectal cancer.

METHODS

Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines with the random-effects model were adopted using Review Manager Version 5.3 for pooled estimates.

RESULTS

We retrieved eleven relevant articles including 1728 patients (350 patients in the sTME group and 1438 patients in the TME group). There was no significant difference between the two groups in terms of mortality (OR = 0.90, 95%CI [0.21 to 3.77], p = 0.88), morbidity (OR = 1.19, 95%CI [0.59 to 2.38], p = 0.63), conversion to open surgery (OR = 1.34, 95%CI [0.61 to 2.94], p = 0.47), anastomotic leak (OR = 1.38, 95%CI [0.50 to 3.83], p = 0.53), hospital stay (MD = 0.23 day, 95%CI [- 1.63 to 2.10], p < 0.81), diverting stoma rate (OR = 0.69, 95%CI [0.44 to 1.09], p = 0.11), abdominoperineal resection rate (OR = 1.47, 95%CI [0.91 to 2.37], p = 0.11), local recurrence (OR = 0.94, 95%CI [0.44 to 2.04], p = 0.88), and distant recurrence (OR = 0.88, 95%CI [0.52 to 1.48], p = 0.62). sTME was associated with significantly longer operative time (MD = 25.62 min, 95%CI[11.92 to 39.32], p < 0.001) lower number of harvested lymph nodes (MD =  - 2.25 lymph node, 95%CI [- 3.86 to - 0.65], p = 0.006), and higher proportion of incomplete TME (OR = 0.25, 95%CI [0.11 to 0.61], p = 0.002).

CONCLUSIONS

sTME is not associated with increased postoperative morbidity, mortality, or local recurrence. However, the operative times are longer and yield a poor specimen quality.

Completion Surgery in Unfavorable Rectal Cancer after Transanal Endoscopic Microsurgery: Does It Achieve Satisfactory Sphincter Preservation, Quality of Total Mesorectal Excision Specimen, and Long-term Oncological Outcomes?

BACKGROUND

Unfavorable adenocarcinoma after transanal endoscopic microsurgery requires "completion surgery" with total mesorectal excision. The literature on this procedure is very limited.

OBJECTIVE

This study aims to assess the percentage of transanal endoscopic microsurgery that will require completion surgery.

DESIGN

This is an observational study with prospective data collection and retrospective analysis from patients who were operated on consecutively.

SETTINGS

The study was conducted at a single academic institution.

PATIENTS

Patients undergoing transanal endoscopic microsurgery from June 2004 to December 2018 who later required total mesorectal excision were included.

MAIN OUTCOME MEASURES

All the patients followed the same protocol: preoperative study, indication of transanal endoscopic microsurgery with curative intent, performance of transanal endoscopic microsurgery, and completion surgery indication 3 to 4 weeks after transanal endoscopic microsurgery.

RESULTS

Seven hundred seventy-four patients underwent transanal endoscopic microsurgery, 622 with curative intent (group I: adenoma, 517; group II: adenocarcinoma, 105). Completion surgery was indicated in 64 of 622 (10.3%) patients: group I, 40 of 517 (7.7%) and group II, 24 of 105 (22.9%). After applying exclusion criteria, completion surgery was performed in 55 patients (8.8%). Abdominoperineal resection was performed in 23 (45.1%); the initial lesion was within 6 cm of the anal verge in 19 of these 23 (82.6%). The clinical morbidity rate (Clavien Dindo> II) was 3 of 51 (5.9%). Total mesorectal excision was graded as complete in 42 of 49 (85.7%). The circumferential resection margin was tumor-free in 47 of 50 (94%). Median follow-up was 58 months. Local recurrence was recorded in 2 of 51 (3.9%) and systemic recurrence was recorded in 7 of 51 (13.7%); 5-year disease-free survival was 86%.

LIMITATIONS

The limitations are defined by the study's observational design and the retrospective analysis.

CONCLUSION

The indication of completion surgery after transanal endoscopic microsurgery is low, but is higher in the indication of adenocarcinoma. Compared with initial total mesorectal excision, completion surgery requires a higher rate of abdominoperineal resection, but has similar postoperative morbidity, total mesorectal excision quality, and oncological results. See Video Abstract at http://links.lww.com/DCR/B423.

CIRUGA COMPLEMENTARIA EN CNCER DE RECTO DESFAVORABLE DESPUS DE UNA TEM SE OBTIENE SATISFACTORIAMENTE PRESERVACIN DEL ESFNTER, CALIDAD DE MUESTRA DE ETM Y RESULTADOS ONCOLGICOS A LARGO PLAZO

ANTECEDENTES:El adenocarcinoma con evolución desfavorable luego de una de microcirugía endoscópica transanal (TEM) requiere "cirugía de finalización" con la excisión total del mesorecto. La literatura sobre este procedimiento es muy limitada.OBJETIVO:Evaluar el porcentaje de microcirugía endoscópica transanal que requerió cirugía completa.DISEÑO:Estudio observacional con recolección prospectiva de datos y análisis retrospectivo de pacientes operados consecutivamente.AJUSTES:El estudio se realizó en una sola institución académica.PACIENTES:Aquellos pacientes sometidos a microcirugía endoscópica transanal desde junio de 2004 hasta diciembre de 2018 que luego requirieron excisón toztal del mesorecto.PRINCIPALES MEDIDAS DE RESULTADO:Todos los pacientes siguieron el mismo protocolo: estudio preoperatorio, indicación de microcirugía endoscópica transanal con intención curativa, realización de microcirugía endoscópica transanal e indicación de cirugía complementaria 3-4 semanas después de la microcirugía endoscópica transanal.RESULTADOS:Setecientos setenta y cuatro pacientes fueron sometidos a microcirugía endoscópica transanal, 622 con intención curativa (grupo I, adenoma: 517, grupo II, adenocarcinoma: 105). la cirugía complementaria fué indicada en 64/622 (10.3%), grupo I: 40/517 (7.7%) y grupo II 24/105 (22.9%). Después de aplicar los criterios de exclusión, la cirugía complementaria se realizó en 55 pacientes (8,8%). La resección abdominoperineal fué realizada en 23 (45,1%); en 19 de estos casos 23 (82,6%) la lesión inicial se encontraba dentro los 6 cm del margen anal. La tasa de morbilidad clínica (Clavien-Dindo > II) fue de 3/51 (5,9%). La excisión total del mesorecto se calificó como completa en 42/49 (85,7%). El margen de resección circunferencial se encontraba libre de tumor en 47/50 (94%). La mediana de seguimiento fue de 58 meses. La recurrencia local se registró en 2/51 (3.9%) y la recurrencia sistémica en 7/51 (13.7%); La supervivencia libre de enfermedad a 5 años fue del 86%.LIMITACIONES:Todas definidas por el diseño observacional y el análisis retrospectivo del mismo.CONCLUSIÓN:La indicación de completar la cirugía después de una TEM es baja, pero es más alta cuando la indicación es por adenocarcinoma. En comparación con la excisión total del mesorecto inicial, la cirugía complementaria requiere una tasa más alta de resección abdominoperineal, pero tiene una morbilidad postoperatoria, una calidad de excisión total del mesorecto y resultados oncológicos similares. ConsulteVideo Resumen en http://links.lww.com/DCR/B423. (Traducción-Dr. Xavier Delgadillo).

Clinical outcomes of transanal total mesorectal excision using a lateral-first approach for low rectal cancer: a propensity score matching analysis

BACKGROUND

Although transanal total mesorectal excision (ta-TME) is adopted for rectal cancer surgery by an increasing number of surgeons, it is still technically challenging. We have employed a lateral-first approach for ta-TME to overcome technical difficulties. However, its outcomes and advantage over conventional laparoscopic TME remain unclear.

METHODS

Thirty-five consecutive patients who underwent ta-TME using a lateral-first approach (the ta-TME group) and 53 consecutive patients who underwent conventional laparoscopic TME (the lap-TME group) for low rectal cancer were included. Propensity score matching (PSM) was used to create balanced cohorts of ta-TME (n = 28) and lap-TME (n = 28). Their clinical outcomes were compared after PSM.

RESULTS

The operative time and intraoperative blood loss were significantly lower in the ta-TME group than in the lap-TME group (P = 0.042 and P < 0.001, respectively). Postoperative complications ≥ Clavien-Dindo grade II were significantly less and postoperative hospital stay was significantly shorter in the ta-TME group (35.7% vs. 78.6%, P = 0.003, and 18 days vs. 32 days, P < 0.001, respectively). The distal margin was significantly larger in the ta-TME when excluding the abdominoperineal resection cases (20 mm vs. 10 mm, P = 0.032). The positive radial margin was observed in 2 of 28 patients (7.1%) in the ta-TME group.

CONCLUSIONS

Ta-TME using a lateral-first approach is feasible and may offer several advantages over lap-TME in terms of short-term outcomes. It might be an alternative safe approach for ta-TME. To confirm the oncological superiority of this surgery, further study in a larger population and for a longer follow-up period is warranted.

Outcomes of completion total mesorectal excision are not compromised by prior transanal minimally invasive surgery

AIM

Transanal minimally invasive surgery (TAMIS) is used increasingly often as an organ-preserving treatment for early rectal cancer. If final pathology reveals unfavourable histological prognostic features, completion total mesorectal excision (cTME) is recommended. This study is the first to investigate the results of cTME after TAMIS.

METHOD

Data were retrieved from the prospective database of the Elisabeth-TweeSteden Hospital. Completion TME patients were case matched with a control group of patients undergoing primary TME (pTME). Primary and secondary outcomes were surgical outcomes and oncological outcomes, respectively.

RESULTS

From 2011 to 2017, 20 patients underwent cTME and were compared with 40 patients undergoing pTME. There were no significant differences in operating time (238 min vs 226 min, P = 0.53), blood loss (137 ml vs. 158 ml, P = 0.88) or complications (45% vs 55%, P = 0.07) between both groups. There was no 90-day mortality in the cTME group. The mesorectal fascia was incomplete in three patients (15%) in the cTME group compared with no breaches in the pTME group (P = 0.083). There were no local recurrences in either group. In three patients (15%), distant metastases were detected after cTME compared with one patient (2.5%) in the pTME group (P = 0.069). After cTME patients had a 1- and 5-year disease-free survival of 85% compared with 97.5% for the pTME group (P = 0.062).

CONCLUSION

Completion TME surgery after TAMIS is not associated with increased peri- or postoperative morbidity or mortality compared with pTME surgery. After cTME surgery patients have a similar disease-free and overall survival when compared with patients undergoing pTME.

Total mesorectal excision for low and middle rectal cancer: laparoscopic versus transanal approach-a meta-analysis

BACKGROUND

Transanal total mesorectal excision (TaTME) appeared to be a challenging alternative to Laparoscopic Total Mesorectal Excision (LaTME) for low and middle rectal cancer. However, evidence remains low on the possible benefits of TaTME. The aim of this study was to perform a meta-analysis of comparative studies between TaTME and LaTME.

METHODS

A systematic review and meta-analysis based on Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) guidelines was conducted on Medline, Embase, and Cochrane database. The following outcomes were assessed: conversion, operative time, morbidity, length of stay, readmission rate, and pathological and oncological results.

RESULTS

After review of 756 identified records, 14 studies were included (case-matched control n = 10, prospective cohort n = 3, retrospective study n = 1) comparing 495 TaTME and 547 LaTME. No randomized trial was available. Following criteria were significantly improved after TaTME vs. LaTME: readmission's rate (9% after TaTME vs. 18% after LaTME, OR 0.44, 95%CI 0.26-0.74, p = 0.002), length of stay (OR - 2.17, 95%CI - 3.68 to - 0.66, p = 0.005), overall morbidity (34 vs. 41%, OR 0.65, 95%CI 0.46-0.91, p = 0.001), major morbidity (8.7 vs. 14%, OR 0.53, 95%CI 0.34-0.83, p = 0.005), anastomotic leak (6.4 vs. 11.6%, OR 0.53, 95%CI 0.31-0.93, p = 0.03), and circumferential resection margin (CRM) involvement (4 vs. 8.8%, OR 0.48, 95%CI 0.27-0.86, p = 0.01). No significant differences were observed between TaTME and LaTME regarding conversion's rate (3.2 vs. 8.8%, p = 0.09), operative time (OR - 10.73, p = 0.26), intraoperative complications (8.1 vs. 6.3%, p = 0.48), minor morbidity (27.9 vs. 29.6%, p = 0.27), positive distal resection margin (1.4 vs. 1.4%, p = 0.93), complete TME (75 vs. 75%, p = 0.74), harvested lymph nodes (OR 0.38, p = 0.44), and local recurrence rate (3.5 vs. 2.2%, p = 0.64).

CONCLUSION

This meta-analysis based on nonrandomized studies suggests that TaTME seems better than LaTME in terms of overall and major morbidities, anastomotic leak, readmission rate, CRM involvement, and length of stay. These results need to be confirmed by randomized controlled trial.

Rectal cancer treatment by transanal total mesorectal excision: Results in 100 consecutive patients

INTRODUCTION

The aim of this study is to describe and evaluate our clinical short-term surgical results of laparoscopic transanal total mesorectal excision.

METHODS

Analysis of 100 consecutive patients with mid and lower rectal cancer who underwent transanal total mesorectal excision from November 2013 to September 2018. Main outcomes described are operative data, morbidities, mortality and quality of the specimen. A comparative analysis was done between gender and simultaneous vs. non simultaneous abdominal-perineal surgery.

RESULTS

Mean patient age was 67 years (56-75), and 67% were male. On MRI, 50% were stage T3 tumors, and 52% had positive nodes. Mean distance of the tumor from anal verge was 4.9±1.3cm. A total of 58% underwent neoadjuvant treatment. Mean operative time was 262±40.7min; it was shorter in females (P<.001) and in simultaneous 2-field surgery. Median specimen distal free margin was 1.5cm (0.5-2.4). A total of 89% of the specimens were with complete mesorectum, with better results when a simultaneous approach was used (P=.047). The mean number of retrieved lymph-nodes was 15.2±11.6, and 26% of patients had positive nodes. Median length of stay was 5.5 days (4-8). Morbidities occurred in 36% of cases, and one patient died.

CONCLUSIONS

According to our experience, laparoscopic transanal total mesorectal excision is safe and effective with adequate circumferential and distal free margins and high quality of the resected mesorectum specimen. Post-operative morbidity is acceptable, according to the current literature.

The Effectiveness of Contralateral Drainage in Reducing Superficial Incisional Surgical Site Infection in Loop Ileostomy Closure: Prospective, Randomized Controlled Trial

BACKGROUND

Loop ileostomy reduces the rates of morbidity due to colorectal anastomotic dehiscence. For its part, ileostomy closure is associated with low mortality (0-4%) but substantial morbidity (11-37%). Incisional surgical site infection (SSI) is one of the most frequent complications (2-40%).

METHODS

A single-center, prospective, randomized controlled clinical trial of two study groups: control (conventional primary skin closure) and experimental (primary skin closure with a contralateral Penrose^® drain).

RESULTS

Seventy patients undergoing loop ileostomy closure between April 2013 and June 2017 were included (35 per branch). Four were later removed from the study. Six of the remaining 66 patients (per protocol analysis) were diagnosed with incisional SSI (9.1%); there were no statistically significant differences between the two groups (control group: 9.7%; experimental group: 8.6%) or between the risk factors associated with incisional SSI. Rates of overall and relevant morbidity (Clavien ≥ III) were considerable (28.1% and 9.1%, respectively), and there were no statistically significant differences between the two groups. No patients died.

CONCLUSION

Contralateral drainage does not significantly affect the results of primary ileostomy closure. The rate of incisional SSI was similar in the drainage and non-drainage groups, and the overall rate of 9.1% was in the low range of those reported in the literature. The absence of mortality (0%) and the non-negligible rates of overall and relevant morbidity (28.1% and 9.1%, respectively) in our series suggest that loop ileostomy is a safe procedure. However, the bowel reconstruction involves risks that must be borne in mind.

CLINICAL TRIAL REGISTRATION

The study was registered and approved by the clinical research ethics committee of the study center (reference number 2012076). Clinical trial was registered in ClinicalTrial.gov (identification number NCT02574702 and reference: ILEOS-ISS_2013).

Comparison of Short-Term Clinical and Pathological Outcomes after Transanal versus Laparoscopic Total Mesorectal Excision for Low Anterior Rectal Resection Due to Rectal Cancer: A Systematic Review with Meta-Analysis

Background: Transanal total mesorectal excision (TaTME) is a new technique that is designed to overcome the limits of the open and laparoscopic approach for rectal resections. Objective: This study is designed to compare TaTME with standard laparoscopic TME (LaTME). Methods: We searched Medline, Embase, and Scopus databases covering a up to October 2018. Inclusion criteria for study enrolment: (1) study comparing laparoscopic resection of rectal cancer vs. TaTME for rectal malignancy, (2) reporting of overall morbidity, operative time, or major complications. Results: Eleven non-randomized studies were eligible with a total of 778 patients. We found statistical significant differences in regard to major complications in favour of TaTME (RR = 0.55; 95% CI 0.31–0.97; p = 0.04). We did not found significant differences regarding overall complications intraoperative adverse effects, operative time, anastomotic leakage, intra-abdominal abscess occurrence, Surgical Site Infection, reoperations, Length of stay, completeness of mesorectal excision, R0 resection rate, number of harvested lymph nodes, circumferential resection margin, and distal resection margin. Conclusions: This meta-analysis shows benefits of TaTME technique regarding major postoperative complications. Regarding clinicopathological features transanal approach is not superior to LaTME. Currently, the quality of the evidence on benefits of TaTME is low due to lack of randomized controlled trials, which needs to be taken into consideration in further evaluation of the technique. Further evaluation of TaTME require conducting large randomized control trials.