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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION

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

Transanal total mesorectal excision: short- and long-term results of four certified colorectal cancer centers in Germany

BACKGROUND

Transanal total mesorectal excision (TaTME), a novel approach for treating low rectal cancer, holds promise. However, concerns exist in certain countries about their oncologic safety due to less-than-optimal outcomes on global studies. This research seeks to evaluate the long-term oncologic outcomes focusing on local recurrence rate and overall survival after TaTME surgery in Germany.

PATIENTS AND METHODS

This study analyzed data from patients who underwent elective TaTME surgery between 2014 and 2021 in four certified colorectal cancer centers in Germany. Primary endpoints were 3-year local recurrence rate and local recurrence-free survival (LRFS). Secondary outcomes encompassed overall survival (OS), operative time, completeness of local tumor resection, lymph node resection, and postoperative complications.

RESULTS

A total of 378 patients were analyzed (mean age 61.6 years; 272 males, 72%). After a median follow-up period of 2.5 years, 326 patients with UICC-stages I-III and tumor operability included in survival analyses. Local recurrence was observed in 8 individuals, leading to a 3-year cumulative local recurrence rate of 2.2% and a 3-year LRFS rate of 88.1%. The 3-year OS rate stood at 88.9%. Within 30 days after surgery, anastomotic leakage occurred in 19 cases (5%), whereas a presacral abscess was present in 12 patients (3.2%).

CONCLUSION

TaTME proves effective in addressing the anatomical and technical challenges of low rectal surgery and is associated with pleasing short- and long-term results. However, its safe integration into surgical routine necessitates sufficient knowledge and a previously completed training program.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

This was a prospective cohort study.

SETTINGS

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

PATIENTS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

LIMITATIONS

This single-center study had a small sample size.

CONCLUSIONS

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

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

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

Essential knowledge and technical tips for total mesorectal excision and related procedures for rectal cancer

Total mesorectal excision (TME) has greatly improved rectal cancer surgery outcomes by reducing local recurrence and enhancing patient survival. This review outlines essential knowledge and techniques for performing TME. TME emphasizes the complete resection of the mesorectum along embryologic planes to minimize recurrence. Key anatomical insights include understanding the rectal proper fascia, Denonvilliers fascia, rectosacral fascia, and the pelvic autonomic nerves. Technical tips cover a step-by-step approach to pelvic dissection, the Gate approach, and tailored excision of Denonvilliers fascia, focusing on preserving pelvic autonomic nerves and ensuring negative circumferential resection margins. In Korea, TME has led to significant improvements in local recurrence rates and survival with well-adopted multidisciplinary approaches. Surgical techniques of TME have been optimized and standardized over several decades in Korea, and minimally invasive surgery for TME has been rapidly and successfully adopted. The review emphasizes the need for continuous research on tumor biology and precise surgical techniques to further improve rectal cancer management. The ultimate goal of TME is to achieve curative resection and function preservation, thereby enhancing the patient's quality of life. Accurate TME, multidisciplinary-based neoadjuvant therapy, refined sphincter-preserving techniques, and ongoing tumor research are essential for optimal treatment outcomes.

Treatment Options for Distal Rectal Cancer in the Era of Organ Preservation

OPINION STATEMENT

The introduction of total mesorectal excision into the radical surgery of rectal cancer has significantly improved the oncological outcome with longer survival and lower local recurrence. Traditional treatment modalities of distal rectal cancer, relying on radical surgery, while effective, take their own set of risks, including surgical complications, potential damage to the anus, and surrounding structure owing to the pursuit of thorough resection. The progress of operating methods as well as the integration of systemic therapies and radiotherapy into the peri-operative period, particularly the exciting clinical complete response of patients after neoadjuvant treatment, have paved the way for organ preservation strategy. The non-inferiority oncological outcome of "watch and wait" compared with radical surgery underscores the potential of organ preservation not only to control local recurrence but also to reduce the need for treatments followed by structure destruction, hopefully improving the long-term quality of life. Radical radiotherapy provides another treatment option for patients unwilling or unable to undergo surgery. Organ preservation points out the direction of treatment for distal rectal cancer, while additional researches are needed to answer remaining questions about its optimal use.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Transanal Total Mesorectal Excision for Rectal Cancer

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

What Is the Comparative Efficacy of Surgical, Endoscopic, Transanal Resection, and Radiotherapy Modalities in the Treatment of Rectal Cancer?

BACKGROUND

Rectal cancer is a significant healthcare burden, and effective treatment is crucial. This research aims to compare the effectiveness of surgical and endoscopic resection, transanal resection, and radiotherapy.

METHODS

A literature analysis was conducted in order to identify relevant studies, by comparing the different surgical approaches and variables affecting treatment decisions. The findings were analyzed and synthesized to provide a comprehensive overview.

RESULTS

Surgical treatment, particularly TME (total mesorectal excision), proved consistent efficacy in achieving complete tumor resection and improving long-term survival. Endoscopic treatment and transanal resection techniques were promising for early-stage tumors but were associated with higher local recurrence rates. Radiotherapy, especially in combination with chemotherapy, played a crucial role in locally advanced cases, improving local control and reducing recurrence risk. Patient data, tumor characteristics, and healthcare system factors were identified as important factors in treatment modality selection.

CONCLUSION

Surgical treatment, specifically TME, remains the recommended standard approach for rectal cancer, providing excellent oncological outcomes. Endoscopic treatment and transanal resection techniques can be considered for selected early-stage cases, while radiotherapy is beneficial for locally advanced tumors. Treatment decisions should be personalized based on patient and tumor characteristics, considering the available resources and expertise within the healthcare system.

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.

The endorectal incision level of transanal total mesorectal excision (taTME): An emphasis on the distance from the anterior vs. posterior mesorectal ends to the anal verge

BACKGROUND

There is no intraluminal guidance to ensure complete inclusion of the mesorectum in transanal total mesorectal excision (taTME). This study aimed to assess the distance difference between the anterior and posterior mesorectal terminal ends and the anal verge as a potential risk for residual mesorectum after resection.

METHODS

Forty-four surgical specimens of extra-levator abdominoperineal excision (ELAPE) and 28 mid-sagittal cadaveric specimens were included to this study. The distance between the mesorectum terminal end (T) and the endoluminal landmarks (dentate line (D)/anal verge (A)) was measured and compared between men and women. Furthermore, 66 MRI images from The Cancer Imaging Archive (TCIA) were used to validate the same concept in a non-Asian population.

RESULTS

The mesorectal terminal end was found to be aligned along with the levator hiatus. From the midsagittal view, the ELAPE specimens showed that the distance between T and A anteriorly was significantly longer than the same distance posteriorly (34.74±7.79mm vs 23.74±4.24mm, P<0.001). Similarly, the distance measured in the cadaveric specimens was significantly longer anteriorly than posteriorly (P<0.001). The validation cohort of non-Asian MRI image has confirmed the same (56.68±14.17mm vs. 38.18 ±10.42mm, P<0.001(. There was no significant difference between men and women.

CONCLUSIONS

Because of the remarkable distance difference between the anterior and posterior mesorectal terminal ends away from the anal verge, the taTME proctectomy level may not meet the required mesorectal end. Thus, if TME is planned, aligning the proctectomy level around the levator hiatus would be the best place that can ensure complete TME.

Feasibility and safety of robotic surgery for low rectal cancer combined with transanal total mesorectal excision

PURPOSE

Laparoscopic surgery for low rectal cancer is often challenging. Transanal total mesorectal excision (TaTME) and robotic surgery have been introduced to overcome the technical difficulties in laparoscopic surgery and achieve more favorable outcomes. Hybrid robotic surgery, which combines TaTME with the abdominal robotic approach, incorporates the advantages of each of these surgical techniques and might achieve less invasive and safer surgery. This study evaluated the safety and feasibility of hybrid robotic surgery with TaTME (hybrid TaTME).

METHODS

We retrospectively reviewed 162 TaTME cases performed at our department from September 2016 to May 2022. Among them, 92 cases of conventional TaTME and 30 of hybrid TaTME were eligible. We used propensity score matching analysis (PSM) to adjust for patients' characteristics and compared the short-term outcomes of the two treatment groups.

RESULTS

Twenty-seven cases in each group were extracted using PSM. The operation time in hybrid TaTME was comparable to that in conventional TaTME. There was no significant difference in the postoperative hospital stay between the two groups. Other intra- and post-operative outcomes were also comparable between the two groups. Furthermore, no significant differences were observed between the two groups in the curative resection and recurrence rates.

CONCLUSION

Hybrid TaTME for low rectal cancer was as favorable as conventional TaTME in producing satisfactory short-term outcomes. However, furthermore, larger-scale studies conducted over longer study periods are needed to evaluate the validity of the findings.

Automatic purse-string suture skill assessment in transanal total mesorectal excision using deep learning-based video analysis

BACKGROUND

Purse-string suture in transanal total mesorectal excision is a key procedural step. The aims of this study were to develop an automatic skill assessment system for purse-string suture in transanal total mesorectal excision using deep learning and to evaluate the reliability of the score output from the proposed system.

METHODS

Purse-string suturing extracted from consecutive transanal total mesorectal excision videos was manually scored using a performance rubric scale and computed into a deep learning model as training data. Deep learning-based image regression analysis was performed, and the purse-string suture skill scores predicted by the trained deep learning model (artificial intelligence score) were output as continuous variables. The outcomes of interest were the correlation, assessed using Spearman's rank correlation coefficient, between the artificial intelligence score and the manual score, purse-string suture time, and surgeon's experience.

RESULTS

Forty-five videos obtained from five surgeons were evaluated. The mean(s.d.) total manual score was 9.2(2.7) points, the mean(s.d.) total artificial intelligence score was 10.2(3.9) points, and the mean(s.d.) absolute error between the artificial intelligence and manual scores was 0.42(0.39). Further, the artificial intelligence score significantly correlated with the purse-string suture time (correlation coefficient = -0.728) and surgeon's experience (P< 0.001).

CONCLUSION

An automatic purse-string suture skill assessment system using deep learning-based video analysis was shown to be feasible, and the results indicated that the artificial intelligence score was reliable. This application could be expanded to other endoscopic surgeries and procedures.

Meta-analysis of transanal vs laparoscopic total mesorectal excision of low rectal cancer: Importance of appropriate patient selection

BACKGROUND

Achieving a clear resection margins for low rectal cancer is technically challenging. Transanal approach to total mesorectal excision (TME) was introduced in order to address the challenges associated with the laparoscopic approach in treating low rectal cancers. However, previous meta-analyses have included mixed population with mid and low rectal tumours when comparing both approaches which has made the interpretation of the real differences between two approaches in treating low rectal cancer difficult.

AIM

To investigate the outcomes of transanal TME (TaTME) and laparoscopic TME (LaTME) in patients with low rectal cancer.

METHODS

A comprehensive systematic review of comparative studies was performed in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards. Intraoperative and postoperative complications, anastomotic leak, R0 resection, completeness of mesorectal excision, circumferential resection margin (CRM), distal resection margin (DRM), harvested lymph nodes, and operation time were the investigated outcome measures.

RESULTS

We included twelve comparative studies enrolling 969 patients comparing TaTME (n = 969) and LaTME (n = 476) in patients with low rectal tumours. TaTME was associated with significantly lower risk of postoperative complications (OR: 0.74, P = 0.04), anastomotic leak (OR: 0.59, P = 0.02), and conversion to an open procedure (OR: 0.29, P = 0.002) in comparison with LaTME. Moreover, the rate of R0 resection was significantly higher in the TaTME group (OR: 1.96, P = 0.03). Nevertheless, TaTME and LaTME were comparable in terms of rate of intraoperative complications (OR: 1.87; P = 0.23), completeness of mesoractal excision (OR: 1.57, P = 0.15), harvested lymph nodes (MD: -0.05, P = 0.96), DRM (MD: -0.94; P = 0.17), CRM (MD: 1.08, P = 0.17), positive CRM (OR: 0.64, P = 0.11) and procedure time (MD: -6.99 min, P = 0.45).

CONCLUSION

Our findings indicated that for low rectal tumours, TaTME is associated with better clinical and short term oncological outcomes compared to LaTME. More randomised controlled trials are required to confirm these findings and to evaluate long term oncological and functional outcomes.

Laparoscopic intersphincteric resection vs. transanal total mesorectal excision in overweight patients with low rectal cancer

Objective

Anus-preserving surgery in overweight patients with low rectal cancer has been a challenge due to the narrow operating space. Intersphincteric resection (ISR) was once a standard therapeutic option for low rectal cancer. The effectiveness of transanal total mesorectal excision (taTME) in treating this group of patients remains uncertain as a new surgical strategy. The aim of this study was to evaluate the short-term effects of taTME with ISR in overweight patients with low rectal cancer.

Methods

A total of 53 patients with low rectal cancer were treated with taTME in 31 cases and ISR in 22 cases. The surgery-related data, pathological manifestations of surgical specimens, postoperative recovery, and postoperative complications were compared.

Results

Patients in both groups completed the surgery successfully. There were no significant differences in operative time, blood loss, anastomotic distance from the anal verge and ileostomy between the two groups (P > 0.05). TaTME group performed or virtually finished resection of the rectal mesentery, and no positive cases of Circumferential Resection Margin (CRM) or Distal Resection Margin (DRM) were detected in either group. The number of lymph nodes found in surgical specimens did not change significantly between the two groups (P = 0.391). In the subgroup analysis, however, more lymph nodes were detected in female patients undergoing taTME than in male patients (P = 0.028). The ISR group took less time to remove the drainage tubes (P = 0.013) and the same results were obtained in both groups of male patients in the subgroup analysis (P = 0.011). There were no statistically significant differences in time to start liquid diet, time to remove catheters, time to start flatus, time to begin ambulation, postoperative hospital stay, and readmission within 30 days after surgery between the two groups (P > 0.05). However, female patients in the taTME group were initiated ambulation earlier than males in the subgroup analysis (P = 0.034). The difference was insignificant in the occurrence of postoperative complications between the two groups (P > 0.05).

Conclusion

taTME is safe and feasible for the treatment of overweight patients with low rectal cancer.

Comparison between robotic-assisted and laparoscopic sphincter-preserving operations for ultra-low rectal cancer

Aim

Sphincter-preserving operations for ultra-low rectal cancer include low anterior and intersphincteric resection. In low anterior resection, the distal rectum is divided by a transabdominal approach, which is technically demanding. In intersphincteric resection, a perineal approach is used. We aimed to evaluate whether robotic-assisted surgery is technically superior to laparoscopic surgery for ultra-low rectal cancer. We compared the frequency of low anterior resection in cases of sphincter-preserving operations.

Method

We investigated 183 patients who underwent sphincter-preserving robotic-assisted or laparoscopic surgery for ultra-low rectal cancer (lower border within 5 cm of the anal verge) between April 2010 and March 2020. The frequency of low anterior resection was compared between laparoscopic and robotic-assisted surgeries. The clinicopathological factors associated with an increase in performing low anterior resection were analyzed by multivariate analyses.

Results

Overall, 41 (22.4%) and 142 (77.6%) patients underwent laparoscopic and robotic-assisted surgery, respectively. Patient characteristics were similar between the groups. Low anterior resection was done significantly more frequently in robotic-assisted surgery (67.6%) than in laparoscopic surgery (48.8%) (P = 0.04). Multivariate analyses showed that tumor distance from the anal verge (P < 0.01) and robotic-assisted surgery (P = 0.02) were significantly associated with an increase in the performance of low anterior resection. The rate of postoperative complications or pathological results was similar between the groups.

Conclusion

Compared with laparoscopic surgery, robotic-assisted surgery significantly increased the frequency of low anterior resection in sphincter-preserving operations for ultra-low rectal cancer. Robotic-assisted surgery has technical superiority over laparoscopic surgery for ultra-low rectal cancer treatment.

Quality of life and functional outcomes after transanal total mesorectal excision for rectal cancer-results from the implementation period in Denmark

BACKGROUND

The standard operation for mid- and low rectal cancer total mesorectal excision (TME) is routinely performed as minimally invasive surgery. TME is associated with temporary or permanent functional impairment of pelvic organs, causing reduced quality of life (QoL). Concerns have been raised that the newest minimally invasive approach, transanal TME (TaTME), may further reduce urogenital and anorectal functions.

OBJECTIVE

To determine if functional outcomes affecting QoL are altered after TaTME. Primary end-point is the impact of TaTME on QoL and functional outcomes. Secondary end-point is assessing differences in QoL and functional outcomes after TME surgery from below (TaTME) or above (transabdominal TME).

DESIGN, SETTING, AND PARTICIPANTS

Observational study consisting of prospectively registered self-reported questionnaire data collected at baseline and follow-ups after TaTME. All patients who underwent TaTME during the Danish national implementation phase were included. Central surveillance of the implementation included questionnaires concerning QoL and functional outcomes. Analyses of functional results from the Danish cohort of the ROLARR trial (Jayne et al. in JAMA 318:1569-1580, (2017) are reported separately for perspective, representing the transabdominal approach to TME, i.e., laparoscopic- or robotic-assisted TME (LaTME/RoTME). Applied questionnaires include EORTC QLQ-C30, SF-36, LARS, ICIQ-MLUTS, ICIQ-FLUTS, IPSS, IIEF, SVQ, and FSFI.

RESULTS

A total of 115 TaTME procedures were registered August 2016 to April 2019. LaTME/RoTME patients (n = 92) were operated on January 2011 to September 2014. A temporary postoperative decrease of QoL (global health status and functional scales) was observed, yet long-term results were unaffected by surgery in both groups. In TaTME patients, the anorectal dysfunction increased significantly (p < 0.001) from preoperative baseline to 13.5 months follow-up, where 67.5% (n = 52) reported major LARS symptoms. Urinary function was not significantly impaired after TME regardless of technique. The paucity of responses concerning sexual function precludes conclusions.

CONCLUSIONS

Although an initial reduction in QoL after TME occurs, it normalizes within the first year postoperatively. In concurrence with international results, we found that significant anorectal dysfunction is common after TaTME. No data on anorectal function was available for LaTME/RoTME patients for comparison. We found no indications that transanal TME is inferior to transabdominal TME surgery concerning urogenital functions or health-related QoL.

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.

Development and evaluation of a virtual knowledge assessment tool for transanal total mesorectal excision

BACKGROUND

Transanal total mesorectal excision (TATME) is difficult to learn and can result in serious complications. Current paradigms for assessing performance and competency may be insufficient. This study aims to develop and provide preliminary validity evidence for a TATME virtual assessment tool (TATME-VAT) to assess the cognitive skills necessary to safely complete TATME dissection.

METHODS

Participants from North America, Europe, Japan and China completed the test via an interactive online platform between 11/2019 and 05/2020. They were grouped into expert, experienced and novice surgeons depending on the number of independently performed TATMEs. TATME-VAT is a 24-item web-based assessment evaluating advanced cognitive skills, designed according to a blueprint from consensus guidelines. Eight items were multiple choice questions. Sixteen items required making annotations on still frames of TATME videos (VCT) and were scored using a validated algorithm derived from experts' responses. Annotation (range 0-100), multiple choice (range 0-100), and overall scores (sum of annotation and multiple-choice scores, normalized to μ = 50 and σ = 10) were reported.

RESULTS

There were significant differences between the expert, experienced, and novice groups for the annotation (p < 0.001), multiple-choice (p < 0.001), and overall scores (p < 0.001). The annotation (p = 0.439) and overall (p = 0.152) scores were similar between the experienced and novice groups. Annotation scores were higher in participants with 51 or more vs. 30-50 vs. less than 30 cases. Scores were also lower in users with a self-reported recent complication vs. those without.

CONCLUSIONS

This study describes the development of an interactive video-based virtual assessment tool for TATME dissection and provides initial validity evidence for its use.

Trends in General Surgery Resident Experience with Colorectal Surgery: An Analysis of the Accreditation Council for Graduate Medical Education Case Logs

OBJECTIVE

Colorectal surgery is a core component of general surgery. The volume of colorectal surgery performed by general surgery residents throughout training has not been studied. This study aims to analyze trends observed in colorectal-specific case numbers logged by general surgery residents over 16 years.

DESIGN

Case number data for general surgery residents was extracted from the publicly available, annually published Accreditation Council for Graduate Medical Education (ACGME) database from 2003 to 2019. Cases were categorized as open or laparoscopic colectomy/proctectomy, colectomy with ileoanal pull-thru, abdomino-perineal resection (APR), transanal rectal tumor excision (TRE), anorectal procedure, colonoscopy, and total colorectal cases. The average case numbers per category was calculated for each year. Linear regression analyzed trends in case categories for all residents and those logged as surgeon chief and junior residents.

SETTING

ACGME accredited general surgery residency programs.

PARTICIPANTS

Not applicable.

RESULTS

General surgery residents reported increased numbers of all, chief, and junior resident colorectal cases over the study period (124.5-173.7 cases/yr; 38.4-53.0 cases/yr; 86.4-120.6 cases/yr, all p = 0.00). Average cases for all, chief, and junior residents have increased for laparoscopic colectomy/proctectomy (4.6-26.4 cases/year; 2.7-12.9 cases/year; 2.0-13.5 cases/year, all p = 0.00), anorectal surgeries (26.7-37.7 cases/year; 5.4-9.9 cases/year; 21.3-27.8 cases/year, all p = 0.00), and colonoscopies (35.9-70.6 cases/year, p = 0.00; 6.6-14.1 cases/year, p = 0.01; 29.4-56.5 cases/year, p = 0.00). Average cases for all, chief, and junior residents have decreased for open colectomy/proctectomy (52.0-34.9 cases/year; 21.2-14.3 cases/year; 30.9-20.6 cases/year, all p = 0.00), APR (3.3-2.7 cases/year, p = 0.00; 1.8-1.3 cases/year, p = 0.00; 1.5-1.4 cases/year, p = 0.02), TRE (1.9-1.1 cases/year; 0.7-0.4 cases/year; 1.2-0.6 cases/year, all p = 0.00). Ileoanal pull-thru did not demonstrate a linear trend.

CONCLUSIONS

The increase in exposure to colectomies/proctectomies, anorectal procedures and colonoscopies is encouraging, as these common colorectal operations will be encountered in general surgery practice. The observed low case numbers for TRE, APR, and ileoanal pull-thru suggest a need for specialized training.

Limitations and Concerns with Transanal Total Mesorectal Excision for Rectal Cancer

Transanal total mesorectal excision (TaTME) was developed to overcome the technical challenges of a minimally invasive (ultra-) low anterior resection. This new technique has recently come under careful scrutiny as technical pitfalls were reported, in specific relation to the transanal approach. Patients are at risk for urologic lesions. Moreover, carbon dioxide embolism is a rare but potentially life-threatening complication. The benefit of TaTME from an oncological point of view has neither been clarified. Hypothetically, better visualization of the lower rectum could lead to better dissection and total mesorectal excision (TME) specimens, resulting in better oncologic results. Up until now, retrospective multicenter reports seem to show that short-term oncologic results are not inferior after TaTME as compared with after laparoscopic TME. Alarming reports have however been published from Norway suggesting a high incidence and particular multifocal pattern of early local recurrence. In this article, a balanced overview is given of the most important technical pitfalls and oncological concerns arising with this new procedure.

[Minimum case volume regulations in surgery from the perspective of the specialist society (DGCH) : Balancing act between science, politics, treatment reality and a range of other aspects]

Die wissenschaftlich begründete, fachchirurgische Diskussion um die gesetzliche Vorgabe von Mindesteingriffszahlen für diverse Organsysteme und ausgewählte operative Maßnahmen als Basis einer Qualitätssicherung und Versorgungsoptimierung ist nicht neu. Hierzu liegen umfangreiche und auch belastbare Daten aus nationalen und internationalen Studien für die kolorektale Chirurgie, die Pankreaschirurgie, die Ösophaguschirurgie, die Leberchirurgie und die Magenchirurgie vor. Jüngst hat die Anhebung der Mindestmenge für komplexe Eingriffe am Ösophagus durch den Gemeinsamen Bundesausschuss (G-BA) von 10 auf 26 pro Klinik und Jahr die Debatte um dieses Thema, aber auch die Debatte über die Zentralisierung im Gesundheitswesen im Generellen neu aufgerollt. Die Anhebung erscheint aus Sicht der politischen Gremien wissenschaftlich gut begründet und in der praktischen Umsetzung realisierbar. Aus Sicht der tagtäglich mit den entsprechenden hochkomplexen Entitäten vertrauten Ärzten ergibt sich allerdings eine sehr viel breitere Diskussionsgrundlage, welche nur partiell durch ein Gutachten des Instituts für Qualität und Wirtschaftlichkeit im Gesundheitswesen (IQWiG) als Grundlage des G‑BA-Beschlusses abgedeckt wird. Für die wissenschaftlich orientierte chirurgische Fachgesellschaft steht dabei in erster Linie die wissenschaftliche Evidenz als Handlungsmaxime im Vordergrund. Gleichwohl können und dürfen Aspekte der Versorgungsrealität nicht ausgeblendet werden. Die Empfehlungen der Fachgesellschaft müssen sich somit neben der Ergebnisqualität auch an der praktischen Realisierbarkeit orientieren. Darüber hinaus sind Fragen der Weiterbildung, das Recht des Patienten auf freie Arztwahl sowie auch der Erhalt der Attraktivität des Berufsbildes Chirurg immanente Themen der chirurgischen Fachgesellschaft.

Transanal total mesorectal excision: short- and long-term results of the first hundred cases of a certified colorectal cancer center in Germany

BACKGROUND

Since 2010, laparoscopic transanal total mesorectal excision (TaTME) has been increasingly used for low and very low rectal cancer. It is supposed to improve visibility and access to the dissection planes in the pelvis. This study reports on short- and long-term outcomes of the first 100 consecutive patients treated with TaTME in a certified German colorectal cancer center.

PATIENTS AND METHODS

Data were derived from digital patient files and official cancer registry reports for patients with TaTME tumor surgery between July 2014 and January 2020. The primary outcome was the 3-year local recurrence rate and local recurrence-free survival (LRFS). Secondary endpoints included overall survival (OAS), disease-free survival (DFS), operation time, completeness of local tumor resection, lymph node resection, and postoperative complications. The Kaplan-Meier method was employed for the survival analyses; competing risks were considered in the time-to-event analysis.

RESULTS

During the observation period, the average annual operation time decreased from 272 to 178 min. Complete local tumor resection was achieved in 97% of the procedures. Major postoperative complications (Clavien-Dindo 3-4) occurred in 11% of the cases. At a median follow-up time of 2.7 years, three patients had suffered from a local recurrence. Considering competing risks, this corresponds to a 3-year cumulative incidence rate for local recurrence of 2.2% and a 3-year LRFS of 81.9%. 3-year OAS was 82.9%, and 3-year DFS was 75.7%.

CONCLUSION

TaTME is associated with favorable short and long-term outcomes. Since it is technically demanding, structured training programs and more research on the topic are indispensable.

Transanal Total Mesorectal Excision for Malignant Rectal Lesion: A Prospective Cohort Study

AIMS: The main outcome of this study was to use the transanal total mesorectal excision (TaTME) technique for rectal cancer resection and to assess as a primary endpoint the short-term oncological outcome; in terms of circumferential resection margin, longitudinal resection margins (proximally and distally), and lymph nodes (LN) retrieval, while secondary endpoints were operative time, estimated blood loss, length of hospital stay, cost per case, and overall complication rate. METHODS: This was a prospective cohort study. Forty patients were included and subjected to TaTME from May 2018 to January 2020 and patients were followed up for a period of 6 months. RESULTS: Primary endpoint: Depending on the post-operative specimen pathological assessment; circumferential resection margin (CRM) was free in all patients, proximal resection margins had a mean 14.37 2.87 cm, distal resection margins had a mean 2.08 ± 0.4 cm and LNs retrieval had a mean 13.27 ± 5.9, and number of positive LNs had a mean 2.40 ± 3.77. Secondary endpoints: Mean total operative time (from induction of anesthesia till skin closure) was 179.10, estimated blood loss (using gauze visual analog plus what was obtained in the OR suction device) was 133.67 66.59 ml, the length of hospital stay (admission till discharge) was 5.27 ± 1.08 days, cost per case had a mean (in 1000 USD) 2.95 ± 0.12, and overall complication rate was 10%. CONCLUSION: TaTME represents a promising complementary technique to laparoscopic TME in the step of low rectal dissection.

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.

Influence of Minimally Invasive Resection Technique on Sphincter Preservation and Short-term Outcome in Low Rectal Cancer in the Netherlands

BACKGROUND

Transanal and robotic-assisted total mesorectal excision are techniques that can potentially overcome challenges encountered with a pure laparoscopic approach in patients with rectal cancer.

OBJECTIVE

The aim of this study was to evaluate the proportion and predictive factors of restorative procedures and subsequent short-term outcomes of 3 minimally invasive techniques to treat low rectal cancer.

DESIGN

This is a nationwide observational comparative registry study.

SETTINGS

Patients with rectal cancer were selected from the mandatory Dutch ColoRectal Audit.

PATIENTS

Patients with low rectal cancer (≤5 cm) who underwent curative minimally invasive total mesorectal excision between 2015 and 2018 were included.

MAIN OUTCOME MEASURES

The primary outcomes measured were the proportion of restorative procedure, positive circumferential resection margin, and postoperative complications.

RESULTS

A total of 3466 patients were included for analysis, of which 33% underwent a restorative procedure. Resections were performed laparoscopically in 2845 patients, transanally in 448 patients, and were robot-assisted in 173 patients, with a proportion of restorative procedures of 28%, 66%, and 40%. The transanal approach was independently associated with a restorative procedure (OR, 4.11; 95% CI, 3.21-5.26; p < 0.001). Independent risk factors for a nonrestorative procedure, irrespective of the surgical technique, were age >75 years, ASA physical status ≥3, BMI >30, history of abdominal surgery, clinical T4-stage, mesorectal fascia ≤1 mm, neoadjuvant therapy, and having a procedure in 2015 to 2016 versus 2017 to 2018. The circumferential resection margin involvement was similar for all 3 groups (5.4%, 5.1%, and 5.1%). Short-term postoperative complications were less favorable for the newer techniques than for the laparoscopic approach.

LIMITATIONS

This study was limited because of the registry's variables and different group sizes.

CONCLUSION

Patients with low rectal cancer in the Netherlands are more likely to receive a restorative procedure with a transanal approach, compared with a laparoscopic or robotic procedure. Short-term oncological outcomes are comparable between the 3 minimally invasive techniques. See Video Abstract at http://links.lww.com/DCR/B608.

INFLUENCIA DE LA TCNICA DE RESECCIN MINIMAMENTE INVASIVA CON PRESERVACIN DE ESFNTERES EN LA RESOLUCIN A CORTO PLAZO EN CANCER DE TERCIO INFERIOR DE RECTO EN LOS PASES BAJOS

ANTECEDENTES:La excisión mesorrectal transanal y asistida por robot son técnicas que potencialmente pueden superar algunos obstáculos que podemos encontrar en un abordaje exclusivamente laparoscópico en pacientes con cáncer de recto.OBJECTIVOS:El objetivo de este estudio es evaluar la proporción y los factores de predicción positivos de los procedimientos restauradores y los resultados subsecuentes a corto plazo de tres técnicas mínimamente invasivas para tratar el cáncer de tercio inferior de recto.DISEÑO:Es un estudio comparativo observacional del registro nacional.ESCENARIO:Pacientes con cáncer de recto seleccionados del Registro Oficial de la Auditoría Holandesa Colo-rectal.PACIENTGES:Pacientes con cáncer de tercio inferior de recto (≤5 centimetros) sometidos a excision mesorrectal total mínimamente invasiva curativa.PRINCIPALES PARAMETROS DE EFECTIVIDAD:Proporción de procedimientos restauradores, margen de resección circunferencial positivo y complicaciones postoperatorias.RESULTADOS:Se incluyeron un total de 3,466 pacientes para análisis, de los cuales 33% fueron sometidos a procedimiento restaurador. Las resecciones fueron laparoscópica en 2,845 pacientes, transanal en 448 y asistidas por robot en 173, con una proporción de procedimientos restauradores en 28%, 66% y 40% respectivamente. El abordaje transanal se correlacionó en forma independiente con el procedimiento restaurador (OR 4.11; 95% CI 4.11; 95% CI 3.21-5.26; p<0.001). Los factores de riesgo independientes para un procedimiento no restaurador, sin tomar en cuenta la técnica quirúrgica fueron: edad >75, American Society of Anesthesiologist ≥3, índice de masa corporal >30, antecedente de cirugía abdominal, Estadio clínico T4, fascia mesorrectal ≤1 millimetro, terapia neoadyuvante y haber sido sometido al procedimiento en 2015-2016 y no en 2017-2018. El margen circunferencial de resección involucrado fue similar para los tres grupos (5.4%, 5.1% y 5.1%). Las complicaciones postquirúrgicas a corto plazo fueron menos favorables para las técnicas nuevas comparadas con el abordaje laparoscópico.LIMTANTES:El estudio tiene la limitación de las variables dependientes del registro y la diferencia entre el número de pacientes en cada grupo.CONCLUSION:Los pacientes con cáncer de tercio inferior de recto en Holanda se tratan con mayor frecuencia mediante un procedimiento restaurador transanal en comparación con los abordajes laparoscópico o robótico. Los resultados favorables desde el punto de vista oncológico a corto plazo son comparables entre las tres técnicas de invasión mínima. Consulte Video Resumenhttp://links.lww.com/DCR/B608.

Development of a performance rubric for transanal endoscopic rectal purse-string sutures

BACKGROUND

Placing a transanal endoscopic rectal purse-string suture (taEPS) is the crucial first component of transanal total mesorectal excision (taTME). However, no structured training is available to improve the procedure-specific skills for taEPS. The aim of this study was to create a performance rubric to improve taEPS skills and provide preliminary evidence for its validity.

METHODS

A performance rubric was created based on technical considerations for taEPS, identified by consulting with taTME surgical and performance assessment experts. Ten independent, blinded raters assessed 10 videotaped taEPS procedures of consecutive taTME cases, at National Cancer Center Hospital East (NCCHE), Chiba, Japan, in January 2018-March 2019 using the rubric and the Global Operative Assessment of Laparoscopic Skills (GOALS). Internal consistency and inter-rater reliabilities were calculated. Videotaped taEPS procedures were timed and assessed by the rubric. Correlation between rubric scores and suturing times were analyzed.

RESULTS

The rubric consists of four items: loading the needle (LN), atraumatic needle passage (AP), planned suture path (PS), and overall performance (OA). Videotaped performances were graded on a 3-point Likert scale; scores were calculated as sums of the points. Cronbach's α for internal consistency was 0.713. Inter-rater reliabilities were LN: 0.73, AP: 0.76, PS: 0.71, and OA: 0.70. Rubric and GOALS scores were strongly correlated (r = 0.964, p < 0.001). In 112 consecutive taEPS performances, rubric scores were strongly correlated with suturing time (r =  - 0.69, p < 0.001). Surgeons' experience with taTME was associated with rubric scores and suturing time.

CONCLUSIONS

This study provides preliminary validation for the taEPS skill performance rubric. The rubric's structured training may facilitate skill acquisition by providing trainees with critical clinical considerations.

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.

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 nationwide comparison of short-term outcomes after transanal, open, laparoscopic, and robot-assisted total mesorectal excision

AIM

Laparoscopic rectal cancer surgery has several limitations. Transanal total mesorectal excision (TaTME) can potentially overcome these limitations. The aim of this study was to compare the rates of non-radical surgery and anastomotic leakage after TaTME, open TME (OpTME), laparoscopic TME (LaTME) and robotic TME (RoTME) procedures in a nationwide cohort.

METHODS

We extracted the demographic, perioperative and pathological data of patients who underwent a curative OpTME, LaTME, RoTME or TaTME procedure between January 2014 and December 2018 from the national database of the Danish Colorectal Cancer Group (DCCG). We conducted multiple group-comparisons, uni- and multivariate analyses to determine the factors associated with positive resection margin (+RM) and anastomotic leakage.

RESULTS

We included 2393 patients (OpTME = 205, LaTME = 1163, RoTME = 713 and TaTME = 312). The rate of +RM was 5.7% after TaTME. The lowest rate of +RM was achieved after RoTME (8.2%, 4.7%, 2.52%, and 5.7%, after OpTME, LaTME, RoTME and TaTME respectively, p < 0.001). In multivariate analysis, having a T4 tumour and intraoperative bowel perforation were associated with the risk of +RM (p < 0.001, p < 0.001, respectively). The factors associated with anastomotic leakage in multivariate analysis were male gender, high BMI and intraoperative bowel perforation (p < 0.001, p = 0.049, p = 0.002, respectively). TaTME was associated with the highest rate of sphincter-saving procedures (79.8%, p < 0.001), the lowest rate of bowel perforation (2.9%, p = 0.028) and the lowest rate of conversion to open surgery (1.3%, p < 0.001).

CONCLUSIONS

In a nationwide audit of TME approaches, the rate of +RM was lowest after RoTME. No differences were found between the four approaches regarding the risk of anastomotic leakage. TaTME offered advantages related to sphincter-saving, perforation and conversion.

Transanal total mesorectal excision and transabdominal robotic surgery for rectal cancer: A retrospective study

BACKGROUND

Transabdominal robotic surgery and transanal total mesorectal excision (TaTME) are newly introduced strategies for rectal cancer. These procedures might have many advantages in rectal cancer treatment in terms of improving oncological and functional outcomes, especially in cases involving advanced cancer or technical difficulty. In the present study, we aimed to clarify the advantages and disadvantages of transabdominal robotic surgery and laparoscopic TaTME as a hybrid surgery for rectal cancer.

MATERIALS AND METHODS

We retrospectively evaluated six patients who underwent hybrid surgery for rectal cancer from August 2018 to April 2020. Both clinical and pathological outcomes were assessed.

RESULTS

Two patients showed circumferential margin involvement both before and after neoadjuvant therapy. Three patients were planned to undergo hybrid surgery with intersphincteric resection because of a narrow pelvis. One patient was planned to undergo hybrid surgery for a giant tumor of >10 cm. The median length of hospitalization was 17 days. No patients required conversion to an open procedure. All patients underwent formation of defunctioning ileostomies. Two patients had a stapled anastomosis and four had a hand-sewn coloanal anastomosis. Complications included one case of anastomotic leakage, which was managed conservatively with ultrasound- and computed tomography-guided drainage and antibiotics. Histological analysis revealed that all specimens had a negative radial margin and distal margin. The median number of lymph nodes harvested was 17.5. Two patients showed extensive lymph node metastases, including lateral node metastasis.

CONCLUSION

Hybrid surgery was performed safely and may improve oncological outcomes for rectal cancer. This technique has many potential benefits and would be alternative option in multimodal strategies for rectal cancer.

Local Recurrence and Disease-Free Survival After Transanal Total Mesorectal Excision: Results From the International TaTME Registry

BACKGROUND

The oncologic safety of transanal total mesorectal excision (TaTME) for rectal cancer has recently been questioned, with high local recurrence (LR) rates reported in Dutch and Norwegian experiences. The objective of this study was to evaluate the oncologic safety of TaTME in a large cohort of patients with primary rectal cancer, primarily in terms of LR, disease-free survival (DFS), and overall survival (OS).

PATIENTS AND METHODS

This was a prospective international registry cohort study, including all patients who underwent TaTME for primary rectal adenocarcinoma from February 2010 through December 2018. The main endpoints were 2-year LR rate, pattern of LR, and independent risk factors for LR. Secondary endpoints included 2-year DFS and OS rates. Kaplan-Meier survival analysis was used to calculate actuarial LR, DFS, and OS rates.

RESULTS

A total of 2,803 patients receiving primary TaTME were included, predominantly men (71%) with a median age of 65 years (interquartile ratio, 57-73 years). After a median follow-up of 24 months (interquartile ratio, 12-38 months), the 2-year LR rate was 4.8% (95% CI, 3.8%-5.8%) with a unifocal LR pattern in 99 of 103 patients (96%). Independent risk factors for LR were male sex, threatened resection margin on baseline MRI, pathologic stage III cancer, and a positive circumferential resection margin on final histopathology. The 2-year DFS and OS rates were 77% (95% CI, 75%-79%) and 92% (95% CI, 91%-93%), respectively.

CONCLUSIONS

This largest TaTME cohort to date supports the oncologic safety of the TaTME technique for rectal cancer in patients treated in units that contributed to an international registry, with an acceptable 2-year LR rate and a predominantly unifocal LR pattern.

Comparison of laparoscopic versus robot-assisted versus transanal total mesorectal excision surgery for rectal cancer: a retrospective propensity score-matched cohort study of short-term outcomes

BACKGROUND

Laparoscopic total mesorectal excision (TME) surgery for rectal cancer has important technical limitations. Robot-assisted and transanal TME (TaTME) may overcome these limitations, potentially leading to lower conversion rates and reduced morbidity. However, comparative data between the three approaches are lacking. The aim of this study was to compare short-term outcomes for laparoscopic TME, robot-assisted TME and TaTME in expert centres.

METHODS

Patients undergoing rectal cancer surgery between 2015 and 2017 in expert centres for laparoscopic, robot-assisted or TaTME were included. Outcomes for TME surgery performed by the specialized technique in the expert centres were compared after propensity score matching. The primary outcome was conversion rate. Secondary outcomes were morbidity and pathological outcomes.

RESULTS

A total of 1078 patients were included. In rectal cancer surgery in general, the overall rate of primary anastomosis was 39.4, 61.9 and 61.9 per cent in laparoscopic, robot-assisted and TaTME centres respectively (P < 0.001). For specialized techniques in expert centres excluding abdominoperineal resection (APR), the rate of primary anastomosis was 66.7 per cent in laparoscopic, 89.8 per cent in robot-assisted and 84.3 per cent in TaTME (P < 0.001). Conversion rates were 3.7 , 4.6 and 1.9 per cent in laparoscopic, robot-assisted and TaTME respectively (P = 0.134). The number of incomplete specimens, circumferential resection margin involvement rate and morbidity rates did not differ.

CONCLUSION

In the minimally invasive treatment of rectal cancer more primary anastomoses are created in robotic and TaTME expert centres.

Local Recurrence After Transanal Total Mesorectal Excision for Rectal Cancer: A Multicenter Cohort Study

OBJECTIVE

This study aimed to determine local recurrence (LR) rate and pattern after transanal total mesorectal excision (TaTME) for rectal cancer.

BACKGROUND

TaTME for mid- and low rectal cancer has known a rapid and worldwide adoption. Recently, concerns have been raised on the oncological safety in light of reported high LR rates with a multifocal pattern.

METHODS

This was a multicenter observational cohort study in 6 tertiary referral centers. All consecutive TaTME cases for primary rectal adenocarcinoma from the first TaTME case in every center until December 2018 were included for analysis. Patients with benign tumors, malignancies other than adenocarcinoma and recurrent rectal cancer, as well as exenterative procedures, were excluded. The primary endpoint was 2-year LR rate. Secondary endpoints included patterns and treatment of LR and histopathological characteristics of the primary surgery.

RESULTS

A total of 767 patients were identified and eligible for analysis. Resection margins were involved in 8% and optimal pathological outcome (clear margins, (nearly) complete specimen, no perforation) was achieved in 86% of patients. After a median follow-up of 25.5 months, 24 patients developed LR, with an actuarial cumulative 2-year LR rate of 3% (95% CI 2-5). In none of the patients, a multifocal pattern of LR was observed. Thirteen patients had isolated LR (without systemic disease) and 10/13 could be managed by salvage surgery of whom 8 were disease-free at the end of follow-up.

CONCLUSIONS AND RELEVANCE

This study shows good loco regional control after TaTME in selected cases from tertiary referral centers and does not indicate an inherent oncological risk of the surgical technique.

Should Transanal Total Mesorectal Excision Be Implemented in Medium-Sized Colorectal Unit? Technical and Oncological Outcome

Purpose

This study was performed to evaluate the outcome of implementation of transanal total mesorectal excision (TaTME) for low rectal cancer in a regional hospital and in comparison to laparoscopic (Lap) TME.

Methods

Consecutive patients with low rectal cancer of which the lowest border of the tumour was located beween 1 and 5 cm from the puborectalis who underwent TME at North District Hospital between January 2013 and December 2019 were included. Clinical, operative, and pathologic outcomes were compared between Lap TME and TaTME. The primary end point was complication profile.

Results

Thirty-five patients underwent Lap TME and 45 patients underwent TaTME for low rectal cancer. The conversion rate of the TaTME group was significantly lower than that of the Lap TME group (4.4% vs. 20%, P=0.029), but the operating time was longer (259 minutes vs. 219 minutes, P=0.009). The tumour location was significantly lower in the TaTME group, but the distal resection margins were adequate and not different between both groups. The TaTME group had higher incidence rates of prolonged ileus and urinary tract infection, but the other complications were similar between the two groups. The resection margin positivity rates of the TaTME and Lap TME groups were 2.2% and 5.7%, respectively (P=0.670). At a median follow up of 39 months, no abnormal early recurrence was detected.

Conclusion

It is technically feasible and oncologically safe to perform TaTME in a medium-volume colorectal unit. Patients with difficult pelvic anatomy can benefit by reducing the risk of conversion and margin positivity rate.

Two-Year Follow-Up of the First Transanal Total Mesorectal Excision (TaTME) Case Performed in Community Hospital in Hawai'i: A Case Report and Literature Review

Surgical management of rectal cancer has evolved with the advent of total mesorectal excision (TME) and neo-adjuvant treatment allowing for more sphincter-preserving proctectomies. The laparoscopic approach to TME has numerous advantages over the open approach, including faster recovery, fewer wound complications, and overall reduced morbidity. However, laparoscopic dissection around the distal portion of the rectum is particularly difficult, and thus makes achieving TME completeness and negative resection margins for low rectal tumors a challenge. Transanal TME (TaTME) is designed to overcome these difficulties. It is performed in addition to laparoscopic operation as a bottom-up approach facilitating dissection around the distal rectum. More importantly, TaTME has been shown to have the potential to improve oncological outcomes of minimally-invasive sphincter-preserving proctectomy by providing better TME specimen quality and resection margins. Although interest in TaTME has been growing worldwide, the technique is still relatively new, and adoption into routine practice may be challenging. Potential criteria for successful adoption of the TaTME technique include experience in laparoscopic rectal resection and transanal minimally-invasive surgery (TAMIS), cadaveric TaTME training, and a multidisciplinary approach to selection and management of patients with rectal cancer. Once these criteria are met, gradual and careful implementation of TaTME could be feasible. This report describes the 2-year follow-up of the first TaTME case in Hawai'i managed by a multidisciplinary oncological team in a community hospital setting.

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.

Transanal Total Mesorectal Excision in Mid-Low Rectal Cancer: Evaluation of the Learning Curve and Comparison of Short-term Results With Standard Laparoscopic Total Mesorectal Excision

BACKGROUND

Ever since transanal total mesorectal excision was introduced by Sylla and Lacy in 2010, it has become more popular among colorectal surgeons. However, some surgeons hesitate to use it, because this novel approach differs greatly from laparoscopic total mesorectal excision and requires a long learning curve.

OBJECTIVE

This study analyzed the learning curve of transanal total mesorectal excision procedure and compared the different phases of transanal total mesorectal excision with laparoscopic total mesorectal excision.

DESIGN

This is retrospective case-control study.

SETTINGS

We used data from the approved colorectal cancer database of the Sixth Affiliated Hospital of Sun Yat-sen University.

PATIENTS

The patients involved in this study underwent transanal total mesorectal excision performed by a single surgeon (L.K.) or underwent laparoscopic transanal total mesorectal excision performed by experienced surgeons.

INTERVENTIONS

Transanal or laparoscopic resection of mid-low rectal cancer was conducted.

MAIN OUTCOMES MEASURES

Perioperative complication and resection margin were measured.

RESULTS

A total of 342 patients were included in both groups. The learning curve of transanal total mesorectal excision was divided into 3 phases. Data show that demographics and tumor characteristics were not significantly different between the matched groups. Indeed, during phase 1, only operative time was longer than in the laparoscopic group, whereas, during phase 2, results from the transanal group were comparable with the laparoscopic group. Results show that, during phase 3, operative time, intraoperative blood loss, and postoperative hospital stay were all lower than in the laparoscopic group. Local recurrence occurred in 3 patients during phase 1 and in 1 patient during phase 2.

LIMITATIONS

This study was a small retrospective study and focused on just 1 surgeon performing transanal total mesorectal excision.

CONCLUSIONS

Short-term and histopathologic outcomes are similar compared between a transanal group and matched laparoscopic group. Transanal total mesorectal excision also provided good oncologic outcomes. See Video Abstract at http://links.lww.com/DCR/B450.

ESCISIN MESORRECTAL TOTAL TRANSANAL EN EL CNCER DE RECTO MEDIOBAJO EVALUACIN DE LA CURVA DE APRENDIZAJE Y COMPARACIN DE RESULTADOS A CORTO PLAZO CON TME LAPAROSCPICA ESTNDAR

ANTECEDENTES:Desde que Sylla y Lacy introdujeron la escisión mesorrectal total transanal en 2010, se ha vuelto más popular entre los cirujanos colorrectales. Sin embargo, algunos cirujanos dudan en utilizarlo, porque este nuevo método difiere mucho de la escisión mesorrectal total laparoscópica y requiere una larga curva de aprendizaje.OBJETIVO:Este estudio analizó la curva de aprendizaje del procedimiento de escisión mesorrectal total transanal y comparó las diferentes fases de la escisión mesorrectal total transanal con la escisión mesorrectal total laparoscópica.DISEÑO:Este es un estudio retrospectivo de casos y controles.ENTORNO CLINICO:Utilizamos base de datos de cáncer colorrectal aprobada del Sexto Hospital Afiliado de la Universidad Sun Yat-sen (Guangzhou, China).PACIENTES:Los pacientes involucrados en este estudio fueron sometidos a escisión mesorrectal total transanal realizada por un solo cirujano (LK) o se sometieron a escisión mesorrectal total transanal laparoscópica realizada por cirujanos experimentados.INTERVENCIONES:Resección transanal o laparoscópica de cáncer de recto medio-bajo.PRINCIPALES MEDIDAS DE VOLARCION:complicación perioperatoria y margen de resección.RESULTADOS:Se incluyó un total de 342 pacientes en ambos grupos. La curva de aprendizaje de la escisión mesorrectal total transanal se dividió en tres fases. Los datos muestran que las características demográficas y tumorales no fueron significativamente diferentes entre los grupos emparejados. De hecho, durante la fase 1, solo el tiempo operatorio fue más largo que en el grupo laparoscópico. Mientras que durante la fase 2, los resultados del grupo transanal fueron comparables a los del grupo laparoscópico. Los resultados muestran que durante la fase 3, el tiempo operatorio, la pérdida de sangre intraoperatoria y la estancia hospitalaria postoperatoria fueron menores que en el grupo laparoscópico. La recurrencia local ocurrió en 3 pacientes durante la fase 1 y en 1 paciente durante la fase 2.LIMITACIONES:Este estudio fue un estudio retrospectivo pequeño y se centró en un solo cirujano que realizaba la escisión mesorrectal total transanal.CONCLUSIÓN:Los resultados a corto plazo e histopatológicos son similares en comparación entre el grupo transanal y el grupo laparoscópico emparejado. La escisión mesorrectal total transanal también proporcionó buenos resultados oncológicos. Consulte Video Resumen en http://links.lww.com/DCR/B450.

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.

Controversies and consensus in transanal total mesorectal excision (taTME): Is it a valid choice for rectal cancer?

Transanal total mesorectal excision (taTME) is a novel approach to radical surgery for low rectal cancer. taTME is associated with the benefits of a higher rate of free distal resection margins (DRM) under direct visualization, better visualization of the mesorectal plane, and the feasibility of overcoming the restriction of the distal pelvis. Thus, it is increasingly used globally. In this review, we investigated whether taTME yields better short- and long-term outcomes than laparoscopic TME.

The gut microbiota and colorectal surgery outcomes: facts or hype? A narrative review

BACKGROUND

The gut microbiota (GM) has been proposed as one of the main determinants of colorectal surgery complications and theorized as the "missing factor" that could explain still poorly understood complications. Herein, we investigate this theory and report the current evidence on the role of the GM in colorectal surgery.

METHODS

We first present the findings associating the role of the GM with the physiological response to surgery. Second, the change in GM composition during and after surgery and its association with colorectal surgery complications (ileus, adhesions, surgical-site infections, anastomotic leak, and diversion colitis) are reviewed. Finally, we present the findings linking GM science to the application of the enhanced recovery after surgery (ERAS) protocol, for the use of oral antibiotics with mechanical bowel preparation and for the administration of probiotics/synbiotics.

RESULTS

According to preclinical and translational evidence, the GM is capable of influencing colorectal surgery outcomes. Clinical evidence supports the application of an ERAS protocol and the preoperative administration of multistrain probiotics/synbiotics. GM manipulation with oral antibiotics with mechanical bowel preparation still has uncertain benefits in right-sided colic resection but is very promising for left-sided colic resection.

CONCLUSIONS

The GM may be a determinant of colorectal surgery outcomes. There is an emerging need to implement translational research on the topic. Future clinical studies should clarify the composition of preoperative and postoperative GM and the impact of the GM on different colorectal surgery complications and should assess the validity of GM-targeted measures in effectively reducing complications for all colorectal surgery locations.

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.

Transanal total mesorectal excision for rectal cancer: Surgical outcomes and short-term oncological outcomes in a single-institution consecutive series

INTRODUCTION

Rectal cancer surgery is continuously evolving. Transanal total mesorectal excision (TaTME) is a relatively new surgical approach with possible advantages in comparison to current standard surgical techniques. Several studies in recent years have validated this approach regarding safety and effectiveness. We describe our initial experience with TaTME evaluating surgical parameters, post-operative outcomes and short-term oncological outcomes.

METHODS

This is a retrospective study reviewing all patients who underwent TaTME in a single institution from May 2015 to April 2018.

RESULTS

The cohort included 25 patients with an average age of 60.4 (range: 40-86), of which 13 (52%) patients were male. The average body mass index was 26.1. The overall 30-day morbidity rate was 40%, with 20% (five cases) being severe complications, defined by Clavien-Dindo Grade of 3b or above. There were three major interoperative complications. Four cases (16%) required reoperation during the first 30 post-operative days. The median length of stay was 8 days. The surgery duration was on average 296 min (range: 205-510). Negative resection margins were achieved in all patients. At a median follow-up period of 14 months, there were no local recurrences, and 4 cases (16%) had a distant recurrence.

CONCLUSION

This study describes our initial experience with TaTME, which requires a substantial learning curve to minimise complications and morbidity. Oncological outcomes as expressed by the resection margins, number of lymph nodes harvested and local recurrence rates were all comparable to previously published data.

Exploring the perioperative outcomes of a sample of successful adopters of transanal total mesorectal excision (taTME) during the learning phase

BACKGROUND

Transanal total mesorectal excision can be a technically challenging operation to master. While many early adopters have reported adequate outcomes, others have failed to reproduce these results. There are contradicting data on oncologic outcomes during the learning phase of this technique. Thus, our objective was to perform a multicentered assessment of oncological outcomes in patients undergoing transanal total mesorectal excision during the learning phase in a sample of successful adopting centers.

METHODS

Surgeons from 8 centers with experience in the management of rectal cancer were invited to participate. The initial 51 consecutive benign and malignant cases of the participating units were retrospectively reviewed, but only 366 cancer cases were included in the analysis. Procedures were divided into implementation (ie, the first 10 cases) and postimplementation (ie, case 11 on onwards) groups, and the main outcome was the incidence of local recurrence.

RESULTS

The overall prevalence of local recurrence was 4.1% at a median follow-up of 35 months (interquartile range 20.3-44.2); among implementation and postimplementation groups local recurrence was 7.5% and 3.1%, respectively, and the rate of local recurrence was observed to be nearly 60% lower in the postimplementation group (hazard ratio [95% confidence interval] = 0.43 [0.26-0.72]) Total mesorectal excision specimens were complete or nearly complete in 87.7% of cases, and the circumferential and distal margins were clear in 93.2% and 92.6%, respectively CONCLUSION: Local recurrence rate was low during the learning phase of the transanal total mesorectal excision in a sample of rectal cancer surgeons with acceptable surgical and oncologic outcomes. Both the prevalence and rate of local recurrence were markedly lower in the postimplementation phase, indicating improvement as experience accumulated.

A novel method for near-infrared fluorescence imaging of the urethra during perineal and transanal surgery: demonstration in a cadaveric model

AIM

Transanal total mesorectal excision is a promising novel sphincter-saving procedure for low rectal cancer. However, the transanal bottom-up dissection is associated with increased rates of iatrogenic urethral injuries. Near-infrared fluorescence (NIRF) imaging, given its deeper tissue penetration, has been explored in a limited number of studies for enhanced intra-operative urethral visualization. In this study, we explored the feasibility of a novel, ultrabright, biocompatible fluorescent polymer to coat urinary catheters for the purpose of intra-operative urethral visualization.

METHODS

In an ex vivo experiment, using a near-infrared laparoscope, the fluorescent signal of a coated catheter (near-infrared coating of equipment, NICE) was qualitatively and quantitatively compared to the signal of indocyanine green (ICG)/Instillagel® mixtures and ICG-filled catheters at several concentrations. Also, in three male human torsos, using fluorescent urinary catheters, NIRF-guided perineal dissections and a transanal total mesorectal excision were performed. Intra-operative NIRF-based urethral visualization was performed systematically.

RESULTS

During the qualitative and quantitative fluorescence signal assessment, NICE-coated catheters were clearly superior to the ICG-based solutions. In the cadaveric experiments, enhanced urethral visualization was possible even at early stages of dissection, when the organ was covered by several tissue layers.

CONCLUSIONS

NICE-coated catheters represent a promising potential to allow for NIRF-based intra-operative urethral visualization.

Transanal total mesorectal excision: 3-year oncological outcomes

BACKGROUND

Rectal cancer treatment has evolved with the implementation of new surgical techniques. Transanal total mesorectal excision (TaTME) is the most recent approach developed to facilitate pelvic dissection of mid- and distal rectal tumours. The purpose of this study was to analyse the short- and mid-term oncological outcomes of TaTME.

METHODS

A study was conducted on patients treated with TaTME for rectal cancer at two colorectal units in Portugal between March 2016 and December 2018. Clinical, pathological and oncological data were retrospectively analysed. Primary endpoints were 3-year overall survival, disease-free survival and local recurrence. Secondary endpoints were clinical and pathological outcomes.

RESULTS

Fifty patients (31 males, [62%], median age 66 years [range 40-85 years]) underwent TaTME, 49 (98%) for malignant and 1 (2%) for benign disease. There were no cases of conversion, 49 (98%) patients had complete or near-complete mesorectum, all the resections were R0 with adequate distal and circumferential margins. With a median follow-up of 36 months, there were 2 cases (4%) of local recurrence and 3-year estimated overall survival and disease-free survival were 90% and 79%, respectively.

CONCLUSIONS

TaTME can provide safe mid-term oncological outcomes, similar to what has been published for classic and laparoscopic TME. Our results also show how demanding this novel approach can be and the consequent need for audited data and standardized implementation.

TransAnal Total Mesorectal Excision (TaTME) in Peru: Case series

•

Transanal total mesorectum excision is feasible for mid and low rectal cancer.

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Good quality of the mesorectum specimen is obtain after TaTME surgery.

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TaTME with intersphincteric resection is a feasible option for selected cases of very low rectal cancer.

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Surgical complication rates after intersphincteric TaTME with hand-sewn coloanal anastomosis could be higher.

Introduction

Describe and demonstrate the feasibility and safety of TaTME in short term outcomes in the Instituto Nacional de Enfermedades Neoplásicas (INEN) in Peru.

Materials and methods

Case series with retrospective and prospective data collection of patients with middle and inferior rectal cancer who underwent TaTME between January 2015 and March 2020. Patients and tumor characteristics, operative details, postoperative complications and pathological results were analyzed.

Results

Nineteen patients were included. The median age was 56 years old (range 40–69). Ten were female. The median distance from the anal verge was 4 cm (range 3–6) and 17 cases were located in the inferior rectum. Eleven patients with clinical stage III. Thirteen (68.4%) patients received neoadjuvant treatment. There was no conversion to open surgery reported. Ten (52.6%) cases had intersphincteric resection and 18 (94.7%) had primary coloanal anastomosis, 13 (72.2%) of them with hand-sewn. All patients had a diversion with ileostomy. The median operative time was 330 min (range 270–480). Median postoperative hospital stay of 5 days (range 3–18). The overall rate of postoperative complication was 21.1%, two cases (10.5%) had anastomotic leakage and mortality was present in one (5.3%) patient. 94.5% had an optimal TME specimen, only one case (5.3%) had positive circumferential resection margin and positive distal margin. The median tumor size in the specimen was 4 cm (range 2–11) and nine (47.4%) patients had ypT3 on pathology.

Conclusion

TaTME is a safe and feasible technique with good pathological results.

Current Surgical Strategies for the Treatment of Rectal Adenocarcinoma and the Risk of Local Recurrence

BACKGROUND

Despite new medical and surgical strategies, 5-year local recurrence of rectal adenocarcinoma was reported in up to 25% of cases. Therefore, we aimed to review surgical strategies for the prevention of local recurrences in rectal cancer.

SUMMARY

After implementation of the total mesorectal excision (TME), surgical resection of rectal adenocarcinoma with anterior resection or abdominoperineal excision (APE) allowed decrease in local recurrence (3% at 5 years). More recently, extralevator APE was described as an alternative to APE, decreasing specimen perforation and recurrence rate. Moreover, technique modifications were developed to optimize rectal resection, such as the laparoscopic or robotic approach, and transanal TME. However, the technical advantages conferred by these techniques did not translate into a decreased recurrence rate. Lateral lymph node dissection is another technique, which aimed at improving the long-term outcomes; nevertheless, there is currently no evidence to recommend its routine use. Strategies to preserve the rectum are also emerging, such as local excision, and may be beneficial for subgroups of patients. Key Messages: Rectal cancer management requires a multidisciplinary approach, and surgical strategy should be tailored to patient factors: general health, previous perineal intervention, anatomy, preference, and tumor characteristics such as stage and localization.

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.