Quality of life after rectal cancer surgery: differences between laparoscopic and transanal total mesorectal excision

The Frequency of Urination Dysfunction in Patients Operated on for Rectal Cancer: A Systematic Review with Meta-Analyses

The frequency of long-term urination dysfunction after surgery for rectal cancer remains unclear, yet it is essential to establish this to improve treatment strategies. Randomized controlled trials (RCTs), non-RCTs, and cohort studies were included with patients having undergone sphincter-preserving total (TME) or partial mesorectal excision (PME) for the treatment of primary rectal cancer in this review. The outcome was urination dysfunction reported at least three months postoperatively, both overall urination dysfunction and subdivided into specific symptoms. The online databases PubMed, Embase, and Cochrane CENTRAL were searched, bias was assessed using the Newcastle-Ottawa scale, and results were synthesized using one-group frequency meta-analyses. A total of 55 studies with 15,072 adults were included. The median follow-up was 29 months (range 3-180). The pooled overall urination dysfunction was 21% (95% confidence interval (CI) 12%-30%) 3-11 months postoperatively and 25% (95% CI 19%-32%) ≥12 months postoperatively. Retention and incontinence were common 3-11 months postoperatively, with pooled frequencies of 11% and 14%, respectively. Increased urinary frequency, retention, and incontinence seemed even more common ≥12 months postoperatively, with pooled frequencies of 37%, 20%, and 23%, respectively. In conclusion, one in five patients experienced urination dysfunction more than a year following an operation for rectal cancer.

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

OBJECTIVE

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Quality of life and functional outcomes after laparoscopic total mesorectal excision (LaTME) and transanal total mesorectal excision (taTME) for rectal cancer. an updated meta-analysis

PURPOSE

Concerns exist regarding the potential for transanal total mesorectal excision (TaTME) to yield poorer functional outcomes compared to laparoscopic TME (LaTME). The aim of this study is to assess the functional outcomes following taTME and LaTME, focusing on bowel, anorectal, and urogenital disorders and their impact on the patient's QoL.

METHODS

A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and A Measurement Tool to Assess systematic Reviews (AMSTAR) guidelines. A comprehensive search was conducted in Medline, Embase, Scopus, and Cochrane Library databases. The variables considered are: Low Anterior Resection Syndrome (LARS), International Prostate Symptom Score (IPSS) and Jorge-Wexner scales; European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C29 and QLQ-C30 scales.

RESULTS

Eleven studies involving 1020 patients (497-taTME group/ 523-LaTME group) were included. There was no significant difference between the treatments in terms of anorectal function: LARS (MD: 2.81, 95% CI: - 2.45-8.08, p = 0.3; I2 = 97%); Jorge-Wexner scale (MD: -1.3, 95% CI: -3.22-0.62, p = 0.19). EORTC QLQ C30/29 scores were similar between the groups. No significant differences were reported in terms of urogenital function: IPSS (MD: 0.0, 95% CI: - 1.49-1.49, p = 0.99; I2 = 72%).

CONCLUSIONS

This review supports previous findings indicating that functional outcomes and QoL are similar for rectal cancer patients who underwent taTME or LaTME. Further research is needed to confirm these findings and understand the long-term impact of the functional sequelae of these surgical approaches.

Functional outcomes and quality of life following open versus laparoscopic versus robot-assisted versus transanal total mesorectal excision in rectal cancer patients: a systematic review and meta-analysis

BACKGROUND

The standard surgical treatment for rectal cancer is total mesorectal excision (TME), which may negatively affect patients' functional outcomes and quality of life (QoL). However, it is unclear how different TME techniques may impact patients' functional outcomes and QoL. This systematic review and meta-analysis evaluated functional outcomes of urinary, sexual, and fecal functioning as well as QoL after open, laparoscopic (L-TME), robot-assisted (R-TME), and transanal total mesorectal excision (TaTME).

METHODS

A systematic review and meta-analysis, based on the preferred reporting items for systematic reviews and meta-analysis statement, were conducted (PROSPERO: CRD42021240851). A literature review was performed (sources: PubMed, Medline, Embase, Scopus, Web of Science, and Cochrane Library databases; end-of-search date: September 1, 2023), and a quality assessment was performed using the Methodological index for non-randomized studies. A random-effects model was used to pool the data for the meta-analyses.

RESULTS

Nineteen studies were included, reporting on 2495 patients (88 open, 1171 L-TME, 995 R-TME, and 241 TaTME). Quantitative analyses comparing L-TME vs. R-TME showed no significant differences regarding urinary and sexual functioning, except for urinary function at three months post-surgery, which favoured R-TME (SMD [CI] -0 .15 [- 0.24 to - 0.06], p = 0.02; n = 401). Qualitative analyses identified most studies did not find significant differences in urinary, sexual, and fecal functioning and QoL between different techniques.

CONCLUSIONS

This systematic review and meta-analysis highlight a significant gap in the literature concerning the evaluation of functional outcomes and QoL after TME for rectal cancer treatment. This study emphasizes the need for high-quality, randomized-controlled, and prospective cohort studies evaluating these outcomes. Based on the limited available evidence, this systematic review and meta-analysis suggests no significant differences in patients' urinary, sexual, and fecal functioning and their QoL across various TME techniques.

Low anterior resection syndrome and quality of life after intersphincteric resection for rectal cancer: a propensity score-matched study

PURPOSE

Our aim was to perform a propensity score-matched study to compare the long-term functional outcomes and quality of life following intersphincteric resection vs. low anterior resection (LAR) with very low anastomosis.

METHODS

Patients who underwent intersphincteric resection or low anterior resection with low anastomosis (≤ 4 cm from the anal verge) for rectal cancer between January 2017 and June 2020 were retrospectively included. A propensity score-matching process was performed. Functional outcomes and quality of life were assessed using the European Quality of Life 5 Dimensions 3 Level Version (EQ-5D-3L), EORC-QLQ C30, EORC-QLQ CR29, Low Anterior Resection Syndrome (LARS), Wexner, and International Prostate Symptom Score (IPSS) questionnaires. The primary outcome was the presence of LARS at least 12 months after surgery. The second outcome was the postoperative quality of life of included patients.

RESULTS

After propensity matching, 128 patients were included, including 58 males and 70 females with a median age of 59.5. Patients in the intersphincteric resection group showed a higher incidence of incontinence to flatus (32.8% versus 14.0%, p = 0.043) and stools (42.2% versus 21.9%, p = 0.046), pain/discomfort (25.0% versus 7.8%, p = 0.001), and bowel dysfunction, while the LARS scores (15.0 versus 13.2, p = 0.461) and major LARS rates (26.6% versus 14.1%, p = 0.078) were comparable in both groups.

CONCLUSION

ISR leads to increased bowel incontinence rate and increased anal pain, without affecting the grade of low anterior resection syndrome, fecal urgency, and clustering. LAR might be the preferred sphincteric-preserving approach when negative resection margins and a safe anastomosis are guaranteed. Patients should be fully informed about potential functional impairment after sphincter-preservation procedures.

Functional outcomes after transanal total mesorectal excision (TaTME): a random forest analysis to predict patients' outcomes

PURPOSE

Anorectal, sexual, and urinary dysfunction are common issues after rectal cancer surgery, although seldom explored. The primary aim of this study was to investigate postoperative anorectal functional results.

METHODS

Patients with mid/low-rectal cancer treated with transanal TME (TaTME) with primary anastomosis with/without diverting stoma between 2015 and 2020 were reviewed and selected if they had a minimum follow-up of 6 months (from the primary procedure or stoma reversal). Patients were interviewed using validated questionnaires and the primary outcome was bowel function based on Low Anterior Resection Syndrome (LARS) scores. Statistical analyses were performed to identify clinical/operative variables correlated with worse outcomes. A random forest (RF) algorithm was computed to classify patients at a greater risk of minor/major LARS.

RESULTS

Ninety-seven patients were selected out of 154 TaTME performed. Overall, 88.7% of the patients had a protective stoma and 25.8% reported major LARS at mean follow-up of 19.0 months. Statistical analyses documented that age, operative time, and interval to stoma reversal correlated with LARS outcomes. The RF analysis disclosed worse LARS symptoms in patients with longer operative time (> 295 min) and stoma reversal interval (> 5.6 months). If the interval ranged between 3 and 5.6 months, older patients (> 65 years) reported worse outcomes. Finally, no statistical difference was documented when comparing the rate of minor/major LARS in the first 27 cases versus others.

CONCLUSION

One-quarter of the patients developed major LARS after TaTME. An algorithm based on clinical/operative variables, such as age, operative time, and time to stoma reversal, was developed to identify categories at risk for LARS symptoms.

Neoadjuvant chemoradiation therapy combined with immunotherapy for microsatellite stable ultra-low rectal cancer (CHOICE II): study protocol of a multicentre prospective randomised clinical trial

INTRODUCTION

Neoadjuvant chemoradiotherapy (nCRT) could bring tumour shrinking and downstaging and increase the probability of organ preservation for patients with low rectal cancer. But for ultra-low rectal cancer, there is little possibility for organ preservation. Immunotherapy has been shown to have significant survival benefits in microsatellite instability-high patients but poor response in microsatellite stable (MSS) patients. Studies have demonstrated that radiotherapy and immunotherapy have synergistic effects in cancer treatment. There is no existing evidence about the clinical efficacy of immunotherapy combined with nCRT for patients with MSS ultra-low rectal cancer.

METHOD AND ANALYSIS

This trial is an open-labelled multicentre prospective randomised controlled trial (NCT05215379) with two parallel groups and allocation ratio 1:1 (nCRT+immunotherapy vs nCRT group). Eligible participants will be aged 18-75 years, with a desire for anus preservation, confirmed cT1-3aN0-1M0 rectal adenocarcinoma, confirmed MSS type, inferior margin of ≤5 cm from the anal verge. The primary endpoint of this trial is complete clinical response (cCR) rate. Immunotherapy is added after 1 week of chemoradiotherapy for two cycles, and then the patients will be administered two cycles of immunotherapy and CAPOX. The evaluations will be carried out after the completion of the whole neoadjuvant therapy. We expect the programme to improve the cCR rate and the quality of life for patients with ultra-low rectal cancer.

ETHICS AND DISSEMINATION

This trial was approved by the Ethics committee of Changhai Hospital and other medical centres (Grant number:CHEC2022-118). The results of this study will provide further insight into the clinical efficacy of immunotherapy in combination with nCRT in patients with MSS ultra-low rectal cancer.

TRIAL REGISTRATION NUMBER

NCT05215379.

Low anterior resection syndrome

Low anterior resection syndrome (LARS) is the distressful defecatory functional problem after sphincter-saving surgery for rectal cancer. Although the symptoms of fecal urgency, frequency, and incontinence may develop in most of the patients after surgery, there is no definitive treatments for LARS. Multifactorial etiologies and various risk factors have been identified, but the reduction of storage capacity in the rectum is one of the main reasons for LARS. Anal sphincter muscle or nerve damage during rectoanal resection or anastomosis construction, and intersphincteric resection for low-lying tumors or hand-sewing anastomosis, are the absolute risk factors for LARS. Preoperative radiotherapy, postoperative complications, such as anastomosis leakage, or longer duration of stoma, are also risk factors. The severity of LARS can be confirmed using the LARS score questionnaire. The questionnaire has been translated to numerous language versions including Korean and have been validated. Diverse empirical treatments, such as loperamide, fiber, probiotics, or enema, have been tried, but the safety and efficacy have not been verified yet. The 5-Hydroxytryptamine (5-HT) receptor antagonist, ramosetron, used for diarrhea-dominant irritable bowel syndrome, is one potential drug for relieving the symptoms of major LARS. A randomized-controlled trial suggested the use of ramosetron could be safe and efficacious for patients who have major LARS after sphincter-saving rectal cancer surgery. Novel techniques or drugs for relieving the symptoms of LARS should be developed more and further studies are necessary.

A systematic review and meta-analysis of minimally invasive total mesorectal excision versus transanal total mesorectal excision for mid and low rectal cancer

Background

Minimally invasive total mesorectal excision (MiTME) and transanal total mesorectal excision (TaTME) are popular trends in mid and low rectal cancer. However, there is currently no systematic comparison between MiTME and TaTME of mid and low-rectal cancer. Therefore, we systematically study the perioperative and pathological outcomes of MiTME and TaTME in mid and low rectal cancer.

Methods

We have searched the Embase, Cochrane Library, PubMed, Medline, and Web of Science for articles on MiTME (robotic or laparoscopic total mesorectal excision) and TaTME (transanal total mesorectal excision). We calculated pooled standard mean difference (SMD), relative risk (RR), and 95% confidence intervals (CIs). The protocol for this review has been registered on PROSPERO (CRD42022374141).

Results

There are 11010 patients including 39 articles. Compared with TaTME, patients who underwent MiTME had no statistical difference in operation time (SMD -0.14; CI -0.31 to 0.33; I²⁼84.7%, P=0.116), estimated blood loss (SMD 0.05; CI -0.05 to 0.14; I²⁼48%, P=0.338), postoperative hospital stay (RR 0.08; CI -0.07 to 0.22; I²⁼0%, P=0.308), over complications (RR 0.98; CI 0.88 to 1.08; I²⁼25.4%, P=0.644), intraoperative complications (RR 0.94; CI 0.69 to 1.29; I²⁼31.1%, P=0.712), postoperative complications (RR 0.98; CI 0.87 to 1.11; I²⁼16.1%, P=0.789), anastomotic stenosis (RR 0.85; CI 0.73 to 0.98; I²⁼7.4%, P=0.564), wound infection (RR 1.08; CI 0.65 to 1.81; I²⁼1.9%, P=0.755), circumferential resection margin (RR 1.10; CI 0.91 to 1.34; I²⁼0%, P=0.322), distal resection margin (RR 1.49; CI 0.73 to 3.05; I²⁼0%, P=0.272), major low anterior resection syndrome (RR 0.93; CI 0.79 to 1.10; I²⁼0%, P=0.386), lymph node yield (SMD 0.06; CI -0.04 to 0.17; I²⁼39.6%, P=0.249), 2-year DFS rate (RR 0.99; CI 0.88 to 1.11; I²⁼0%, P = 0.816), 2-year OS rate (RR 1.00; CI 0.90 to 1.11; I²⁼0%, P = 0.969), distant metastasis rate (RR 0.47; CI 0.17 to 1.29; I²⁼0%, P = 0.143), and local recurrence rate (RR 1.49; CI 0.75 to 2.97; I²⁼0%, P = 0.250). However, patients who underwent MiTME had fewer anastomotic leak rates (SMD -0.38; CI -0.59 to -0.17; I²⁼19.0%, P<0.0001).

Conclusion

This study comprehensively and systematically evaluated the safety and efficacy of MiTME and TaTME in the treatment of mid to low-rectal cancer through meta-analysis. There is no difference between the two except for patients with MiTME who have a lower anastomotic leakage rate, which provides some evidence-based reference for clinical practice. Of course, in the future, more scientific and rigorous conclusions need to be drawn from multi-center RCT research.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO, identifier CRD42022374141.

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

INTRODUCTION AND IMPORTANCE

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

CASE PRESENTATION

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

CLINICAL DISCUSSION

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

CONCLUSION

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

Transanal ileal pouch anal anastomosis for ulcerative colitis in children and adults: a systematic review and meta-analysis

PURPOSE

The incidence of pediatric onset ulcerative colitis (UC) is increasing, with increasing rate of children eventually requiring surgical treatment. Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the preferred surgical treatment. Although transanal IPAA (ta-IPAA) is becoming widely accepted for adult UC patients, data regarding this procedure in children are scarce. Nevertheless, some adult publications also include patients under 18 years old. This systematic review and meta-analysis aimed to summarize surgical and functional outcomes following ta-IPAA, and extract conclusion regarding pediatric UC patients.

METHODS

PubMed, Cochrane Library databases, Embase, Web of science and Google Scholar databases were searched, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses [PRISMA] guidelines. The final search was updated in April 2022. Four comparative cohorts (n = 868) and 11 non-comparative case series (n = 241) were included. Six reports included children. Anastomotic leak, complications, operative time, conversion rate, length of stay and functional outcomes were examined.

RESULTS

A total of 1103 patients, ranging 9-79 years were included in this review. We found no difference in risk for anastomotic leak (OR 1.36, 95% CI 0.46-4.06), minor and major complications (OR 0.92, 95% CI 0.48-1.76 and OR 0.78 95% CI 0.36-1.69, respectively) comparing ta-IPAA to transabdominal IPAA. Short- and long-term follow-up showed satisfying functional outcomes and quality of life.

CONCLUSIONS

Our review suggests that ta-IPAA is not inferior to transabdominal IPAA. Implementation of this method in children is technically feasible due to familiarity with the dissection plane. Long-term functional outcomes and quality of life are paramount in the pediatric population and should be particularly investigated. Multicenter prospective studies are required to investigate pediatric UC patients undergoing ta-IPAA.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Quality of Life of Patients with Surgically Treated Colorectal Cancer: A Narrative Review

INTRODUCTION

Quality of life is a topic increasingly being addressed by researchers. Due to the increasing incidence of colorectal cancer, this issue is particularly relevant. Despite the increasing number of publications on this topic each year, it still requires further research. The aim of this study was to analyze the available literature from the past 10 years, addressing the topic of QoL in patients with colorectal cancer which has been treated surgically.

MATERIAL AND METHODS

This review is based on 93 articles published between 2012 and 2022. It analyzes the impact of socioeconomic factors, the location and stage of the tumor, stoma and the method of surgical treatment on patients' QoL and sexual functioning.

RESULTS

CRC has a negative impact on patients' financial status, social functioning, pain and physical functioning. Patients with stage II or III cancer have an overall lower QoL than patients with stage I. The more proximally the lesion is located to the sphincters, the greater the negative impact on the QoL. There was a significant difference in favor of laparoscopic surgery compared with open surgery. In patients with a stoma, the QoL is lower compared with patients with preserved gastrointestinal tract continuity. The more time has passed since surgery, the more the presence of a stoma has a negative impact on QoL. Surgery for CRC negatively affects patients' sex lives, especially in younger people and among men.

CONCLUSIONS

This study may contribute to the identification of the factors that affect the QoL of patients with surgically treated colorectal cancer. This will allow even more effective and complete treatment, facilitating patients' return to normal physical, mental and social functioning.

Transanal total mesorectal excision for treating a lower rectal inflammatory myofibroblastic tumor: A case report

Rectal inflammatory myofibroblastic tumors are extremely rare, with no reports of their preoperative diagnosis. A 17-year-old woman who presented with low-grade fever, repeated diarrhea, constipation, and a 1-month history of anal pain was referred to our hospital. Rectal examination revealed a palpable hard mass with a smooth surface at the posterior wall 4 cm from the anal verge. Colonoscopy revealed a 4.0-cm submucosal tumor in the upper edge of the anal canal. Computed tomography and magnetic resonance imaging revealed a 5.0 × 4.0 cm-sized well-defined tumor contacting the rectum. Computed tomography-guided biopsy was performed, and an inflammatory myofibroblastic tumor was diagnosed. There have been no reports of surgery for a rectal inflammatory myofibroblastic tumor using transanal total mesorectal excision. We preoperatively diagnosed the patient with an inflammatory myofibroblastic tumor in the lower rectum and achieved anorectal preservation and curative resection with transanal total mesorectal excision, providing good view of the deep pelvis.

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.

Prospective multicentre observational cohort to assess quality of life, functional outcomes and cost-effectiveness following minimally invasive surgical techniques for rectal cancer in 'dedicated centres' in the Netherlands (VANTAGE trial): a protocol

INTRODUCTION

Total mesorectal excision is the standard of care for rectal cancer, which can be performed using open, laparoscopic, robot-assisted and transanal technique. Large prospective (randomised controlled) trials comparing these techniques are lacking, do not take into account the learning curve and have short-term or long-term oncological results as their primary endpoint, without addressing quality of life, functional outcomes and cost-effectiveness. Comparative data with regard to these outcomes are necessary to identify the optimal minimally invasive technique and provide guidelines for clinical application.

METHODS AND ANALYSIS

This trial will be a prospective observational multicentre cohort trial, aiming to compare laparoscopic, robot-assisted and transanal total mesorectal excision in adult patients with rectal cancer performed by experienced surgeons in dedicated centres. Data collection will be performed in collaboration with the prospective Dutch ColoRectal Audit and the Prospective Dutch ColoRectal Cancer Cohort. Quality of life at 1 year postoperatively will be the primary outcome. Functional outcomes, cost-effectiveness, short-term outcomes and long-term oncological outcomes will be the secondary outcomes. In total, 1200 patients will be enrolled over a period of 2 years in 26 dedicated centres in the Netherlands. The study is registered at https://www.trialregister.nl/9734 (NL9734).

ETHICS AND DISSEMINATION

Data will be collected through collaborating parties, who already obtained approval by their medical ethical committee. Participants will be included in the trial after having signed informed consent. Results of this study will be disseminated to participating centres, patient organisations, (inter)national society meetings and peer-reviewed journals.

Transanal total mesorectal excision combined with intersphincteric resection has similar long-term oncological outcomes to laparoscopic abdominoperineal resection in low rectal cancer: a propensity score-matched cohort study

Background

Transanal total mesorectal excision (taTME) or intersphincteric resection (ISR) has recently proven to be a valid and safe surgical procedure for low rectal cancer. However, studies focusing on the combination of these two technologies are limited. This study aimed to evaluate perioperative results, long-term oncologic outcomes, and anorectal functions of patients with low rectal cancer undergoing taTME combined with ISR, by comparing with those of patients undergoing laparoscopic abdominoperineal resection (laAPR).

Methods

After 1:1 propensity score matching, 200 patients with low rectal cancer who underwent laAPR (n = 100) or taTME combined with ISR (n = 100) between September 2013 and November 2019 were included. Patient demographics, clinicopathological characteristics, oncological outcomes, and anal functional results were analysed.

Results

Patients in the taTME-combined-with-ISR group had less intraoperative blood loss (79.6 ± 72.6 vs 107.3 ± 65.1 mL, P = 0.005) and a lower rate of post-operative complications (22.0% vs 44.0%, P < 0.001) than those in the laAPR group. The overall local recurrence rates were 7.0% in both groups within 3 years after surgery. The 3-year disease-free survival rates were 86.3% in the taTME-combined-with-ISR group and 75.1% in the laAPR group (P = 0.056), while the 3-year overall survival rates were 96.7% and 94.2%, respectively (P = 0.319). There were 39 patients (45.3%) in the taTME-combined-with-ISR group who developed major low anterior resection syndrome, whereas 61 patients (70.9%) had good post-operative anal function (Wexner incontinence score ≤ 10).

Conclusion

We found similar long-term oncological outcomes for patients with low rectal cancer undergoing laAPR and those undergoing taTME combined with ISR. Patients receiving taTME combined with ISR had acceptable post-operative anorectal function.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Robotic surgery contributes to the preservation of bowel and urinary function after total mesorectal excision: comparisons with transanal and conventional laparoscopic surgery

BACKGROUND

Determine whether robotic surgery is more effective than transanal and conventional laparoscopic surgery in preserving bowel and urinary function after total mesorectal excision (TME).

METHODS

Of 79 lower rectal cancer patients who underwent function-preserving TME between 2016 and 2020, 64 patients consented to a prospective questionnaire-based functional observation study (52 responded). At 6 months post-resection or ileostomy closure, Wexner, low anterior resection syndrome (LARS), modified fecal incontinence quality of life, and international prostate symptom scores were used to evaluate bowel and urinary function, comparing robotic surgery (RTME) with transanal (taTME) or conventional laparoscopic surgery (LTME).

RESULTS

RTME was performed in 35 patients (54.7%), taTME in 15 (23.4%), and LTME in 14 (21.9%). While preoperative bowel/urinary functions were similar in all three procedures, and the distance from the anal verge to tumor was almost the same, more hand-sewn anastomoses were performed and the anastomotic height from the anal verge was shorter in taTME than RTME. At 2 years post-resection, 8 patients (12.5%) had a permanent stoma; RTME showed a significantly lower rate of permanent stoma than taTME (2.9% vs. 40%, p < 0.01). Despite no significant difference, all bowel function assessments were better in RTME than in taTME or LTME. Major LARS was observed in all taTME and LTME cases, but only 78.8% of RTME. No clear difference arose between RTME and taTME in urinary function; urinary dysfunction was more severe in LTME than RTME (36.4% vs. 6.1%, p = 0.02).

CONCLUSIONS

In function-preserving TME for lower rectal cancer, robotic surgery was suggested to be more effective than transanal and conventional laparoscopic surgery in terms of bowel and urinary functions.

UEG and EAES rapid guideline: Systematic review, meta-analysis, GRADE assessment and evidence-informed European recommendations on TaTME for rectal cancer

BACKGROUND

Evidence and practice recommendations on the use of transanal total mesorectal excision (TaTME) for rectal cancer are conflicting.

OBJECTIVE

We aimed to summarize best evidence and develop a rapid guideline using transparent, trustworthy, and standardized methodology.

METHODS

We developed a rapid guideline in accordance with GRADE, G-I-N, and AGREE II standards. The steering group consisted of general surgeons, members of the EAES Research Committee/Guidelines Subcommittee with expertise and experience in guideline development, advanced medical statistics and evidence synthesis, biostatisticians, and a guideline methodologist. The guideline panel consisted of four general surgeons practicing colorectal surgery, a radiologist with expertise in rectal cancer, a radiation oncologist, a pathologist, and a patient representative. We conducted a systematic review and the results of evidence synthesis by means of meta-analyses were summarized in evidence tables. Recommendations were authored and published through an online authoring and publication platform (MAGICapp), with the guideline panel making use of an evidence-to-decision framework and a Delphi process to arrive at consensus.

RESULTS

This rapid guideline provides a weak recommendation for the use of TaTME over laparoscopic or robotic TME for low rectal cancer when expertise is available. Furthermore, it details evidence gaps to be addressed by future research and discusses policy considerations. The guideline, with recommendations, evidence summaries, and decision aids in user-friendly formats can also be accessed in MAGICapp: https://app.magicapp.org/#/guideline/4494 .

CONCLUSIONS

This rapid guideline provides evidence-informed trustworthy recommendations on the use of TaTME for rectal cancer.

Functional Outcomes after Transanal Surgery

Transanal surgery has gained in popularity during the latter part of the last decade for both rectal cancer and benign disease. The current role for local excision of early rectal neoplastic lesions has expanded due to better understanding of risk factors for lymph node metastasis and heightened awareness for the long-term sequelae of radical surgery. Transanal resection of the rectum (both for cancer or inflammatory bowel diseases) has now been established as a successful procedure that overcomes some of the limitations of the abdominal approaches. Once the feasibility, safety, and the oncologic results of transanal minimally invasive approaches for patients with rectal cancer have been acknowledged, quality of life and functional outcomes have become increasingly important issues. This article provides an overview of the different techniques currently available for the minimally invasive transanal treatment of rectal lesions, particularly focusing on functional outcomes.

Clinical Status and Future Prospects of Transanal Total Mesorectal Excision

Low rectal cancer has always posed surgical challenges to gastrointestinal surgeons. Transanal total mesorectal excision (taTME) is a novel approach to radical resection for low rectal cancer. Compared with conventional laparoscopic TME (laTME), taTME is relevant to the benefits of better vision of the mesorectal plane, feasibility of operating in a narrow pelvis, and exact definition of distal resection margin, which may lead to a higher possibility of free circumferential resection margin, better quality of TME specimen, and lower conversion rate. Although there are concerns about its long-term oncological outcomes and complex learning curve, taTME is a promising alternative for rectal cancer. In this review, we discuss the application status and prospects of taTME.

Quality of Life in Patients With Rectal Resections and End-to-End Primary Anastomosis Using a Standardized Perioperative Pathway

Objectives: Lower rectal resection is associated with a high rate of postoperative complications and, therefore, adversely impacts the postoperative health-related quality of life (QoL). Though sporadically practiced in different centers, there is no standard perioperative protocol for the management of patients with rectal growths. The aim of this analysis is to evaluate the patient-reported outcomes after low rectal resections followed by an end-to-end-reconstruction and temporary covering ileostomy using a multidisciplinary fail-safe-concept.

Methods: Between 2015 and 2020, we evaluated patient reported outcomes after open and laparoscopic rectal resections with end-to-end reconstruction with a primary straight anastomosis using a standardized perioperative pathway All patients with stoma were excluded from the study. The data for the QoL of patients was collected using the established Low Anterior Resection Syndrome (LARS)-score and the EORTC-C30 and CR-29 questionnaires at a single postoperative timepoint.

Results: We recruited 78 stoma-free patients for this analysis. Of 78 patients included in the study, 87.2% were operated laparoscopically and the mean global health status was 67.95 points, while a major LARS was detected in 48 (61.5%) patients. No anastomotic leakage (AL) occurred within the study cohort. There was no significant change in the LARS-score or the global health status depending on the follow-up-period.

Conclusion: This study shows that good QoL and functional outcomes with no AL are achievable following end-to-end straight anastomosis using a standardized perioperative surgical fail-safe protocol procedure.

Functional Outcomes and Quality of Life After Transanal Total Mesorectal Excision for Rectal Cancer: A Prospective Observational Study

BACKGROUND

Few studies have addressed the functional impact after transanal total mesorectal excision.

OBJECTIVE

This study aimed to evaluate function and health-related quality of life among patients with rectal cancer treated with transanal total mesorectal excision.

DESIGN

Consecutive patients treated between 2016 and 2018 were selected. Their function and quality of life were studied preoperatively and at 3 and 12 months after surgery.

SETTING

This is a prospective case series.

PATIENTS

Patients were eligible if they had primary anastomosis, their diverting stoma had been reversed, and they did not have anastomotic leakage. Forty-five patients were finally included. A total of 31 (68.8%) and 32 patients (71.1%) completed the 3- and 12-month surveys.

INTERVENTIONS

Standard transanal total mesorectal excision was performed.

MAIN OUTCOME MEASURES

The primary end point was functional and quality-of-life outcomes using validated questionnaires. Secondary end points included values obtained with endoanal ultrasounds, anorectal manometries, and rectal sensation testing.

RESULTS

Wexner and Low Anterior Resection Syndrome scores significantly increased 3 months after surgery but returned to baseline values at 12 months. The rate of "major low anterior resection syndrome" at the end of follow-up was 25.0% (+11.7% compared with baseline, p = 0.314). Sexual and urinary functions remained stable throughout the study, although a meaningful clinical improvement was detected in male sexual interest. Among quality-of-life domains, all deteriorations returned to baseline values 12 months after surgery, except worsening of flatulence symptoms, and improvement in insomnia and constipation. At 12 months, an expected decrease in the mean width of the internal sphincter, the anal resting pressure, and the tenesmus threshold volume was found.

LIMITATIONS

This study was limited by its small sample size, the absence of a comparative group, and significant missing data in female sexual difficulty and in ultrasounds and manometries at 3 months.

CONCLUSIONS

Patients undergoing transanal total mesorectal excision report acceptable quality-of-life and functional outcomes 12 months after surgery. See Video Abstract at http://links.lww.com/DCR/B541.

RESULTADOS FUNCIONALES Y CALIDAD DE VIDA DE LOS PACIENTES DESPUS DE LA ESCISIN MESORRECTAL TOTAL TRANSANAL PARA CNCER DE RECTO UN ESTUDIO PROSPECTIVO OBSERVACIONAL

ANTECEDENTES:Pocos estudios han abordado el impacto funcional después de la escisión mesorrectal total transanal.OBJETIVO:Evaluar la función y la calidad de vida relacionada con la salud en pacientes con cáncer de recto tratados con escisión mesorrectal total transanal.DISEÑO:Se seleccionaron pacientes consecutivos tratados entre 2016 y 2018. Se estudió su función y calidad de vida, en la etapa preoperatoria, a los tres y doce meses postoperatorios.METODO:Serie de casos prospectivos.PACIENTES:Los pacientes eran incluidos en presencia de anastomosis primaria, cierre del estoma de derivación y en ausencia de fuga anastomótica. Finalmente se incluyeron cuarenta y cinco pacientes. Un total de 31 (68,8%) y 32 pacientes (71,1%) completaron las encuestas de tres y doce meses, respectivamente.INTERVENCIONES:Escisión mesorrectal total transanal estándar.PRINCIPALES MEDIDAS DE RESULTADO:Los criterio de evaluación principal fueron los resultados funcionales y de calidad de vida mediante cuestionarios previamente validados. Los criterios de evaluación secundarios incluyeron los valores obtenidos con ecografía endoanal, manometría anorrectal y prueba de sensibilidad rectal.RESULTADOS:La escala de Wexner y el síndrome de resección anterior baja aumentaron significativamente tres meses después de la cirugía, pero volvieron a los valores iniciales a los doce meses. La tasa de "síndrome de resección anterior inferior grave" al final del seguimiento fue del 25,0% (+ 11,7% en comparación con el valor inicial, p = 0,314). La función sexual y urinaria se mantuvo estable durante todo el estudio, aunque se detectó una mejora clínica significativa en la libido masculina. Entre los criterios que evalúan la calidad de vida, todas las alteraciones en la misma volvieron a los valores iniciales, doce meses después de la cirugía, excepto el aumento de flatulencia, la mejoría del insomnio y el estreñimiento. A los doce meses, se encontró una disminución esperada en el grosor medio del esfínter interno, la presión anal en reposo y el volumen umbral para la presencia de tenesmo.LIMITACIONES:Tamaño de muestra limitado, ausencia de un grupo comparativo, falta significativa de datos para identificar la dificultad para la actividad sexual femenina y el efectuar ecografía y manometría a los tres meses.CONCLUSIONES:Los pacientes sometidos a escisión mesorrectal total transanal refieren una calidad de vida y resultados funcionales aceptables a los doce meses después de la cirugía. Consulte Video Resumen en http://links.lww.com/DCR/B541.

Laparoscopic Proctocolectomy With Transanal Total Mesorectal Excision for Ulcerative Colitis

Transanal total mesorectal excision (TaTME) refers to endoscopic retrograde total mesorectal excision and is becoming increasingly popular worldwide. TaTME improves surgical manipulation and minimizes the risk of local recurrence of rectal cancer by ensuring circumferential resection margins. TaTME is mainly indicated for patients in whom transabdominal approaches are expected to be technically challenging. We extended the indications for TaTME to include surgery for ulcerative colitis lesions that might be cancerous in the rectum. Here, we report a case of proctocolectomy with TaTME for ulcerative colitis. A 38-year-old woman who was receiving treatment for ulcerative colitis underwent a biopsy for random samples from the transverse colon to the rectum. Histopathological findings revealed noninvasive dysplasia with p53 overexpression, suggestive of cancer. We extended the indication of TaTME to surgery for ulcerative colitis. We formed two surgical teams and performed laparoscopic proctocolectomy with TaTME simultaneously. This simultaneous operation reduced the duration of the procedures in the present case. The patient was discharged without any complications and underwent loop ileostomy closure four months postoperatively. The patient recovered without significant loss of the anal sphincter function and is doing well four months after the second surgery. We propose laparoscopic proctocolectomy with TaTME to be conducted simultaneously by two teams as a safe and effective technique that is associated with a shorter operation time than that reported previously. Additionally, TaTME was useful in confirming the appropriate dissection layer as well as in surgical manipulation. Hence, TaTME could serve as a useful therapeutic option for ulcerative colitis surgery.

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.

Low anterior resection syndrome: can it be prevented?

Surgery remains the cardinal treatment in colorectal cancers but changes in bowel habits after rectal cancer surgery are common and disabling conditions that affect patients' quality of life. Low anterior resection syndrome is a disorder of bowel function after rectal resection resulting in a lowering of the QoL and recently has been defined by an international working group not only by specified symptoms but also by their consequences. This review aims to explore an extensive bibliographic research on preventive strategies for LARS. All "modifiable variables," quantified by the LARS Score, such as type of anastomosis, neoadjuvant therapy, surgical strategy, and diverting stoma, were evaluated, while "non-modifiable variables" such as age, sex, BMI, ASA, preoperative TMN, tumor height, and type of mesorectal excision were excluded from the comparative analysis. The role of defunctioning stoma, local excision, neoadjuvant radiotherapy, and non operative management seems to significantly affect risk of LARS, while type of anastomosis and surgical TME approach do not impact on LARS incidence or gravity in the long term period. Although it is established that some variables are associated with a greater onset of LARS, in clinical practice, technical difficulties and oncological limits often make difficult the application of some prevention plans. Transtomal irrigations, intraoperative neuromonitoring, pelvic floor rehabilitation before stoma closure, and early transanal irrigation represent new arguments of study in preventive strategies which could, if not eliminate the symptoms, at least mitigate them.

Meta-analysis of transanal versus laparoscopic total mesorectal excision for rectal cancer: a 'New Health Technology' assessment in South Korea

Purpose

Under the South Korea's unique health insurance structure, any new surgical technology must be evaluated first by the government in order to consider whether that particular technology can be applied to patients for further clinical trials as categorized as 'New Health Technology,' then potentially covered by the insurance sometime later. The aim of this meta-analysis was to assess the safety and efficacy of transanal total mesorectal excision (TaTME) for rectal cancer, activated by the National Evidence-based Healthcare Collaborating Agency (NECA) TaTME committee.

Methods

We systematically searched Ovid-MEDLINE, Ovid-Embase, Cochrane, and Korean databases (from their inception until August 31, 2019) for studies published that compare TaTME with laparoscopic total mesorectal excision (LaTME). End-points included perioperative and pathological outcomes.

Results

Sixteen cohort studies (7 for case-matched studies) were identified, comprising 1,923 patients (938 TaTMEs and 985 LaTMEs). Regarding perioperative outcomes, the conversion rate was significantly lower in TaTME (risk ratio, 0.19; 95% confidence interval, 0.11-0.34; P < 0.001); whereas other perioperative outcomes were similar to LaTME. There were no statistically significant differences in pathological results between the 2 procedures.

Conclusion

Our meta-analysis showed comparable results in preoperative and pathologic outcomes between TaTME and LaTME, and indicated the benefit of TaTME with low conversion. Extensive evaluations of well-designed, multicenter randomized controlled trials are required to come to unequivocal conclusions, but the results showed that TaTME is a potentially beneficial technique in some specific cases. This meta-analysis suggests that TaTME can be performed for rectal cancer patients as a 'New Health Technology' endorsed by NECA in South Korea.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Combined transabdominal-transanal surgical approach for iatrogenic rectovaginal fistula: two case reports

Rectovaginal fistula (RVF) is a type of anastomotic leakage that may occur after low anterior resection for rectal cancer. The repair of RVF can be challenging because of the scar tissue stenosis and incomplete obstruction. Two patients presented in our department with vaginal faecal discharge almost 7 months after the radical resection of rectal cancer. On vaginal examination, titanium nails related to the rectal surgery were found in the vaginal wall. The patients were diagnosed with RVF. Considering that RVF positions in the patients were high and might adhere to the pelvic tissue, a combined transabdominal-transanal resection and vaginal repair surgery was performed. About 3 months after surgery, both patients underwent colonic closure surgery, with consequent good recovery. A combined transabdominal-transanal approach may provide distinct advantages in surgical repair of difficult cases of RVF.

The incidence and risk factors of low anterior resection syndrome (LARS) after sphincter-preserving surgery of rectal cancer: a systematic review and meta-analysis

BACKGROUND

Many patients after sphincter-preserving surgery experienced anorectal functional disturbances which were known as low anterior resection syndrome (LARS). Although many studies investigated LARS, there was inconsistency of their assessment tools and results. The aim of this systematic review was to elucidate the incidence and risk factors of LARS by a validated tool-LARS score.

METHODS

A systematic literature search in Pubmed, Embase, and Cochrane Library was conducted in April 2020. Studies investigating patients who were evaluated by LARS score 1 year after their sphincter-preserving surgery due to rectal cancer were included. Meta-analysis of incidence was conducted using the double arcsine method. Meta-analysis of each risk factor was conducted using a random effects model.

RESULTS

A total of 50 studies were included. The pooled incidence of major LARS was 44% (95% CI 40-48%; I² = 88%; 36 studies). Long course neoadjuvant radiotherapy (OR 2.89, 95% CI 2.06-4.05; I² = 47%; P < 0.01; 10 studies), total mesorectal excision (TME) (OR 2.13, 95% CI 1.49-3.04; I² = 53%; P < 0.01; 7 studies), anastomotic leak (OR 1.98, 95% CI 1.34-2.93; I² = 39%; P < 0.01; 9 studies), and diverting stoma (OR 1.89, 95% CI 1.58-2.27; I² = 0%; P < 0.01; 13 studies) were associated with increased risk of major LARS. No significant difference was found in major LARS incidence between transanal TME and laparoscopic TME (OR 1.36, 95% CI 0.78-2.40; I² = 19%; P = 0.28; 4 studies). Pouch reconstruction failed to lower the risk of major LARS in long term (OR 1.43, 95% CI 0.88-2.33; I² = 70%; P = 0.29; 9 studies).

CONCLUSION

The incidence of major LARS after sphincter-preserving surgery is relatively high. Neoadjuvant radiotherapy, TME, anastomostic leak, and diverting stoma are major risk factors. No significant differences in postoperative anorectal functions were observed between transanal and laparoscopic TME. Pouch reconstruction was not found to be significantly beneficial to anorectal functions in long term.

Oncology Outcomes of Total Mesorectal Excision with Preservation of Both the Superior Rectum Artery and Left Colonic Artery for Upper-Rectal and Sigmoid Colon Cancers: A Meta-Analysis

Background: Total mesorectal resection (TME) has become the standard surgical procedure for resection of colorectal cancer tumors. We presented a systematic meta-analysis to evaluate the surgical outcomes of laparoscopic TME surgery with preservation or nonpreservation of both the superior rectum artery (SRA) and left colonic artery (LCA) for upper-rectal and sigmoid colon cancers. Methods: The comparative studies were systematically searched on PubMed, Science Direct, Web of Science, Wanfang Data, and China National Knowledge Infrastructure (CNKI) up to April 2021. Primary outcomes were oncology outcomes. And secondary outcomes involved surgical outcomes of interest and postoperative recovery. Results: Five relevant studies with a total of 761 patients undergoing laparoscopic TME surgery were eligible for meta-analysis. Three hundred seven patients received TME with preservation of both SRA and LCA (Group A), and 454 received TME surgery alone (Group B), respectively. Our results indicated that Group A had a less total postoperative complications (P = .000), lower anastomotic leakage rate (P = .002), shorter length of stay (P = .008), and longer operative time (P = .002). However, there was no significant difference between the two groups in terms of lymph node dissections (P = .188), intraoperative bleeding (P = .474), the first postoperative defecation (P = .943), recurrence rate (P = .547), and conversive rate (P = .504). Conclusions: Based on our meta-analysis, laparoscopic TME surgery with preservation of both the SRA and LCA for upper-rectal and sigmoid colon cancers may significantly receive better clinical and surgical outcomes. More well-designed large sample studies are required to replicate the short-term benefits and long-term oncologic outcomes.

Comparison of patient-reported quality of life and functional outcomes following laparoscopic and transanal total mesorectal excision of rectal cancer

Purpose

The effect of transanal total mesorectal excision (TaTME) on patients' quality of life and functional outcomes is not fully understood. This study aimed to compare the quality of life and bowel, anorectal, and urogenital functions after laparoscopic and TaTME.

Methods

Laparoscopic or TaTME was performed for 202 propensity score-matched patient pairs with rectal cancer between January 2014 and December 2017 at the National Cancer Center, Korea. The outcomes for all patients were assessed using anorectal manometry, the European Organization for Research and Treatment of Cancer (EORTC) Core Quality of Life Questionnaire (QLQ-C30) and Colorectal Cancer-Specific Quality of Life Questionnaire (QLQ-CR38), low anterior resection syndrome (LARS) score, Fecal Incontinence Severity Index, and International Prostate Symptom Score (IPSS). This retrospective comparative study included patients who completed anorectal manometry and the questionnaires before treatment and at 1 year after surgery.

Results

The EORTC QLQ-C30 and QLQ-CR38 showed comparable outcomes regarding the quality of life in both groups. More patients experienced major LARS in the transanal group at 1 year postoperatively (31.0% vs. 6.8% in the laparoscopic group, P = 0.004). Multivariable analysis revealed no significant difference in the LARS score between the groups at 1 year postoperatively (odds ratio, 2.30; 95% confidence interval, 0.79–6.72; P = 0.127). Significant differences in the IPSS were not noted between the groups.

Conclusion

The quality of life and functional outcomes were comparable between the laparoscopic and transanal approaches; however, our findings suggest a higher rate of LARS after TaTME.

Oncological and Functional Outcomes of Transanal Total Mesorectal Excision in a Teaching Hospital in the Netherlands

Purpose

Transanal total mesorectal excision (TaTME) was developed to overcome surgical difficulties experienced in distal pelvic dissection. Concerns have been raised about potential worse postoperative functional outcomes after TaTME. Also, the oncological safety was questioned. This study aimed to describe the functional, surgical, oncological outcomes and quality of life (QoL) after TaTME.

Methods

All consecutive TaTME cases for rectal cancer without disseminated disease between December 2016 and April 2019 were included. The Wexner incontinence score, low anterior resection syndrome (LARS) score, fecal incontinence-related QoL, and the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-core questionnaire and 29-item module (EORTC QLQ-C30/CR29) were collected. Kaplan-Meier analysis was used to calculate local recurrence-free survival.

Results

Thirty patients were eligible for analysis of which 23 received questionnaires. Response rate was 74%. After a median follow-up of respectively 20.0 and 23.0 months for functional and oncological outcomes, the median (interquartile range) of Wexner incontinence and LARS scores were 9.0 (7.0-12.0) and 33.1 (25.0-39.0). Major LARS was present in 73.3%. Fecal incontinence, general and colorectal-specific QoL subdomains that are associated with poor bowel function scored in line with previously reported data. The 2-year actuarial cumulative local recurrence rate was 3.7% (95% confidence interval, 2.4%-5.0%).

Conclusion

TaTME may lead to significant functional impairments. Patients should receive preoperative counseling on this topic and be fully aware of the potential consequences of their treatment. Oncological data were in line with other short- to moderate-term data and did not show alarming results.

Comparing functional outcomes between transanal total mesorectal excision (TaTME) and laparoscopic total mesorectal excision (LaTME) for rectal cancer: a systematic review and meta-analysis

BACKGROUND

There is concern that transanal total mesorectal excision (TaTME) may result in poorer functional outcomes as compared to laparoscopic TME (LaTME). These concerns arise from the fact that TaTME entails both a low anastomosis and prolonged dilatation of the anal sphincter from the transanal platform.

OBJECTIVES

This paper aimed to assess the comparative functional outcomes following TaTME and LaTME, with a focus on anorectal and genitourinary outcomes.

DATA SOURCES

A meta-analysis and systematic review was performed on available literature between 2000 and 2020 from the PubMed, EMBASE, Medline, and Cochrane Library databases.

STUDY SELECTION

All comparative studies assessing the functional outcomes following taTME versus LaTME in adults were included.

MAIN OUTCOME MEASURE

Functional anorectal and genitourinary outcomes were evaluated using validated scoring systems.

RESULTS

A total of seven studies were included, consisting of one randomised controlled trial and six non-randomised studies. There were 242 (52.0%) and 233 (48.0%) patients in the TaTME and LaTME groups respectively. Anorectal functional outcomes were similar in both groups with regard to LARS scores (30.6 in the TaTME group and 28.3 in the LaTME group), Jorge-Wexner incontinence scores, and EORTC QLQ C30/29 scores. Genitourinary function was similar in both groups with IPSS scores of 5.5 to 8.0 in the TaTME group, and 3.5 to 10.1 in the LaTME group. (p = 0.835).

CONCLUSION

This review corroborates findings from previous studies in showing that the transanal approach is not associated with increased anal sphincter damage. Further prospective clinical trials are needed in this field of research.

Comparison of oncological and functional outcomes and quality of life after transanal or laparoscopic total mesorectal excision for rectal cancer: a systematic review and meta-analysis

BACKGROUND

The aim of this study was to compare long-term oncological, functional outcomes and quality of life (QoL) after transanal total mesorectal excision (TaTME) and laparoscopic total mesorectal excision (LaTME) for rectal cancer.

METHODS

A systematic review and meta-analysis based on Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were conducted on PubMed and Cochrane database. Non-randomized controlled trials (NRCTs) which compared TaTME with LaTME were included.

RESULTS

Ten non-randomized studies were identified, including a total of 638 patients (323 TaTME and 315 LaTME). Age, sex, body mass index, neoadjuvant treatment and American Society of Anesthesiologists (ASA) staging of patients in the two groups were comparable in all included studies. The follow-up period was significantly shorter in the TaTME group than in the LaTME group. No significant differences in local (p = 0.71) and distant (p = 0.23) recurrence rate, 2-year disease-free (p = 0.86) and overall (p = 0.25) survival was found. Also, no significant differences in function outcomes and QoL, including the Wexner score (p = 0.48) or the International Prostate Syndrome Score (IPSS) (p = 0.64) were found. However, the low anterior resection syndrome (LARS) score was significantly higher in the TaTME group (p = 0.04).

CONCLUSIONS

TaTME and LaTME have similar long-term oncological and functional outcomes as well as QoL. The only exception is higher LARS scores after TaTME. The current data are based mainly on observational studies and further randomized controlled trials are required.

SP rTaTME: initial clinical experience with single-port robotic transanal total mesorectal excision (SP rTaTME)

BACKGROUND

The technical difficulty and steep learning curve of transanal total mesorectal excision (taTME) has limited widespread adoption. The single-port (SP) daVinci robot is designed to facilitate single-incision and natural-orifice transluminal endoscopic surgery (NOTES). This paper describes the first clinical experience of single-port robotic taTME (SP rTaTME).

METHODS

This was a prospective study on consecutive patients with rectal cancer who underwent SP rTaTME proctosigmoidectomy with handsewn coloanal anastomosis in December 2018 and January 2019. The primary outcome was technical feasibility of the procedure. The secondary outcomes include blood loss, intraoperative complications, length of hospital stay, quality of the TME specimen, short- and long-term morbidity and mortality, as well as short-term oncologic follow -up.

RESULTS

There were two patients, a 48-year-old male and a 38-year-old female. Both operations were completed successfully without complications or conversion. Estimated blood loss was 200 mL and 130 mL. In both cases the TME was completed transanally using the SP robot. In the first patient, the abdominal portion was completed through an abdominal single-incision; in the second patient the operation was entirely performed transanally as a pure NOTES procedure. In both cases, the final pathology report showed a complete TME with negative margins. Patients were discharged on postoperative day 3 and 4,respectively. There was no long-term morbidity or mortality.

CONCLUSIONS

SP rTaTME is feasible and can be safely performed. It provides excellent optics and dexterity to work in a limited space. Future studies are required to further define the safety profile and the ultimate utility of the SP robot for taTME.

Transanal total mesorectal excision and low anterior resection syndrome

BACKGROUND

Bowel dysfunction after rectal cancer surgery is common, with some experiencing low anterior resection syndrome (LARS) is common after rectal cancer surgery. This study examined if transanal total mesorectal excision (TaTME) has a similar risk of LARS and altered quality of life (QoL) as patients who undergo low anterior resection (LAR).

METHODS

Patients who underwent TaTME or traditionally approached total mesorectal excision in a prospective colorectal cancer cohort study (2014-2019) were propensity score matched in a 1 : 1 ratio. LARS and QoL scores were assessed before and after surgery with a primary endpoint of major LARS at 12 months analysed for possible association between factors by logistic regression.

RESULTS

Of 61 TaTME and 317 LAR patients eligible, 55 from each group were propensity score matched. Higher LARS scores (30.6 versus 25.4, P = 0.010) and more major LARS (65 versus 42 per cent, P = 0.013; OR 2.64, 95 per cent c.i. 1.22 to 5.71) were reported after TaTME. Additionally, QoL score differences (body image, bowel frequency, and embarrassment) were worse in the TaTME group.

CONCLUSIONS

TaTME may be associated with more severe bowel dysfunction than traditional approaches to rectal cancer.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Short-term outcomes of medium-low rectal cancer treated by taTME and experience of 22 cases

BACKGROUND AND METHODS

Transanal total mesorectal excision (taTME) is a novel radical resection technique that may address the unsatisfactory functional and oncological outcomes of medium-low rectal cancers. Although its oncological safety remains unclear, taTME has demonstrable value in surgery, complications, and oncological outcomes. Here, we explore the short-term outcomes of rectal cancer after taTME and discuss the surgical experience. Twenty-two patients with medium-low rectal cancer who underwent taTME were retrospectively evaluated. Comprehensive demographic, oncological, and clinical data were analyzed and the perioperative state and postoperative follow-up were evaluated.

RESULTS

Over a median follow-up period of 24.4 (4-36) months, local recurrence occurred in one patient at 6 months postsurgery. Fecal incontinence was the most common postoperative complication, and 3-6 months of pelvic-floor-rehabilitation training greatly improved  anal function CONCLUSIONS: taTME achieved satisfactory short-term outcomes in oncological complications and postoperative functions. Accurate intraoperative anatomical location, identification of the rectovesical fascia, and neuroprotection are critical. However, this procedure has a steep learning curve, and large samples and multicenter studies are required to substantiate its effectiveness.

DISCUSSION

We retrospectively analyzed the oncological and functional prognosis of 22 patients with colorectal cancer undergoing taTME surgery and preliminarily concluded taTME can be regarded as a safe and feasible treatment.

Transanal proctocolectomy and ileal pouch-anal anastomosis (TaIPAA) for ulcerative colitis: medium term functional outcomes in a single centre

Background

Transanal dissection of the rectum has been recently introduced for ileal pouch-anal anastomosis (IPAA) in UC showing promising results. Thanks to the precise identification of the rectotomy site the risk of long rectal stump is avoided, and a single stapled anastomosis is performed easily. The aim of this study is to analyze our initial experience of transanal proctocolectomy and ileal pouch-anal anastomosis (TaIPAA), considering postoperative complications and medium-term functional outcomes.

Methods

Our Center has experienced the transanal approach for proctectomy and IPAA since August 2018. All patients underwent Enhanced Recovery After Surgery (ERAS) protocol. Postoperative complications occurring within 30 days after surgery were taken into consideration. Fecal continence, genito-urinary activity and global quality of life at 1 and 6 months after ileostomy reversal have been assessed.

Results

Until March 2019, 8 patients underwent transanal proctocolectomy and ileal pouch-anal anastomosis (TaIPAA). In all cases the laparoscopic approach was performed during the transabdominal phase; abdominal drainage was never used. At the time of the pouch construction a defunctioning loop ileostomy was created in all patients. Stoma closure was performed in all cases at a median time of 6 months after surgery. Postoperative complications occurred in only one patient, who showed rectal bleeding, not required a re-invertation. There were no cases of anastomotic leakage. Medium-term functional outcomes were determined prospectively using previously validated quality of life questionnaires (Cleveland Global Quality of Life). Fecal incontinence for liquid or solid stool, genitourinary and sexual functions were also investigated, showing comparable results with the literature data.

Conclusions

In our experience, transanal proctocolectomy and ileal pouch-anal anastomosis provided good short and medium-term functional results in UC.

Robotic versus transanal total mesorectal excision in sexual, anorectal, and urinary function: a multicenter, prospective, observational study

PURPOSE

Improved long-term survival after low anterior resection (LAR) for rectal cancer highlights the importance of functional outcome. Urogenital and anorectal dysfunction is frequently reported after conventional LAR. Advanced minimally invasive techniques such as robotic (RoTME) and transanal total mesorectal excision (TaTME) might improve functional results by precisely dissecting and preserving autonomic nerves. We compared functional outcomes after RoTME or TaTME in a multicenter study.

METHODS

One hundred twenty patients (55 RoTME/65 TaTME) were prospectively included in four participating centers. Anorectal (Wexner and low anterior resection syndrome (LARS) Score), urinary (International Consultation on Incontinence-Male/Female Lower Urinary Tract Symptoms Score (ICIQ-MLUTS/ICIQ-FLUTS) and International Prostate Symptom Scale (IPSS)), and sexual (International Index of Erectile Function (IIEF), Female Sexual Function Index (FSFI)) outcomes at 12 months after surgery were compared to preoperative scores. The response rate to the 1-year postoperative functional assessment by questionnaire was 79.5%.

RESULTS

RoTME enabled better anorectal function compared to TaTME (LARS score 4.3 ± 2.2 vs. 9.8 ± 1.5, p = 0.038, respectively). TaTME proved superior at preserving male urinary function, while female urinary function was comparable in both groups, with only mild postoperative impairment (RoTME vs. TaTME, respectively: ICIQ-MLUTS 13.8 ± 4.9 vs. 1.8 ± 5.8, p = 0.038; ICIQ-FLUTS Incontinence Score - 0.3 ± 1.0 vs. - 0.2 ± 0.9, p = 0.844). Both techniques demonstrated comparable male (RoTME - 13.4 ± 2.7 vs. TaTME - 11.7 ± 3.4, p = 0.615) and female (RoTME 5.2 ± 4.6 vs. TaTME 10.5 ± 6.4, p = 0.254) sexual function.

CONCLUSION

After adjustment for risk factors, RoTME provided better anorectal functional results, whereas TaTME was better at preserving male urinary function. Overall, both techniques demonstrated only mild postoperative functional impairment.

One-year evaluation of anorectal functionality and quality of life in patients affected by mid-to-low rectal cancer treated with transanal total mesorectal excision

Surgery of mid-to-low rectal cancer is still considered challenging. Transanal total mesorectal excision has been proposed to facilitate the mesorectal dissection, gain sphincter-saving procedures, and reduce functional sequelae. Few studies have investigated long-term functional outcomes and patients' quality of life. The aim of this study was to compare functional outcomes and quality of life before and after transanal total mesorectal excision in 1-year follow-up. Between February 2016 and April 2019, 51 patients with mid- or low rectal cancer undergoing transanal total mesorectal excision at Fondazione Policlinico Universitario "A. Gemelli" were enrolled. Neoadjuvant radiochemotherapy was administered to locally advanced cancers. Before and after the surgical procedure, patients were examined collecting clinical data, LARS score, CCFIS, SF36 and FIQL, performing anorectal manometry and endoanal ultrasonography. Thirty-three patients were eligible and completed the 12 months follow-up. After treatment, six patients (18.2%) had minor or major LARS. A mild but significant increase of CCFIS was documented. Only the mean resting pressure significantly decreased at follow-up. No sphincter lesions were documented. FIQL assessment showed significant reduction of lifestyle, coping/behaviour, and embarrassment, while an increase of general health was assessed by SF36. At both uni- and multivariate analyses the neoadjuvant radiochemotherapy had a not negligible impact. Transanal total mesorectal excision represents a safe approach to patients treated for mid- or low rectal cancer. The functional sequelae can be limited in severity, with a low incidence of minor/major LARS, particularly faecal incontinence. These results are comparable to those obtained by the conventional total mesorectal excision.

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.

Role of minimally invasive surgery for rectal cancer

Rectal cancer is one of the most common malignancies worldwide. Surgical resection for rectal cancer usually requires a proctectomy with respective lymphadenectomy (total mesorectal excision). This has traditionally been performed transabdominally through an open incision. Over the last thirty years, minimally invasive surgery platforms have rapidly evolved with the goal to accomplish the same quality rectal resection through a less invasive approach. There are currently three resective modalities that complement the traditional open operation: (1) Laparoscopic surgery; (2) Robotic surgery; and (3) Transanal total mesorectal excision. In addition, there are several platforms to carry out transluminal local excisions (without lymphadenectomy). Evidence on the various modalities is of mixed to moderate quality. It is unreasonable to expect a randomized comparison of all options in a single trial. This review aims at reviewing in detail the various techniques in regard to intra-/perioperative benchmarks, recovery and complications, oncological and functional outcomes.

Role of minimally invasive surgery for rectal cancer

Rectal cancer is one of the most common malignancies worldwide. Surgical resection for rectal cancer usually requires a proctectomy with respective lymphadenectomy (total mesorectal excision). This has traditionally been performed transabdominally through an open incision. Over the last thirty years, minimally invasive surgery platforms have rapidly evolved with the goal to accomplish the same quality rectal resection through a less invasive approach. There are currently three resective modalities that complement the traditional open operation: (1) Laparoscopic surgery; (2) Robotic surgery; and (3) Transanal total mesorectal excision. In addition, there are several platforms to carry out transluminal local excisions (without lymphadenectomy). Evidence on the various modalities is of mixed to moderate quality. It is unreasonable to expect a randomized comparison of all options in a single trial. This review aims at reviewing in detail the various techniques in regard to intra-/perioperative benchmarks, recovery and complications, oncological and functional outcomes.

Optimising functional outcomes in rectal cancer surgery

Background

By improved surgical technique such as total mesorectal excision (TME), multimodal treatment and advances in imaging survival and an increased rate of sphincter preservation have been achieved in rectal cancer surgery. Minimal-invasive approaches such as laparoscopic, robotic and transanal-TME (ta-TME) enhance recovery after surgery. Nevertheless, disorders of bowel, anorectal and urogenital function are still common and need attention.

Purpose

This review aims at exploring the causes of dysfunction after anterior resection (AR) and the accordingly preventive strategies. Furthermore, the indication for low AR in the light of functional outcome is discussed. The last therapeutic strategies to deal with bowel, anorectal, and urogenital disorders are depicted.

Conclusion

Functional disorders after rectal cancer surgery are frequent and underestimated. More evidence is needed to define an indication for non-operative management or local excision as alternatives to AR. The decision for restorative resection should be made in consideration of the relevant risk factors for dysfunction. In the case of restoration, a side-to-end anastomosis should be the preferred anastomotic technique. Further high-evidence clinical studies are required to clarify the benefit of intraoperative neuromonitoring. While the function of ta-TME seems not to be superior to laparoscopy, case-control studies suggest the benefits of robotic TME mainly in terms of preservation of the urogenital function. Low AR syndrome is treated by stool regulation, pelvic floor therapy, and transanal irrigation. There is good evidence for sacral nerve modulation for incontinence after low AR.

Transanal Ileal Pouch-Anal Anastomosis for Ulcerative Colitis has Comparable Long-Term Functional Outcomes to Transabdominal Approach: A Multicentre Comparative Study

BACKGROUND

The transanal approach to ileal pouch-anal anastomosis [Ta-IPAA] provides better access to the lower pelvis with lower short-term morbidity in ulcerative colitis [UC]. The aim of this study was to assess the long-term functional outcomes after Ta-IPAA vs transabdominal IPAA [Abd-IPAA] in UC.

METHODS

A multicentre cohort analysis was performed between March 2002 and September 2017. Patient characteristics, surgical details and postoperative outcomes were compared. CGQL [Cleveland global quality of life] score at 12 months with a functioning pouch was considered the primary end point.

RESULTS

A total of 374 patients [100 Ta-IPAA vs 274 Abd-IPAA] were included. Ta-IPAA demonstrated a comparable overall quality of life [CGQL score] to Abd-IPAA [0.75 ± 0.11 vs 0.71 ± 0.14; respectively, p = 0.1]. Quality of life [7.71 ± 1.17 vs 7.30 ± 1.46; p = 0.04] and energy-level items [7.16 ± 1.52 vs 6.66 ± 1.68; p = 0.03] were significantly better after Ta-IPAA, while the quality of health item was comparable [7.68 ± 1.26 vs 7.64 ± 1.44; p = 0.96]. Analysis excluding anastomotic leaks did not change the overall CGQL scores. Stool frequencies [>10/24 h: 22% vs 21%; p = 1.0] and the rate of a single episode of major incontinence during the following 12-month period [27% vs 26%; p = 0.89] were similar. The differences in 30-day morbidity rates [33% vs 41%; p = 0.2] and anastomotic leak rates were not significant [6% vs 13%; p = 0.09].

CONCLUSIONS

This study provides evidence of comparable long-term functional outcome and quality of life after Ta-IPAA and Abd-IPAA for UC.