Transanal endoscopic total mesorectal excision: technical aspects of approaching the mesorectal plane from below--a preliminary report

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.

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.

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

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.

Transanal Total Mesorectal Excision: Description of the Technique

Surgery remains the gold standard for the treatment of locally advanced rectal cancer. The most effective approach to reduce locoregional recurrence is total mesorectal excision (TME). However, obtaining an optimal TME is demanding, especially in low rectal tumors and anatomically unfavorable pelvis. Transanal TME (taTME) was developed to facilitate low pelvis dissection and potentially provide optimal outcomes for oncologic resection. Current studies have reported satisfactory short-term outcomes. However, taTME is a technically challenging procedure and must be learned in an appropriate training process to allow for a safe implementation. Previous experience in laparoscopic and transanal surgery is strongly recommended. In this work, we provide a detailed discussion of the technique, based on the realization of more than 400 taTME interventions.

Total Mesorectal Excision Technique-Past, Present, and Future

While the treatment of rectal cancer is multimodal, above all, a proper oncological resection is critical. The surgical management of rectal cancer has substantially evolved over the past 100 years, and continues to progress as we seek the best treatment. Rectal cancer was historically an unsurvivable disease, with poor understanding of the embryological planes, lymphatic drainage, and lack of standardized technique. Major improvements in recurrence, survival, and quality of life have resulted from advances in preoperative staging, pathologic assessment, the development and timing of multimodal therapies, and surgical technique. The most significant contribution in advancing rectal cancer care may be the standardization and widespread implementation of total mesorectal excision (TME). The TME, popularized by Professor Heald in the early 1980s as a sharp, meticulous dissection of the tumor and mesorectum with all associated lymph nodes through the avascular embryologic plane, has shown universal reproducible reductions in local recurrence and improvement in disease-free and overall survival. Widespread education and training of surgeons worldwide in the TME have significantly impact outcomes for rectal cancer surgery, and the procedure has become the gold standard for curative resection of rectal cancer. In this article, we discuss the evolution of the standard abdominal approach to the TME, with emphasis on the history, relevant anatomy, standard procedure steps, oncologic outcomes, and technical evolution.

Transanal total mesorectal excision: the Slagelse experience 2013-2019

OBJECTIVE

To describe outcomes after transanal total mesorectal excision (TaTME) 5 years from implementation at a large-volume colorectal unit, including local recurrence, distant metastasis, and survival.

BACKGROUND

Transanal total mesorectal excision (TaTME) is a relatively new procedure for mid- and low-rectal cancer, with well-documented safety and feasibility. However, data on long-term results are limited.

METHODS

This study was based on a prospective data collection via a maintained database in a large colorectal unit. The database included patients who underwent TaTME from December 2013 through July 2019. We have updated the database through a review of patient charts, including radiology and pathology reports. Data collection included operative details, intraoperative findings, postoperative complications, pathologic results, and oncologic results.

RESULTS

During the study period, two hundred patients underwent TaTME in the study period (men = 147). The mean BMI was 26.7%, and the mean tumor height from the anal verge was 7.86 cm. Neoadjuvant treatment was given to 22% of patients. Anastomotic leakage occurred in 9.3% of patients, and the overall rate of postoperative complications was 24.5%. The TME specimen was incomplete in 11% of patients, and the CRM was positive in 5.5% of patients. Local recurrence (LR) occurred in seven patients with a follow-up of at least 2 years (4.7%). Distant metastasis (DM) occurred in 12% of patients. The overall survival was 90% and disease-free survival was 81%. The operating time was reduced in the later period of our experience.

CONCLUSIONS

This study showed that TaTME is feasible, safe, and had acceptable short-term outcomes and an acceptable rate of LR. The study included, however, one group that was non-randomized, and the follow-up was not long enough for most patients. Studies with longer follow-up data are awaited.

Trans-perineal minimally invasive approach during extralevator abdominoperineal excision for advanced low rectal cancer: A retrospective cohort study

BACKGROUND

This study is to evaluate trans-perineal minimally invasive approach for extralevator abdominoperineal excision (TP-ELAPE) in a synchronous lithotomy position for locally advanced low rectal cancer.

METHODS

Between May 2013 and February 2016, 14 patients with locally advanced low rectal cancer underwent TP-ELAPE for the perineal phase of extralevator abdominoperineal excision, and 18 patients underwent conventional ELAPE.

RESULTS

There was no positive circumferential resection margin in both groups. Patients who received TP-ELAPE had similar bowel perforation rate (7.1% vs. 5.6%, p = 1.000), longer transperineal operative time (100 vs. 40 min, p < 0.001) and higher surgical difficulty visual analog scale (VAS) scores (6 vs. 2, p < 0.001), while had shorter total procedure time (215 vs. 260 min, p = 0.015), lower VAS pain scores on day 1 postoperatively (5 vs. 6.5, p = 0.049), shorter postoperative anus exhausting time (22 h vs 28 h, p = 0.006), and shorter postoperative hospital stay (11.5 d vs 13.5d, p = 0.028) compared with patients who received conventional ELAPE. There was no local recurrence with median follow-up time of 53 months in the TP-ELAPE group and 51 months in the conventional ELAPE group. There were no differences for disease-free survival (p = 0.835) and overall survival (p = 0.829) between groups.

CONCLUSIONS

TP-ELAPE approach in the synchronous lithotomy position might be a feasible approach for low rectal cancer, while ensuring a radical and safe surgical procedure.

Transanal total mesorectal excision for locally advanced middle-low rectal cancers

Background

This study investigated the results of transanal total mesorectal excision (TaTME) combined with laparoscopy for locally advanced mid–low rectal cancer.

Methods

Patients with mid–low locally advanced rectal cancer (T3 category or above and/or N+) who underwent rectal resection with TaTME technique were enrolled prospectively. Patients who had distant metastasis, multiple malignancies, intestinal obstruction or perforation, or a clinical complete response to chemoradiotherapy were excluded. Postoperative results, including morbidity, circumferential resection margin (CRM) assessment, short‐term survival and functional outcomes, were analysed.

Results

Thirty‐eight patients, with 25 mid and 13 low rectal tumours, who had elective resection by TaTME from March 2015 to September 2018 were included. There were 25 men and 13 women. Mean(s.d.) age was 58·2(16·4) years and mean(s.d.) BMI was 24·2(2·5) kg/m². Tumours were 3–9 cm from the anal verge. Mean(s.d.) duration of surgery was 210(42) min. All patients had hand‐sewn anastomoses and protective ileostomies. There were no conversions, abdominal perineal resections or postoperative deaths. Four patients had a complication, including three presacral abscesses, all managed by transanastomotic drainage. At 3 months after ileostomy closure, all patients had perfect continence. Apart from a greater tumour diameter in patients with low rectal cancers (6·0 cm versus 4·6 cm in those with mid rectal tumours; P = 0·035), clinical features were similar in the two groups. CRM positivity was greater for low than for mid rectal tumours (3 of 13 versus 0 of 25 respectively; P = 0·034), and more patients with a low tumour had TME grade 2 (4 of 13 versus 1 of 25; P = 0·038). There was no difference in oncological outcomes at 17 months.

Conclusion

Although this study cohort was small, special attention should be paid to bulky low rectal tumours to reduce the rate of CRM positivity.

Short- and long-term outcomes of transanal versus laparoscopic total mesorectal excision for mid-to-low rectal cancer: a meta-analysis

BACKGROUND AND OBJECTIVES

Transanal total mesorectal excision (TaTME) is positioned at the cutting edge of minimally invasive approach to mid- and low rectal cancer. This meta-analysis was to compare the short- and long-term outcomes of TaTME versus laparoscopic total mesorectal excision (LTME) and to evaluate the safety, efficacy, and possible superiority of TaTME.

METHODS

A comprehensive search was conducted for randomized controlled trials (RCTs) and non-RCTs (NRCTs) comparing TaTME with LTME. Inter-group differences were evaluated via standardized mean differences and relative risks (RRs). All outcomes were analyzed using fixed effects or random effects models according to the heterogeneity. Statistical analysis was performed using Stata/SE 12.0 software.

RESULTS

Eleven studies (1 RCT and 10 NRCTs) with involving 757 patients were included. Among which, 361 patients underwent TaTME and 396 patients underwent LTME. Comparing the surgical and oncological quality of resection of TaTME with that of LTME, reports of TaTME indicated favorable outcomes considering mesorectal resection quality, circumferential resection margin involvement, intraoperative blood loss, conversions, and postoperative complications, while the differences between the two groups had no statistical significance in terms of distal resection margin, harvested lymph node, operation time, hospital stay, recurrence, 2-year overall survival (OS), and 2-year disease-free survival.

CONCLUSION

TaTME is a promising surgical technique and is fully a safe, efficacious, and diffusible alternative to LTME in managing mid- and distal rectal cancer. Larger scale, national, multicentric RCTs are warranted to further verify these results and the possible superiority of TaTME.

The anatomy of transanal minimally invasive surgery: Perineal distances and transanal angles

The recent interest in transanal, minimally invasive surgery has highlighted the importance of an in depth understanding of this complex region. We applied data from an anatomical study of the perineum to the concept of transanal minimally invasive surgery with the aim to describe more accurately anatomy relevant to this surgical technique. A consecutive series of adult patients undergoing colonoscopy were approached for consent to measure dimensions and angles of the perineum before the examination. Distances from the posterior margin of the anus to the coccyx, and the anterior margin of the anus to the posterior edge of the scrotum or introitus were measured. Then, using a pediatric proctoscope and a protractor, the anoperineal angle and the recto perineal angles were measured. The anorectal angle was derived from these measurements. Data is described using means and standard deviations. Measurements were obtained from 106 patients undergoing elective colonoscopy for average risk screening with no history of defecatory disorder. Posterior perineal length was similar in both sexes (4.5 cm ± 0.9 in women and 4.6 cm ±0.7 in men) but the anterior perineum was significantly shorter in women (2.5 ± 0.8). The mean anoperineal angle was 93° (±9), and mean rectoperineal angle was 73° (±9). These angles varied significantly between the sexes. The mean anorectal angle (derived) was 160° (±9), and did not differ significantly between the sexes. There was no correlation between the posterior perineal length and ano perineal, recto perineal, or anorectal angles. Limitations: small sample size. Anoperineal and recto perineal differ significantly between the sexes. Surgeons using transanal minimally invasive surgical techniques should expect to alter the alignment of their dissection accordingly. This study shows the magnitude of the differences that can exist. Clin. Anat. 32:68-72, 2019. © 2018 Wiley Periodicals, Inc.

Transanal Total Mesorectal Excision: Why, When, and How

Transanal total mesorectal excision (taTME) has evolved over the past decade fueled by advances in minimally invasive surgery. The technique aims to overcome the constraints posed by a narrow rigid pelvis and poor TME visualization that are encountered during "top-down" rectal surgery. A more accurate pelvic dissection should subsequently result in safer oncological resections and better preservation of pelvic autonomic nerves. taTME is an advanced complex technique that requires dedicated training and experience in TME surgery. Initial results from small cohorts are promising and confirmation by randomized controlled trials is eagerly awaited.

Operative vectors, anatomic distortion, fluid dynamics and the inherent effects of pneumatic insufflation encountered during transanal total mesorectal excision

BACKGROUND

Transanal total mesorectal excision (taTME) is an altogether different approach to rectal cancer surgery, and the effects of carbon dioxide (CO₂) on this dissection remain poorly described.

METHODS

This article critically examines the effect of carbon dioxide insufflation and the workspace it creates during the process of taTME. The unique aspects of insulation with this approach are governed by the laws of physics, especially the principles of fluid dynamics, an area that remains poorly described for laparoscopy and not at all described for taTME.

RESULTS

A summary of established factors which affect the operative field of the taTME surgeon is delineated and further explored. In addition, new concepts regarding gas delivery, such as insufflation vectors, anatomic distortion, hyper-dissection, and workspace volume rate of change as a function of taTME dissection time, are addressed. Collectively, these factors pose important challenges which increase case complexity and are thus essential for taTME trainers and trainees alike to understand.

CONCLUSIONS

Although an invisible gas, CO₂ insufflation with taTME produces markedly visible effects which are imposed upon the operative field. This can result in anatomic distortion and misperception of operative planes. Thus, practicing taTME surgeons should be cognizant of these effects.

Transanal Total Mesorectal Excision: Pneumodissection of Retroperitoneal Structures Eases Laparoscopic Rectal Resection

INTRODUCTION

Laparoscopic total mesorectal excision is effective and safe but often technically challenging because of inadequate exposure. Transanal total mesorectal excision was introduced to mitigate this limitation and improve the quality of mesorectal dissection in even the most challenging cases. Currently, the technique for transanal total mesorectal excision dissection is not standardized.

TECHNIQUE

The sequential approach to transanal total mesorectal excision mirrors the principles of the transanal abdominal transanal procedure. It begins with the transanal step, followed by the laparoscopic step, and then the transanal total mesorectal excision. The perirectal space is entered via a full-thickness dissection of the anterior rectal wall. Carbon dioxide is left flowing, widening the embryonic planes between the mesorectal and pelvic fascias, then moving upward through the retroperitoneal space. The surgeon switches to the abdominal field and begins laparoscopic dissection, consisting of inferior mesenteric artery dissection and division, inferior mesenteric vein dissection and division, and possible splenic flexure dissection. Pneumodissection facilitates this procedure by distancing the inferior mesenteric artery from the hypogastric nerves and opening the embryonic fusion plane between the Toldt and Gerota fascias to allow faster division of the left colon lateral attachments. The operation continues with a switch to the perineal field and mesorectal excision.

RESULTS

A total of 102 patients underwent transanal total mesorectal excision as described. Mean operative time was 185.0 + 87.5 minutes (range, 60-480 min), and there was no conversion to open surgery. Postoperative morbidity was 33.3%. Mortality rate at 30 days was 1.96% (2 cases). Quality of mesorectal excision according to Quirke was assessed in all of the specimens and found to be complete in 99 cases (97.1%) and nearly complete in 2.9% of cases.

CONCLUSIONS

Transanal total mesorectal excision may benefit from pneumodissection, expedites the laparoscopic step, and the sequential approach facilitates the visualization of the correct dissection planes. The safety and cost-effectiveness of the procedure still warrant consideration. See Video at http://links.lww.com/DCR/A418.

Transanal total mesorectal excision: technical aspects of approaching the mesorectal plane from below

Standardization of transanal total mesorectal excision requires the delineation of the principal procedural components before implementation in practice. This technique is a bottom-up approach to a proctectomy with the goal of a complete mesorectal excision for optimal outcomes of oncologic treatment. A detailed stepwise description of the approach with technical pearls is provided to optimize one's understanding of this technique and contribute to reducing the inherent risk of beginning a new procedure. Surgeons should be trained according to standardized pathways including online preparation, observational or hands-on courses as well as the potential for proctorship of early cases experiences. Furthermore, technological pearls with access to the "video-in-photo" (VIP) function, allow surgeons to link some of the images in this article to operative demonstrations of certain aspects of this technique.

Long-term outcomes by a transanal approach to total mesorectal excision for rectal cancer

BACKGROUND

The challenge of performing a good total mesorectal excision (TME) dissection, particularly in the distal 1/3 of the rectum, has spurred interest in new techniques. Robotic surgery is advocated by some, and more recently, a "new" approach, the transanal total mesorectal excision, has been popularized to address this problem. While great interest in this technique exists, little long-term outcome data are available. We have been utilizing a transanal abdominal transanal approach to TME in order to facilitate the distal dissection, and here, we provide our long-term outcomes using this approach in the management of rectal cancer.

METHODS

From a prospectively maintained rectal cancer database, we identified 373 consecutive rectal cancers treated with sphincter preservation surgery through a combined transanal and abdominal approach to TME. Perioperative, pathological, and oncologic outcomes were analyzed.

RESULTS

Three hundred and seventy-three patients with rectal cancer underwent a transanally initiated TME with mean follow-up of 5.5 years. 91% of cancers were in the distal rectum. 68.9% were men and 53.2% of cancers were tethered or fixed on presentation. 97.7% received neoadjuvant radiotherapy (mean 5405 cGy, 5-fluorouracil based); average time from completion of neoadjuvant therapy to surgery was 11 weeks. 180 and 193 patients underwent completion of their operation through open and laparoscopic abdominal approaches. 96% of TME specimens were complete/near complete, 94% had a negative circumferential resection margin, and 98.6% had a negative distal margin. Perioperative morbidity and mortality rates were 13.4 and 0.3%. Overall local recurrence (LR), DM, and Kaplan-Meier 5-year actuarial survival were 7.4, 19.5, and 90%, respectively.

CONCLUSION

This is the first report of long-term data using a transanal approach to TME supporting this approach for rectal cancer. Our data with 5-year follow-up show that adequate distal and circumferential margins with very good-quality TME specimens, and a low risk for LR with excellent overall survival can be achieved using this technique. Our long-term results support the promising reports of early experiences in the literature.

Transanal Total Mesorectal Excision: A Novel Approach to Rectal Surgery

Less invasive approaches continue to be explored and refined for diseases of the colon and rectum. The current gold standard for the surgical treatment of rectal cancer, total mesorectal excision (TME), is a technically precise yet demanding procedure with outcomes measured by both oncologic and functional outcomes (including bowel, urinary, and sexual). To date, the minimally invasive approach to rectal cancer has not yet been perfected, leaving ample opportunity for rectal surgeons to innovate. Transanal TME has recently emerged as a safe and effective technique for both benign and malignant diseases of the rectum. While widespread acceptance of this surgical approach remains tempered at this time due to lack of long-term oncologic outcome data, short-term outcomes are promising and there is great excitement surrounding the promise of this technique.

[Hybrid TAMIS total mesorectal excision. A new perspective in treatment of distal rectal cancer - Technique and results]

BACKGROUND

Transanal minimally invasive surgery (TAMIS) represents a promising technique for total mesorectal excision (TME) with respect to radicalness and preservation of function. There are only few publications in the literature describing results in patients with distal rectal cancer.

METHODS

Between May 2013 and March 2015, 24 selected patients with a rectal carcinoma < 6 cm from the anal verge underwent a laparoscopically assisted TAMIS TME (Hybrid-TAMIS TME) procedure. This prospective observational study was conducted to examine the safety of the technique and the quality of TME surgery in distal rectal cancer and to assess the short-term postoperative outcome.

RESULTS

The median age of patients (18 male and 6 female) at the time of surgery was 57 years (range 35-77 years) and 7 patients (29 %) had a body mass index (BMI) > 30 kg/m(2). Specimen excision was carried out transanally in 19 patients. Pathological grading of TME specimens was good in 22 (92 %) and moderate in 2 cases. After neoadjuvant radiochemotherapy a complete pathological remission was identified in five patients. The median distal resection margin was 7 mm (range 2-30 mm), the median circumferential resection margin was 6 mm (range <1 mm-30 mm) and in 2 patients the tumor was ≤ 1 mm from the positive circumferential margin. A colonic reservoir was created in 19 patients (79 %) and no 30-day mortalities occurred. Morbidity was 29 %, including 1 anastomotic leak, 2 hematomas and 1 neurogenic bladder.

CONCLUSION

Hybrid-TAMIS TME for distal rectal cancer is safe and can provide a sphincter-preserving high-quality TME in difficult cases. Studies with long-term follow-up assessing oncological and functional results are mandatory.

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

Transanal total mesorectal excision (TaTME) has been developed to improve quality of TME for patients with mid and low rectal cancer. However, despite enthusiastic uptake and teaching facilities, concern exists for safe introduction. TaTME is a complex procedure and potentially a learning curve will hamper clinical outcome. With this systematic review, we aim to provide data regarding morbidity and safety of TaTME. A systematic literature search was performed in MEDLINE (PubMed), EMBASE (Ovid) and Cochrane Library. Case reports, cohort series and comparative series on TaTME for rectal cancer were included. To evaluate a potential effect of case volume, low-volume centres (n ≤ 30 total volume) were compared with high-volume centres (n > 30 total volume). Thirty-three studies were identified (three case reports, 25 case series, five comparative studies), including 794 patients. Conversion was performed in 3.0% of the procedures. The complication rate was 40.3, and 11.5% were major complications. The quality of the mesorectum was “complete” in 87.6%, and the circumferential resection margin (CRM) was involved in 4.7%. In low- versus high-volume centres, the conversion rate was 4.3 versus 2.7%, and major complication rates were 12.2 versus 10.5%, respectively. TME quality was “complete” in 80.5 versus 89.7%, and CRM involvement was 4.8 and 4.5% in low- versus high-volume centres, respectively. TaTME for mid and low rectal cancer is a promising technique; however, it is associated with considerable morbidity. Safe implementation of the TaTME should include proctoring and quality assurance preferably within a trial setting.

Transanal total mesorectal excision: dissection tips using 'O's and 'triangles'

PURPOSE

Transanal total mesorectal excision (taTME) requires specific technical expertise, as it is often difficult to ascertain the correct dissection plane. Consequently, one can easily enter an incorrect plane, potentially resulting in bleeding (sidewall or presacral vessels), autonomic nerve injury and urethral injury. We aim to demonstrate specific visual features, which may be encountered during surgery and can guide the surgeon to perform the dissection in the correct plane.

METHOD

Specific features of dissection in the correct and incorrect planes are demonstrated in the accompanying video.

RESULTS

The 'triangles' created using appropriate traction can aid in performing a precise dissection in the correct plane. Recognition of features described as 'O's can alert surgeons that they are entering a new fascial plane and can avoid incursion into an incorrect plane.

CONCLUSION

Understanding and recognizing the described features which can be encountered in taTME surgery, a safe and accurate TME dissection can be facilitated.

Feasibility of transanal endoscopic total mesorectal excision for rectal cancer: results of a pilot study

Purpose

To evaluate the feasibility of transanal total mesorectal excision (TME) in patients with rectal cancer.

Methods

This study enrolled 12 patients with clinically node negative rectal cancer located 4–12 cm from the anal verge who underwent transanal endoscopic TME with the assistance of single port laparoscopic surgery between September 2013 and August 2014. The primary endpoint was TME quality; secondary endpoints included number of harvested lymph nodes and postoperative complications within 30 days (NCT01938027).

Results

The 12 patients included 7 males and 5 females, of median age 59 years and median body mass index 24.2 kg/m². Tumors were located on average 6.7 cm from the anal verge. Four patients (33.3%) received preoperative chemoradiotherapy. Median operating time was 195 minutes and median blood loss was 50 mL. There were no intraoperative complications and no conversions to open surgery. TME was complete or nearly complete in 11 patients (91.7%). Median distal resection and circumferential resection margins were 18.5 mm and 10 mm, respectively. Median number of harvested lymph nodes was 15. Median length of hospital stay was 9 days. There were no postoperative deaths. Six patients experienced minor postoperative complications, including urinary dysfunction in 2, transient ileus in 3, and wound abscess in 1.

Conclusion

This pilot study showed that high-quality TME was possible in most patients without serious complications. Transanal TME for patients with rectal cancer may be feasible and safe, but further investigations are necessary to evaluate its long-term functional and oncologic outcomes and to clarify its indications.

Comparison of short-term clinical outcomes between transanal and laparoscopic total mesorectal excision for the treatment of mid and low rectal cancer: A meta-analysis

AIM

The objective of this meta-analysis was to evaluate the feasibility, safety, and short-term clinical outcomes of transanal total mesorectal excision (TaTME) comparing with laparoscopy total mesorectal excision (LapTME) for mid and low rectal cancer.

METHODS

Relevant studies were searched from the databases of Pubmed, Embase, and the Cochrane Library. The qualities of all of the included studies were evaluated using Newcastle-Ottawa Scale (NOS). The synthesized outcomes were pooled using fixed-effects models or random-effects models, which weighted the odds ratio (OR) or mean difference (MD) with 95% confidence intervals (95% CI). A funnel plot was used to evaluate the publication bias.

RESULTS

Seven original studies including 209 TaTME patients and 257 LapTME patients with rectal cancer met the inclusion criteria in this meta-analysis. Compared with LapTME, TaTME showed a longer CRM, lower rate of positive CRM, complete TME rate, and less operative time. There were no significant differences in the outcomes of the harvested lymph nodes, distal margin distance, hospital stay, intraoperative complications, anastomotic leakage, postoperative complications, reoperation, readmission, or conversion between the TaTME group and the LapTME group.

CONCLUSIONS

Compared with LapTME, TaTME is a feasible and safe approach for patients with mid and low rectal cancer. In addition, TaTME showed a better short-term clinical outcomes, such as a longer CRM, lower risk of positive CRM, higher complete quality of TME rate, and shorter operative duration. Further prospective studies with long-term follow-up are required.

[Total mesorectal excision in rectal cancer management: laparoscopic or transanal?]

AIM

To evaluate and compare intraoperative features, early surgical outcomes, quality of excised specimen after laparoscopic and transanal total mesorectal excision (LA-TME and TA-TME).

MATERIAL AND METHODS

Prospective randomized study included 45 patients with confirmed rectal adenocarcinoma (cT2-4N0-2M0) since October 2013. LA-TME and TA-TME groups consisted of 23 and 22 patients respectively. Inclusion criteria were patients with primary-operable rectal cancer and satisfactory response after neoadjuvant chemo- and radiotherapy. Both groups were comparable in stages of cancer, age and body mass index (BMI). Median length from anal edge was 6.5 cm and 7 cm in TA-TME and LA-TME groups respectively. There was significantly greater number of patients after chemo- and radiotherapy in TA-TME group (86% vs. 48%, p=0.006).

RESULTS

Surgery time was 305 and 320 minutes in LA-TME and TA-TME groups recpectively, median blood loss -- less than 100 ml. Mean hospital-stay was 8.0 days in both groups. Each group had 1 conversion including laparoscopic procedure in TA-TME group. Transanal extraction of specimen was performed in 86% vs. 48% in TA-TME and LA-TME groups respectively (p=0.021). Complications (Clavien-Dindo sclale) were observed in 27% and 26% in TA-TME and LA-TME groups respectively without statistically significance. Complications IIIb, IVb and V degrees were not diagnosed in TA-TME group. Also in this group «good», «satisfactory» and «unsatisfactory» quality of TME was obtained in 68%, 14% and 18% of cases. At the same time in LA-TME group these values were 74%, 9% and 17% respectively (p=0.859). One of operated patients had «positive» lateral edge (TA-TME). Median distal edge of resection was 21 mm and 23 mm in TA-TME and LA-TME groups respectively.

CONCLUSION

Preliminary data show comparable early outcomes after transanal and laparoscopic techniques. Laparotomy and associated compications are avoided in case of transanal extraction of specimen. Further researches are necessary to study functional and long-term results.

Technologies, technical steps, and early postoperative results of transanal TME

INTRODUCTION

First described in 1982, TME overcomes most of the concerns regarding adequate local control after anterior rectal resection. TME requires close sharp dissection along the so-called Heald's plane down to the levators, with distal dissection often cumbersome. In recent years, Transanal TME was introduced with the aim to improve distal rectal dissection and quality of mesorectal excision.

MATERIAL AND METHODS

A prospective, non-randomized study, started in 2013, is currently ongoing in two Italian Centers. Study objectives were assessing the safety of TaTME and TME quality. TaTME technique and technologies as performed in these centers and cumulative results at ≤30 postoperative days of the first 102 patients are reported.

RESULTS

Early postoperative morbidity and mortality rates were 33.3% (34 pts, 16 Clavien-Dindo I + II and 18 Clavien-Dindo III + IV + V), and 1.96% (two deaths), respectively. The quality of mesorectal excision according to Quirke was: complete in 97.1% and nearly complete in 2.9% of the cases.

CONCLUSIONS

The results confirm the effectiveness of TaTME, especially regarding the quality of the mesorectal dissection. Open questions regarding standardization, anatomical landmarks, indications, morbidity (with special regard to local infection and sepsis), learning curve and oncological outcomes require further answers from larger studies and RCTs before definitive validation of this procedure.  .

A Systematic Review of Outcomes After Transanal Mesorectal Resection for Rectal Cancer

BACKGROUND

Transanal mesorectal resection has been developed to facilitate minimally invasive proctectomy for rectal cancer.

OBJECTIVE

The purpose of this study was to evaluate the evidence regarding technical parameters, oncological outcomes, morbidity, and mortality after transanal mesorectal resection.

DATA SOURCES

The Cochrane Library, PubMed, and MEDLINE databases were reviewed.

STUDY SELECTION

Systematic review of the literature from January 2005 to September 2015 was used for study selection.

INTERVENTION

Intervention included transanal mesorectal resection for rectal cancer.

MAIN OUTCOME MEASURES

Technical parameters, histological outcomes, morbidity, and mortality were the outcomes measured.

RESULTS

Fifteen predominately retrospective studies involving 449 patients were included (mean age, 64.3 years; 64.1% men). Different platforms were used. The operative mortality rate was 0.4% and the cumulative morbidity rate 35.5%. Circumferential resection margins were clear in 98%, and the resected mesorectum was grade III in 87% of patients. Median follow-up was 14.7 months. There were 4 local recurrences (1.5%) and 12 patients (5.6%) with metastatic disease. No study followed patients long enough to report on 5-year overall and disease-free survival rates. Functional outcome was only reported in 3 studies.

LIMITATIONS

A low number of procedures were performed by expert early adopters. There are no comparative or randomized data included in this study and inconsistent reporting of outcome variables.

CONCLUSIONS

Transanal mesorectal resection for rectal cancer may enhance negative circumferential margin rates with a reasonable safety profile. Contemporary randomized, controlled studies are required before there can be universal recommendation.

Short-term outcomes after transanal and laparoscopic total mesorectal excision for rectal cancer

BACKGROUND

Transanal total mesorectal excision (taTME) has potential benefits of better visual control, especially in male patients with a high body mass index and low rectal cancer. However, this method has not yet been validated in clinical trials. The aim of this study was to compare the short-term outcomes of transanal and laparoscopic (lap) TME.

METHODS

From October 2013 to January 2015, consecutive patients undergoing transanal or laparoscopic TME for biopsy-proven mrT1-4aN0-2M0 rectal cancer were included in a prospective database. Patients with Eastern Cooperative Oncology Group performance status 2 and higher and patients undergoing partial mesorectal excision were excluded. This analysis focused on short-term surgical outcomes.

RESULTS

From October 2013 to January 2015, 22 taTME procedures and 23 laparoscopic TME procedures were performed. Patient characteristics were comparable between groups, but more patients in the taTME group underwent neoadjuvant (chemo) radiotherapy (87 vs. 48 %, p = 0.006). Median operative time was 320 min in the taTME group and 305 min in the lapTME group. There was one conversion in each group, but the transanal procedure was converted to laparoscopic resection. Transanal specimen extraction was performed in 86 versus 48 % patients in taTME and lapTME groups accordingly (p = 0.021). There was no post-operative mortality and post-operative morbidity in the taTME and lapTME groups was similar (27 vs. 26 %). One patient in the taTME group had positive circumferential resection margins. Oncologic results from resected specimens were comparable.

CONCLUSIONS

Our initial experience demonstrates comparable short-term results for taTME and lap TME. Further investigation is necessary to assess long-term functional and oncologic outcomes.

Four anastomotic techniques following transanal total mesorectal excision (TaTME)

Transanal total mesorectal excision (TaTME) is a novel approach pioneered to tackle the challenges posed by difficult pelvic dissections in rectal cancer and the restrictions in angulation of currently available laparoscopic staplers. To date, four techniques can be employed in order to create the colorectal/coloanal anastomosis following TaTME. We present a technical note describing these techniques and discuss the risks and benefits of each.

Transanal vs laparoscopic total mesorectal excision for rectal cancer: initial experience from Denmark

AIM

Laparoscopic total mesorectal excision (LaTME) has improved short-term outcomes of rectal cancer surgery with comparable oncological results to open approach. LaTME can be difficult in the lowermost part of the rectum, leading potentially to higher rates of complications, conversion to open surgery and probably suboptimal oncological quality. Transanal TME (TaTME) can potentially solve these problems. The aim of this study was to compare the short-term results after TaTME with those after LaTME.

METHOD

A prospectively collected database of consecutive patients who underwent TaTME was maintained. Results were compared with those who underwent LaTME in the preceding period. Patients who underwent low anterior resection or intersphincteric abdominoperineal excision were included. Primary end-points were radical resection and specimen quality. Secondary end-points were complications, rates of conversion, operating time and hospital stay.

RESULTS

In total, 50 patients were included (TaTME = 25, LaTME = 25). The groups were comparative in demographic data and tumour characteristics. Circumferential resection margin was positive in one patient in the TaTME group vs four patients in the LaTME group (P = 0.349). All patients in the TaTME group had either complete or nearly complete specimen quality, while four patients in the LaTME group had incomplete specimen quality (P = 0.113). Less blood loss, shorter operating time and shorter hospital stay were found in the TaTME group (P values 0.016, 0.002 and 0.020 respectively). Intra-operative complications were comparable (P = 0.286).

CONCLUSION

The TaTME procedure had comparable pathological results and acceptable short-term postoperative outcomes compared to LaTME.

Transanal total mesorectal excision: Towards standardization of technique

AIM: To describe the role of Transanal total mesorectal excision (TaTME) in minimally invasive rectal cancer surgery, to examine the differences in patient selection and in reported surgical techniques and their impacts on postoperative outcomes and to discuss the future of TaTME.

METHODS: MEDLINE (PubMed), EMBASE, and The Cochrane Library were systematically searched through the 1^st of March 2015 using a predefined search strategy.

RESULTS: A total of 20 studies with 323 patients were included. Most studies were single-arm prospective studies with fewer than 100 patients. Multiple transanal access platforms were used, and the laparoscopic approach was either multi- or single port. The procedure was initiated transanally or transabdominally. If a simultaneous approach with 2 operating surgeons was chosen, the operative time was significantly reduced.

CONCLUSION: TaTME was also associated with better TME specimens and a longer distal resection margin. TaTME is thus feasible in expert hands, but the learning curve and safety profile are not well defined. Long-term follow-up regarding anal function and oncological outcomes should be performed in the future.

Transanal total mesorectal excision: A valid option for rectal cancer?

Low anterior resection can be a challenging operation, especially in obese male patients and in particular after radiotherapy. Transanal total mesorectal excision (TaTME) might offer technical advantages over laparoscopic or open approaches particularly for tumors in the distal third of the rectum. The aim of this article is to review the current experience with TaTME. The limits and future developments are also explored. Although the experience with TaTME is still limited, it might be a promising alternative to laparoscopic TME, especially for difficult cases where laparoscopy is too demanding. The preliminary data on complications and short-term oncological outcomes are good, but also emphasize the importance of careful patient selection. Finally, there is a need for large-scale trials focusing on long-term outcomes and oncological safety before widespread adoption can be recommended.

A think tank of the Italian Society of Colorectal Surgery (SICCR) on the surgical treatment of inflammatory bowel disease using the Delphi method: ulcerative colitis

The majority of patients suffering from ulcerative colitis (UC) are managed successfully with medical treatment, but a relevant number of them will still need surgery at some point in their life. Medical treatments and surgical techniques have changed dramatically in recent years, and available guidelines from relevant societies are rapidly evolving, providing UC experts with updated and valid practical recommendations. However, some aspects of the management of UC patients are still debated, and the application of guidelines in clinical practice may be suboptimal. The Italian Society of Colorectal Surgery (SICCR) sponsored the think tank in order to identify critical aspects of the surgical management of UC in Italy. The present paper reports the results of a think tank of Italian colorectal surgeons concerning surgery for UC and was not developed as an alternative to authoritative guidelines currently available. Members of the SICCR voted on several items proposed by the writing committee, based on evidence from the literature. The results are presented, focusing on points to be implemented. UC management relies on evaluations that need to be individualized, but points of major disagreement reported in this paper should be considered in order to develop strategies to improve the quality of the evidence and the application of guidelines in a clinical setting.

Transanal total mesorectal excision: a pure NOTES approach for selected patients

BACKGROUND

The concept of natural orifice transluminal endoscopic surgery (NOTES) has stimulated the development of various "incisionless" procedures. One of the most popular is the transanal approach for rectal lesions. The aims of this study were to report how we standardized NOTES technique for transanal mesorectal excision without abdominal assistance, discuss the difficulties and surgical outcomes of this technique and report its feasibility in a small group of selected patients.

METHODS

Three consecutive female patients underwent transanal NOTES rectal resection without transabdominal laparoscopic assistance for rectal lesions. Functional results were assessed with the Fecal Incontinence Quality of Life scale and the Wexner score.

RESULTS

The technical steps are described in details and complemented with a video. All procedures were completed without transabdominal laparoscopic help. The mesorectal plane was entirely dissected without any disruption, and distal and circumferential margins were tumor-free. No major complications were observed. Functional results show a significant impairment after surgery with improvement at 6 months to levels near those of the preoperative period.

CONCLUSIONS

The performance and publication of NOTES procedures are subject to much discussion. Despite the small number of patients, this procedure appears feasible and can be accomplished maintaining fecal continence and respecting oncologic principles.

Initial experience of transanal total mesorectal excision with rigid or flexible transanal platforms in cadavers

BACKGROUND

Transanal total mesorectal excision (taTME) is expected to provide benefits in the removal of the complete mesorectum for low rectal lesions, and several clinical studies regarding this technique have been reported. However, a transanal platform has not yet been standardized, and diverse transanal endoluminal surgery access devices have been used, based on individual surgeon preferences. In the present study, we performed laparoscopy-assisted taTME in cadavers and compared the characteristics of four different platforms.

METHODS

Between January 2013 and April 2015, laparoscopy-assisted taTME was performed on six fresh cadavers. Flexible [SILS™ Port (Covidien), GelPOINT(®) Path Transanal Access Platform (Applied Medical)] and rigid [TEO(®) (Karl Storz Endoskope), TEM (Richard Wolf)] transanal access platforms were used on three cadavers each.

RESULTS

All cadavers were male, with a mean age of 69.2 (range 57-86) years. The mean operation time was 146.3 (range 140-155) min with flexible platforms and 206.7 (range 150-260) min with rigid platforms. The mean specimen length was 23 (range 18-26) cm. Complete or nearly complete mesorectal specimens were obtained in all cases, except for one case using the TEM platform. Flexible platforms (SILS and GelPOINT) provided a short set-up time, relatively atraumatic retraction, and easy application of familiar laparoscopic instruments; a narrow operative field was its limitation. The rigid platforms (TEO and TEM) enabled larger and more stable operative fields and space than did the SILS platform, but they were limited by a narrow view, prolonged set-up time, rigidity, and long channels relative to the short distance from the anus to the rectal closure site.

CONCLUSION

In this preliminary study, laparoscopy-assisted taTME was a feasible and safe procedure using both rigid and soft platforms, despite some limitations of each platform.