Comparison of transanal total mesorectal excision (TaTME) versus laparoscopic TME for rectal cancer: A case matched study

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.

Single-stapled anastomosis is associated with a lower anastomotic leak rate than double-stapled technique after minimally invasive total mesorectal excision for MRI-defined low rectal cancer

BACKGROUND

After total mesorectal excision, distal rectal transection and anastomosis are critical for short-term, oncological, and functional outcomes, including anastomotic leak. A double-pursestring, single-stapled anastomosis avoids cross-stapling, overcoming the potential drawbacks of transabdominal rectal transection and double-stapled anastomosis. This study aims to compare the anastomotic leak rate in double-stapled and single-stapled anastomoses after minimally invasive total mesorectal excision for magnetic resonance imaging-defined low rectal cancer.

METHODS

Adult patients (>18 years old) undergoing minimally invasive total mesorectal excision for magnetic resonance imaging-defined low rectal cancer with a stapled low anastomosis (below 5 centimeters from the anal verge) between January 2010 and January 2022 at a single institution were allocated to 2 groups according to the anastomosis: double-stapled (abdominal stapled transection and double-stapled anastomosis) or single-stapled (transanal rectal transection and double-pursestring single-stapled anastomosis). The exclusion criteria were nonrestorative procedures or any type of manual anastomosis. The primary endpoint was the rate of 90-day clinical and radiologic anastomotic leak.

RESULTS

In total, 185 single-stapled and 458 double-stapled were included. Clinical and tumor characteristics were comparable between the groups. The 90-day anastomotic leak rate was significantly lower in the single-stapled group (6.48% vs 15.28%; P = .002), with similar rates of grade and timing. Thirty- and 90-day complication rates were higher in the double-stapled group (P = .0001; P = .02), with comparable Clavien-Dindo grades. At multivariable analysis, double-stapled anastomosis (P = .01), active smoking (P = .03), and the presence of comorbidities (P = .01) resulted as independent risk factors for an anastomotic leak.

CONCLUSION

Transanal transection and double-pursestring, single-stapled anastomosis were associated with a lower anastomotic leak rate after minimally invasive total mesorectal excision for magnetic resonance imaging-defined low rectal cancer.

Transanal Total Mesorectal Excision (TaTME) versus Laparoscopic Total Mesorectal Excision for Lower Rectal Cancer: A Propensity Score-Matched Analysis

Studies have reported positive short-term and histopathological results of transanal total mesorectal excision (TaTME) for mid-low rectal cancer. The long-term oncological outcomes are diverse, and concerns regarding the high local recurrence (LR) rate of TaTME have recently increased. We retrospectively analyzed 298 consecutive patients who underwent Laparoscopic TME (LapTME) or TaTME between January 2015 and December 2019. Propensity score-matching (PSM) was performed with patients matched for demographics and stage. After PSM, 63 patients were included in each group. The TaTME group had a longer mean operative time (394 vs. 333 min, p < 0.001). The blood loss, diverting stoma rate, and conversion rate were similar. Postoperatively, TaTME and LapTME had compatible complications, recovery, and hospital stay. A similar specimen quality was detected in both groups. After a mean follow-up period of 41−47 months, TaTME had less LR than LapTME (9.5% vs. 23.8%, p = 0.031). The 3-year overall survival was 80.3% in the TaTME group and 73.6% in the LapTME group (p = 0.331). The 3-year disease-free survival (DFS) rate was 72.0% in the TaTME group and 56.6% in the LapTME group (p = 0.038). In conclusion, better DFS and fewer LR events were observed after TaTME; thus, TaTME can be considered a safe and feasible approach in patients with low rectal cancer.

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.

Anastomotic leakage and chronic presacral sinus after transanal total mesorectal excision (taTME) for rectal cancer: A comparative study to laparoscopic TME

BACKGROUND

Several studies have shown that there are no significant differences in anastomotic leakage associated with Transanal total mesorectal excision (taTME) versus laparoscopic TME (lapTME) for rectal cancer; however, little is known about late anastomotic leakage, such as that primarily found in the chronic presacral sinus. We aimed to compare the occurrence of anastomotic leakage and chronic presacral sinus in rectal cancer for taTME and lapTME.

METHODS

In this retrospective cohort study, data were collected for patients with rectal cancer who underwent surgery between January 2009 and September 2019. Of the 220 patients included in this study, 182 were in the lapTME group and 38 in the taTME group. We compared factors associated with anastomotic leakage and chronic presacral sinus formation between the two groups. A binary-logistic model was used to determine the risk factors for chronic presacral sinus.

RESULTS

Anastomotic leakage occurred in six patients (15.8%) in the taTME group and 36 patients (19.7%) in the lapTME group. Chronic presacral sinus occurred in three patients (7.9%) in the taTME group and 15 patients (8.2%) in the lapTME group. There was no significant difference in anastomotic leakage or chronic presacral sinus between groups (P = 0.569 and P = 1.000, respectively). Pathologic stage III or higher was significantly associated with chronic presacral sinus formation (P = 0.006).

CONCLUSION

There were no significant differences between taTME and lapTME regarding the incidence of anastomotic leakage or chronic presacral sinus. Almost one-third of anastomotic leakages developed into chronic presacral sinus.