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Abstract
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.
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Affiliation(s)
- Caterina Foppa
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy,Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Francesco Maria Carrano
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy,Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Rozzano, Milan, Italy,Address for correspondence Antonino Spinelli, MD, PhD Division of Colon and Rectal Surgery, Department of Surgery, Humanitas Clinical and Research CenterIRCCS, Building 2, Via Manzoni 56, Rozzano, Milano 20089Italy
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Ryan OK, Ryan ÉJ, Creavin B, Rausa E, Kelly ME, Petrelli F, Bonitta G, Kennelly R, Hanly A, Martin ST, Winter DC. Surgical approach for rectal cancer: A network meta-analysis comparing open, laparoscopic, robotic and transanal TME approaches. Eur J Surg Oncol 2020; 47:285-295. [PMID: 33280950 DOI: 10.1016/j.ejso.2020.06.037] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 06/19/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The optimal approach for total mesorectal excision (TME) of rectal cancer remains controversial. AIM To compare short- and long-term outcomes after open (OpTME), laparoscopic (LapTME), robotic (RoTME) and transanal TME (TaTME). METHODS A systematic search of electronic databases was performed up to January 1, 2020 for randomized controlled trials (RCTs) comparing at least 2 TME strategies. A Bayesian arm-based random effect network meta-analysis (NMA) was performed, specifically, a mixed treatment comparison (MTC). RESULTS 30 RCTs (and six updates) of 5586 patients with rectal cancer were included. No significant differences were identified in recurrence rates or survival rates. Operating time was shorter with OpTME (surface under the cumulative ranking curve [SUCRA] 0.96) compared to LapTME, RoTME and TaTME. Although OpTME was associated with the most blood loss (SUCRA 0.90) and had a slower recovery with increased length of stay (SUCRA 0.90) compared to the minimally invasive techniques, there was no difference in postoperative morbidity. OpTME was associated with a more complete TME specimen compared to LapTME (Risk Ratio [RR] 1.05, 95% Credible Interval [CrI] 1.01, 1.11), and TaTME had less involved CRMs (RR 0.173, 95% CrI 0.02, 0.76) versus LapTME. There were no differences between the modalities in terms of deep TME defects, DRM distance, or lymph node yield. CONCLUSIONS While OpTME was the most effective TME modality for short term histopathological resection quality, there was no difference in long-term oncologic outcomes. Minimally invasive approaches enhance postoperative recovery, at the cost of longer operating times. Technique selection should be based on individual tumour characteristics and patient expectations, as well as surgeon and institutional expertise.
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Affiliation(s)
- Odhrán K Ryan
- School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland.
| | - Éanna J Ryan
- Department of Surgery, Surgical Professorial Unit, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Ben Creavin
- Department of Surgery, Surgical Professorial Unit, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Emanuele Rausa
- Division of Surgical Oncology, ASST-Bergamo Ovest, Treviglio, Italy
| | - Michael E Kelly
- Department of Surgery, Surgical Professorial Unit, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Fausto Petrelli
- Division of Surgical Oncology, ASST-Bergamo Ovest, Treviglio, Italy
| | - Gianluca Bonitta
- Division of Surgical Oncology, ASST-Bergamo Ovest, Treviglio, Italy
| | - Rory Kennelly
- Department of Surgery, Surgical Professorial Unit, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland.
| | - Ann Hanly
- Department of Surgery, Surgical Professorial Unit, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Seán T Martin
- Department of Surgery, Surgical Professorial Unit, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Des C Winter
- School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland; Department of Surgery, Surgical Professorial Unit, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
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