Early Experience With Transanal Total Mesorectal Excision Compared With Laparoscopic Total Mesorectal Excision for Rectal Cancer: A Propensity Score-Matched Analysis

Transanal total mesorectal excision for locally advanced rectal cancer following neoadjuvant chemoradiotherapy

PURPOSE

To examine the clinical impact of transanal total mesorectal excision (TaTME) for locally advanced rectal cancer after neoadjuvant chemoradiotherapy (NACRT).

METHODS

This retrospective study included 91 patients undergoing surgery for rectal cancer after NACRT between 2011 and 2022. Among them, 24, 22, and 45 patients underwent open (Open), conventional laparoscopic (Lap), and TaTME surgeries, respectively. We compared their clinical outcomes.

RESULTS

Operative time, blood loss, transfusion, morbidity, and hospital stay were significantly lower in the TaTME group than in the Open or Lap groups. The multivariate regression analyses identified only the TaTME approach as a significant factor for reducing morbidity. Both 3 yrear relapse-free survival (RFS) and local recurrence-free survival (LRFS) were significantly better in the TaTME group than in the Open or Lap groups (3 yr RFS: 94.7%, 80.4%, and 66.7%, and 3 yr LRFS: 100%, 90.5%, and 82.2% for the TaTME, Lap, and Open groups, respectively). Multivariate analyses of potential risk factors for recurrence identified body mass index, combined resection, and pathological stage, but not the TaTME approach, as significant predictors of recurrence.

CONCLUSION

TaTME reduced morbidity significantly in patients with locally advanced rectal cancer undergoing NACRT, compared with open or laparoscopic surgery.

Prediction of postoperative complications following transanal total mesorectal excision in middle and low rectal cancer: development and internal validation of a clinical prediction model

PURPOSE

The objective of this study is to develop a nomogram for the personalized prediction of postoperative complication risks in patients with middle and low rectal cancer who are undergoing transanal total mesorectal excision (taTME). This tool aims to assist clinicians in early identification of high-risk patients and in addressing preoperative risk factors to enhance surgical safety.

METHODS

In this case-control study, 207 patients diagnosed with middle and low rectal cancer and undergoing taTME between February 2018 and November 2023 at The First Affiliated Hospital of Xiamen University were included. Independent risk factors for postoperative complications were analyzed using the Least Absolute Shrinkage and Selection Operator (LASSO) regression and multifactorial logistic regression models. A predictive nomogram was constructed using R Studio.

RESULTS

Among the 207 patients, 57 (27.5%) experienced postoperative complications. The LASSO and multifactorial logistic regression analyses identified operation time (OR = 1.010, P = 0.007), smoking history (OR = 9.693, P < 0.001), anastomotic technique (OR = 0.260, P = 0.004), and ASA score (OR = 9.077, P = 0.051) as significant predictors. These factors were integrated into the nomogram. The model's accuracy was validated through receiver operating characteristic curves, calibration curves, consistency indices, and decision curve analysis.

CONCLUSION

The developed nomogram, incorporating operation time, smoking history, anastomotic technique, and ASA score, effectively forecasts postoperative complication risks in taTME procedures. It is a valuable tool for clinicians to identify patients at heightened risk and initiate timely interventions, ultimately improving patient outcomes.

Oncologic outcomes following transanal total mesorectal excision: the United States experience

AIM

The benefits and short-term outcomes of transanal total mesorectal excision (taTME) for rectal cancer have been demonstrated previously, but questions remain regarding the oncologic outcomes following this challenging procedure. The purpose of this study was to analyze the oncologic outcomes following taTME at high-volume centers in the USA.

METHODS

This was a multicenter, retrospective observational study of 8 tertiary care centers. All consecutive taTME cases for primary rectal cancer performed between 2011 and 2020 were included. Clinical, histopathologic, and oncologic data were analyzed. Primary endpoints were rate of local recurrence, distal recurrence, 3-year disease recurrence, and 3-year overall survival. Secondary endpoints included perioperative complications and TME specimen quality.

RESULTS

A total of 391 patients were included in the study. The median age was 57 years (IQR: 49, 66), 68% of patients were male, and the median BMI was 27.4 (IQR: 24.1, 31.0). TME specimen was complete or near complete in 94.5% of cases and the rates of positive circumferential radial margin and distal resection margin were 2.0% and 0.3%, respectively. Median follow-up time was 30.7 months as calculated using reverse-KM estimator (CI 28.1-33.8) and there were 9 cases (2.5%) of local recurrence not accounting for competing risk. The 3-year estimated rate of disease recurrence was 19% (CI 15-25%) and the 3-year estimated overall survival was 90% (CI 87-94%).

CONCLUSION

This large multicenter study confirms the oncologic safety and perioperative benefits of taTME for rectal cancer when performed by experienced surgeons at experienced referral centers.

Transanal total mesorectal excision: single center study on risk factors for major complications

Purpose

Transanal total mesorectal excision (TaTME) as a novel surgical approach for mid and low rectal cancer has gained significant research interest in recent years. The main objective of this study is to identify the risk factors associated with major complications after TaTME and evaluate the perioperative clinical outcomes.

Methods

A retrospective analysis was performed on the clinical data of patients with mid-to-low rectal cancer who underwent TaTME surgery and were admitted to the First Affiliated Hospital of Xiamen University from January 2018 to May 2023. Univariate and multivariate regression methods were employed to analyze the risk factors influencing the occurrence of major complications (Clavien-Dindo III-V).

Results

This study included a total of 179 eligible cases, with no perioperative deaths. The overall incidence of early complications was 25.1%, with a rate of 10.1% for mild complications and 15.0% for major complications. The postoperative anastomotic leakage rate within 30 days was 6.7%. Multivariate analysis demonstrated that male (P=0.030), pathological T ≥ 3 (P=0.018) and manual anastomosis (P=0.009) were independent risk factors for the development of major complications after surgery.

Conclusion

In this study, the incidence of early complications and anastomotic leakage rate in TaTME were both relatively low. Male, pathological T stage ≥ 3 and manual anastomosis were independent risk factors for the occurrence of major complications in a cohort of patients with mid and low rectal cancer undergoing TaTME.

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-center comparative study of short-term outcomes of transanal and laparoscopic total mesorectal excisions for low and middle rectal cancers

BACKGROUND

Transanal total mesorectal excision is a promising surgical treatment for rectal cancer. However, evidence regarding the differences in outcomes between the transanal and laparoscopic total mesorectal excisions is scarce. We compared the short-term outcomes of transanal and laparoscopic total mesorectal excisions for low and middle rectal cancers.

METHODS

This retrospective study included patients who underwent low anterior or intersphincteric resection for middle (5-10 cm) or low (< 5 cm) rectal cancer at the National Cancer Center Hospital East, Japan, from May 2013 to March 2020. Primary rectal adenocarcinoma was confirmed histologically. Circumferential resection margins (CRMs) of resected specimens were measured; margins ≤ 1 mm were considered positive. The operative time, blood loss, hospitalization length, postoperative readmission rate, and short-term treatment results were compared.

RESULTS

Four hundred twenty-nine patients were divided into two mesorectal excision groups: transanal (n = 295) and laparoscopic (n = 134). Operative times were significantly shorter in the transanal group than in the laparoscopic group (p < 0.001). The pathological T stage and N status were not significantly different. The transanal group had significantly lower positive CRM rates (p = 0.04), and significantly lower incidence of the Clavien-Dindo grade III (p = 0.02) and IV (p = 0.03) complications. Both groups had distal margin positivity rates of 0%.

CONCLUSIONS

Compared to laparoscopic, transanal total mesorectal excision for low and middle rectal cancers has lower incident postoperative complication and CRM-positivity rates, demonstrating the safety and usefulness of local curability for middle and low rectal cancers.

The taTME learning curve for mid-low rectal cancer: a single-center experience in China

Purpose

As transanal total mesorectal excision (taTME) is performed worldwide, the optimization of existing training and guidance programs to enhance new taTME learners’ competence in performing this procedure is warranted. This study aimed to evaluate the taTME learning curve in patients with mid-low rectal cancer.

Methods

Patients who underwent taTME for mid-low rectal cancer between October 2015 and August 2021 at a single center were included. A cumulative sum (CUSUM) learning curve analysis was performed with the total operation time as the study outcome. The learning curve was analyzed using risk-adjusted CUSUM analysis, with postoperative complications and anastomotic leakage (AL) as outcomes.

Results

In total, 104 consecutive patients were included in this study. The CUSUM learning curve for total operative time started declining after 42 cases (309.1 ± 84.4 vs. 220.2 ± 46.4, P < 0.001). The risk-adjusted CUSUM (RA-CUSUM) learning curve for postoperative complications fluctuated in cases 44–75 and declined significantly after case 75. The RA-CUSUM learning curve for AL declined after 68 cases.

Conclusions

taTME had learning curves of 42, 75, and 68 cases for total operative time, postoperative complications, and AL, respectively. A surgeon may require 42 and 75 cases to achieve “proficiency” and “mastery” in taTME procedures, respectively.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-022-02763-3.

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.

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.