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.
Introduction
Transanal total mesorectal excision (TaTME) has rapidly emerged as a novel approach for rectal cancer surgery. Safety profiles are still emerging and more comparative data is urgently needed. This study aimed to compare indications and short‐term outcomes of TaTME, open, laparoscopic, and robotic TME internationally.
Methods
A pre‐planned analysis of the European Society of Coloproctology (ESCP) 2017 audit was performed. Patients undergoing elective total mesorectal excision (TME) for malignancy between 1 January 2017 and 15 March 2017 by any operative approach were included. The primary outcome measure was anastomotic leak.
Results
Of 2579 included patients, 76.2% (1966/2579) underwent TME with restorative anastomosis of which 19.9% (312/1966) had a minimally invasive approach (laparoscopic or robotic) which included a transanal component (TaTME). Overall, 9.0% (175/1951, 15 missing outcome data) of patients suffered an anastomotic leak. On univariate analysis both laparoscopic TaTME (OR 1.61, 1.02–2.48, P = 0.04) and robotic TaTME (OR 3.05, 1.10–7.34, P = 0.02) were associated with a higher risk of anastomotic leak than non‐transanal laparoscopic TME. However this association was lost in the mixed‐effects model controlling for patient and disease factors (OR 1.23, 0.77–1.97, P = 0.39 and OR 2.11, 0.79–5.62, P = 0.14 respectively), whilst low rectal anastomosis (OR 2.72, 1.55–4.77, P < 0.001) and male gender (OR 2.29, 1.52–3.44, P < 0.001) remained strongly associated. The overall positive circumferential margin resection rate was 4.0%, which varied between operative approaches: laparoscopic 3.2%, transanal 3.8%, open 4.7%, robotic 1%.
Conclusion
This contemporaneous international snapshot shows that uptake of the TaTME approach is widespread and is associated with surgically and pathologically acceptable results.
Цель исследования-сравнительный анализ непосредственных хирургических результатов методик реконструкции после низкой передней резекции прямой кишки. Материал и методы. Проведен ретроспективный анализ результатов проспективного рандомизированного контролируемого исследования, в которое включены 90 пациентов с диагнозом «рак нижне-или среднеампулярного отдела прямой кишки» сТ1-4aN0-2M0. Результаты. В группу А набраны 22 пациента с J-образными резервуарами, в группу Б с анастомозами бок в конец-30. В контрольную группу В с анастомозами конец в конец вошли 38 пациентов, что связано с интраоперационной конверсией анастомозов ввиду анатомо-конституциональных особенностей пациентов. Причины конверсии: узкий мужской таз и висцеральное ожирение, недостаточная длина низводимой кишки. Достоверных различий в частоте послеоперационных осложнений между группами не выявлено: 13,6%-в группе А, 16,7%-в группе Б и 34,2%-в контрольной группе В (р=0,705). При малоинвазивной тотальной мезоректумэктомии операции были достоверно продолжительней и составили в среднем 230 мин (110-380), при открытых ТМЭ медиана соответствовала 180 мин (110-240) (р=0,001). Заключение. Формирование J-образных резервуаров в сравнении с другими видами анастомозов имеет больше ограничений, связанных с фактором мужского пола, висцерального ожирения и недостаточной длины низводимых отделов ободочной кишки. Непосредственные хирургические результаты в группе J-образных резервуаров сопоставимы с контрольной и основной группой (анастомозы бок в конец). Ключевые слова: рак прямой кишки, низкая передняя резекция прямой кишки, толстокишечный резервуар, тотальная мезоректумэктомия.
Introduction
The mainstay of management for locally advanced rectal cancer is chemoradiotherapy followed by surgical resection. Following chemoradiotherapy, a complete response may be detected clinically and radiologically (cCR) prior to surgery or pathologically after surgery (pCR). We aim to report the overall complete pathological response (pCR) rate and the reliability of detecting a cCR by conventional pre‐operative imaging.
Methods
A pre‐planned analysis of the European Society of Coloproctology (ESCP) 2017 audit was performed. Patients treated by elective rectal resection were included. A pCR was defined as a ypT0 N0 EMVI negative primary tumour; a partial response represented any regression from baseline staging following chemoradiotherapy. The primary endpoint was the pCR rate. The secondary endpoint was agreement between post‐treatment MRI restaging (yMRI) and final pathological staging.
Results
Of 2572 patients undergoing rectal cancer surgery in 277 participating centres across 44 countries, 673 (26.2%) underwent chemoradiotherapy and surgery. The pCR rate was 10.3% (67/649), with a partial response in 35.9% (233/649) patients. Comparison of AJCC stage determined by post‐treatment yMRI with final pathology showed understaging in 13% (55/429) and overstaging in 34% (148/429). Agreement between yMRI and final pathology for T‐stage, N‐stage, or AJCC status were each graded as ‘fair’ only (n = 429, Kappa 0.25, 0.26 and 0.35 respectively).
Conclusion
The reported pCR rate of 10% highlights the potential for non‐operative management in selected cases. The limited strength of agreement between basic conventional post‐chemoradiotherapy imaging assessment techniques and pathology suggest alternative markers of response should be considered, in the context of controlled clinical trials.
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