Canadian taTME expert collaboration (CaTaCO) position statement

Abstract

Introduction Transanal total mesorectal excision (taTME) is a novel approach to surgery for rectal cancer. The technique has gained significant popularity in the surgical community due to the promising ability to overcome technical difficulties related to the access of the distal pelvis. Recently, Norwegian surgeons issued a local moratorium related to potential issues with the safety of the procedure. Early adopters of taTME in Canada have recognized the need to create guidelines for its adoption and supervision. The objective of the statement is to provide expert opinion based on the best available evidence and authors' experience. Methods The procedure has been performed in Canada since 2014 at different institutions. In 2016, the first Canadian taTME congress was held in the city of Toronto, organized by two of the authors. In early 2019, a multicentric collaborative was established [The Canadian taTME expert Collaboration] which aimed at ensuring safe performance and adoption of taTME in Canada. Recently surgeons from 8 major Canadian rectal cancer centers met in the city of Toronto on December 7 of 2019, to discuss and develop a position statement. There in person, meeting was followed by 4 rounds of Delphi methodology. Results The generated document focused on the need to ensure a unified approach among rectal cancer surgeons across the country considering its technical complexity and potential morbidity. The position statement addressed four domains: surgical setting, surgeons' requirements, patient selection, and quality assurance. Conclusions Authors agree transanal total mesorectal excision is technically demanding and has a significant risk for morbidity. As of now, there is uncertainty for some of the outcomes. We consider it is possible to safely adopt this operation and obtain adequate results, however for this purpose it is necessary to meet specific requirements in different domains.

Association of Transanal Total Mesorectal Excision With Local Recurrence of Rectal Cancer

“…The CaTaCO has recently published guidelines for the safe use of transanal TME, focusing on institution, surgeon, patient selection, and quality assurance. 27 These guidelines recommend that surgeons and hospitals only perform transanal TME if they initially have an adequate case volume, multidisciplinary expert support, and extensive experience in both minimally invasive rectal cancer surgery and transanal endoscopic surgery. At present, national credentialing and quality assurance oversight do not exist in Canada.…”

“…The Canadian taTME Expert Collaboration (CaTaCO), formed in 2019, includes 8 tertiary academic referral centers in Canada. 27 In this cohort study, all consecutive patients with primary rectal cancer treated by transanal TME at the participating CaTaCO centers between January 2014 and December 2018 had demographic, operative, pathologic, and follow-up data collected and merged into a single database. Procedures performed for benign diagnoses were excluded.…”

“…Disease-free survival was defined as the time to cancer recurrence or death from any cause. 27 Duration of follow-up was calculated based on the date of resection and the most recent follow-up with the managing team (surgeon, medical or radiation oncologist, or primary physician). Anastomotic leak was defined as evidence of pelvic infection, determined by a combination of symptoms, imaging, and/or radiologic findings.…”

Controversies and consensus in transanal total mesorectal excision (taTME): Is it a valid choice for rectal cancer?

“…The Canadian taTME expert collaboration recommended a minimum number of 50 cases performed as primary operator to overcome the learning curve. 18 Koedam et al 19 utilized cumulative sum analysis on the issue of learning curve with a total of 138 patients. They reported a significant difference in postoperative outcomes after the first 40 patients (47.5 vs. 17.5%).…”

“…However, there is paucity of data on the learning curve in the current literature. The Canadian taTME expert collaboration recommended a minimum number of 50 cases performed as primary operator to overcome the learning curve 18 . Koedam et al 19 utilized cumulative sum analysis on the issue of learning curve with a total of 138 patients.…”