Statistical, Clinical, Methodological Evaluation of Local Recurrence Following Transanal Total Mesorectal Excision for Rectal Cancer: A Systematic Review

Abstract

BACKGROUND: A recent Norwegian moratorium challenged the status quo of transanal total mesorectal excision for rectal cancer by reporting increased early multifocal local recurrences. OBJECTIVE: The aim of this systematic review and meta-analysis was to evaluate the local recurrence rates following transanal total mesorectal excision as well as to assess statistical, clinical, and methodological bias in reports published to date. DATA SOURCES: The PubMed and MEDLINE (via Ovid) databases were systematically searched. STUDY SELECTION: Descriptive or comparative studies reporting rates of local recurrence at a median follow-up of 6 months (or more) after transanal total mesorectal excision were included. INTERVENTIONS: Patients underwent transanal total mesorectal excision. MAIN OUTCOME MEASURES: Local recurrence was any recurrence located in the pelvic surgery site. The untransformed proportion method of 1-arm meta-analysis was utilized. Untransformed percent proportion with 95% confidence interval was reported. Ad hoc meta-regression with the Omnibus test was utilized to assess risk factors for local recurrence. Among-study heterogeneity was evaluated: statistically by I 2 and τ2, clinically by summary tables, and methodologically by a 33-item questionnaire. RESULTS: Twenty-nine studies totaling 2906 patients were included. The pooled rate of local recurrence was 3.4% (2.7%–4.0%) at an average of 20.1 months with low statistical heterogeneity (I 2 = 0%). Meta-regression yielded no correlation between complete total mesorectal excision quality (p = 0.855), circumferential resection margin (p = 0.268), distal margin (p = 0.886), and local recurrence rates. Clinical heterogeneity was substantial. Methodological heterogeneity was linked to the excitement of novelty, loss aversion, reactivity to criticism, indication for transanal total mesorectal excision, nonprobability sampling, circular reasoning, misclassification, inadequate follow-up, reporting bias, conflict of interest, and self-licensing. LIMITATIONS: The studies included had an observational design and limited sample and follow-up. CONCLUSION: This systematic review found a pooled rate of local recurrence of 3.4% at 20 months. However, given the substantial clinical and methodological heterogeneity across the studies, the evidence for or against transanal total mesorectal excision is inconclusive at this time.

Morbidity, Mortality, and Pathologic Outcomes of Transanal Versus Laparoscopic Total Mesorectal Excision for Rectal Cancer Short-term Outcomes From a Multicenter Randomized Controlled Trial

“…Currently, taTME as an alternative to laTME in selected patients with rectal cancer has become popular in skilled surgeons. A recent meta-analysis demonstrated similar technical success with acceptable oncologic and perioperative outcomes in rectal cancer patients treated by taTME versus laTME,4 and other systematic reviews verified these trends 5,6. By contrast, an international taTME registry found a relatively high percentage of perioperative complications including an anastomotic failure rate of 15.7%,7 and a Norwegian case review of 110 taTME procedures indicated increased early multifocal local recurrences, resulting in a moratorium on taTME 8.…”

“…A recent meta-analysis demonstrated similar technical success with acceptable oncologic and perioperative outcomes in rectal cancer patients treated by taTME versus laTME, 4 and other systematic reviews verified these trends. 5 , 6 By contrast, an international taTME registry found a relatively high percentage of perioperative complications including an anastomotic failure rate of 15.7%, 7 and a Norwegian case review of 110 taTME procedures indicated increased early multifocal local recurrences, resulting in a moratorium on taTME. 8 Therefore, the role of taTME is still a matter of debate pending the outcomes from the multicenter ongoing randomized controlled trials (RCTs) COLOR III and ETAP-GRECCAR 11.…”

Correlation of Presacral Tumour Recurrence with Tumour Metastasis and Long-Term Tumour Recurrence Risk in Patients with Rectal Cancer

“…Patients with presacral tumour recurrence will not only suffer unbearable pain due to the influence on bone structure but also face higher treatment difficulty, which seriously compromise their quality of life [13]. Local recurrence of RC always increases the difficulty of treatment for patients, and recurrence in different parts often causes different tumour metastasis, long-term recurrence, and prognosis [14,15]. However, at present, there is no reliable assessment method for the prognosis and recurrence of CR, and corresponding preventive measures are lacking.…”

Longitudinal Analysis of Local Recurrence and Survival After Transanal Abdominal Transanal Radical Proctosigmoidectomy for Low Rectal Cancer Treated With Neoadjuvant Chemoradiation

“…To report an objective number, a pooled analysis of 29 TaTME studies found an LR rate of 3.4% on a median follow-up of 20 months. 31 However, there were both upper and lower rectal cancers, variation in distance to the anal verge, and differing clinical stage and rates of NACRT. The International TaTME registry 2-year LR rate was reported at 4.8% but included rectal cancers up to 10 cm from the ARR, American Joint Committee on Cancer stages I to IV, and a minority that received NACRT.…”

“…This differs from the Dutch and Norwegian multicenter data sets, demonstrating higher rates of LR arising sooner after the index surgery and with a multifocal pattern. 21,31 The reason behind the difference in outcomes cannot be definitively stated; however, differences in patients’ selection need to be considered, such as in the Norwegian cancer registry, only 58% of the patients had NACRT. In addition, suboptimal execution and learning curve effects were implicated.…”