Transanal versus conventional total mesorectal excision for rectal cancer using the IDEAL framework for implementation

Abstract

Background Transanal total mesorectal excision (TaTME) is an innovative technique for distal rectal cancer dissection. It has been shown to have similar short-term outcomes to conventional open and laparoscopic total mesorectal excision (cTME), but recent studies have raised concern about increased morbidity and local recurrence rates. The aim of this study was to assess outcomes after TaTME versus cTME for rectal cancer. Methods TaTME was implemented in 2014 using IDEAL principles in a single institution. The institution maintains databases for all patients undergoing rectal cancer surgery. This retrospective review compared data collected from all patients who had TaTME with those from a propensity-matched cohort of patients who underwent cTME. The primary outcome was a composite pathological measure combining margin status and quality of total mesorectal excision (TME). Short-term clinical and survival outcomes were also measured. Results Propensity matching created 109 matched pairs for analysis. Nine patients (8.3 per cent) undergoing TaTME had positive margins and/or incomplete TME, compared with 11 (10.5 per cent) undergoing cTME (P = 0.65). There were no significant differences in morbidity between the TaTME and cTME groups, including number of anastomotic leaks (13.8 versus 18.3 per cent; P = 0.37). The estimated 3-year local recurrence-free survival rate was 96.3 per cent in both groups (P = 0.39). Estimated 3-year overall (93.6 per cent for TaTME versus 94.5 per cent for cTME; P = 0.09) and disease-free (88.1 versus 76.1 per cent; P = 0.90) survival rates were similar. Conclusion TaTME provided similar outcomes to cTME for rectal cancer with the application of IDEAL principles.

Local Recurrence-Free Survival After TaTME: A Canadian Institutional Experience

“…24 Consistent with expert guidelines introduced in Canada and the United States, careful patient selection and formal proctored training are crucial. 5,6 As reported by Robertson et al, 25 TaTME comprised a select proportion of patients with its uptake at our institution.…”

Challenges and Learning Curves in Adopting TaTME and Robotic Surgery for Rectal Cancer: A Cusum Analysis

“…and a risk of increasing the incidence of local recurrence. That is why a structured program for the incorporation of the technique has been established [ 6 , 26 , 27 ], and taTME is indicated only for cancers in the middle and lower thirds of the rectum in patients with unfavorable anatomical factors. Moreover, to prevent possible complications and difficulties during the learning curve, the technique is evolving to incorporate other approaches, such as transanal rectal transection with a singled-stapled anastomosis (TTSS) [ 28 ] and robotic-taTME [ 29 ].…”

Applications of machine learning in surgery: ethical considerations

“…While there are highly regulated and structured models for the assessment of innovative pharmaceuticals, the development of innovative surgical practice remains largely unregulated and variable [9] . To fill the gap, the IDEAL framework and recommendations have been designed for evaluating the safety and efficacy of innovative surgical interventions and have been increasingly used since their introduction [10,11] . The IDEAL framework describes five stages of innovation in surgery: idea, development, exploration, assessment, and long-term outcomes.…”