Transanal total mesorectal excision for locally advanced middle–low rectal cancers

Abstract

Background This study investigated the results of transanal total mesorectal excision (TaTME) combined with laparoscopy for locally advanced mid–low rectal cancer. Methods Patients with mid–low locally advanced rectal cancer (T3 category or above and/or N+) who underwent rectal resection with TaTME technique were enrolled prospectively. Patients who had distant metastasis, multiple malignancies, intestinal obstruction or perforation, or a clinical complete response to chemoradiotherapy were excluded. Postoperative results, including morbidity, circumferential resection margin (CRM) assessment, short‐term survival and functional outcomes, were analysed. Results Thirty‐eight patients, with 25 mid and 13 low rectal tumours, who had elective resection by TaTME from March 2015 to September 2018 were included. There were 25 men and 13 women. Mean(s.d.) age was 58·2(16·4) years and mean(s.d.) BMI was 24·2(2·5) kg/m2. Tumours were 3–9 cm from the anal verge. Mean(s.d.) duration of surgery was 210(42) min. All patients had hand‐sewn anastomoses and protective ileostomies. There were no conversions, abdominal perineal resections or postoperative deaths. Four patients had a complication, including three presacral abscesses, all managed by transanastomotic drainage. At 3 months after ileostomy closure, all patients had perfect continence. Apart from a greater tumour diameter in patients with low rectal cancers (6·0 cm versus 4·6 cm in those with mid rectal tumours; P = 0·035), clinical features were similar in the two groups. CRM positivity was greater for low than for mid rectal tumours (3 of 13 versus 0 of 25 respectively; P = 0·034), and more patients with a low tumour had TME grade 2 (4 of 13 versus 1 of 25; P = 0·038). There was no difference in oncological outcomes at 17 months. Conclusion Although this study cohort was small, special attention should be paid to bulky low rectal tumours to reduce the rate of CRM positivity.

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

“…8,10 Both advantages and disadvantages associated with the procedure of taTME, which concern the technical feasibility of taTME. A retrospective study by Thien et al 13 reported a mean duration of surgery of 210 min with single team. In later stages of enrollment, six patients underwent surgery with double teams, and mean duration was 150 min (p = .002).…”

“…In later stages of enrollment, six patients underwent surgery with double teams, and mean duration was 150 min (p = .002). 13 In this context, Chen et al 14 reported that the duration of surgery can be markedly reduced by using a two-team approach. Meanwhile, Mege et al 15 evaluated 34 consecutive patients who underwent taTME and did not observe a significant difference in operating time between standard laTME and taTME with a single surgical team (237 ± 48 vs. 260 ± 45 min, p = .1).…”

“…However, evidence from recent studies support the feasibility of taTME, indicating that the technical difficulties during laTME surgery can be addressed by adequate proficiency in the laparoscopic technique and specific training for taTME. 8,10,[13][14][15]…”

“…A retrospective study by Thien et al 13 reported a mean duration of surgery of 210 min with single team. In later stages of enrollment, six patients underwent surgery with double teams, and mean duration was 150 min ( p = .002) 13 . In this context, Chen et al 14 reported that the duration of surgery can be markedly reduced by using a two‐team approach.…”

“…In their study, surgeons used the step‐by‐step approach rather than the synchronous abdominal and transanal approach, which means they needed to replace the retractor during surgery, thus slightly prolonging the operation time. However, evidence from recent studies support the feasibility of taTME, indicating that the technical difficulties during laTME surgery can be addressed by adequate proficiency in the laparoscopic technique and specific training for taTME 8,10,13–15 …”