Transanal Versus Laparoscopic TME

Abstract

T here has been a great evolution in the surgical treatment for rectal cancer over the past several decades, and as new technologies have become available the surgical techniques have continued to evolve in an attempt to obtain better both oncologic and functional outcomes. Over the last 2 decades, the utility of minimally invasive approaches in the management of rectal cancer has been one of the most analyzed topics in the field. Multicentered, phase III randomized controlled trials compared short-term and long-term outcomes of laparoscopic versus open total mesorectal excision (TME) surgery with comparable disease-free survival, overall survival, and local recurrence (LR) rates. 1,2 However trials have failed to prove equivalence on short-term pathological outcomes, reflecting the numerous challenges associated with working in a confined space within the pelvis, especially in male patients with midlow rectal tumors. These challenges were highlighted in the American College of Surgeons Oncology Group (ACOSOG) Z6051, the Australasian Laparoscopic Cancer of the Rectum (ALaCaRT) trials. [1][2][3][4] In an effort to overcome these limitations of laparoscopic surgery for mid and low rectal cancer, robotic and transanal TME (taTME) techniques have been developed but availability and access varies around the globe. [5][6][7] In this issue of Annals of Surgery, the Chinese Transanal Endoscopic Surgery Collaborative (CTESC) group report the short-term results of a phase III randomized trial of taTME versus laparoscopic TME (laTME). 8 This study was a multicentered, randomized, phase 3 clinical trial to test the noninferiority of taTME versus laTME at 16 centers across China. The primary endpoint of disease-free survival will be reported in the future, however short-term outcomes including for surgery "success" are reported now. A total of 1115 patients with clinical Stage I-III mid and low rectal cancer (mean distance from anal verge was 5.2 cm in each group) were randomized 1:1 to undergo either taTME or laTME. The investigators considered the surgery to be a "success" based on achievement of the same composite pathological outcomes of TME quality, circumferential resection margin > 1 mm and distal resection margin > 1 mm used in the ALaCaRT and Z6051 trials. Overall, taTME was associated with similar rates of a successful surgical resection, when compared with laTME (98.9% vs. 98.7%; P > 0.99). In addition, there was a low overall rate of intraoperative (4.8% vs. 6.1%, P = 0.42) or postoperative (13.4% vs. 12.1%, P = 0.53) complications in the taTME versus laTME groups, respectively. Based on these findings, the investigators conclude that taTME can be safely performed. These data are in contrast to the prior laparoscopic trials and some of the more recently reported outcomes after taTME. 9 Indeed, the high rate of technical success in the CTESC trial may be in part explained by the strict criteria for surgeon verification. To participate on the trial, surgeons were required to have previously performed least 100 laTME...

Beyond the transanal total mesorectal excision moratorium: local and distant recurrence among patients operated for low rectal tumours—5-year follow-up from a Norwegian University Hospital

“…This is an analysis of a prospectively collected database on patients who underwent TME for adenocarcinoma located less than 10 cm from the anal verge over an interval of 7.5 years (January 2014 to June 2021). Patients were stratified according to surgical approach—laparoscopic TME (LapTME, n = 159), open TME (OpTME, n = 89), or TaTME ( n = 55)—and the cohorts compared with respect to histopathology, anastomotic leak, mortality, local pelvic recurrence, and disease-free survival 4 , 5 . The full methodology is available in the supplementary material .…”