Combined NOTES total mesorectal excision and single-incision laparoscopy principles for conservative proctectomy: a single-centre study.

Transanal total mesorectal excision (TaTME) is an alternative technique for rectal surgery that could facilitate the mobilization and the distal transection of the rectum. Our objective was to analyze whether the presence of factors affecting the difficulty of laparoscopic total mesorectal excision (TME) could affect surgical and oncological outcomes of TaTME for mid and low rectal cancer. 20 patients (13 male, 7 female) with a mean age of 66.5 years (range 55.5–75.7) and mid–low rectal cancer were prospectively submitted to TaTME. Every TaTME procedure was performed by two teams of experienced surgeons working simultaneously. Adverse conditions for laparoscopic TME were considered to be male gender, obesity, benign prostatic hypertrophy, low rectal cancer, pT3-T4, tumor size >5 cm, and neoadjuvant therapy. These factors were matched to surgical (morbidity, operative time, conversion rate) and pathological (quality of mesorectum, circumferential resection margin) outcomes. Male gender was associated with longer operative time (285 vs. 240 min, p = 0.031). There were no significant associations among the rest of the analyzed factors complicating laparoscopic TME and pathological and surgical outcomes of TaTME. Multivariate analysis showed that male gender was independently associated with operative time (β = 0.18 OR 1.019 CI95%:1.001–1.037; p = 0.042). TaTME seems to be more difficult in males but not in obesity, benign prostatic hypertrophy, low rectal cancer, pT3-T4, tumor size >5 cm, or neoadjuvant therapy. TaTME could be considered an alternative surgery for low rectal cancer in the presence of these factors affecting laparoscopic TME.

Transanal total mesorectal excision versus laparoscopic total mesorectal excision for mid and low rectal cancer (COLOR III): short-term outcomes of an international, multicentre, phase 3, randomised, controlled, non-inferiority trial.

Total mesorectal excision has become the standard treatment for rectal cancer, and several investigators have shown that a transanal approach is a feasible option. This study aimed to evaluate the efficacy of transanal endoscopic total mesorectal excision in patients with rectal cancer. This study was a prospective, single-arm phase II trial. It was registered on clinicaltrials.gov under identifier NCT02406118. Inpatients at a hospital specializing in oncology were selected. This prospective study enrolled 49 patients with rectal cancer located 3 to 12 cm from the anal verge who were scheduled to undergo radical surgery. Laparoscopy-assisted transanal total mesorectal excision was performed. The primary end point was total mesorectal excision quality and circumferential resection margin. Secondary end points included the number of harvested lymph nodes, operation time, and 30-day postoperative complications. From March 2015 to April 2016, 32 men and 17 women with rectal cancer were enrolled. The mean age was 61.2 years, and mean BMI was 23.3 kg/m. The mean operating time was 158 minutes, and the mean estimated blood loss was 89.3 mL. There were no intraoperative complications and no conversions to open surgery. Successful treatment based on total mesorectal excision quality and circumferential resection margin was achieved in 45 patients (91.8%). Fifteen patients (30.6%) had 30-day postoperative complications, including 7 (14.3%) with anastomotic dehiscence, 5 (10.2%) with urinary retention, 2 (4.1%) with abdominal wound complications, and 1 (2.0%) with ileus. There was no postoperative mortality. This was a noncomparative single-arm trial conducted at a single institution. Transanal endoscopic total mesorectal excision showed acceptable results based on perioperative and short-term oncologic outcomes. Further investigations are necessary to show the benefits and long-term outcomes of this procedure. See Video Abstract at http://links.lww.com/DCR/A563.

Comparing efficacy and safety of transanal vs. laparoscopic total mesorectal excision for middle and low rectal cancer: Updated meta-analysis.

To evaluate systematically the short- and long-term outcomes between laparoscope-assisted transanal total mesorectal excision (LA-taTME) and laparoscopic total mesorectal excision (L-TME) in the treatment of mid and low rectal cancer. Literatures comparing LA-taTME with L-TME published from January 2014 to January 2018 were systematically selected through searching PubMed, Ovid, EMbase, Cochrane Library, CNKI and Wanfang databases. Literature screening and methodology quality evaluation were carried out by two surgeons independently. Randomized controlled trial (RCT) was evaluated by the modified Jadad rating scale, in which 1 to 3 and 4 to 7 were considered as low and high quality,respectively(total scores: 7). Non-randomized controlled trial (NRCT) was assessed by the modified Newcastle Ottawa Scale (NOS), in which 1 to 3, 4 to 6, and 7 to 9 were defined as low, moderate, and high quality, respectively (total score: 9). Ratio of incomplete mesorectum, positive rate of circumferential resection margin (CRM), number of harvested lymph node, distance of distal resection margin, operation time, intraoperative blood loss, morbidity of postoperative complication, conversion rate, hospital stay, recurrence, 2-year disease-free survival (DFS) and 2-year overall survival (OS) were compared and analyzed by using Stata/SE12.0 software. Fourteen studies including 1 RCT and 13 NRCTs were enrolled finally. Among them, the RCT with a score of 6 was considered to be of high quality; all NRCTs (2 with 6 stars, 5 with 7 stars, and another 6 with 8 stars) were indicative of moderate to high quality; 450 patients underwent LA-taTME and 498 patients underwent L-TME. No significant differences were observed in terms of age, gender, tumor location and TNM stage between two approaches (all P>0.05). Compared to L-TME, LA-taTME had lower ratio of incomplete mesorectum (RR=0.53, 95%CI: 0.31 to 0.93, P=0.026), lower positive rate of CRM (RR=0.50, 95%CI: 0.29 to 0.86, P=0.012), lower conversion rate(RR=0.48, 95%CI: 0.26 to 0.86, P=0.014), lower morbidity of postoperative complication (RR=0.81, 95%CI: 0.67 to 0.99, P=0.036) and less intraoperative blood loss (SMD=-0.38, 95%CI:-0.68 to -0.08, P=0.013). While the differences between two groups had no statistical significance in terms of operative duration, number of harvested lymph node, distance of distal resection margin, hospital stay, overall recurrence, 2-year DFS and 2-year OS (all P>0.05). The short- and long-term outcomes of LA-taTME and L-TME for the treatment of mid and low rectal cancer are comparable, while LA-taTME can reduce the ratio of incomplete mesorectum, positive rate of CRM, conversion rate, and morbidity of postoperative complication, and intraoperative blood loss.

Transanal total mesorectal excision (taTME) is a hot topic currently in colorectal surgery. It has several advantages for lower rectal cancer, especially for male obese patients with narrow pelvis. But the indication of taTME which can really achieve the completeness of TME is limited. In terms of management and regulation, it is necessary to strictly control the indications for surgery. In the initial stage of development, patients with lower rectal cancer, with early stage and real difficulties in laparoscopy should be selected. TaTME is still premature in terms of technique, devices and instruments, with relative higher morbidity in its current form. We should pay more attentions to the safety of taTME to avoid the complications. Also, we should pay more attentions to indication and standardization of techniques, the improvement of instruments and training program of the technique. TaTME should be operated in large teaching hospitals for research purpose in the initial stage. Only with the high-quality evidence of clinical trials, can the technique be spread widely. Now, taTME is still a complementary technique to traditional abdominal surgery for lower rectal cancer. With the accumulation of standardized technique and high-quality of clinical evidence, the value of taTME will be assessed fairly.

PurposeThis study aimed to compare short-term postoperative and oncologic outcomes of a transanal endoscopic total mesorectal excision (TME) to those of a transabdominal robotic TME.MethodsA total of 62 patients with rectal cancer underwent transanal (n = 26) or robotic (n = 36) TME between June 2013 and December 2014. After case-matching by tumor location and TNM stage, 45 patients were included for analysis. The median follow-up period was 21.3 months. Operative, histopathologic and postoperative outcomes and recurrences were analyzed.ResultsPatients younger than 60 years of age were more frequently observed in the robotic TME group (75.0% vs. 47.6%, P = 0.059), but tumor location, cT and cN category, and preoperative chemoradiotherapy were not different between the 2 groups. Estimated blood loss was greater in the transanal group (283 mL vs. 155 mL, P = 0.061); however, the operation time and the rate of a diverting ileostomy and subsequent ileostomy repair were not different between the groups. The proximal resection margin was longer in the transanal TME group (20.8 cm ± 16.0 cm, P = 0.030), but the distal resection margins, involvements of the circumferential resection margin, TME quality, numbers of retrieved lymph nodes, postoperative complications, including anastomotic leak and voiding difficulty, and recurrence rates for the 2 groups were not statistically different.ConclusionTransanal endoscopic and transabdominal robotic TME showed similar histopathologic and postoperative outcomes with the exception of the estimated blood loss and the proximal resection margin for a select group of patients.

Transanal total mesorectal excision (TaTME) is positioned at the cutting edge of minimally invasive approach to mid- and low rectal cancer. This meta-analysis was to compare the short- and long-term outcomes of TaTME versus laparoscopic total mesorectal excision (LTME) and to evaluate the safety, efficacy, and possible superiority of TaTME. A comprehensive search was conducted for randomized controlled trials (RCTs) and non-RCTs (NRCTs) comparing TaTME with LTME. Inter-group differences were evaluated via standardized mean differences and relative risks (RRs). All outcomes were analyzed using fixed effects or random effects models according to the heterogeneity. Statistical analysis was performed using Stata/SE 12.0 software. Eleven studies (1 RCT and 10 NRCTs) with involving 757 patients were included. Among which, 361 patients underwent TaTME and 396 patients underwent LTME. Comparing the surgical and oncological quality of resection of TaTME with that of LTME, reports of TaTME indicated favorable outcomes considering mesorectal resection quality, circumferential resection margin involvement, intraoperative blood loss, conversions, and postoperative complications, while the differences between the two groups had no statistical significance in terms of distal resection margin, harvested lymph node, operation time, hospital stay, recurrence, 2-year overall survival (OS), and 2-year disease-free survival. TaTME is a promising surgical technique and is fully a safe, efficacious, and diffusible alternative to LTME in managing mid- and distal rectal cancer. Larger scale, national, multicentric RCTs are warranted to further verify these results and the possible superiority of TaTME.

Although transanal total mesorectal excision (TaTME) is a promising treatment for low rectal cancer, it is considered technically demanding, and the number of cases required to become proficient in TaTME remains unknown. The purpose of this study was to assess the TaTME learning curve based on the total mesorectal excision completion time. This retrospective analysis comprised 128 individuals who received TaTME between September 2016 and December 2021. The cumulative sum method was used to generate the learning curve. The duration of the procedure from the beginning to the end of the circumferential rendezvous was used to define the total mesorectal excision completion time. The learning curve consists of 3 phases: phase I (learning phase: cases 1 to 38), phase II (consolidation phase: cases 39 to 70), and phase III (maturing phase: cases 71 to 128). As the phases varied, both the overall operative time and total mesorectal excision completion time decreased considerably. Through the 3 phases of TaTME, intraoperative adverse events decreased, and in phase III, none occurred. Only 1 instance of local recurrence occurred during phase III, and none occurred during phase I or II. After 70 operations, the surgeon could join the mastery phase of TaTME based on the total mesorectal excision completion time. After the mastering phase began, there were no intraoperative negative occurrences. From the beginning, the oncological safety could be guaranteed.

Transanal total mesorectal excision (taTME) is a novel approach to radical surgery for low rectal cancer; however, it is not clear whether taTME causes a more severe inflammatory stress response than laparoscopic total mesorectal excision (laTME). Therefore, the authors conducted this study to address this question, with the secondary objective of analyzing the predictive effect of inflammatory indexes on postoperative infective complications between laTME and taTME. A total of 545 cases of laTME and 544 cases of taTME from the TaLaR randomized controlled trial were included. Inflammatory stress response was assessed via C-reactive protein (CRP), white blood cell count, neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, lymphocyte-monocyte ratio, and prognostic nutritional index. Inflammatory indexes were measured and calculated preoperatively (t1) and on postoperative days one (t2) and seven (t3). The accuracy of inflammatory indexes as predictor of infective complications was evaluated by areas under the receiver operating characteristic curve. Preoperative blood parameters were comparable between the two surgical methods. There were no significant differences in CRP, white blood cell count, neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, lymphocyte-monocyte ratio, or prognostic nutritional index between the two surgical methods at any time point ( P >0.05). Among the inflammatory indexes at three time points, CRP on the first postoperative day was the most accurate predictor of infective complications, which is suitable for two surgical methods. The AUC was 0.7671 ( P <0.0001) with a cutoff of 39.84mg/l, yielding 94% sensitivity and 47% specificity. Compared with laTME, taTME surgery has no obvious disadvantage with respect to the postoperative inflammatory stress response. In addition, inflammatory indexes were favorable in predicting infective complications, with the best results for CRP on the first postoperative day. Defining the specific predictors for laTME and taTME is unnecessary.

BackgroundTransanal total mesorectal excision (taTME) is an emerging surgical technique for rectal cancer. However, the oncological and perioperative outcomes are controversial when compared with conventional laparoscopic total mesorectal excision (laTME).MethodsA systematic review and meta-analysis based on Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines was conducted in PubMed, Embase and Cochrane database. All original studies published in English that compared taTME with laTME were included for critical appraisal and meta-analysis. Data synthesis and statistical analysis were carried out using RevMan 5.3 software.ResultsA total of seven studies including 573 patients (taTME group = 270; laTME group = 303) were included in our meta-analysis. Concerning the oncological outcomes, no differences were observed in harvested lymph nodes, distal resection margin (DRM) and positive DRM between the two groups. However, the taTME group showed a higher rate of achievement of complete grading of mesorectal quality (OR = 1.75, 95% CI = 1.02–3.01, P = 0.04), a longer circumferential resection margin (CRM) and less involvement of positive CRM (CRM: WMD = 0.96, 95% CI = 0.60–1.31, P <0.01; positive CRM: OR = 0.39, 95% CI = 0.17–0.86, P = 0.02). Concerning the perioperative outcomes, the results for hospital stay, intraoperative complications and readmission were comparable between the two groups. However, the taTME group showed shorter operation times (WMD = –23.45, 95% CI = –37.43 to –9.46, P <0.01), a lower rate of conversion (OR = 0.29, 95% CI = 0.11–0.81, P = 0.02) and a higher rate of mobilization of the splenic flexure (OR = 2.34, 95% CI = 0.99–5.54, P = 0.05). Although the incidence of anastomotic leakage, ileus and urinary morbidity showed no difference between the groups, a significantly lower rate of overall postoperative complications (OR = 0.65, 95% CI = 0.45–0.95, P = 0.03) was observed in the taTME group.ConclusionsIn comparison with laTME, taTME seems to achieve comparable technical success with acceptable oncologic and perioperative outcomes. However, multicenter randomized controlled trials are required to further evaluate the efficacy and safety of taTME.

PurposeLaparoscopic surgery for low rectal cancer is often challenging. Transanal total mesorectal excision (TaTME) and robotic surgery have been introduced to overcome the technical difficulties in laparoscopic surgery and achieve more favorable outcomes. Hybrid robotic surgery, which combines TaTME with the abdominal robotic approach, incorporates the advantages of each of these surgical techniques and might achieve less invasive and safer surgery. This study evaluated the safety and feasibility of hybrid robotic surgery with TaTME (hybrid TaTME).MethodsWe retrospectively reviewed 162 TaTME cases performed at our department from September 2016 to May 2022. Among them, 92 cases of conventional TaTME and 30 of hybrid TaTME were eligible. We used propensity score matching analysis (PSM) to adjust for patients’ characteristics and compared the short-term outcomes of the two treatment groups.ResultsTwenty-seven cases in each group were extracted using PSM. The operation time in hybrid TaTME was comparable to that in conventional TaTME. There was no significant difference in the postoperative hospital stay between the two groups. Other intra- and post-operative outcomes were also comparable between the two groups. Furthermore, no significant differences were observed between the two groups in the curative resection and recurrence rates.ConclusionHybrid TaTME for low rectal cancer was as favorable as conventional TaTME in producing satisfactory short-term outcomes. However, furthermore, larger-scale studies conducted over longer study periods are needed to evaluate the validity of the findings.

Previous studies have demonstrated the advantages of short-term histopathological outcomes and complications associated with transanal total mesorectal excision (TME) compared with laparoscopic TME. However, the long-term oncological outcomes of transanal TME remain ambiguous. This study aims to compare 3-year disease-free survival of transanal TME with laparoscopic TME. To evaluate 3-year disease-free survival between transanal TME and laparoscopic TME in patients with rectal cancer. This randomized, open-label, noninferiority, phase 3 clinical trial was performed in 16 different centers in China. Between April 2016 and June 2021, a total of 1115 patients with clinical stage I to III mid-low rectal cancer were enrolled. The last date of participant follow-up was in June 2024. Participants were randomly assigned in a 1:1 ratio before their surgical procedure to undergo either transanal TME (n = 558) or laparoscopic TME (n = 557). The primary end point was 3-year disease-free survival, with a noninferiority margin of -10% for the comparison between transanal TME and laparoscopic TME. Secondary outcomes included 3-year overall survival and 3-year local recurrence. In the primary analysis set, the median patient age was 60 years. A total of 692 male and 397 female patients were included in the analysis. Three-year disease-free survival was 82.1% (97.5% CI, 78.4%-85.8%) for the transanal TME group and 79.4% (97.5% CI, 75.6%-83.4%) for the laparoscopic TME group, with a difference of 2.7% (97.5% CI, -3.0% to 8.1%). The lower tail of a 2-tailed 97.5% CI for the group difference in 3-year disease-free survival was above the noninferiority margin of -10 percentage points. Furthermore, the 3-year local recurrence was 3.6% (95% CI, 2.0%-5.1%) for transanal TME and 4.4% (95% CI, 2.6%-6.1%) for laparoscopic TME. Three-year overall survival was 92.6% (95% CI, 90.4%-94.8%) for transanal TME and 90.7% (95% CI, 88.3%-93.2%) for laparoscopic TME. In patients with mid-low rectal cancer, 3-year disease-free survival for transanal TME was noninferior to that of laparoscopic TME. ClinicalTrials.gov Identifier: NCT02966483.

Down-to-up total mesorectal excision (TME) or transanal TME (taTME) has gained worldwide popularity. taTME is one of the most promising innovations of the last years in the field of gastrointestinal surgery. Due to the better view of the dissection planes even in difficult patients (i.e., narrow pelvis or low rectal cancer), taTME seems to achieve both better TME quality reducing the rate of incomplete TME and lower rates of positive circumferential resection margins. taTME has overall morbidity and anastomotic leak rates comparable with the up-to-down TME. Mid-term results of taTME seems to be comparable with those of the up-to-down approach but definitive conclusions cannot be drawn since the short follow-up and small cohort of patients of the present studies.

Natural orifice translumenal endoscopic surgery (NOTES) has always made more sense in the colorectal field where the target organ for entry houses the pathology. To address the question whether an adequate total mesorectal excision (TME) for rectal cancer can be performed from a transanal bottoms-up approach, we performed a case-matched study. Starting in 2009, transanal TME (taTME) surgery was selectively used for rectal cancer after neoadjuvant therapy and prospectively entered into a database. Between March 2012 and February 2014, 17 consecutive taTME rectal cancer patients were identified and case-matched to multiport laparoscopic TME (MP TME) based on age, body mass index, uT stage, radiation dose, level in the rectum, and procedure. Perioperative outcomes, morbidity, mortality, local recurrence, completeness of TME, and radial and distal margins were analyzed. Statistically significant differences were identified using Student's t test. There were 12 transanal abdominal transanal (TATA)/5 abdominoperineal resection procedures in each group. Data regarding overall/taTME/MP TME are as follows: % positive-circumferential margin: 2.9/0/5.9% (p=0.32). Distal margin: 0/0/0%. Complete or near-complete TME: 97.1/100/94.1% (p=0.32). Incomplete TME 2.9/0/5.9% (p=0.32). Local recurrence: 2.9/5.9/0% (p=0.32). There were no perioperative mortalities. Morbidity in each group: 26.4/23.5/29.4% (p=0.79). There were no differences in perioperative or postoperative outcomes except days to clear liquids (1/2days, p=0.03) and largest incision length (1.3/2.6cm, p=0.05). We demonstrated no differences in perioperative/postoperative outcomes or pathologic TME outcomes of transanal or bottoms-up TME compared to standard laparoscopic TME. TaTME is a promising progressive approach to NOTES and deserves additional evaluation.