Long Term Functional Outcomes After Transabdominal Versus Transanal Total Mesorectal Excision: A Matched Comparative Study.

Functional outcomes and quality of life (QoL) after transanal total mesorectal excision (TaTME) are very important factors in the evaluation of TaTME in comparison with other approaches to TME. The most common functional problems after resection of the rectum include bowel, urologic and sexual dysfunctions. In this study, we present our experience with QoL after TaTME; the results are compared with worldwide literature in the discussion. QoL was assessed by a questionnaire. The total of 54 patients were analysed. A general questionnaire for oncological diseases was used - European Organisation for Research and Treatment of Cancer (EORTC)-QLQ-C30, together with EORTC-QLQ-CR29 - a specific questionnaire for colorectal cancer. The Low Anterior Resection Syndrome (LARS) score was also obtained in all patients. Mean follow-up was 42.65 months (range 9-91 months). The mean LARS score in patients undergoing TaTME was 30.7 while a major LARS was observed in 64.2% of those with LARS. Of all of the symptoms in the EORTC-QLQ-C30 survey, the most serious problems which affected patients undergoing TaTME were diarrhoea (30.25), fatigue (23.87) and insomnia (20.37). In the QLQ-CR29 survey the problems included flatulence (50.94), faecal incontinence (45.06) and stool frequency (35.19). The results of EORTC-QLQ-C30 and QLQ-CR29 are quite heterogeneous. In this study the QoL of patients with advanced rectal tumours (of whom 81.5% received neoadjuvant therapy) undergoing TaTME is comparable to results in the current literature. The most severe symptoms affecting QoL after TaTME are flatulence, faecal incontinence, and stool frequency. Other serious symptoms include fatigue and insomnia. LARS was recorded in 73.6% of patients undergoing TaTME, mostly a major LARS.

The aim of this study was to compare long-term oncological, functional outcomes and quality of life (QoL) after transanal total mesorectal excision (TaTME) and laparoscopic total mesorectal excision (LaTME) for rectal cancer. A systematic review and meta-analysis based on Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were conducted on PubMed and Cochrane database. Non-randomized controlled trials (NRCTs) which compared TaTME with LaTME were included. Ten non-randomized studies were identified, including a total of 638 patients (323 TaTME and 315 LaTME). Age, sex, body mass index, neoadjuvant treatment and American Society of Anesthesiologists (ASA) staging of patients in the two groups were comparable in all included studies. The follow-up period was significantly shorter in the TaTME group than in the LaTME group. No significant differences in local (p = 0.71) and distant (p = 0.23) recurrence rate, 2-year disease-free (p = 0.86) and overall (p = 0.25) survival was found. Also, no significant differences in function outcomes and QoL, including the Wexner score (p = 0.48) or the International Prostate Syndrome Score (IPSS) (p = 0.64) were found. However, the low anterior resection syndrome (LARS) score was significantly higher in the TaTME group (p = 0.04). TaTME and LaTME have similar long-term oncological and functional outcomes as well as QoL. The only exception is higher LARS scores after TaTME. The current data are based mainly on observational studies and further randomized controlled trials are required.

PurposeImproved long-term survival after low anterior resection (LAR) for rectal cancer highlights the importance of functional outcome. Urogenital and anorectal dysfunction is frequently reported after conventional LAR. Advanced minimally invasive techniques such as robotic (RoTME) and transanal total mesorectal excision (TaTME) might improve functional results by precisely dissecting and preserving autonomic nerves. We compared functional outcomes after RoTME or TaTME in a multicenter study.MethodsOne hundred twenty patients (55 RoTME/65 TaTME) were prospectively included in four participating centers. Anorectal (Wexner and low anterior resection syndrome (LARS) Score), urinary (International Consultation on Incontinence—Male/Female Lower Urinary Tract Symptoms Score (ICIQ-MLUTS/ICIQ-FLUTS) and International Prostate Symptom Scale (IPSS)), and sexual (International Index of Erectile Function (IIEF), Female Sexual Function Index (FSFI)) outcomes at 12 months after surgery were compared to preoperative scores. The response rate to the 1-year postoperative functional assessment by questionnaire was 79.5%.ResultsRoTME enabled better anorectal function compared to TaTME (LARS score 4.3 ± 2.2 vs. 9.8 ± 1.5, p = 0.038, respectively). TaTME proved superior at preserving male urinary function, while female urinary function was comparable in both groups, with only mild postoperative impairment (RoTME vs. TaTME, respectively: ICIQ-MLUTS 13.8 ± 4.9 vs. 1.8 ± 5.8, p = 0.038; ICIQ-FLUTS Incontinence Score − 0.3 ± 1.0 vs. − 0.2 ± 0.9, p = 0.844). Both techniques demonstrated comparable male (RoTME − 13.4 ± 2.7 vs. TaTME − 11.7 ± 3.4, p = 0.615) and female (RoTME 5.2 ± 4.6 vs. TaTME 10.5 ± 6.4, p = 0.254) sexual function.ConclusionAfter adjustment for risk factors, RoTME provided better anorectal functional results, whereas TaTME was better at preserving male urinary function. Overall, both techniques demonstrated only mild postoperative functional impairment.

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.

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.

For transanal total mesorectal excision (TaTME), the indication for single-stapling technique (SST) has been expanded to include lower anastomosis, even in intersphincteric resection (ISR). We focused on the anastomotic techniques following ISR with TaTME and examined the feasibility and safety of the SST below the anorectal junction (ARJ). Data on postoperative anastomosis-related complications and anorectal function was evaluated in comparison to conventional manual hand-sewn coloanal anastomosis in ISR with TaTME. We examined patients with 3-6 cm tumors from the anal verge who underwent ISR with TaTME between January 2018 and March 2020, and whose anastomotic line was located below the ARJ. Postoperative short-term outcomes and anorectal functions were compared. We also analyzed the effects of various factors on major low anterior resection syndrome (LARS) using multivariate logistic regression analysis. In total, 87 patients-48 in the hand-sewn anastomosis group and 39 in the SST group-were included in this study. SST below the ARJ in ISR with TaTME did not exacerbate surgical outcomes, including anastomosis-related complications. The SST group had a significantly lower LARS score as compared to the hand-sewn anastomosis group, and the proportion of major LARS was significantly lower. Only hand-sewn anastomosis was identified as a statistically significant independent risk factor for major LARS. In TaTME, SST below the ARJ was safe and feasible and had a lower negative impact on postoperative anastomosis-related complications and anorectal function as compared to hand-sewn anastomosis. Thus, SST is a promising anastomotic option for patients with low-lying rectal tumors.

BackgroundRectal resection with total mesorectal excision is a difficult surgery with potential risks of complications. This study aims to assess the quality of life (QoL) of patients with low rectal cancer who have bowel function disorders equivalent to major low anterior resection syndrome (LARS) and its risk factors before treatment.MethodsA descriptive cross-sectional study was conducted on 83 patients diagnosed with low rectal cancer who had not been treated. Quality of life was assessed by the European Organisation for Research and Treatment of Cancer's (EORTC) 30-Item Core Quality of Life Questionnaire (QLQ-C30) and the LARS scale.ResultsFiffty-five (66.3%) patients had moderate/major low anterior resection syndrome, of which 34 (41%) patients had major low anterior resection syndrome. The study implicated that old age, smoking, and alcohol consumption were risk factors associated with high scores on the scale for LARS (p<0.05). Patients with low rectal cancer had low overall QoL score. In the symptom area of increased financial hardship scores, factors that adversely affected the poor quality of life in patients with low rectal cancer were fatigue and bowel dysfunction with p<0.05.ConclusionThe percentage of rectal cancer patients with low anterior resection syndrome was high, and the associated risk factors were old age, smoking, and drinking alcohol. Before treatment, the physical and mental health of patients with low rectal cancer with major low anterior resection syndrome was very poor.

Total mesorectal excision has evolved from open to minimally invasive techniques. To overcome difficulties in the lowest part of the pelvis, transanal total mesorectal excision was introduced and has gained acceptance in the recent years. The results of transanal total mesorectal excision seem to be comparable to laparoscopic total mesorectal excision. Whether or not transanal total mesorectal excision has changed the pattern of defects in the retrieved mesorectal specimens is yet to be clarified. To determine the pattern of mesorectal defects following transanal total mesorectal excision, compared to laparoscopic total mesorectal excision. The primary end-point was the location of defects in the part of the mesorectum below the peritoneal reflection, as it is this part, which is dissected from below in the transanal total mesorectal excision procedure. From our transanal total mesorectal excision database that includes all transanal total mesorectal excision procedures performed at our institution since 2013, we have included 29 patients who originally had defects in their retrieved specimens. Another 29 patients who underwent laparoscopic total mesorectal excision with mesorectal defects served as a control group. All specimen photos and pathology reports were reviewed systematically; sites and pattern of defects were defined. A higher ratio of the defects in the laparoscopic total mesorectal excision group was located below the peritoneal reflection (P = 0.043). The distribution of defects by anatomical quadrant was not statistically different between the groups. The ratio of defects below the peritoneal reflection was lower in the transanal total mesorectal excision group. Whether this is due to a lower incidence of defect in transanal total mesorectal excision is not part of our study.

To assess factors independently associated with low anterior resection syndrome (LARS) following resection or rectal cancer. Cross-sectional study carried out in two acute-care teaching hospitals in Barcelona, Spain. Patients who had undergone sphincter preserving low anterior resection with curative intent, with total or partial mesorectal excision (with and without protective ileostomy) between January 2001 and December 2009 completed a self-administered questionnaire to assess bowel dysfunction after rectal cancer surgery. Predictors of LARS were assessed by univariate and multivariate analyses. The questionnaire was sent to 329 patients (response rate 57.7%). Six cases of incomplete questionnaires were excluded. The study population included 184 patients (66.8% men) with a mean age of 63 years. There were 44 (23.9%) patients with no LARS, 36 (19.6%) with minor LARS and 104 (56.2%) with major LARS. In the univariate analysis, total mesorectal excision (P = 0.0008), protective ileostomy (P = 0.002), preoperative and postoperative radiotherapy (P = 0.0000), postoperative chemotherapy (P = 0.0046) and age (P = 0.035) were significantly associated with major LARS, whereas in the multivariate analysis, total mesorectal excision (odds ratio [OR] 2.18, 95% confidence interval [CI] 1.02-4.65), preoperative radiotherapy (OR 4.33, 95% CI 2.03-9.27) and postoperative radiotherapy (OR 9.52, 95% CI 1.74-52.24) were independent risk factors for major LARS. In this study, the risk of having major LARS increases with total mesorectal excision and both neoadjuvant and adjuvant radiotherapy. This article is protected by copyright. All rights reserved.

Objective To evaluate the defecation function of patients with low rectal cancer after laparoscopic-assisted transanal total mesorectal excision (TaTME), and analyze the influencing factors. Methods The retrospective case-control study was conducted. The clinicopathological data of 55 patients with low rectal cancer who underwent laparoscopic-assisted TaTME in the First Hospital of Jilin University from May 2017 to December 2018 were collected. There were 39 males and 16 females, aged (60±11)years, with a range from 24 to 80 years. Among the 55 patients, 21 were in TNM stage Ⅰ, 14 were in TNM stage Ⅱ, and 20 were in TNM stage Ⅲ; 24 were in pathological stage T1-2 and 31 were in pathological stage T3. Observation indicators: (1) surgical and postoperative conditions; (2) follow-up; (3) analysis of influencing factors for postoperative defecation function. Follow-up was performed using questionnaires by telephone interview to detect the complications at 3 and 6 months after surgery up to June 2019. The measurement data with normal distribution were expressed as Mean±SD, and comparison between groups was done using the t test. Count data were expressed as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test or Fisher exact probability. Univariate and multivariate analyses were performed using logistic regression models. Results (1) Surgical and postoperative conditions: 55 patients successfully underwent laparoscopic-assisted TaTME without conversion to open surgery. The operation time, volume of intraoperative blood loss, diameter of postoperative pathological specimen, time to urinary catheter removal, distance between the anastomostic stoma and anal verge, and tumor diameter were (246±62)minutes, (69±27)mL, (3.5±0.7) cm, (2.1±0.9)days, (2.4±0.5)cm, and (3.9±1.6)cm, respectively. (2) Follow-up: 55 patients were followed up at 3 months and 6 months after surgery, and the low anterior resection syndrome questionnaires were completed. Among the 55 patients, 35 had low anterior resection syndrome at 3 months after surgery, and 24 had low anterior resection syndrome at 6 months after surgery, showing a significant difference (χ2=4.42, P 5 cm were independent risk factors affecting the defecation function of patients at 3 months after surgery (odds ratio=1.135, 6.057, 95% confidence interval: 1.089-1.323, 1.206-30.435, P<0.05). The distance between the anastomotic stoma and anal verge <2 cm was an independent risk factor affecting the defecation function of patients at 6 months after surgery (odds ratio=2.724, 95% confidence interval: 1.982-3.066, P<0.05). Conclusions The incidence of low anterior resection syndrome after laparoscopic-assisted TaTME for low rectal cancer is high. Distance between the anastomotic storna and anal verge and tumor diameter are independent risk factors for the postoperative defecation founction. Key words: Rectal neoplasms; Rectal cancer; Transanal total mesorectal excision; Low anterior resection syndrome; Laparocopy

Objective: To explore the impact of neoadjuvant immunotherapy on the occurrence of low anterior resection syndrome (LARS) in patients with locally advanced rectal cancer who underwent restorative anterior resection, and to analyze associated risk factors. Methods: This study was an observational study. Patients with adenocarcinoma, mucinous adenocarcinoma, or signet ring cell carcinoma of the rectum located 0-10 cm from the anal verge who received neoadjuvant immunotherapy followed by curative restorative anterior resection at Peking University Cancer Hospital between November 2019 and February 2024 were retrospectively examined. Exclusion criteria were as follows: (1) metastasis detected preoperatively;(2) follow-up <1 year or stoma closure <6 months; (3) local recurrence or metastasis during follow-up; and (4) stoma without closure or stoma re-creation. The Chinese version of the LARS questionnaire was used to assess bowel function by telephone interview, and patients were classified based on score into no LARS (0-20 points), minor LARS (21-29 points), and major LARS (30-42 points). The incidence of LARS, major LARS, and associated risk factors were analyzed. Results: A total of 52 patients (34 men) were included for analysis. Mean age was 58.0 ± 9.8 years and mean body mass index was 25.1 ± 2.6 kg/m2. Median follow-up was 27.5 months (range, 12.0-63.7). Median LARS score was 21 (range, 1-41). Twenty-six patients (50.0%) developed LARS after surgery, and half of these (13 cases) were classified as major LARS. Stool clustering (repeated defecation within 1 hour) was observed in 80.8% (42/52) of patients. Distance between the tumor edge and the dentate line [odds ratio (OR), 3.597; 95% confidence interval (CI), 1.140-11.360; P=0.026], management of the left colic artery (OR, 0.133; 95% CI, 0.026-0.691; P=0.008), and interval of stoma closure (OR, 5.250; 95%CI, 1.381-19.960; P=0.011) were significantly associated with LARS. Interval of stoma closure was significantly associated with major LARS (OR, 4.200; 95%CI, 1.064-16.584; P=0.040). In multivariate logistic regression, ≤3.5 cm between the tumor edge and the dentate line (OR, 7.407; 95%CI, 1.377-40.000; P=0.020), non-preservation of the left colic artery (OR, 8.403; 95%CI, 1.183-58.823; P=0.033) and interval of stoma closure >6 months (OR, 10.865; 95% CI, 2.039-57.896; P=0.005) were independent risk factors for LARS. Interval of stoma closure >6 months (OR, 4.356; 95% CI, 1.105-17.167; P=0.035) were independent risk factors for major LARS. Conclusion: Patients with locally advanced rectal cancer treated with neoadjuvant immunotherapy experienced a high incidence of LARS after curative surgery, with stool clustering as the predominant symptom. Tumor edge-dentate line distance ≤3.5 cm, non-preservation of the left colic artery, and interval of stoma closure >6 months were risk factors for LARS.

Low Anterior Resection Syndrome (LARS) is a common functional disorder following sphincter-preserving surgery for rectal cancer, significantly affecting patients’ quality of life. Its development is multifactorial and influenced by surgical factors, including the use of a diverting stoma, as well as perioperative management. The aim of this study was to evaluate the incidence and severity of LARS and to analyze its association with selected clinical and treatment-related variables. A retrospective analysis was conducted on 40 patients who underwent low anterior resection for rectal cancer. Functional outcomes were assessed using the validated LARS score questionnaire, and patients were classified into no LARS, minor LARS, and major LARS groups. Variables analyzed included type of surgery (with or without diverting stoma), preoperative radiotherapy, anastomotic leakage, and timing of stoma reversal. Among the included patients, 10 (25%) had no LARS, 12 (30%) had minor LARS, and 18 (45%) had major LARS. A higher proportion of major LARS was observed among patients who underwent surgery with a diverting stoma than among those without stoma protection. Delayed stoma reversal (more than 2 months) was strongly associated with severe LARS, whereas early reversal (less than 2 months) was not associated with major symptoms. Preoperative radiotherapy and anastomotic leakage were also associated with grater LARS severity. These findings emphasize the role of surgical planning and perioperative management in minimizing the functional impact of LARS. Further studies are required to better define risk factors and optimize postoperative bowel function in affected patients.

BackgroundThe prevalence of major low anterior resection syndrome (LARS) after rectal cancer surgery varies from 17·8 to 56·0 per cent, but data from high‐quality studies are sparse. The aim of this study was to determine the prevalence of LARS and its association with quality of life (QoL) in a large, well defined, population‐based cohort.MethodsThis was a population‐based study that included all patients who had curative rectal cancer surgery with total or partial mesorectal excision in Stockholm County in Sweden between 2007 and 2013. Patients without a remaining stoma, free from cancer and alive in April 2017 were eligible for the study. The LARS score questionnaire, EORTC QLQ‐C30 and Cleveland Clinic Florida Fecal Incontinence score were used as outcome measures. Adjusted mean scores (and differences) of EORTC QLQ‐C30 for LARS groups were calculated using repeated measures ANCOVA regression models while adjusting for predefined confounders.ResultsIn total, 481 patients (82·6 per cent response rate) were included in the analysis. Mean follow‐up time was 6·7 (range 3·4–11·0) years after surgery. The prevalence of LARS was 77·4 per cent (370 of 478 patients), with 53·1 per cent (254 of 478) experiencing major LARS. Patients with major LARS reported worse on all EORTC QLQ‐C30 subscales (except for financial difficulties) than patients without LARS. A higher mean LARS score was associated with a greater impact on bowel‐related QoL.ConclusionAfter anterior resection for rectal cancer, the majority of patients suffer from major LARS with a negative impact on QoL.

Transanal total mesorectal excision (TaTME) remains a challenging technique for rectal dissection. This study aimed to evaluate the clinical and oncological outcomes of TaTME, compared to those of the laparoscopic TME (LaTME) in rectal cancer. Using propensity score-matched analyses, we analyzed retrospective data from 134 consecutive patients with rectal cancer who underwent TaTME or LaTME from January 2011 to June 2020 in our hospital. Clinical and oncological outcomes were evaluated. The primary endpoint was the 2-year local recurrence rate. Before data analysis, significant group-dependent differences were observed only in the tumor height (p<0.01). After analysis, preoperative patient demographics were similar between the TaTME and LaTME groups. The operative time was significantly shorter in the TaTME group (p=0.02), and the rates of hand-sewn anastomosis and protective loop ileostomy were significantly higher (p<0.01). The TaTME group showed a null conversion to open surgery compared to the LaTME group (5.9%). The postoperative complications, including anastomotic leak, were comparable between the two groups. However, the rate of Clavien-Dindo grade III tended to be lower in the TaTME group (p=0.07). There were no statistically significant differences in terms of pathological findings, and the 2-year local recurrence rate was similar between the two groups (both 5.9%). TaTME based on embryology along the fascia is feasible and seems a safe alternative to LaTME in selected patients with rectal cancer when considering the conversion rate and the operative time.

BackgroundAnastomotic leak (AL) after colorectal anastomosis can be a risk factor for bowel dysfunction, namely low anterior resection syndrome (LARS). The present study aimed to assess bowel dysfunction in patients who developed AL after anterior resection compared to patients without AL.MethodsWe conducted a PRISMA‐compliant systematic review of PubMed, Scopus and Cochrane Library for randomized and observational studies investigating the association between AL after anterior resection and bowel dysfunction. The main outcomes were LARS, faecal incontinence and urgency. Pairwise meta‐analyses were conducted to calculate the relative risk (RR) of the study outcomes and their 95% confidence intervals (CI).ResultsThis review included 20 retrospective studies comprising 4764 patients (61.6% male, median age 63 years). AL was detected in 14% of patients and those who experienced AL had a higher risk of LARS (six studies; 1329 patients, RR: 1.27 95%CI: 1.02, 1.58, p = 0.035), major LARS (seven studies; 1395 patients, RR: 1.38, 95%CI: 1.07, 1.79, p = 0.012), urgency (five studies; 955 patients, RR: 1.15, 95%CI: 1.04, 1.27, p = 0.005) and had higher LARS scores (seven studies; 1450 patients, WMD: 6.64, 95%CI: 3.76, 9.52, p < 0.001) and Wexner incontinence scores (seven studies; 1045 patients, WMD: 1.72, 95%CI: 0.16, 3.28, p = 0.031).ConclusionBased on low to moderate certainty evidence, AL after colorectal and coloanal anastomoses was significantly associated with an increased risk of LARS, particularly major LARS, urgency and higher LARS and Wexner/Cleveland Clinic Florida‐Fecal Incontinence Scores.