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Transanal total mesorectal excision (taTME) for rectal cancer: beyond the learning curve

  • 2019 SAGES Oral
  • Published:
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Abstract

Background

Transanal total mesorectal excision (taTME) is a surgical approach for low rectal cancer with a learning curve estimated at 40–50 cases. The experience among taTME surgeons beyond their learning curve is limited.

Methods

A retrospective analysis of all taTME cases performed for rectal cancer at two tertiary care hospitals from 2014 to 2019 was conducted. Transanal surgeons had previously performed > 50 taTME cases. Demographic, perioperative, and short-term outcomes were analyzed.

Results

Among 54 taTME patients, 74.1% were male and 27.8% had a BMI ≥ 30. Tumors were stage I (8), II (13), III (29), and IV (4). Complex cases included 4 local recurrences, 4 prior liver resections, and 2 with prior prostate cancer. Thirty tumors were located ≤ 6 cm from the anal verge. On staging MRI, 12 had a positive predicted circumferential radial margin (+CRM), and 4 had internal anal sphincter involvement (+IAS). Forty-seven patients received neoadjuvant therapy. A 2-team approach was used in 51 patients with laparoscopic (83.3%) or robotic (16.7%) abdominal assistance with a 9.2% conversion rate. Low anterior resection with sphincter salvage was achieved in 87% with 8 patients requiring intersphincteric resection. Anastomoses were hand-sewn in 57.4% and all patients were diverted. Median LOS was 5 days with a 42.6% 30-day morbidity rate and 3 postoperative mortalities (ARDS, pulmonary embolism and pseudomembranous colitis). Complete and near complete TME grade was achieved in 94.4% with a 3.7% rate of +CRM. At a median follow-up of 28 months, local and distant recurrence rates were 3.9% and 17.6%, respectively, with no cancer-related mortality.

Conclusion

Indications for taTME at experienced centers have expanded to include complex reoperative cases, local recurrences, metastatic cancer, and tumors with threatened CRM or IAS with evidence of post-treatment tumor regression. In the latter cases, taTME achieves good short-term outcomes and may facilitate R0 resection.

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References

  1. Heald R (1988) The ‘Holy Plane’ of rectal surgery. J R Soc Med 81:503–508

    Article  CAS  Google Scholar 

  2. Heald R, Husband E, Ryall R (1982) The mesorectum in rectal cancer surgery–the clue to pelvic recurrence? Br J Surg 69:613–616

    Article  CAS  Google Scholar 

  3. Guillou P, Quirke P, Thorpe H, Walker J, Jayne D, Smith A, Heath R, Brown J, MRC CLASICC trial group (2005) Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet 365:1718–1726

    Article  Google Scholar 

  4. Jayne D, Guillou P, Thorpe H, Quirke P, Copeland J, Smith A, Heath R, Brown J, UK MRC CLASICC Trial Group (2007) Randomized trial of laparoscopic-assisted resection of colorectal carcinoma: 3-year results of the UK MRC CLASICC Trial Group. J Clin Oncol 25:3061–3068

    Article  Google Scholar 

  5. Kang S, Park J, Jeong S, Nam B, Choi H, Kim D, Lim S, Lee T, Kim D, Kim J, Chang H, Lee H, Kim S, Jung K, Hong Y, Kim J, Sohn D, Kim D, Oh J (2010) Open versus laparoscopic surgery for mid or low rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): short-term outcomes of an open-label randomised controlled trial. Lancet Oncol 11:637–645

    Article  Google Scholar 

  6. Jeong S, Park J, Nam B, Kim S, Kang S, Lim S, Choi H, Kim D, Chang H, Kim D, Jung K, Kim T, Kang G, Chie E, Kim S, Sohn D, Kim D, Kim J, Lee H, Kim J, Oh J (2014) Open versus laparoscopic surgery for mid-rectal or low-rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): survival outcomes of an open-label, non-inferiority, randomised controlled trial. Lancet Oncol 15:767–774

    Article  Google Scholar 

  7. van der Pas M, Haglind E, Cuesta M, Fürst A, Lacy A, Hop W, Bonjer H, COlorectal cancer Laparoscopic or Open Resection II (COLOR II) Study Group (2013) Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol 14:210–218

    Article  Google Scholar 

  8. Bonjer H, Deijen C, Abis G, Cuesta M, van der Pas M, de Lange-de Klerk E, Lacy A, Bemelman W, Andersson J, Angenete E, Rosenberg J, Fuerst A, Haglind E, COLOR II Study Group (2015) A randomized trial of laparoscopic versus open surgery for rectal cancer. N Engl J Med 372:1324–1332

    Article  CAS  Google Scholar 

  9. Fleshman J, Branda M, Sargent D, Boller A, George V, Abbas M, Peters WJ, Maun D, Chang G, Herline A, Fichera A, Mutch M, Wexner S, Whiteford M, Marks J, Birnbaum E, Margolin D, Larson D, Marcello P, Posner M, Read T, Monson J, Wren S, Pisters P, Nelson H (2015) Effect of laparoscopic-assisted resection vs open resection of stage II or III rectal cancer on pathologic outcomes: the ACOSOG Z6051 randomized clinical trial. JAMA 314:1346–1355

    Article  CAS  Google Scholar 

  10. Fleshman J, Branda M, Sargent D, Boller A, George V, Abbas M, Peters WJ, Maun D, Chang G, Herline A, Fichera A, Mutch M, Wexner S, Whiteford M, Marks J, Birnbaum E, Margolin D, Larson D, Marcello P, Posner M, Read T, Monson J, Wren S, Pisters P, Nelson H (2019) Disease-free survival and local recurrence for laparoscopic resection compared with open resection of stage II to III rectal cancer: follow-up results of the ACOSOG Z6051 randomized controlled trial. Ann Surg 269:589–595

    Article  Google Scholar 

  11. Stevenson A, Solomon M, Lumley J, Hewett P, Clouston A, Gebski V, Davies L, Wilson K, Hague W, Simes J, ALaCaRT Investigators (2015) Effect of laparoscopic-assisted resection vs open resection on pathological outcomes in rectal cancer: the ALaCaRT randomized clinical trial. JAMA 314:1356–1363

    Article  CAS  Google Scholar 

  12. Stevenson A, Solomon M, Brown C, Lumley J, Hewett P, Clouston A, Gebski V, Wilson K, Hague W, Simes J, Australasian Gastro-Intestinal Trials Group (AGITG) ALaCaRT investigators (2019) Disease-free survival and local recurrence after laparoscopic-assisted resection or open resection for rectal cancer: the australasian laparoscopic cancer of the rectum randomized clinical trial. Ann Surg 269:596–602

    Article  Google Scholar 

  13. Jayne D, Pigazzi A, Marshall H, Croft J, Corrigan N, Copeland J, Quirke P, West N, Rautio T, Thomassen N, Tilney H, Gudgeon M, Bianchi P, Edlin R, Hulme C, Brown J (2017) Effect of robotic-assisted vs conventional laparoscopic surgery on risk of conversion to open laparotomy among patients undergoing resection for rectal cancer: the ROLARR randomized clinical trial. JAMA 318:1569–1580

    Article  Google Scholar 

  14. Nagtegaal I, Marijnen C, Kranenbarg E, van de Velde C, van Krieken J, Committee Pathology Review, Investigators Cooperative Clinical (2002) Circumferential margin involvement is still an important predictor of local recurrence in rectal carcinoma: not one millimeter but two millimeters is the limit. Am J Surg Pathol 26:350–357

    Article  Google Scholar 

  15. Nagtegaal I, van de Velde C, van der Worp E, Kapiteijn E, Quirke P, van Krieken J, Cooperative Clinical Investigators of the Dutch Colorectal Cancer Group (2002) Macroscopic evaluation of rectal cancer resection specimen: clinical significance of the pathologist in quality control. J Clin Oncol 20:1729–1734

    Article  Google Scholar 

  16. Targarona E, Balague C, Pernas J, Martinez C, Berindoague R, Gich I, Trias M (2008) Can we predict immediate outcome after laparoscopic rectal surgery? Multivariate analysis of clinical, anatomic, and pathologic features after 3-dimensional reconstruction of the pelvic anatomy. Ann Surg 247:642–649

    Article  Google Scholar 

  17. Sylla P, Rattner D, Delgado S, Lacy A (2010) NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance. Surg Endosc 24:1205–1210

    Article  Google Scholar 

  18. Veltcamp Helbach M, Deijen C, Velthuis S, Bonjer H, Tuynman J, Sietses C (2016) Transanal total mesorectal excision for rectal carcinoma: short-term outcomes and experience after 80 cases. Surg Endosc 30:464–470

    Article  CAS  Google Scholar 

  19. Tuech J, Karoui M, Lelong B, De Chaisemartin C, Bridoux V, Manceau G, Delpero J, Hanoun L, Michot F (2015) A step toward NOTES total mesorectal excision for rectal cancer: endoscopic transanal proctectomy. Ann Surg 261:228–233

    Article  Google Scholar 

  20. Burke J, Martin-Perez B, Khan A, Nassif G, de Beche-Adams T, Larach S, Albert M, Atallah S (2016) Transanal total mesorectal excision for rectal cancer: early outcomes in 50 consecutive patients. Colorectal Dis 18:570–577

    Article  CAS  Google Scholar 

  21. Chen C, Lai Y, Jiang J, Chu C, Huang I, Chen W, Cheng A, Yang S (2016) Transanal total mesorectal excision versus laparoscopic surgery for rectal cancer receiving neoadjuvant chemoradiation: a matched case-control study. Ann Surg Oncol 23:1169–1176

    Article  Google Scholar 

  22. Perez D, Melling N, Biebl M, Reeh M, Baukloh J, Miro J, Polonski A, Izbicki J, Knoll B, Pratschke J, Aigner F (2018) Robotic low anterior resection versus transanal total mesorectal excision in rectal cancer: a comparison of 115 cases. Eur J Surg Oncol 44:237–242

    Article  Google Scholar 

  23. de Lacy F, van Laarhoven J, Pena R, Arroyave M, Bravo R, Cuatrecasas M, Lacy A (2018) Transanal total mesorectal excision: pathological results of 186 patients with mid and low rectal cancer. Surg Endosc 32:2442–2447

    Article  Google Scholar 

  24. Perdawood S, Thinggaard B, Bjoern M (2018) Effect of transanal total mesorectal excision for rectal cancer: comparison of short-term outcomes with laparoscopic and open surgeries. Surg Endosc 32:2312–2321

    Article  Google Scholar 

  25. Penna M, Hompes R, Arnold S, Wynn G, Austin R, Warusavitarne J, Moran B, Hanna G, Mortensen N, Tekkis P, Collaborative TaTME Registry (2017) Transanal total mesorectal excision: international registry results of the first 720 cases. Ann Surg 266:111–117

    Article  Google Scholar 

  26. Penna M, Hompes R, Arnold S, Wynn G, Austin R, Warusavitarne J, Moran B, Hanna G, Mortensen N, Tekkis P, International TaTME Registry Collaborative (2019) Incidence and risk factors for anastomotic failure in 1594 patients treated by transanal total mesorectal excision: results from the international TaTME registry. Ann Surg 269:700–711

    Article  Google Scholar 

  27. Koedam T, Veltcamp Helbach M, van de Ven P, Kruyt P, van Heek N, Bonjer H, Tuynman J, Sietses C (2018) Transanal total mesorectal excision for rectal cancer: evaluation of the learning curve. Tech Coloproctol 22:279–287

    Article  CAS  Google Scholar 

  28. Lee L, Kelly J, Nassif G, deBeche-Adams T, Albert M, Monson J (2018) Defining the learning curve for transanal total mesorectal excision for rectal adenocarcinoma. Surg Endosc. https://doi.org/10.1007/s00464-018-6360-4

    Article  PubMed  PubMed Central  Google Scholar 

  29. Dindo D, Demartines N, Clavien P (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213

    Article  Google Scholar 

  30. Adamina M, Buchs N, Penna M, Hompes R, St.Gallen Colorectal Consensus Expert Group (2018) St.Gallen consensus on safe implementation of transanal total mesorectal excision. Surg Endosc 32:1091–1103

    Article  Google Scholar 

  31. McLemore E, Harnsberger C, Broderick R, Leland H, Sylla P, Coker A, Fuchs H, Jacobsen G, Sandler B, Attaluri V, Tsay A, Wexner S, Talamini M, Horgan S (2016) Transanal total mesorectal excision (taTME) for rectal cancer: a training pathway. Surg Endosc 30:4130–4135

    Article  Google Scholar 

  32. Sylla P, Bordeianou L, Berger D, Han K, Lauwers G, Sahani D, Sbeih M, Lacy A, Rattner D (2013) A pilot study of natural orifice transanal endoscopic total mesorectal excision with laparoscopic assistance for rectal cancer. Surg Endosc 27:3396–3405

    Article  Google Scholar 

  33. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines): Rectal Cancer 2019. Version 1.2019: https://www.nccn.org/professionals/physician_gls/PDF/rectal.pdf. Accessed 15 March 2019

  34. McLemore E, Coker A, Devaraj B, Chakedis J, Maawy A, Inui T, Talamini M, Horgan S, Peterson M, Sylla P, Ramamoorthy S (2013) TAMIS-assisted laparoscopic low anterior resection with total mesorectal excision in a cadaveric series. Surg Endosc 27:3478–3484

    Article  Google Scholar 

  35. Quirke P, Durdey P, Dixon M, Williams N (1986) Local recurrence of rectal adenocarcinoma due to inadequate surgical resection. Histopathological study of lateral tumour spread and surgical excision. Lancet 2:996–999

    Article  CAS  Google Scholar 

  36. Telem D, Han K, Kim M, Ajari I, Sohn D, Woods K, Kapur V, Sbeih M, Perretta S, Rattner D, Sylla P (2013) Transanal rectosigmoid resection via natural orifice translumenal endoscopic surgery (NOTES) with total mesorectal excision in a large human cadaver series. Surg Endosc 27:74–80

    Article  Google Scholar 

  37. Borstlap W, Harran N, Tanis P, Bemelman W (2016) Feasibility of the TAMIS technique for redo pelvic surgery. Surg Endosc 30:5364–5371

    Article  CAS  Google Scholar 

  38. Yamaguchi T, Imai M, Uematsu D (2017) Hybrid approach using laparoscopy and transanal minimally invasive surgery to treat rectal cancer with invasion to the seminal vesicles. Asian J Endosc Surg 10:219–222

    Article  Google Scholar 

  39. Uematsu D, Akiyama G, Sugihara T, Magishi A, Ono K, Yamaguchi T, Sano T (2018) Transanal total pelvic exenteration with sphincter-preserving surgery. Dis Colon Rectum 61:641

    Article  Google Scholar 

  40. Uematsu D, Akiyama G, Sugihara T, Magishi A, Yamaguchi T, Sano T (2017) Transanal total pelvic exenteration: pushing the limits of transanal total mesorectal excision with transanal pelvic exenteration. Dis Colon Rectum 60:647–648

    Article  Google Scholar 

  41. Deijen CL, Velthuis S, Tsai A, Mavroveli S, de Lange-de Klerk ES, Sietses C, Tuynman JB, Lacy AM, Hanna GB, Bonjer HJ (2016) COLOR III: a multicentre randomised clinical trial comparing transanal TME versus laparoscopic TME for mid and low rectal cancer. Surg Endosc 30(8):3210–3215

    Article  Google Scholar 

  42. Lelong B, de Chaisemartin C, Meillat H, Cournier S, Boher J, Genre D, Karoui M, Tuech J, Delpero J, French Research Group of Rectal Cancer Surgery (GRECCAR) (2017) A multicentre randomised controlled trial to evaluate the efficacy, morbidity and functional outcome of endoscopic transanal proctectomy versus laparoscopic proctectomy for low-lying rectal cancer (ETAP-GRECCAR 11 TRIAL): rationale and design. BMC Cancer 17:253

    Article  Google Scholar 

  43. Sylla P. Multicenter phase II study of transanal TME (taTME) ClinicalTrials.gov2017. https://clinicaltrials.gov/ct2/show/NCT03144765. Accessed 23 Aug 2018

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Acknowledgements

Podium presentation at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2019 Annual Meeting, April 3–6, 2019, Baltimore, Maryland.

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Authors and Affiliations

  1. Division of Colon and Rectal Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, Box 1259, New York, NY, 10029, USA

    Anthony P. D’Andrea, Antoinette Bonaccorso, Jordan M. Cuevas, Deepika Bhasin & Patricia Sylla

  2. Department of Surgery, Los Angeles Medical Center, Southern California Kaiser Permanente Medical Group, Los Angeles, CA, USA

    Elisabeth C. McLemore, Motahar Basam, Anna T. Tsay & Vikram Attaluri

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  1. Anthony P. D’Andrea
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  2. Elisabeth C. McLemore
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Correspondence to Patricia Sylla.

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Disclosures

Patricia Sylla is a consultant for Ethicon, Medtronic, Olympus, GI Supply, and SafeHeal. Anthony D’Andrea, Elisabeth McLemore, Antoinette Bonaccorso, Jordan Cuevas, Anna Tsay, Deepika Bhasin, Motahar Basam, and Vikram Attaluri have nothing to disclose.

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D’Andrea, A.P., McLemore, E.C., Bonaccorso, A. et al. Transanal total mesorectal excision (taTME) for rectal cancer: beyond the learning curve. Surg Endosc 34, 4101–4109 (2020). https://doi.org/10.1007/s00464-019-07172-4

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