|
1
|
Jingtao Z, Bin W, Haoyu B, Hexin L, Xuejun Y, Tinghao W, Zhiwen X, Jun Y. Prediction of postoperative complications following transanal total mesorectal excision in middle and low rectal cancer: development and internal validation of a clinical prediction model. Int J Colorectal Dis 2024; 39:133. [PMID: 39150559 PMCID: PMC11329424 DOI: 10.1007/s00384-024-04702-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/31/2024] [Indexed: 08/17/2024]
Abstract
PURPOSE The objective of this study is to develop a nomogram for the personalized prediction of postoperative complication risks in patients with middle and low rectal cancer who are undergoing transanal total mesorectal excision (taTME). This tool aims to assist clinicians in early identification of high-risk patients and in addressing preoperative risk factors to enhance surgical safety. METHODS In this case-control study, 207 patients diagnosed with middle and low rectal cancer and undergoing taTME between February 2018 and November 2023 at The First Affiliated Hospital of Xiamen University were included. Independent risk factors for postoperative complications were analyzed using the Least Absolute Shrinkage and Selection Operator (LASSO) regression and multifactorial logistic regression models. A predictive nomogram was constructed using R Studio. RESULTS Among the 207 patients, 57 (27.5%) experienced postoperative complications. The LASSO and multifactorial logistic regression analyses identified operation time (OR = 1.010, P = 0.007), smoking history (OR = 9.693, P < 0.001), anastomotic technique (OR = 0.260, P = 0.004), and ASA score (OR = 9.077, P = 0.051) as significant predictors. These factors were integrated into the nomogram. The model's accuracy was validated through receiver operating characteristic curves, calibration curves, consistency indices, and decision curve analysis. CONCLUSION The developed nomogram, incorporating operation time, smoking history, anastomotic technique, and ASA score, effectively forecasts postoperative complication risks in taTME procedures. It is a valuable tool for clinicians to identify patients at heightened risk and initiate timely interventions, ultimately improving patient outcomes.
Collapse
Affiliation(s)
- Zhu Jingtao
- Department of Gastrointestinal Oncology Surgery, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, 361003, Fujian, China
- The School of Clinical Medicine, Fujian Medical University, Fuzhou, China
| | - Wu Bin
- Department of Gastrointestinal Oncology Surgery, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, 361003, Fujian, China
- School of Medicine, Xiamen University, Xiamen, China
| | - Bai Haoyu
- Department of Gastrointestinal Oncology Surgery, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, 361003, Fujian, China
- School of Medicine, Xiamen University, Xiamen, China
| | - Lin Hexin
- Department of Gastrointestinal Oncology Surgery, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, 361003, Fujian, China
- The School of Clinical Medicine, Fujian Medical University, Fuzhou, China
| | - Yu Xuejun
- Department of Gastrointestinal Oncology Surgery, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, 361003, Fujian, China
- School of Medicine, Xiamen University, Xiamen, China
| | - Wang Tinghao
- Department of Gastrointestinal Oncology Surgery, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, 361003, Fujian, China
- The School of Clinical Medicine, Fujian Medical University, Fuzhou, China
| | - Xu Zhiwen
- Department of Gastrointestinal Oncology Surgery, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, 361003, Fujian, China
- School of Medicine, Xiamen University, Xiamen, China
| | - You Jun
- Department of Gastrointestinal Oncology Surgery, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, 361003, Fujian, China.
- The School of Clinical Medicine, Fujian Medical University, Fuzhou, China.
- School of Medicine, Xiamen University, Xiamen, China.
| |
Collapse
|
|
2
|
Neary E, Ibrahim T, Verschoor CP, Zhang L, Patel SV, Chadi SA, Caycedo-Marulanda A. A systematic review and meta-analysis of oncological outcomes with transanal total mesorectal excision for rectal cancer. Colorectal Dis 2024; 26:837-850. [PMID: 38590019 DOI: 10.1111/codi.16982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 09/17/2023] [Accepted: 01/21/2024] [Indexed: 04/10/2024]
Abstract
AIM Transanal total mesorectal (taTME) excision is a method used to assist in the radical removal of the rectum. By adopting the concept of natural orifice surgery, it offers potential benefits over conventional techniques. Early enthusiasm for this strategy led to its rapid and widespread adoption. The imposing of a local moratorium was precipitated by the discovery in Norway of an uncommon multifocal pattern of locoregional recurrence. The aim of this systematic review and meta-analysis was to determine the incidence of local recurrence after taTME for rectal cancer. METHOD Conforming to the Cochrane Handbook for Systematic Reviews of Interventions and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines checklist, a systematic review and meta-analysis was conducted. This included case series and comparative studies between taTME and preferentially laparoscopic procedures published between 2010 and 2021. RESULTS There were a total of 1175 studies retrieved. After removal and screening for quality and relevance, the final analysis contained 40 studies. The local recurrence rate following taTME was 3.4% (95% CI 2.9%-3.9%, I2 = 0%) in 4987 patients with follow-up durations ranging from 0.7 to 5.5 years. Compared with laparoscopic TME, local recurrence was not statistically different for the taTME group (p = 0.076); however, it was less probable (OR = 0.51, 95% CI 0.24-1.09, I2 = 0%). Systemic recurrence and circumferential resection margin status were secondary outcomes; however, the differences were not statistically significant. CONCLUSION Our data suggest that the local recurrence for regular laparoscopic and transanal TME surgeries may be comparable, suggesting that taTME can be performed without influencing locoregional oncological outcomes in patients treated at specialized institutions and who have been cautiously selected.
Collapse
Affiliation(s)
- Emma Neary
- Queen's University, Kingston, Ontario, Canada
| | - Tarek Ibrahim
- Division of Oncology, Department of Surgery, University Health Network and Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Chris P Verschoor
- Health Sciences North Research Institute, Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | - Lisa Zhang
- Queen's University, Kingston, Ontario, Canada
| | - Sunil V Patel
- Queen's University, Kingston, Ontario, Canada
- Department of Surgery, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Sami A Chadi
- Division of Oncology, Department of Surgery, University Health Network and Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Antonio Caycedo-Marulanda
- Queen's University, Kingston, Ontario, Canada
- Health Sciences North Research Institute, Northern Ontario School of Medicine, Sudbury, Ontario, Canada
- Orlando Health Colon and Rectal Institute, Orlando, Florida, USA
| |
Collapse
|
|
3
|
Xu Z, Zhu J, Bai H, Xiao L, Wang T, Lin H, Hong Q, You J. Transanal total mesorectal excision: single center study on risk factors for major complications. Front Oncol 2023; 13:1277979. [PMID: 37927458 PMCID: PMC10622653 DOI: 10.3389/fonc.2023.1277979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 09/26/2023] [Indexed: 11/07/2023] Open
Abstract
Purpose Transanal total mesorectal excision (TaTME) as a novel surgical approach for mid and low rectal cancer has gained significant research interest in recent years. The main objective of this study is to identify the risk factors associated with major complications after TaTME and evaluate the perioperative clinical outcomes. Methods A retrospective analysis was performed on the clinical data of patients with mid-to-low rectal cancer who underwent TaTME surgery and were admitted to the First Affiliated Hospital of Xiamen University from January 2018 to May 2023. Univariate and multivariate regression methods were employed to analyze the risk factors influencing the occurrence of major complications (Clavien-Dindo III-V). Results This study included a total of 179 eligible cases, with no perioperative deaths. The overall incidence of early complications was 25.1%, with a rate of 10.1% for mild complications and 15.0% for major complications. The postoperative anastomotic leakage rate within 30 days was 6.7%. Multivariate analysis demonstrated that male (P=0.030), pathological T ≥ 3 (P=0.018) and manual anastomosis (P=0.009) were independent risk factors for the development of major complications after surgery. Conclusion In this study, the incidence of early complications and anastomotic leakage rate in TaTME were both relatively low. Male, pathological T stage ≥ 3 and manual anastomosis were independent risk factors for the occurrence of major complications in a cohort of patients with mid and low rectal cancer undergoing TaTME.
Collapse
Affiliation(s)
- Zhiwen Xu
- School of Medicine, Xiamen University, Xiamen, China
| | - Jingtao Zhu
- School of Clinical Medicine, Fujian Medical University, Fuzhou, China
| | - Haoyu Bai
- School of Medicine, Xiamen University, Xiamen, China
| | - Liangbin Xiao
- School of Clinical Medicine, Fujian Medical University, Fuzhou, China
| | - Tinghao Wang
- School of Clinical Medicine, Fujian Medical University, Fuzhou, China
| | - Hexin Lin
- Department of Gastrointestinal Oncology Surgery, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Qingqi Hong
- Department of Gastrointestinal Oncology Surgery, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Jun You
- School of Medicine, Xiamen University, Xiamen, China
- Department of Gastrointestinal Oncology Surgery, The First Affiliated Hospital of Xiamen University, Xiamen, China
| |
Collapse
|
|
4
|
Matsuda T, Sawada R, Hasegawa H, Yamashita K, Harada H, Urakawa N, Goto H, Kanaji S, Oshikiri T, Kakeji Y. Learning Curve for Transanal Total Mesorectal Excision for Low Rectal Malignancy. J Am Coll Surg 2023; 236:1054-1063. [PMID: 36735483 DOI: 10.1097/xcs.0000000000000608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND 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. STUDY DESIGN 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. RESULTS 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. CONCLUSIONS 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.
Collapse
Affiliation(s)
- Takeru Matsuda
- From the Division of Gastrointestinal Surgery (Matsuda, Sawada, Hasegawa, Yamashita, Harada, Urakawa, Goto, Kanaji, Oshikiri, Kakeji)
- Division of Minimally Invasive Surgery (Matsuda), Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Ryuichiro Sawada
- From the Division of Gastrointestinal Surgery (Matsuda, Sawada, Hasegawa, Yamashita, Harada, Urakawa, Goto, Kanaji, Oshikiri, Kakeji)
| | - Hiroshi Hasegawa
- From the Division of Gastrointestinal Surgery (Matsuda, Sawada, Hasegawa, Yamashita, Harada, Urakawa, Goto, Kanaji, Oshikiri, Kakeji)
| | - Kimihiro Yamashita
- From the Division of Gastrointestinal Surgery (Matsuda, Sawada, Hasegawa, Yamashita, Harada, Urakawa, Goto, Kanaji, Oshikiri, Kakeji)
| | - Hitoshi Harada
- From the Division of Gastrointestinal Surgery (Matsuda, Sawada, Hasegawa, Yamashita, Harada, Urakawa, Goto, Kanaji, Oshikiri, Kakeji)
| | - Naoki Urakawa
- From the Division of Gastrointestinal Surgery (Matsuda, Sawada, Hasegawa, Yamashita, Harada, Urakawa, Goto, Kanaji, Oshikiri, Kakeji)
| | - Hironobu Goto
- From the Division of Gastrointestinal Surgery (Matsuda, Sawada, Hasegawa, Yamashita, Harada, Urakawa, Goto, Kanaji, Oshikiri, Kakeji)
| | - Shingo Kanaji
- From the Division of Gastrointestinal Surgery (Matsuda, Sawada, Hasegawa, Yamashita, Harada, Urakawa, Goto, Kanaji, Oshikiri, Kakeji)
| | - Taro Oshikiri
- From the Division of Gastrointestinal Surgery (Matsuda, Sawada, Hasegawa, Yamashita, Harada, Urakawa, Goto, Kanaji, Oshikiri, Kakeji)
| | - Yoshihiro Kakeji
- From the Division of Gastrointestinal Surgery (Matsuda, Sawada, Hasegawa, Yamashita, Harada, Urakawa, Goto, Kanaji, Oshikiri, Kakeji)
| |
Collapse
|
|
5
|
Challenges and Learning Curves in Adopting TaTME and Robotic Surgery for Rectal Cancer: A Cusum Analysis. Cancers (Basel) 2022; 14:cancers14205089. [PMID: 36291872 PMCID: PMC9600114 DOI: 10.3390/cancers14205089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 10/12/2022] [Accepted: 10/14/2022] [Indexed: 11/20/2022] Open
Abstract
Simple Summary Rectal cancer surgery remains a challenge and information about the learning curve in adopting new techniques is lacking. This paper analyzes our experience in taTME (since 2015) and robotic surgery (since 2018) at a fully accredited referral center for the treatment of rectal cancer in Spain. In this retrospective study, we aim to analyze the learning curves for taTME and robot-assisted rectal procedures in the incorporation of these platforms into our practice. We sought to describe our team’s experience in incorporating these techniques and to analyze the difficulties that we have had. Hoping that sharing our experience can help other groups improve their results during the difficult initial phase of incorporating new techniques. Abstract New techniques are being developed to improve the results of laparoscopic surgery for rectal cancer. This paper analyzes the learning curves for transanal total mesorectal excision (taTME) and robot-assisted surgery in our colorectal surgery department. We analyzed retrospectively data from patients undergoing curative and elective surgery for rectal cancer ≤12 cm from the anal verge. We excluded extended surgeries. We used cumulative sum (CUSUM) curve analysis to identify inflection points. Between 2015 and 2021, 588 patients underwent surgery for rectal cancer at our center: 67 taTME and 79 robot-assisted surgeries. To overcome the operative time learning curve, 14 cases were needed for taTME and 53 for robot-assisted surgery. The morbidity rate started to decrease after the 17th case in taTME and after the 49th case in robot-assisted surgery, but it is much less abrupt in robot-assisted group. During the initial learning phase, the rate of anastomotic leakage was higher in taTME (35.7% vs. 5.7%). Two Urological lesions occurred in taTME but not in robot-assisted surgery. The conversion rate was higher in robot-assisted surgery (1.5% vs. 10.1%). Incorporating new techniques is complex and entails a transition period. In our experience, taTME involved a higher rate of serious complications than robot-assisted surgery during initial learning period but required a shorter learning curve.
Collapse
|
|
6
|
Burghgraef TA, Sikkenk DJ, Verheijen PM, Moumni ME, Hompes R, Consten ECJ. The learning curve of laparoscopic, robot-assisted and transanal total mesorectal excisions: a systematic review. Surg Endosc 2022; 36:6337-6360. [PMID: 35697853 PMCID: PMC9402498 DOI: 10.1007/s00464-022-09087-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 01/29/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND The standard treatment of rectal carcinoma is surgical resection according to the total mesorectal excision principle, either by open, laparoscopic, robot-assisted or transanal technique. No clear consensus exists regarding the length of the learning curve for the minimal invasive techniques. This systematic review aims to provide an overview of the current literature regarding the learning curve of minimal invasive TME. METHODS A systematic literature search was performed. PubMed, Embase and Cochrane Library were searched for studies with the primary or secondary aim to assess the learning curve of either laparoscopic, robot-assisted or transanal TME for rectal cancer. The primary outcome was length of the learning curve per minimal invasive technique. Descriptive statistics were used to present results and the MINORS tool was used to assess risk of bias. RESULTS 45 studies, with 7562 patients, were included in this systematic review. Length of the learning curve based on intraoperative complications, postoperative complications, pathological outcomes, or a composite endpoint using a risk-adjusted CUSUM analysis was 50 procedures for the laparoscopic technique, 32-75 procedures for the robot-assisted technique and 36-54 procedures for the transanal technique. Due to the low quality of studies and a high level of heterogeneity a meta-analysis could not be performed. Heterogeneity was caused by patient-related factors, surgeon-related factors and differences in statistical methods. CONCLUSION Current high-quality literature regarding length of the learning curve of minimal invasive TME techniques is scarce. Available literature suggests equal lengths of the learning curves of laparoscopic, robot-assisted and transanal TME. Well-designed studies, using adequate statistical methods are required to properly assess the learning curve, while taking into account patient-related and surgeon-related factors.
Collapse
Affiliation(s)
- Thijs A Burghgraef
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, the Netherlands.
- Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands.
| | - Daan J Sikkenk
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, the Netherlands
| | - Paul M Verheijen
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, the Netherlands
| | - Mostafa El Moumni
- Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| | - Roel Hompes
- Department of Surgery, University Medical Center Amsterdam, Location AMC, Amsterdam, the Netherlands
| | - Esther C J Consten
- Department of Surgery, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, the Netherlands
- Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, the Netherlands
| |
Collapse
|
|
7
|
Abstract
BACKGROUND Restorative proctocolectomy with IPAA is the standard procedure in ulcerative colitis patients with medical refractory disease or dysplasia and select patients with IBD unclassified or Crohn's disease. A variety of minimally invasive techniques have become increasingly utilized, including the transanal IPAA. Unfortunately, despite its growing popularity, there is a lack of high-quality data for the transanal approach. OBJECTIVE The aim of this study was to investigate clinical outcomes, including complication rates, during our initial experience with the transanal approach. DESIGN The study design was a single-center prospective case series. SETTINGS The study was conducted at a tertiary referral center. PATIENTS The study included patients with ulcerative colitis, IBD unclassified, and Crohn's disease undergoing 2- or 3-stage restorative proctocolectomy with IPAA. INTERVENTIONS Consecutive patients after November 2016 undergoing restorative proctocolectomy with transanal approach were compared with a historic cohort of patients who underwent an open approach before October 2016. MAIN OUTCOME MEASURES The primary outcome measure was early and late anastomotic leak rates during our learning curve. Secondary outcomes included postoperative clinical measures. RESULTS The study group consisted of 100 open and 65 transanal approach patients. Median (interquartile range) estimated blood loss was lower with the transanal approach (100 [50-150] vs 150 [100-250] mL; p = 0.007), and hospital stay was lower in the transanal group by 2 days ( p < 0.001). There was a significantly higher rate of anastomotic leaks with the transanal approach compared with the open approach (n = 7 [11%] vs n = 2 [2%] respectively; p = 0.03). There were fewer, but statistically insignificant, anastomotic complications in the third tertile, which was later in our learning curve. LIMITATIONS The study was nonrandomized with consecutive assignment, introducing possible selection and chronology biases. CONCLUSION Restorative proctocolectomy with the transanal approach was associated with lower blood loss and shorter hospital stay but a significantly higher anastomotic leak rate. The transanal minimally invasive approach for pouch surgery offers some advantages but carries a steep learning curve. See Video Abstract at http://links.lww.com/DCR/B842 . EXPERIENCIA DE UN SOLO CENTRO DE PROCTECTOMA TRANSANAL CON ANASTOMOSIS ILEOANAL CON RESERVORIO ILEAL PARA ENFERMEDAD INFLAMATORIA INTESTINAL ANTECEDENTES:La proctocolectomía restaurativa con anastomosis ileoanal con reservorio ileal es el procedimiento estándar en pacientes con colitis ulcerativa con enfermedad médica refractaria o displasia y pacientes seleccionados con enfermedad inflamatoria intestinal no clasificada o enfermedad de Crohn. Se ha utilizado cada vez más una variedad de técnicas mínimamente invasivas, incluido el enfoque de anastomosis ileoanal con reservorio ileal transanal. Desafortunadamente, a pesar de su creciente popularidad, hay falta de datos de alta calidad para el enfoque transanal.OBJETIVO:Investigar los resultados clínicos, incluidas las tasas de complicaciones, durante nuestra experiencia inicial con el enfoque transanal.DISEÑO:Serie de casos prospectivos de un solo centro.AJUSTES:Centro de referencia terciario.PACIENTES:Pacientes con ulcerativa, enfermedad inflamatoria intestinal no clasificada y enfermedad de Crohn sometidos a proctocolectomía restaurativa de 2 o 3 etapas con anastomosis ileoanal con reservorio ileal.INTERVENCIONES:Pacientes consecutivos después de noviembre del 2016 sometidos a proctocolectomía restaurativa con abordaje transanal fueron comparados con una cohorte histórica que se sometieron a un abordaje abierto antes de octubre del 2016.PRINCIPALES MEDIDAS DE RESULTADO:La principal medida de resultado fueron las tasas de fuga anastomótica temprana y tardía durante nuestra curva de aprendizaje. Los resultados secundarios incluyeron medidas clínicas postoperatorias.RESULTADOS:El grupo de estudio estuvo formado por 100 pacientes con abordaje abierto y 65 por vía transanal. La media de pérdida sanguínea estimada fue menor con el abordaje transanal (100 [50-150] vs 150 [100-250] mL; p = 0.007) y la estancia hospitalaria fue menor en el grupo transanal por 2 días ( p < 0.001). Hubo una tasa significativamente mayor de fugas anastomóticas con el abordaje transanal en comparación con el abordaje abierto (n = 7 [11%] vs n = 2 [2%] respectivamente, p = 0.03). Hubo menos complicaciones anastomóticas, pero estadísticamente insignificantes, en el tercer tercil, posterior en nuestra curva de aprendizaje.LIMITACIONES:Estudio no randomizado con asignación consecutiva que presenta posibles sesgos de selección y cronología.CONCLUSIÓNES:La proctocolectomía restaurativa con abordaje transanal se asoció a una menor pérdida sanguínea y estancia hospitalaria más corta, pero con una tasa de fuga anastomótica significativamente mayor. El abordaje transanal mínimamente invasivo para cirugía de reservorio ofrece algunas ventajas, pero conlleva a una curva de aprendizaje pronunciada. Consulte Video Resumen en http://links.lww.com/DCR/B842 . (Traducción- Dr. Francisco M. Abarca-Rendon ).
Collapse
|
|
8
|
Naghawi H, Chau J, Madani A, Kaneva P, Monson J, Mueller C, Lee L. Development and evaluation of a virtual knowledge assessment tool for transanal total mesorectal excision. Tech Coloproctol 2022; 26:551-560. [PMID: 35503143 DOI: 10.1007/s10151-022-02621-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 04/10/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Transanal total mesorectal excision (TATME) is difficult to learn and can result in serious complications. Current paradigms for assessing performance and competency may be insufficient. This study aims to develop and provide preliminary validity evidence for a TATME virtual assessment tool (TATME-VAT) to assess the cognitive skills necessary to safely complete TATME dissection. METHODS Participants from North America, Europe, Japan and China completed the test via an interactive online platform between 11/2019 and 05/2020. They were grouped into expert, experienced and novice surgeons depending on the number of independently performed TATMEs. TATME-VAT is a 24-item web-based assessment evaluating advanced cognitive skills, designed according to a blueprint from consensus guidelines. Eight items were multiple choice questions. Sixteen items required making annotations on still frames of TATME videos (VCT) and were scored using a validated algorithm derived from experts' responses. Annotation (range 0-100), multiple choice (range 0-100), and overall scores (sum of annotation and multiple-choice scores, normalized to μ = 50 and σ = 10) were reported. RESULTS There were significant differences between the expert, experienced, and novice groups for the annotation (p < 0.001), multiple-choice (p < 0.001), and overall scores (p < 0.001). The annotation (p = 0.439) and overall (p = 0.152) scores were similar between the experienced and novice groups. Annotation scores were higher in participants with 51 or more vs. 30-50 vs. less than 30 cases. Scores were also lower in users with a self-reported recent complication vs. those without. CONCLUSIONS This study describes the development of an interactive video-based virtual assessment tool for TATME dissection and provides initial validity evidence for its use.
Collapse
Affiliation(s)
- Hamzeh Naghawi
- The Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University Health Center, Montreal, QC, Canada
| | - Johnny Chau
- The Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University Health Center, Montreal, QC, Canada
| | - Amin Madani
- The University Health Network - Toronto General Hospital, Toronto, ON, Canada
| | - Pepa Kaneva
- The Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University Health Center, Montreal, QC, Canada
| | - John Monson
- AdventHealth Medical Group, Orlando, FL, USA
| | - Carmen Mueller
- The Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University Health Center, Montreal, QC, Canada
| | - Lawrence Lee
- The Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University Health Center, Montreal, QC, Canada. .,Colon and Rectal Surgery, Department of Surgery, McGill University Health Centre, 1001 Decarie Boulevard, DS1-3310, Montreal, QC, H4A 3J1, Canada.
| |
Collapse
|
|
9
|
Ourô S, Ferreira M, Roquete P, Maio R. Transanal versus laparoscopic total mesorectal excision: a comparative study of long-term oncological outcomes. Tech Coloproctol 2022; 26:279-290. [PMID: 35050434 DOI: 10.1007/s10151-022-02570-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 01/07/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Transanal total mesorectal excision (TaTME) is the most recent approach developed to improve pelvic dissection in surgery for mid and low rectal tumors. There are still inconsistencies regarding the technique's oncological results. The aim of this study was to analyze clinical and oncological outcomes of the learning curve of TaTME in comparison to laparoscopic TME (lapTME). METHODS Rectal cancer patients who had TaTME and lapTME in two Portuguese colorectal units between March 2016 and December 2018 were eligible. Primary endpoints were 5-year overall survival, disease-free survival, and local recurrence. Secondary endpoints were clinical and pathological outcomes. RESULTS Forty-four patients underwent TaTME (29 men) and 39 lapTME (27 men) with a median age of 69 and 66 (p = 0.093), respectively. No differences were observed concerning baseline characteristics, emphasizing their comparability. In the TaTME group, there were more hand-sewn anastomosis (0 lapTME versus 7 TaTME, p = 0.018) with significantly less distance to the dentate line (40 mm lapTME versus 20 mm TaTME, p = 0.005) and significantly more loop ileostomies performed (28 lapTME versus 41 TaTME, p = 0.001). There were no differences in post-operative mortality, morbidity, readmissions, and stoma closure. Groups were similar in relation to specimen quality, margins, and resectability; however, TaTME had a significantly higher node yield (14 lapTME versus 20 TaTME, p = 0.002). Finally, no disparities were noted in oncological outcomes, namely local and distant recurrence, 5-year overall survival, and disease-free survival. CONCLUSIONS Even with the disadvantage of the learning curve of a new technique, TaTME appears to be comparable to lapTME, with similar long-term oncological outcomes. It has, however, a demanding learning curve, significant risk for morbidity and should be used only for selected patients.
Collapse
Affiliation(s)
- S Ourô
- Consultant in General and Colorectal Surgery, Surgical Department of Hospital Beatriz Ângelo, Avenida Carlos Teixeira 514, Loures, Portugal.
- NOVA Medical School, Lisbon, Portugal.
| | - M Ferreira
- Consultant in General Surgery, Surgical Department of Hospital Beatriz Ângelo, Lisbon, Portugal
| | - P Roquete
- Consultant in General Surgery, Surgical Department of Hospital da Luz, Lisbon, Portugal
| | - R Maio
- Consultant in General Surgery, Head of the Surgical Department of Hospital Beatriz Ângelo, Lisbon, Portugal
- Full Professor of Surgery, NOVA Medical School, Lisbon, Portugal
| |
Collapse
|
|
10
|
Lau SYC, Choy KT, Yang TWW, Heriot A, Warrier SK, Guest GD, Kong JC. Defining the learning curve of transanal total mesorectal excision: a systematic review and meta-analysis. ANZ J Surg 2021; 92:355-364. [PMID: 34676655 DOI: 10.1111/ans.17262] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/14/2021] [Accepted: 09/19/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Transanal total mesorectal excision (taTME) represents a novel approach to rectal dissection. Although many structured training programs have been developed worldwide to assist surgeons in implementing this new technique, the learning curve (LC) of taTME has yet to be conclusively defined. This is particularly important given the concerns regarding the complication profile and oncological safety of taTME. The aim of this review was to provide an up-to-date systematic review and meta-analysis of the LC for taTME, comparing the difference of outcomes between the LC and after learning curve (ALC) groups. METHODS An up-to-date systematic review was performed on the available literature between 2010-2020 on PubMed, EMBASE, Medline and Cochrane Library databases. All studies comparing taTME procedures before and after LC were analysed. RESULTS Seven retrospective studies of prospectively collected databases were included, comparing 333 (51.0%) patients in the LC group and 320 (49.0%) patients in the ALC group. There was a significantly reduced number of adverse intra-operative events, anastomotic leaks and improved quality of mesorectal excision in the ALC group. CONCLUSION This review shows that there is a significant improvement in clinical outcomes between the LC and ALC groups which supports the need for careful mastery and ongoing technical refinement during the LC in taTME. This procedure should be performed on a subset of carefully selected patients in the hands of experienced and well-trained teams dedicated to ongoing audit.
Collapse
Affiliation(s)
- Steve Yee Chiang Lau
- Department of Surgery, University Hospital Geelong, Geelong, Victoria, Australia.,Department of Surgery, Epworth Geelong Hospital, Deakin University, Geelong, Victoria, Australia
| | - Kay Tai Choy
- Department of Surgery, Austin Hospital, Melbourne, Victoria, Australia
| | - Tze Wei Wilson Yang
- Department of Colorectal Surgery, Alfred Hospital, Melbourne, Victoria, Australia
| | - Alexander Heriot
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - Satish K Warrier
- Department of Colorectal Surgery, Alfred Hospital, Melbourne, Victoria, Australia.,Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - Glenn D Guest
- Department of Surgery, University Hospital Geelong, Geelong, Victoria, Australia.,Department of Surgery, Epworth Geelong Hospital, Deakin University, Geelong, Victoria, Australia
| | - Joseph C Kong
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Division of Cancer Research, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| |
Collapse
|
|
11
|
Butterworth JW, Butterworth WA, Meyer J, Giacobino C, Buchs N, Ris F, Scarpinata R. A systematic review and meta-analysis of robotic-assisted transabdominal total mesorectal excision and transanal total mesorectal excision: which approach offers optimal short-term outcomes for mid-to-low rectal adenocarcinoma? Tech Coloproctol 2021; 25:1183-1198. [PMID: 34562160 DOI: 10.1007/s10151-021-02515-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 08/24/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Resection of low rectal adenocarcinoma can be challenging in the narrow pelvis of male patients. Transanal total mesorectal excision (TaTME) appears to offer technical advantages for distal rectal tumours, and robotic-assisted transabdominal TME (rTME) was introduced in effort to improve operative precision and ergonomics. However, no study has comprehensively compared these approaches. The aim of the present study was to perform a systematic review of the literature to compare postoperative short-term outcomes in rTME and TaTME. METHODS A systematic online search (1974-July 2020) of MEDLINE, Embase, web of science and google scholar was conducted for trials, prospective or retrospective studies involving rTME, or TaTME for rectal cancer. Outcome variables included: hospital stay; operation duration, blood loss; resection margins; proportion of histologically complete resected specimens; lymph nodes; overall complications; anastomotic leak, and 30-day mortality. RESULTS Sixty-two articles met the inclusion criteria, including 37 studies (3835 patients) assessing rTME resection, 23 studies (1326 patients) involving TaTME and 2 comparing both (165 patients). Operating time was longer in rTME (309.2 min, 95% CI 285.5-332.8) than in TaTME studies (256.2 min, 95% CI 231.5-280.9) (p = 0.002). rTME resected specimens had a larger distal resection margin (2.62 cm, 95% CI 2.35-2.88) than in TaTME studies (2.10 cm, 95% CI 1.83-2.36) (p = 0.007). Other outcome variables did not significantly differ between the two techniques. CONCLUSIONS rTME provides similar pathological and short-term outcomes to TaTME and both are reasonable surgical approaches for patients with mid-to-low rectal cancer. To definitively answer the question of the optimal TME technique, we suggest a prospective trial comparing both techniques assessing long-term survival as a primary outcome.
Collapse
Affiliation(s)
- J W Butterworth
- Kings College Hospitals, Princess Royal University Hospital, Farnborough Common, London, BR6 8ND, Kent, UK.
| | | | - J Meyer
- Division of Digestive Surgery, Geneva University Hospital, Geneva, Switzerland
| | - C Giacobino
- Division of Digestive Surgery, Geneva University Hospital, Geneva, Switzerland
| | - N Buchs
- Division of Digestive Surgery, Geneva University Hospital, Geneva, Switzerland
| | - F Ris
- Division of Digestive Surgery, Geneva University Hospital, Geneva, Switzerland
| | - R Scarpinata
- Kings College Hospitals, Princess Royal University Hospital, Farnborough Common, London, BR6 8ND, Kent, UK
| |
Collapse
|
|
12
|
Kwon SH, Joo YI, Kim SH, Lee DH, Baek JH, Chung SS, Shin JY, Eun CS, Kim NK. Meta-analysis of transanal versus laparoscopic total mesorectal excision for rectal cancer: a 'New Health Technology' assessment in South Korea. Ann Surg Treat Res 2021; 101:167-180. [PMID: 34549040 PMCID: PMC8424436 DOI: 10.4174/astr.2021.101.3.167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 06/11/2021] [Accepted: 07/13/2021] [Indexed: 12/30/2022] Open
Abstract
Purpose Under the South Korea's unique health insurance structure, any new surgical technology must be evaluated first by the government in order to consider whether that particular technology can be applied to patients for further clinical trials as categorized as 'New Health Technology,' then potentially covered by the insurance sometime later. The aim of this meta-analysis was to assess the safety and efficacy of transanal total mesorectal excision (TaTME) for rectal cancer, activated by the National Evidence-based Healthcare Collaborating Agency (NECA) TaTME committee. Methods We systematically searched Ovid-MEDLINE, Ovid-Embase, Cochrane, and Korean databases (from their inception until August 31, 2019) for studies published that compare TaTME with laparoscopic total mesorectal excision (LaTME). End-points included perioperative and pathological outcomes. Results Sixteen cohort studies (7 for case-matched studies) were identified, comprising 1,923 patients (938 TaTMEs and 985 LaTMEs). Regarding perioperative outcomes, the conversion rate was significantly lower in TaTME (risk ratio, 0.19; 95% confidence interval, 0.11-0.34; P < 0.001); whereas other perioperative outcomes were similar to LaTME. There were no statistically significant differences in pathological results between the 2 procedures. Conclusion Our meta-analysis showed comparable results in preoperative and pathologic outcomes between TaTME and LaTME, and indicated the benefit of TaTME with low conversion. Extensive evaluations of well-designed, multicenter randomized controlled trials are required to come to unequivocal conclusions, but the results showed that TaTME is a potentially beneficial technique in some specific cases. This meta-analysis suggests that TaTME can be performed for rectal cancer patients as a 'New Health Technology' endorsed by NECA in South Korea.
Collapse
Affiliation(s)
- Sun-Ho Kwon
- Division for New Health Technology Assessment, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Yea-Il Joo
- Division for New Health Technology Assessment, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Seon Hahn Kim
- TaTME Assessment Committee, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea.,Division of Colorectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Dae Ho Lee
- TaTME Assessment Committee, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea.,Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong-Heum Baek
- TaTME Assessment Committee, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea.,Division of Colon and Rectal Surgery, Department of Surgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Soon Sup Chung
- TaTME Assessment Committee, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea.,Department of General Surgery, Ewha Womans University College of Medicine, Seoul, Korea
| | - Ji-Yeon Shin
- TaTME Assessment Committee, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea.,Department of Preventive Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Chang Soo Eun
- TaTME Assessment Committee, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea.,Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Nam Kyu Kim
- TaTME Assessment Committee, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea.,Department of Surgery, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| |
Collapse
|
|
13
|
Van Oostendorp SE, Belgers HJ(E, Hol JC, Doornebosch PG, Belt EJT, Oosterling SJ, Kusters M, Bonjer HJ(J, Sietses C, Tuynman JB. The learning curve of transanal total mesorectal excision for rectal cancer is associated with local recurrence: results from a multicentre external audit. Colorectal Dis 2021; 23:2020-2029. [PMID: 33969621 PMCID: PMC8453958 DOI: 10.1111/codi.15722] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 03/19/2021] [Accepted: 05/02/2021] [Indexed: 12/14/2022]
Abstract
AIM Transanal total mesorectal excision (TaTME) has been suggested as a potential solution for the resection of challenging mid and low rectal cancer. This relatively complex procedure has been implemented in many centres over the last years, despite the absence of long-term safety data. Recently, concern has arisen because of an increase in local recurrence in the implementation phase. The aim of this study was to assess the correlation between accumulated experience and local recurrences. METHOD An independent clinical researcher performed an external audit of consecutive series of all TaTME procedures in six centres in the Netherlands. Kaplan-Meier estimated local recurrence rates were calculated and multivariate Cox proportional hazards regression analysis performed to assess risk factors for local recurrence. Primary outcome was the local recurrence rate in the initial implementation (cases 1-10), continued adoption (cases 11-40) and prolonged experience (case 41 onward). RESULTS Six hundred and twenty-four consecutive patients underwent TaTME for rectal cancer with a median follow-up of 27 months (range 1-82 months). The estimated 2- and 3-year local recurrence rates were 4.6% and 6.6%, respectively. Cox proportional hazards regression revealed procedural experience to be an independent factor in multivariate analysis next to advanced stage (ycMRF+, pT3-4, pN+) and pelvic sepsis. Corrected analysis projected the 3-year local recurrence rates to be 9.7%, 3.3% and 3.5% for the implementation, continued adoption and prolonged experience cohorts, respectively. CONCLUSION This multicentre study shows a high local recurrence rate (12.5%) after implementation of TaTME which lowers to an acceptable rate (3.4%) when experience increases. Therefore, intensified proctoring and further precautions must be implemented to reduce the unacceptably high risk of local recurrence at units starting this technique.
Collapse
Affiliation(s)
- Stefan E. Van Oostendorp
- Department of SurgeryAmsterdam UMCVrije Universiteit AmsterdamCancer Centre AmsterdamAmsterdamThe Netherlands
| | | | - Jeroen C. Hol
- Department of SurgeryAmsterdam UMCVrije Universiteit AmsterdamCancer Centre AmsterdamAmsterdamThe Netherlands
- Department of SurgeryGelderse Vallei HospitalEdeThe Netherlands
| | | | - Eric J. Th. Belt
- Department of SurgeryAlbert Schweitzer HospitalDordrechtThe Netherlands
| | | | - Miranda Kusters
- Department of SurgeryAmsterdam UMCVrije Universiteit AmsterdamCancer Centre AmsterdamAmsterdamThe Netherlands
| | - H. J. (Jaap) Bonjer
- Department of SurgeryAmsterdam UMCVrije Universiteit AmsterdamCancer Centre AmsterdamAmsterdamThe Netherlands
| | - Colin Sietses
- Department of SurgeryGelderse Vallei HospitalEdeThe Netherlands
| | - Jurriaan B. Tuynman
- Department of SurgeryAmsterdam UMCVrije Universiteit AmsterdamCancer Centre AmsterdamAmsterdamThe Netherlands
| |
Collapse
|
|
14
|
Lau S, Kong J, Bell S, Heriot A, Stevenson A, Moloney J, Hayes J, Merrie A, Eglinton T, Guest G, Clark D, Warrier S. Transanal mesorectal excision: early outcomes in Australia and New Zealand. Br J Surg 2021; 108:214-219. [PMID: 33711138 DOI: 10.1093/bjs/znaa098] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 10/22/2020] [Accepted: 10/24/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Transanal total mesorectal excision (taTME) aims to overcome some of the technical challenges faced when operating on mid and low rectal cancers. Specimen quality has been confirmed previously, but recent concerns have been raised about oncological safety. This multicentre prospective study aimed to evaluate the safety of taTME among early adopters in Australia and New Zealand. METHODS Data from all consecutive patients who had taTME for rectal cancer from July 2014 to February 2020 at six tertiary referral centres in Australasia were recorded and analysed. RESULTS A total of 308 patients of median age of 64 years underwent taTME. Some 75.6 per cent of patients were men, and the median BMI was 26.8 kg/m2. The median distance of tumour from anal verge was 7 cm. Neoadjuvant chemoradiotherapy was administered to 57.8 per cent of patients. The anastomotic leak rate was 8.1 per cent and there was no mortality within 30 days of surgery. Pathological examination found a complete mesorectum in 295 patients (95.8 per cent), a near-complete mesorectum in seven patients (2.3 per cent), and an incomplete mesorectum in six patients (1.9 per cent). The circumferential resection margin and distal resection margin was involved in nine patients (2.9 per cent), and two patients (0.6 per cent) respectively. Over a median follow-up of 22 months, the local recurrence rate was 1.9 per cent and median time to local recurrence was 30.5 months. CONCLUSION This study showed that, with appropriate training and supervision, skilled minimally invasive rectal cancer surgeons can perform taTME with similar pathological and oncological results to open and laparoscopic surgery.
Collapse
Affiliation(s)
- S Lau
- Department of Surgery, University Hospital Geelong, Geelong, Victoria, Australia
| | - J Kong
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - S Bell
- Department of Surgery, Alfred Hospital, Melbourne, Victoria, Australia
| | - A Heriot
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - A Stevenson
- Department of Surgery, Royal Brisbane Hospital, Herston, Queensland, Australia
| | - J Moloney
- Department of Surgery, Royal Brisbane Hospital, Herston, Queensland, Australia
| | - J Hayes
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | - A Merrie
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | - T Eglinton
- Department of Surgery, University of Otago, Christchurch, New Zealand
| | - G Guest
- Department of Surgery, University Hospital Geelong, Geelong, Victoria, Australia
| | - D Clark
- Department of Surgery, Royal Brisbane Hospital, Herston, Queensland, Australia
| | - S Warrier
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Surgery, Alfred Hospital, Melbourne, Victoria, Australia
| |
Collapse
|
|
15
|
Robertson RL, Karimuddin A, Phang T, Raval M, Brown C. Transanal versus conventional total mesorectal excision for rectal cancer using the IDEAL framework for implementation. BJS Open 2021; 5:6246778. [PMID: 33889949 PMCID: PMC8062257 DOI: 10.1093/bjsopen/zrab002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 12/11/2020] [Accepted: 01/01/2021] [Indexed: 01/04/2023] Open
Abstract
Background Transanal total mesorectal excision (TaTME) is an innovative technique for distal rectal cancer dissection. It has been shown to have similar short-term outcomes to conventional open and laparoscopic total mesorectal excision (cTME), but recent studies have raised concern about increased morbidity and local recurrence rates. The aim of this study was to assess outcomes after TaTME versus cTME for rectal cancer. Methods TaTME was implemented in 2014 using IDEAL principles in a single institution. The institution maintains databases for all patients undergoing rectal cancer surgery. This retrospective review compared data collected from all patients who had TaTME with those from a propensity-matched cohort of patients who underwent cTME. The primary outcome was a composite pathological measure combining margin status and quality of total mesorectal excision (TME). Short-term clinical and survival outcomes were also measured. Results Propensity matching created 109 matched pairs for analysis. Nine patients (8.3 per cent) undergoing TaTME had positive margins and/or incomplete TME, compared with 11 (10.5 per cent) undergoing cTME (P = 0.65). There were no significant differences in morbidity between the TaTME and cTME groups, including number of anastomotic leaks (13.8 versus 18.3 per cent; P = 0.37). The estimated 3-year local recurrence-free survival rate was 96.3 per cent in both groups (P = 0.39). Estimated 3-year overall (93.6 per cent for TaTME versus 94.5 per cent for cTME; P = 0.09) and disease-free (88.1 versus 76.1 per cent; P = 0.90) survival rates were similar. Conclusion TaTME provided similar outcomes to cTME for rectal cancer with the application of IDEAL principles.
Collapse
Affiliation(s)
- R L Robertson
- Department of Surgery, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - A Karimuddin
- Department of Surgery, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - T Phang
- Department of Surgery, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - M Raval
- Department of Surgery, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - C Brown
- Department of Surgery, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
|
16
|
Caycedo-Marulanda A, Lee L, Chadi SA, Verschoor CP, Crosina J, Ashamalla S, Brown CJ. Association of Transanal Total Mesorectal Excision With Local Recurrence of Rectal Cancer. JAMA Netw Open 2021; 4:e2036330. [PMID: 33533932 PMCID: PMC7859847 DOI: 10.1001/jamanetworkopen.2020.36330] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Proponents of novel transanal total mesorectal excision (TME) suggest the procedure overcomes the technical and oncologic challenges of conventional approaches for treating rectal cancer. Recently, however, there has been controversy regarding the oncologic safety of the procedure. OBJECTIVE To assess the association of transanal TME with the incidence of local recurrence (LR) of cancer and the probability of remaining free of LR during follow-up. DESIGN, SETTING, AND PARTICIPANTS This multicenter cohort study used data from 8 high-volume rectal cancer academic institutions from across Canada on all consecutive patients with primary rectal cancer treated by transanal TME at the participating centers. The study was conducted between January 2014 and December 2018, and data were analyzed from April 1, 2020, to September 15, 2020. EXPOSURE Transanal TME. MAIN OUTCOMES AND MEASURES The incidence of LR was reported as a direct measure of quality of resection. The cumulative probability of LR- and systemic recurrence (SR)-free survival at 36 months was estimated. Local recurrence and SR were defined as radiologic or endoscopic evidence of 1 or more new lesions in or outside the pelvis, respectively, documented during surveillance after the removal of the primary tumor. RESULTS Of 608 total patients included in the analysis, 423 (69.6%) were male; the median age was 63 years (interquartile range [IQR], 54-70 years). Local recurrence was identified in 22 patients (3.6%) after a median follow-up of 27 months (IQR, 18-38 months). The median time to LR was 13 months (IQR, 9-19 months). Sixteen of the 22 patients with LR (72.7%) were male, 14 (63.6%) received neoadjuvant chemoradiation, and 12 (54.5%) had American Joint Committee on Cancer stage III disease. Of those with LR, 16 (72.7%) had a negative circumferential radial margin and 20 (90.9%) had a negative distal resection margin, 2 (9.1%) experienced conversion to open surgery, and 15 (68.2%) also developed SR. The probability of LR-free survival at 36 months was 96% (95% CI, 94%-98%). According to the Cox proportional hazards regression model, the hazard ratio of LR was estimated to be 4.2 (95% CI, 2.9-6.2) times higher among patients with a positive circumferential radial margin than among those with a negative circumferential radial margin. CONCLUSIONS AND RELEVANCE In this cohort study, transanal TME performed by experienced surgeons was associated with an incidence of LR and SR that is in line with the published literature on open and laparoscopic TME, suggesting that transanal TME may be an acceptable approach for management of rectal cancer.
Collapse
Affiliation(s)
- Antonio Caycedo-Marulanda
- Department of Surgery, Kingston Health Sciences Centre, Queen’s University, Kingston, Ontario, Canada
- Health Sciences North Research Institute, Sudbury, Ontario, Canada
| | - Lawrence Lee
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Sami A. Chadi
- Division of Surgical Oncology and General Surgery, University Health Network and Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Jordan Crosina
- Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | - Shady Ashamalla
- Department of Surgery Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Carl J. Brown
- Department of Surgery, St Paul’s Hospital, The University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
|
17
|
Gardner IH, Kelley KA, Abdelmoaty WF, Sharata A, Hayman AV, Whiteford MH. Transanal total mesorectal excision outcomes for advanced rectal cancer in a complex surgical population. Surg Endosc 2021; 36:167-175. [PMID: 33416990 DOI: 10.1007/s00464-020-08251-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 12/16/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND Total mesorectal excision (TME) is the gold standard for oncologic resection in low and mid rectal cancers. However, abdominal approaches to TME can be hampered by poor visibility, inadequate retraction, and distal margin delineation. Transanal TME (taTME) is a promising hybrid technique that was developed to mitigate the difficulties of operating in the low pelvis and to optimize the circumferential resection and distal margins. METHODS The objective of this study was to characterize our experience implementing taTME at our institution in a technically challenging patient population. We performed a retrospective review of consecutive patients who underwent taTMEs between November 2013 and May 2019 for rectal cancer at a tertiary community cancer center. Outcome measures included pathologic grading of TME specimen, post-operative complications, and oncologic outcomes. RESULTS Forty-four patients with mid and low rectal cancer underwent low anterior resection via taTME. The most common staging modality was rectal MRI which demonstrated T3 or T4 tumors in 89% of our patients prior to neoadjuvant. Eighty-six percent of patients underwent neoadjuvant chemoradiation. The initial cases were performed sequentially as a single team, but we later transitioned to a synchronous, two-team approach. Ninety-one percent of TME grades were complete or near complete. Only one patient (2.3%) had a positive circumferential margin. Six patients developed anastomotic leaks with an overall anastomotic complication rate of 18.2%. Two patients (4.5%) with primary rectal cancer developed local recurrence, one of which developed multifocal local recurrence. CONCLUSIONS Using the taTME approach on selected locally advanced low rectal cancers, especially in technically complex irradiated and obese male patients, has yielded comparably safe and effective outcomes to laparoscopic proctectomy.
Collapse
Affiliation(s)
- Ivy H Gardner
- Department of Surgery, Oregon Health and Science University, Portland, USA
| | | | - Walaa F Abdelmoaty
- Department of Surgery, Oregon Health and Science University, Portland, USA
| | - Ahmed Sharata
- Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, Providence Cancer Institute, 4805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA
| | - Amanda V Hayman
- Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, Providence Cancer Institute, 4805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA
| | - Mark H Whiteford
- Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, Providence Cancer Institute, 4805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA.
| |
Collapse
|
|
18
|
Ye J, Tian Y, Li F, van Oostendorp S, Chai Y, Tuynman J, Tong W. Comparison of transanal total mesorectal excision (TaTME) versus laparoscopic TME for rectal cancer: A case matched study. Eur J Surg Oncol 2020; 47:1019-1025. [PMID: 33309105 DOI: 10.1016/j.ejso.2020.11.131] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 10/28/2020] [Accepted: 11/20/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Transanal total mesorectal excision (TaTME) has been developed to improve the quality of laparoscopic TME for patients with rectal cancer. Recently, international concern on TaTME was raised by a national cohort study showing an increased rate of local recurrences. This study aimed to compare clinicopathological and mid-term oncological outcomes of TaTME versus laparoscopic TME (LaTME) for mid and low rectal cancer of a high volume center. METHODS From August 2014 to October 2019, patients with mid or low rectal cancer who received TaTME procedure were identified. The cases were matched with patients treated with LaTME. Data were retrospectively collected including operative details, postoperative morbidity, pathologic results, and oncologic outcomes. Primary endpoint was the local recurrence (LR) rate. RESULTS Propensity score matching yielded 70 patients in each of the groups. There were no statistically significant differences between the 2 groups in terms of postoperative complications, conversion rate to open surgery and circumferential resection margin. Local recurrence occurred in 2 patients (2.9%) in the transanal group, whereas 1 patient developed a local recurrence in the laparoscopic group (1.4%)(p = 0.559). Kaplan-Meier survival analysis showed a 2 year Local recurrence rate 1.5% VS 1.6%(p = 0.934), DFS 88.0% VS 87.7%, OS 94.0% vs 100% for transanal and laparoscopic group, respectively. CONCLUSIONS In a high volume center the transanal total mesorectal procedure is feasible, and appears to be safe alternative to laparoscopic surgery. Oncological outcomes were acceptable and no increased multi or unifocal local recurrence rate was found.
Collapse
Affiliation(s)
- Jingwang Ye
- Department of General Surgery, Daping Hospital, Army Medical University, 400042, Chongqing, China
| | - Yue Tian
- Department of General Surgery, Daping Hospital, Army Medical University, 400042, Chongqing, China
| | - Fan Li
- Department of General Surgery, Daping Hospital, Army Medical University, 400042, Chongqing, China
| | - Stefan van Oostendorp
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Yiming Chai
- School of Liberal Arts Education, Ningxia Vocational Technical College of Industry and Commerce, Ningxia, China
| | - Jurriaan Tuynman
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Weidong Tong
- Department of General Surgery, Daping Hospital, Army Medical University, 400042, Chongqing, China.
| |
Collapse
|
|
19
|
Caycedo-Marulanda A, Nadeau K, Verschoor CP, Sands D, Spinelli A, Ashamalla S, Patel SV, Di Candido F, Mujukian A, Zaghiyan K, Stevenson G, Wolthuis A, Clark DA, D'Hoore A, Stevenson A, Wexner SD. Exploring the perioperative outcomes of a sample of successful adopters of transanal total mesorectal excision (taTME) during the learning phase. Surgery 2020; 169:774-781. [PMID: 33243484 DOI: 10.1016/j.surg.2020.10.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 10/06/2020] [Accepted: 10/19/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Transanal total mesorectal excision can be a technically challenging operation to master. While many early adopters have reported adequate outcomes, others have failed to reproduce these results. There are contradicting data on oncologic outcomes during the learning phase of this technique. Thus, our objective was to perform a multicentered assessment of oncological outcomes in patients undergoing transanal total mesorectal excision during the learning phase in a sample of successful adopting centers. METHODS Surgeons from 8 centers with experience in the management of rectal cancer were invited to participate. The initial 51 consecutive benign and malignant cases of the participating units were retrospectively reviewed, but only 366 cancer cases were included in the analysis. Procedures were divided into implementation (ie, the first 10 cases) and postimplementation (ie, case 11 on onwards) groups, and the main outcome was the incidence of local recurrence. RESULTS The overall prevalence of local recurrence was 4.1% at a median follow-up of 35 months (interquartile range 20.3-44.2); among implementation and postimplementation groups local recurrence was 7.5% and 3.1%, respectively, and the rate of local recurrence was observed to be nearly 60% lower in the postimplementation group (hazard ratio [95% confidence interval] = 0.43 [0.26-0.72]) Total mesorectal excision specimens were complete or nearly complete in 87.7% of cases, and the circumferential and distal margins were clear in 93.2% and 92.6%, respectively CONCLUSION: Local recurrence rate was low during the learning phase of the transanal total mesorectal excision in a sample of rectal cancer surgeons with acceptable surgical and oncologic outcomes. Both the prevalence and rate of local recurrence were markedly lower in the postimplementation phase, indicating improvement as experience accumulated.
Collapse
Affiliation(s)
- Antonio Caycedo-Marulanda
- Department of Surgery, Queen's University, Kingston, Canada; Health Sciences North Research Institute, Sudbury, Canada.
| | - Kara Nadeau
- Department of Surgery, Northern Ontario School of Medicine, Health Sciences North, Sudbury, Canada
| | | | - Dana Sands
- Department of Surgery, Cleveland Clinic, Weston, FL
| | - Antonino Spinelli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, IRCCS, Rozzano-Milano, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milano, Italy
| | - Shady Ashamalla
- Department of Surgery, University Health Network, Toronto, Canada
| | - Sunil V Patel
- Department of Surgery, Queen's University, Kingston, Canada
| | - Francesca Di Candido
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, IRCCS, Rozzano-Milano, Italy
| | - Angela Mujukian
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Karen Zaghiyan
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Grant Stevenson
- School of Public Health, Faculty of Medicine, University of Queensland, Brisbane, Australia; Department of Surgery, University of Queensland, Brisbane, Australia
| | | | - David A Clark
- Department of Surgery, University of Queensland, Brisbane, Australia; Department of Surgery, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Andre D'Hoore
- Department of Surgery, University Hospital Leuven, Belgium
| | - Andrew Stevenson
- Department of Surgery, University of Queensland, Brisbane, Australia; Department of Surgery, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | | |
Collapse
|
|
20
|
Ourô S, Albergaria D, Ferreira MP, Costeira B, Roquete P, Ferreira D, Maio R. Transanal total mesorectal excision: 3-year oncological outcomes. Tech Coloproctol 2020; 25:205-213. [PMID: 33113009 DOI: 10.1007/s10151-020-02362-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 10/16/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Rectal cancer treatment has evolved with the implementation of new surgical techniques. Transanal total mesorectal excision (TaTME) is the most recent approach developed to facilitate pelvic dissection of mid- and distal rectal tumours. The purpose of this study was to analyse the short- and mid-term oncological outcomes of TaTME. METHODS A study was conducted on patients treated with TaTME for rectal cancer at two colorectal units in Portugal between March 2016 and December 2018. Clinical, pathological and oncological data were retrospectively analysed. Primary endpoints were 3-year overall survival, disease-free survival and local recurrence. Secondary endpoints were clinical and pathological outcomes. RESULTS Fifty patients (31 males, [62%], median age 66 years [range 40-85 years]) underwent TaTME, 49 (98%) for malignant and 1 (2%) for benign disease. There were no cases of conversion, 49 (98%) patients had complete or near-complete mesorectum, all the resections were R0 with adequate distal and circumferential margins. With a median follow-up of 36 months, there were 2 cases (4%) of local recurrence and 3-year estimated overall survival and disease-free survival were 90% and 79%, respectively. CONCLUSIONS TaTME can provide safe mid-term oncological outcomes, similar to what has been published for classic and laparoscopic TME. Our results also show how demanding this novel approach can be and the consequent need for audited data and standardized implementation.
Collapse
Affiliation(s)
- S Ourô
- Surgical Department of Hospital Beatriz Ângelo, Loures, Portugal.
- NOVA Medical School, Lisbon, Portugal.
- Surgical Department, Hospital Beatriz Ângelo, Avenida Carlos Teixeira 514, Loures, Portugal.
| | - D Albergaria
- Surgical Department of Hospital Beatriz Ângelo, Loures, Portugal
- NOVA Medical School, Lisbon, Portugal
| | - M P Ferreira
- Surgical Department of Hospital Beatriz Ângelo, Loures, Portugal
| | - B Costeira
- Surgical Department of Hospital Beatriz Ângelo, Loures, Portugal
| | - P Roquete
- Surgical Department of Hospital da Luz, Lisbon, Portugal
| | - D Ferreira
- Surgical Department of Hospital da Luz, Lisbon, Portugal
| | - R Maio
- Surgical Department of Hospital Beatriz Ângelo, Loures, Portugal
- NOVA Medical School, Lisbon, Portugal
| |
Collapse
|
|
21
|
Persiani R, Agnes A, Belia F, D'Ugo D, Biondi A. The learning curve of TaTME for mid-low rectal cancer: a comprehensive analysis from a five-year institutional experience. Surg Endosc 2020; 35:6190-6200. [PMID: 33106887 PMCID: PMC8523384 DOI: 10.1007/s00464-020-08115-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 10/16/2020] [Indexed: 12/13/2022]
Abstract
Background Transanal total mesorectal excision (TaTME) was introduced in 2009 as a dedicated approach for the treatment of mid-low rectal cancer. We aimed to describe and discuss the learning curve for 121 consecutive TaTME procedures performed by the same team. Methods The primary outcome was the number of operations required to decrease the mean operative time (mOT). The secondary outcomes were the number of operations required to decrease the major complication (MC) rate, the anastomotic leakage (AL) rate, the clinical anastomotic failure rate, and the reoperation rate. A cumulative sum (CUSUM) curve analysis was used to identify the inflection points. As an integrative analysis, Bernoulli CUSUM curves, risk-adjusted CUSUM curves based on the observed-expected outcomes, and CUSUM curves targeting results reported in the literature were created. Results Seventy-one cases were needed to overcome the OT learning curve sufficiently to reach mastery. The MC and reoperation rates started to decrease after the 54th case and further decreased after the 69th case. The AL rate started to decrease after the 27th case and remained stable at 5–5.1%. The comparison between the different phases of the learning curves confirmed these turning points. Conclusions TaTME had a learning curve of 71 cases for the mOT, 55–69 cases for MCs and reoperation, and 27 cases for AL. According to our results, attention should be paid during the first part of the learning curve to avoid an increased rate of MCs and AL. Electronic supplementary material The online version of this article (10.1007/s00464-020-08115-0) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Roberto Persiani
- Dipartimento Scienze Mediche e Chirurgiche, UOC di Chirurgia Generale, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli n. 8, 00168, Rome, Italy
- Università Cattolica del Sacro Cuore, Largo Francesco Vito n. 1, 00168, Rome, Italy
| | - Annamaria Agnes
- Dipartimento Scienze Mediche e Chirurgiche, UOC di Chirurgia Generale, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli n. 8, 00168, Rome, Italy
- Università Cattolica del Sacro Cuore, Largo Francesco Vito n. 1, 00168, Rome, Italy
| | - Francesco Belia
- Università Cattolica del Sacro Cuore, Largo Francesco Vito n. 1, 00168, Rome, Italy
| | - Domenico D'Ugo
- Dipartimento Scienze Mediche e Chirurgiche, UOC di Chirurgia Generale, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli n. 8, 00168, Rome, Italy
- Università Cattolica del Sacro Cuore, Largo Francesco Vito n. 1, 00168, Rome, Italy
| | - Alberto Biondi
- Dipartimento Scienze Mediche e Chirurgiche, UOC di Chirurgia Generale, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli n. 8, 00168, Rome, Italy.
- Università Cattolica del Sacro Cuore, Largo Francesco Vito n. 1, 00168, Rome, Italy.
| |
Collapse
|
|
22
|
van Oostendorp SE, Sietses C, Hompes R, Kusters M, Tuynman J. Author response to: Evidence supporting the sunk cost fallacy of advocating for transanal total mesorectal excision. Br J Surg 2020; 107:e348. [PMID: 32506454 DOI: 10.1002/bjs.11719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 04/29/2020] [Indexed: 11/10/2022]
Affiliation(s)
- S E van Oostendorp
- Department of Surgery, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | - C Sietses
- Department of Surgery, Gelderse Vallei Hospital, Ede, The Netherlands
| | - R Hompes
- Amsterdam UMC, Location AMC, Cancer Centre Amsterdam, Amsterdam, The Netherlands
| | - M Kusters
- Department of Surgery, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | - J Tuynman
- Department of Surgery, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| |
Collapse
|
|
23
|
Canadian taTME expert collaboration (CaTaCO) position statement. Surg Endosc 2020; 34:3748-3753. [PMID: 32504263 PMCID: PMC7395021 DOI: 10.1007/s00464-020-07680-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/27/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Transanal total mesorectal excision (taTME) is a novel approach to surgery for rectal cancer. The technique has gained significant popularity in the surgical community due to the promising ability to overcome technical difficulties related to the access of the distal pelvis. Recently, Norwegian surgeons issued a local moratorium related to potential issues with the safety of the procedure. Early adopters of taTME in Canada have recognized the need to create guidelines for its adoption and supervision. The objective of the statement is to provide expert opinion based on the best available evidence and authors' experience. METHODS The procedure has been performed in Canada since 2014 at different institutions. In 2016, the first Canadian taTME congress was held in the city of Toronto, organized by two of the authors. In early 2019, a multicentric collaborative was established [The Canadian taTME expert Collaboration] which aimed at ensuring safe performance and adoption of taTME in Canada. Recently surgeons from 8 major Canadian rectal cancer centers met in the city of Toronto on December 7 of 2019, to discuss and develop a position statement. There in person, meeting was followed by 4 rounds of Delphi methodology. RESULTS The generated document focused on the need to ensure a unified approach among rectal cancer surgeons across the country considering its technical complexity and potential morbidity. The position statement addressed four domains: surgical setting, surgeons' requirements, patient selection, and quality assurance. CONCLUSIONS Authors agree transanal total mesorectal excision is technically demanding and has a significant risk for morbidity. As of now, there is uncertainty for some of the outcomes. We consider it is possible to safely adopt this operation and obtain adequate results, however for this purpose it is necessary to meet specific requirements in different domains.
Collapse
|
|
24
|
Caycedo-Marulanda A, Patel S, Merchant S, Brown C. Introduction of new techniques and technologies in surgery: Where is transanal total mesorectal excision today? World J Gastrointest Surg 2020; 12:203-207. [PMID: 32551026 PMCID: PMC7289648 DOI: 10.4240/wjgs.v12.i5.203] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 04/14/2020] [Accepted: 05/13/2020] [Indexed: 02/06/2023] Open
Abstract
The introduction of new surgical techniques and technologies has traditionally been unregulated. In many settings surgeons frequently adopt novel procedures without following a structured program of implementation or supervision. The appearance of innovative technology played a pivotal role in the advancement of new surgical techniques during the industrial revolution. Innovation has been an essential component of surgical development, which led to contemporary surgical techniques such as minimally invasive surgery. Different initiatives have been developed to guide the safe introduction of new surgical techniques and other procedures. Those include comprehensive concepts such as the Idea, Development, Exploration, Assessment, Long-term study framework, which could be particularly relevant when reflecting on the novel transanal total mesorectal excision (taTME), introduced a decade ago. This relatively novel and complex procedure promised to overcome some of the major limitations of traditional surgical approaches for rectal cancer. According to the Idea, Development, Exploration, Assessment, Long-term study framework, taTME is in the phase of exploration, where there is an existing and increasing number of reports being published as the experience grows. The current management of rectal cancer is in a state of radical evolution, with multiple options that were not previously available. TaTME is only one technique amongst many which could be part of a rectal cancer surgeon’s armamentarium; however, it requires further rigorous study and evaluation.
Collapse
Affiliation(s)
- Antonio Caycedo-Marulanda
- Department of surgery, Queen’s University and Kingston General Hospital, Kingston K7L 2V7, Ontario, Canada
| | - Sunil Patel
- Department of surgery, Queen’s University and Kingston General Hospital, Kingston K7L 2V7, Ontario, Canada
| | - Shaila Merchant
- Department of surgery, Queen’s University and Kingston General Hospital, Kingston K7L 2V7, Ontario, Canada
| | - Carl Brown
- Department of Surgery, University of British Columbia and St. Paul Hospital, Vancouver V6Z 1Y6, British Columbia, Canada
| |
Collapse
|