Advertisement

Exploring the perioperative outcomes of a sample of successful adopters of transanal total mesorectal excision (taTME) during the learning phase

Published:November 24, 2020DOI:https://doi.org/10.1016/j.surg.2020.10.018

      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.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • MacFarland J.K.
        • Ryall R.D.
        • Heald R.J.
        Mesorectal excision for rectal cancer.
        Lancet. 1993; 341: 457-460
        • Lawson E.H.
        • Melvin J.C.
        • Geltzeiler C.B.
        • et al.
        Advances in the management of rectal cancer.
        Curr Probl Surg. 2019; 56: 100648
        • Kawada K.
        • Sakai Y.
        Can we predict surgical difficulty of rectal surgery?.
        Ann Laparosc Endosc Surg. 2018; 3: 44
        • Sylla P.
        • Rattner D.W.
        • Delgado S.
        • Lacy A.M.
        NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance.
        Surg Endosc. 2010; 24: 1205-1210
        • van Oostendorp S.E.
        • Koedam T.W.A.
        • Sietses C.
        • Bonjer H.J.
        • Tuynman J.B.
        Transanal total mesorectal excision compared to laparoscopic TME for mid and low rectal cancer—current evidence.
        Ann Laparosc Endosc Surg. 2018; 3: 41
        • Hajibandeh S.
        • Hajibandeh S.
        • Eltair M.
        • et al.
        Meta-analysis of transanal total mesorectal excision versus laparoscopic total mesorectal excision in management of rectal cancer.
        Int J Colorectal Dis. 2020; 35: 575-593
        • Hopper A.N.
        • Jamison M.H.
        • Lewis W.G.
        Learning curves in surgical practice.
        Postgrad Med J. 2007; 83: 777-779
        • Atallah S.B.
        • DuBose A.C.
        • Burke J.P.
        • et al.
        Uptake of transanal total mesorectal excision in North America.
        Dis Colon Rectum. 2017; 60: 1023-1031
        • Lacy A.M.
        • Tasende M.M.
        • Delgado S.
        • et al.
        Transanal total mesorectal excision for rectal cancer: outcomes after 140 patients.
        J Am Coll Surg. 2015; 221: 415-423
        • Penna M.
        • Hompes R.
        • Arnold S.
        • et al.
        Transanal total mesorectal excision.
        Ann Surg. 2017; 266: 111-117
        • Caycedo-Marulanda A.
        • Verschoor C.P.
        Experience beyond the learning curve of transanal total mesorectal excision (taTME) and its effect on the incidence of anastomotic leak.
        Tech Coloproctol. 2020; 24: 309-316
        • Hol J.C.
        • van Oostendorp S.E.
        • Tuynman J.B.
        • Sietses C.
        Long-term oncological results after transanal total mesorectal excision for rectal carcinoma.
        Tech Coloproctol. 2019; 23: 903-911
        • Wolthuis A.M.
        • Bislenghi G.
        • de Buck van Overstraeten A.
        • D’Hoore A.
        Transanal total mesorectal excision: towards standardization of technique.
        World J Gastroenterol. 2015; 21: 12686-12711
        • Penna M.
        • Buchs N.C.
        • Bloemendaal A.L.
        • Hompes R.
        Transanal total mesorectal excision for rectal cancer: the journey towards a new technique and its current status.
        Expert Rev Anticancer Ther. 2016; 16: 1145-1153
        • Perdawood S.K.
        • Kroeigaard J.
        • Eriksen M.
        • Mortensen P.
        Transanal total mesorectal excision: the Slagelse experience 2013–2019 [e-pub ahead of print].
        Surg Endosc. 2020; (Accessed June 20, 2020)https://doi.org/10.1007/s00464-020-07454-2
        • Antoun A.
        • Chau J.
        • Alsharqawi N.
        • et al.
        P338: summarizing measures of proficiency in transanal total mesorectal excision—a systematic review.
        Surg Endosc. 2020; (Accessed September 15, 2020)https://doi.org/10.1007/s00464-020-07935-4
        • Lee L.
        • Kelly J.
        • Nassif G.J.
        • deBeche-Adams T.C.
        • Albert M.R.
        • Monson J.R.T.
        Defining the learning curve for transanal total mesorectal excision for rectal adenocarcinoma.
        Surg Endosc. 2020; 34: 1534-1542
        • Koedam T.W.A.
        • Veltcamp Helbach M.
        • van de Ven P.M.
        • et al.
        Transanal total mesorectal excision for rectal cancer: evaluation of the learning curve.
        Tech Coloproctol. 2018; 22: 279-287
        • Larsen S.G.
        • Pfeffer F.
        • Körner H.
        • Norwegian Colorectal Cancer Group
        Norwegian moratorium on transanal total mesorectal excision.
        Br J Surg. 2019; 106: 1120-1121
        • van Oostendorp S.E.
        • Belgers H.J.
        • Bootsma B.T.
        • et al.
        Locoregional recurrences after transanal total mesorectal excision of rectal cancer during implementation.
        Br J Surg. 2020; 107: 1211-1220
        • Veltcamp Helbach M.
        • van Oostendorp S.E.
        • Koedam T.W.A.
        • et al.
        Structured training pathway and proctoring; multicenter results of the implementation of transanal total mesorectal excision (TaTME) in the Netherlands.
        Surg Endosc. 2019; 34: 192-201
        • Fleshman J.
        • Branda M.
        • Sargent D.J.
        • et al.
        Effect of laparoscopic-assisted resection vs open resection of stage ii or iii rectal cancer on pathologic outcomes.
        JAMA. 2015; 314: 134655
        • Clavien P.A.
        • Barkun J.
        • de Oliveira M.L.
        • et al.
        The Clavien-Dindo classification of surgical complications: five-year experience.
        Ann Surg. 2009; 250: 187-196
        • Kusters M.
        • Marijnen C.A.M.
        • van de Velde C.J.H.
        • et al.
        Patterns of local recurrence in rectal cancer; a study of the Dutch TME trial.
        Eur J Surg Oncol. 2010; 36: 470-476
        • TaTME Guidance Group representing the ESCP (European Society of Coloproctology), in collaboration with the ASCRS (American Society of Colon and Rectal Surgeons), ACPGBI (Association of Coloproctology of Great Britain and Ireland), ECCO (European Crohn’s and Colitis Organisation), EAES (European Association of Endoscopic Surgeons), ESSO (European Society of Surgical Oncology), CSCRS (Canadian Society of Colorectal Surgery), CNSCRS (Chinese Society of Colorectal Surgery), CSLES (Chinese Society of Laparo-Endoscopic Surgery), CSSANZ (Colorectal Surgical Society of Australia and New Zealand), JSES (Japanese Society of Endoscopic Surgery), SACP (Argentinian Society of Coloproctology), SAGES (Society of American Gastrointestinal and Endoscopic Surgeons), SBCP (Brazilian Society of Coloproctology), Swiss-MIS (Swiss Association for Minimally Invasive Surgery)
        International expert consensus guidance on indications, implementation and quality measures for transanal total mesorectal excision.
        Colorectal Dis. 2020; 22: 749-755
        • Caycedo-Marulanda A.
        • Brown C.J.
        • Chadi S.A.
        • et al.
        Canadian taTME expert collaboration (CaTaCO) position statement.
        Surg Endosc. 2020; 34: 3748-3753
        • Fearnhead N.S.
        • Acheson A.G.
        • Brown S.R.
        • et al.
        • and the Association of Coloproctology of Great Britain, Ireland (ACPGBI) Executive, Getting It Right First Time (GIRFT)
        The ACPGBI recommends pause for reflection on transanal total mesorectal excision.
        Colorectal Dis. 2020; 22: 745-748
        • Wasmuth H.H.
        • Faerden A.E.
        • Myklebust T.Å.
        • et al.
        Transanal total mesorectal excision for rectal cancer has been suspended in Norway.
        Br J Surg. 2020; 107: 121-130
        • Stevenson A.R.L.
        • Solomon M.J.
        • Lumley J.W.
        • et al.
        • and the ALaCaRT Investigators
        Effect of laparoscopic-assisted resection vs open resection on pathological outcomes in rectal cancer.
        JAMA. 2015; 314: 1356-1363
        • Sylla P.
        • Knol J.J.
        • D’Andrea A.P.
        • et al.
        and the International taTME Urethral Injury Collaborative. Urethral injury and other urologic injuries during transanal total mesorectal excision [e-pub ahead of print].
        Ann Surg. 2019; (Accessed June 20, 2020)https://doi.org/10.1097/SLA.0000000000003597
        • de Neree Tot Babberich M.P.M.
        • van Groningen J.T.
        • Dekker E.
        • et al.
        and the Dutch Surgical Colorectal Audit. Laparoscopic conversion in colorectal cancer surgery; is there any improvement over time at a population level?.
        Surg Endosc. 2018; 32: 3234-3246
        • Penna M.
        • Hompes R.
        • Arnold S.
        • et al.
        • and the International TaTME Registry Collaborative
        Incidence and risk factors for anastomotic failure in 1594 patients treated by transanal total mesorectal excision: results from the International TaTME Registry.
        Ann Surg. 2019; 269: 700-711
        • Bashir Mohamed K.
        • Hansen C.H.
        • Krarup P.M.
        • Fransgård T.
        • Madsen M.T.
        • Gögenur I.
        The impact of anastomotic leakage on recurrence and long-term survival in patients with colonic cancer: a systematic review and meta-analysis.
        Eur J Surg Oncol. 2020; 46: 439-447
        • Furnée E.J.B.
        • Aukema T.S.
        • Oosterling S.J.
        • et al.
        • and the Dutch Snapshot Research Group
        Influence of conversion and anastomotic leakage on survival in rectal cancer surgery: retrospective cross-sectional study.
        J Gastrointest Surg. 2019; 23: 2007-2018
        • Bonjer H.J.
        • Deijen C.L.
        • Abis G.A.
        • et al.
        • and the COLOR II Study Group
        A randomized trial of laparoscopic versus open surgery for rectal cancer.
        N Engl J Med. 2015; 372: 1324-1332
        • Kang S.B.
        • Park J.W.
        • Jeong S.Y.
        • et al.
        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. 2010; 11: 637-645
        • Deijen C.L.
        • Tsai A.
        • Koedam T.W.A.
        • et al.
        Clinical outcomes and case volume effect of transanal total mesorectal excision for rectal cancer: a systematic review.
        Tech Coloproctol. 2016; 20: 811-824
        • McLemore E.C.
        • Harnsberger C.R.
        • Broderick R.C.
        • et al.
        Transanal total mesorectal excision (taTME) for rectal cancer: a training pathway.
        Surg Endosc. 2016; 30: 4130-4135
        • Penna M.
        • Hompes R.
        • Mackenzie H.
        • Carter F.
        • Francis N.K.
        First international training and assessment consensus workshop on transanal total mesorectal excision (taTME).
        Tech Coloproctol. 2016; 20: 343-352
        • Francis N.
        • Penna M.
        • Mackenzie H.
        • Carter F.
        • Hompes R.
        • and the International TaTME Educational Collaborative Group
        Consensus on structured training curriculum for transanal total mesorectal excision (TaTME).
        Surg Endos. 2017; 31: 2711-2719
        • Abbott S.C.
        • Stevenson A.R.L.
        • Bell S.W.
        • et al.
        An assessment of an Australasian pathway for the introduction of transanal total mesorectal excision (taTME).
        Colorectal Dis. 2018; 20: O1-O6
        • Wynn G.R.
        • Austin R.C.T.
        • Motson R.W.
        Using cadaveric simulation to introduce the concept and skills required to start performing transanal total mesorectal excision.
        Colorectal Dis. 2018; 20: 496-501
        • Deijen C.L.
        • Velthuis S.
        • Tsai A.
        • et al.
        COLOR III: a multicentre randomised clinical trial comparing transanal TME versus laparoscopic TME for mid and low rectal cancer.
        Surg Endosc. 2016; 30: 3210-3215
        • Icahn School of Medicine at Mount Sinai
        Multicenter phase II study of transanal– TME (taTME).
        (NLM identifier: NCT03144765. Accessed June 20, 2020)
        • Lelong B.
        • de Chaisemartin C.
        • Meillat H.
        • et al.
        • and the French Research Group of Rectal Cancer Surgery (GRECCAR)
        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. 2017; 17: 253