Quality Indicators of Transanal Total Mesorectal Excision (TaTME) for Rectal Cancer

Introduction Transanal total mesorectal excision (TaTME) has revolutionized the surgical techniques for lower-third rectal cancer. The aim of the present study was to analyze the outcomes of quality indicators of TaTME for rectal cancer compared with laparoscopic TME (LaTME). Methods A cohort prospective study with 50 (14 female and 36 male) patients, with a mean age of 67 (range: 55.75 to 75.25) years, who underwent surgery for rectal cancer. In total, 20 patients underwent TaTME, and 30, LaTME. Every TaTME procedure was performed by experienced colorectal surgeons. The sample was divided into two groups (TaTME and LaTME), and the quality indicators of the surgery for rectal cancer were analyzed. Results There were no statistically significant differences regarding the patients and the main characteristics of the tumor (age, gender, American Society of Anesthesiologists [ASA] score, body mass index [BMI], tumoral stage, neoadjuvant therapy, and distance from the tumor to the external anal margin) between the two groups. The rates of: postoperative morbidity (TaTME: 35%; LaTME: 30%; p = 0.763); mortality (0%); anastomotic leak (TaTME: 10%; LaTME: 13%; p = 0.722); wound infection (TaTME: 0%; LaTME: 3.3%; p = 0.409); reoperation (TaTME: 5%; LaTME: 6.6%; p = 0.808); and readmission (TaTME: 5%; LaTME: 0%; p = 0.400), as well as the length of the hospital stay (TaTME: 13.5 days; LaTME: 11 days; p = 0.538), were similar in both groups. There were no statistically significant differences in the rates of positive circumferential resection margin (TaTME: 5%; LaTME: 3.3%; p = 0.989) and positive distal resection margin (TaTME: 0%; LaTME: 3.3%; p = 0.400), the completeness of the TME (TaTME: 100%; LaTME: 100%), and the number of lymph nodes harvested (TaTME: 15; LaTME: 15.5; p = 0.882) between two groups. Conclusion Transanal total mesorectal excision is a safe and feasible surgical procedure for middle/lower-third rectal cancer.

Predictors of Surgical Difficulty in Laparoscopic Total Mesorectal Excision

Concerns have been raised regarding the oncological safety of laparoscopic total mesorectal excision (TME) as compared to an open approach. This study aimed to identify risk factors for surgically difficult laparoscopic TME. All consecutive laparoscopic rectal cancer cases were included from a prospectively maintained colorectal cancer database. The primary outcome was to identify risk factors for surgically difficult TME. A Surgical Difficulty Risk Score (SDRS) between 0 and 6 was calculated for each case with cases achieving an SDRS of 2 or greater being deemed as surgically difficult. A total of 2795 consecutive cases of laparoscopic TME were identified, with 464 (16.6%) surgically difficult cases. Univariate analysis found that operating in the male pelvis, performing abdomino-perineal resections, Hartmann’s procedures, and proctocolectomies were all significantly associated with higher operative difficulty (P < 0.001). A higher nodal stage of cancer (P = 0.046), and the resection of another organ (P = 0.003) were significantly associated with higher surgical difficulty. On multivariate analysis, a female pelvis was associated with a favorable laparoscopic resection (Odds ratio [OR] 0.54, 95% CI 0.43–0.67, P < 0.001), whereas patients who had another organ resection (OR 2.6, 95% CI 1.53–4.42, P < 0.001), nodal positivity (OR 1.37, 95% CI 1.11–1.69, P = 0.003), and high ASA scores had more difficult surgeries. Predictive factors for surgically difficult laparoscopic TME include male gender, high ASA scores, mid and low rectal cancer, positive nodal stage, and resection of another organ at time of surgery.

Current Challenges for Education and Training in Transanal Surgery

Transanal endoscopic microsurgery (TEM) is a technique that was introduced in the 1980s for improved exposure to upper rectal polyps. This technique, though initially difficult to master due to new skill acquisition for surgeons, has spared many patients proctectomy. There are many benign indications for transanal endoscopic surgery which has led to in vivo operating room training with fewer undesirable effects to the patient. With the explosion of laparoscopic technology this transanal technique is no longer limited to intraluminal pathology, but is now being used to remove the entire rectum. In transanal total mesorectal excision (taTME), benign indications are less common, translating to potentially more severe oncologic patient consequences during the early phase of adoption. For this reason, strict training criteria consensus guidelines have been developed by the experts in taTME. The current consensus statements agree that training surgeons should have performed a minimum of 10 laparoscopic TME procedures and should have some experience with transanal surgery. Surgeons need to attend a formal training course and should start clinically on benign or early malignant pathology without threated circumferential resection margins. Surgeons also need to have their first cases proctored until deemed proficient by the proctor and monitor their morbidity, oncologic, and functional outcomes prospectively.

Laparoscopic tme with sphincter preservation for rectal cancer: Five-year results

Introduction: Laparoscopic surgery for rectal cancer has showed many advantages. Adjuvant chemotherapy can improve local recurrence, metastasis and survival. Materials and Methods: We reviewed rectal cancer patients who underwent laparoscopic rectal resection and adjuvant radio-chemotherapy at UMC from 11/ 2013 to 08/2016. Results: The local recurrence rate was 8,8%, the distant metastases was 19,3%. The 5 years overall survival (OS) and disease- free survival (DFS) were 82,7% and 74,6%, respectively. Conclusions: Laparoscopic resection and adjuvant radio-chemotherapy for rectal cancer was effective and safe on oncologic outcome, good results on survival. Keywords: Laparoscopic surgery, adjuvant therapy. Tóm tắt Đặt vấn đề: Phẫu thuật nội soi điều trị ung thư trực tràng có nhiều ưu điểm. Điều trị hỗ trợ sau mổ giúp cải thiện tỉ lệ tái phát tại chỗ, di căn xa và sống còn. Phương pháp nghiên cứu: Hồi cứu các người bệnh ung thư trực tràng được phẫu thuật nội soi cắt đoạn đại trực tràng và điều trị hoá - xạ trị sau mổ từ 11/2013 đến 08/2016 tại Bệnh viện Đại học Y dược TP. Hồ Chí Minh. Kết quả: Tỉ lệ tái phát tại chỗ 8.8%, di căn xa 19,3%. Tỉ lệ sống chung và sống không bệnh sau 5 năm lần lượt là 82,7% và 74,6%. Kết luận: Phẫu thuật nội soi cắt đoạn đại trực tràng và điều trị hỗ trợ trong ung thư trực tràng hiệu quả và an toàn về mặt ung thư học, kết quả tốt về mặt sống còn.