Defining the learning curve for transanal total mesorectal excision for rectal adenocarcinoma

Lee, Lawrence; Kelly, Justin; Nassif, George; deBeche-Adams, Teresa; Albert, Matthew; Monson, J. R. T.

doi:10.1007/s00464-018-6360-4

Cited by 89 publications

(111 citation statements)

References 31 publications

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“…A recent study that defined proficiency in TaTME as high-quality TME (complete/near-complete mesorectal envelope, and negative distal and circumferential resection margin) showed a learning curve of at least 45-51 cases. 19 This finding is consistent with the results of a systematic review by Deijen and colleagues, which demonstrated that there is a difference in oncologic outcomes at high-volume (> 30 cases) and low-volume (< 30 cases) centres, with high-volume centres having a higher "complete" TME rate as well as a lower circumferential resection margin involvement and fewer major complications. 20 In another single-centre study, which assessed 138 patients operated on over a 5-year period, there was a substantial drop in major complications once a surgeon's experience exceeded 40 patients.…”

Section: Discussionsupporting

confidence: 89%

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Implementing new surgical technology: a national perspective on case volume requirement for proficiency in transanal total mesorectal excision

Palter

Montbrun

2020

CJS

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Background: Early data suggest that transanal total mesorectal excision (TaTME) is a safe alternative to the abdominal approach for rectal cancer. This study aims to understand the approach to the management of rectal cancer in Canada and to ascertain perspectives on introducing TaTME. Methods: Surgeons were invited to complete a survey that asked about their management practices relating to rectal cancer and their opinions regarding TaTME. Results: Ninety-four surgeons completed the survey (38% response rate). The number of rectal cancer cases handled annually by surgeons varied widely (1-80 cases, median 15 cases). Twenty-seven percent of respondents performed TaTME at the time of the survey, and 43% of those who did not said they planned on learning the technique. Surgeons who performed TaTME felt that a higher annual volume of rectal cancer cases was required to maintain proficiency than did non-TaTME surgeons (median 20 cases [interquartile range (IQR) 15-25 cases] v. 15 cases [IQR 10-20 cases]). Surgeons who performed TaTME also felt that a higher annual volume of TaTME cases was required to maintain proficiency (median 12 cases [IQR 10-19 cases] v. 9 cases [IQR 5-10 cases]). Conclusion: These findings help define the current practice environment for rectal cancer surgeons in Canada and highlight the complex issues associated with learning TaTME. Contexte : Selon des données préliminaires, l'exérèse totale du mésorectum par voie transanale (ou TaTME, pour transanal total mesorectal excision) est une solution de rechange sécuritaire à l'approche abdominale pour le cancer du rectum. Cette étude vise à faire le point sur le traitement du cancer rectal au Canada et à mesurer l'intérêt à l'endroit de la technique TaTME. Méthodes : Des chirurgiens ont été invités à répondre à un sondage sur leur façon de prendre en charge le cancer rectal et sur leur opinion au sujet de la TaTME.

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Section: Discussionsupporting

confidence: 89%

“…(10)(11)(12)(13)(14)(15)(16)(17)(18)(19) 9(5)(6)(7)(8)(9)(10) IQR = interquartile range; TaTME = transanal total mesorectal excision. *Surgeons who were performing TaTME at the time of the survey.†Surgeons who were not performing TaTME at the time of the survey.…”

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confidence: 99%

Implementing new surgical technology: a national perspective on case volume requirement for proficiency in transanal total mesorectal excision

Palter

Montbrun

2020

CJS

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“…A high rate of positive margins despite low tumour stage, the high rate of permanent stomas and perioperative morbidity may be indicative of suboptimal TaTME procedures. An unsupervised learning curve without proctoring, as shown by experienced single-port surgeons, takes over 40 procedures 10,11 .…”

Section: Discussionmentioning

confidence: 99%

“…Despite these positive results, it is also acknowledged that TaTME is a difficult technique and has a long learning curve with associated morbidity 10,11 . The international TaTME registry 3 and a systematic review 4 have shown that widespread adoption results in less favourable clinical outcomes than reported in the initial cohorts treated in expert centres.…”

Section: Introductionmentioning

confidence: 99%

Locoregional recurrences after transanal total mesorectal excision of rectal cancer during implementation

Oostendorp

Belgers

Bootsma

et al. 2020

British Journal of Surgery

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Background: Transanal total mesorectal excision (TaTME) has been proposed as an approach in patients with mid and low rectal cancer. The TaTME procedure has been introduced in the Netherlands in a structured training pathway, including proctoring. This study evaluated the local recurrence rate during the implementation phase of TaTME. Methods: Oncological outcomes of the first ten TaTME procedures in each of 12 participating centres were collected as part of an external audit of procedure implementation. Data collected from a cohort of patients treated over a prolonged period in four centres were also collected to analyse learning curve effects. The primary outcome was the presence of locoregional recurrence. Results: The implementation cohort of 120 patients had a median follow up of 21⋅9 months. Short-term outcomes included a positive circumferential resection margin rate of 5⋅0 per cent and anastomotic leakage rate of 17 per cent. The overall local recurrence rate in the implementation cohort was 10⋅0 per cent (12 of 120), with a mean(s.d.) interval to recurrence of 15⋅2(7⋅0) months. Multifocal local recurrence was present in eight of 12 patients. In the prolonged cohort (266 patients), the overall recurrence rate was 5⋅6 per cent (4⋅0 per cent after excluding the first 10 procedures at each centre). Conclusion: TaTME was associated with a multifocal local recurrence rate that may be related to suboptimal execution rather than the technique itself. Prolonged proctoring, optimization of the technique to avoid spillage, and quality control is recommended.

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“…Although the learning curve of taTME has not been fully clarified 7,49) , the skills are believed to be difficult to acquire and care should be taken to avoid serious complications, especially in the early learning stages 50) . Deijen et al in their study performed pooled-analysis and compared clinical outcomes between low-volume (< 30 cases) and high-volume ("30 cases) centers.…”

Section: Education and Trainingmentioning

confidence: 99%

Transanal TME: new standard or fad?

Hasegawa

Yoshida

Morimoto

et al. 2019

J Anus Rectum Colon

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Transanal total mesorectal excision (taTME) has been developed to overcome the difficulty of laparoscopic dissection and transection in the deep pelvis. TaTME has several clinical benefits over laparoscopic surgery, such as better exposure of the distal rectum and direct determination of distal resection margin. Although evidence demonstrating the true benefits of taTME over laparoscopic TME (LapTME) is still insufficient, accumulating data have revealed that, as compared with LapTME, taTME is associated with shorter operative time and a lower conversion rate without jeopardizing other short-term outcomes. However, taTME is a technically demanding procedure with specific complications such as urethral injury, and so sufficient experience of LapTME and step-by-step acquisition of the skills needed for this procedure are requisite. The role of transanal endoscopic surgery is expected to change, along with the recent progress in the treatment of rectal cancer, such as robotic surgery and the watch-and-wait strategy. Optimization of treatment will be needed in the future in terms not only of oncological but also of functional outcomes.

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Defining the learning curve for transanal total mesorectal excision for rectal adenocarcinoma

Abstract: TA-TME is a complex technique that requires a minimum of 45-51 cases to reach an acceptable incidence of high-quality TME and lower operative duration.

Cited by 89 publications

References 31 publications

Implementing new surgical technology: a national perspective on case volume requirement for proficiency in transanal total mesorectal excision

Implementing new surgical technology: a national perspective on case volume requirement for proficiency in transanal total mesorectal excision

Locoregional recurrences after transanal total mesorectal excision of rectal cancer during implementation

Transanal TME: new standard or fad?

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