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

Abstract

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.

The learning curve of TaTME for mid-low rectal cancer: a comprehensive analysis from a five-year institutional experience

“…A recent report from the Netherlands [11] reported the local recurrence rate during the implementation of TaTME in a structured national training program. The authors pointed out that even if the surgeons were proctored, there was a clear learning curve effect in the first ten cases, with a recurrence rate of 10% and an AL rate of 17%, which were strictly correlated with the occurrence of intraoperative complications.…”

“…However, there have been some reports of specific surgical complications associated with TaTME (urethral injuries, pelvic wall injuries, carbon dioxide embolism, nerve damage) [9,10]. A more worrisome issue is the unexpectedly high rate of early locoregional recurrence reported in two studies analyzing oncological outcomes in the early phase of TaTME implementation [10,11]. In light of these reports, the need for standardized surgical education and proper training in this technique have been advocated [12].…”

Initial Experience with the Safe Implementation of Transanal Total Mesorectal Excision (TaTME) as a Standardized Procedure for Low Rectal Cancer

“…A selection bias, however, with inclusion of cases with accumulation of risk factors for inappropriate TME cannot be disclaimed. Those were exclusively excluded in comparing studies like COLOR II [ 8 , 10 , 13 , 16 , 24 , 25 , 26 ].…”

Total neoadjuvant therapy for locally advanced rectal cancer: the fuse is lit

“…Is total neoadjuvant therapy (TNT) the new standard of care for patients with locally advanced rectal cancer (LARC) 1 ? It is clear that the primacy of good‐quality surgery and clear margins are key 2–6 . Yet even after neoadjuvant chemoradiotherapy (CRT), total mesorectal excision and adjuvant chemotherapy, distant metastatic disease arises in as many as half of patients with LARC 7 .…”

“…This has been highlighted by the recent focus on extramesorectal nodal metastatic burden, and how it should be managed with combination therapy and surgery 10,11 . Prognosis may be affected more by surgical complications than by chemotherapy issues 2–12 , so why not consider TNT to improve oncological outcomes?…”