Oncologic Outcomes After Transanal Total Mesorectal Excision for Rectal Cancer

Abstract

BACKGROUND: Recent series have raised concerns about the oncologic outcomes of transanal total mesorectal excision for mid and low rectal cancer. There is a paucity of large data sets from the United States to contribute to the ongoing international discourse. OBJECTIVE: This study aimed to investigate the rate of local recurrence and other oncologic outcomes in patients undergoing transanal total mesorectal excision for rectal adenocarcinoma. DESIGN: This study is a retrospective review of patients undergoing transanal total mesorectal excision for primary rectal cancer from January 2014 to December 2019. SETTINGS: This study was conducted at a single academic tertiary care medical center in the United States. PATIENTS: Consecutive patients aged ≥18 years undergoing surgical resection for primary rectal cancer were selected. INTERVENTION: The transanal total mesorectal excision procedures were performed utilizing a 2-team approach. MAIN OUTCOME MEASURES: Primary outcomes were pathologic quality, local and distant recurrence, treatment-related complications, and overall- and cancer-specific survival. RESULTS: Seventy-nine consecutive patients were included. The median age was 58 years (interquartile range, 50–64), and median BMI was 28 kg/m2 (interquartile range, 24.6–32.4). The mesorectum was complete in 69 patients (87.3%), nearly complete in 9 (11.4%), and incomplete in 1 (1.3%). There was circumferential resection margin involvement (<1 mm) in 4 patients (5.1%), and no patients had a positive distal margin (<1 mm) or intraoperative rectal perforation. Composite optimal pathology was achieved in 94.9% of specimens. Median follow-up was 29 months (range, 6–68). There were no local recurrences. Distant metastases were found in 10 (13.5%) patients and diagnosed after a median of 14 months (range, 0.6–53). Disease-free survival was 91.2% at 2 years, and overall survival was 94.7% at 2 years. LIMITATIONS: Retrospective design, a single center, and relatively short follow-up period were limitations of this study. CONCLUSION: The oncologic outcomes of this cohort support the use of transanal total mesorectal excision in the surgical management of mid to low rectal cancer at centers with appropriate expertise. See Video Abstract at http://links.lww.com/DCR/B723. RESULTADOS ONCOLÓGICOS DESPUÉS DE LA EXCISIÓN TOTAL DEL MESORRECTO POR VÍA TRANSANAL EN CASOS DE CÁNCER RECTAL ANTECEDENTES: Estudios recientes han suscitado preocupación sobre los resultados oncológicos de la excisión total del mesorecto por vía transanal en casos de cáncer de recto medio y bajo. Existe una gran escasez de conjuntos de datos en los Estados Unidos, para contribuir en el actual discurso internacional sobre el tema. OBJETIVO: Investigar la tasa de recurrencia local y otros resultados oncológicos en pacientes sometidos a una excisión total del mesorrecto por vía transanal por adenocarcinomas de recto. DISEÑO: Revisión retrospectiva de pacientes sometidos a excisión total del mesorecto por vía transanal en casos de cáncer de r...

Local Recurrence-Free Survival After TaTME: A Canadian Institutional Experience

“…In Canada, 608 patients undergoing TaTME at 8 high-volume centers were found to have an LR rate of 3.6% after a median follow-up of 27 months. 12 In addition, Maykel et al 11 published a study on the largest single-center series in the United States of 79 patients, demonstrating no LR within a median follow-up of 29 months, optimal pathologic specimen (94.9%), low conversion rate (1.3%), and low anastomotic leak rate (3.8%). Although reports on long-term data are limited, Hol et al 13 demonstrated an overall LR rate of 3.5% with a longer duration of follow-up of 54.8 months in their cohort of 159 patients, with a median time to recurrence of 19.2 months.…”

“…Our results are comparable to other studies on TaTME, with anastomotic leak rates varying between 3.8% and 15% and falling within the acceptable range for higher-risk colorectal and coloanal anastomoses (5%–19%). 8,11,12,18,26,27 Nonetheless, the morbidity associated with anastomotic leaks cannot be underappreciated, and every effort must be made to minimize these occurrences.…”

“…[7][8][9] Although some observational studies have demonstrated local recurrence (LR) rates in keeping with the current standard, limited long-term follow-up exists. 8,[10][11][12][13] Furthermore, population data from Norway suggesting unacceptable LR raised serious concerns about the safety of TaTME and led to a nationwide moratorium. 14 The present study aimed to determine LR-free survival and disease-free survival (DFS) in patients treated by TaTME for rectal cancer at a high-volume tertiary center in Canada.…”

“…7–9 Although some observational studies have demonstrated local recurrence (LR) rates in keeping with the current standard, limited long-term follow-up exists. 8,10–13 Furthermore, population data from Norway suggesting unacceptable LR raised serious concerns about the safety of TaTME and led to a nationwide moratorium. 14…”

Indications and Technical Considerations for Transanal Total Mesorectal Excision

“…9,10 Several retrospective studies published both before and since the Norwegian audit have refuted these results and have demonstrated acceptable 2-and 3-year local recurrence, disease-free survival, and overall survival when performed by surgeons with adequate expertise in the procedure. 6,12,13 The mechanism of multifocal pelvic local recurrence observed in the Norwegian study is postulated to be from luminal shedding of malignant cells that result from an incomplete distal purse string. This has led to a recommendation to perform a double purse string to ensure occlusion of the rectal lumen.…”