Structured training pathway and proctoring; multicenter results of the implementation of transanal total mesorectal excision (TaTME) in the Netherlands

Abstract

Background Transanal total mesorectal excision (TaTME) is a new complex technique with potential to improve the quality of surgical mesorectal excision for patients with mid and low rectal cancer. The procedure is technically challenging and has shown to be associated with a relative long learning curve which might hamper widespread adoption. Therefore, a national structured training pathway for TaTME has been set up in the Netherlands to allow safe implementation. The aim of this study was to monitor safety and efficacy of the training program with 12 centers. Methods Short-term outcomes of the first ten TaTME procedures were evaluated in 12 participating centers in the Netherlands within the national structured training pathway. Consecutive patients operated during and after the proctoring program for rectal carcinoma with curative intent were included. Primary outcome was the incidence of intraoperative complications, secondary outcomes included postoperative complications and pathological outcomes. Results In October 2018, 12 hospitals completed the training program and from each center the first 10 patients were included for evaluation. Intraoperative complications occurred in 4.9% of the cases. The clinicopathological outcome reported 100% for complete or nearly complete specimen, 100% negative distal resection margin, and the circumferential resection margin was positive in 5.0% of patients. Overall postoperative complication rate was 45.0%, with 19.2% Clavien-Dindo ≥ III and an anastomotic leak rate of 17.3%. Conclusions This study shows that the nationwide structured training program for TaTME delivers safe implementation of TaTME in terms of intraoperative and pathology outcomes within the first ten consecutive cases in each center. However, postoperative morbidity is substantial even within a structured training pathway and surgeons should be aware of the learning curve of this new technique.Keywords TaTME · TAMIS · Rectal cancer · Proctoring · Training Transanal total mesorectal excision (TaTME) has been proposed as a potentially better alternative to the laparoscopic standard TME for mid and distal rectal cancer [1][2][3][4]. The bottom-up approach for the deep pelvic region increases exposure and facilitates the distal mesorectal excision. Especially those difficult cases such as obese patients, low rectal and Other Interventional Techniques Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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

“…The structured training pathway was set up in the Netherlands in 2014 as a programme for postgraduate colorectal surgeons in centres with an annual volume of total mesorectal excision (TME) surgery for rectal cancer of 20 procedures or more and with known proficiency in laparoscopic TME. The clinical data from patients in the structured training pathway were collected prospectively, as described previously 17 . The first five procedures were discussed with and assisted by an experienced proctor, after which the following procedures were performed independently.…”

“…The first five procedures were discussed with and assisted by an experienced proctor, after which the following procedures were performed independently. The first ten patients in each of the centres that completed the structured training pathway were included to evaluate clinical outcomes during the implementation of TaTME 17 . In addition, a larger cohort of patients from four centres that continued TaTME after training, with a procedure volume greater than 45, was collected to assess learning curve effects.…”

“…In the Netherlands, a structured training pathway, including proctoring sessions by dedicated trainers, has been set up to ensure safe implementation of TaTME and minimization of learning curve effects 17 . A collective review of the short-term outcomes of the first ten patients in 12 proctored centres revealed a major morbidity rate of 19⋅2 per cent and involved CRMs in 5⋅0 per cent of patients 17 . The aim of the present study was to evaluate the oncological outcomes of the initial patients who underwent TaTME within the structured training pathway.…”

Transanale totale mesorektale Exzision – eine sinnvolle Operationstechnik zur individualisierten Behandlung von Patienten mit Rektumkarzinom

“…Im Rahmen einer internationalen Konsensuskonferenz in St. Gallen wurden die Standards erarbeitet, sie sind mittlerweile publiziert und werden, wie man an den nahezu europaweit inhaltsgleichen Kursen erkennen kann, auch in weitem Umfang so umgesetzt [23]. Nach Durchlaufen eines entsprechenden Ausbildungscurriculums ist die sichere Einführung der Methode an High-Volume Zentren möglich [47,48].…”

Rektumkarzinom – Robotic Setup, Port Placement, strukturierte OP-Schritte

“…Hierdurch kann im engen Becken und hinter der Prostata das Rektum besser erreicht werden. Die Methode ist allerdings sehr komplex, schwierig zu erlernen und erfordert sowohl ein intensives Trainingsprogramm als auch eine hohe Fallzahl, bevor sie sicher durchgeführt werden kann [7]. Darüber hinaus mehren sich kritische Stimmen in Hinblick auf potenzielle Komplikationen, wie frühzeitige Beckenrezidive und erhöhte Anastomoseninsuffizienzraten nach TaTME [8,9].…”