Three-Year Nationwide Experience with Transanal Total Mesorectal Excision for Rectal Cancer in the Netherlands: A Propensity Score-Matched Comparison with Conventional Laparoscopic Total Mesorectal Excision

Abstract

on behalf of the Dutch ColoRectal Cancer Audit Group BACKGROUND: Transanal total mesorectal excision (TaTME) is a relatively new and demanding technique for rectal cancer treatment. Results from national datasets are absent and comparative data with laparoscopic TME (lapTME) are scarce. Therefore, this study aimed to evaluate the initial TaTME experience in the Netherlands, by comparing outcomes with conventional lapTME. STUDY DESIGN: Patients with rectal cancer who underwent curative TaTME or lapTME were selected from the nationwide and mandatory Dutch ColoRectal Audit (DCRA), between January 2015 and December 2017. Primary outcome was circumferential resection margin (CRM) involvement. Secondary outcomes included operative details and short-term (<30 days) clinical course. Propensity score matching was performed for 7 factors. RESULTS: There were 3,777 patients included for analysis (TaTME, n ¼ 416, lapTME, n ¼ 3361). Transanal TME was performed in 38 hospitals and lapTME in 90 hospitals. Before matching, the patient category within the TaTME group was technically more challenging in terms of tumor height and preoperative threatened margins. After 1:1 matching, 396 patients were included in each group, with comparable baseline characteristics. Circumferential resection margin involvement was 4.3% after TaTME and 4.0% after lapTME (p ¼ 1.000). Conversion rate was significantly lower in TaTME (1.5% vs 8.6%, p < 0.001). Anastomotic leak rate was not significantly different (16.5% vs 12.2%, p ¼ 0.116). Other postoperative outcomes were also comparable between the groups. Significant independent risk factors for CRM involvement in TaTME were preoperative threatened margin on MRI (odds ratio [OR] 5.48, 95% CI 1.33 to 22.54) and conversion (OR 30.12, 95% CI 3.70 to 245.20). CONCLUSIONS: This first nationwide study shows early experience with adoption of TaTME in the Netherlands. Considering that current data represent initial TaTME experience, acceptable short-term outcomes were demonstrated when compared with the well-established lapTME.

Transanal total mesorectal excision for rectal cancer has been suspended in Norway

“…The mortality rate was higher after TaTME than those in the national cohorts and other studies, but this finding should be interpreted with caution owing to the small number of events.…”

“…The indication for TaTME has currently been extended to include higher tumours and women. The oncological results after TaTME have been evaluated in terms of risk factors such as CRM and completeness of mesorectal fascia.…”

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

“…The TaTME registry 3 , representing more than 300 centres voluntarily entering data, recorded an anastomotic failure rate of 15⋅6 per cent among 1594 patients, which is higher than rates from expert centres. In addition, a population-based study 12 documented an overall morbidity rate of 42⋅3 per cent, anastomotic leakage in 16⋅0 per cent and a circumferential resection margin (CRM)-positive rate of 4⋅4 per cent. These latter studies show that the promise of TaTME has not yet been met on a large scale.…”

The value of force and torque measurements in transanal total mesorectal excision (TaTME)

“…However, concerns exist about the learning curve and therefore, patient safety [15,16]. Although cohort data reported proper short-term clinical outcomes, the real-world implementation so far has failed to better clinical outcomes [17]. The oncological outcome has yet to be published, preferably from randomized data [3,18].…”