Three-year outcome after transanal versus laparoscopic total mesorectal excision in locally advanced rectal cancer: a multicenter comparative analysis

Abstract

Background: For patients with mid and distal rectal cancer, robust evidence on long-term outcome and causal treatment effects of transanal total mesorectal excision (TaTME) is lacking. This multicentre retrospective cohort study aimed to assess whether TaTME reduces locoregional recurrence rate compared to laparoscopic total mesorectal excision (LapTME). Methods: Consecutive patients with rectal cancer within 12 cm from the anal verge and clinical stage II-III were selected from three institutional databases. Outcome after TaTME (Nov 2011-Feb 2018) was compared to a historical cohort of patients treated with LapTME (Jan 2000-Feb 2018) using the inverse probability of treatment weights method. The primary endpoint was three-year locoregional recurrence. Results: A total of 710 patients were analysed, 344 in the TaTME group and 366 in the LapTME group. At 3 years, cumulative locoregional recurrence rates were 3.6% (95% CI, 1.1-6.1) in the TaTME group and 9.6% (95% CI, 6.5-12.7) in the LapTME group (HR = 0.4; 95% CI, 0.23-0.69; p = 0.001). Three-year cumulative disease-free survival rates were 74.3% (95% CI, 68.8-79.8) and 68.6% (95% CI, 63.7-73.5) (HR = 0.82; 95% CI, 0.65-1.02; p = 0.078) and three-year overall survival 87.2% (95% CI, 82.7-91.7) and 82.2% (95% CI, 78.0-86.2) (HR = 0.74; 95% CI, 0.53-1.03; p = 0.077), respectively. In patients who underwent sphincter preservation procedures, TaTME was associated with a significantly better disease-free survival (HR = 0.78; 95% CI, 0.62-0.98; p = 0.033). Conclusions: These findings suggest that TaTME may improve locoregional recurrence and disease-free survival rates among patients with mid and distal locally advanced rectal cancer.

UEG and EAES rapid guideline: Systematic review, meta-analysis, GRADE assessment and evidence-informed European recommendations on TaTME for rectal cancer

“…Some 822 records and 46 full text articles were screened, out of which 17 met the eligibility criteria. Sixeen studies addressed Q1 [29][30][31][32][33][34][35][36][37][38][39][40][41][42][43][44] and one study addressed Q2 [45]. The study selection flowchart and considerations on record selection, and risk of bias summaries are provided in the Appendix; detailed files including discarded records with reasons, and risk of bias judgements with detailed justifications are available online [20].…”

“…Data on disease-free and overall survival were provided by one study only; local recurrence at 2 years was provided by two studies [ 40 , 44 ]; however, the study was at critical risk of bias with regard to this outcome and did therefore not enter the analysis as per ROBINS-I methodology [ 23 ]. Low anterior resection syndrome and quality of life were reported by only a few studies [ 35 , 43 ].…”

“…We decided to not downgrade for both inconsistency and imprecision; however, we double-downgraded for very serious imprecision 16 Completeness of TME assessed using the Quirke criteria. 17 Primary study [ 29 , 30 , 32 , 34 , 37 , 42 , 44 ] Baseline/comparator Control arm of reference used for intervention 18 Risk of Bias: no serious. Due to confounding.…”

“…Primary study [29,30,32,34,37,42,44] Baseline/comparator Control arm of reference used for intervention Inconsistency: serious. Point estimates vary widely, the confidence interval of some of the studies do not overlap with those of most included studies/ the point estimate of some of the included studies, the direction of the effect is not consistent among the included studies, the magnitude of statistical heterogeneity was high, with I^2: 84%.…”

Neoadjuvant chemotherapy and radiotherapy followed by resection/ablation in stage IV rectal cancer patients with potentially resectable metastases

“…Currently, the optimal treatment of stage IV rectal cancer remains unclear [ 19 ]. In the context of a locally advanced primary tumor with synchronous metastasis, an effective treatment schedule should combine locoregional control with an adequate dose of systemic chemotherapy for all tumor sites [ 20 ]. In this present study, neoadjuvant chemotherapy and radiotherapy followed by resection/ablation and subsequent adjuvant chemotherapy achieved long-term survival with a relatively low recurrence rate and tolerable toxicities in rectal cancer patients with potentially resectable synchronous metastases, demonstrating the feasibility of this treatment schedule.…”