Transanal total mesorectal excision: a systematic review of the experimental and clinical evidence

Abstract

Achieving a clear distal or circumferential resection margins with laparoscopic total mesorectal excision (TME) may be laborious, especially in obese males and when operating on advanced distal rectal tumors with a poor response to neoadjuvant treatment. Transanal (TaTME) is a new natural orifice translumenal endoscopic surgery modality in which the rectum is mobilized transanally using endoscopic techniques with or without laparoscopic assistance. We conducted a comprehensive systematic review of publications on this new technique in PubMed and Embase databases from January, 2008, to July, 2014. Experimental and clinical studies written in English were included. Experimental research with TaTME was done on pigs with and without survival models and on human cadavers. In these studies, laparoscopic or transgastric assistance was frequently used resulting in an easier upper rectal dissection and in a longer rectal specimen. To date, 150 patients in 16 clinical studies have undergone TaTME. In all but 15 cases, transabdominal assistance was used. A rigid transanal endoscopic operations/transanal endoscopic microsurgery (TEO/TEM) platform was used in 37 patients. Rectal adenocarcinoma was the indication in all except for nine cases of benign diseases. Operative times ranged from 90 to 460 min. TME quality was deemed intact, satisfactory, or complete. Involvement in circumferential resection margins was detected in 16 (11.8 %) patients. The mean lymph node harvest was equal or greater than 12 in all studies. Regarding morbidity, pneumoretroperitoneum, damage to the urethra, and air embolism were reported intraoperatively. Mean hospital stay varied from 4 to 14 days. Postoperative complications occurred in 34 (22.7 %) patients. TaTME with TEM is feasible in selected cases. Oncologic safety parameters seem to be adequate although the evidence relies on small retrospective series conducted by highly trained surgeons. Further studies are expected.

Transanalinė totalinė mezorektalinė ekscizija (taTME): pirmoji mūsų patirtis

“…Moreover, taTME was developed to overcome technical difculties associated with open and laparoscopic TME [2]. The most common technical problems, as mentioned above, are a large tumour, located in the lower third rectum, obesity or narrow pelvis.…”

“…TaTME is a new natural orifice translumenal endoscopic surgery modality combined of three rectal surgery techniques -total mesorectal excision (TME), trans-anal trans-abdominal (TATA), and trans-anal endoscopic microsurgery (TEM) [2,3]. The rectum is dissected transanally using the TME principles and it is called "down-to-up" TME [4].…”

Transanal total mesorectal excision: a pure NOTES approach for selected patients

“…A recent systematic review identifies 16 clinical studies that included 150 patients who underwent TAMIS-TME [16]. Transabdominal assistance was used in all patients except in 12 patients reported in 4 publications [30][31][32][33] ( Table 5).…”

“…TAMIS surgery has proven to be feasible for the same indications as TEM (resection of benign tumors, selected rectal cancers and palliative resections in patients in poor medical condition) [11][12][13][14]. Furthermore, other applications have progressively been developed, with the use of this approach having recently been communicated in the treatment of rectourethral fistulas, proctectomy in inflammatory bowel disease and ''down-to-up'' total mesorectal excision (TME) [15,16]. From our point of view, the ''down-to-up'' transanal approach to the rectum and mesorectum (TAMIS-TME) in neoplastic disease is the most relevant application due to the prevalence and importance of this disease since, in spite of progress in this area, its management still presents difficulties.…”

The role of transanal total mesorectal excision in rectal surgery

“…Anatomical factors that may make TaTME a preferred approach for rectal cancer include male gender, low cancers, narrow pelvis, high body mass index, and distorted tissue planes due to neoadjuvant radiotherapy [27][28][29] . Although the use of TaTME seems clearly advantageous for the treatment of mid and low rectal cancer, there are potential advantages to its use in upper rectal cancer, above the peritoneal reflection.…”