Transanal total mesorectal excision for rectal cancer: evaluation of the learning curve

Koedam, T. W. A.; Helbach, M. Veltcamp; Ven, Peter M. van de; Kruyt, Ph.M.; Heek, N. Tjarda van; Bonjer, H. Jaap; Tuynman, Jurriaan B.; Sietses, C.

doi:10.1007/s10151-018-1771-8

Cited by 128 publications

(152 citation statements)

References 25 publications

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“…The extent of dissection in each approach usually differs from case to case, however, rectal transection and dissection of the extra-peritoneal part of the rectum is performed transanally. There are several potential benefits of the two-team approach over the one-team approach, including assistance with exposure of the operative field and/or enhanced comprehension of the surgical anatomy 7) . However, the two-team approach requires extra human and device resources that might not always be available with the exception of in specialized centers.…”

Section: Operative Proceduresmentioning

confidence: 99%

Transanal TME: new standard or fad?

Hasegawa

Yoshida

Morimoto

et al. 2019

J Anus Rectum Colon

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Transanal total mesorectal excision (taTME) has been developed to overcome the difficulty of laparoscopic dissection and transection in the deep pelvis. TaTME has several clinical benefits over laparoscopic surgery, such as better exposure of the distal rectum and direct determination of distal resection margin. Although evidence demonstrating the true benefits of taTME over laparoscopic TME (LapTME) is still insufficient, accumulating data have revealed that, as compared with LapTME, taTME is associated with shorter operative time and a lower conversion rate without jeopardizing other short-term outcomes. However, taTME is a technically demanding procedure with specific complications such as urethral injury, and so sufficient experience of LapTME and step-by-step acquisition of the skills needed for this procedure are requisite. The role of transanal endoscopic surgery is expected to change, along with the recent progress in the treatment of rectal cancer, such as robotic surgery and the watch-and-wait strategy. Optimization of treatment will be needed in the future in terms not only of oncological but also of functional outcomes.

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Section: Operative Proceduresmentioning

confidence: 99%

Transanal TME: new standard or fad?

Hasegawa

Yoshida

Morimoto

et al. 2019

J Anus Rectum Colon

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“…Laparoscopic right hemicolectomy with extended D3 lymph node dissection offers a good long-term outcome for colon cancer treatment [3]. Several approaches have been used when performing a laparoscopic right hemicolectomy but most are generally comparable [4].…”

Section: Supporting Informationmentioning

confidence: 99%

Purse‐string reinforcement in transanal total mesorectal excision: a further essential step to increase oncological safety – a video vignette

et al. 2019

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Dear Editor, After the first clinical use of transanal total mesorectal excision (TaTME) in 2009, the technique has been embraced by several colorectal units as a 'tool' to tackle those cancers that are difficult to manage through a purely abdominal approach [1]. That early enthusiasm has been stifled by reports of severe morbidity and the complexity of the technique, with demonstration of a steep learning curve even for surgeons with significant experience in minimally invasive surgery [2][3][4]. Even more alarming is the observation of an unusual early and multifocal pattern of local recurrences after TaTME, which raises valid concerns about the oncological safety of the technique [5]. The exact cause for this particular recurrence pattern remains unclear and requires further careful assessment.The concept of TaTME with the crucial parts of oncological dissection are very similar to the transabdominal transanal (TATA) technique; however, the type of recurrence pattern in seen in TaTME is not encountered in the latter technique [6,7]. There are therefore aspects of TaTME that differ from TATA and are the most likely culprits for these multifocal recurrences, i.e. the endoscopic purse-string and use of transanal insufflation. The theoretical risk of tumour cell spillage and aerosolization of these tumour cells by the transanal air inflow could explain the multifocal pattern of these early recurrences. The current research of our group is focusing on the biology of these recurrences and potential contamination during surgery.To improve safety by avoiding spillage of bacterial and tumour cells during dissection, the authors propose and demonstrate a modification of the current technique to tackle the potential oncological Achilles' heel of the TaTME technique, namely a reinforcement of the purse-string. The initial steps of TaTME are respected, including identification of a safe distal tumour margin, lumen closure with an air-tight purse-string suture, meticulous wash-out of the rectal stump and full-thickness rectotomy [8]. After completion of the circumferential full-thickness rectal wall transection, we recommend routinely performing a running suture using a 3-0 V-Loc TM (Medtronic, Minneapolis, Minnesota, USA) over the initial purse-string and repeating a thorough second wash-out with a tumouricidal solution (Video S1 in the online Supporting Information). These extra steps ensure complete occlusion of the rectal lumen and inversion of the rectal mucosa, thus achieving a superior airtight seal during the entire procedure.The authors believe that these additional steps may contribute to an oncologically safe procedure, eliminating the theoretical risk of tumour cell aerosolization and with it multifocal pelvic implantation.

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“…Those specific complications and difficulties highlight the need for structured and accredited training program. Several authors have addressed the proper training pathway to the incorporation of TaTME into clinical practice [19][20][21][22][23][24][25] .…”

Section: Training Programmentioning

confidence: 99%

“…Koedam et al [26] evaluated the learning curve of TaTME in 138 patients with rectal cancer over a 60-month period. The authors reported improvement in postoperative outcomes after the first 40 patients, showing a decrease in major postoperative complications from 47.5% to 17.5% and leakage rate from 27.5% to 5%.…”

Section: Training Programmentioning

confidence: 99%

The role of transanal total mesorectal excision in rectal surgery

Yellinek¹,

Wexner²

2018

MIS

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Transanal total mesorectal excision (TaTME) is the newest approach for the resection of rectal cancer, according to the principles of TME. The evolution of TaTME started almost 40 years ago and is a combination of several important developments in both micro-endoscopic surgery and transanal surgery. The preliminary clinical data have revealed acceptable TME quality. Clinical trials to determine the long-term oncological results are still in process. In order to master TaTME, the surgeon should be an expert in laparoscopic rectal surgery as well as transanal microsurgery and follow a stepwise training approach. Robotic TaTME using a single-port robotic system is a promising future development.

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Transanal total mesorectal excision for rectal cancer: evaluation of the learning curve

Cited by 128 publications

References 25 publications

Transanal TME: new standard or fad?

Transanal TME: new standard or fad?

Purse‐string reinforcement in transanal total mesorectal excision: a further essential step to increase oncological safety – a video vignette

The role of transanal total mesorectal excision in rectal surgery

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