Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_869_Библиотеки_им_академика_М_И_Перельмана.pdf
Functional Outcomes to Transanal Minimally Invasive Surgery (TAMIS) and Transanal Total Mesorectal Excision (taTME)
Elisabeth C. McLemore and Patricia Sylla
38
Anorectal Function and Assessment
Transanal minimally invasive surgery (TAMIS)
and transanal total mesorectal excision (taTME)
may impact defecatory, sexual, and urinary
function. There are a number of ongoing clinical
trials assessing the impact of these procedures
on functional outcomes; however, the current
data available for review is limited. This chapter
will address what is currently known regarding
changes in bowel function following TAMIS
and taTME.
Anorectal physiology and bowel continence
are the result of a complex and dynamic interplay
between pelvic oor musculature and timely contraction and relaxation of the sphincter muscle
complex [1]. Formal and functional assessment
of anorectal function includes anal manometry,
dynamic defecography, cross-sectional imaging,
and continence scoring systems such as the
Cleveland Clinic Incontinence Index (CCII,
Table 38.1) [1, 2]. Anal manometry measures
rectal compliance and capacitance as well as anal
resting and squeeze pressures. Defecography
E. C. McLemore (*)
Colon and Rectal Surgery, Los Angeles Medical
Center, Kaiser Permanente, Department of Surgery,
Los Angeles, CA, USA
e-mail: Elisabeth.c.mclemore@kp.org
P. Sylla
Division of Colon and Rectal Surgery, Icahn School
of Medicine at Mount Sinai, New York, NY, USA
evaluates the coordination of the pelvic oor
muscles, rectum, and sphincter muscle relaxation
during evacuation [3].
Assessing the severity of fecal incontinence (FI)
can be measured using a variety of instruments
ranging from healthcare-directed question to
response grading scoring system such as the CCII
[1]. The CCII assesses the frequency and severity
of accidental loss of gas, liquid stool, and solid
stool [1]. There are a variety of validated questionnaires assessing patient’s perception of the severity
of their bowel, bladder, and sexual function and
impact on their quality of life. These are particularly helpful to assess preoperative and monitor
postoperative functional outcomes [1, 4–7].
The Colorectal Functional Outcome
Questionnaire (COREFO) is a validated instrument that focuses on assessing bowel function
after colorectal surgery [4]. Low anterior resection syndrome (LARS) is a well-established syndrome characterized by alteration in bowel habits
following low anterior resection. Patients with
LARS typically have increased fecal urgency,
frequency, and clustering of bowel movements. A
validated scoring system known as the LARS
Score [8] is another instrument available to assess
the impact on function after rectal surgery.
TAMIS and taTME are relatively modern evolutions of transanal microscopic surgery (TEM)
and low anterior resection (LAR), respectively.
As such, the functional outcome data available
for review is limited at this time. The bowel
© Springer Nature Switzerland AG 2019
S. Atallah (ed.), Transanal Minimally Invasive Surgery (TAMIS) and Transanal Total Mesorectal
Excision (taTME), https://doi.org/10.1007/978-3-030-11572-2_38
399
400
E. C. McLemore and P. Sylla
Table 38.1 Cleveland clinic incontinence index
Incontinence
Gas
Liquid
Stool
Pad usage
Lifestyle
alteration
Scale of 5–20
Minimal–No fecal incontinence: score of 5
Full fecal incontinence: score of 20
<1x per
month (1)
1–2x per
month (2)
Weekly
(3)
Daily
(4)
functional outcomes after TAMIS and taTME
will be reviewed separately in the remainder of
this chapter.
Functional Outcomes: TAMIS
TAMIS [9] is a modern evolution of the transanal
endoscopic microsurgery (TEM) technique pioneered by Gerhard Buess in 1983 [10]. TEM has
been a disruptive technique in colorectal surgery.
The initial results comparing TEM to the standard of care, transanal excision (TAE) revealed
that TEM was associated with superior quality of
resection demonstrated by the higher rate of
achieving negative margins [10, 11]. Long-term
results revealed that TEM resection of rectal
lesions also resulted in a lower local recurrence
rate compared to TAE [12–16]. More recently,
multiple transanal platforms have been developed, and new techniques and terminology (such
as TAMIS) have broadened the utility and applications of the TEM technique.
Prior to consideration of any transanal endoscopic surgical resection technique for removal
of rectal lesions, patients must rst undergo a
systematic evaluation to properly characterize
and stage the rectal lesion. The history and physical examination is the cornerstone of preoperative evaluation prior to considering a surgical
technique, such as TAMIS. An overall assessment of the patient’s general health is important
to determine the ability to tolerate general anesthesia and determine the surgical approach.
Previous anorectal surgery is an important consideration when planning TAMIS.The presence
of an anal or anastomotic stricture will hinder the
surgeon’s ability to position the operating transanal access platform.
The coexistence of fecal incontinence or borderline continence may alter the operative plan, as
temporary and permanent fecal incontinence have
been reported with transanal endoscopic microsurgery (TEM) [17, 18]. Multiple small TEM studies
have documented a transient decrease in sphincter
resting pressures on anal manometry that was proportional to the duration of the procedure, with
resting pressures returning to baseline 12months
postoperatively [19–22]. Alterations in resting
anal sphincter pressures did not translate into any
detrimental effects on continence. In a study of 41
TEM cases, Cataldo et al. found no signicant
changes in the Fecal Incontinence Severity Index
(FISI) or Fecal Incontinence Quality of Life
(FIQL) scores 6weeks postoperatively relative to
preoperative scores [17].
A recent study that longitudinally assessed
anorectal function and quality of life in 102 TEM
patients preoperatively and at 6, 12, 26, and
52weeks postoperatively found that the general
quality of life scores (EQ-5D) were signicantly
lower at 6 and 12weeks but returned to baseline
at 26 weeks. Similar to prior studies, anorectal
function as assessed by colorectal functional outcome (COREFO) was worse at 6weeks postoperatively but returned to baseline at 12 weeks
postoperatively [23]. However, two TEM series
reported persistent sphincter dysfunction following TEM on long-term assessment using either
St. Mark’s fecal incontinence score or Wexner
and Kamm incontinence scores [24, 25]. Dafnis
etal. reported a 37% rate of various degrees of
fecal incontinence in 48 patients at a median follow- up of 22months following TEM and found a
correlation with OR time [25]. Restivo etal. also
reported a 28% incidence of variable degrees of
fecal incontinence at a median follow-up of
40 months among a cohort of 89 patients who
underwent TEM.Preoperative radiotherapy and
perioperative complications were found to be
independent risk factor for functional disturbances [24].
TAMIS is a more recent surgical technique
compared to TEM, and naturally, the reported
38 Functional Outcomes to Transanal Minimally Invasive Surgery (TAMIS) and Transanal Total…
401
functional outcome data after TAMIS is less
robust in comparison. Albert and Atallah have
reported their outcomes after TAMIS in their rst
50 cases in 2013 reporting on margin status,
specimen integrity, and postoperative complications [26]. The adoption of TAMIS has since then
grown, as reected by several additional midsize
case series that have been published [27].
However, most early TAMIS case series have not
reported on functional outcomes. In a small prospective study conducted by Schiphorst et al.,
functional outcomes following TAMIS were
assessed in 37 patients using FISI score preoperatively and at 3, 6, 9, and 12months postoperatively [28]. Among 17 patients with decreased
preoperative fecal continence at baseline,
improved FISI scores were noted in 88%, while
among 18 patients with normal continence at
baseline, no change in FISI scores was found in
83%, suggesting preserved long-term anorectal
function following TAMIS procedures.
In 2017, Clermonts etal. published the incidence of impaired fecal incontinence in 42
patients who underwent TAMIS [29]. The fecal
incontinence severity index (FISI) [30] was utilized to assess fecal continence over a median
follow-up time period of 36 months (range
24–48). The preoperative FISI score was 8.3
points. One year following TAMIS, the mean
FISI score was 5.4 points (p=0.5). Three years
after TAMIS, the mean FISI score was 10.1
points (p = 0.01). Overall, fecal continence
improved in 11 patients (26%) and decreased in
20 patients (48%) [29].
More recently, 37 patients who underwent
TAMIS were compared to healthy controls in an
attempt to further evaluate the quality of life in
patients following TAMIS [31]. The quality of
life outcomes were measured using the Short
Form 36 health survey (SF-36) questionnaire.
The postoperative quality of life scores in the
TAMIS group were similar to those reported by
Dutch healthy controls. The quality of life scores
for the “social functioning” domain were lower
in patients who had undergone TAMIS compared
to healthy controls (84 vs. 100 points, p=0.03).
The authors concluded that TAMIS is a safe technique with postoperative quality of life scores
similar to that of healthy case matched controls at
3-year follow-up. There seems to be no association between fecal incontinence scores and
reported quality of life. However, the potential
negative impact of TAMIS on fecal continence
and/or quality of life should not be underestimated and should be discussed during preoperative counseling.” [31]
There is growing interest in formal evaluation
of functional outcomes after TAMIS and other
transanal endoscopic surgical resection techniques. We eagerly await long-term functional
outcomes following TAMIS in the setting of
larger multicenter studies. In the meantime, it is
advisable to follow the cautionary report by
Clermonts and colleagues and continue to counsel patients preoperatively regarding the potential
impact on social and functional outcomes after
transanal endoscopic surgery using any type of
transanal access device.
Functional Outcomes: taTME
With increasing interest in natural orice surgery,
the dynamic evolution of transanal and endoluminal surgical techniques continues. These techniques began with transanal endoluminal surgical
removal of rectal masses and have progressed to
transanal radical proctectomy for rectal cancer.
The rst case of taTME was performed in 2009
by Sylla, Rattner, Delgado, and Lacy [32]. The
improved visibility and working space associated
with the taTME technique are appealing and have
resulted in many surgeons to return to the cadaver
lab for additional rectal cancer surgical training
in the taTME technique [33, 34].
There are several ongoing clinical trials further evaluating the safety and efcacy of the
taTME technique. Many of these trials are also
assessing functional outcomes in addition to
oncologic outcomes after taTME.A multicenter
phase II study of transanal TME (taTME) led by
Patricia Sylla (Mt. Sinai Hospital, New York
City) is currently enrolling patients with Stage
I–III rectal cancer (NCT03144765, ClinicalTrials.
gov Identier). A single-center clinical trial titled
“Transanal total mesorectal excision for rectal
402
E. C. McLemore and P. Sylla
cancer on anal physiology plus fecal incontinence” led by Dr. Tracy Hull (Cleveland Clinic,
Ohio) is also actively enrolling patients for further evaluation of this technique (NCT03283540,
ClinicalTrials.gov Identier). The COLOR III,
an international multicenter randomized clinical
trial comparing taTME versus laparoscopic TME
for mid and low rectal cancer, has also added
functional outcome assessment to the secondary
endpoints and is also actively enrolling patients.
Without any results from multicenter phase II
and randomized phase III clinical trials, there is
little known at this time regarding functional outcomes after taTME. Preliminary comparative
reviews published in July 2018 by Veltcamp
Helbach et al. demonstrated comparable functional and quality of life outcomes in patients
undergoing taTME and laparoscopic TME [35].
A total of 27 patients who underwent taTME and
27 patients who underwent laparoscopic TME
were asked to complete 5 questionnaires related
to functional outcomes and quality of life. All of
the taTME procedures were performed by a single surgeon at the Gelderse Vallei Hospital with a
minimum of 7months follow-up [27]. One item
concerning fecal incontinence was scored worse
for taTME. The LARS symptoms and urinary
functional outcomes were similar between the
two groups [35].
Understanding the impact of TME on anorectal physiology and fecal continence is complex
and likely depends on several anatomic, medical,
and surgical factors including patient age and
preoperative function, whether preoperative
radiotherapy was administered, whether intersphincteric resection was performed, the extent
of rectal resection, and the level and type of
colorectal or coloanal anastomotic reconstruction. The dynamic loss of the reservoir functional
capacity of the rectum, potential dyscoordination
of the pelvic oor musculature, and impact of the
timely contraction and relaxation of the sphincter
muscle complex after TME is an area of increasing interest in academic, social, and public health
research communities. In the meantime, it would
be wise to follow the cautionary reports currently
available in the literature and continue to council
patients preoperatively regarding the potential
impact on social and functional outcomes after
TME for rectal cancer using any surgical technical approach.
References
1. Jorge JM, Wexner SD.Etiology and management of
fecal incontinence. Dis Colon Rectum. 1993;36:77–
97. PMID: 8416784.
2. Habr-Gama A, Lynn PB, Jorge JM, São Julião GP,
Proscurshim I, Gama-Rodrigues J, Fernandez LM,
Perez RO.Impact of organ-preserving strategies on
Anorectal function in patients with distal rectal cancer
following Neoadjuvant Chemoradiation. Dis Colon
Rectum. 2016;59(4):264–9. PMID: 26953984.
3. Ramage L, Simillis C, Yen C, Lutterodt C, Qiu S, Tan
E, Kontovounisios C, Tekkis P. Magnetic resonance
defecography versus clinical examination and uoroscopy: a systematic review and meta-analysis. Tech
Coloproctol. 2017;21(12):915–27. Review. PMID:
29094218.
4. Bakx R, Sprangers MA, Oort FJ, van Tets WF, etal.
Development and validation of a colorectal functional outcome questionnaire. Int J Color Dis. 2005;
20:126–36. PMID: 15449078.
5. Todd H. Rockwood incontinence severity and QOL
scales for fecal incontinence. Gastroenterology.
2004;126:S106–13. PMID:14978646.
6. Rosen R, Brown C, Heiman J, Leiblum S, et al.
The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther.
2000;26:191–208. PMID: 10782451.
7. Rosen RC, Riley A, Wagner G, Osterloh IH, et al.
The international index of erectile function (IIEF): a
multidimensional scale for assessment of erectile dysfunction. Urology. 1997;49:822–30. PMID: 9187685.
8. Emmertsen KJ, Laurberg S. Low anterior resection
syndrome score: development and validation of a
symptom-based scoring system for bowel dysfunction after low anterior resection for rectal cancer. Ann
Surg. 2012;255(5):922–8. PMID: 22504191.
9. Atallah S, Albert M, Larach S.Transanal minimally
invasive surgery: a giant leap forward. Surg Endosc.
2010;24(9):2200–5.
10. Buess BF. Local surgical treatment of rectal cancer.
Eur J Cancer. 1995;31A:1233–7.
11. Cataldo PA.Transanal endoscopic microsurgery. Surg
Clin North Am. 2006;86:915–25.
12. Rai V, Mishra N.Transanal approach to rectal polyps
and cancer. Clin Colon Rectal Surg. 2016;29(1):65–70.
13. Althumairi A, Gearhart SL.Local excision for early
rectal cancer: transanal endoscopic microsurgery and
beyond. J Gastrointest Oncol. 2015;6(3):296–306.
14. Whiteford M. Transanal endoscopic microsurgery
(TEM) resection of rectal tumors. J Gastrointest Surg.
2007;11(2):155–7.
38 Functional Outcomes to Transanal Minimally Invasive Surgery (TAMIS) and Transanal Total…
403
15. Khoury R, Duek SD, Issa N, Khoury W. Transanal
endoscopic microsurgery for large benign rectal tumors; where are the limits? Int J Surg.
2016;29:128–31.
16. Darwood RJ, Wheeler JM, Borley NR. Transanal
endoscopic microsurgery is a safe and reliable technique even for complex rectal lesions. Br J Surg.
2008;95(7):915–8.
17. Cataldo PA, O’Brien S, Osler T.Transanal endoscopic
microsurgery: a prospective evaluation of functional
results. Dis Colon Rectum. 2005;48(7):1366–71.
18. Jakubauskas M, Jotautas V, Poskus E, Mikalauskas S,
Valeikaite-Tauginiene G, Strupas K, Poskus T.Fecal
incontinence after transanal endoscopic microsurgery. Int J Color Dis. 2018;33(4):467–72. PMID:
29470728.
19. Allaix ME, Rebecchi F, Giaccone C, Mistrangelo M,
Morino M.Long-term functional results and quality
of life after transanal endoscopic microsurgery. Br J
Surg. 2011;98:1635–43.
20. Mora López M, Serra Aracil X, Hermoso Bosch J,
Rebasa P, Navarro Soto S. Study of anorectal function after transanal endoscopic surgery. Int J Surg.
2015;13:142–7.
21. Kennedy ML, Lubowski DZ, King DW. Transanal
endoscopic microsurgery excision: is anorectal function compromised? Dis Colon Rectum.
2002;45:601–4.
22. Bridoux V, Schwarz L, Suaud L, Dazza M, Michot F,
Tuech J-J.Transanal minimal invasive surgery with
the Endorec(TM) trocar: a low cost but effective technique. Int J Color Dis. 2014;29:177–81.
23. Hompes R, Ashraf SQ, Gosselink MP, van Dongen
KW, Mortensen NJ, Lindsey I, etal. Evaluation of quality of life and function at 1 year after transanal endoscopic microsurgery. Color Dis. 2015;17:O54–61.
24. Restivo A, Zorcolo L, D’Alia G, Cocco F, Cossu A,
Scintu F, etal. Risk of complications and long-term
functional alterations after local excision of rectal tumors with transanal endoscopic microsurgery
(TEM). Int J Color Dis. 2015;31(2):257–66.
25. Dafnis G, Påhlman L, Raab Y, Gustafsson UM, Graf
W. Transanal endoscopic microsurgery: clinical and
functional results. Color Dis. 2004;6:336–42.
26. Albert MR, Atallah SB, deBeche-Adams TC, Izfar
S, Larach SW. Transanal minimally invasive surgery (TAMIS) for local excision of benign neoplasms and early-stage rectal cancer: efcacy and
outcomes in the rst 50 patients. Dis Colon Rectum.
2013;56(3):301–7.
27. McLemore EC, Weston LA, Coker AM, Jacobsen
GR, Talamini MA, Horgan S, Ramamoorthy SL.Am
J Surg. 2014;208(3):372–81.
28. Schiphorst AH, Langenhoff BS, Maring J, Pronk A,
Zimmerman DD. Transanal minimally invasive surgery: initial experience and short-term functional
results. Dis Colon Rectum. 2014;57(8):927–32.
29. Clermonts SHEM, van Loon YT, Schiphorst AHW,
Wasowicz DK, Zimmerman DDE. Transanal
minimally invasive surgery for rectal polyps and
selected malignant tumors: caution concerning
intermediate-term functional results. Int J Color Dis.
2017;32(12):1677–85. PMID: 28905101.
30. Rockwood TH, Church JM, Fleshman JW, Kane RL,
Mavrantonis C, Thorson AG, Wexner SD, Bliss D,
Lowry AC.Patient and surgeon ranking of the severity
of symptoms associated with fecal incontinence: the
fecal incontinence severity index. Dis Colon Rectum.
1999;42(12):1525–32. PMID: 10613469.
31. Clermonts SHEM, van Loon YT, Wasowicz DK,
Langenhoff BS, Zimmerman DDE. Comparative
quality of life in patients following transanal minimally invasive surgery and healthy control subjects.
J Gastrointest Surg. 2018;22(6):1089–97. PMID:
29508218.
32. Sylla P, Rattner DW, Delgado S, Lacy AM. NOTES
transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance.
Surg Endo. 2010;24(5):1205–10.
33. McLemore EC, Harnsberger CR, Broderick RC,
Leland H, Sylla P, Coker AM, Fuchs HF, Jacobsen GR,
Sandler B, Attaluri V, Tsay AT, Wexner SD, Talamini
MA, Horgan S. Transanal total mesorectal excision
(taTME) for rectal cancer: a training pathway. Surg
Endosc. 2016;30(9):4130–5. PMID: 26659246.
34. Penna M, Whiteford M, Hompes R, Sylla
P. Developing and assessing a cadaveric training model for transanal total mesorectal excision:
initial experience in the UK and USA. Color Dis.
2017;19(5):476–84. PMID: 27647728.
35. Veltcamp Helbach M, TWA K, Knol JJ, Velthuis S,
Bonjer HJ, Tuynman JB, Sietses C. Quality of life after
rectal cancer surgery: differences between laparoscopic
and transanal total mesorectal excision. Surg Endosc.
2019;33(1):79–87. https://doi.org/10.1007/s00464-
018-6276-z. Epub 2018 Jul 2. PMID 29967994.
Oncologic Outcomes
SharafKarimPerdawood
39
Grading of TME Specimen
Total mesorectal excision (TME) is considered
the gold standard surgical procedure for mid and
low rectal cancer since Bill Heald described it and
showed dramatic improvements in the long- term
oncologic outcomes [1–3]. Thus, the goal of the
surgery is to achieve a perfect quality TME, where
the mesorectum is excised “totally” as the name
implies. This goal is unfortunately not always
achievable in every case, especially in challenging
cases where there are anatomical factors that render the dissection difcult; prototypically this
occurs when the dissection is performed on an
obese male patient with a narrow pelvic inlet.
With the introduction of TME in the era of open
surgery, perfect specimens could be retrieved by
well-trained colorectal surgeons in most cases,
and data were reproducible in numerous studies.
Even recently, data from open surgery show very
high rates of satisfactory results [4, 5]. With the
available evidence from open surgery, new minimal invasive techniques must be rigorously compared to these standards, as the oncological
quality should never be jeopardized. Ever since
the introduction of laparoscopic surgery, the question of whether it can reproduce the results from
open surgery remains essentially unanswered for
S. K. Perdawood (*)
Slagelse Hospital, Department of Surgery,
Slagelse, Denmark
rectal cancer. With no doubt about the short-term
benets of laparoscopy, the oncologic results continue to be questioned [6–12]. In search for the
optimal method to achieve a perfect TME, technological advances like robotic and transanal surgeries are to be regarded as ongoing efforts to
achieve Heald’s TME in a minimal invasive manner, especially where access to the low rectum is
challenging by other modalities.
Regardless of the approach used, surgeons
must assure that the quality of the TME is as
close to perfect as possible. Fortunately, TME
grading is well-standardized for the excised
specimen. Efforts by pathologists alongside
advances in the surgical technique and the surgeons who help modernize the approach to rectal cancer surgery have led to a standard and
reproducible description of the excised specimens [13–15]. The plane of surgery during
TME constituted an independent factor for
local recurrence in a recent analysis of a randomized clinical trial (P=0.002) [16]. While
rates of “complete” specimens after open TME
are acceptable in most publications from highvolume centers, laparoscopic surgery seems to
lag behind. For this reason, taTME (a minimally invasive technique with improved
access) could show immediate signs of
improvement in the quality of the performed
surgery through an improvement in the rates of
“complete” mesorectal specimen as dened by
Phil Quirke [15].
© Springer Nature Switzerland AG 2019
S. Atallah (ed.), Transanal Minimally Invasive Surgery (TAMIS) and Transanal Total Mesorectal
Excision (taTME), https://doi.org/10.1007/978-3-030-11572-2_39
405
406
S. K. Perdawood
The initial reported cases of taTME demonstrated a remarkably high rate of “complete”
mesorectal envelopes, and some even reported
100% intact TME specimens [17–24]. However,
terms like “satisfactory” or “good” results should
be interpreted with caution of whether the specimens were “complete” or “nearly complete.”
With the increasing adoption of the procedure
and liberal inclusion of difcult cases, a tendency
is seen toward a fall in the rates of specimen “completeness” [25–28]. These studies have showed
rates of “complete” specimens ranging from 47%
to 84%. The largest published series with number
of patients included ranging from 50 to 186 plus
taTME registry data have shown promising results,
with rates of specimen “completeness” that are
comparable with those achieved through standard
laparoscopic approach [28–37] .
In the taTME registry study by Penna et al.
[29], the TME specimen was “complete or near
complete” in 96% of cases (85% complete, 11%
near complete, 4% incomplete). However, patients
were registered from several centers, and there is
probably a case selection bias, especially of the
initial cases. The two reports from Barcelona with
140 and 186 patients are probably overlapping;
nonetheless the series of 186 patients is the largest
published to date [30, 31] . The authors reported
rates of specimen “completeness” of 97.1% and
97.5%. These are without a doubt excellent results
from experienced team that standardized the technique of taTME, which is still considered by most
colorectal surgeons to be a challenging and complex approach. The second largest published
series from one center to date is from Denmark
[34] and shows a rate of 86% specimen “completeness.” Other series have similarly acceptable
rates of at least 84% [28, 32, 37] . A comparative
study by Velthuis etal. (2014) demonstrated that
the TME quality was improved with the taTME
approach versus the laparoscopic approach (96%
vs. 72%, p<0.05) [37].
An apparent conclusion of the investigators
has been that to improved surgical access with
taTME, translated into improved TME quality.
This has been shown to be the case with transanal
dissection in similar fashion without using the
transanal platforms, prior to the advent of the
modern approach to taTME. Marks et al. [37]
reported results of 370 rectal cancer surgeries
where TME was initiated from below. In 96% of
cases, the TME specimen was either “complete”
or “nearly complete.” In conclusion, taTME
seems to overcome difculties in the dissection
of the lowest part of the rectum and may result in
superior TME quality in select cases, although
comparative, randomized trials are still lacking.
Circumferential Resection Margin
One of the most important goals of surgery for rectal cancer is to achieve a free resection margin,
mainly through retrieval of a perfect specimen. The
circumferential resection margin of the mesorectal
specimen has a great prognostic impact on the local
recurrence and distant metastasis [38, 39]. It is the
circumferential resection that is more frequently
involved and is one of the more challenging aspects
of TME surgery. Numerous studies have shown
alarmingly high rates of circumferential resection
margin involvement, worse in tumors located in the
lowest part of the rectum [40–42]. To date, published series of taTME have shown quite acceptable rates of involved circumferential resection
margins. Even in advanced cases of rectal cancer
selected for taTME, Rouanet etal. [19] reported a
free margin in 87% of 30 patients with advanced
rectal cancer. Overall, most studies report no
involved circumferential resection margins; this
can be partly attributed to selection of less challenging cases. The rates of circumferential margin
involvement in the reported series range from zero
to 11.8% [22, 25, 34, 36, 43–47] . Data from the
international registry showed an involved circumferential margin rate of 2.4%; however as a cautionary note, 7.1% of this registry was “not
reported” [29]. With the largest published number
of consecutive cases from a single center, De Lacy
et al. have reported a rate of involved margin of
8.1% (dened as CRM ≤ 1 mm, excluding T4
tumors) [31]. Perdawood et al. [48] have shown
comparable rates of margin involvement among
patients treated by open, standard laparoscopic
and transanal procedures. In analyzing these rates
with those of standard laparoscopic approach, clear
39 Oncologic Outcomes
407
benets of taTME could be demonstrated, showing
at least comparative rates of involvement of circumferential resection margin [49–52]. Finally, in
a randomized trial comparing the transanal
approach to radical rectal resection versus laparoscopic surgery by Denost etal., the rate of circumferential resection margin was signicantly lower
with the transanal approach (4% vs. 18%, p=0.02).
These data suggest that taTME has the potential to improve rectal cancer care, through lower
rates of positive circumferential resection margins when compared to standard laparoscopic
approaches, as realized by most published series
to date. However, this must be interpreted with
caution since they are mostly from centers with
special interest and experience in taTME surgery.
With appropriate training and experience, the rate
of circumferential resection margin positivity
may be lowered by utilizing this novel approach
to radical rectal cancer resection.
Distal Resection Margin
In laparoscopic or open TME, transection of the
rectum is done without direct view of the tumor
itself and these techniques depending on tactile
assessment of the tumor. Potentially, this can lead
to lower anastomosis than necessary. Even worse,
with such top-down approaches, there exists a
real risk of transecting across the tumor and jeopardizing the oncologic outcome of the operation.
This risk can be theoretically eliminated in
taTME, due to direct visualization of the tumor
allowing for a precise transection of the rectal
lumen with a suitable safe margin.
While theoretically the risk of a positive distal
resection margin should be zero, this is not what
has been observed. While registry data suggests
that the distal resection margin positive rate is
quite low (0.3%) [29], other data contradict this
nding. In fact, the rate of positive distal resection margin has been reported to be as high as
8.7% in the center with the most experience with
this approach [53]. While positive distal resection
margins are still inexplicably observed with
taTME for rectal cancer, overall, a longer distal
resection margin is appreciated [54]. In a 2015
study by Fernandez-Hevia etal., the distal resection margin was longer with the taTME approach
when compared to the laparoscopic approach
(2.8 vs. 1.7cm, p<0.01). This is not necessarily
an advantage, and a very low anastomosis can be
the end result, which compromises the functional
outcomes.
Local Recurrence
The most crucial goal of surgery for rectal cancer
is disease-free survival by providing local tumor
clearance. Local cancer recurrence is therefore an
important parameter of the quality of surgery. In
standard laparoscopy, a local recurrence rate of
5% was observed in both laparoscopic and open
TME groups in a randomized clinical trial comparing the two approaches for rectal cancer [55].
The study had locoregional recurrence at 3years
as the primary end-point.
While taTME is still a relatively new procedure and long-term results from the largest series
are not yet available, several cases of local recurrences have already been reported. Rouanet etal.
[19] reported local recurrence in 1 patient out of
30 with an observation period of 21months. The
circumferential resection margin was involved in
this case. Veltcamp et al. reported two cases of
local recurrence among 80 (2.5%) patients who
underwent taTME [32]. The follow-up time was
30months. A similar rate of local recurrence rate
of 2.3% was reported among 140 patients by
Lacy etal. where the mean follow-up time was
15 months [30]. One case of local recurrence
among 32 (3.1%) operated patients was reported
by de ´Angelis etal. [56], and here the follow-up
time was 24months. Burke etal. [35] reported
local recurrence in 2 out of 50 patients (4%) after
a median follow-up period of 15.1months.
After nearly a decade since the introduction of
taTME, more studies to be awaited with special
focus on the long-term results, including local
recurrence. The pattern of recurrence is also an
interesting subject due to the inherent nature of the
procedure that involves transluminal transection,
insufation of CO
retractor with traumatic instruments, and transanal
, xation of the anal sphincter
2
408
S. K. Perdawood
specimen retrieval. All of these can potentially
lead to tumor cell implantation and increase the
risk of local recurrence. One published case of
local recurrence raises the suspicion of implantation similar to port-site metastasis [57], which is
seen in laparoscopic colorectal surgery.
Distant Metastasis
There is slowly emerging data on distant metastases after taTME for rectal cancer. However, the
follow-up periods remain relatively short. Atallah
et al. [25] reported 1 distant metastasis in 20
patients (5%) after a mean 6months of follow up. Lacy etal. [30] found 7.6% metastasis in 140
patients with a follow-up period of 15months.
Buchs etal. [36] found metastases in 6 out of 40
patients (15%). In this study, a case mix is seen,
with a relatively high number of low tumors, and
the complications rate is relatively high despite
acceptable specimen grading quality. Burke etal.
[35] reported 8 distant metastases in 50 patients
(16%) after a follow-up of 15.1 months. Mege
et al. [58] reported metastases of 15% in 34
patients with mean follow-up of 13months.
It is not evident from the literature, whether
these reported metastatic cases occurred in
patients with more advanced cancers or in
patients with a poor quality of the retrieved specimen. Further studies with longer follow-up and
larger patient population can probably give a
clearer picture of the rates and the metastatic pattern after taTME.
References
1. Heald RJ.A new approach to rectal cancer. Br J Hosp
Med. 1979;22:277–81.
2. Heald RJ.The ‘Holy Plane’ of rectal surgery. J R Soc
Med. 1988;81:503–8.
3. Heald RJ, Moran BJ, Ryall RD, Sexton R, MacFarlane
JK. Rectal cancer: the Basingstoke experience of
total mesorectal excision, 1978–1997. Arch Surg.
1998;133:894–9.
4. Fleshman J, Branda M, Sargent DJ, Boller AM,
George V, Abbas M, Peters WR Jr, Maun D, Chang
G, Herline A, Fichera A, Mutch M, Wexner S,
Whiteford M, Marks J, Birnbaum E, Margolin D,
Larson D, Marcello P, Posner M, Read T, Monson J,
Wren SM, Pisters PW, Nelson H. Effect of laparoscopic-assisted resection vs open resection of stage
II or III rectal cancer on pathologic outcomes: the
ACOSOG Z6051 randomized clinical trial. JAMA.
2015;314:1346–55.
5. Stevenson AR, Solomon MJ, Lumley JW, Hewett P,
Clouston AD, Gebski VJ, Davies L, Wilson K, Hague
W, Simes J. Effect of laparoscopic-assisted resection
vs open resection on pathological outcomes in rectal cancer: the ALaCaRT randomized clinical trial.
JAMA. 2015;314:1356–63.
6. Heald R, Moran B, Pahlman L, Christensen HK.
Optimising surgery for rectal cancer. Ugeskr Laeger.
2011;173:1044–7.
7. Heald RJ, Ryall RD. Recurrence and survival after
total mesorectal excision for rectal cancer. Lancet.
1986;1:1479–82.
8. Heald RJ.Laparoscopic resection for colorectal cancer: limitations and concerns. Semin Laparosc Surg.
1995;2:242–5.
9. Heald RJ.Total mesorectal excision is optimal surgery for rectal cancer: a Scandinavian consensus. Br J
Surg. 1995;82:1297–9.
10. Heald RJ. Rectal cancer: the surgical options. Eur J
Cancer. 1995;31A:1189–92.
11. Heald RJ.Total mesorectal excision. Acta Chir Iugosl.
1998;45:37–8.
12. Heald RJ. Total mesorectal excision. The new
European gold standard. G Chir. 1998;19:253–5.
13. Quirke P, Durdey P, Dixon MF, Williams NS.Local
recurrence of rectal adenocarcinoma due to inadequate surgical resection. Histopathological study of
lateral tumour spread and surgical excision. Lancet.
1986;2:996–9.
14. Quirke P, Palmer T, Hutchins GG, West
NP. Histopathological work-up of resection specimens, local excisions and biopsies in colorectal cancer. Dig Dis. 2012;30(Suppl 2):2–8.
15. Quirke P, Steele R, Monson J, Grieve R, Khanna
S, Couture J, O’Callaghan C, Myint AS, Bessell
E, Thompson LC, Parmar M, Stephens RJ, SebagMonteore D.Effect of the plane of surgery achieved
on local recurrence in patients with operable rectal
cancer: a prospective study using data from the MRC
CR07 and NCIC-CTG CO16 randomised clinical
trial. Lancet. 2009;373:821–8.
16. Kitz J, Fokas E, Beissbarth T, Strobel P, Wittekind
C, Hartmann A, Ruschoff J, Papadopoulos T, Rosler
E, Ortloff-Kittredge P, Kania U, Schlitt H, Link KH,
Bechstein W, Raab HR, Staib L, Germer CT, Liersch
T, Sauer R, Rodel C, Ghadimi M, Hohenberger
W. Association of plane of total mesorectal excision
with prognosis of rectal cancer: secondary analysis of
the CAO/ARO/AIO-04 phase 3 randomized clinical
trial. JAMA Surg. 2018;153:e181607.
17. Sylla P, Rattner DW, Delgado S, Lacy AM. NOTES
transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance.
Surg Endosc. 2010;24:1205–10.
39 Oncologic Outcomes
409
18. Zhang H, Zhang YS, Jin XW, Li MZ, Fan JS, Yang
ZH. Transanal single-port laparoscopic total mesorectal excision in the treatment of rectal cancer. Tech
Coloproctol. 2013;17:117–23.
19. Rouanet P, Mourregot A, Azar CC, Carrere S, Gutowski
M, Quenet F, Saint-Aubert B, Colombo PE.Transanal
endoscopic proctectomy: an innovative procedure for
difcult resection of rectal tumors in men with narrow
pelvis. Dis Colon Rectum. 2013;56:408–15.
20. Lacy AM, Adelsdorfer C, Delgado S, Sylla P, Rattner
DW. Minilaparoscopy-assisted transrectal low anterior resection (LAR): a preliminary study. Surg
Endosc. 2013;27:339–46.
21. Velthuis S, van den Boezem PB, van der Peet DL,
Cuesta MA, Sietses C.Feasibility study of transanal
total mesorectal excision. Br J Surg. 2013;100:828–
31. discussion 831.
22. de Lacy AM, Rattner DW, Adelsdorfer C, Tasende
MM, Fernandez M, Delgado S, Sylla P, Martinez-Palli
G.Transanal natural orice transluminal endoscopic
surgery (NOTES) rectal resection: “down-to-up” total
mesorectal excision (TME)--short-term outcomes in
the rst 20 cases. Surg Endosc. 2013;27:3165–72.
23. Leroy J, Barry BD, Melani A, Mutter D, Marescaux
J.No-scar transanal total mesorectal excision: the last
step to pure NOTES for colorectal surgery. JAMA
Surg. 2013;148:226–30. discussion 231.
24. Sylla P, Bordeianou LG, Berger D, Han KS, Lauwers
GY, Sahani DV, Sbeih MA, Lacy AM, Rattner DW.A
pilot study of natural orice transanal endoscopic
total mesorectal excision with laparoscopic assistance
for rectal cancer. Surg Endosc. 2013;27:3396–405.
25. Atallah S, Martin-Perez B, Albert M, DebecheAdams T, Nassif G, Hunter L, Larach S. Transanal
minimally invasive surgery for total mesorectal excision (TAMIS-TME): results and experience with the
rst 20 patients undergoing curative-intent rectal cancer surgery at a single institution. Tech Coloproctol.
2014;18:473–80.
26. Wolthuis AM, de Buck van Overstraeten A, D'Hoore
A.Dynamic article: transanal rectal excision: a pilot
study. Dis Colon Rectum. 2014;57:105–9.
27. Zorron R, Phillips HN, Wynn G, Neto MP, Coelho
D, Vassallo RC. “Down-to-up” transanal NOTES
Total mesorectal excision for rectal cancer: preliminary series of 9 patients. J Minim Access Surg.
2014;10:144–50.
28. Tuech JJ, Karoui M, Lelong B, De Chaisemartin
C, Bridoux V, Manceau G, Delpero JR, Hanoun L,
Michot F. A step toward NOTES total mesorectal
excision for rectal cancer: endoscopic transanal proctectomy. Ann Surg. 2015;261:228–33.
29. Penna M, Hompes R, Arnold S, Wynn G, Austin R,
Warusavitarne J, Moran B, Hanna GB, Mortensen NJ,
Tekkis PP.Transanal total mesorectal excision: international registry results of the rst 720 cases. Ann
Surg. 2017;266:111–7.
30. Lacy AM, Tasende MM, Delgado S, FernandezHevia M, Jimenez M, De Lacy B, Castells A, Bravo
R, Wexner SD, Heald RJ. Transanal total mesorec-
tal excision for rectal cancer: outcomes after 140
patients. J Am Coll Surg. 2015;221:415–23.
31. de Lacy FB, van Laarhoven J, Pena R, Arroyave
MC, Bravo R, Cuatrecasas M, Lacy AM. Transanal
total mesorectal excision: pathological results of 186
patients with mid and low rectal cancer. Surg Endosc.
2018;32:2442–7.
32. Veltcamp Helbach M, Deijen CL, Velthuis S, Bonjer
HJ, Tuynman JB, Sietses C. Transanal total mesorectal excision for rectal carcinoma: short-term outcomes and experience after 80 cases. Surg Endosc.
2016;30:464–70.
33. Chen CC, Lai YL, Jiang JK, Chu CH, Huang IP,
Chen WS, Cheng AY, Yang SH. Transanal total
mesorectal excision versus laparoscopic surgery for
rectal cancer receiving neoadjuvant chemoradiation: a matched case-control study. Ann Surg Oncol.
2016;23:1169–76.
34. Perdawood SK, Thinggaard BS, Bjoern MX. Effect
of transanal total mesorectal excision for rectal
cancer: comparison of short-term outcomes with
laparoscopic and open surgeries. Surg Endosc.
2017;32(5):2312–21.
35. Burke JP, Martin-Perez B, Khan A, Nassif G, de
Beche-Adams T, Larach SW, Albert MR, Atallah
S.Transanal total mesorectal excision for rectal cancer: early outcomes in 50 consecutive patients. Color
Dis. 2016;18:570–7.
36. Buchs NC, Wynn G, Austin R, Penna M, Findlay JM,
Bloemendaal AL, Mortensen NJ, Cunningham C,
Jones OM, Guy RJ, Hompes R.A two-centre experience of transanal total mesorectal excision. Color Dis.
2016;18:1154–61.
37. Velthuis S, Nieuwenhuis DH, Ruijter TE, Cuesta MA,
Bonjer HJ, Sietses C. Transanal versus traditional
laparoscopic total mesorectal excision for rectal carcinoma. Surg Endosc. 2014;28(12):3494–9.
38. Marks JH, Myers EA, Zeger EL, Denittis AS,
Gummadi M, Marks GJ. Long-term outcomes by a
transanal approach to total mesorectal excision for
rectal cancer. Surg Endosc. 2017;31:5248–57.
39. Quirke P, Dixon MF. The prediction of local recurrence in rectal adenocarcinoma by histopathological
examination. Int J Color Dis. 1988;3:127–31.
40. Birbeck KF, Macklin CP, Tifn NJ, Parsons W, Dixon
MF, Mapstone NP, Abbott CR, Scott N, Finan PJ,
Johnston D, Quirke P.Rates of circumferential resection margin involvement vary between surgeons and
predict outcomes in rectal cancer surgery. Ann Surg.
2002;235:449–57.
41. Nagtegaal ID, van de Velde CJ, Marijnen CA, van
Krieken JH, Quirke P.Low rectal cancer: a call for a
change of approach in abdominoperineal resection. J
Clin Oncol. 2005;23:9257–64.
42. Fleshman J. Current status of minimally invasive surgery for rectal cancer. J Gastrointest Surg.
2016;20:1056–64.
43. Nagtegaal ID, Quirke P.What is the role for the circumferential margin in the modern treatment of rectal
cancer? J Clin Oncol. 2008;26:303–12.