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_894_Библиотеки_им_академика_М_И_Перельмана.pdf
402
C. Ianiro et al.
full mechanical bowel preparation, with or without enemas is also recommended to keep the
endoluminal surgical eld free of fecal debris. In
the US, TES procedures are typically performed
as ambulatory surgery cases, and patients are
admitted for observation if and when complex
peritoneal entry was noted and repaired.
Procedures are usually performed under general
anesthesia, although there have been reports of
TAMIS performed under spinal anesthesia [50].
Patients are typically positioned in lithotomy
position regardless of tumor orientation. However
in case of high-risk anterior and lateral rectal
tumors, namely located ≥8cm from the AV, with
high probability of peritoneal entry during fullthickness dissection, patients are usually placed
in prone position using a split-leg table.
Following insertion and set up of the rigid
TEO, TEM or TAMIS platform, the rectum is
distended to 12–15 mmHg with CO2. After
achieving adequate pneumorectum and visualization, the rectal lesion is scored circumferentially
with electocautery mark with a 0.5–1cm circumferential margin (Fig.22.3a). The lesion is then
dissected full-thickness using monopolar cautery
and/or bipolar energy, until the perirectal fat or
mesorectum is reached (Fig.22.3b). Of note, dissection can be greatly facilitated by the use of
angled and exible-tip laparoscopic instruments,
which help reduce instrument crossing and collision. Another important recent addition to the
TES armentarium has been the use of specialized
high-ow insufation and smoke evacuation systems that help maintain a stable pneumorectum
and clear eld of view in the face of heavy smoke
and uctuations in CO
pressures. The TEM plat-
2
form is equipped with its own integrated automatic pressure-controlled CO2 insufation
system, and the Airseal insufation system
(SurgiQuestInc, Milford, CT, USA), which provides a continuous ow circuit that evacuates
CO2 and smoke and quickly recirculates ltered
and high-pressure CO2, helps main a stable pneumorectum at all time and has become the most
commonly platform during TAMIS.
Following dissection, the lesion is then
extracted transanally, oriented with sutures on a
at surface for pathologic assessment, and the
rectal defect is closed with sutures (Fig.22.3c–f).
In addition to standard intracorporeal suturing
with a laparoscopic needle holder, there are several suturing devices and materials commercially
available to facilitate endoluminal suture closure
such as the Endo Stich™ device (Medtronic,
Manseld, MA), and the Cor-Knot device (LSI
Solutions, Victor, NY) Air-tight closure can be
achieved using continuous and/or interrupted
absorbable monolament sutures or permanent
sutures, with or without the assistance of clips,
silver bullets (Richard Wolf), or self-locking
barbed sutures (V-loc, Medtronic).
Mean operative time in large TEM and TEO
series typically range from 70 to 95 min [103–
105] with variations primarily related to size of
lesions, depth of resection (submucosal vs. fullthickness), distance from the anal verge, complexity of the suture closure, and the learning
curve effect. Although one of the quoted advantages of TAMIS was shorter operative set-up and
OR time relative to TEM/TEO, among published
TAMIS series (N = 12–75), the mean OR time
ranges from 45 to 123min, with the largest series
reporting OR time of 76 and 77min respectively
(Table 22.1) [32–50]. There has not been any prospective comparative trial of TEM, TEO and
TAMIS published to date.
Intraoperative Complications
Intraoperative complications of TES are fairly
uncommon but include bleeding, adjacent organ
injury, complicated peritoneal entry and conversion. The most common intraoperative challenges, particularly for the novice, are related to
technical difculties establishing, or maintaining
adequate pneumorectum during the case. CO2
leakage during TES results in suboptimal rectal
distention and exposure, the sources of which
must be sought then corrected. Typical causes of
CO2 leakage include dislocation or malpositioning of the transanal platform, leakage around the
platform, which necessitates either suture xation to the perianal skin (TAMIS) or repositioning of the platform (TEM/TEO). It is also
important to verify that the platform has been
22 Rectal Carcinoma: Operative Treatment, Transanal
a b
403
c
e
d
f
Fig. 22.3 Procedural steps of transanal endoscopic surgery. The lesion is marked circumferentially with monopolar cautery (a). The lesion is dissected full-thickness
through the rectal wall down to the mesorectum or perirectal fat (b). The lesion is resected en-bloc (c) and passed
off the eld (d). Full thickness rectal defects are closured
using sutures or a suturing device (e). Additional sutures
are placed as needed until complete air-tight closure is
achieved (f)
404
C. Ianiro et al.
correctly assembled, and that inner and outer rubber TEM/TEO ports have not been damaged or
displaced. Finally, the patient should remain
completely paralyzed until completion of the
case, as patient movement causes impairment of
pneumorectum and exposure. In the event of sudden loss of pneumorectum during the case, it is
important to ensure that there hadn’t been leakage of CO2 from an unrecognized rectal defect
into the peritoneal cavity which would require
prompt closure.
Bleeding during full-thickness rectal dissection can usually be controlled with monopolar
cautery or bipolar energy. Laparoscopic clips and
sutures can also be used to control bleeding vessels. Adjuncts such as gauze and laparoscopic
suction tip are essential to avoid rapid accumulation of blood in an already narrow eld.
Although rare, TES can result in visceral
organ injury, including injury to structures anterior to the rectum including the vagina, prostate,
bladder, and urethra, which, if not recognized and
repaired promptly, often results in pelvic or perirectal abscesses and delayed rectovisceral stulas. In addition, peritoneal entry can result in
inadvertent injury to the colon and small bowel
during attempted suture closure of the rectal
defect. In their series of 402 TEM cases, Guerrieri
etal. have reported 2 cases of urethral injury during TEM resection of anterior-based rectal
lesions [106]. Among one of the largest TAMIS
series published to date (N = 15), Keller et al.
reported one occurrence of a rectovaginal stula
resulting from a cautery injury, which was managed non-operatively [107].
Peritoneal Entry
The management of peritoneal entry (PE) during
TES, either unplanned or anticipated based on
location and/or extent of the rectal lesion, remains
controversial. Earlier TEM reports considered PE
to be a complication requiring conversion to
abdominal procedure with abdominal lavage,
radical resection with or without fecal diversion
due to concern of peritonitis from bacterial contamination [108, 109]. From an oncologic stand-
point, PE during TEM for rectal cancer was also
feared to increase the risk of tumor cell spillage
and thus the risk of peritoneal tumor implants
[69]. With further experience, however, these
concerns have not been realized. Recent TEM/
TEO series have reported an incidence of PE
ranging from 0 to as high as 32.5%, but across
larger TEM series from experienced centers
(N≥300), the rate of PE ranges 5–10.7% [110,
111]. The studies have highlighted risks factors
for PE which include full-thickness resection of
lesions located in the upper rectum, anteriorly or
laterally along the rectal wall, and during resection of circumferential or near-circumferential
rectal lesions [112, 113]. With regards to the
morbidity associated with PE, several studies
have reported no differences in the incidence of
infectious complications or other adverse events
in TEM cases with vs. without PE [114–116].
Finally, several studies have demonstrated no
adverse short or long-term oncologic outcomes
in patients in whom peritoneal entry occurred
during TEM excision of rectal tumors [70, 104].
Morino et al. followed 13 patients with rectal
adenocarcinoma in whom peritoneal perforation
occurred during TEM [115]. At a median followup of 48months (range 12–150), there were no
reports of distant metastasis. Two patients with
T2 and T3 tumors developed local recurrences
and subsequently died from disease progression.
Based on these studies, TES experts do not consider tumor location 10cm or more from the anal
verge to a contraindication to TEM, as long as
full-thickness suture closure of rectal defects can
be achieved transanally by experienced operators
[112–114, 117, 118].
It is important to note however that entry into
the peritoneal cavity, with subsequent difculty
maintaining adequate pneumorectum and visualization due to leakage of CO2 into the abdominal
cavity, presents a considerable technical challenge to the surgeon. This occurrence, which is
commonly referred to as complicated PE [118],
is associated with a higher risk of conversion to
an abdominal procedure and/or fecal diversion.
For lesions that are at high-risk for PE
during full-thickness dissection, patients should
preemptively be placed in prone position to help
22 Rectal Carcinoma: Operative Treatment, Transanal
405
mitigate the loss of pneumorectum resulting from
leakage of CO2 into the peritoneal cavity [115].
This maneuver permits the surgeon to maintain a
stable pneumorectum and facilitate adequate closure of the rectal wall defect. Other strategies to
compensate for loss of pneumorectum into the
peritoneal cavity include decompressing the
pneumoperitoneum with a veress needle or trocar. Over time, and in experienced centers as
demonstrated in the largest TEM and TEO series,
conversion rates following peritoneal entry have
steadily decreased, with conversion rates ranging
from 0 to 40% but averaging 10% or less [115].
Loss of pneumorectum and rectal luminal collapse, which occurs with PE is greatly mitigated
when using the rigid TEM and TEO platforms.
With regards to the occurrence and management
of PE during TAMIS, which lack the rectal stenting ability of rigid platforms, a review of 390
TAMIS procedures for rectal lesions located at an
average of 7.6cm from the AV, reported inadvertent PE in only 4 cases (1.025%) [119]. All 4
cases of PE occurred during dissection of upper
rectal lesions and 2 (50%) could be closed transanally while the others required abdominal conversion. Only four TAMIS series that include 32–75
patients, have reported an incidence of PE ranging
from 2 to 9.4% [32, 34, 49, 107]. Among the 10
cases of PE during TAMIS across all 4 studies, 6
required conversion to laparoscopy or laparotomy
from inability to effectively close the rectal wall
defect, and while in 2 cases, the defect could be
closed transanally, patients were diverted with a
loop ileostomy [107] This relatively high incidence of conversion and/or diversion following
PE during TAMIS may reect the long learning
curve required for managing these complex rectal
lesions, and the currently small experience with
TAMIS to date. But it may also reect technical
limitations of shorter TAMIS platforms, which do
not always permit adequate retraction and exposure of the proximal rectum [118]. Molina etal.
reviewed their experience with incidence of PE
among various TES modalities including 51 TEO,
21 TEM and 6 TAMIS cases. PE occurred in
28.2% of cases involving high-risk anterior/lateral
lesions located an average of 13.1cm from the
anal verge. Interestingly, PE occurred in 4/6 of
TAMIS cases compared to 18/72 of TEM/TEO
cases. Although transanal suture closure of PE
defects could be performed in 90.9% of cases, this
could be accomplished with TEM and TEO platforms, but not with TAMIS platforms. All 4
TAMIS cases with PE were converted to TEO for
suture closure, due to the inability to maintain
adequate exposure through the shorter TAMIS
platforms. Conversion to laparoscopic LAR and
Hartmann’s procedure was required in 2/18 TEM/
TEO cases (11.1%) TEM/TEO cases with PE,
which is consistent with previously reported TEM
conversion rates [118].
Conversion
Conversion to TAE or LAR may be required in
cases where adequate exposure of rectal lesions
cannot be achieved or maintained, full-thickness
rectal wall defect closure cannot be completed,
when unexpected advanced pathology is encountered, or in cases of major intraoperative complication such as major bleeding or organ injury.
Abdominal conversion is more likely to occur
with proximal and circumferential rectal lesions,
and is strongly related to the operator’s learning
curve with advanced TES techniques. In the largest multicenter TEM/TEO series published to
date, among 693 cases, conversion to TAE or
abdominal procedures was required in 4.3%
[110], which is consistent with the 0–5.3% conversion rates reported in large TEM/TEO series
from experienced centers [104, 116, 120, 121].
Low rectal lesions, which are obscured by the
TAMIS platform, will need to remove the TAMIS
platform to complete the distal dissection and
defect closure using TAE technique, partially
detracting from the benets of TES.
Positive Margins
Positive resection margins are an important predictor of local recurrence for malignant rectal
lesions and, along with specimen fragmentation,
constitute an important metric of the quality and
efcacy of local excision including TAE and
406
C. Ianiro et al.
TEM.Positive resection margins strongly correlate with local recurrence of rectal adenomas.
With respect to rectal cancers resected using
TEM, positive margin rates range across TEM
and TEO series from less than 2% to as high as
8.8% [57, 96, 104, 105, 111]. Across TAMIS
series, rates of positive margins also vary but
have generally been 6% or less for larger series
that typically include both benign and malignant
pathologies (Table22.1) [32–50]. In a meta-analysis of 6 studies that compared perioperative and
oncologic outcomes following TAE vs. TEM for
rectal neoplasms (adenomas and cancer), TEM
was associated with a higher rate of negative
resection margins (OR 5.28), reduced incidence
of specimen fragmentation (OR 0.10), and lower
rate of local recurrence (OR 0.25) relative to TAE
[24]. While this meta-analysis was limited by the
retrospective design of the studies, heterogeneity
in tumor type, size and stage, and lack of standardized follow-up schedule for assessment of
LR, it conrms the superiority of TES over TAE
for the local excision of rectal neoplasms with
improved local control achieved through the use
of transanal endoscopic platforms [24].
and 18–55% respectively for TME (Tables 22.1,
22.2, and 22.3). In additional, the majority of
TES-related complications are relatively minor
and transient and major complications are noted
in 10% or less of cases [104, 108, 121–123].
The most common postoperative surgical
complication following TES is hemorrhage,
which is reported in 1 to 13% of patients, and is
usually managed conservatively. The most common non-surgical complication is urinary retention, which occurs in 5–10% of patients [104,
111, 121, 124]. With regards to TAMIS, the pub-
lished rate of perioperative complications range
0–25%, with bleeding and urinary retention being
the most common complications as well [29,
104, 111, 121]. In a review of published TAMIS
series between 2010 and 2013, a total of 29 complications were reported among 367 patients
(7.9%) [47]. The incidence of bleeding and suture
dehiscence was 2.7% and 0.5% respectively, and
conversion to TAE, TEM or laparoscopic
abdominal approach was required in 2.3%. There
were no deaths reported following TAMIS, and
the average length of hospital stay was 1.9days.
Functional Outcomes
Postoperative Complications
Several studies have demonstrated that patients
A major advantage of TES is the exceedingly low
morbidity and mortality rates achieved relative to
TME. Mortality across TEM, TEO and TAMIS
series remains <1% with 30-day morbidity rates
ranging 6–23% in the largest TEM/TEO series
(N = 262 to 693 patients) relative to historical
30-day mortality and morbidity rates of 2–5%
Table 22.2 Outcomes after TEM for T1 rectal cancer vs. TME
Author TEM:TME (n)
Heintz etal. [84] 58:45 2:8 0:2 6:1 75.5:78.1
Lee etal. [86] 74 (T1 52,
T22): 100 (T1
17, T2 83)
Ptok etal. [159] 120 (TAE 85,
TEM 35):359
De Graaf etal. [122] 80:75 5:48 0:3 15:0 75:77
Palma etal. [158] 34:17 5:12 0:1 2:0 82.3:82.3
Morbidity
TEM:TME (n)
4.1%:48% TEM<TME (T1 only) 2:0 (T1 only)
11:82 0:0 6:2 83.6:91.5
without pre-existing anal sphincter dysfunction, can experience a transient decrease in
resting anal and contractile pressures following TEM/TEO, with no impact on long term
anorectal function. Multiple small TEM studies have documented a transient decrease in
sphincter resting pressures on anal manometry
Mortality
TEM:TME (n)
5 year LR
TEM:TME (n)
5 year survival
TEM:TME (%)
100:92.9
22 Rectal Carcinoma: Operative Treatment, Transanal
407
Table 22.3 NCCN guidelines for transanal excision of
rectal cancer [68]
T1 lesion
Well to moderately differentiated adenocarcinoma
No lymphovascular invasion
No perineural invasion
Less than 3cm in diameter
Occupying less than 1/3 circumference of the lumen
Mobile, non-xed
Within 8cm of the anal verge
Anticipated clear Margin (>3mm)
that was proportional to the duration of the
procedure, with resting pressures returning to
baseline 12months postoperatively [124–127].
Alterations in resting anal sphincter pressures
did not translate into any detrimental effects on
continence. In a study of 41 TEM cases,
Cataldo etal. 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 [128]. 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 12 weeks, but returned to baseline at
26 weeks. Similar to prior studies, anorectal
function as assessed by colorectal functional
outcome (COREFO) was worse at 6 weeks
postoperatively, but returned to baseline at
12weeks postoperatively [129]. However, two
TEM series reported persistent sphincter dysfunction following TEM in on long term
assessment using either St. Mark’s fecal incontinence score or Wexner and Kamm incontinence scores [130, 131]. 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 [131]. Restivo etal. also
reported a 28% incidence of variable degrees
of fecal incontinence at a median follow-up of
40months among a cohort of 89 patients who
underwent TEM. Preoperative radiotherapy
and perioperative complications were found to
be independent risk factor for functional disturbances [130]. In a small prospective study
conducted by Schiphorst etal., functional outcomes following TAMIS were assessed in 37
patients using FISI score preoperatively and at
3, 6, 9 and 12 months postoperatively [43].
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 were found in 83%,
suggesting preserved long-term anorectal function following TAMIS procedures.
Future Directions: Transanal TME (TATME)
One of the most exciting advances in transanal
endoscopic surgery has been the evolution of
transanal Natural Orice Transluminal
Endoscopic Surgery (NOTES). The transanal
approach offers the possibility of “incisionless”
colorectal resection, whereby rectal and/or
colon dissection followed by specimen
extraction is performed primarily through the
anus. Transanal TME has evolved from the
“open” transanal transabdominal approach
(TATA). The addition of a transanal endoscopic
surgery platform signicantly expanded the
proximal reach of the distal TME dissection.
Low rectal tumors abutting the anorectal ring
and that are eligible for sphincter-preserving
LAR can be extraordinarily difcult to resect
with negative distal and circumferential margins
and intact mesorectal fascia, particularly in
patients with visceral obesity. This is largely
due to difculties with effective tissue traction
and counter-traction and optimal positioning of
the linear stapler in the deep and narrow male
pelvis. These difculties that have not been
entirely overcome by the use of a laparoscopy as
reected by CRM positivity rates persistently
nearing 10% and conversion rates ranging
8–29% in the most recently large randomized
trials of open vs. laparoscopic TME for rectal
cancer [12–14].
408
C. Ianiro et al.
As in TATA, transanal dissection in taTME is
initiated by delineating the planned distal resection margin and placing a purse string suture to
occlude the rectum 1cm below the tumor. When
the tumor is near the dentate line, intersphincteric
resection, either partial or complete, is carried
out rst, followed by full-thickness dissection of
the rectum and mesorectum (Fig. 22.4). This
“bottom-up” approach has several advantages
over traditional abdominal procedures,
particularly when used for mid-and low rectal
tumors. In addition to improved tissue retraction
and exposure relative to traditional anal retractors
using during TATA, transanal platforms are
equipped with HD and even 3D optics, which, in
combination with CO2 distention and effective
Fig. 22.4 Procedural steps of transanal TME. Following
distention of the rectum with CO
form, the rectum is occluded with a suture below the rectal
tumor and the rectal mucosal is scored circumferentially
with monopolar cautery (a). Full-thickness rectal dissection is carried out circumferentially (b) and extended cephalad. The mesorectum is dissected posteriorly along the
plane between the mesorectal fascia and the endopelvic
through the TES plat-
2
fascia (c). Anterior and lateral mobilization of the rectum
is extended cephalad, making sure not to injure the posterior vaginal wall, prostate and pelvic sidewall nerves (d).
Dissection is extended cephalad until the peritoneal reection is reached and divided anteriorly (e). taTME specimen
following completion of laparoscopic-assisted transanal
TME dissection
22 Rectal Carcinoma: Operative Treatment, Transanal
Fig. 22.4 (continued)
409
smoke evacuation, greatly enhance visualization
of tissue planes. Multiple dissecting instruments
can be inserted through the multiport platform
and optimally positioned to carry out mesorectal
dissection with signicantly less encumbrance
from anterior structures such as the bladder, or
uterus, and unobstructed access to the rectoprostatic/rectovaginal plane, and lateral pelvic sidewalls. While taTME dissection can be performed
prior to or following abdominal left colonic
mobilization and vessel transection, it can also
be performed with a 2-team approach, i.e.
simultaneously with the abdominal procedure,
with the advantage of combined input and
guidance with dissection along the correct planes,
and a potentially shorter operative time. Finally,
when transanal specimen extraction is feasible,
the abdominal extraction site can be eliminated,
and standard coloanal or colorectal reconstruction
can be carried out.
Since the rst case report of laparoscopicassisted transanal TME for rectal cancer in 2010,
over 600 cases reports and series of pure and
hybrid transanal TME with LAR or APR for
benign and malignant indications have been
published to date, with the largest series by Lacy
etal. from 2015 which included 140 consecutive
patients (Table 22.4) [43, 132–150] Although
these clinical series include substantial variations
in patient selection, surgical techniques, duration
of follow-up and outcome measures, review of
the cumulative results from the largest taTME
series demonstrate favorable outcomes with
respect to procedural safety and preliminary
oncologic and functional outcomes in carefully
selected patients (Table 22.4) [142–150]. Two
recently published systematic reviews of 510
and 449 taTME cases by Similis et al. and
Arunachalam et al. respectively, reported an
overall morbidity of 34%, 30-day mortality rate
<1%, mean OR time ranging 143–450 min, a
2.3% conversion rate to open surgery [151, 152].
Conversion was attributed to unfavourable rectal
tumors, severe abdominal adhesions, difculties
related to visceral obesity, and organ injury.
Intraoperative complications during transanal
dissection include bleeding and organ injury
namely three cases of urethral injuries, as well as
rectal, bladder and ureteral injury. Anastomotic
leak rates ranged 6.1–9.1% [143, 153] and
reoperation was needed in 3.7–9.1% for pelvic
abscess, anastomotic leaks, small bowel
obstruction and ischemic conduit. The mean
LOS ranged 4.3–16.6 days. With respect to
oncologic outcomes, among the 510 cumulative
taTME cases reported by Similis et al., the
mesorectum was graded as complete or nearly
complete in 88% and 6% respectively with a
negative CRM in 95% and negative distal
margins in 99.7%.
410
Rate of
+ve
Rate
of +ve
Follow up
(months)
21
12 (not
CRM
(n) LR (n) DR (n)
DM
(n)
Morbidity
rate
30.0% 0 4 12 (not
specied)
specied)
39.0% 0 2 2 0 <24
36.0% 1 2 2 8 15.1
20.0% 0 2 NR NR NR
C. Ianiro et al.
32.6% 2 14 NR NR 1
IntraOp complication rate
(n)
embolism (1)
LAR:APR:
P:IAPR:HAR
Abdominal
approach Platform
Table 22.4 Short-term outcomes for published taTME series with >30 patients
Author Patients (n)
52:4:0:0 0 26.0% 0 3 1 2 29
Endorec
Trochar,
SILS port,
GelPoint
path
(8), open (4),
RA (1)
30 LA TEO 30:0:0:0 Urethral injury (2), air
56 LA (41), SILS
Rounet etal.
[143]
Tuech etal.
[144]
140 LA GelPoint 138:0:2:0 0 34.3% NR 9 1 8 15
Lacy etal.
[142]
32 LA, SILS GelPoint 32:0:0:0 0 25.0% 2 1 1 1 36
De’Angelis
(3)
65:15:0:0 Bleeding (2), perforation
GelPoint
path
80 LA, SILS SILS port,
etal. [149]
Veltcamp
32 LA TEO 32:0:0:0 0 31.0% 0 0 NR NR 1
Helbach
etal. [145]
Serra-Aracil
etal. [146]
ureteral injury (1), iliac
vessel injury (1)
vaginal injury (1)
Urethral injury (5),
GelPoint 43:6:1:0 Urethral injury (1),
(14), HA (19),
RA (10)
50 Open (4), LA
Burke etal.
[147]
NR (Cancer cases)
Open (21), LA
50 LA, SILS GelPoint 50:0:0:0 Presacral bleeding (2),
720
Chen etal.
[148]
Penna etal.
bladder injury (2), vaginal
perforation (1), unilateral
resection of hypogastric
nerves (1), rectal
perforation anastomosis
(2)
537:14:0:42:30
(553), SILS
(93), robotic
(4), missing
(49)
(cancer:
634,
benign:
86)
[150]
LA laparoscopic assisted, HA hand assisted, RA robotic assisted, TEO transanal endoscopic operation, SILS single incision laparoscopic surgery port, Gelpoint GelPOINT path
transanal access platform, NR not reported, LAR low anterior resection, APR abdominoperineal excision, P proctocolectomy, IAPR intersphincteric APR, HAR high anterior
resection, LR local recurrence, DR distant recurrence
22 Rectal Carcinoma: Operative Treatment, Transanal
411
These published results were corroborated in
the recently published rst international taTME
registry that included 720 taTME cases, 634 of
which were performed for rectal cancers [150].
The majority of patients were male (68%) with
a mean age of 62.4years and BMI of 26.5kg/
m2. The median tumor height from anorectal
junction on MRI was 3cm and 57% received
neoadjuvant therapy. The overall morbidity and
mortality rates at 30-days were 32.6% and 0.5%
respectively which are similar to those reported
in previous TME trials and other large taTME
studies [12–14, 154]. Abdominal conversion
was noted in 6.3%, 5 cases of urethral injuries
were reported, and the anastomotic leak rate
was 6.7%. With respect to oncologic outcomes,
R0 resection was achieved in 97.3% and the
mesorectum was graded as complete or near
complete in 96% [150], which compares favourably with the 7–12.1% rate of positive CRM
reported in the previous randomized trials of
laparoscopic vs. open TME [12–14, 154].
Overall, while short-term oncologic results
from taTME series compare favorably to historical laparoscopic and open TME outcomes, longterm oncologic outcomes remain scarce. In one
series of 30 taTME performed for locally
advanced low rectal tumors, at a median follow-up
period up of 29 months (range, 18–52), Tuech
et al. reported an OS of 96.4%, DFS of 94.2%,
and local recurrence rate of 1.7% [144]. Likewise,
data on functional results following taTME are
limited with only 4 studies reporting Wexner
scores 3–12months post-taTME [143, 155–159].
While no prospective comparative study
or randomized controlled trial of transanal vs.
laparoscopic TME has yet been published, the
cumulative published evidence thus far suggests that when performed by well-trained and
experienced surgeons, and offered to appropriately selected patients, taTME with laparoscopic
assistance is equivalent to laparoscopic TME and
may become the procedure of choice for low
rectal tumors in order to minimize the risk of
conversion, incomplete TME and R1 resection.
Currently, two prospective, randomized trials (Us
taTME and COLOR III) comparing taTME to
other minimally invasive approaches are ongoing
(https://www.clinicaltrials.gov/ct2/show/NCT
03144765?term=PATRICIA+SYLLA&rank
=1 and https://www.clinicaltrials.gov/ct2/show/
NCT02736942?term=COLOR+III&rank=1).
Proposed Training Pathways
forTATME
TaTME is emerging as a useful technique to
overcome many of the limitations of traditional
TME from an abdominal approach. Early
experience has revealed that a new skill set is
required to gain an understanding of the novel
anatomical landmarks from an inverted approach
[160], the fundamental steps of the procedure,
and the increased complexity of laparoscopic
surgery in the most challenging of conditions
with patients that are morbidly obese, male, have
large prostates, and have irradiated, low rectal
cancers. Add to this the more extensive nature of
the full thickness and circumferential transanal
dissection and signicantly increased risk of
technical misadventures during taTME which is
considerably more difcult that typical TES
excision of a rectal polyp. It is for these reasons
and reports of complications in early case series
[143] that international consensus panels have
expressed patience and caution in adopting
taTME into clinical practice through structured
and supervised training [161]. McLemore
proposed six prerequisite skills for the potential
taTME surgeon to possess: (1) expertise in TME
for rectal cancer, (2) expertise in minimally
invasive TME from the abdominal approach, (3)
expertise in transanal endoscopic surgery (TEM
or TAMIS), (4) expertise in intersphincteric
(transanal transabdominal/TATA) dissection for
very low rectal invasive neoplasms, (5) practice
in taTME techniques in human cadaver models,
and (6) IRB approved data collection with
publication of outcomes and/or participation in a
clinical registry. European (http://www.lorec.
nhs.uk or https://tatme.medicaldata.eu/) and
United States (https://tatme.ostrichconsortium.
org) registries are currently available.