Marta Penna

Transanal Total Mesorectal Excision: International Registry Results of the First 720 Cases

Objective: This study aims to report short-term clinical and oncological outcomes from the international transanal Total Mesorectal Excision (taTME) registry for benign and malignant rectal pathology. Background: TaTME is the latest minimally invasive transanal technique pioneered to facilitate difficult pelvic dissections. Outcomes have been published from small cohorts, but larger series can further assess the safety and efficacy of taTME in the wider surgical population. Methods: Data were analyzed from 66 registered units in 23 countries. The primary endpoint was “good-quality TME surgery.” Secondary endpoints were short-term adverse events. Univariate and multivariate regression analyses were used to identify independent predictors of poor specimen outcome. Results: A total of 720 consecutively registered cases were analyzed comprising 634 patients with rectal cancer and 86 with benign pathology. Approximately, 67% were males with mean BMI 26.5 kg/m2. Abdominal or perineal conversion was 6.3% and 2.8%, respectively. Intact TME specimens were achieved in 85%, with minor defects in 11% and major defects in 4%. R1 resection rate was 2.7%. Postoperative mortality and morbidity were 0.5% and 32.6% respectively. Risk factors for poor specimen outcome (suboptimal TME specimen, perforation, and/or R1 resection) on multivariate analysis were positive CRM on staging MRI, low rectal tumor <2 cm from anorectal junction, and laparoscopic transabdominal posterior dissection to <4 cm from anal verge. Conclusions: TaTME appears to be an oncologically safe and effective technique for distal mesorectal dissection with acceptable short-term patient outcomes and good specimen quality. Ongoing structured training and the upcoming randomized controlled trials are needed to assess the technique further.

A systematic review of transanal total mesorectal excision: is this the future of rectal cancer surgery?

The surgical technique used for transanal total mesorectal excision (TaTME) was reviewed including the oncological quality of resection and the peri‐operative outcome.

First international training and assessment consensus workshop on transanal total mesorectal excision (taTME)

The interest and adoption of transanal total mesorectal excision (taTME) is growing rapidly worldwide. This new technique has arisen thanks to advances in minimally invasive surgery and transanal approaches. The ultimate goal of the procedure is to improve clinical, oncological and functional outcomes of rectal excision by obtaining a meticulous TME resection in cancer cases, whilst avoiding injury to surrounding pelvic structures. Transanal TME is a complex procedure and demands excellent, prerequisite surgical skills in order to complete the operation in a safe and efficient manner. The ‘‘bottom-up’’ approach also reveals a completely new viewpoint of the pelvic anatomy for most surgeons. The combination of complexity and unfamiliarity has triggered the occurrence of adverse events, such as urethral injuries [1, 2], which were rarely encountered previously in conventional laparoscopic or open resections. Uptake of a new operation is also associated with a proficiency-gain curve during which there is increased morbidity and mortality [3]. These adverse outcomes during the introduction and dissemination of taTME must be honestly reported, properly analysed and addressed accordingly. Only then can we avoid a ‘‘dip’’ in the adoption curve we saw early on in the laparoscopic experience due to port site metastasis.

Four anastomotic techniques following transanal total mesorectal excision (TaTME)

Abstract Transanal total mesorectal excision (TaTME) is a novel approach pioneered to tackle the challenges posed by difficult pelvic dissections in rectal cancer and the restrictions in angulation of currently available laparoscopic staplers. To date, four techniques can be employed in order to create the colorectal/coloanal anastomosis following TaTME. We present a technical note describing these techniques and discuss the risks and benefits of each.

A two centre experience of transanal total mesorectal excision.

Transanal total mesorectal excision (TaTME) offers a promising alternative to the standard surgical abdominopelvic approach for rectal cancer. The aim of this study was to report a two‐centre experience of this technique, focusing on the short‐term and oncological outcome.

Laparoscopic Lavage Versus Primary Resection for Acute Perforated Diverticulitis: Review and Meta-analysis

Objective: To compare clinical outcomes after laparoscopic lavage (LL) or colonic resection (CR) for purulent diverticulitis. Background: Laparoscopic lavage has been suggested as an alternative treatment for traditional CR. Comparative studies to date have shown conflicting results. Methods: Electronic searches of Embase, Medline, Web of Science, and Cochrane databases were performed. Weighted mean differences (WMD) were calculated for effect size of continuous variables and pooled odds ratios (POR) calculated for discrete variables. Results: A total of 589 patients recruited from 3 randomized controlled trials (RCTs) and 4 comparative studies were included; 85% as Hinchey III. LL group had younger patients with higher body mass index and lower ASA grades, but comparable Hinchey classification and previous diverticulitis rates. No significant differences were noted for mortality, 30-day reoperations and unplanned readmissions. LL had higher rates of intraabdominal abscesses (POR = 2.85; 95% confidence interval, CI, 1.52–5.34; P = 0.001), peritonitis (POR = 7.80; 95% CI 2.12–28.69; P = 0.002), and increased long-term emergency reoperations (POR = 3.32; 95% CI 1.73–6.38; P < 0.001). Benefits of LL included shorter operative time, fewer cardiac complications, fewer wound infections, and shorter hospital stay. Overall, 90% had stomas after CR, of whom 74% underwent stoma reversal within 12-months. Approximately, 14% of LL patients required a stoma; 48% obtaining gut continuity within 12-months, whereas 36% underwent elective sigmoidectomy. Conclusions: The preservation of diseased bowel by LL is associated with approximately 3 times greater risk of persistent peritonitis, intraabdominal abscesses and the need for emergency surgery compared with CR. Future studies should focus on developing composite predictive scores encompassing the wide variation in presentations of diverticulitis and treatment tailored on case-by-case basis.

Developing and assessing a cadaveric training model for transanal total mesorectal excision: initial experience in the UK and USA

Transanal total mesorectal excision (taTME) has become one of the most promising technical advancements in the surgical treatment of rectal cancer, with rising numbers of surgeons seeking training. We describe our experience with human cadaveric courses for taTME delivered in two countries.

Fluorescence to highlight the urethra: a human cadaveric study.

AbstractBackgroundUrethral injury is a complication feared by surgeons performing transanal TME (TaTME) or abdominoperineal excision (APE) procedures. Injury during TaTME occurs when the prostate is inadvertently mobilised or as a direct injury similar to the direct injury during the perineal dissection of APE procedures. We performed a proof of principle study to assess the feasibility of using indocyanine green (ICG) to fluoresce the urethra in human cadavers.MethodsIndocyanine green at varying doses was mixed with Instillagel and infiltrated into the urethra of male human cadavers. The urethra was exposed through either a perineal incision or by mobilisation of the prostate during a TaTME dissection and fluorescence observed using a PINPOINT laparoscope (NOVADAQ). Brightness was assessed on the images using ImageJ (National Institute of Health). ResultsEight cadavers were included in the study. Fluorescence was visualised in the urethra in all eight cadavers. Minimal dissection was required to obtain fluorescence transperineally. In one cadaver, the urethra was demonstrated under fluorescence using a simulated TaTME with additional fluorescence also being observed in the prostate. There was no correlation between brightness and dosing.ConclusionsThis novel proof of principle study demonstrates a simple way in which the urethra may be easily identified preventing it from injury during surgery.

Incidence and Risk Factors for Anastomotic Failure in 1594 Patients Treated by Transanal Total Mesorectal Excision: Results From the International Tatme Registry

Objective: To determine the incidence of anastomotic-related morbidity following Transanal Total Mesorectal Excision (TaTME) and identify independent risk factors for failure. Background: Anastomotic leak and its sequelae are dreaded complications following gastrointestinal surgery. TaTME is a recent technique for rectal resection, which includes novel anastomotic techniques. Methods: Prospective study of consecutive reconstructed TaTME cases recorded over 30 months in 107 surgical centers across 29 countries. Primary endpoint was “anastomotic failure,” defined as a composite endpoint of early or delayed leak, pelvic abscess, anastomotic fistula, chronic sinus, or anastomotic stricture. Multivariate regression analysis performed identifying independent risk factors of anastomotic failure and an observed risk score developed. Results: One thousand five hundred ninety-four cases with anastomotic reconstruction were analyzed; 96.6% performed for cancer. Median anastomotic height from anal verge was 3.0 ± 2.0 cm with stapled techniques accounting for 66.0%. The overall anastomotic failure rate was 15.7%. This included early (7.8%) and delayed leak (2.0%), pelvic abscess (4.7%), anastomotic fistula (0.8%), chronic sinus (0.9%), and anastomotic stricture in 3.6% of cases. Independent risk factors of anastomotic failure were: male sex, obesity, smoking, diabetes mellitus, tumors >25 mm, excessive intraoperative blood loss, manual anastomosis, and prolonged perineal operative time. A scoring system for preoperative risk factors was associated with observed rates of anastomotic failure between 6.3% to 50% based on the cumulative score. Conclusions: Large tumors in obese, diabetic male patients who smoke have the highest risk of anastomotic failure. Acknowledging such risk factors can guide appropriate consent and clinical decision-making that may reduce anastomotic-related morbidity.

St.Gallen consensus on safe implementation of transanal total mesorectal excision

BackgroundThe management of rectal cancer has evolved over the years, including the recent rise of Transanal Total Mesorectal Excision (TaTME). TaTME addresses the limitations created by the bony confines of the pelvis, bulky tumours, and fatty mesorectum, particularly for low rectal cancers. However, guidance is required to ensure safe implementation and to avoid the pitfalls and potential major morbidity encountered by the early adopters of TaTME. We report a broad international consensus statement, which provides a basis for optimal clinical practice.MethodsForty international experts were invited to participate based on clinical and academic achievements. The consensus statements were developed using Delphi methodology incorporating three successive rounds. Consensus was defined as agreement by 80% or more of the experts.ResultsA total of 37 colorectal surgeons from 20 countries and 5 continents (Europe, Asia, North and South America, Australasia) contributed to the consensus. Participation to the iterative Delphi rounds was 100%. An expert radiologist, pathologist, and medical oncologist provided recommendations to maximize relevance to current practice. Consensus was obtained on all seven different chapters: patient selection and surgical indication, perioperative management, patient positioning and operating room set up, surgical technique, devices and instruments, pelvic anatomy, TaTME training, and outcomes analysis.ConclusionsThis multidisciplinary consensus statement achieved more than 80% approval and can thus be graded as strong recommendation, yet acknowledging the current lack of high level evidence. It provides the best possible guidance for safe implementation and practice of Transanal Total Mesorectal Excision.