Series
N
Age (year)
Gender
BMI (kg/m2)
Tumor location
Neoadjuvant CRT
Operative technique
Veltcamp Helbach et al. [41]
80
66.5 (42–86)
M (48), F (32)
27.5 (19.5–40)
5.3 (1–10) cm from DL
Yes (65) No (15)
LA, SILS
Lacy et al. [43]
140
65.5 + 12.7
M (89), F (51)
25.2 + 3.9
7.6 + 3.6 cm from AV
Yes (94) No (46)
LA
Tuech et al. [44]
56
65 (39–83)
M (41), F (15)
27 (20–42)
4.0 (0–5) cm from AV
Yes (47) No (9)
LA (41), SILS (8), laparotomy (4), RA (1)
Muratore et al. [45]
26
66 (38–84)
M (16), F (10)
26.2 (16.9–38.2)
4.4 (3–6) cm from AV
Yes (19) No (7)
LA, SILS
Serra-Aracil et al. [46]
32
68 (39–88)
M (24), F (8)
25 (20–35)
8.0 (5–10) cm from AV
Yes (16) No (16)
LA
Rouanet et al. [47]
30
65 (43–82)
M (30)
26.0 (21.0–32.4)
<5 cm from AV (20), 5–10 cm from AV (10)
Yes (29) No (1)
LA
Atallah et al. [71]
50
56.5 (50.0–65.0)
M (30), F (20)
26.0 (22.7–31.2)
4.4 (3.0–5.5) cm from AV
Yes (43) No (7)
Open (4), LA (14), HA (19), RA (10)
Chouillard et al. [49]
16
57.7 (34–81)
M (6), F (10)
27.9 (21–38)
Mid- or low rectal tumors
NR
SILS, pure
Chen et al. [50]
50
57.3 (29–80)
M (38), F (12)
24.2 (16–37)
5.8 (2–10) cm from AV
Yes (50)
LA, SILS
De’Angelis et al. [54]
32
64.9
M (21), F (11)
25.19
4.0 (2.5–5) cm from AV
Yes (27) No (5)
LA
Perdawood et al. [51]
25
70 (54–76)
M (19), F (6)
28 (18–46)
8.0 (4–10) cm from AV
Yes (7) No (18)
LA
Buchs et al. [52]
20
59.3 (32–87)
M (14), F (6)
27.1 (17.4–38.4)
2.0 (0–7) from anorectal junction
Yes (6) No (14)
LA, RA
Kang et al. [53]
20
58.6 (36–84)
M (12), F (8)
22.2 (16.7–27.5)
6.1 (3–12) cm from AV
Yes (6) No (14)
LA, SILS, pure
Transanal platform | Type of resection | Operating time (min) | Final stage (n) | Number of lymph nodes collected | TME quality | Positive distal margin | Positive CRM |
|---|---|---|---|---|---|---|---|
SILS port (Covidien USA); GelPoint (applied medical) | LAR 65, APR 15 | 204 (91–447) | ypT0 (6), ypT1 (3), ypT2 (29), ypT3 (42), N0 (44), N1 (21), N2 (15) | 14 (6–30) | 71 complete, 7 near complete, incomplete 2 | 0 | 2 |
GelPoint (applied medical) | LAR 138, 2 proctocolectomy w IPAA | 166 (60–360) | Complete response (15); stage I (34); stage II (43); stage III (39); stage IV (9) | 14.7 + 6.8 | Complete 136; nearly complete 3; incomplete 1 | N/R | 9 (6.4%) |
Endorec (aspide) (42), SILS port (Covidien) (11), GelPoint (applied medical) (3) | APR 4, LAR 52 | 270 (150–495) | NR | 12 (7–29) | 47 complete, 9 nearly complete, 0 incomplete | N/R | 3 |
SILS port (Covidien) | LAR 25, APR 1 | 241 (150–360) | pT0 (5), pT1 (7), pT2 (6), pT3 (8), pN+ (7) | 10 (median 8) | 23 complete, 3 near compete | 0 | 0 |
TEO (Storz) | LAR 32 | 240 (165–360) | Stage 0 (2), stage I (7), stage II (10), stage III (12), stage IV (1) | NR | 30 complete; 2 near complete | 0 | 0 |
TEO (Storz) | LAR 30 | 304 (120–432) | pCR 0, pT1 (1), pT2 (8), pT3 (18), pT4 (3), pN0 (14), pN1 (13), pN2 (3) | 13 (8–32) | 30 complete | 0 | 4 |
GelPoint (applied medical) | APR 7 (12%), LAR 43 (86%) | 267 (227–331) | pCR (12), pT1 (2), pT2 (11), pT3 (21), pT4 (4); N0 (34), N1 (8), N2 (8) | 18 (12–24) | 36 complete, 13 near complete, 1 incomplete | 1 (2%) | 2 (4%) |
SILS port (Covidien) | LAR 14, APR 2 | 265 (155–440) | pTy (1), pT1 (3), pT2 (4), pT3 (7), pT4 (1); N0 (11), N1 (4), N2 (1) | 17 (12–81) | 16 complete | 0 | 0 |
GelPoint (applied medical) | LAR 50 | 182.1 + 55.4 | ypT1/T2N0 (13); ypT3/T4N0 (12); ypTanyN1-2 (17), pCR (8) | 16 (6–42) | NR | 0 | 2 (4%) |
GelPoint (applied medical) | LAR 32 | 195 | pT1 (3); ypT2 (12); ypT3 (11); ypT4 (2); N0 (27), N1 (5), N2 (0) | 17 (7.14) | 27 complete, 3 nearly complete, 2 incomplete | 2 (6.2%) | 1 (3.1%) |
GelPoint (applied medical) | LAR 18, APR 7 | NR | T0 (0), T1 (0), T2 (8), T3 (16), T4 (1); N0 (14), N1 (8), N2 (3) | 21 (9–42) | 20 complete, 5 nearly complete | 0 | 1 (4%) |
Gloveport (4), GelPoint (applied medical) (16) | LAR 16, ELAPE 2, completion proctectomy 1, APR 1 | 315.3 + 77.1 | T0 (4), T1 (0), T2 (8), T3 (5), T4 (0); N0 (10), N1 (5), N2 (2) | 23 (11–45) | 16 complete, 1 near complete | 0 | 1 (5.9%) |
SILS port (Covidien) | LAR 20 | 200 (70–420) | Complete response (2), tis (2), stage I (10), stage II (4), stage III (2) | 12 (1–20) | 18 complete, 2 near complete | 0 | 0 |
Table 21.2
Postoperative outcomes of published clinical series on transanal TME for rectal cancer
Series | Length of stay (d) | Intraoperative complications (n) | Follow-up period (months) | Morbidity rate (%) | Early postoperative complications (n) | Late postoperative complications (n) | Functional outcomes | Recurrence |
|---|---|---|---|---|---|---|---|---|
Veltcamp Helbach et al. [41] N = 80 | 8 (3–41) | Laparotomy (4), bleeding (2), perforation (3), abdominal incision for extraction (7) | 24 | 39 | Anastomotic leakage, ischemia of proximal limb of colon, small bowel laceration, revision of colostomy, small bowel obstruction, hematoma, full-thickness ischemia of mucosa distal to anastomosis | NR | NR | Local recurrences (2) |
Lacy et al. [43] N = 140 | 7.8 (3–39) | None | 15.0 + 9.1 | 34 | Adhesive obstruction (1); anastomotic leak (12); ileostomy obstruction/ileus (11); intra-abdominal collection (4); bleeding (5); anastomotic bleed (3); high ileostomy output (2); acute pancreatitis (1); urinary retention (3); fever (5); blood transfusion (3); ascites (1) | Anastomotic stricture (6); colitis (4); high ileostomy output (3); ileostomy obstruction (2); intestinal obstruction (1); rectovaginal fistula (1) | NR | 11 after excluding 9 patients with stage IV lesions (includes 8 with distant mets [6.1], 1 with local recurrence [0.8], and 2 with both distant mets and local recurrence [1.5]) |
Tuech et al. [44] N = 56 | 10 (6–21) | 3 conversion, 6 delayed coloanal anastomosis | 29 months (18–52) | 26 | Anastomotic leak not requiring reoperation (3), pelvic sepsis without evidence of anastomotic leak (3), transient urinary disorders (5), blood transfusion (2), cerebral infarction (1) | NR | Wexner 5 (3–18) | Local recurrence (1), distal recurrence (2) |
Muratore et al. [45] N = 26 | 7 (3–25) | 0 | 23 months (16–30) | 27 | Myocardial infarction (1), asymptomatic anastomotic leak (2), transient urinary retention (1), lymphorrhea (1), intestinal obstruction (2) | NR | NR | Distal recurrence (2) |
Serra-Aracil et al. (2015) N = 32 | 8 (4–20) | 0 | NR | 31 | Nosocomial infection (3), SSI (3), anastomotic leakage (3), SBO requiring reintervention (1), necrosis of descending colon due to injury of marginal artery (1) | NR | NR | NR |
Rouanet et al. [47] N = 30 | 14 (8–25) | 2 urethral injury (due to anterior bulky tumor and concurrent prostatic tumor), 1 air embolism | 21 (10–41) | 30 | Sepsis (2), bowel obstruction (1), anastomotic leak (1) | NR | Median Wexner score 11 | Local or distal recurrence (14) |
Atallah et al. [71] N = 50 | 4.5 (4.0–8.0) | 3 (6%), 1 urethral injury, 1 ureteral injury, 1 injury to iliac vessels | 15.1 (7.0–23.2) | 36 | Ileus (9), pelvic abscess (4), anastomotic leak (3), urinary retention (2), pneumonia (1), SSI (1), reoperations (6) | NR | NR | Local recurrence (2), distal recurrence (8) |
Chouillard et al. [49] N = 16 | 10.4 (4–29) | 9 months (3–29) | 19 | Intestinal obstruction (2), pelvic abscess (1) | NR | 0 | ||
Chen et al. (2015) N = 50 | 7.4 (5–18) | 2 presacral bleeding, 1 vaginal wall injury | 20 | UTI (1), pelvic abscess (3), rectovaginal fistula (1), anastomosis defect (3), pseudomembranous colitis (1), bleeding (1) | NR | NR | NR | |
De’Angelis et al. [54] N = 32 | 7.8 | 0 | 32.6 months | 25 | Urinary disorder (1), urinary infection (1), wound infection (1), anastomotic leak causing pelvic abscess (2), transfusion (1), anastomotic leak medically managed (1), anastomotic leak requiring surgical drainage (1) | NR | Wexner score 9 | Local recurrence (1), distal recurrence (1) |
Perdawood et al. (2015) N = 25 | 5 (2–43) | 2 bleeding | NR | 52 | Anastomotic leakage requiring readmission (2), high ileostomy output (2), stoma necrosis (1), mechanical obstruction from adhesions (2) | NR | Wexner 4.5 (0–7) | NR |
Buchs et al. [52] N = 20 | 7 (3–36) | 1 (5%) | 10 months (6–21) | 30 | High ileostomy output, anastomotic leak | Delayed pelvic sepsis secondary to contained anastomotic leak (1) | NR | Distal recurrence (1) |
Kang et al. [53] N = 20 | NR | 1 (5%) massive bleeding, 1 (5%) prostate and urethra injury | 5 months (1–8) | 20 | Urethral injury (1), urinary retentions (2), anastomotic hemorrhage (1), mild anastomotic leak (1) | NR | Wexner 5.0 (3–11) | 0 |
The international experience with taTME is still preliminary and based on small to larger single-institutional case series, with no randomized trial comparing taTME with open or laparoscopic TME. However, there have been five retrospective studies that compare outcomes of matched cohorts of patients who underwent taTME versus laparoscopic TME [50, 51, 54–56]. Fernandez-Hevia et al. [55] retrospectively matched 37 cases of laparoscopic-assisted taTME with 37 cases of laparoscopic TME for rectal cancer and demonstrated no significant differences with respect to quality of the mesorectal specimen, lymph node harvest, resection margins, or intraoperative complications. They also demonstrated comparable 30-day postoperative complications, but a statistically significant lower readmission rate in the taTME group (2% vs. 6%) [55]. Velthuis et al. [56] retrospectively matched 25 cases of laparoscopic-assisted taTME with 25 cases of laparoscopic TME and interestingly found that taTME was associated with a significantly higher rate of complete mesorectum than laparoscopic TME (92% vs. 72%). The studies by de’Angelis, Perdawood, and Chen each retrospectively compared laparoscopic-assisted taTME with laparoscopic TME, demonstrating shorter operative times and hospital stays with no differences in intra-/postoperative complications and oncologic outcomes [50, 51, 54]. Currently, the COLOR III trial is in preparation that will compare standard laparoscopic TME versus transanal TME [57].
It is notable that the overall experience for a pure transanal approach to TME without laparoscopic assistance is sparse but growing. Leroy and Zhang described the first two cases of a pure taTME in 2013, demonstrating that it was feasible and safe for mid-to-low-lying rectal cancer [58, 59]. Since then, there have been a total of 21 cases of pure taTME reported [49, 53]. In the study by Chouillard et al., 16 patients underwent taTME, either with or without abdominal assistance. Ten, eight women and two men, out of the 16 were performed in pure fashion, with no ileostomy or conversion to laparoscopy [49]. Kang et al. [53] reported a series of 20 taTME with and without abdominal assistance, 15 of which were performed in pure fashion in nine men and six women. In their experience, pure taTME was easier to perform in women than in men, as demonstrated by the four patients requiring conversion to laparoscopy being all men. Reasons for conversion to laparoscopy included prostatic and urethral injury leading to significant hemorrhage, unsatisfactory exposure accompanied by mild hemorrhage, and having resistance to delivery of the specimen due to bulky mesorectum [53].
Indications for Transanal Total Mesorectal Excision
Although the data with respect to oncologic and functional outcomes have not yet matured, transanal endoscopic proctectomy, with or without TME, has been shown to be feasible and effective in the treatment of benign and malignant disease of the rectum. There is a growing consensus regarding specific indications and contraindications for this approach based on specific pathology, tumor stage, and favorable versus unfavorable anatomical factors.
Benign Indications
Transanal endoscopic completion proctectomy is a particularly attractive approach when seeking to avoid abdominal entry during removal of retained rectal stumps. Indications for a transanal endoscopic approach are the same as for any other approach to completion proctectomy, including inflammatory bowel disease. The transanal approach also lends itself well to intersphincteric proctectomy in cases of refractory radiation proctitis or fecal incontinence, strictures, rectovaginal fistulas, or other complex pelvic fistula, as well as colorectal anastomotic complications. Depending on the length of the residual rectal stump to be removed, a pure transanal endoscopic approach or hybrid approach with laparoscopic or robotic assistance can be performed. Furthermore, depending on the specific pathology warranting proctectomy, rectal dissection can be carried out along the rectal wall with preservation of the mesorectum, or in combination with total mesorectal dissection.
There have been seven series published on transanal endoscopic proctectomy for benign indications, describing outcomes in a total of 86 patients [60–66]. These have been outlined in Table 21.3. Procedures performed included completion proctectomy, restorative proctocolectomy with coloanal anastomosis or ileal pouch-anal anastomosis (IPAA), and APR. These were performed primarily in hybrid fashion with transabdominal laparoscopic assistance. Indications were for refractory diversion and radiation proctitis, ulcerative colitis and Crohn’s disease, large carpeting villous adenomas of the rectum, fecal incontinence, rectal strictures, and complex fistulas [60–66]. The length of the resected retained rectal stumps ranged from 8 to 30 cm. There were no deaths or major procedural complications, but three patients required conversion to open proctectomy due to intra-abdominal adhesions [62, 63]. The cumulative morbidity across the series was 35% (30/86 cases) and included urinary tract infections, presacral hematoma, several cases of delayed perineal wound healing, a perineal dehiscence requiring reoperation, an incarcerated parastomal hernia, and a colocutaneous fistula to the perineum requiring reoperation. Although these preliminary reports demonstrate the feasibility and procedural safety of a primarily transanal endoscopic approach for distal rectal dissection in ulcerative colitis, data on short-term pouch function are lacking.
Table 21.3
Published clinical series on taTME for benign indications
Series | Age (year) | Gender | BMI (kg/m2) | Indications | Operative technique | Transanal platform | Type of resection |
|---|---|---|---|---|---|---|---|
De Buck van Overstraeten [60] N = 11 | 34 (22–66) | M (3), F (8) | NR | UC | LA | GelPoint path | Completion proctectomy |
Tasende [61] N = 18 | 40.5 (15.7) | M (13), F (5) | 26.4 (SD 11.1) | UC | LA | GelPoint path | Restorative proctocolectomy w IPAA |
Leo [62] N = 16 | 46 (26–70) | M (10), F (6) | NR | UC | LA | GelPoint path | Restorative proctocolectomy w IPAA |
Wolthuis [63] N = 14 | 65 (38–87) | M (5), F (9) | 25 (17–32) | Fistula (1), IBD (2), incontinence (1), circular TVA (2), complication of surgery (3), cancer (5) | LA (11), pure TAMIS (3) | GelPoint path | Coloanal anastomosis (7), intersphincteric proctectomy (7) |
Bremers [64] N = 9 | NR | NR | NR | IBD (6), lynch (1), collagenous colitis (1), anastomotic leak (1) | Transanal | TEM | Proctectomy |
Liyanage [65] N = 12 | 66 (SD 13) | M (7), F (5) | NR | IBD (9), neoplasia (2), proctitis (1) | Transanal | TEM | Proctectomy |
McLemore [66] N = 6 | (22–74) | M (2), F (4) | 30.5 (22–51) | Proctitis | LA transanal | GelPoint path | Completion proctectomy (2), APR (1), restorative proctocolectomy with coloanal anastomosis (1), restorative proctocolectomy w IPAA (1) |
Operating time (min) | Rectal stump (cm) | Anastomosis | Conversions | Intraoperative complications (n) | Morbidity rate | Functional outcomes
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