Transanal total mesorectal excision (taTME) for cancer located in the lower rectum: Short- and mid-term results

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Abstract

Background

Laparoscopic trans-abdominal total mesorectal excision is technically demanding. Transanal Total Mesorectal Excision (taTME) is a new technique which seems to provide technical advantages. This study describes the results of taTME in a consecutive series of patients with low rectal cancer.

Methods

From January 2012 to December 2013, a consecutive series of 26 patients with low rectal cancer underwent laparoscopic taTME with coloanal anastomosis. cT4 or Type II-III rectal cancer (according to Rullier's classification) were contraindications to taTME. After anal sleeve mucosectomy, the rectal wall was transected at the ano-rectal junction. A single-access multichannel port was inserted in the anal canal. taTME was performed from down to up until the sacral promontory posteriorly and the Pouch of Douglas anteriorly were reached. A laparoscopic trans-abdominal approach was used to complete the left colon mobilization.

Results

Sixteen patients (61.5%) were male. The mean distance of the rectal cancer from the anal verge was 4.4 cm (range 3–6). Nineteen patients (73.1%) received long-course neoadjuvant radiotherapy. At final pathology, resection margins were negative in all the patients: the mean distal and radial resection margins were 19 mm and 11.2 mm, respectively. TME was complete in 23 patients (88.5%) and nearly complete in three. Postoperative mortality was 3.8%. The overall morbidity rate was 26.9% (7 patients): two patients (7.7%) had an anastomotic leakage (Dindo I-d). After a mean follow up of 23 months, no patients have developed a local recurrence.

Conclusions

laparoscopic taTME allow wide resection margins and good quality TME.

Introduction

There is increasing evidence suggesting that sphincter-saving procedures for cancers located in the lower rectum are oncologically safe.1 Recent studies have provided further evidence that laparoscopic low anterior resections with coloanal anastomosis have similar short- and long-term outcomes when compared with open procedures.2, 3 However, laparoscopic total mesorectal excision (TME) for low rectal cancers is technically and oncologically demanding, mainly in obese and male patients with a narrow pelvis and a bulky mesorectum. Because of the confines of the bony pelvis, the thinning of the distal mesorectum, and the laparoscopic approach, obtaining adequate distal as well circumferential resection margins is challenging. The difficulty of laparoscopic trans-abdominal TME has been recently highlighted by two European studies analyzing almost two thousand patients operated on for rectal cancer in a short-time period: less than 15% of these patients underwent a laparoscopic TME.4, 5

In 1995 Bannon et al. reported on their preliminary experience of transanal abdominal transanal proctosigmoidectomy (TATA) in 65 patients with low rectal cancer.6 More recent studies have suggested that transanal rectal dissection reduces the risk of positive distal and radial resection margins increasing the number of sphincter-saving procedures.7, 8 Moreover, it seems to facilitates the laparoscopic abdominal time of the up-to down mesorectal dissection.8, 9

Recently, Lacy's group has reported a series of 20 patients with rectal cancer, only one third in the lower rectum, who underwent laparoscopic transanal TME (taTME).10 Laparoscopic taTME seems to have technical and oncological advantages when compared with the “open” transanal approach to the mesorectal dissection. First of all, laparoscopic taTME allows a complete mobilization of the rectum-mesorectum whereas the “open” taTME allows only a partial mobilization.7, 8 Moreover, the better vision of the dissection planes due to the laparoscopic approach seems to improve TME quality.

Aim of the present series is to analyze the short- and mid-term results of a series of 26 patients with cancer located in the lower rectum who underwent laparoscopic taTME combined with trans-abdominal laparoscopic surgery and coloanal anastomosis.

Section snippets

Material and methods

From January 2012 to December 2013, 72 patients with mid-low rectal adenocarcinoma underwent low anterior resection in our Surgical Department. Indication for taTME was the presence of a low rectal cancer requiring a low anterior resection with colo-anal anastomosis. cT4 or Type II-III rectal cancers (according to Rullier's classification1) at the preoperative staging were contraindications to taTME. Of the 72 patients with mid-low rectal cancer, 35 patients had a cancer located in the mid

Preoperative characteristics

There were 16 male patients with a mean age of 65.8 years (range 38–84) (Table 1). Sixteen patients (61.5%) were male. Mean BMI was 26.2 (range 16.9–38.2) Kg/m2: in 6 patients the BMI was ≥30 kg/m2. The mean distance of the rectal cancer from the anal verge was 4.4 cm from (range 3–6 cm). According to Rullier's classification, all the patients had type I rectal cancers.1 At the diagnosis, 24 patients (92.3%) were staged as cT2-3 and 16 (61.5%) as cN+. More than two thirds of the patients

Discussion

In the last ten years, treatment of cancer located in the lower rectum is changed with an increased rate of sphincter-saving procedures.1, 2 Several randomized controlled studies, among many retrospective studies, have shown the safety and feasibility of a laparoscopic approach to rectal cancer even when located in the lower rectum.2, 3, 14 Despite this change of strategy, the reported rate of 2-years local recurrence is low, around 2–5%.2 In the present series, 96% of the patients have

Source of support/Financial disclosure

None reported.

Authors' contribution

1. A. Muratore: analysis and interpretation of data, drafting of the manuscript, revision and final approval.

2. A. Mellano: acquisition, analysis and interpretation of data, drafting of the manuscript.

3. P. Marsanic: acquisition, analysis and interpretation of data, revision of the manuscript.

4. M. De Simone: revision and final approval of the manuscript Paper Category: colorectal neoplasia.

Disclosures

Dott. Alfredo Mellano, M.D., Dott. Patrizia Marsanic, M.D., and dott. Michele De Simone, M.D. have no conflicts of interest of financial ties do disclose.

Dott. Andrea Muratore have been a speaker for Covidien (UK) Commercial Ltd at a surgical meeting in 2014.

Conflict of interest statement

All authors do not have conflicts of interest.

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