Transanal total mesorectal excision in selected patients with “difficult pelvis”: a case–control study of “difficult” rectal cancer patients

Transanal total mesorectal excision (taTME) yields potential benefits for patients with a narrow pelvis and previous chemoradiotherapy by facilitating mobilization of the lower part of the mesorectum. The aim of this study was to investigate the role of taTME in patients with “difficult pelvis.”

This single-institution retrospective nonrandomized cohort study included patients with difficult pelvis who underwent either laparoscopic total mesorectal excision (lapTME) or taTME during 2013–2016. “Difficult pelvis” was defined as a combination of male gender, high body mass index (BMI; ≥25 mg/m²), and previous chemoradiotherapy. Main outcome measures included TME quality, rate of stapling anastomoses, operative time, and postoperative complications.

In total, 26 patients underwent lapTME and 26 underwent taTME. The median BMI was 29.2 kg/m2 and 28.3 kg/m2 in the laparoscopic and transanal groups, respectively (p = 0.8). The median operative time was 270 and 295 min, respectively (p = 0.2). One (3.8%) patient died in the laparoscopic group, whereas no deaths occurred in the taTME group. The rate of grade III–IV complications was three (11.5%) vs. three (11.5%), respectively (p = 1.0). Grade 1 TME was observed in four (17.4%) vs. four (16%) patients, respectively (p = 1.0; per protocol). Stapling anastomosis was performed on 17 (68%) vs. 21(84%) patients, respectively (p = 0.2). The median follow-up was 28.2 months. There was one case (3.8%) of distant failure in each group and one (3.8%) patient in the laparoscopic group developed a local recurrence.

In rectal cancer patients with difficult pelvis, taTME may lead to higher rates of stapling anastomoses without compromising other surgical outcomes. We did not find any differences in specimen quality or other surgical outcomes between the two groups.