Oncological outcomes after transanal total mesorectal excision for rectal cancer

Francis, Nader; Penna, Marta; Dritsas, Spyridon; Kinsey, Harry; Moran, Brendan; Nicol, Deborah; Courtney, Edward; Carter, Fiona; Roodbeen, Sapho; Arnold, Steve; Mortensen, Neil; White, Paul; Hompes, Roel; Wynn, Greg

Abstract

Transanal total mesorectal excision (TaTME) was developed to overcome the technical difficulties of a transabdominal minimal-access approach to resection of low rectal cancer1–4. TaTME was reported to be feasible and effective, with the potential advantage of better access to the distal rectum and mesorectum, and theoretical capability of delivering oncologically superior specimens5,6.

In the UK, a national training initiative was developed and piloted, confirming the feasibility and safety of this technique within a structured training framework7,8. However, a widely publicized moratorium on TaTME9 was issued in 2019 in Norway, substantiated by reports of higher-than-expected local recurrence rates, in particular multifocal recurrence. In response to this publication, the Association of Coloproctology of Great Britain and Ireland10 issued recommendations in 2020 proposing a pause to the practice of TaTME in the UK.

The aim of the present study was to collate oncological data from English centres that had adopted TaTME to investigate the oncological safety of the technique and factors associated with local recurrence.

Methods
This was an observational study, using data collated from centres performing TaTME in England. Centres that performed over 10 procedures were identified from the international TaTME registry, and the designated principal investigator at each site was contacted to enter their data into a pro forma developed by the steering committee. Adult patients undergoing TaTME for histologically proven rectal cancer with the intention to cure and no detectable metastases at time of diagnosis were eligible for inclusion.

Oncological data were collected on the following variables. Locoregional recurrence was defined as any recurrent disease in the pelvis in the previous area of dissection, at the anastomotic site, or as pelvic nodal disease11. Suspected locoregional recurrence had to be confirmed by imaging (CT/MRI and/or PET). Disease-free survival (DFS) was measured from the date of TaTME for rectal cancer until the date of the first documented pelvic recurrence or development of metastatic disease. Overall survival (OS) was measured from the date of TaTME for rectal cancer until the date of last follow-up or death from any cause.

Demographic, patient, and histopathological data were also collected, as was information on postoperative short-term outcomes including complications (classified according to Clavien and Dindo).

Differences in OS and DFS were compared using Kaplan–Meier curves and analysed using the log rank test. A Cox proportional hazards regression model was used to predict oncological outcomes, adjusted for stratification factors, including tumour site, margin assessment (both distal and circumferential), presence of liver metastases not detected before operation, preoperative administration of radiotherapy, age, sex, and final histological TNM classification (T2, T3, T4 and N1/2 with T0/T1 and N0 respectively as reference).

Results
A total of 478 TaTMEs were performed in 16 centres in England between February 2013 and September 2021. The median age of the patients was 66 (i.q.r. 59–73) years and 372 patients (77.8 per cent) were men. Most patients had an ASA grade of II (18.2 per cent) or III (61.9 per cent). Median BMI was 28 (i.q.r. 22–31) kg/m2, and the median tumour height from the anal verge on MRI was 7 (6–9) cm. Some 153 patients (33.0 per cent) received neoadjuvant therapy; 75 per cent had long-course chemoradiotherapy and 24 per cent short-course radiotherapy (Table 1). Restorative anterior resection was undertaken in 426 patients (89.1 per cent), and 46 (9.6 per cent) had abdominoperineal excision (44 intersphincteric, 9.2 per cent). The vast majority of procedures (85.9 per cent) involved the use of an Airseal device (ConMed Surgiquest AirSeal® [Swindon, UK] iFS—Insufflator). Purse-string failure was reported in 15 patients (3.1 per cent).

• Journal Article Type: Article
• Acceptance Date: May 13, 2023
• Online Publication Date: Jun 14, 2023
• Publication Date: Dec 31, 2023
• Deposit Date: May 16, 2023
• Publicly Available Date: Dec 7, 2023
• Journal: British Journal of Surgery
• Print ISSN: 0007-1323
• Electronic ISSN: 1365-2168
• Publisher: Wiley
• Peer Reviewed: Peer Reviewed
• Volume: 110
• Issue: 12
• Pages: 1614-1617
• DOI: https://doi.org/10.1093/bjs/znad168
• Keywords: Oncological outcomes; Oncology; transanal total mesorectal excision; rectal cancer; cancer
• Public URL: https://uwe-repository.worktribe.com/output/10784419
• Publisher URL: https://academic.oup.com/bjs/advance-article/doi/10.1093/bjs/znad168/7197390?login=false