Primer caso de escisión mesorrectal total transanal (TaTME) para el tratamiento del cáncer de recto medio en un centro docente universitario: descripción de la técnica / First case of transanal total mesorectal excision (TaTME) for middle rectal cancer in a teaching tertiary center: technical aspects / Primeiro caso de excisão total do mesorreto transanal (TaTME) para tratamento de câncer de reto meio em um centro universitário de ensino: aspectos tecnicos

La escisión mesorrectal transanal (TaTME: transanal total mesorectal escision) es la última de una larga lista de desarrollos técnicos y tecnológicos para el tratamiento del cáncer de recto medio y bajo. Incluso para los cirujanos colorrectales experimentados, lograr una escisión mesorrectal total (emt) de calidad en cirugía oncológica no siempre es sencillo, por la dificultad de obtener un adecuado acceso a la pelvis. Los estudios realizados han mostrado resultados comparables al abordaje laparoscópico, con tasas elevadas de escisiones mesorrectales completas y bajo porcentaje de margen circunferencial radial (CRM: circumferential radial margin) y distal positivos, con un adecuado número de ganglios resecados. Como toda técnica nueva, su implementación puede traer consecuencias no intencionales. La complejidad del abordaje, la dificultad en la identificación de nuevos repères y planos anatómicos, ha llevado a complicaciones graves como la lesión uretral o la siembra tumoral pelviana. Por ello, la comunidad quirúrgica ha retrasado la implementación masiva de la técnica y desarrollado estrategias de enseñanza y monitorización de este procedimiento para su realización en centros de alto volumen. El objetivo de esta publicación es presentar el primer caso de TaTME en un centro docente universitario y difundir en nuestra comunidad científica el fundamento de la técnica, sus indicaciones, describir los principales pasos técnicos, complicaciones, resultados oncológicos y funcionales.

Transanal total mesorectal excision (TaTME) is the last of a long list of technical and technological developments for treatment of middle and low rectal cancer. Even for skilled colorectal surgeons, achieving a good quality total mesorectal excision (TME) in oncology surgery is not always simple, due to the difficulty of obtaining optimal access to the pelvis. So far, studies have shown similar results to laparoscopic surgery, with high rates of complete mesorectal excisions and low rate of circumferential radial margin (CRM) and distal margin with an appropriate number of resected lymph nodes. Like every new technique, its implementation can bring unwanted consequences. The complexity of the approach, the difficulty in the identification of new landmarks and anatomic planes, has led to serious complications such as urethral injury or tumoral seeding. This has made slowdown the massive implementation of the technique among the surgical community, addressing the need of developing training programs and mentoring of this procedure that belongs to high volume centers. The aim of this publication is to present the first case of TaTME in a teaching tertiary center and spread, in our scientific community, the principles of the technique, its indications, main technical steps, complications and functional and oncologic results.

A excisão mesorretal transanal (TaTME: transanal total mesorectal escision) é o mais recente de uma longa linha de desenvolvimentos técnicos e tecnológicos para o tratamento do câncer retal inferior e médio. Mesmo para cirurgiões colorretais experientes, nem sempre é fácil obter uma excisão total do mesorreto (EMT) de qualidade em cirurgia de câncer, devido à dificuldade de obter acesso adequado à pelve. Os estudos realizados mostraram resultados comparáveis ​​à abordagem laparoscópica, com altas taxas de excisões completas do mesorreto e baixo percentual de margem radial circunferencial positiva (CRM: circumferential radial margin) e distal, com número adequado de linfonodos ressecados. Como qualquer nova técnica, sua implementação pode ter consequências não intencionais. A complexidade da abordagem, a dificuldade em identificar novos repères e planos anatômicos, levou a complicações graves, como lesão uretral ou semeadura de tumor pélvico. Por esse motivo, a comunidade cirúrgica atrasou a implementação massiva da técnica e desenvolveu estratégias de ensino e acompanhamento desse procedimento para sua realização em centros de alto volume. O objetivo desta publicação é apresentar o primeiro caso de TaTME em um centro de ensino universitário e divulgar em nossa comunidade científica as bases da técnica, suas indicações, descrever as principais etapas técnicas, complicações, resultados oncológicos e funcionais.

Quality indicators of transanal total mesorectal excision (TaTME) for rectal cancer

Introduction: Transanal total mesorectal excision (TaTME) has revolutionized the surgical techniques for lower-third rectal cancer. The aim of the present study was to analyze the outcomes of quality indicators of TaTME for rectal cancer compared with laparoscopic TME (LaTME). Methods: A cohort prospective study with 50 (14 female and 36male) patients, with a mean age of 67 (range: 55.75 to 75.25) years, who underwent surgery for rectal cancer. In total, 20 patients underwent TaTME, and 30, LaTME. Every TaTME procedure was performed by experienced colorectal surgeons. The sample was divided into two groups (TaTME and LaTME), and the quality indicators of the surgery for rectal cancer were analyzed. Results: There were no statistically significant differences regarding the patients and the main characteristics of the tumor (age, gender, American Society of Anesthesiologists [ASA] score, body mass index [BMI], tumoral stage, neoadjuvant therapy, and distance from the tumor to the external anal margin) between the two groups. The rates of: postoperativemorbidity (TaTME: 35%; LaTME: 30%; p=0.763);mortality (0%); anastomotic leak (TaTME: 10%; LaTME: 13%; p=0.722); wound infection (TaTME: 0%; LaTME: 3.3%; p=0.409); reoperation (TaTME: 5%; LaTME: 6.6%; p=0.808); and readmission (TaTME: 5%; LaTME: 0%; p=0.400), as well as the length of the hospital stay (TaTME: 13.5 days; LaTME: 11 days; p=0.538), were similar in both groups. There were no statistically significant differences in the rates of positive circumferential resection margin (TaTME: 5%; LaTME: 3.3%; p=0.989) and positive distal resection margin (TaTME: 0%; LaTME: 3.3%; p=0.400), the completeness of the TME (TaTME: 100%; LaTME: 100%), and the number of lymph nodes harvested (TaTME: 15; LaTME: 15.5; p=0.882) between two groups. Conclusion: Transanal total mesorectal excision is a safe and feasible surgical procedure for middle/lower-third rectal cancer. (AU)

Using taTME to maintain restorative options in locally advanced rectal cancer: A technical note.

BACKGROUND: The safe adoption of transanal total mesorectal excision (taTME) has occurred in Australasia as previously reported by the current authors. Planes beyond TME can be utilised in more advanced cases to achieve negative margins during transanal dissection. METHODS: In this article we describe how taTME is used to perform an en-bloc partial vaginectomy and aid restore intestinal and vaginal continuity in a young female with a locally advanced rectal cancer and posterior vaginal wall involvement in the pre-treatment magnetic resonance imaging. RESULTS: The transanal technique allowed the surgeons to remove a disc of vagina, ensure organ preservation and control the main R1 risk point. An R0 resection was achieved. CONCLUSION: This technical note highlights that in experienced hands, taTME may be safely implemented to maintain restorative options in locally advanced rectal cancer requiring resection beyond the total mesorectal excision plane.

A combination treatment of transanal total mesorectal excision and Turnbull-Cutait abdominoperineal pull-through procedure for a low rectal cancer

ABSTRACT Surgical treatment for low rectal cancer has changed dramatically during the preceding several decades, and the optimal surgical approach remains incompletely developed. Transanal total mesorectal excision is likely the most promising approach for the dissection of the distal part of the mesorectum in a manner that allows for a technically easy and oncologically safe operation. Long after it was first described, the Turnbull-Cutait abdominoperineal pull-through procedure has recently been reintroduced in surgical practice for the treatment of patients with complex anorectal conditions. The current report describes a case of distal rectal cancer involving successful surgical treatment with a combination of the two aforementioned methods and patient discharge without a diverting stoma.

RESUMO tratamento cirúrgico para o câncer de reto baixo mudou drásticamente durante as últimas décadas, mas uma abordagem cirúrgica de excelência ainda continua incompletamente desenvolvida. A excisão total do mesorreto por via transanal parece ser a abordagem mais promissora para a dissecção da parte distal do mesorreto de forma a assegurar uma cirurgia oncológicamente segura com uma técnica simples. Muito depois de sua descrição, o pull-through abdominoperineal de Turnbull-Cutait tem sido reintroduzido na prática cirúrgica para o tratamento de pacientes com enfermidades anorretais complexas. Este relato descreve um caso de câncer de reto baixo que se beneficiou de um tratamento cirúrgico bem sucedido a partir da combinação das duas técnicas supracitadas com o paciente recebendo alta hospitalar sem ostomia de proteção.

Recent advances in the management of rectal cancer: No surgery, minimal surgery or minimally invasive surgery.

Over the last decade, with the acceptance of the need for improvements in the outcome of patients affected with rectal cancer, there has been a significant increase in the literature regarding treatment options available to patients affected by this disease. That treatment related decisions should be made at a high volume multidisciplinary tumor board, after pre-operative rectal magnetic resonance imaging and the importance of total mesorectal excision (TME) are accepted standard of care. More controversial is the emerging role for watchful waiting rather than radical surgery in complete pathologic responders, which may be appropriate in 20% of patients. Patients with early T1 rectal cancers and favorable pathologic features can be cured with local excision only, with transanal minimal invasive surgery (TAMIS) because of its versatility and almost universal availability of the necessary equipment and skillset in the average laparoscopic surgeon, emerging as the leading option. Recent trials have raised concerns about the oncologic outcomes of the standard "top-down" TME hence transanal TME (TaTME "bottom-up") approach has gained popularity as an alternative. The challenges are many, with a dearth of evidence of the oncologic superiority in the long-term for any given option. However, this review highlights recent advances in the role of chemoradiation only for complete pathologic responders, TAMIS for highly selected early rectal cancer patients and TaTME as options to improve cure rates whilst maintaining quality of life in these patients, while we await the results of further definitive trials being currently conducted.

The quest for precision in transanal total mesorectal excision.

Transanal total mesorectal excision (TME) is an emerging minimally invasive approach to rectal cancer, with encouraging preliminary results. However, the new surgical anatomy of the bottom-up approach complicates surgical understanding and increases the risks of inadvertent injuries to crucial anatomical structures, including nerves. Key elements to improve the safety and stimulate interest in such a complex technique might be robotics and image guidance, to enhance the level of precision. In this editorial, some of the technologies that could be used for precision TME are outlined, in light of the experience of our Institute for Image-Guided Surgery.