Quality of life and functional outcomes after transanal total mesorectal excision for rectal cancer-results from the implementation period in Denmark.

BACKGROUND: The standard operation for mid- and low rectal cancer total mesorectal excision (TME) is routinely performed as minimally invasive surgery. TME is associated with temporary or permanent functional impairment of pelvic organs, causing reduced quality of life (QoL). Concerns have been raised that the newest minimally invasive approach, transanal TME (TaTME), may further reduce urogenital and anorectal functions. OBJECTIVE: To determine if functional outcomes affecting QoL are altered after TaTME. Primary end-point is the impact of TaTME on QoL and functional outcomes. Secondary end-point is assessing differences in QoL and functional outcomes after TME surgery from below (TaTME) or above (transabdominal TME). DESIGN, SETTING, AND PARTICIPANTS: Observational study consisting of prospectively registered self-reported questionnaire data collected at baseline and follow-ups after TaTME. All patients who underwent TaTME during the Danish national implementation phase were included. Central surveillance of the implementation included questionnaires concerning QoL and functional outcomes. Analyses of functional results from the Danish cohort of the ROLARR trial (Jayne et al. in JAMA 318:1569-1580, (2017) are reported separately for perspective, representing the transabdominal approach to TME, i.e., laparoscopic- or robotic-assisted TME (LaTME/RoTME). Applied questionnaires include EORTC QLQ-C30, SF-36, LARS, ICIQ-MLUTS, ICIQ-FLUTS, IPSS, IIEF, SVQ, and FSFI. RESULTS: A total of 115 TaTME procedures were registered August 2016 to April 2019. LaTME/RoTME patients (n = 92) were operated on January 2011 to September 2014. A temporary postoperative decrease of QoL (global health status and functional scales) was observed, yet long-term results were unaffected by surgery in both groups. In TaTME patients, the anorectal dysfunction increased significantly (p < 0.001) from preoperative baseline to 13.5 months follow-up, where 67.5% (n = 52) reported major LARS symptoms. Urinary function was not significantly impaired after TME regardless of technique. The paucity of responses concerning sexual function precludes conclusions. CONCLUSIONS: Although an initial reduction in QoL after TME occurs, it normalizes within the first year postoperatively. In concurrence with international results, we found that significant anorectal dysfunction is common after TaTME. No data on anorectal function was available for LaTME/RoTME patients for comparison. We found no indications that transanal TME is inferior to transabdominal TME surgery concerning urogenital functions or health-related QoL.

Manometric assessment of anorectal function after transanal total mesorectal excision.

BACKGROUND: Low anterior resection syndrome (LARS) is common following surgery for mid and low rectal cancer. Transanal total mesorectal excision (TaTME) involves intraoperative stretching of the anal sphincter while an anal single port is placed, which can potentially further disturb anorectal function. The aim of our study was to systematically assess anal function after TaTME using anorectal manometry and questionnaires. METHODS: Patients who had TaTME for rectal cancer at our institution were prospectively assessed by means of anorectal manometry and the standard LARS score. The primary endpoint was the resting pressure to assess internal sphincter damage and the secondary endpoints were squeeze pressure to assess external anal sphincter and analysis of correlation between LARS score and these two manometry parameters. Patients who had laparoscopic TME (LaTME) served as a control group. RESULTS: Out of 81 patients invited to participate 48 accepted. There were 36 in theTaTMEgroup, and 12 in the LaTMEgroup. The mean follow-up time from the index operation date to the assessment date was 41.34 months (± SD 24.834). The mean resting pressure did not differ significantly between the groups (36.44 mmHg ± 18.514 and 36.58 mmHg ± 13.318 in the TaTME and LaTME groups, respectively, p = 0.981). The mean squeeze pressure was also comparable (125.00 mmHg ± 66.141 and 111.83 mmHg ± 51.111 in the TaTME and LaTME groups, respectively, p = 0.533). The mean LARS score was comparable and showed comparable results. The analysis of correlation between LARS score and manometry parameters showed no significant associations between resting or squeeze pressure and L:ARS score. CONCLUSIONS: Following TME surgery, the resting and squeeze pressures of the anal sphincter measured by manometry were generally decreased, with no differences between the transanal and laparoscopic approaches.

The Pattern of Defects in Mesorectal Specimens: Is There a Difference between Transanal and Laparoscopic Approaches?

BACKGROUND:: Total mesorectal excision has evolved from open to minimally invasive techniques. To overcome difficulties in the lowest part of the pelvis, transanal total mesorectal excision was introduced and has gained acceptance in the recent years. The results of transanal total mesorectal excision seem to be comparable to laparoscopic total mesorectal excision. Whether or not transanal total mesorectal excision has changed the pattern of defects in the retrieved mesorectal specimens is yet to be clarified. PURPOSE:: To determine the pattern of mesorectal defects following transanal total mesorectal excision, compared to laparoscopic total mesorectal excision. The primary end-point was the location of defects in the part of the mesorectum below the peritoneal reflection, as it is this part, which is dissected from below in the transanal total mesorectal excision procedure. METHODS:: From our transanal total mesorectal excision database that includes all transanal total mesorectal excision procedures performed at our institution since 2013, we have included 29 patients who originally had defects in their retrieved specimens. Another 29 patients who underwent laparoscopic total mesorectal excision with mesorectal defects served as a control group. All specimen photos and pathology reports were reviewed systematically; sites and pattern of defects were defined. RESULTS:: A higher ratio of the defects in the laparoscopic total mesorectal excision group was located below the peritoneal reflection (P = 0.043). The distribution of defects by anatomical quadrant was not statistically different between the groups. CONCLUSIONS:: The ratio of defects below the peritoneal reflection was lower in the transanal total mesorectal excision group. Whether this is due to a lower incidence of defect in transanal total mesorectal excision is not part of our study.