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Uptake of Transanal Total Mesorectal Excision in North America: Initial Assessment of a Structured Training Program and the Experience of Delegate Surgeons

Atallah, Sam B. M.D.; DuBose, Arielle C. M.D.; Burke, John P. M.B., B.Ch., B.A.I., Ph.D., F.R.C.S.I.; Nassif, George D.O.; deBeche-Adams, Teresa M.D.; Frering, Taylor B.S.; Albert, Matthew R. M.D.; Monson, John R.T. M.B.B.Ch., M.D.

doi: 10.1097/DCR.0000000000000823
Original Contributions: Colorectal/Anal Neoplasia
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BACKGROUND: Transanal total mesorectal excision is a new approach to curative-intent rectal cancer surgery. Training and surgeon experience with this approach has not been assessed previously in America.

OBJECTIVE: The purpose of this study was to characterize a structured training program and to determine the experience of delegate surgeons.

DESIGN: Data were assimilated from an anonymous, online survey delivered to attendees on course completion. Data on surgeon performance during hands-on cadaveric dissection were collected prospectively.

SETTINGS: This study was conducted at a single tertiary colorectal surgery referral center, and cadaveric hands-on training was conducted at a specialized surgeon education center.

MAIN OUTCOME MEASURES: The main outcome measurement was the use of the course and surgeon experience posttraining.

RESULTS: During a 12-month period, eight 2-day transanal total mesorectal excision courses were conducted. Eighty-one colorectal surgeons successfully completed the course. During cadaveric dissection, 71% achieved a complete (Quirke 3) specimen; 26% were near complete (Quirke 2), and 3% were incomplete (Quirke 1). A total of 9.1% demonstrated dissection in the incorrect plane, whereas 4.5% created major injury to the rectum or surrounding structures, excluding the prostate. Thirty eight (46.9%) of 81 surgeon delegates responded to an online survey. Of survey respondents, 94.6% believed training should be required before performing transanal total mesorectal excision. Posttraining, 94.3% of surgeon delegates planned to use transanal total mesorectal excision for distal-third rectal cancers, 74.3% for middle-third cancers, and 8.6% for proximal-third cancers. The most significant complication reported was urethral injury; 5 were reported by the subset of survey respondents who had performed this operation postcourse.

LIMITATIONS: The study was limited by inherent reporting bias, including observer and recall biases.

CONCLUSIONS: Although this structured training program for transanal total mesorectal excision was found to be useful by the majority of respondents, the risk of iatrogenic injury after training remains high, suggesting that this training pedagogy alone is insufficient. See Video Abstract at

Center for Colon and Rectal Surgery, Florida Hospital, Orlando, Florida

Financial Disclosure: Drs Atallah, Albert, deBeche-Adams, Nassif, and Monson are paid consultants for Applied Medical, Inc, receiving teaching honoraria. Drs Albert and Atallah are paid consultants for ConMed, Inc, and Dr Monson is an advisor for and Covidien-Medtronic, Inc. This training program was funded by an educational grant from Applied Medical, Inc.

Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Los Angeles, CA, April 30 to May 4, 2016.

Received the Pennsylvania Society of Colon & Rectal Surgeons Award 2016.

Correspondence: Sam Atallah, M.D., Center for Colon and Rectal Surgery, 242 Loch Lomond Dr, Orlando, FL 32792. E-mail:

© 2017 The American Society of Colon and Rectal Surgeons