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Transanal TME ‘New Kid on the Block’ in Rectal Cancer

Carlson, Robert H.

doi: 10.1097/01.COT.0000471984.65374.14
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BARCELONA, Spain—Transanal total mesorectal excision (TME), a new alternative in the surgical treatment of rectal cancer, appears to be as safe and effective as standard laparoscopic TME but with a shorter time in surgery and a lower early readmission rate.

“Transanal TME is the new kid on the block,” said Andre D'Hoore, MD, PhD, Chair of the Department of Abdominal Surgery at University Hospital Leuven in Belgium, speaking here at the European Society for Medical Oncology World Congress on Gastrointestinal Cancer.

D'Hoore said transanal TME and other variations in transanal minimally invasive surgery do not replace standard techniques but can facilitate them, and allow the surgeon to continue using familiar laparoscopic instruments.

Transanal TME is one type of natural orifice transluminal endoscopic surgery—in this case, using the rectum as access in colorectal surgery.

He cited a study published earlier this year in which the researchers said the transanal route for endoscopy “is intuitively better suited than other access routes in rectal cancer surgery” (Annals of Surgery 2015;261:221-227).

The study, which compared transanal TME with standard laparoscopic TME, showed transanal TME to be feasible, safe, and associated with a shorter surgical time and a lower early readmission rate.

“The study opened a new era in rectal cancer surgery,” D'Hoore said. The major findings:

  • Time in surgery for the 37 patients undergoing transanal TME was 216 minutes versus 252 for the 37 patients undergoing laparoscopic TME;
  • Coloanal anastomosis was necessary in 16 percent of the transanal TME patients versus 43 percent in the laparoscopic TME patients;
  • Readmisson rates were six versus 22 percent, respectively; and
  • Early morbidity was equal between the two study arms.

Transanal TME begins with internal occlusion of the rectal tube, and a transmural incision finds the plane of the mesorectum, D'Hoore explained.

“Once in the plane, rather than doing the TME endoluminally, it is done outside the lumen. You get the sacrum and the mesorectum and don't need any additional instruments.”

The surgeon can also control the neurovascular bundles and see the mesorectum during the transanal procedure.

D'Hoore said the transanal approach overcomes a major independent predictor for conversion and morbidity in laparoscopic TME, the narrow male pelvis.

The approach is also an improvement over laparoscopic TME in a subgroup of patients with bulky mesorectum. Even with fine visual control, it is technically very difficult to retract the mesorectum and reach the pelvic floor, he said.

“Transanal TME is a technique in evolution and the learning curve still has to be defined, but it reduces the need for conversions to laparotomy,” he said, predicting that technology will follow with different new transanal platforms and robotic adaptations.

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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