Experience beyond the learning curve of transanal total mesorectal excision (taTME) and its effect on the incidence of anastomotic leak.

BACKGROUND: The most important advancement in the surgical management of rectal cancer has been the introduction of total mesorectal excision (TME). Technical limitations to approaching mid and distal lesions remain. The recently described transanal TME makes it possible to minimize some of the difficulties by improving access. Anastomotic leak is a persistent concern after colorectal surgery no matter what technique is used. The objective of this study was to explore the impact of experience on the incidence of anastomotic leak after transanal TME. Secondary endpoints were local recurrence and margin status. METHODS: A retrospective cohort study was conducted over a period of 3 years at a tertiary care center in Northern Ontario with high volume of rectal cancer patients. The initial 100 consecutive patients with rectal neoplasia who had transanal TME surgery were included. All cases were performed by a single team. The main outcome assessed was the incidence of anastomotic leak beyond a pre-determined learning curve, as previously established in the literature. For statistical analysis, associations between patient characteristics and outcomes were estimated using ordinary least squares and logistic regression. RESULTS: Six cases of anastomotic leak occurred over the course of the study, the last of which occurred in the 37th patient. Relative to a baseline anastomotic leak rate of 7.8%, cumulative sum (CUSUM) analysis indicated that a 50% improvement in risk occurred at trial 50 of 85 patients that had an anastomosis performed. Two patients developed local recurrence during the study period. No correlation between learning curve and oncologic outcomes was identified. CONCLUSIONS: Proficiency is likely to have a positive effect on the 30-day occurrence of anastomotic leak. Larger studies are required to explore the impact of experience on local recurrence.

Transperineal minimally invasive APE: preliminary outcomes in a multicenter cohort.

BACKGROUND: Abdominoperineal excision (APE) for rectal cancer is associated with a relatively high risk of positive margins and postoperative morbidity, particularly related to perineal wound healing problems. It is unknown whether the use of a minimally invasive approach for the perineal part of these procedures can improve postoperative outcomes without oncological compromise. The aim of this study was to evaluate the feasibility of minimally invasive transperineal abdominoperineal excision (TpAPE) METHODS: This multicenter retrospective cohort study included all patients having TpAPE for primary low rectal cancer. The primary endpoint was the intraoperative complication rate. Secondary endpoints included major morbidity (Clavien-Dindo ≥ 3), histopathology results, and perineal wound healing. RESULTS: A total of 32 TpAPE procedures were performed in five centers. A bilateral extralevator APE (ELAPE) was performed in 17 patients (53%), a unilateral ELAPE in 7 (22%), and an APE in 8 (25%). Intraoperative complications occurred in five cases (16%) and severe postoperative morbidity in three cases (9%). There were no perioperative deaths. A positive margin (R1) was observed in four patients (13%) and specimen perforation occurred in two (6%). The unilateral extralevator TpAPE group had worse specimen quality and a higher proportion of R1 resections than the bilateral ELAPE or standard APE groups. The rate of uncomplicated perineal wound healing was 53% (n = 17) and three patients (9%) required surgical reintervention. CONCLUSIONS: TpAPE seems to be feasible with acceptable perioperative morbidity and a relatively low rate of perineal wound dehiscence, while histopathological outcomes remain suboptimal. Additional evaluation of the viability of this technique is needed in the form of a prospective trial with standardization of the procedure, indication, audit of outcomes and performed by surgeons with vast experience in transanal total mesorectal excision.

Transanal total mesorectal excision (taTME) in a single-surgeon setting: refinements of the technique during the learning phase.

BACKGROUND: Transanal total mesorectal excision (taTME) is a safe and effective technique. We have progressively developed a systematic approach in the single-surgeon setting. The aim of this study was to compare our early vs late single-surgeon taTME experience as well as present the technical and logistical modifications that were crucial to achieve successful implementation of a taTME program. METHODS: Review of prospectively collected data on 27 patients who had taTME in June 2015-September 2016 (early cohort) was included and compared with 43 patients who underwent taTME in October 2016-September 2017 (late cohort). Procedures were performed by a single-surgeon team at Health Sciences North (Sudbury, Ontario, Canada). Inclusion criteria were T1-3 or downstaged T4 mid- and low-rectal lesions. Cases of non-neoplastic disease were excluded. Outcomes assessed included mesorectal integrity, margin status, operative time, complications, morbidity, length of stay and 30-day readmission. RESULTS: A total of 70 cases were included. Patients were divided into early (27 patients, 14 males; mean age 60.74 ± 9.77 years) and late (43 patients, 29 males; mean age 63.48 ± 10.85 years) cohorts. During the early phase, procedural modifications including regular takedown of the splenic flexure, intra-corporeal division of the mesentery, liberal use of a Pfannenstiel incision for extraction, abundant washing of the surgical field and regular use of the ICG technology were progressively introduced. There was no mortality nor statistically significant difference between the early and late cohort in terms of morbidity (33.3 vs 39.4% p = 0.727), anastomotic leak (14.8 vs 4.6% p = 0.19), operating time (5.05 ± 1.26 vs 4.96 ± 1.14 h p = 0.755), length of stay (4.0 ± 2.54 vs 4.81 ± 3.63 days p = 0.394) and CRM negative margin (96.3 vs. 97.7% p = 0.999), and no incomplete specimens were obtained on either cohort. CONCLUSIONS: This study confirms the safety and effectiveness of single-surgeon implementation of taTME technique. Technical challenges experienced in this setting were not obstacles for further refinement and to establish a tendency towards better outcomes. Overcoming technical challenges is possible, familiarity with taTME is slow yet progressive, and improvement tends to occur with experience.

How Is Rectal Cancer Managed: a Survey Exploring Current Practice Patterns in Canada.

INTRODUCTION: Locally advanced rectal cancers are most often treated with neoadjuvant chemoradiation followed by surgical resection. However, there are differing opinions surrounding management of rectal cancer, including a lack of consensus on the optimal time interval between chemoradiation and surgery, and the management of patients with complete clinical response following neoadjuvant therapy. This study seeks to summarize management trends for rectal cancer among a sample of Canadian surgeons. METHODS: A 14-question survey was distributed to surgeons across Canada managing rectal cancer. Surgeons were identified from the membership lists of the Canadian Association of General Surgeons and the Canadian Society of Colon and Rectal Surgeons. Web-based questionnaires were distributed by email. RESULTS: A total of 115 surgeons were emailed the survey with a response rate of 38.4%. Approximately 50% of surgeon responders had been in practice for more than 10 years, with the majority practicing in academic centers. Half were considered high-volume rectal cancer surgeons with more than 20 cases per year. All surgeons used magnetic resonance imaging for staging of rectal cancer, but only 50% presented all rectal cancer cases at multidisciplinary cancer conferences. The majority of surgeons applied minimally invasive techniques for surgical resection, including the utilization of transanal endoscopic microsurgery (TEMs) and transanal minimally invasive surgery (TAMIS); however, only a small fraction performed high-volume transanal total mesorectal excision (taTME). Regarding the management of complete clinical response (cCR) following neoadjuvant chemoradiation, less than 5% chose the watch and wait management strategy for all patients and 40% did not use it at all. The majority of surgeons reported waiting between eight and 10 weeks between chemoradiation and surgery, and 40% made that decision regardless of patient or tumor factors. CONCLUSION: The majority of surveyed surgeons use MRI for pelvic staging and discuss rectal cancer cases at multidisciplinary cancer conference. Many are using minimally invasive techniques; however, the use of taTME is not yet widespread. Surgeons currently favor longer intervals from neoadjuvant chemoradiation to surgery, and the management strategy for patients with complete clinical response remains controversial. Great variability exists in rectal cancer management, thus presenting an opportunity for improvements by adopting standardization and centralization of rectal cancer management.