Comparative efficacy analysis of laparoscopic-assisted transanal total mesorectal excision vs laparoscopic transanal mesorectal excision for low-lying rectal cancer

BACKGROUND With the continuous development of laparoscopic techniques in recent years,laparoscopic total mesorectal excision(LapTME)and laparoscopic-assisted transanal total mesorectal excision(TaTME)have gradually become important surgical techniques for treating low-lying rectal cancer(LRC).However,there is still controversy over the efficacy and safety of these two surgical modalities in LRC treatment.AIM To compare the efficacy of LapTME vs TaTME in patients with LRC.METHODS Ninety-four patients with LRC who visited and were treated at the Affiliated Hengyang Hospital of Hunan Normal University&Hengyang Central Hospital between December 2022 and March 2024 were selected and divided into the LapTME(n=44)and TaTME(n=50)groups.Clinical operation indexes,postoperative recovery indicators,and postoperative complications were recorded.The anal resting pressure(ARP),anal maximum systolic pressure(MSP),and maximum tolerated volume(MTV)of the anal canal were also measured.The intestinal function of patients was evaluated by the Memorial Sloan Kettering Cancer Center(MSKCC)bowel function questionnaire.Serum norepinephrine(NE),adrenaline(AD),and cortisol(Cor)levels were measured.The Quality of Life Questionnaire Core 30(QLQC30)was used for quality of life assessment.RESULTS Compared with the LapTME group,the surgery time in the TaTME group was longer;intraoperative blood loss was low;time of anal exhaust,first postoperative ambulation,intestinal recovery,and hospital stay were shorter;and the distal incisal margin and specimen lengths were longer.The TaTME group also showed higher ARP,MSP,and MTV values and higher MSKCC and QLQ-C30 scores than the LapTME group 3 months postoperatively.Cor,AD,and NE levels were lower in the TaTME group than those in the LapTME group during recovery.CONCLUSION We demonstrated that TaTME better improved anal function,reduced postoperative stress,and accelerated postoperative recovery and,hence,was safer for patients with LRC.

Evolution of transanal total mesorectal excision for rectal cancer:From top to bottom

The gold standard for curative treatment of locally advanced rectal cancer involves radical resection with a total mesorectal excision(TME). TME is the most effective treatment strategy to reduce local recurrence and improve survival outcomes regardless of the surgical platform used. However, there are associated morbidities, functional consequences, and quality of life(QoL) issues associated with TME; these risks must be considered during the modern-day multidisciplinary treatment for rectal cancer. This has led to the development of new surgical techniques to improve patient, oncologic, and QoL outcomes. In this work, we review the evolution of TME to the transanal total mesorectal excision(TaTME) through more traditional minimally invasive platforms. The review the development, safety and feasibility, proposed benefits and risks of the procedure, implementation and education models, and future direction for research and implementation of the TaTME in colorectal surgery. While satisfactory short-term results have been reported, the procedure is in its infancy, and long term outcomes and definitive results from controlled trials are pending.As evidence for safety and feasibility accumulates,structured training programs to standardize teaching,training, and safe expansion will aid the safe spread of the TaTME.

Real-time in vivo distal margin selection using confocal laser endomicroscopy in transanal total mesorectal excision for rectal cancer

BACKGROUND Transanal total mesorectal excision(TaTME)allows patients with ultralow rectal cancer to be treated with sphincter-saving surgery.However,accurate delineation of the distal resection margin(DRM),which is essential to achieve R0 resection for low rectal cancer in TaTME,is technically demanding.AIM To assess the feasibility of optical biopsy using probe-based confocal laser endomicroscopy(pCLE)to select the DRM during TaTME for low rectal cancer.METHODS A total of 43 consecutive patients who were diagnosed with low rectal cancer and scheduled for TaTME were prospectively enrolled from January 2019 to January 2021.pCLE was used to determine the distal edge of the tumor as well as the DRM during surgery.The final pathological report was used as the gold standard.The diagnostic accuracy of pCLE examination was calculated.RESULTS A total of 86 pCLE videos of 43 patients were included in the analyses.The sensitivity,specificity and accuracy of real-time pCLE examination were 90.00%[95%confidence interval(CI):76.34%-97.21%],86.96%(95%CI:73.74%-95.06%)and 88.37%(95%CI:79.65%-94.28%),respectively.The accuracy of blinded pCLE reinterpretation was 86.05%(95%CI:76.89%-92.58%).Furthermore,our results show satisfactory interobserver agreement(κ=0.767,standard error=0.069)for the detection of cancer tissue by pCLE.There were no positive DRMs(≤1 mm)in this study.The median DRM was 7 mm[interquartile range(IQR)=5-10 mm].The median Wexner score was 5(IQR=3-6)at 6 mo after stoma closure.CONCLUSION Real-time in vivo pCLE examination is feasible and safe for selecting the DRM during TaTME for low rectal cancer(clinical trial registration number:NCT04016948).

Transanal vs laparoscopic total mesorectal excision for rectal cancer:a multicenter randomized phase III clinical trial(TaLaR trial)protocol

Background:Total mesorectum excision(TME)is considered the standard surgical procedure for rectal-cancer treatment.Transanal TME(taTME)is a new procedure to treat low rectal cancer.Some published studies have proven that taTME can provide a better-quality resected specimen in low-rectal-cancer patients in comparison to the transabdominal procedure,yet long-term outcomes must be investigated.We designed this non-inferiority trial(TaLaR trial)to compare short-term and long-term outcomes between taTME and laparoscopic TME(lapTME)for rectal cancer.Methods:The TaLaR trial is a phase III open-labeled multicenter randomized-controlled trial.Patients who are diagnosed with rectal cancer with no more than T3N2 stage,and with the tumor location below the peritoneal reflection by magnetic resonance imaging scan,digital rectal examination,or colonoscopy,qualify for this study.After calculating,a total of 1,114 patients(557 per group)will be randomly allocated to either the taTME or the lapTME group.Primary endpoints are the 3-year disease-free survival(DFS)rate and the 5-year overall survival(OS)rate.Secondary endpoints include specimen quality,perioperative results,pelvic and anal function,and quality of life.Discussion:The TaLaR trial is expected to clarify whether taTME can achieve comparable oncological outcomes,as well as improve specimen quality and recovery conditions in rectal-cancer patients compared with lapTME.

Role of minimally invasive surgery for rectal cancer

Rectal cancer is one of the most common malignancies worldwide.Surgical resection for rectal cancer usually requires a proctectomy with respective lymphadenectomy(total mesorectal excision).This has traditionally been performed transabdominally through an open incision.Over the last thirty years,minimally invasive surgery platforms have rapidly evolved with the goal to accomplish the same quality rectal resection through a less invasive approach.There are currently three resective modalities that complement the traditional open operation:(1)Laparoscopic surgery;(2)Robotic surgery;and(3)Transanal total mesorectal excision.In addition,there are several platforms to carry out transluminal local excisions(without lymphadenectomy).Evidence on the various modalities is of mixed to moderate quality.It is unreasonable to expect a randomized comparison of all options in a single trial.This review aims at reviewing in detail the various techniques in regard to intra-/perioperative benchmarks,recovery and complications,oncological and functional outcomes.

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(Ta TME"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 Ta TME 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.

International consensus on natural orifice specimen extraction surgery(NOSES)for colorectal cancer

In recent years,natural orifice specimen extraction surgery(NOSES)in the treatment of colorectal cancer has attracted widespread attention.The potential benefits of NOSES including reduction in postoperative pain and wound complications,less use of postoperative analgesic,faster recovery of bowel function,shorter length of hospital stay,better cosmetic and psychological effect have been described in colorectal surgery.Despite significant decrease in surgical trauma of NOSES have been observed,the potential pitfalls of this technique have been demonstrated.Particularly,several issues including bacteriological concerns,oncological outcomes and patient selection are raised with this new technique.Therefore,it is urgent and necessary to reach a consensus as an industry guideline to standardize the implementation of NOSES in colorectal surgery.After three rounds of discussion by all members of the International Alliance of NOSES,the consensus is finally completed,which is also of great significance to the long-term progress of NOSES worldwide.

Re-appraisal and consideration of minimally invasive surgery in colorectal cancer

Throughout history,surgeons have been on a quest to refine the surgical treatment options for their patients and to minimize operative trauma.During the last three decades,there have been tremendous advances in the field of minimally invasive colorectal surgery,with an explosion of different technologies and approaches offered to treat well-known diseases.Laparoscopic surgery has been shown to be equal or superior to open surgery.The boundaries of laparoscopy have been pushed further,in the form of single-incision laparoscopy,natural-orifice transluminal endoscopic surgery and robotics.This paper critically reviews the pathway of development of minimally invasive surgery,and appraises the different minimally invasive colorectal surgical approaches available to date.