Abstract
AimTo evaluate the evidence concerning the quality of surgical resection in laparoscopic (LapTME), robotic (RobTME) and transanal (TaTME) total mesorectal excision for mid-/low rectal cancer.MethodsA systematic literature search of the PubMed, EMBASE and Cochrane Central Register of Controlled Trials databases was performed. A Bayesian network meta-analysis was utilized to compare surgical resection involved in these 3 surgical techniques by using ADDIS software. Rates of positive circumferential resection margins (CRMs) were the primary endpoint.ResultsA total of 34 articles, 2 randomized clinical trials (RCTs) and 32 non-RCTs, were included in this meta-analysis. Pooled data showed CRM positivity in 114 of 1763 LapTME procedures (6.5%), 54 of 1051 RobTME procedures (5.1%) and 60 of 1276 TaTME procedures (4.7%). There was no statistically significant difference among these 3 surgical approaches in terms of CRM involvement rates and all other surgical resection quality outcomes. The incomplete mesorectal excision rates were 9.6% (69/720) in the LapTME group, 1.9% (11/584) in the RobTME group and 5.6% (45/797) in the TaTME group. Pooled network analysis observed a higher but not statistically significant risk of incomplete mesorectum when comparing both LapTME with RobTME (OR = 1.99; 95% CI = 0.48-11.17) and LapTME with TaTME (OR = 1.90; 95% CI = 0.99-5.25). By comparison, RobTME was most likely to be ranked the best or second best in terms of CRM involvement, complete mesorectal excision, rate of distal resection margin (DRM) involvement and length of DRMs. In addition, RobTME achieved a greater mean tumor distance to the CRM than TaTME. It is worth noting that TaTME was most likely to be ranked the worst in terms of CRM involvement for intersphincteric resection of low rectal cancer.ConclusionOverall, RobTME was most likely to be ranked the best in terms of the quality of surgical resection for the treatment of mid-/low rectal cancer. TaTME should be performed with caution in the treatment of low rectal cancer.
Highlights
Total mesorectal excision (TME) remains the leading surgical approach in the treatment of patients with mid- and low rectal cancer [1]
Specific research equations were formulated for each database using the following search terms: rectal cancer, rectal carcinoma, surgery, total mesorectal excision, laparoscopy, laparoscopic surgery, transanal total mesorectal excision, TaTME, and robotic surgery
Pooled network analysis observed a higher but not statistically significant risk of incomplete mesorectum when comparing both laparoscopic TME (LapTME) with RobTME (OR = 1.99; 95% confidence interval (CI) = 0.48-11.17) and LapTME with TaTME (OR = 1.90; 95% CI = 0.99-5.25)
Summary
Total mesorectal excision (TME) remains the leading surgical approach in the treatment of patients with mid- and low rectal cancer [1]. The feasibility of laparoscopic TME (LapTME) has been assessed in several studies and has been widely practiced as an alternative to open surgery in the treatment of mid-/low rectal cancer. This procedure has been found to be oncologically safe and associated with minimally invasive advantages, such as less pain, a shorter hospitalization time, and faster bowel function return [2]. Two randomized studies [ALaCaRT trial [3] and ACOSOG Z6051 trial [4]] on laparoscopic and open surgeries for the treatment of rectal cancer raised concerns regarding the quality of oncological resection, highlighting the risk of positive circumferential resection margins (CRMs) and incomplete mesorectal excision
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