Transanal Total Mesorectal Excision Research Articles

Does Pathological Complete Response after Neoadjuvant Therapy Influence Postoperative Morbidity in Rectal Cancer after Transanal Total Mesorectal Excision?

It is still unclear if pathological complete response (pCR) after neoadjuvant chemoradiotherapy (CRT) in patients treated for rectal cancer causes worse postoperative outcomes, especially after transanal total mesorectal excision (TaTME). Worse postoperative outcomes might be an argument for an organ preserving watch and wait strategy in fragile patients and patients with comorbidities. The aim of this study is to evaluate whether patients treated for rectal cancer who had pCR to neoadjuvant therapy develop worse postoperative outcomes after TaTME than patients without complete response. Comparative retrospective analysis (with nearest neighbor matching algorithm) of postoperative outcomes in two groups of patients, with pCR, n = 15 and without pCR (non-pCR), n = 57. All patients were operated on only by one surgical approach, TaTME, for middle and distal rectal tumors. All procedures were performed by one surgical team between 2014 and 2020 at the University Hospital Brno in Czech Republic. Overall morbidity was comparable between the groups (pCR group - 53.8% vs. non-pCR - 38.6%, p = 0.381). Anastomotic leak (AL) was observed in 33.3% of patients with pCR and in 17.5% of patients in the non-pCR group without statistical significance (p = 0.281). In conclusion, pathological complete response after neoadjuvant therapy does not appear to affect postoperative morbidity in rectal cancer after TaTME. Therefore, in patients with complete response who are not adherent to W&W surveillance, surgical resection can be perform without increased postoperative complications.

Oncologic Outcomes After Transanal Total Mesorectal Excision for Rectal Cancer.

BACKGROUND:Recent series have raised concerns about the oncologic outcomes of transanal total mesorectal excision for mid and low rectal cancer. There is a paucity of large data sets from the United States to contribute to the ongoing international discourse.OBJECTIVE:This study aimed to investigate the rate of local recurrence and other oncologic outcomes in patients undergoing transanal total mesorectal excision for rectal adenocarcinoma.DESIGN:This study is a retrospective review of patients undergoing transanal total mesorectal excision for primary rectal cancer from January 2014 to December 2019.SETTINGS:This study was conducted at a single academic tertiary care medical center in the United States.PATIENTS:Consecutive patients aged ≥18 years undergoing surgical resection for primary rectal cancer were selected.INTERVENTION:The transanal total mesorectal excision procedures were performed utilizing a 2-team approach.MAIN OUTCOME MEASURES:Primary outcomes were pathologic quality, local and distant recurrence, treatment-related complications, and overall- and cancer-specific survival.RESULTS:Seventy-nine consecutive patients were included. The median age was 58 years (interquartile range, 50–64), and median BMI was 28 kg/m2 (interquartile range, 24.6–32.4). The mesorectum was complete in 69 patients (87.3%), nearly complete in 9 (11.4%), and incomplete in 1 (1.3%). There was circumferential resection margin involvement (<1 mm) in 4 patients (5.1%), and no patients had a positive distal margin (<1 mm) or intraoperative rectal perforation. Composite optimal pathology was achieved in 94.9% of specimens. Median follow-up was 29 months (range, 6–68). There were no local recurrences. Distant metastases were found in 10 (13.5%) patients and diagnosed after a median of 14 months (range, 0.6–53). Disease-free survival was 91.2% at 2 years, and overall survival was 94.7% at 2 years.LIMITATIONS:Retrospective design, a single center, and relatively short follow-up period were limitations of this study.CONCLUSION:The oncologic outcomes of this cohort support the use of transanal total mesorectal excision in the surgical management of mid to low rectal cancer at centers with appropriate expertise. See Video at http://links.lww.com/DCR/B723.RESULTADOS ONCOLÓGICOS DESPUÉS DE LA EXCISIÓN TOTAL DEL MESORRECTO POR VÍA TRANSANAL EN CASOS DE CÁNCER RECTAL ANTECEDENTES: Estudios recientes han suscitado preocupación sobre los resultados oncológicos de la excisión total del mesorecto por vía transanal en casos de cáncer de recto medio y bajo. Existe una gran escasez de conjuntos de datos en los Estados Unidos, para contribuir en el actual discurso internacional sobre el tema. OBJETIVO: Investigar la tasa de recurrencia local y otros resultados oncológicos en pacientes sometidos a una excisión total del mesorrecto por vía transanal por adenocarcinomas de recto. DISEÑO: Revisión retrospectiva de pacientes sometidos a excisión total del mesorecto por vía transanal en casos de cáncer de recto primario desde enero de 2014 hasta diciembre de 2019. AJUSTE: Centro médico Universitario de atención terciaria único en los Estados Unidos. PACIENTES: Aquellos pacientes consecutivos de ≥ 18 años de edad, sometidos a resección quirúrgica por cáncer de recto primario. INTERVENCIÓN: Los procedimientos de excisión total del mesorecto por vía transanal se realizaron utilizando un enfoque de dos equipos. PRINCIPALES MEDIDAS DE RESULTADO: Los resultados primarios fueron la calidad anatomo-patológica de las piezas, la recidiva local y a distancia, las complicaciones relacionadas con el tratamiento y la sobrevida global específica para el cáncer. RESULTADOS: Se incluyeron 79 pacientes consecutivos. La mediana de edades fue de 58 años (IQR, 50–64) y la mediana del índice de masa corporal fue de 28 kg / m (IQR, 24,6–32,4). El mesorrecto se encontraba completo en 69 pacientes (87,3%), casi completo en 9 (11,4%) e incompleto en 1 (1,3%). Hubo afectación de CRM (<1 mm) en 4 pacientes (5,1%) y ningún paciente tuvo un margen distal positivo (<1 mm) o perforación rectal intraoperatoria. La histopatología óptima compuesta se logró en el 94,9% de las muestras. La mediana de seguimiento fue de 29 meses (rango 6–68). No se presentaron recurrencias locales. Se encontraron metástasis a distancia en 10 (13,5%) pacientes y se diagnosticaron después de una mediana de 14 meses (rango 0,6–53). La sobrevida libre de enfermedad fue del 91,2% a los 2 años y la sobrevida global fue del 94,7% a los 2 años. LIMITACIONES: Diseño retrospectivo, unicéntrico y período de seguimiento relativamente corto. CONCLUSIÓN: Los resultados oncológicos de este estudio de cohortes, apoyan la realización de excisión total del mesorecto por vía transanal para el tratamiento quirúrgico del cáncer de recto medio y bajo, en centros con la experiencia adecuada. Consulte Video Resumen en http://links.lww.com/DCR/B723. (Traducción—Dr. Xavier Delgadillo)

Development and evaluation of a virtual knowledge assessment tool for transanal total mesorectal excision.

Transanal total mesorectal excision (TATME) is difficult to learn and can result in serious complications. Current paradigms for assessing performance and competency may be insufficient. This study aims to develop and provide preliminary validity evidence for a TATME virtual assessment tool (TATME-VAT) to assess the cognitive skills necessary to safely complete TATME dissection. Participants from North America, Europe, Japan and China completed the test via an interactive online platform between 11/2019 and 05/2020. They were grouped into expert, experienced and novice surgeons depending on the number of independently performed TATMEs. TATME-VAT is a 24-item web-based assessment evaluating advanced cognitive skills, designed according to a blueprint from consensus guidelines. Eight items were multiple choice questions. Sixteen items required making annotations on still frames of TATME videos (VCT) and were scored using a validated algorithm derived from experts' responses. Annotation (range 0-100), multiple choice (range 0-100), and overall scores (sum of annotation and multiple-choice scores, normalized to μ = 50 and σ = 10) were reported. There were significant differences between the expert, experienced, and novice groups for the annotation (p < 0.001), multiple-choice (p < 0.001), and overall scores (p < 0.001). The annotation (p = 0.439) and overall (p = 0.152) scores were similar between the experienced and novice groups. Annotation scores were higher in participants with 51 or more vs. 30-50 vs. less than 30 cases. Scores were also lower in users with a self-reported recent complication vs. those without. This study describes the development of an interactive video-based virtual assessment tool for TATME dissection and provides initial validity evidence for its use.

AB026. SOH22ABS096. Any port in a storm?—Tips and tricks from the surgical toolkit of robotic, transanal total mesorectal excision (TaTME), laparoscopic and open approaches to access a rectal stump in a frozen pelvis

AB026. SOH22ABS096. Any port in a storm?—Tips and tricks from the surgical toolkit of robotic, transanal total mesorectal excision (TaTME), laparoscopic and open approaches to access a rectal stump in a frozen pelvis

Transanal total mesorectal excision oncological results

Relevance. Transanal total mesorectal is a new surgical technique of rectal cancer treatment. Purpose of research. To evaluate transanal total mesorectal excision oncological results. Materials and methods. 66 patients with rectal cancer I–IV stage were included. Results. Median follow-up was 42.9±22.8 (1–83.7) months. Progression of the disease was in 13 (19.7%) cases. Local recurrence rate was 5 (7.6%) with mean time to recurrence 14.2±11.3 (5–32.3) months. Distant metastasis was diagnosed in 10 (15.2%) cases, mean time when they were diagnosed was 15.04±12.09 (3.5–37.5) months. Combination of local recurrences and distant metastasis was in 2 (3%) cases. Seven (10.6%) patients died. Mean life expectancy was 27.3±17.2 (8.0–50.2) months. Five (7.5%) patients died because of progression of oncological disease. Mean life expectancy was 34.11±15.5 (15.5–50.2) months. Six-year local recurrence free, disease free and overall survival was 77, 87 и 84%, respectively. No risk factors of local recurrence were found. Conclusion. Transanal total mesorectal excision oncological results are сomparable with conventional surgery, though further trials are necessary.

The advantages of transanal total mesorectal excision for residual cancer of the rectal stump after subtotal colectomy for ulcerative colitis – A Video Vignette

-

A Way to Start Transanal Total Mesorectal Excision for Rectal Cancer

Abstract Introduction The optimal rectal cancer care is achieved by a multidisciplinary approach, with a high-quality surgical resection, with complete mesorectal excision and adequate margins. New approaches like the transanal total mesorectal excision (TaTME) aim to achieve these goals, maximizing the sphincter preservation ratio, with good oncologic and functional results. This report describes a way to implement TaTME without a proctor, presents the first case series of this approach in a center experienced in rectal cancer, and compares the results with those of the international literature. Methods We performed a retrospective study of the first 10 consecutive patients submitted to TaTME for rectal cancer at our institution. The primary outcomes were postoperative complications, pathological specimen quality and local recurrence rate. The results and performance were compared with the outcomes of a known structured program with proctorship and with the largest meta-analysis on this topic. Results All patients had locally advanced cancer; therefore, all underwent neoadjuvant therapy. A total of 30% had postoperative complications, without mortality or re-admissions. In comparison with the structured training program referred, no differences were found in postoperative complications and reintervention rates, resulting in a similar quality of resection. Comparing these results with those of the largest meta-analysis on the subject, no differences in the postoperative complication rates were found, and very similar outcomes regarding anastomotic leaks and oncological quality of resection were registered. Conclusion The results of this study validate the safety and effectiveness of our pathway regarding the implementation of the TaTME approach, highlighting the fact that it should be done in a center with proficiency in minimally invasive rectal surgery.

Transanal total mesorectal excision and robotic ultra‐low anterior resection with en bloc left seminal vesicle excision: a video vignette

Transanal TME is typically utilised for resection of low rectal lesions to overcome the potential technical limitations of abdominal TME resections. Advanced applications for beyond TME surgery have rarely been described. Herein we adopt a hybrid robotic transanal TME approach with Indocyanine Green injection into the ureters for a safe en-bloc resection of seminal vesicle with an ultra-low anterior resection. The combined technique allows the abdominal operator to leave the standard anatomical plane and subsequently return to it for seamless seminal vesicle resection. This may provide a useful aid for colorectal surgeons when it comes to T4 resections.

Pathologic outcomes of transanal versus laparoscopic total mesorectal excision for rectal cancer: a meta-analysis of 26 studies.

Transanal total mesorectal excision (TaTME) has the potential advantages for patients with low rectal cancer. The objective of this meta-analysis was to identify the pathologic outcomes between the TaTME and laparoscopic total mesorectal excision (LaTME) in rectal cancer. The literature searches were conducted in PubMed, Cochrane Library, and EMBASE with English language restriction. The primary endpoint was circumferential margin (CRM), and the secondary endpoints were distal resection margin (DRM), mesorectal excision quality, and harvested lymph nodes. Our research identified 1090 articles, and 26 studies met the inclusion criteria for the meta-analysis. The positive CRM was lower in the TaTME than the LaTME (OR = 0.72; 95% CI = 0.53, 0.98; P = 0.04). There was no significant difference in the positive CRM between the TaTME and LaTME published after 2016 (OR = 0.80; 95% CI = 0.57, 1.12; P = 0.19), prospective study (OR = 2.70; 95% CI = 0.51, 14.24; P = 0.24), respective study (OR = 0.76; 95% CI = 0.55, 1.04; P = 0.09), BMI > 26 (OR = 1.00; 95% CI = 0.63, 1.58; P = 0.98), or sample size > 100 (OR = 0.84; 95% CI = 0.57, 1.23; P = 0.38). In addition, there was no significant difference observed between the TaTME and LaTME in terms of DRM, mesorectum incompleteness, and harvested lymph nodes. The TaTME is associated with lower positive CRM compared to the LaTME and similar pathologic outcomes including DRM, harvested lymph node, and mesorectal excision quality.

Risk factors for postoperative ileus after diverting loop ileostomy closure

BackgroundPostoperative ileus is one of the most common complications after diverting loop ileostomy closure. Some reports have investigated the risk factors for postoperative complications or ileus after ileostomy closure; however, these studies did not evaluate the index surgery sufficiently. In this study, we evaluated the risk factors, including the details of the index surgery, for ileus after diverting ileostomy closure.MethodsThis was a retrospective study of patients who underwent ileostomy closure following index surgery for rectal cancer. Patients who developed postoperative ileus [POI (+)] and patients who did not [POI (−)] after ileostomy closure were compared.ResultsSixty-eight patients were evaluated and were divided into two groups: POI (+) (n = 11) and POI (−) (n = 57), and the groups were compared. There were no significant differences in the details of the index surgery, operative procedure, transanal total mesorectal excision, lateral lymph node dissection, operating time, or blood loss. The incidence of Clavien–Dindo grade ≥ III complications and adjuvant chemotherapy after index surgery were significantly higher in the POI (+) group.ConclusionsThe incidence of Clavien–Dindo grade ≥ III complications and adjuvant chemotherapy after index surgery may increase the risk of postoperative ileus after ileostomy closure.

Structured training curriculums for transanal total mesorectal excision in China: refinement is needed.

BackgroundTransanal total mesorectal excision (TaTME) is an alternative for mid-low rectal cancer. In China, this procedure has been performed in high-volume centers with structured training curriculums. The efficacy of the TaTME structured training curriculums in China is still unclear. This multicenter study aimed to explore the effectiveness of the structured training curriculums in China.MethodsSeven high-volume centers in China participated in this study. The first 25 patients who underwent TaTME in each center were enrolled. In the cohort, patients were divided into 3 groups. The first 5 procedures (group 1) were performed under proctoring according to the requirement of structured training curriculums. The latter 20 cases without proctoring were split into 2 groups (10 cases in each group, groups 2 and 3) according to the order of operation date. The baseline characteristics, perioperative complications, and pathological outcomes were compared between groups 1 and 2, as well as between groups 2 and 3.ResultsSymptomatic anastomotic leakage (AL) occurred in 18.6% of the patients in group 2 compared with 5.7% in group 1 (P1=0.08) and 5.0% in group 3 (P2=0.04). Seven (11.3%) patients in group 2 developed defecation disorders whereas no patients had this complication in group 3 (P2=0.02). Compared with group 2, the operative time was shorter (235 vs. 223 min, P2=0.40), while the rates of intraoperative complications (15.7% vs. 5.7%, P2=0.10), postoperative complications (31.3% vs. 25.7%, P2=0.06), AL (20.0% vs. 8.6%, P2=0.04), and positive distal resection margin (DRM) (7.5% vs. 2.9%, P2=0.27) were lower in group 3.ConclusionsThe effect of the structured training curriculums was acceptable but needed further improvement. The prevalence of anastomosis-related complications and the quality control of specimens are still not optimal, and measures for refinement (for example, more cases under proctoring) are needed in the curriculums.

Redo surgery after low anterior resection for chronic pelvic sinus and anastomotic disruption. Could pull-through procedure with delayed anastomosis be a feasible alternative? Case reports and narrative review.

IntroductionA considerable step forward in low rectal cancer resection has been done in the last decades. Maintaining total mesorectal excision as the gold standard treatment, new techniques such as Trans-Anal Mini-Invasive Surgery (TAMIS) and Trans-Anal Total Mesorectal Excision (TATME), which have been added to improve skills in laparoscopic and robotic surgery, currently represent the advancement of this procedure. Despite improvements in surgical techniques, complications after low anterior resection for rectal cancer still remain a challenge. Drainage and colostomy are the main treatments used to overcome the problem caused by anastomosis failure, and most patients will never been restored. Different techniques of redo surgery could be proposed to deal complex cases, although remaining high risk procedures.Case presentationWe present two clinical cases with a late complication of the colorectal anastomosis: one with a late leakage of low colorectal anastomoses, treated with Hartman procedure, that developed a pelvic chronic sinus; the another one with complete anastomotic disruption after massive suture bleeding; both treated with delayed pull-through anastomosis, according to Turnbull-Cutait technique. We also made a review of relative literature, in order to back our therapeutic iters.DiscussionBoth the procedures were carried out satisfactorily, with restoration of intestinal continuity and good anastomotic result. It allows the resolutions of the chronic sepsis caused by the pelvic sinus and maintenance of intestinal continuity with a good Wexner incontinence score. Literary review demonstrated that this procedure still remains undervalued and not widely exploited.ConclusionDelayed pull-through coloanal anastomosis could be considered as a valid option, in order to preserve intestinal continuity in septic or complicated low colorectal anastomosis.

Short-term complications after transanal total mesorectal excision for mid-low rectal cancer

Objective: To summarize short-term postoperative complications of transanal total mesorectal excision (taTME) in the treatment of middle-low rectal cancer. Methods: A descriptive case series of cases was constructed. Clinical data of consecutive 83 patients with mid-low rectal cancer who received taTME treatment from November 2016 to April 2021 at Department of General Surgery of Beijing Friendship Hospital, Capital Medical University were collected. Among 83 patients, 58 (69.9%) were males, with a mean age of (61.4±11.8) years; 42 (50.6%) were low rectal cancer, 41 (49.4%) were middle rectal cancer. Short-term postoperative complication was defined as complication occurring within 30 days after operation. The complication was graded according to the Clavien-Dindo classification. At the same time, the morbidity of short-term postoperative complication in the first 40 patients and that in the last 43 patients were compared to understand the differences before and after passing the taTME learning curve. Results: Two patients (2.5%) were converted to laparotomy ; 78 (94.0%) completed anastomosis.While 5 (6.0%) underwent permanent stoma. The total operation time of transabdominal+ transanal procedure was (246.9±85.0) minutes, and the median intraoperative blood loss was 100 (IQR: 100) ml. Seventy-five cases (75 /78, 96.2%) underwent defunctioning stoma, including 74 cases of diverting ileostomy, 1 case of diverting transverse colostomy and 3 cases without stoma. The morbidity of complication within 30 days after operation was 38.6% (32/83), and the morbidity of complication after discharge was 8.4% (7/83). Minor complications accounted for 31.3% (26/83) and major complications accounted for 7.2% (6/83). No patient died within 30 days after operation. The incidence of anastomotic leakage was 15.4% (12/78). Eight patients (9.6%) were hospitalized again due to complications after discharge. The median postoperative hospital stay was 7 (IQR: 3) days. All the patients with minor (I-II) complications received conservative treatment. One patient with grade C anastomotic leakage was transferred to intensive care unit and received a second operation due to sepsis and multiple organ dysfunction. Two patients with paralytic ileus (Clavien-Dindo IIIa) underwent endoscopic ileus catheter placement. There were 3 patients with Clavien-Dindo III or above respiratory complications, including 1 patient with pleural effusion and ultrasound-guided puncture, 2 patients with respiratory failure who were improved and discharged after anti-infection and symptomatic treatment. One patient underwent emergency ureteral stent implantation due to urinary infection (Clavien-Dindo IIIb). The morbidity of postoperative complication in the first 40 cases was 50.0% (20/40), and that in the latter 43 cases decreased significantly (27.9%, 12/43), whose difference was statistically significant (χ(2)=4.270, P=0.039). Conclusions: The procedure of taTME has an acceptable morbidity of short-term postoperative complication in the treatment of mid-low rectal cancer. The accumulation of surgical experience plays an important role in reducing the morbidity of postoperative complication.

Transanal Endoscopic Platforms: TAMIS versus Rigid Platforms: Pros and Cons.

Transanal endoscopic surgery encompasses the minimally invasive surgical techniques used to operate in the rectum under magnification while maintaining pneumorectum via a resectoscope or port. The view, magnification, and surgical precision afforded by these advanced transanal techniques have resulted in excellent specimen quality and low recurrence rates, especially compared with traditional transanal surgery. For rigid platforms, the surgeon operates through a rigid 4-cm diameter steel proctoscope of varying lengths that is clamped to the operating table with an articulating arm. Transanal minimally invasive surgery (TAMIS) is a newer flexible platform using a disposable port which "hooks" into the anorectal ring to remain in place. The cost-effectiveness and versatility of the TAMIS platform have resulted in its popularity and use in more advanced applications such as transanal total mesorectal excision. Ultimately, the choice of operating platform should be based on surgeon preference, patient characteristics, availability, and cost. The pros and cons of each platform will be discussed in this article.

Limitations and Concerns with Transanal Total Mesorectal Excision for Rectal Cancer.

Transanal total mesorectal excision (TaTME) was developed to overcome the technical challenges of a minimally invasive (ultra-) low anterior resection. This new technique has recently come under careful scrutiny as technical pitfalls were reported, in specific relation to the transanal approach. Patients are at risk for urologic lesions. Moreover, carbon dioxide embolism is a rare but potentially life-threatening complication. The benefit of TaTME from an oncological point of view has neither been clarified. Hypothetically, better visualization of the lower rectum could lead to better dissection and total mesorectal excision (TME) specimens, resulting in better oncologic results. Up until now, retrospective multicenter reports seem to show that short-term oncologic results are not inferior after TaTME as compared with after laparoscopic TME. Alarming reports have however been published from Norway suggesting a high incidence and particular multifocal pattern of early local recurrence. In this article, a balanced overview is given of the most important technical pitfalls and oncological concerns arising with this new procedure.

Transanal versus Laparoscopic Total Mesorectal Excision in Male Patients with Low Tumor Location after Neoadjuvant Therapy: A Propensity Score-Matched Cohort Study.

Background Since Sylla and Lacy successfully reported the transanal total mesorectal excision in 2010, taTME was considered to have the potential to overcome some problematic laparoscopic cases in male, low advanced rectal cancer. However, the evidence is still lacking. This study compared the short and long outcomes of taTME with laTME in these “challenging” patients to explore the advantages of taTME among the patients. Method After propensity score matching analysis, 106 patients were included in each group from 325 patients who met the including standard. Statistical analysis was used to compare the differences of perioperative outcomes, histopathological results, and survival results between taTME and laTME groups. Results The mean time of pelvic operation in the taTME group was significantly shorter than in the laTME group (62.2 ± 14.2 mins vs 81.1 ± 18.9 mins, P = 0.003). The complication incidence rate and the rate of protective loop ileostomy in the taTME group were significantly lower than those in the laTME group (19.8% vs 38.7%, P = 0.003 and 70.8% vs 92.5%, P < 0.001). In long-term result, there was no significant difference between the two groups for 3-year OS (87.3% vs 85.4%, P = 0.86) or 3-year DFS (74.9% vs 70.1%, P = 0.92). The 2-year cumulative local recurrence rate was similar between the two groups (1.1% vs 5.8%, P = 0.22). Conclusion This study demonstrated that taTME might reduce the incidence of postoperative complications, especially of anastomotic leakage in these “challenging” patients. taTME may be considered to have clear advantages for “challenging” patients.

UEG and EAES rapid guideline: Systematic review, meta-analysis, GRADE assessment and evidence-informed European recommendations on TaTME for rectal cancer

BackgroundEvidence and practice recommendations on the use of transanal total mesorectal excision (TaTME) for rectal cancer are conflicting.ObjectiveWe aimed to summarize best evidence and develop a rapid guideline using transparent, trustworthy, and standardized methodology.MethodsWe developed a rapid guideline in accordance with GRADE, G-I-N, and AGREE II standards. The steering group consisted of general surgeons, members of the EAES Research Committee/Guidelines Subcommittee with expertise and experience in guideline development, advanced medical statistics and evidence synthesis, biostatisticians, and a guideline methodologist. The guideline panel consisted of four general surgeons practicing colorectal surgery, a radiologist with expertise in rectal cancer, a radiation oncologist, a pathologist, and a patient representative. We conducted a systematic review and the results of evidence synthesis by means of meta-analyses were summarized in evidence tables. Recommendations were authored and published through an online authoring and publication platform (MAGICapp), with the guideline panel making use of an evidence-to-decision framework and a Delphi process to arrive at consensus.ResultsThis rapid guideline provides a weak recommendation for the use of TaTME over laparoscopic or robotic TME for low rectal cancer when expertise is available. Furthermore, it details evidence gaps to be addressed by future research and discusses policy considerations. The guideline, with recommendations, evidence summaries, and decision aids in user-friendly formats can also be accessed in MAGICapp: https://app.magicapp.org/#/guideline/4494.ConclusionsThis rapid guideline provides evidence-informed trustworthy recommendations on the use of TaTME for rectal cancer.

New Frontiers in Management of Early and Advanced Rectal Cancer.

Simple SummaryRectal cancer has the capacity to present in a variety of forms. Depending on subtle differences in the characteristics of the tumor, it is possible for the treatment protocol to vary drastically. There are many tools available to optimize patients’ outcomes when treating rectal cancer of these various stages. Advances in early-stage, local presentation of rectal cancer focus on minimally invasive endoluminal surgery. Lesions completely responding to neoadjuvant chemoradiation non-operative surveillance have been explored. For rectal cancers patients with problematic pelvic anatomy, new platforms for resection, such as transanal total mesorectal excision and robotic total mesorectal excision, have been introduced. Late solid organ and peritoneal metastasis, originally thought to be a terminal disease, have undergone recent advances in hepatic and pulmonary metastasectomy, cytoreductive surgery, and intraperitoneal chemotherapy. Understanding these various therapeutic interventions will pave the way for improved patient outcomes.It is important to understand advances in treatment options for rectal cancer. We attempt to highlight advances in rectal cancer treatment in the form of a systematic review. Early-stage rectal cancer focuses on minimally invasive endoluminal surgery, with importance placed on patient selection as the driving factor for improved outcomes. To achieve a complete pathologic response, various neoadjuvant chemoradiation regimens have been employed. Short-course radiation therapy, total neoadjuvant chemotherapy, and others provide unique advantages with select patient populations best suited for each. With a clinical complete response, a “watch and wait” non-operative surveillance has been introduced with preliminary equivalency to radical resection. Various modalities for total mesorectal excision, such as robotic or transanal, have advantages and can be utilized in select patient populations. Tumors demonstrating solid organ or peritoneal spread, traditionally defined as unresectable lesions conveying a terminal diagnosis, have recently undergone advances in hepatic and pulmonary metastasectomy. Hepatic and pulmonary metastasectomy has demonstrated clear advantages in 5-year survival over standard chemotherapy. With the peritoneal spread of colorectal cancer, HIPEC with cytoreductive therapy has emerged as the preferred treatment. Understanding the various therapeutic interventions will pave the way for improved patient outcomes.

Surgical Training for Transanal Total Mesorectal Excision in a Live Animal Model: A Preliminary Experience.

Background: In this preliminary experience, the feasibility and effectiveness of surgical training with an animal model for transanal total mesorectal excision (TaTME) were evaluated. Methods: The training was conducted in two experimental animal laboratories in Italy authorized by the Italian Ministry of Health, using female Danish Landrace pigs under the supervision of surgeons with extensive experience in TaTME, animal laboratory training and cadaver laboratory training. The procedure was divided into separate steps, and all the participants were guided step-by-step throughout the entirety of the procedure. Results: During all the editions of the animal laboratory, all the procedures were completed with no major damage to the anatomical structures or intraoperative death of the animals. Live animal tissue is very similar to human tissue, helping trainees improve their tactile feedback. The bleeding effect improved the value of the training and taught the participants how to address this complication. The lack of mesorectal tissue in pigs compared with humans was the main difference. Animal laboratories should not be considered alternatives to cadaver laboratories but as complementary training activities due to their effectiveness and lower costs. Conclusions: Surgical training in animal models for TaTME seems to be effective and could be an opportunity to improve training alongside the use of a cadaver laboratory and proctoring.

Report from 'ESCP 2021 Virtual': the 16th Scientific and Annual Conference of the European Society of Coloproctology, 22-24 September 2021.

Report from 'ESCP 2021 Virtual': the 16th Scientific and Annual Conference of the European Society of Coloproctology, 22-24 September 2021.