Objective: To methodically assess the clinical effectiveness and safety of robot-assisted total rectal mesenteric resection (RTME), laparoscopic-assisted total rectal mesenteric resection (laTME), and transanal total rectal mesenteric resection (taTME). Methods: A computer search was conducted on PubMed, Embase, Cochrane Library, and Ovid databases to identify English-language reports published between January 2017 and January 2022 that compared the clinical efficacy of the three surgical procedures of RTME, laTME, and taTME. The quality of the studies was evaluated using the NOS and JADAD scales for retrospective cohort studies and randomized controlled trials, respectively. Direct meta-analysis and reticulated meta-analysis were performed using Review Manager software and R software, respectively. Results: Twenty-nine publications comprising 8,339 patients with rectal cancer were ultimately included. The direct meta-analysis indicated that the length of hospital stay was longer after RTME than after taTME, whereas according to the reticulated meta-analysis the length of hospital stay was shorter after taTME than after laTME (MD=-0.86, 95%CI: -1.70 to -0.096, P=0.036). Moreover, the incidence of anastomotic leak was lower after taTME than after RTME (OR=0.60, 95%CI: 0.39 to 0.91, P=0.018). The incidence of intestinal obstruction was also lower after taTME than after RTME (OR=0.55, 95%CI: 0.31 to 0.94, P=0.037). All of these differences were statistically significant (all P<0.05). There were no statistically significant differences between the three surgical procedures regarding the number of lymph nodes cleared, length of the inferior rectal margin, or rate of positive circumferential margins (all P>0.05). An inconsistency test using nodal analysis revealed no statistically significant differences between the results of direct and indirect comparisons of the six outcome indicators (all P>0.05). Furthermore, we detected no significant overall inconsistency between direct and indirect evidence. Conclusion: taTME has advantages over RTME and laTME, in terms of radical and surgical short-term outcomes in patients with rectal cancer.
Humans ; Robotics ; Robotic Surgical Procedures/adverse effects* ; Network Meta-Analysis ; Retrospective Studies ; Postoperative Complications/etiology* ; Transanal Endoscopic Surgery/methods* ; Rectum/surgery* ; Rectal Neoplasms/pathology* ; Laparoscopy/methods* ; Treatment Outcome

Transanal total mesorectal resection (taTME) has come a long way since it was first used in the clinic in 2010.The learning curve of this procedure is long due to different surgical approaches, different perspectives and different anatomical positions. Many surgeons experience complications during this procedure. Although the advantages and problems of this procedure have been reported in much literature, the anatomy and operation methods of taTME introduced in literatures and training centers are too complicated, which makes many surgeons encounter difficulties in carrying out taTME surgery. According to the author's experience in learning and carrying out this operation, spatial expansion process of ultralow rectal cancer was divided into three stages. At each stage, according to different pulling forces, three different schemes of triangular stability mechanics model were adopted for separation. From point to line, from line to plane, the model can protect the safety of peripheral blood vessels and nerves while ensuring total mesorectal excision . This model simplifies the complex surgical process and is convenient for beginners to master taTME surgical separation skills.
Humans ; Rectum/surgery* ; Laparoscopy/methods* ; Transanal Endoscopic Surgery/methods* ; Rectal Neoplasms/surgery* ; Proctectomy/methods* ; Postoperative Complications ; Treatment Outcome

Although transanal endoscopic surgery has been developed for more than 40 years, it remains relatively unknown to most domestic colleagues. In 2019, the Chinese Society of Transanal Total Mesorectal Excision (CSTa) and the Chinese Society of Colon and Rectal Surgeons (CSCRS) organized domestic experts to write and publish the "Chinese Expert Consensus on Transanal Endoscopic Surgery (2019 Edition)", which elaborated on the definition, surgical methods, indications, contraindications, basic principles, key issues and complications of transanal endoscopic surgery, and provided a certain theoretical foundation for the development of transanal endoscopic surgery in China. In the past four years, the scope of application of transanal endoscopic techniques has been expanded, and many prospective and retrospective clinical research have provided more evidence-based medical evidence. Therefore, the Chinese Society of Transanal Total Mesorectal Excision (CSTa) once again organized domestic experts to write the "Expert Consensus and Operation Guidelines for Transanal Endoscopic Surgery in China (2023 Edition)", updating the expert consensus opinions on the definition, indications, complications and learning curve of transanal endoscopic surgery and adding operation guidelines. The aim is to promote the standardized practices in transanal endoscopic surgery and facilitate a shorter learning curve for surgeons.
Humans ; Rectum/surgery* ; Rectal Neoplasms/surgery* ; Consensus ; Prospective Studies ; Retrospective Studies ; Transanal Endoscopic Surgery/methods*

Objective: To compare the short-term and long-term outcomes between transanal total mesorectal excision (taTME) and laparoscopic total mesorectal excision (laTME) for mid-to-low rectal cancer and to evaluate the learning curve of taTME. Methods: This study was a retrospective cohort study. Firstly, consecutive patients undergoing total mesorectal excision who were registered in the prospective established database of Division of Colorectal Diseases, Department of General Surgery, Peking Union Medical College Hospital during July 2014 to June 2020 were recruited. The enrolled patients were divided into taTME and laTME group. The demographic data, clinical characteristics, neoadjuvant treatment, intraoperative and postoperative complications, pathological results and follow-up data were extracted from the database. The primary endpoint was the incidence of anastomotic leakage and the secondary endpoints included the 3-year disease-free survival (DFS) and the 3-year local recurrence rate. Independent t-test for comparison between groups of normally distributed measures; skewed measures were expressed as M (range). Categorical variables were expressed as examples (%) and the χ(2) or Fisher exact probability was used for comparison between groups. When comparing the incidence of anastomotic leakage, 5 variables including sex, BMI, clinical stage evaluated by MRI, distance from tumor to anal margin evaluated by MRI, and whether receiving neoadjuvant treatment were balanced by propensity score matching (PSM) to adjust confounders. Kaplan-Meier curve and Log-rank test were used to compare the DFS of two groups. Cox proportional hazard model was used to analyze and determine the independent risk factors affecting the DFS of patients with mid-low rectal cancer. Secondly, the data of consecutive patients undergoing taTME performed by the same surgical team (the trananal procedures were performed by the same main surgeon) from February 2017 to March 2021 were separately extracted and analyzed. The multidimensional cumulative sum (CUSUM) control chart was used to draw the learning curve of taTME. The outcomes of 'mature' taTME cases through learning curve were compared with laTME cases and the independent risk factors of DFS of 'mature' cases were also analyzed. Results: Two hundred and forty-three patients were eventually enrolled, including 182 undergoing laTME and 61 undergoing taTME. After PSM, both fifty-two patients were in laTME group and taTME group respectively, and patients of these two groups had comparable characteristics in sex, age, BMI, clinical tumor stage, distance from tumor to anal margin by MRI, mesorectal fasciae (MRF) and extramural vascular invasion (EMVI) by MRI and proportion of receiving neoadjuvant treatment. After PSM, as compared to laTME group, taTME group showed significantly longer operation time [(198.4±58.3) min vs. (147.9±47.3) min, t=-4.321, P<0.001], higher ratio of blood loss >100 ml during surgery [17.3% (9/52) vs. 0, P=0.003], higher incidence of anastomotic leakage [26.9% (14/52) vs. 3.8% (2/52), χ(2)=10.636, P=0.001] and higher morbidity of overall postoperative complications [55.8%(29/52) vs. 19.2% (10/52), χ(2)=14.810, P<0.001]. Total harvested lymph nodes and circumferential resection margin involvement were comparable between two groups (both P>0.05). The median follow-up for the whole group was 24 (1 to 72) months, with 4 cases lost, giving a follow-up rate of 98.4% (239/243). The laTME group had significantly better 3-year DFS than taTME group (83.9% vs. 73.0%, P=0.019), while the 3-year local recurrence rate was similar in two groups (1.7% vs. 3.6%, P=0.420). Multivariate analysis showed that and taTME surgery (HR=3.202, 95%CI: 1.592-6.441, P=0.001) the postoperative pathological staging of UICC stage II (HR=13.862, 95%CI:1.810-106.150, P=0.011), stage III (HR=8.705, 95%CI: 1.104-68.670, P=0.040) were independent risk factors for 3-year DFS. Analysis of taTME learning curve revealed that surgeons would cross over the learning stage after performing 28 cases. To compare the two groups excluding the cases within the learning stage, there was no significant difference between two groups after PSM no matter in the incidence of anastomotic leakage [taTME: 6.7%(1/15); laTME: 5.3% (2/38), P=1.000] or overall complications [taTME: 33.3%(5/15), laTME: 26.3%(10/38), P=0.737]. The taTME was still an independent risk factor of 3-year DFS only analyzing patients crossing over the learning stage (HR=5.351, 95%CI:1.666-17.192, P=0.005), and whether crossing over the learning stage was not the independent risk factor of 3-year DFS for mid-low rectal cancer patients undergoing taTME (HR=0.954, 95%CI:0.227-4.017, P=0.949). Conclusions: Compared with conventional laTME, taTME may increase the risk of anastomotic leakage and compromise the oncological outcomes. Performing taTME within the learning stage may significantly increase the risk of postoperative anastomotic leakage.
Anastomotic Leak/etiology* ; Humans ; Laparoscopy/methods* ; Postoperative Complications/epidemiology* ; Prognosis ; Prospective Studies ; Rectal Neoplasms/pathology* ; Rectum/surgery* ; Retrospective Studies ; Transanal Endoscopic Surgery/methods* ; Treatment Outcome

Thanks to the new surgical approach, transanal total mesorectal excision (taTME) has a better operative field exposure than laparoscopic-assisted total mesorectal excision (laTME), especially for male patients with obesity, pelvic stenosis or prostate hypertrophy. Nevertheless, whether the urogenital function and quality of life after taTME are better as compared to laTME requires further study. According to the existing studies, taTME and laTME are not significantly different in symptoms of the urology system for male patients, but some large sample clinical studies show that the incidence of urethral mechanical injury after taTME is higher. Unfortunately, there is no elaboration on that for females. The sexual function of male patients after taTME and laTME is both impaired. The sexual function of male patients will be relieved to different degrees over time, but there is no significant difference. Compared with laTME, taTME shows advantages in the sexual function for female patients. There is no significant difference in short-term urogenital system function between taTME and laTME at present. As a new surgical approach, the impact on urogenital system function after taTME is acceptable. However, whether there is a significant difference in urogenital function between taTME and laTME needs further research. In addition, functional results still need comprehensive evaluation, and preoperative baseline evaluation also needs to be enhanced. The functional evaluation for male and female should be carried out separately rather than confused. Questionnaire for evaluation of functional results also needs to be verified.
Female ; Humans ; Laparoscopy/methods* ; Male ; Operative Time ; Postoperative Complications/epidemiology* ; Quality of Life ; Rectal Neoplasms/surgery* ; Rectum/surgery* ; Transanal Endoscopic Surgery/methods* ; Treatment Outcome

In recent years, transanal total mesorectal excision (taTME) has been a hot spot in the field of colorectal surgery. Compared with the traditional laparoscopic technique, taTME has potential advantages in the treatment of rectal diseases. However, the procedural safety and effectiveness of taTME need further verification. In order to ensure the safe and standardized implementation of this procedure, the European Society of Coloproctology, together with 14 international academic organizations related to colorectal surgery and minimally invasive surgery, has developed the international expert consensus guidance on indications, implementation and quality measures for taTME. This paper introduces the background of the international consensus guidance, and interprets its core contents, including the surgical indications (complex pelvic conditions, malignant and benign rectal diseases), surgical quality and outcome evaluation, structured training, and expert center. It is expected to provide reference and guidance for Chinese colorectal surgery colleagues performing taTME.
Consensus ; Humans ; Laparoscopy ; Quality Indicators, Health Care ; Rectal Neoplasms/surgery* ; Rectum/surgery* ; Transanal Endoscopic Surgery

Humans ; Laparoscopy ; Proctectomy ; Quality of Life ; Rectal Neoplasms/surgery* ; Rectum/surgery* ; Transanal Endoscopic Surgery

The difficulty of transanal total mesorectal excision (TME) is to find the correct dissection plane of perirectal space. As a complex new surgical procedure, the fascial anatomic landmarks of transanal approach operation are more likely to be ignored. It is often found that dissection plane is false after the secondary injury occurs during the operation, which results in the damage of pelvic autonomic nerves. Meanwhile, the mesorectum is easily damaged if the dissection plane is too close to the rectum. Thus, the safety of oncologic outcomes could be limited by difficulty achieving adequate TME quality. The promotion and development of the theory of perirectal fascial anatomy provides a new thought for researchers to design a precise approach for transanal endoscopic surgery. Transanal total mesorectal excision based on fascial anatomy offers a solution to identify the transanal anatomic landmarks precisely and achieves pelvic autonomic nerve preservation. In this paper, the authors focus on the surgical experience of transanal total mesorectal excision based on the theory of perirectal fascial anatomy, and discuss the feature of perirectal fascial anatomy dissection and technique of pelvic autonomic nerve preservation during transanal approach operation.
Autonomic Pathways/surgery* ; Humans ; Proctectomy ; Rectal Neoplasms/surgery* ; Rectum/surgery* ; Transanal Endoscopic Surgery

Transanal total mesorectal excision (taTME) is one of the hotspots in colorectal surgery in recent years. Although most studies confirm that taTME is safe and feasible, some studies still showed that the morbidity of complication and local recurrence rate of taTME were higher than traditional laparoscopic surgery. This article reviews and analyzes the short-term and long-term outcomes of taTME and the related progress of postoperative function. The results showed that there were no significant differences in the main short-term and long-term efficacy between taTME and traditional laparoscopic TME, but taTME had potential advantages in postoperative functional recovery. The results of case study after passing the learning curve suggested that taTME had better short-term and long-term efficacy. Moreover, with the maturity of taTME technology, transanal endoscopic surgery has gradually shown its advantages in the treatment of complex pelvic diseases. In the future, the application of single-port robot will further promote the development of natural orifice transluminal endoscopic colorectal surgery.
Humans ; Neoplasm Recurrence, Local ; Proctectomy ; Rectal Neoplasms/surgery* ; Rectum/surgery* ; Transanal Endoscopic Surgery

As a novel surgical technique, taTME has developed rapidly in recent years. TaTME inevitably attracts some skepticism on safety, efficacy, and indication. First, the controversies over taTME are mainly reflected on the safety and effectiveness of taTME. On one hand, the increase of surgical complications, such as urethral injury, CO2 embolism, anastomotic leakage and pelvic infection, has raised concerns about the safety of taTME. Second, the poor quality of taTME specimens, the increased local recurrence rate and the impaired anal function after taTME, also make people question the effectiveness of taTME. Third, there are more or less controversies in the selection of taTME cases, surgical procedures and cost-effectiveness. However, it can not be denied that taTME has a promising future in view of both surgical theory and clinical practice. Furthermore, taTME is a relatively safe and effective supplementary surgical procedure, especially for patients with low rectal cancer. We should attach more importance to structured training for beginners and conduct high-quality clinical studies in the future development of taTME in China, so as to ensure the safe implementation of taTME and obtain high-level evidence-based medicine evidence, and then standardize the clinical practice of taTME.
Humans ; Neoplasm Recurrence, Local ; Proctectomy ; Rectal Neoplasms/surgery* ; Rectum/surgery* ; Transanal Endoscopic Surgery