TaTME-DCAA feasible for low rectal cancer

A retrospective, propensity score-matched analysis from Singapore demonstrates the feasibility of transanal total mesorectal excision with delayed coloanal anastomosis (TaTME-DCAA) as a surgical alternative for non-metastatic low rectal cancer.

“[TaTME-DCAA had] similar short-term outcomes, histopathologic results, morbidity rates, and bowel function compared with other minimally invasive methods of TME, while avoiding bowel diversion [which has been tied to a considerable morbidity risk] and stoma-related complications [which have negative psychosocial effects],” said the researchers.

Twelve patients who underwent elective TaTME-DCAA for low rectal cancer* at Singapore General Hospital from November 2021 to June 2022 were included in the analysis. They were matched with patients who have undergone laparoscopic TME with immediate coloanal anastomosis (LTME-ICAA; n=36) and robotic TME with ICAA (RTME-ICAA; n=36) between January 2019 and December 2020. [Surg Laparosc Endosc Percutan Tech 2023;doi:10.1097/SLE.0000000000001247]

Histopathologic, perioperative outcomes

RTME had the longest median distal resection margin compared with LTME and TaTME, but the between-group differences were not statistically significant (1.5 vs 1.4 and 1.0 cm; p=0.625).

All TaTME, LTME, and RTME groups had comparable tumour sizes (largest tumour diameter, 3.7 vs 3.5 vs 4.3 cm; p=0.418), total lymph node harvest (20 vs 20 vs 21; p=0.730), and pathologic T (p=0.498) and N stages (p=0.294).

Albeit lacking statistical significance, TaTME-DCAA was the quickest among procedures (308 vs 330 [LTME] and 360 mins [RTME]; p=0.567). Median total length of hospital stay for TaTME, LTME, and RTME were similar (10 vs 10 vs 9 days; p=0.532), as were LARS** (p=0.905) and Wexner scores (p=0.252).

The LARS and Wexner scores align with those seen in previous reports. [Dig Surg 2019;36:409-417; Int J Surg 2018;56:234-241] According to the researchers, this may be partly attributable to early pharmacotherapy and referral to an onsite gastrointestinal functional unit for assessment and biofeedback therapy for suitable patients.

Follow-up duration was shorter with TaTME than LTME and RTME (7 vs 28 and 28 months; p<0.001). This, according to the researchers, could have been due to the late adoption of TaTME in their facility. “Despite the significantly shorter follow-up duration, TaTME-DCAA did not result in inferior bowel function compared with LTME-ICAA and RTME-ICAA,” they said.

Hospitalization cost

Overall inpatient cost of TaTME-DCAA (31,087 SGD) compares favourably with LTME-ICAA (29,927 SGD) but is significantly cheaper than RTME-ICAA (36,750 SGD).

Median cost of index hospitalization was highest for TaTME-DCAA (higher than RTME-ICAA by 1,579 SGD and LTME-ICAA by 8,917 SGD; p=0.001). But upon the addition of hospitalization charges for stoma reversal, RTME-ICAA became the costliest approach overall (higher than LTME-ICAA by 6,823 SGD and TaTME-DCAA by 5,663 SGD; p=0.002).

“This substantial disparity was largely driven by the higher surgical procedure and consumable costs with RTME. TaTME-DCAA was still more costly overall compared with LTME-ICAA, but the median difference was only 1,160 SGD,” they said.

Overcomes difficulties of deep pelvic surgery

“The management of low rectal cancer deep within the confines of the bony pelvis is a perennial challenge for colorectal surgeons,” the researchers noted.

The minimally invasive TaTME builds on the established benefits of laparoscopic surgery and offers a unique solution to overcome the technical difficulties of deep pelvic surgery such as restricted working space and the challenge of securing the distal resection margin. It enables more precise tissue dissection and reduces operative abdominal trauma. [Ann Acad Med Singap 2018;47:188-190]

“In our experience, TaTME is the most technically synergistic [approach] with DCAA compared with other TME methods,” the researchers said.