Transanal Total Mesorectal Excision (TaTME) is being used to treat rectal cancer in some worlwide surgical departments. However, very little is known about indications, patients who can benefit from this approach, complications, and outcomes. Is it a valid approach? Is it going to overwhelm rectal anterior resection (RAR)?
Recently I found a publication from Prof. Dr. Juan Santi Azagra in Linkedin with a picture of a slide entitled: “Bad news for TaTME”. Got my attention. One of the mentioned publications in the slide, was a commentary from Dr. Gachabayov from the Department of Surgery of Westchester Medical Center (New York, USA): “Is taTME delivering?”. Must read it.
TaTME is being used because of the concern for positive circumferencial resection margins (CRM) and bad quality of total mesorectal excision (TME) in obese males with narrow pelvis, when using open or laparoscopic approaches. This concern is not supported by english language literature, says Dr. Gachabayov. What appears to be true is that open surgery is better than laparoscopic when comparing technical aspects, but they are equal when comparing survival rates. Additionally, robotic surgery seems to have better results in circumferencial resection margin than both open and laparoscopic approaches (p=0,02).
About TaTME the authors are clear and precise in the discussion. When using TaTME a low coloanal anastomosis is always performed regardless tumor location. Is impressive to know that 38% of patients submitted to TaTME had a tumor located between 10-13 cm from anal verge. Meaning? An unnecessary low coloanal anastomosis with organ loss, functional disadvantage and potential morbidity was offered. As the authors state a low coloanal anastomosis must be dictated by tumor location and not by surgical technique. Additionally, the particular patient who we are treating will dictate the best treatment option, I think.
“A learning curve is not a valid justification for patient injury”.
in New York State memorandum
While I was reading the manuscript from Dr Gachabayov, I was wondering what advantages would TaTME offer to the patients? Well… according to the authors, the three oncologic advantages claimed, improved distal resection margin, decreased rate of positive CRM, better TME quality, are all based in bad quality papers (read the article to understand the authors’ point of view).
The most shocking information I got from this article is going to let you speechless. Last January in Oslo the results from the National Norwegian TaTME database were presented. These results completely slayed TaTME. This technique had an increased local recurrence rate, demonstrated a new pattern of recurrence (multifocality), and it occurred early after TaTME. Consequences arose: TaTME was suspended in Norway.
I believe this manuscript from Dr Gachabayov from New York is extremely important, and all surgeons should read it. TaTME must be submitted to good quality RCTs to avoid its misuse to all patients with rectal cancer. If precise indications are not found for TaTME, it will be short living. Till then, this minimally invasive technique should not be routine and should only be offered in a trial setting. TaTME is far from being gold standard, I think.
The first rectal cancer resection was performed through transanal approach.
Finally, like many of you should know, Dr. Jacques Lisfranc performed the first rectal cancer resection. What many of us do not remember is that he used the transanal approach, which was common in the 1800’s. Dr Gachabayov begins his manuscript with this information to introduce an important idea: “Nowadays, the unfortunate state of affairs is that advancement in a career is no longer supported by premise that crediting the founding fathers and doing justice to the literature has a meaning.” Transanal approach is not new… Instead forgetting and ignoring, remember the past. History allows us to avoid in the future the errors of the past.
Link to PubMed:
Dr Carlos Eduardo Costa Almeida
General Surgeon