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Transanal total mesorectal excision in
rectal cancer: why, how and when
Andrea Muratore*,1, Alfredo Mellano1, Andrea Failla1, Patrizia Marsanic1
& Raffaele De Luca2
Practice points
●●
Up-to-down total mesorectal excision (TME) is the gold-standard approach to rectal cancer.
●●
Up-to-down TME is technically demanding in patients with narrow pelvis or low rectal cancer.
●●
own-to-up TME or transanal TME (taTME) seems to increase the oncological safety in patients with mid-low rectal
D
cancer.
●●
taTME seems to improve the quality of the mesorectal excision.
●●
taTME seems to decrease the rate of positive radial resection margins in patients with low rectal cancer.
●●
Patients with narrow pelvis or low rectal cancer may benefit more from the down-to-up approach.
●●
S tudies with longer follow-up and larger cohort of patients are needed to draw more conclusive results about taTME
approach.
Down-to-up total mesorectal excision (TME) or transanal TME (taTME) has gained worldwide
popularity. taTME is one of the most promising innovations of the last years in the field of
gastrointestinal surgery. Due to the better view of the dissection planes even in difficult
patients (i.e., narrow pelvis or low rectal cancer), taTME seems to achieve both better TME
quality reducing the rate of incomplete TME and lower rates of positive circumferential
resection margins. taTME has overall morbidity and anastomotic leak rates comparable with
the up-to-down TME. Mid-term results of taTME seems to be comparable with those of the
up-to-down approach but definitive conclusions cannot be drawn since the short follow-up
and small cohort of patients of the present studies.
First draft submitted: 30 October 2015; Accepted for publication: 10 December 2015;
Published online: 5 February 2016
Up-to-down total mesorectal excision (TME) is the gold-standard approach to mid-low rectal cancers
with 65% rates of 5 years survival and 6–10% rates of local recurrence [1] . Laparoscopic up-to-down
TME is safe with short- and long-term results comparable with the open approach [2–4] . However,
up-to-down TME for mid-low rectal cancers is technically and oncologically demanding, mainly
in obese and male patients with a narrow pelvis; obtaining adequate resection margins as well as
good quality TME specimens in this subset of patients is challenging [5,6] . Moreover, two European
studies have recently highlighted the difficulty in performing laparoscopic up-to-down TME,
analyzing almost 2000 patients operated on for rectal cancer in a short-time period: less than 15%
out of almost 2000 patients with rectal cancer had a laparoscopic TME [7,8] .
Department Surgical Oncology, Candiolo Cancer Institute – FPO, IRCCS, 10060 Candiolo, Torino, Italy
Department Surgical Oncology, Istituto Tumori ‘G Paolo II’, Bari, Italy
*Author for correspondence:[email protected]
Keywords
• down-to-up • rectal cancer
• resection margins • taTME
• TME • TME quality
1
2
10.2217/crc.15.35 © 2016 Future Medicine Ltd
Colorect. Cancer (Epub ahead of print)
part of
ISSN 1758-194X
Perspective Muratore, Mellano, Failla, Marsanic & De Luca
In 1995, Bannon et al. reported on their preliminary experience of ‘open’ down-to-up TME
in 65 patients with low rectal cancer [9] . More
recent papers have suggested that ‘open’ downto-up TME reduces the risk of positive resection
margins, either distal or radial, and increases
the number of sphincter-saving procedures in
low rectal cancer patients [10,11] . In 2010, the
first case of laparoscopic down-to-up TME or
transanal TME (taTME) was reported [12] . Since
this report, laparoscopic down-to-up TME has
gained popularity all over the world. Besides the
lower rates of positive resection margins, the perceived benefits of the laparoscopic taTME seem
to include ease of procedure and better TME
quality due to better view of the dissection
planes [13–15] .
Why switching from up-to-down TME to
down-to-up TME?
●●TME quality
Down-to-up TME, either open or laparoscopic,
is technically demanding, especially when performed in patients with a narrow pelvis (usually
male), in obese patients or in patients with a
low rectal cancer [5,6,8] . In this subset of patients,
obtaining an adequate view of the dissection
plane may be extremely difficult, jeopardizing
the integrity of the mesorectal fascia. It is well
known that non-complete TME excision is correlated with higher recurrence rates [16] . The first
advantage of the down-to-up TME is a better
view of the dissection planes and, as a consequence, a better quality of mesorectal excision
(Table 1) . In the series approaching the rectum
from up-to-down, the rate of incomplete TME
ranges from the 3% rate of the COLOR II study,
with only 17% of the patients having a cancer
located in the low rectum, to the 9.5% rate of the
study from Marinello et al., reporting a 42% rate
of patients with low rectal cancer [2,13,17] . When
the down-to-up approach is used, despite higher
numbers of low rectal cancer patients, the rate of
incomplete TME decreases to 3% or less [13,15] .
●●Resection margins
Both open and laparoscopic up-to-down TME
are technically demanding when the cancer is
located in the lower rectum. The technical difficulty is due to the anatomy of the anorectal
canal and of the pelvic floor which have been
described as a ‘tunnel in a funnel’. Thereafter,
obtaining adequate resection margins, in particular radial resection margins, may be tricky
10.2217/crc.15.35
Colorect. Cancer (Epub ahead of print)
especially in male patients with a deep narrow
angulated pelvis. In a recent prospective study
from a single Sweden center, the distance from
the anal verge was significantly lower in the
patients with positive circumferential resection
margins (CRM ≤1 mm) than in those with
negative CRM: 4.3 versus 8 cm, respectively
(p = 0.001) [19] . In effect, three recent series have
reported rate of positive circumferential resection margin in up to 15% of the patients with
low rectal cancer approached transabdominally
(up-to-down TME) (Table 2) [3,11,20] . Using the
transanal approach, the dissection of the distal
part of the rectum seems to be more favorable
from an oncological point of view, since the
better view and the possibility of carrying the
dissection posteriorly to the levator ani fascia.
In a French study, 100 patients with low rectal
cancer suitable for a low anterior resection were
randomized between ‘open’ down-to-up TME
and up-to-down TME [11] ; the rate of positive
circumferential resection margins was significantly lower in the down-to-up group: 4 versus
8% (p = 0.025). Similar low rates of positive
circumferential resection margins have been
reported by Mark et al. (‘open’ down-to-up TME
in 106 patients) and by Tuech et al. (laparoscopic
up-to-down TME in 56 patients) [10] . In our
series of 43 patients with low rectal cancer who
underwent laparoscopic down-to-up TME, the
rate of positive circumferential resection margin
was 2.4%. Recently, Kanso et al. have reported
on 85 patients with low rectal cancer who underwent low anterior resection with intersphincteric
resection (down-to-up approach in 51 patients):
no differences in terms of positive distal and
circumferential resection margins were found
according to the type of approach [20] . However,
in both groups a transanal dissection was conducted; the only differences were the timing (as
first step in the down-to-up approach) and the
upward extension (up to 6 cm in the down-to-up
approach, only intersphincteric dissection in the
up-to-down approach).
Regarding the rate of positive distal resection margins, the type of approach (down-toup versus up-to-down TME) does not seem to
make any difference when dealing with cancers
located in the lower rectum (Table 2) . However,
when dealing with cancers located in the mid
rectum, Fernandez-Hevia et al. reported significantly longer distal resection margins in the
taTME group compared with the conventional
laparoscopic up-to-down group: 3.2 versus
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Transanal total mesorectal excision in rectal cancer: why, how & when Perspective
Table 1. Total mesorectal excision quality at final pathology after low anterior resection for mid-low rectal cancer.
Study (year) Patients (n) taTME
BMI kg/m2 Low rectal
cancer (%)
Complete
TME (%)
Nearly complete
TME (%)
Incomplete
TME (%)
Kang et al. (2010)
Van der Pas et al. (2013)
Marinello et al. (2015)
340
1044
625
No
No
No
24.1
26.1
NA
NA
17
42
Helbach et al. (2015)
Lacy et al. (2015)
Tuech et al. (2015)
Our series (2015)
80
140
56
63
Yes
Yes
Yes
Yes
27.5
25.2
27
25.2
5.3 cm†
29.3
100
68
73.5
88
Low 72
Mid 83
88
97.1
84
85
16.5
9
Low 18.5
Mid 9.5
9
2.1
16
15
5.6
3
Low 9.5
Mid 7.9
3
0.7
0
0
Ref.
[2]
[3]
[17]
[14]
[15]
[18]
[13]
Mean distance from the anal verge.
taTME: Transanal TME; TME: Total mesorectal excision.
†
2.2 cm, respectively (p = 0.02) [22] . One possible explanation is that during the down-to-up
approach for mid-rectal cancer, after inserting
the single-port device into the anus, the lower
edge of the cancer is clearly seen and the point
where to do the purse-string suture of the rectal lumen and the transection of the rectal wall
are done distally to the lower edge of the cancer
and under direct vision. On the contrary, during the conventional up-to-down approach, the
clear identification of the distal cancer margin
is often inaccurate. Moreover, even if the location of the cancer can be identified either by
inspection or by intraoperative endoscopy, positioning the stapler well below the lower edge of
the tumor is difficult, especially in male patients
with a narrow pelvis.
When transanal TME
●●Short-/mid-term results & indications
As shown in Table 3, the down-to-up approach
in mid-low rectal cancer has morbidity rates
comparable with the up-to-down approach. The
only randomized study comparing these two
approaches has reported similar rates of postoperative complications: 44% in the up-to-down
group versus 32% in taTME group (p = 0.2) [11] .
When analyzing the rate of anastomotic leak,
the down-to-up approach did not seem to
increase the risk of leakage compared with
the gold-standard transabdominal approach.
Most of the studies do not report major intraoperative complications during the transanal
time of the procedure [13,15,20] . However, Rouane
has recently reported two cases of urethral injury
which occurred at the beginning of their experience: the first patient had a bulky rectal cancer
and the second one a prostatic cancer, hindering
the anterior plane of dissection. In our experience, the only intraoperative complication was
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bladder perforation in a patient previously
undergone radical prostatectomy; the injury was
repaired transanally and the postoperative stay
was regular [28] .
Most of the papers reporting on the oncological long-term results of the taTME approach have
obviously shorter follow-up and smaller cohort
of patients when compared with the papers analyzing the up-to-down approach. This bias hinders partially the results (Table 3) . However, with
median follow-up reported ranging from 15 to
39 months, the overall survival and local recurrence rates seem to compare favorably with those
reported by the up-to-down approach studies.
There are lack of data about functional outcome after taTME. However, there are papers
reporting the functional results after transanal endoscopic microsurgery: despite the use
of a 4 cm in size metallic tube and operating
times up to 150 min, no long-term effects on
anorectal function or quality of life have been
reported [29,30] . A recent paper has analyzed
the functional results of transanal minimally
invasive surgery for rectal polyps [31] . The Fecal
Incontinence Severity Index questionnaire
was completed at 3, 6, 9 and 12 months after
transanal minimally invasive surgery: functional
results were comparable with the transanal
endoscopic microsurgery procedure.
Based on the available data, all the patients
with mid-low rectal cancer and T1–3 at the preoperative staging may benefit from the down-toup approach. Obviously, the transanal approach
seems to achieve the best technical and oncological advantages in the subset of patients with a
narrow pelvis and a low rectal cancer. Previous
rectal surgery is a contraindication to the taTME
approach. Previous radical prostatectomy is not
an absolute contraindication to the taTME
approach but the dissection on the anterior rectal
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Perspective Muratore, Mellano, Failla, Marsanic & De Luca
Table 2. Distal and radial resection margin positivity at final pathology after low anterior resection for low rectal cancer.
Study (year)
Patients (n)
taTME
pT3–4
DRM+
rate
CRM+
rate
CRM(mm)
Ref.
Van der Pas et al. (2013)
Leersum et al. (2014)
Denoist et al. (2014)
243
425
50
50
No
No
No
Yes
106
56
Yes
Yes
NA
NA
8%
2%
(p = 0.362)
1%
NA
13.2%
≈10%
18%
4%
(p = 0.025)
3.8%
5.4%
8
NA
5
7
Marks et al. (2013)
Tuech et al. (2015)
NA
8
[10]
Kanso et al. (2015)
34
51
No
Yes
Yes
9%
10%
(p = 0.88)
2.4%
[20]
43
0%
8%
(p = 0.25)
0%
7
7
Our series (2015)
NA
NA
82% (T4 0%)
80% (T4 4%)
(p = 0.324)
36.3% (T4 0%)
T3 79%
T4 3.6%
46%
39%
(p = 0.57)
T3 23%
T4 4.6%
11
[13]
[3]
[21]
[11]
[18]
CRM+: Positive circumferential resection margin at final pathology; CRM- (mm): Distance in millimeters of the circumferential resection margin from the rectal cancer edge at final
pathology; DRM+: Positive distal resection margin at final pathology; NA: Data not available; taTME: Transanal total mesorectal excision.
plane should be conducted cautiously since the
risk of finding adhesions between the bladder
and the rectum.
How transanal TME (technical points)
Synchronous transanal and abdominal dissection is possible and has two main advantages:
first of all it allows a better exposure of the rectum when the top and bottom dissection planes
are reached. Second, the operating time can be
reduced. However, two experienced staffs of surgeons and nurses are required to work together
without hampering each other.
For most surgeons, the two-step approach is
preferred. The up-to-down approach as a first step
has the advantage of avoiding the CO2 retroperitoneal pneumodissection and the possible colon
distension due to inadequate purse-string suture.
However, the down-to-up approach as a first step
has the important advantage of defining immediately the cancer location, the resection margin
and the type of operation (low anterior resection
versus abdominoperineal resection). In our experience, the taTME approach is usually the first
surgical step unless peritoneal carcinomatosis is
suspected.
Transanal approach: The patients are placed
in a lithotomy position with the right arm
along the body and the thighs/legs abducted
and slightly flexed. The first type of approach
depends on the location of the cancer (low versus
mid rectal cancer):
●● Low rectal cancer: a Lone Star Retractor (Coop-
erSurgical, Inc., CT, USA) is inserted. After
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cutting the anal mucosa just above the dentate
line, a sleeve mucosectomy ± partial/total intersphincteric resection is performed toward the
anorectal junction and the rectal wall is circumferentially transected at the level of the anorectal junction. After the dissection of the first
2 cm of the lower rectum, the anal mucosa is
closed with a running suture and a single-port
device is placed;
●● Mid rectal cancer: the single-port device is
positioned in the anal canal. A purse-string
suture is placed through the rectal mucosa to
tightly occlude the rectum distal to the lower
edge of the cancer. A full-thickness rectal
transection is performed.
After entering the peri-mesorectal space, the
pelvic cavity is inflated with CO2 to a pressure of
10–12 mmHg. The 5-mm laparoscope is introduced trough the upper trocar. The right and left
inferior trocars are used to place the dissection
device and the grasper or the suction-irrigation
device. The mesorectum is circumferentially
dissected from down to up toward the anatomical landmarks of a ‘good’ taTME: the sacral
promontory posteriorly, the Pouch of Douglas
anteriorly and the iliac vessels laterally. In the
posterior plane, after sectioning the rectosacral
fascia, the dissection follows the concavity of the
sacrum. The anterior plane of dissection is conducted in front of or behind the Denonvillier’s
fascia according to the rectal cancer position. In
the lateral plane, particular attention must be
paid to the inferior hypogastric plexus, keeping
future science group
Transanal total mesorectal excision in rectal cancer: why, how & when the dissection in close contact with the fascia of
the mesorectum.
Abdominal approach: The patient is placed in
the Trendelenburg and right lateral tilt position.
By using a hybrid single-port technique (SILS™
Port above the umbilicus, 10-mm Versastep™
trocar in the right iliac fossa [Covidien, MA,
USA]), once the inferior mesenteric vessels are
tied and a complete mobilization of the middistal transverse colon, splenic flexure and
descending sigmoid colon is performed, the
peritoneum of the Douglas pouch is sectioned
and the previous transanal plane of dissection
is easily found. Whenever technically feasible
and oncologically safe, a low inferior mesenteric
artery ligation is performed. The specimen can
be extracted transanally but we prefer to extract
it transabdominally (through the site of the SILS
Port location), since most of the patients have
bulky mesorectum and narrow pelvis. The section point in the descending colon is decided
after having checked the presence of an adequate blood flow of the vessels running along
the colon length (the marginal vessels are cut
Perspective
and the presence of an adequate arterial flow is
checked). A hand-sewn anastomosis (lateroterminal when feasible) is performed for cancers
located in the lower rectum. For cancers located
in the mid rectum, a pursestring suture of the
rectal stump by prolene 0 is performed and
tied around the rod of the anvil. The EEA™
33 circular stapler (4.8-mm staples; Covidien)
is inserted through the anorectal ring, linked
to the rod, and then fired. A loop ileostomy is
performed when needed.
Conclusion & future perspective
After the introduction by Heald of the TME concept in rectal surgery, the down-to-up approach
(taTME) is one of the most interesting and
promising surgical innovations of the last years.
Besides the similar results in terms of postoperative morbidity compared with the gold-standard up-to-down approach, there are increasing
data suggesting that taTME seems to achieve
higher rates of negative resection margins and
good quality TME among patients undergoing
low anterior resection for rectal cancer. Similar
Table 3. Short- and long-term results after up-to-down or down-to-up total mesorectal excision.
Study (year)
taTME
Mid–low
RC rate
Patients (n)
Morbidity rate
AL rate
OS/median
follow-up
Local recurrence
rate
Ref.
Jeong et al. (2014)
No
100%
21.2%
1.2%
91.7%
2.6%
[23]
Law et al. (2004)
No
67%
170
(laparoscopic)
622
23.6%
7.3%
8.1%
[24]
Penninckx et al. (2013)
Van der Pas et al. (2013)
Park et al. (2011)
No
No
No
100%
68%
100%
764
1044
130
31.8%
40%
13.1%
8.4%
12%
3.8%
NA
NA
2.6%
[25]
[26]
Portier et al. (2007)
No
100%
278
NA
NA
10.6%
[27]
Denost et al. (2014)
No
Yes
100%
50
50
[11]
No
Yes
100%
37
37
NA
NA
[22]
Kanso et al. (2015)
No
Yes
100%
34
51
[20]
Yes
100%
106
2.8%
[10]
Lacy et al. (2015)
Yes
79%
140
34%
8.6%
2.1%
[15]
Our series (2015)
Yes
68.3%
63
25%
9.5%
100%
93%
39 months
95%
38.6 months
97%†
15 months
92%†
23 months
NA
Marks et al. (2013)
10%
2%
(p = 0.2)
11%
5%
(p = 0.4)
18%
27%
(p = 0.3)
2.8%
NA
Fernandez-Hevia et al.
(2014)
44%
32%
(p = 0.2)
51%
32%
p = 0.2
47%
47%
p = 0.1
13.2%
66.5%
39.6 months
80.8%/NA
NA
86.6%
32.5 months
83.8%
67 months
NA
4.8%
[13]
[13]
†
3 years.
AL: Anastomotic leak; NA: Not available; OS: Overall survival; RC: Rectal cancer; taTME: Transanal TME.
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10.2217/crc.15.35
Perspective Muratore, Mellano, Failla, Marsanic & De Luca
findings have been found in terms of local recurrence and overall survival rates but studies with
larger cohort of patients and longer follow-up
times are required. A multicenter international
randomized trial (COLOR III) [32] comparing
transanal TME versus conventional laparoscopic resection of mid-low rectal cancer will
start soon [33] . Do we really need a randomized
study to validate this new procedure? I believe
the answer is yes but it is important to keep in
mind that well-designed randomized clinical
trials are expensive and time consuming and,
sometime, unethical. Infact, there are no doubts
that the gold-standard treatment of resectable
colorectal liver metastases in 2015 is surgery
but no randomized studies were ever performed
to confirm it. Studies conducted from existing
databases offer an alternative to randomized
studies, making it possible to study outcomes
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10.2217/crc.15.35
Financial & competing interests disclosure
The authors have no relevant affiliations or financial
involvement with any organization or entity with a financial interest in or financial conflict with the subject matter
or materials discussed in the manuscript. This includes
employment, consultancies, honoraria, stock ownership or
options, expert testimony, grants or patents received or
pending, or royalties.
No writing assistance was utilized in the production of
this manuscript.
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the England taTME Registry [35] which are collecting large cohort of data from many European
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definitive conclusions regarding the oncological
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•
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•
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•• The only randomized study comparing the
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12 Sylla P, Rattner DW, Delgado S, Lacy AM.
NOTES transanal rectal cancer resection
using transanal endoscopic microsurgery and
Colorect. Cancer (Epub ahead of print)
The largest series of transanal total mesorectal
excision (taTME) for low rectal cancer.
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•
A recent and large series of rectal cancer
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Transanal total mesorectal excision in rectal cancer: why, how & when •
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