TaTME for Rectal Cancer Gains Momentum

While it is still early in the evolution of transanal total mesorectal excision (TaTME), the technique is gaining traction as the go-to procedure in select cases, Cleveland Clinic colorectal surgeons report.

Citing a small number of centers around the world that have published early data on TaTME, Conor Delaney, MD, PhD, Chairman, Digestive Disease & Surgery Institute, reports that “early results suggest that the oncological quality of the TaTME for rectal cancer operation appears to be at least as good as traditional laparoscopic surgery.”

In addition, TaTME offers a number of advantages, including:

• Expands a minimally invasive approach to certain patients previously considered challenging for laparoscopy
• The same benefits of less postoperative pain, faster recovery, earlier return to work and reduced length of stay as seen with laparoscopy
• Providing more efficiency than seen with robotic surgery

TaTME evolution

“In colorectal surgery, the technical precision of the operation makes a huge difference to patient outcome, and in no area of colorectal surgery is that more obvious than surgery for rectal cancer,” Dr. Delaney states. “Over the last 20 to 30 years, total mesorectal excision (TME) has proven to be the optimal radical procedure for rectal cancer, reducing local recurrence rates from 30 percent or higher to as low as 3 percent in the hands of leading surgeons.”

Minimally invasive colorectal surgery, which has evolved over the same period, hastens patients’ recovery with smaller scars, fewer complications and less pain, says Dr. Delaney, adding that these benefits now extend to rectal cancer surgery.

“Recently published European data show that laparoscopy provides identical oncological outcomes as TME for rectal cancer, while patients experience less pain and recover more quickly,” he states.

“In parallel with these improvements in care, surgeons have been exploring the concept of operating through natural orifices,” Dr. Delaney notes. “As an extension of this research, a new way of doing rectal cancer surgery developed — TaTME.” A number of Cleveland Clinic colorectal surgeons, including Dr. Delaney, Scott Steele, MD; I. Emre Gorgun, MD; Bradley Champagne, MD (Cleveland Clinic Fairview); and Dana Sands, MD at Cleveland Clinic Florida (Weston), offer TaTME. The surgery is somewhat complicated and requires meticulous technique, Dr. Delaney says. TaTME can also be performed by one team and that method has been used successfully at Cleveland Clinic’s main campus and Fairview Hospital by Drs. Delaney and Champagne respectively.

A workaround in men

Another impetus for the development of TaTME are the bony confines of the male pelvis that make laparoscopy more challenging for rectal cancer, Dr. Champagne points out.

“Data increasingly demonstrate that achieving a clear distal or circumferential resection margin in rectal cancer is the most important element to prevent recurrence,” he says. “There has been a great deal of focus on how to achieve the best margin and the best technical dissection. But distal rectal cancer in a narrow male pelvis can be difficult to work around.

“Nationally, many surgeons have turned to robotics as a solution,” Dr. Champagne notes. “While robotics may offer greater ability to work around distal rectal cancers, studies fail to demonstrate any real improvement in oncologic outcome. Meanwhile, robotics lengthens operative time and increases cost significantly.” As a result, the idea of performing transanal TME was developed for low rectal dissections.

Current indications for TaTME

“The true opportunity with TaTME is not to use it for all cases of rectal cancer, but to help bring minimally invasive surgery to patients who, because of tumor characteristics or body habitus, would not otherwise have been suitable for laparoscopy,” Dr. Delaney explains.

Patients must first meet minimally invasive surgery criteria, generally including a tumor staged at T3 or less, Dr. Champagne notes. Surgeons turn to TaTME when a patient has a tumor low in the rectum or a narrow pelvis or both, and when the surgeon believes a traditional laparoscopic approach will be technically challenging. Thus, TaTME is classically considered for obese male and female patients.

Operative technique

Transanal and laparoscopic teams can work simultaneously during a TaTME procedure, which begins with a specially designed port inserted into the rectum. A laparoscope is then inserted into the abdomen and the operation is completed from above.

Transanal total mesorectal excision (TaTME), demonstrating the dissection from the bottom going superiorly, with intact yellow mesorectal fascia, pink levators in bottom left, and Denonvilliers fascia at the top. (Image courtesy of Karl Storz.)

View of a TaTME specimen showing the intact mesorectal fascia consistent with a high-quality rectal cancer operation.

“TaTME is an exciting new technique that by virtue of the anatomical precision it offers, allows experienced surgeons to bring minimally invasive surgery to more patients with rectal cancer and potentially improve the overall standard of care,” Dr. Delaney says.

“TaTME ensures a great oncologic operation for very distal tumors, and momentum is building for its use,” Dr. Champagne concludes.