Analysis for 76 cases of transanal total mesorectal excision and discussion on the non-patient factors affecting the quality of surgery_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

ZHOU Dongbing , YANG Xuanhua ,  REN Mingyang , TENG Qing , PU Min , Lü Zhenbing , LI Quanlin

Department of Gastrointestinal Surgery, Nanchong Central Hospital, The Second Clinical Institute of North Sichuan Medical College, Nanchong, Sichuan 637000, P. R. China;

Corresponding?author：

REN Mingyang, Email: 2861746489@qq.com

Keywords：

transanal total mesorectal excision; rectal cancer; surgical quality

DOI：

10.7507/1007-9424.201903039

Video：

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Objective To analyze whether transanal total mesorectal excision (taTME) can achieve high-quality TME, explore the non-patient factors affecting the quality of taTME, improve the quality of taTME.Methods The clinical data of 76 patients undergoing taTME from January 2015 to September 2018 in the Department of Gastrointestinal Surgery of Nanchong Central Hospital were retrospectively analyzed. The operative time, intra-operative bleeding volume, positive rate of circumferential margin, integrity of mesorectum, positive rate of margin and complications were taken as the observation indexes of operative quality. The improvement of surgical equipment, structured training, and the accumulation of surgical cases (No. 1–25 cases was early group, No. 26–50 cases was mid-term group, No. 51–76 cases was later stage group) were compared as grouping conditions, and various factors affecting the quality of taTME were analyzed.Results ① Pre- and post-the improvement of surgical equipment: compared to the pre-improvement of surgical equipment group, the distance between tumors and anal margin of patients in the post-improvement of surgical equipment was closer ［(4.9±1.3) cm vs. (5.9±2.7) cm, P=0.040］ and the postoperative hospital stay was shorter ［(10.6±3.9) d vs. (12.4±2.7) d, P=0.023］, while there were no significant difference in the amount of bleeding, the positive rate of circumferential margin, the integrity of mesorectum, the positive rate of margin and the complications in the two groups (P>0.05). ② Pre- and post-training for surgeon: compared to the pre-training group, the operative time in the post-training group was shortened ［(224.6±70.2) min vs. (275±77.0) min, P=0.020］, while there were no statistical differences in the amount of bleeding, the integrity of mesorectum, the difference of the positive rate of circumferential margin, the positive rate of distal margin, postoperative complications and postoperative hospital stay (P>0.05). ③ The cumulative grouping of cases: compared to the later stage group ［（218.8±69.5）min］, the operative time in the early group ［(275.2±82.6) min］ and the mid-term group ［(278.8±37.5) min］ were shortened with statistical difference (P=0.022, P=0.003). Moreover, compared to the early group ［(12.9±2.4) d］, the postoperative hospital stay in the mid-term group ［(10.8±4.0) d］ and the later stage group ［(10.2±3.6) d］ were shortened with statistical significance (P=0.032, P=0.007). However, there were no significant difference in the volume of bleeding, the positive rate of circumferential margin, the positive rate of incisal margin and the degree of mesangial integrity among the three groups (P>0.05).Conclusions taTME can achieve high-quality TME. With the improvement of equipment, the participation of structured training and the accumulation of surgical cases, taTME achieved consistent quality in about 50 cases. The improvement of surgical equipment is the guarantee of the quality of taTME. Structured training is the key to improve the surgical quality of taTME.

Citation： ZHOU Dongbing, YANG Xuanhua, REN Mingyang, TENG Qing, PU Min, Lü Zhenbing, LI Quanlin. Analysis for 76 cases of transanal total mesorectal excision and discussion on the non-patient factors affecting the quality of surgery. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2019, 26(6): 662-667. doi: 10.7507/1007-9424.201903039 Copy

1.	Chen W, Zheng R, Baade PD, et al. Cancer statistics in China. 2015, CA Cancer J Clin, 2016, 66(2): 115-132.
2.	吳在德, 吳漢主編. 外科學. 第7版. 北京: 人民衛生出版社, 2008: 492-498.
3.	Heald RJ. A new solution to some old problems:transanal TME. Tech Coloproctol, 2013, 17(3): 257-258.
4.	Wolthuis AM, Bislenghi G, de Buck van Overstraeten A, et al. Transanal total mesorectal excision: towards standardization of technique. World J Gastroenterol, 2015, 21(44): 12686-12695.
5.	Penna M, Buchs NC, Bloemendaal AL, et al. Transanal total mesorectal excision for rectal cancer: the journey towards a new technique and its current status. Expert Rev Anticancer Ther, 2016, 16(11): 1145-1153.
6.	Deijen CL, Tsai A, Koedam TW, et al. Clinical outcomes and case volume effect of transanal total mesorectal excision for rectal cancer: a systematic review. Tech Coloproctol, 2016, 20(12): 811-824.
7.	楊選華, 滕慶, 黃斌, 等. 經肛手套通路與傳統腹腔鏡全直腸系膜切除術治療直腸癌的近期療效對比研究. 中華胃腸外科雜志, 2018, 21(6): 698-702.
8.	任明揚, 楊選華, 楊旭芬, 等. 自制簡易氣腔恒壓裝置在經肛門全直腸系膜切除術中的應用. 中華胃腸外科雜志, 2018, 21(8): 942-944.
9.	Nagtegaal ID, van de Velde CJ, van der Worp E, et al. Macroscopic evaluation of rectal cancer resection specimen: clinical significance of the pathologist in quality control. J Clin Oncol, 2002, 20(7): 1729-1734.
10.	Jeong SY, Park JW, Nam BH, et al. Open versus laparoscopic surgery for mid-rectal or low-rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): survival outcomes of an open-label, non-inferiority, randomized controlled trial. Lancet Oncol, 2014, 15(7): 767-774.
11.	Bonjer HJ, Deijen CL, Abis G, et al. A randomized trial of laparoscopic versus open surgery for rectal cancer. N Engl J Med, 2015, 372(14): 1324-1332.
12.	van der Pas MH, Haglind E, Cuesta MA, et al. Laparoscopic versus open surgery for rectal cancer (COLOR Ⅱ): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol, 2013, 14(3): 210-218.
13.	楊小丁, 楊烈, 何承峻, 等. 腹腔鏡全直腸系膜切除術治療中低位直腸癌的療效研究. 中國普外基礎與臨床雜志, 2018, 25(12): 1459-1463.
14.	Rouanet P, Mourregot A, Azar CC, et al. Transanal endoscopic proctectomy:an innovative procedure for difficult resection of rectal tumors in men with narrow pelvis. Dis Colon Rectum, 2013, 56(4): 408-415.
15.	Marks J, Mizrahi B, Dalane S, et al. Laparoscopic transanal abdominal transanal resection with sphincter preservation for rectal cancer in the distal 3 cm of the rectum after neoadjuvant therapy. Surg Endosc, 2010, 24(11): 2700-2707.
16.	Penna M, Hompes R, Arnold S, et al. Transanal total mesorectal excision: international registry results of the first 720 cases. Ann Surg, 2017, 266(1): 111-117.
17.	Xu W, Xu Z, Cheng H, et al. Comparison of short-term clinical outcomes between transanal and laparoscopic total mesorectal excision for the treatment of mid and low rectal cancer: A meta-analysis. Eur J Surg Oncol, 2016, 42(12): 1841-1850.
18.	Caycedo-Marulanda A, Jiang HY, Kohtakangas EL. Outcomes of a single surgeon-based transanal-tatal mesorectal excision (TATME) for rectal cancer. J Gastrointest Cancer, 2018, 49(4): 455-462.
19.	Jiang HP, Li YS, Wang B, et al. Pathological outcomes of transanal versus laparoscopic total mesorectal excision for rectal cancer:a systematic review with meta-analysis. Surg Endosc, 2018, 32(6): 2632-2642.
20.	楊選華, 田云鴻, 黃斌, 等. 經肛門全直腸系膜切除術的研究進展. 中國普外基礎與臨床雜志, 2017, 24(11): 1408-1413.
21.	Fernández-Hevia M, Delgado S, Castells A, et al. Transanal total mesorectal excision in rectal cancer: short-term outcomes in comparison with laparoscopic surgery. Ann Surg, 2015, 261(2): 221-227.
22.	Rink AD, Kneist W, Radinski I, et al. Differences in ano-neorectal physiology of ileoanal and coloanal reconstructions for restorative proctectomy. Colorectal Dis, 2010, 12(4): 342-350.
23.	周彤, 李利發. 低位直腸癌保肛手術的研究現狀和展望. 中國普外基礎與臨床雜志, 2019, 26(2): 236-240.
24.	Perdawood SK, Thinggaard BS, Bjoern MX. Effect of transanal total mesorectal excision for rectal cancer: comparison of short-term outcomes with laparoscopic and open surgeries. Surg Endosc, 2018, 32(5): 2312-2321.
25.	Bretagnol F, Lelong B, Laurent C, et al. The oncological safety of laparoscopic total mesorectal excision with sphincter preservation for rectal carcinoma. Surg Endosc, 2005, 19(7): 892-896.
26.	羅雙靈, 蔡永華, 張興偉, 等. 經肛門與腹腔鏡全直腸系膜切除術治療直腸癌的療效分析. 中華消化外科雜志, 2017, 16(7): 703-708.
27.	Xu C, Song HY, Han SL, et al. Simple instruments facilitating achievement of transanal total mesorectal excision in male patients. World J Gastroenterol, 2017, 23(31): 5798-5808.
28.	Tekkis PP, Senagore AJ, Delaney CP, et al. Evaluation of the learning curve in laparoscopic colorectal surgery: comparison of right-sided and left-sided resections. Ann Surg, 2005, 242(1): 83-91.
29.	Penna M, Whiteford M, Hompes R, et al. Developing and assessing a cadaveric training model for transanal total mesorectal excision: initial experience in the UK and USA. Colorectal Dis, 2017, 19(5): 476-484.
30.	Atallah SB, DuBose AC, Burke JP, et al. Uptake of transanal total mesorectal excision in North America: initial assessment of a structured training program and the experience of delegate surgeons. Dis Colon Rectum, 2017, 60(10): 1023-1031.

1. Chen W, Zheng R, Baade PD, et al. Cancer statistics in China. 2015, CA Cancer J Clin, 2016, 66(2): 115-132.
2. 吳在德, 吳漢主編. 外科學. 第7版. 北京: 人民衛生出版社, 2008: 492-498.
3. Heald RJ. A new solution to some old problems:transanal TME. Tech Coloproctol, 2013, 17(3): 257-258.
4. Wolthuis AM, Bislenghi G, de Buck van Overstraeten A, et al. Transanal total mesorectal excision: towards standardization of technique. World J Gastroenterol, 2015, 21(44): 12686-12695.
5. Penna M, Buchs NC, Bloemendaal AL, et al. Transanal total mesorectal excision for rectal cancer: the journey towards a new technique and its current status. Expert Rev Anticancer Ther, 2016, 16(11): 1145-1153.
6. Deijen CL, Tsai A, Koedam TW, et al. Clinical outcomes and case volume effect of transanal total mesorectal excision for rectal cancer: a systematic review. Tech Coloproctol, 2016, 20(12): 811-824.
7. 楊選華, 滕慶, 黃斌, 等. 經肛手套通路與傳統腹腔鏡全直腸系膜切除術治療直腸癌的近期療效對比研究. 中華胃腸外科雜志, 2018, 21(6): 698-702.
8. 任明揚, 楊選華, 楊旭芬, 等. 自制簡易氣腔恒壓裝置在經肛門全直腸系膜切除術中的應用. 中華胃腸外科雜志, 2018, 21(8): 942-944.
9. Nagtegaal ID, van de Velde CJ, van der Worp E, et al. Macroscopic evaluation of rectal cancer resection specimen: clinical significance of the pathologist in quality control. J Clin Oncol, 2002, 20(7): 1729-1734.
10. Jeong SY, Park JW, Nam BH, et al. Open versus laparoscopic surgery for mid-rectal or low-rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): survival outcomes of an open-label, non-inferiority, randomized controlled trial. Lancet Oncol, 2014, 15(7): 767-774.
11. Bonjer HJ, Deijen CL, Abis G, et al. A randomized trial of laparoscopic versus open surgery for rectal cancer. N Engl J Med, 2015, 372(14): 1324-1332.
12. van der Pas MH, Haglind E, Cuesta MA, et al. Laparoscopic versus open surgery for rectal cancer (COLOR Ⅱ): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol, 2013, 14(3): 210-218.
13. 楊小丁, 楊烈, 何承峻, 等. 腹腔鏡全直腸系膜切除術治療中低位直腸癌的療效研究. 中國普外基礎與臨床雜志, 2018, 25(12): 1459-1463.
14. Rouanet P, Mourregot A, Azar CC, et al. Transanal endoscopic proctectomy:an innovative procedure for difficult resection of rectal tumors in men with narrow pelvis. Dis Colon Rectum, 2013, 56(4): 408-415.
15. Marks J, Mizrahi B, Dalane S, et al. Laparoscopic transanal abdominal transanal resection with sphincter preservation for rectal cancer in the distal 3 cm of the rectum after neoadjuvant therapy. Surg Endosc, 2010, 24(11): 2700-2707.
16. Penna M, Hompes R, Arnold S, et al. Transanal total mesorectal excision: international registry results of the first 720 cases. Ann Surg, 2017, 266(1): 111-117.
17. Xu W, Xu Z, Cheng H, et al. Comparison of short-term clinical outcomes between transanal and laparoscopic total mesorectal excision for the treatment of mid and low rectal cancer: A meta-analysis. Eur J Surg Oncol, 2016, 42(12): 1841-1850.
18. Caycedo-Marulanda A, Jiang HY, Kohtakangas EL. Outcomes of a single surgeon-based transanal-tatal mesorectal excision (TATME) for rectal cancer. J Gastrointest Cancer, 2018, 49(4): 455-462.
19. Jiang HP, Li YS, Wang B, et al. Pathological outcomes of transanal versus laparoscopic total mesorectal excision for rectal cancer:a systematic review with meta-analysis. Surg Endosc, 2018, 32(6): 2632-2642.
20. 楊選華, 田云鴻, 黃斌, 等. 經肛門全直腸系膜切除術的研究進展. 中國普外基礎與臨床雜志, 2017, 24(11): 1408-1413.
21. Fernández-Hevia M, Delgado S, Castells A, et al. Transanal total mesorectal excision in rectal cancer: short-term outcomes in comparison with laparoscopic surgery. Ann Surg, 2015, 261(2): 221-227.
22. Rink AD, Kneist W, Radinski I, et al. Differences in ano-neorectal physiology of ileoanal and coloanal reconstructions for restorative proctectomy. Colorectal Dis, 2010, 12(4): 342-350.
23. 周彤, 李利發. 低位直腸癌保肛手術的研究現狀和展望. 中國普外基礎與臨床雜志, 2019, 26(2): 236-240.
24. Perdawood SK, Thinggaard BS, Bjoern MX. Effect of transanal total mesorectal excision for rectal cancer: comparison of short-term outcomes with laparoscopic and open surgeries. Surg Endosc, 2018, 32(5): 2312-2321.
25. Bretagnol F, Lelong B, Laurent C, et al. The oncological safety of laparoscopic total mesorectal excision with sphincter preservation for rectal carcinoma. Surg Endosc, 2005, 19(7): 892-896.
26. 羅雙靈, 蔡永華, 張興偉, 等. 經肛門與腹腔鏡全直腸系膜切除術治療直腸癌的療效分析. 中華消化外科雜志, 2017, 16(7): 703-708.
27. Xu C, Song HY, Han SL, et al. Simple instruments facilitating achievement of transanal total mesorectal excision in male patients. World J Gastroenterol, 2017, 23(31): 5798-5808.
28. Tekkis PP, Senagore AJ, Delaney CP, et al. Evaluation of the learning curve in laparoscopic colorectal surgery: comparison of right-sided and left-sided resections. Ann Surg, 2005, 242(1): 83-91.
29. Penna M, Whiteford M, Hompes R, et al. Developing and assessing a cadaveric training model for transanal total mesorectal excision: initial experience in the UK and USA. Colorectal Dis, 2017, 19(5): 476-484.
30. Atallah SB, DuBose AC, Burke JP, et al. Uptake of transanal total mesorectal excision in North America: initial assessment of a structured training program and the experience of delegate surgeons. Dis Colon Rectum, 2017, 60(10): 1023-1031.

CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Analysis for 76 cases of transanal total mesorectal excision and discussion on the non-patient factors affecting the quality of surgery

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