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Does the Time Elapsed Between Cases Affect Operative Outcomes in the Early Experience of Transanal Total Mesorectal Excision?

Johnny K Chau, MD, Joshua Soloman, Hamzeh Naghawi, MD, Carmen Mueller, MD, MEd, Patrick Charlebois, MD, A. Sender Liberman, MD, Barry Stein, MD, Lawrence Lee, MD, PhD. McGill University

Introduction: A significant proportion of patients still experience poor resection quality for extraperitoneal rectal cancer. Trananal total mesorectal excision (TA-TME) may improve resection quality but is technically challenging. The learning curve of TA-TME may also be affected by the time elapsed between cases (operative interval). Therefore, the objective of this study was to determine the effect of operative interval on the early outcomes of TA-TME and to compare it to laparoscopic TME for mid/low rectal adenocarcinoma.

Methods: All consecutive cases undergoing curative intent sphincter-saving proctectomy for mid and low rectal adenocarcinoma at a single high-volume specialist referral centre from 2012-2018 were reviewed. All cases were performed by fellowship-trained colorectal surgeons. All TA-TME cases were performed by two-team approach including one surgeon who was specifically trained in TA-TME in every case from 2017/07 onwards. Operative interval was defined as the time elapsed since the last approach-specific case. Main outcome measure was poor-quality resection, defined as a composite of involved circumferential resection margin (CRM) or distal margin, or incomplete TME grade.

Results: A total of 128 patients were included(99 lap-TME, 29 TA-TME). All TA-TME cases were performed in 2016-2018 (4 in 2016-17, and 25 in 2017-2018). There were no differences in age, gender, and comorbid status. TATME patients were more likely to be obese (19.4% vs. 3.0%,p=0.003). Distance to anal verge (TATME 6.6cm (SD1.6), lap 6.7cm (SD1.9),p=0.854), pre-treatment threatened/involved CRM (32.1% vs. 19.4%,p=0.197) and neoadjuvant (chemo)radiotherapy (67.9% vs. 67.7%,p=0.986) were similar between groups. TATME patients were more likely to receive a hand-sewn coloanal anastomosis (32.1% vs. 15.2%,p=0.043) and a longer procedure time (341 min (SD159) vs. 285 min (SD71),p=0.007). There was no difference in the proportion of poor quality resections between TATME and lap-TME (10.3% vs. 13.8%,p=0.575). Anastomotic complications, overall 30-day morbidity and length of stay were similar between groups. The TATME group had a longer median interval between procedures (4.6 weeks [IQR2.0-11.0) vs. 3.6 weeks [IQR1.7-8.9,p=0.003). Shorter operative interval was associated with lower risk of poor-quality resection for TA-TME (OR 0.70 per week, 95%CI 0.49-0.99), but not for lap-TME (OR 1.03 per week, 95%CI0.95-1.12).

Conclusions: In our early experience with TA-TME, there was no differences in surgical and clinical outcomes compared to lap-TME for patients undergoing curative sphincter-saving proctectomy for mid and low rectal cancer. Shorter interval between TA-TME cases may result in improved outcomes and should be factored into the learning curve and adoption process.


Presented at the SAGES 2017 Annual Meeting in Houston, TX.

Abstract ID: 93949

Program Number: P354

Presentation Session: Poster Session (Non CME)

Presentation Type: Poster

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