The Future of taTME Round-Up
To kick off day two of the European Society of Coloproctology’s 17th Annual Conference (#ESCP2022) in Dublin, delegates attended a breakfast panel discussion featuring Quentin Denost (France), Ellen van Eetvelde (Belgium) and Conor Delaney (United States), chaired by Willem Bemelman (The Netherlands).
The session centred around the debate around the different approaches for Total Mesorectal Excision (TME) – including the laparoscopic, robotic and taTME (Transanal Total Mesorectal Excision) platforms.
Notably, the newer, innovative taTME platform has fallen victim to controversy in recent years, with concerns raised around the safety and effectiveness of the platform leading to a temporary ban in Norway.
In order to fairly compare the three techniques, Willem Bemelman (The Netherlands) explored a range of studies – and the pitfalls these studies present. He highlighted the difficulties faced when comparing the literature, as – for example – the definition of rectal cancer has changed over the years. Many studies, he says, are diluted by the learning curve effect, or polluted with comparisons to Partial Mesorectal Excision (PME) procedures. As PMEs are generally considered less risky, he suggests that we should focus on the true rectal cancers to truly compare the three techniques.
Looking at the literature, he concluded that in multiple studies, the taTME delivered a lower conversion rate, and that leak rates are more or less equal with other techniques (at 30 days). He observed there is also more restorative surgery, and that surgeons are better able to preserve the sphincter with the taTME platform as opposed to the laparoscopic method, and to a lesser extent, robotics. He also highlighted that the platform enables a team approach – if other experienced surgeons are on hand.
Most importantly, his analysis found that taTME delivers a higher rate of restoration of continuity in the patients who had taTME, but this is still only 50%. So, while these patients received the best technique for the localisation of the tumour, you can still only save the sphincter in 50% of cases.
He concludes that, like with many innovations, there is a learning curve with the taTME approach. TaTME has caught the attention of the profession, and, unsurprisingly problems have been observed with the technique because it is a new, more difficult, technique. But, in experienced hands, the morbidity rate and oncological results after three years is equal to that of comparable techniques.
The importance of skills and experience
No matter the approach to TME, all panellists agreed on the critical importance of a surgeon’s training and of getting a reasonable case volume under their belt to become skilled in one technique. The success of taTME may therefore not depend on the approach itself – but delivering the adequate training, case volume, and support within the wider colorectal team. The presence of an experienced specialist in the unit was also highlighted.
Conor Delaney (United States) explained how this approach works in his team at the Cleveland Clinic: “My personal preference is laparoscopic. We have a big enough team that can focus on different techniques. What we’ve tried to do is have people who can concentrate on different platforms. A number of us will use laparoscopic, then we have someone in Ohio and someone in Florida who will come in to do taTME. If you have a team of ten or more surgeons, you don’t want everyone dabbling!”
However, not all surgeons have the option of calling on large teams such as those common in the United States. Teams in other regions are instead exploiting the emergence of new indications for transanal surgery, which can also be used for pouch complications and Hartman reversal, among others. Willem Bemelman (The Netherlands) explained his team are gaining experience and case volume by using the transanal approach for a range of indications, adding, “This really helped us to master the technique!”.
Ellen van Eetvelde (Belgium) argued that each of the three techniques provide a purpose, and that at the end of the day it’s about what is best for the patient.
She said: “I don’t think it’s a question of robotic, laparoscopic or taTME. It’s a question of how to do the best transection and anastomosis for that patient. And, if that means you need to go transanal because you’re unsure about your distal margin, then you do so. For me, it’s not a competition, it’s complimentary”.
She also highlighted how the different platforms are enabling colorectal surgeons to save the sphincter no matter the approach, but that close consultation with the patient must still be of utmost importance. The options should be explained and offered to the patient so they can make an informed decision. Functional outcomes are not always optimal – there is always some damage.
Quentin Denost added that another key consideration should be assessing the compliance of the patient before surgery, and whether they will actually be compliant with the proposed programme. He also questioned the role of taTME in places where there is no culture of sphincter preserving surgery, highlighting that taTME should never be used just to use the platform.
To conclude the panel, the speakers agreed that each surgeon will do it slightly differently; the important thing is having a solid technique and approach, and picking a primary way to do it so you’re as good at this as possible.
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