Marta Penna - Academia.edu (original) (raw)

Papers by Marta Penna

Research paper thumbnail of Evolution of transanal total mesorectal excision according to the IDEAL framework

BMJ surgery, interventions, & health technologies, Jul 1, 2019

What is already known on the subject? How might these results affect future research or surgical ... more What is already known on the subject? How might these results affect future research or surgical practice? ► When introducing a new surgical technique in the future it is important to follow the steps of the IDEAL framework. The standardization and obligation of a formal training program for surgeons is paramount before widespread adoption of a new technique can take place.

Research paper thumbnail of Developing and assessing a cadaveric training model for transanal total mesorectal excision: initial experience in the UK and USA

Colorectal Disease, May 1, 2017

Aim Transanal total mesorectal excision (taTME) has become one of the most promising technical ad... more Aim Transanal total mesorectal excision (taTME) has become one of the most promising technical advancements in the surgical treatment of rectal cancer, with rising numbers of surgeons seeking training. We describe our experience with human cadaveric courses for taTME delivered in two countries. Method Four fresh human cadaveric workshops conducted in Oxford, UK, in 2015 and two in Chicago, USA, in 2013À2014, trained a total of 52 surgeons. Parameters of operative performance for each delegate were recorded. Previous surgical experience and uptake of taTME in the surgeons' clinical setting were surveyed. Results Forty-seven taTME cases were performed on cadaveric models. Participating surgeons had previous experience in laparoscopic TME surgery and transanal approaches but limited taTME exposure. The pursestring remained occluded throughout in 93% of UK and 60% of US cases. Operative timings for key procedural steps were similar between the two countries with a mean time from start of circumferential dissection to peritoneal entry of 79.5 min (range 25-155). 96% of surgeons dissected transanally to a level S2 or above. The TME specimen quality was complete or near complete in 81%, with improvements noted between the first and second procedure performed. 81% of surgeons surveyed are currently performing taTME in their local hospitals. Conclusion Fresh-frozen cadavers provide excellent teaching models for complex pelvic surgery. A structured training curriculum including reading material, dry-lab purse-string practice and postcourse mentorship will provide surgeons with a more complete training package and ongoing support, to ultimately ensure the safe introduction of taTME in the clinical setting.

Research paper thumbnail of Four anastomotic techniques following transanal total mesorectal excision (TaTME)

Techniques in Coloproctology, Jan 12, 2016

Transanal total mesorectal excision (TaTME) is a novel approach pioneered to tackle the challenge... more Transanal total mesorectal excision (TaTME) is a novel approach pioneered to tackle the challenges posed by difficult pelvic dissections in rectal cancer and the restrictions in angulation of currently available laparoscopic staplers. To date, four techniques can be employed in order to create the colorectal/coloanal anastomosis following TaTME. We present a technical note describing these techniques and discuss the risks and benefits of each.

Research paper thumbnail of Oncological outcomes after transanal total mesorectal excision for rectal cancer

British Journal of Surgery

Research paper thumbnail of P482 Transanal minimally invasive proctectomy (TaMIP) in patients with inflammatory bowel diseases (IBD) within the TaTME international database

Journal of Crohn's and Colitis, 2018

Research paper thumbnail of OP017 Transanal minimally invasive proctectomy with ileal pouch anal anastomosis (Ta-IPAA) in patients with ulcerative colitis: a cohort study from the TaTME international database

Journal of Crohn's and Colitis, 2018

Background: During the last two decades medical therapy for Crohn's disease has been rapidly evol... more Background: During the last two decades medical therapy for Crohn's disease has been rapidly evolving with the aim of preventing complications necessitating surgery. In earlier studies, about 50% of the patients needed abdominal surgery within 10 years and of these 50% had a surgical relapse within another 10 years. Some population-based studies have shown decreasing surgical rates preceding modern medical therapy, but data are conflicting. Methods: All incident patients with at least two diagnostic listings of Crohn's disease and no previous bowel surgery in the Swedish Patient Register 1990-2014 were included in this nationwide cohort study (n = 19 648). Primary and secondary abdominal surgeries were identified through the Swedish Patient Register. The cohort was divided into five different calendar periods of first IBD diagnosis. The first two periods were collected from the in-patient register and the last two periods from both the in-and outpatient registers while the mid-cohort was a mixture. The cumulative incidences of surgeries were calculated using the Kaplan-Meier method. Cumulative incidence of abdominal surgery during all available follow-ups of 19 648 patents with Crohsn's disease. Cumulative incidence of second abdominal surgery during all available follow-ups of 5998 patients with Crohn's disease previously operated.

Research paper thumbnail of P605 Transanal minimally invasive proctectomy (TaMIP) in patients with Crohn’s disease: A cohort study from the TaTME international database

Journal of Crohns & Colitis, 2018

Research paper thumbnail of Transanal TME: Why Go Bottom-Up!

Transanal total mesorectal excision (taTME) is the latest surgical procedure originally developed... more Transanal total mesorectal excision (taTME) is the latest surgical procedure originally developed for rectal cancer resections. It is believed to confer the greatest benefits over the standard abdominal ‘top-down’ approach in the more difficult pelvic dissections, in particular, the low bulky rectal tumours in obese males with a narrow pelvis, in which clear visualisation of the dissection plane from above can be extremely challenging. The level of evidence available so far for this new approach includes non-randomised comparative studies and cohort series, in which the technique has also been adapted for cases with benign pathology and other procedures including abdominoperineal excisions and completion proctectomies. In this chapter, we will summarise the key operative steps of taTME and explore the latest published results on morbidity, oncological and functional outcomes. Future advances and modifications to the technique will also be reviewed.

Research paper thumbnail of Local Recurrence and Disease-Free Survival After Transanal Total Mesorectal Excision: Results From the International TaTME Registry

Journal of the National Comprehensive Cancer Network, 2021

Background: The oncologic safety of transanal total mesorectal excision (TaTME) for rectal cancer... more Background: The oncologic safety of transanal total mesorectal excision (TaTME) for rectal cancer has recently been questioned, with high local recurrence (LR) rates reported in Dutch and Norwegian experiences. The objective of this study was to evaluate the oncologic safety of TaTME in a large cohort of patients with primary rectal cancer, primarily in terms of LR, disease-free survival (DFS), and overall survival (OS). Patients and Methods: This was a prospective international registry cohort study, including all patients who underwent TaTME for primary rectal adenocarcinoma from February 2010 through December 2018. The main endpoints were 2-year LR rate, pattern of LR, and independent risk factors for LR. Secondary endpoints included 2-year DFS and OS rates. Kaplan-Meier survival analysis was used to calculate actuarial LR, DFS, and OS rates. Results: A total of 2,803 patients receiving primary TaTME were included, predominantly men (71%) with a median age of 65 years (interquart...

Research paper thumbnail of Implementation of IDEAL framework of UK training programme for TaTME

Annals of Laparoscopic and Endoscopic Surgery, 2021

Background: As international concern grows regarding the reported early oncological outcomes and ... more Background: As international concern grows regarding the reported early oncological outcomes and technical challenges of transanal total mesorectal excision (TaTME), there is a need for a structured and robust quality assurance process to ensure safe introduction and monitoring of a novel surgical technique. The IDEAL framework has been advocated to guide such a process. The aim of this study was the report the application of IDEAL framework in the development and implementation of TaTME training in the UK. Methods: A five-stage outline (idea, development, exploration, assessment, and long-term study) was applied to describe the development, delivery and assessment of the TaTME training initiative in the UK. Surveys that incorporated the experience of both learners and more experienced surgeons of TaTME, together with experts in education, initiated the process with concepts and development of the training initiative explored at a centrally coordinated pilot training programme. Key components included a cadaver training workshop and a formal proctorship process. Data were recorded on demographics, tumour location, intraoperative, post-operative and histological outcomes. Educational assessment of technical progress was performed using custom-made Global Assessment Scoring (GAS) forms which were completed by both learners and proctors. Long-term outcomes were captured at 24 months. Results: Five selected pilot sites were used by 10 colorectal surgeons during the training initiative and 24 cases were proctored in this period in the exploration phase. Median operative time reduced from initial 331±90 [195-610] to 283±62 [195-340] minutes in the final case. No visceral injuries were reported however there was one conversion to open (4.2%). Histological assessment reported as intact mesorectal TME specimens with clear distal margin and no bowel or tumour perforation in all cases. One case had positive circumferential margin (4%). Assessment of educational outcomes showed GAS score 5 (independent performance) was achieved by case 5 in most operative steps. Long-term follow up showed no evidence of local or regional recurrence but three liver and one lung metastasis at 24 months. Conclusions: Dissemination of a new surgical technique within the confines of IDEAL framework demonstrates the feasibility and safety of surgical training programme for TaTME at a national level.

Research paper thumbnail of Development and early outcomes of the national training initiative for transanal total mesorectal excision in the UK

Colorectal Disease, 2020

AimTransanal total mesorectal excision (TaTME) has attracted substantial interest amongst colorec... more AimTransanal total mesorectal excision (TaTME) has attracted substantial interest amongst colorectal surgeons but its technical challenges may underlie the early reports of visceral injuries and oncological concerns. The aim of this study was to report on the feasibility, development and the outcome of the national pilot training initiative for TaTME‐UK.MethodsTaTME‐UK was successfully launched in September 2017 in partnership with the healthcare industry and endorsed by the Association of Coloproctology of Great Britain and Ireland. This multi‐modal training curriculum consisted of three phases: (i) set‐up; (ii) selection of pilot sites; and (iii) formal proctorship programme. Bespoke Global Assessment Scoring (GAS) forms were designed and completed by both trainees and mentors. Data were collected on patient demographics, tumour characteristics and perioperative clinical and histological outcomes.ResultsTwenty‐four proctored cases were performed by 10 colorectal surgeons from five...

Research paper thumbnail of Predictive Factors and Risk Model for Positive Circumferential Resection Margin Rate After Transanal Total Mesorectal Excision in 2653 Patients With Rectal Cancer

Annals of Surgery, 2019

Objective: The aim of this study was to determine the incidence of, and preoperative risk factors... more Objective: The aim of this study was to determine the incidence of, and preoperative risk factors for, positive circumferential resection margin (CRM) after transanal total mesorectal excision (TaTME). Background: TaTME has the potential to further reduce the rate of positive CRM for patients with low rectal cancer, thereby improving oncological outcome. Methods: A prospective registry-based study including all cases recorded on the international TaTME registry between July 2014 and January 2018 was performed. Endpoints were the incidence of, and predictive factors for, positive CRM. Univariate and multivariate logistic regressions were performed, and factors for positive CRM were then assessed by formulating a predictive model. Results: In total, 2653 patients undergoing TaTME for rectal cancer were included. The incidence of positive CRM was 107 (4.0%). In multivariate logistic regression analysis, a positive CRM after TaTME was significantly associated with tumors located up to 1...

Research paper thumbnail of Transanal total mesorectal excision (TaTME) versus laparoscopic TME for MRI-defined low rectal cancer: a propensity score-matched analysis of oncological outcomes

Surgical Endoscopy, 2018

Background While a shift to minimally invasive techniques in rectal cancer surgery has occurred, ... more Background While a shift to minimally invasive techniques in rectal cancer surgery has occurred, non-inferiority of laparoscopy in terms of oncological outcomes has not been definitely demonstrated. Transanal total mesorectal excision (TaTME) has been pioneered to potentially overcome difficulties experienced when operating with a pure abdominal approach deep down in the pelvis. This study aimed to compare short-term oncological results of TaTME versus laparoscopic TME (lapTME), based on a strict anatomical definition for low rectal cancer on MRI. Methods From June 2013, all consecutive TaTME cases were included and compared to lapTME in a single institution. Propensity score-matching was performed for nine relevant factors. Primary outcome was resection margin involvement (R1), secondary outcomes included intra-and post-operative outcomes. Results After matching, forty-one patients were included in each group; no significant differences were observed in patient and tumor characteristics. The resection margin was involved in 5 cases (12.2%) in the laparoscopic group, versus 2 (4.9%) TaTME cases (P = 0.432). The TME specimen quality was complete in 84.0% of the laparoscopic cases and in 92.7% of the TaTME cases (P = 0.266). Median distance to the circumferential resection margin (CRM) was 5 mm in lapTME and 10 mm in TaTME (P = 0.065). Significantly more conversions took place in the laparoscopic group, 9 (22.0%) compared to none in the TaTME group (P < 0.001). Other clinical outcomes did not show any significant differences between the two groups. Conclusion This is the first study to compare results of TaTME with lapTME in a highly selected patient group with MRIdefined low rectal tumors. A significant decrease in R1 rate could not be demonstrated, although conversion rate was significantly lower in this TaTME cohort.

Research paper thumbnail of A nationwide study on the adoption and short-term outcomes of transanal total mesorectal excision in the UK

Minerva Chirurgica, 2019

BACKGROUND The interest and adoption of transanal total mesorectal excision (TaTME) is growing wo... more BACKGROUND The interest and adoption of transanal total mesorectal excision (TaTME) is growing worldwide, but evidence on nationwide implementation and short-term outcomes is scarce. This study aims to evaluate national results for this relatively new technique in the UK. METHODS All TaTME procedures performed in the UK and recorded on the international TaTME registry between January 2013 and January 2018 were analyzed. Surgeons who received training on TaTME in the UK were sent a survey regarding their experience with implementation of TaTME in their unit. Primary endpoint was a composite for "optimal pathology" (free resection margin (R0) and TME specimen with no major defects and no rectal wall perforations). Secondary outcomes included 30-day clinical course and survey outcomes. RESULTS Forty-two hospitals entered 513 cases over a 5-year period; 28 of 42 hospitals (66.7%) performed ten cases or less. The indication for surgery was cancer in 364 (71.0%) cases. Optimal pathology was achieved in 295 (92.8%), with an involved resection margin (R1) rate of 13 of 513 (4.1%). A Clavien-Dindo ≥III within 30 days was 13.4% (N.=45) and 6.8% (N.=10) in the cancer and benign groups, respectively. Based on the survey (response rate 68 of 86; 79%), 76.1% of the surgeons implemented TaTME in their unit after receiving training, all of whom experienced difficulties with performing TaTME. CONCLUSIONS This study reports acceptable nationwide short-term outcomes of TaTME. However, adoption occurred in a rapid and non-standardized manner. A structured TaTME training program is therefore recommended.

Research paper thumbnail of Transanal Total Mesorectal Excision: Why, When, and How

Clinics in Colon and Rectal Surgery, 2017

Transanal total mesorectal excision (taTME) has evolved over the past decade fueled by advances i... more Transanal total mesorectal excision (taTME) has evolved over the past decade fueled by advances in minimally invasive surgery. The technique aims to overcome the constraints posed by a narrow rigid pelvis and poor TME visualization that are encountered during “top-down” rectal surgery. A more accurate pelvic dissection should subsequently result in safer oncological resections and better preservation of pelvic autonomic nerves. taTME is an advanced complex technique that requires dedicated training and experience in TME surgery. Initial results from small cohorts are promising and confirmation by randomized controlled trials is eagerly awaited.

Research paper thumbnail of Short-term outcomes of transanal completion total mesorectal excision (cTaTME) for rectal cancer: a case-matched analysis

Surgical Endoscopy, 2018

Background Local excision of early rectal tumors as a rectal preserving treatment is gaining popu... more Background Local excision of early rectal tumors as a rectal preserving treatment is gaining popularity, especially since bowel cancer screening programs result in a shift towards the diagnosis of early stage rectal cancers. However, unfavorable histological features predicting high risk for recurrence within the "big biopsy" may mandate completion total mesorectal excision (cTME). Completion surgery is associated with higher morbidity, poorer specimen quality, and less favorable oncological outcomes compared to primary TME. Transanal approach potentially improves outcome of completion surgery for rectal cancer. The aim of this study was to compare radical completion surgery after local excision for rectal cancer by the transanal approach (cTaTME) with conventional abdominal approach (cTME). Methods All consecutive patients who underwent cTaTME for rectal cancer between 2012 and 2017 were case-matched with cTME patients, according to gender, tumor height, preoperative radiotherapy, and tumor stage. Surgical, pathological, and short-term postoperative outcomes were evaluated. Results In total, 25 patients underwent completion TaTME and were matched with 25 patients after cTME. Median time from local excision to completion surgery was 9 weeks in both groups. In the cTaTME and cTME groups, perforation of the rectum occurred in 4 and 28% of patients, respectively (p = 0.049), leading to poor specimen quality in these patients. Number of harvested lymph nodes was higher after cTaTME (median 15; range 7-47) than after cTME (median 10; range 0-17). No significant difference was found in end colostomy rate between the two groups. Major 30-day morbidity (Clavien-Dindo≥ III) was 20 and 32%, respectively (p = 0.321). Hospital stay was significantly longer after cTME. Conclusion TaTME after full-thickness excision is a promising technique with a significantly lower risk of perforation of the rectum and better specimen quality compared to conventional completion TME.

Research paper thumbnail of Personalized management of elderly patients with rectal cancer: Expert recommendations of the European Society of Surgical Oncology, European Society of Coloproctology, International Society of Geriatric Oncology, and American College of Surgeons Commission on Cancer

European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology, Jan 15, 2018

With an expanding elderly population and median rectal cancer detection age of 70 years, the prev... more With an expanding elderly population and median rectal cancer detection age of 70 years, the prevalence of rectal cancer in elderly patients is increasing. Management is based on evidence from younger patients, resulting in substandard treatments and poor outcomes. Modern management of rectal cancer in the elderly demands patient-centered treatment, assessing frailty rather than chronological age. The heterogeneity of this group, combined with the limited available data, impedes drafting evidence-based guidelines. Therefore, a multidisciplinary task force convened experts from the European Society of Surgical Oncology, European Society of Coloproctology, International Society of Geriatric Oncology and the American College Surgeons Commission on Cancer, with the goal of identifying the best practice to promote personalized rectal cancer care in older patients. A crucial element for personalized care was recognized as the routine screening for frailty and geriatrician involvement and ...

Research paper thumbnail of St.Gallen consensus on safe implementation of transanal total mesorectal excision

Surgical endoscopy, 2018

The management of rectal cancer has evolved over the years, including the recent rise of Transana... more The management of rectal cancer has evolved over the years, including the recent rise of Transanal Total Mesorectal Excision (TaTME). TaTME addresses the limitations created by the bony confines of the pelvis, bulky tumours, and fatty mesorectum, particularly for low rectal cancers. However, guidance is required to ensure safe implementation and to avoid the pitfalls and potential major morbidity encountered by the early adopters of TaTME. We report a broad international consensus statement, which provides a basis for optimal clinical practice. Forty international experts were invited to participate based on clinical and academic achievements. The consensus statements were developed using Delphi methodology incorporating three successive rounds. Consensus was defined as agreement by 80% or more of the experts. A total of 37 colorectal surgeons from 20 countries and 5 continents (Europe, Asia, North and South America, Australasia) contributed to the consensus. Participation to the it...

Research paper thumbnail of Incidence and Risk Factors for Anastomotic Failure in 1594 Patients Treated by Transanal Total Mesorectal Excision: Results From the International TaTME Registry

Annals of surgery, Jan 5, 2018

To determine the incidence of anastomotic-related morbidity following Transanal Total Mesorectal ... more To determine the incidence of anastomotic-related morbidity following Transanal Total Mesorectal Excision (TaTME) and identify independent risk factors for failure. Anastomotic leak and its sequelae are dreaded complications following gastrointestinal surgery. TaTME is a recent technique for rectal resection, which includes novel anastomotic techniques. Prospective study of consecutive reconstructed TaTME cases recorded over 30 months in 107 surgical centers across 29 countries. Primary endpoint was "anastomotic failure," defined as a composite endpoint of early or delayed leak, pelvic abscess, anastomotic fistula, chronic sinus, or anastomotic stricture. Multivariate regression analysis performed identifying independent risk factors of anastomotic failure and an observed risk score developed. One thousand five hundred ninety-four cases with anastomotic reconstruction were analyzed; 96.6% performed for cancer. Median anastomotic height from anal verge was 3.0 ± 2.0 cm with...

Research paper thumbnail of Consensus on structured training curriculum for transanal total mesorectal excision (TaTME)

Surgical endoscopy, Jul 1, 2017

The interest and adoption of transanal total mesorectal excision (TaTME) is growing amongst the c... more The interest and adoption of transanal total mesorectal excision (TaTME) is growing amongst the colorectal surgical community, but there is no clear guidance on the optimal training framework to ensure safe practice for this novel operation. The aim of this study was to establish a consensus on a detailed structured training curriculum for TaTME. A consensus process to agree on the framework of the TaTME training curriculum was conducted, seeking views of 207 surgeons across 18 different countries, including 52 international experts in the field of TaTME. The process consisted of surveying potential learners of this technique, an international experts workshop and a final expert's consensus to draw an agreement on essential elements of the curriculum. Appropriate case selection was strongly recommended, and TaTME should be offered to patients with mid and low rectal cancers, but not proximal rectal cancers. Pre-requisites to learn TaTME should include completion of training and ...

Research paper thumbnail of Evolution of transanal total mesorectal excision according to the IDEAL framework

BMJ surgery, interventions, & health technologies, Jul 1, 2019

What is already known on the subject? How might these results affect future research or surgical ... more What is already known on the subject? How might these results affect future research or surgical practice? ► When introducing a new surgical technique in the future it is important to follow the steps of the IDEAL framework. The standardization and obligation of a formal training program for surgeons is paramount before widespread adoption of a new technique can take place.

Research paper thumbnail of Developing and assessing a cadaveric training model for transanal total mesorectal excision: initial experience in the UK and USA

Colorectal Disease, May 1, 2017

Aim Transanal total mesorectal excision (taTME) has become one of the most promising technical ad... more Aim Transanal total mesorectal excision (taTME) has become one of the most promising technical advancements in the surgical treatment of rectal cancer, with rising numbers of surgeons seeking training. We describe our experience with human cadaveric courses for taTME delivered in two countries. Method Four fresh human cadaveric workshops conducted in Oxford, UK, in 2015 and two in Chicago, USA, in 2013À2014, trained a total of 52 surgeons. Parameters of operative performance for each delegate were recorded. Previous surgical experience and uptake of taTME in the surgeons' clinical setting were surveyed. Results Forty-seven taTME cases were performed on cadaveric models. Participating surgeons had previous experience in laparoscopic TME surgery and transanal approaches but limited taTME exposure. The pursestring remained occluded throughout in 93% of UK and 60% of US cases. Operative timings for key procedural steps were similar between the two countries with a mean time from start of circumferential dissection to peritoneal entry of 79.5 min (range 25-155). 96% of surgeons dissected transanally to a level S2 or above. The TME specimen quality was complete or near complete in 81%, with improvements noted between the first and second procedure performed. 81% of surgeons surveyed are currently performing taTME in their local hospitals. Conclusion Fresh-frozen cadavers provide excellent teaching models for complex pelvic surgery. A structured training curriculum including reading material, dry-lab purse-string practice and postcourse mentorship will provide surgeons with a more complete training package and ongoing support, to ultimately ensure the safe introduction of taTME in the clinical setting.

Research paper thumbnail of Four anastomotic techniques following transanal total mesorectal excision (TaTME)

Techniques in Coloproctology, Jan 12, 2016

Transanal total mesorectal excision (TaTME) is a novel approach pioneered to tackle the challenge... more Transanal total mesorectal excision (TaTME) is a novel approach pioneered to tackle the challenges posed by difficult pelvic dissections in rectal cancer and the restrictions in angulation of currently available laparoscopic staplers. To date, four techniques can be employed in order to create the colorectal/coloanal anastomosis following TaTME. We present a technical note describing these techniques and discuss the risks and benefits of each.

Research paper thumbnail of Oncological outcomes after transanal total mesorectal excision for rectal cancer

British Journal of Surgery

Research paper thumbnail of P482 Transanal minimally invasive proctectomy (TaMIP) in patients with inflammatory bowel diseases (IBD) within the TaTME international database

Journal of Crohn's and Colitis, 2018

Research paper thumbnail of OP017 Transanal minimally invasive proctectomy with ileal pouch anal anastomosis (Ta-IPAA) in patients with ulcerative colitis: a cohort study from the TaTME international database

Journal of Crohn's and Colitis, 2018

Background: During the last two decades medical therapy for Crohn's disease has been rapidly evol... more Background: During the last two decades medical therapy for Crohn's disease has been rapidly evolving with the aim of preventing complications necessitating surgery. In earlier studies, about 50% of the patients needed abdominal surgery within 10 years and of these 50% had a surgical relapse within another 10 years. Some population-based studies have shown decreasing surgical rates preceding modern medical therapy, but data are conflicting. Methods: All incident patients with at least two diagnostic listings of Crohn's disease and no previous bowel surgery in the Swedish Patient Register 1990-2014 were included in this nationwide cohort study (n = 19 648). Primary and secondary abdominal surgeries were identified through the Swedish Patient Register. The cohort was divided into five different calendar periods of first IBD diagnosis. The first two periods were collected from the in-patient register and the last two periods from both the in-and outpatient registers while the mid-cohort was a mixture. The cumulative incidences of surgeries were calculated using the Kaplan-Meier method. Cumulative incidence of abdominal surgery during all available follow-ups of 19 648 patents with Crohsn's disease. Cumulative incidence of second abdominal surgery during all available follow-ups of 5998 patients with Crohn's disease previously operated.

Research paper thumbnail of P605 Transanal minimally invasive proctectomy (TaMIP) in patients with Crohn’s disease: A cohort study from the TaTME international database

Journal of Crohns & Colitis, 2018

Research paper thumbnail of Transanal TME: Why Go Bottom-Up!

Transanal total mesorectal excision (taTME) is the latest surgical procedure originally developed... more Transanal total mesorectal excision (taTME) is the latest surgical procedure originally developed for rectal cancer resections. It is believed to confer the greatest benefits over the standard abdominal ‘top-down’ approach in the more difficult pelvic dissections, in particular, the low bulky rectal tumours in obese males with a narrow pelvis, in which clear visualisation of the dissection plane from above can be extremely challenging. The level of evidence available so far for this new approach includes non-randomised comparative studies and cohort series, in which the technique has also been adapted for cases with benign pathology and other procedures including abdominoperineal excisions and completion proctectomies. In this chapter, we will summarise the key operative steps of taTME and explore the latest published results on morbidity, oncological and functional outcomes. Future advances and modifications to the technique will also be reviewed.

Research paper thumbnail of Local Recurrence and Disease-Free Survival After Transanal Total Mesorectal Excision: Results From the International TaTME Registry

Journal of the National Comprehensive Cancer Network, 2021

Background: The oncologic safety of transanal total mesorectal excision (TaTME) for rectal cancer... more Background: The oncologic safety of transanal total mesorectal excision (TaTME) for rectal cancer has recently been questioned, with high local recurrence (LR) rates reported in Dutch and Norwegian experiences. The objective of this study was to evaluate the oncologic safety of TaTME in a large cohort of patients with primary rectal cancer, primarily in terms of LR, disease-free survival (DFS), and overall survival (OS). Patients and Methods: This was a prospective international registry cohort study, including all patients who underwent TaTME for primary rectal adenocarcinoma from February 2010 through December 2018. The main endpoints were 2-year LR rate, pattern of LR, and independent risk factors for LR. Secondary endpoints included 2-year DFS and OS rates. Kaplan-Meier survival analysis was used to calculate actuarial LR, DFS, and OS rates. Results: A total of 2,803 patients receiving primary TaTME were included, predominantly men (71%) with a median age of 65 years (interquart...

Research paper thumbnail of Implementation of IDEAL framework of UK training programme for TaTME

Annals of Laparoscopic and Endoscopic Surgery, 2021

Background: As international concern grows regarding the reported early oncological outcomes and ... more Background: As international concern grows regarding the reported early oncological outcomes and technical challenges of transanal total mesorectal excision (TaTME), there is a need for a structured and robust quality assurance process to ensure safe introduction and monitoring of a novel surgical technique. The IDEAL framework has been advocated to guide such a process. The aim of this study was the report the application of IDEAL framework in the development and implementation of TaTME training in the UK. Methods: A five-stage outline (idea, development, exploration, assessment, and long-term study) was applied to describe the development, delivery and assessment of the TaTME training initiative in the UK. Surveys that incorporated the experience of both learners and more experienced surgeons of TaTME, together with experts in education, initiated the process with concepts and development of the training initiative explored at a centrally coordinated pilot training programme. Key components included a cadaver training workshop and a formal proctorship process. Data were recorded on demographics, tumour location, intraoperative, post-operative and histological outcomes. Educational assessment of technical progress was performed using custom-made Global Assessment Scoring (GAS) forms which were completed by both learners and proctors. Long-term outcomes were captured at 24 months. Results: Five selected pilot sites were used by 10 colorectal surgeons during the training initiative and 24 cases were proctored in this period in the exploration phase. Median operative time reduced from initial 331±90 [195-610] to 283±62 [195-340] minutes in the final case. No visceral injuries were reported however there was one conversion to open (4.2%). Histological assessment reported as intact mesorectal TME specimens with clear distal margin and no bowel or tumour perforation in all cases. One case had positive circumferential margin (4%). Assessment of educational outcomes showed GAS score 5 (independent performance) was achieved by case 5 in most operative steps. Long-term follow up showed no evidence of local or regional recurrence but three liver and one lung metastasis at 24 months. Conclusions: Dissemination of a new surgical technique within the confines of IDEAL framework demonstrates the feasibility and safety of surgical training programme for TaTME at a national level.

Research paper thumbnail of Development and early outcomes of the national training initiative for transanal total mesorectal excision in the UK

Colorectal Disease, 2020

AimTransanal total mesorectal excision (TaTME) has attracted substantial interest amongst colorec... more AimTransanal total mesorectal excision (TaTME) has attracted substantial interest amongst colorectal surgeons but its technical challenges may underlie the early reports of visceral injuries and oncological concerns. The aim of this study was to report on the feasibility, development and the outcome of the national pilot training initiative for TaTME‐UK.MethodsTaTME‐UK was successfully launched in September 2017 in partnership with the healthcare industry and endorsed by the Association of Coloproctology of Great Britain and Ireland. This multi‐modal training curriculum consisted of three phases: (i) set‐up; (ii) selection of pilot sites; and (iii) formal proctorship programme. Bespoke Global Assessment Scoring (GAS) forms were designed and completed by both trainees and mentors. Data were collected on patient demographics, tumour characteristics and perioperative clinical and histological outcomes.ResultsTwenty‐four proctored cases were performed by 10 colorectal surgeons from five...

Research paper thumbnail of Predictive Factors and Risk Model for Positive Circumferential Resection Margin Rate After Transanal Total Mesorectal Excision in 2653 Patients With Rectal Cancer

Annals of Surgery, 2019

Objective: The aim of this study was to determine the incidence of, and preoperative risk factors... more Objective: The aim of this study was to determine the incidence of, and preoperative risk factors for, positive circumferential resection margin (CRM) after transanal total mesorectal excision (TaTME). Background: TaTME has the potential to further reduce the rate of positive CRM for patients with low rectal cancer, thereby improving oncological outcome. Methods: A prospective registry-based study including all cases recorded on the international TaTME registry between July 2014 and January 2018 was performed. Endpoints were the incidence of, and predictive factors for, positive CRM. Univariate and multivariate logistic regressions were performed, and factors for positive CRM were then assessed by formulating a predictive model. Results: In total, 2653 patients undergoing TaTME for rectal cancer were included. The incidence of positive CRM was 107 (4.0%). In multivariate logistic regression analysis, a positive CRM after TaTME was significantly associated with tumors located up to 1...

Research paper thumbnail of Transanal total mesorectal excision (TaTME) versus laparoscopic TME for MRI-defined low rectal cancer: a propensity score-matched analysis of oncological outcomes

Surgical Endoscopy, 2018

Background While a shift to minimally invasive techniques in rectal cancer surgery has occurred, ... more Background While a shift to minimally invasive techniques in rectal cancer surgery has occurred, non-inferiority of laparoscopy in terms of oncological outcomes has not been definitely demonstrated. Transanal total mesorectal excision (TaTME) has been pioneered to potentially overcome difficulties experienced when operating with a pure abdominal approach deep down in the pelvis. This study aimed to compare short-term oncological results of TaTME versus laparoscopic TME (lapTME), based on a strict anatomical definition for low rectal cancer on MRI. Methods From June 2013, all consecutive TaTME cases were included and compared to lapTME in a single institution. Propensity score-matching was performed for nine relevant factors. Primary outcome was resection margin involvement (R1), secondary outcomes included intra-and post-operative outcomes. Results After matching, forty-one patients were included in each group; no significant differences were observed in patient and tumor characteristics. The resection margin was involved in 5 cases (12.2%) in the laparoscopic group, versus 2 (4.9%) TaTME cases (P = 0.432). The TME specimen quality was complete in 84.0% of the laparoscopic cases and in 92.7% of the TaTME cases (P = 0.266). Median distance to the circumferential resection margin (CRM) was 5 mm in lapTME and 10 mm in TaTME (P = 0.065). Significantly more conversions took place in the laparoscopic group, 9 (22.0%) compared to none in the TaTME group (P < 0.001). Other clinical outcomes did not show any significant differences between the two groups. Conclusion This is the first study to compare results of TaTME with lapTME in a highly selected patient group with MRIdefined low rectal tumors. A significant decrease in R1 rate could not be demonstrated, although conversion rate was significantly lower in this TaTME cohort.

Research paper thumbnail of A nationwide study on the adoption and short-term outcomes of transanal total mesorectal excision in the UK

Minerva Chirurgica, 2019

BACKGROUND The interest and adoption of transanal total mesorectal excision (TaTME) is growing wo... more BACKGROUND The interest and adoption of transanal total mesorectal excision (TaTME) is growing worldwide, but evidence on nationwide implementation and short-term outcomes is scarce. This study aims to evaluate national results for this relatively new technique in the UK. METHODS All TaTME procedures performed in the UK and recorded on the international TaTME registry between January 2013 and January 2018 were analyzed. Surgeons who received training on TaTME in the UK were sent a survey regarding their experience with implementation of TaTME in their unit. Primary endpoint was a composite for "optimal pathology" (free resection margin (R0) and TME specimen with no major defects and no rectal wall perforations). Secondary outcomes included 30-day clinical course and survey outcomes. RESULTS Forty-two hospitals entered 513 cases over a 5-year period; 28 of 42 hospitals (66.7%) performed ten cases or less. The indication for surgery was cancer in 364 (71.0%) cases. Optimal pathology was achieved in 295 (92.8%), with an involved resection margin (R1) rate of 13 of 513 (4.1%). A Clavien-Dindo ≥III within 30 days was 13.4% (N.=45) and 6.8% (N.=10) in the cancer and benign groups, respectively. Based on the survey (response rate 68 of 86; 79%), 76.1% of the surgeons implemented TaTME in their unit after receiving training, all of whom experienced difficulties with performing TaTME. CONCLUSIONS This study reports acceptable nationwide short-term outcomes of TaTME. However, adoption occurred in a rapid and non-standardized manner. A structured TaTME training program is therefore recommended.

Research paper thumbnail of Transanal Total Mesorectal Excision: Why, When, and How

Clinics in Colon and Rectal Surgery, 2017

Transanal total mesorectal excision (taTME) has evolved over the past decade fueled by advances i... more Transanal total mesorectal excision (taTME) has evolved over the past decade fueled by advances in minimally invasive surgery. The technique aims to overcome the constraints posed by a narrow rigid pelvis and poor TME visualization that are encountered during “top-down” rectal surgery. A more accurate pelvic dissection should subsequently result in safer oncological resections and better preservation of pelvic autonomic nerves. taTME is an advanced complex technique that requires dedicated training and experience in TME surgery. Initial results from small cohorts are promising and confirmation by randomized controlled trials is eagerly awaited.

Research paper thumbnail of Short-term outcomes of transanal completion total mesorectal excision (cTaTME) for rectal cancer: a case-matched analysis

Surgical Endoscopy, 2018

Background Local excision of early rectal tumors as a rectal preserving treatment is gaining popu... more Background Local excision of early rectal tumors as a rectal preserving treatment is gaining popularity, especially since bowel cancer screening programs result in a shift towards the diagnosis of early stage rectal cancers. However, unfavorable histological features predicting high risk for recurrence within the "big biopsy" may mandate completion total mesorectal excision (cTME). Completion surgery is associated with higher morbidity, poorer specimen quality, and less favorable oncological outcomes compared to primary TME. Transanal approach potentially improves outcome of completion surgery for rectal cancer. The aim of this study was to compare radical completion surgery after local excision for rectal cancer by the transanal approach (cTaTME) with conventional abdominal approach (cTME). Methods All consecutive patients who underwent cTaTME for rectal cancer between 2012 and 2017 were case-matched with cTME patients, according to gender, tumor height, preoperative radiotherapy, and tumor stage. Surgical, pathological, and short-term postoperative outcomes were evaluated. Results In total, 25 patients underwent completion TaTME and were matched with 25 patients after cTME. Median time from local excision to completion surgery was 9 weeks in both groups. In the cTaTME and cTME groups, perforation of the rectum occurred in 4 and 28% of patients, respectively (p = 0.049), leading to poor specimen quality in these patients. Number of harvested lymph nodes was higher after cTaTME (median 15; range 7-47) than after cTME (median 10; range 0-17). No significant difference was found in end colostomy rate between the two groups. Major 30-day morbidity (Clavien-Dindo≥ III) was 20 and 32%, respectively (p = 0.321). Hospital stay was significantly longer after cTME. Conclusion TaTME after full-thickness excision is a promising technique with a significantly lower risk of perforation of the rectum and better specimen quality compared to conventional completion TME.

Research paper thumbnail of Personalized management of elderly patients with rectal cancer: Expert recommendations of the European Society of Surgical Oncology, European Society of Coloproctology, International Society of Geriatric Oncology, and American College of Surgeons Commission on Cancer

European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology, Jan 15, 2018

With an expanding elderly population and median rectal cancer detection age of 70 years, the prev... more With an expanding elderly population and median rectal cancer detection age of 70 years, the prevalence of rectal cancer in elderly patients is increasing. Management is based on evidence from younger patients, resulting in substandard treatments and poor outcomes. Modern management of rectal cancer in the elderly demands patient-centered treatment, assessing frailty rather than chronological age. The heterogeneity of this group, combined with the limited available data, impedes drafting evidence-based guidelines. Therefore, a multidisciplinary task force convened experts from the European Society of Surgical Oncology, European Society of Coloproctology, International Society of Geriatric Oncology and the American College Surgeons Commission on Cancer, with the goal of identifying the best practice to promote personalized rectal cancer care in older patients. A crucial element for personalized care was recognized as the routine screening for frailty and geriatrician involvement and ...

Research paper thumbnail of St.Gallen consensus on safe implementation of transanal total mesorectal excision

Surgical endoscopy, 2018

The management of rectal cancer has evolved over the years, including the recent rise of Transana... more The management of rectal cancer has evolved over the years, including the recent rise of Transanal Total Mesorectal Excision (TaTME). TaTME addresses the limitations created by the bony confines of the pelvis, bulky tumours, and fatty mesorectum, particularly for low rectal cancers. However, guidance is required to ensure safe implementation and to avoid the pitfalls and potential major morbidity encountered by the early adopters of TaTME. We report a broad international consensus statement, which provides a basis for optimal clinical practice. Forty international experts were invited to participate based on clinical and academic achievements. The consensus statements were developed using Delphi methodology incorporating three successive rounds. Consensus was defined as agreement by 80% or more of the experts. A total of 37 colorectal surgeons from 20 countries and 5 continents (Europe, Asia, North and South America, Australasia) contributed to the consensus. Participation to the it...

Research paper thumbnail of Incidence and Risk Factors for Anastomotic Failure in 1594 Patients Treated by Transanal Total Mesorectal Excision: Results From the International TaTME Registry

Annals of surgery, Jan 5, 2018

To determine the incidence of anastomotic-related morbidity following Transanal Total Mesorectal ... more To determine the incidence of anastomotic-related morbidity following Transanal Total Mesorectal Excision (TaTME) and identify independent risk factors for failure. Anastomotic leak and its sequelae are dreaded complications following gastrointestinal surgery. TaTME is a recent technique for rectal resection, which includes novel anastomotic techniques. Prospective study of consecutive reconstructed TaTME cases recorded over 30 months in 107 surgical centers across 29 countries. Primary endpoint was "anastomotic failure," defined as a composite endpoint of early or delayed leak, pelvic abscess, anastomotic fistula, chronic sinus, or anastomotic stricture. Multivariate regression analysis performed identifying independent risk factors of anastomotic failure and an observed risk score developed. One thousand five hundred ninety-four cases with anastomotic reconstruction were analyzed; 96.6% performed for cancer. Median anastomotic height from anal verge was 3.0 ± 2.0 cm with...

Research paper thumbnail of Consensus on structured training curriculum for transanal total mesorectal excision (TaTME)

Surgical endoscopy, Jul 1, 2017

The interest and adoption of transanal total mesorectal excision (TaTME) is growing amongst the c... more The interest and adoption of transanal total mesorectal excision (TaTME) is growing amongst the colorectal surgical community, but there is no clear guidance on the optimal training framework to ensure safe practice for this novel operation. The aim of this study was to establish a consensus on a detailed structured training curriculum for TaTME. A consensus process to agree on the framework of the TaTME training curriculum was conducted, seeking views of 207 surgeons across 18 different countries, including 52 international experts in the field of TaTME. The process consisted of surveying potential learners of this technique, an international experts workshop and a final expert's consensus to draw an agreement on essential elements of the curriculum. Appropriate case selection was strongly recommended, and TaTME should be offered to patients with mid and low rectal cancers, but not proximal rectal cancers. Pre-requisites to learn TaTME should include completion of training and ...