Development and early outcomes of the national training initiative for transanal total mesorectal excision in the UK (original) (raw)
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Consensus on structured training curriculum for transanal total mesorectal excision (TaTME)
Surgical endoscopy, 2017
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 ...
Evaluation of the learning curve of transanal total mesorectal excision: single-centre experience
Videosurgery and Other Miniinvasive Techniques
Introduction: Transanal total mesorectal excision (TaTME) has been recently proposed to overcome the difficulties of the standard TME approach, allowing better visualization and dissection of the mesorectal fascia. Although TaTME seems very promising, the evidence and body of knowledge on achieving proficiency in performing it are still sparse. Aim: To evaluate the learning curve of TaTME based on a single centre's experience. Material and methods: Consecutive patients undergoing TaTME since 2014 in a tertiary referral department were included in the study. All procedures were performed by one experienced surgeon. CUSUM curve analyses were performed to evaluate learning curves. Results: Sixty-six patients underwent TaTME. After analysis of postoperative morbidity rate, intraoperative adverse effects and operative time, we estimated that 40 cases are needed to achieve TaTME proficiency. Subsequently, patients were divided into two groups: before (40 patients) and after overcoming the learning curve (26 patients). Group 1 had higher readmission (p = 0.041) and complication rates (p = 0.019). There were no statistically significant differences in terms of intraoperative adverse effects, length of stay or pathological quality of the specimen. Conclusions: Transanal total mesorectal excision is a promising yet technically demanding procedure and requires at least 40 cases to complete the learning curve. More data are needed to introduce it as a standard procedure for low rectal cancer treatment.
Colorectal Disease, 2017
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.
F1000 - Post-publication peer review of the biomedical literature
Background 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. Methods 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. Results 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 iterative Delphi rounds was 100%. An expert radiologist, pathologist, and medical oncologist provided recommendations to maximize relevance to current practice. Consensus was obtained on all seven different chapters: patient selection and surgical indication, perioperative management, patient positioning and operating room set up, surgical technique, devices and instruments, pelvic anatomy, TaTME training, and outcomes analysis. Conclusions This multidisciplinary consensus statement achieved more than 80% approval and can thus be graded as strong recommendation, yet acknowledging the current lack of high level evidence. It provides the best possible guidance for safe implementation and practice of Transanal Total Mesorectal Excision.
Transanal total mesorectal excision: how are we doing so far?
Colorectal Disease, 2019
Aim This subgroup analysis of a prospective multicentre cohort study aims to compare postoperative morbidity between transanal total mesorectal excision (TaTME) and laparoscopic total mesorectal excision (LaTME). The study was designed as a subgroup analysis of a prospective multicentre cohort study. Patients undergoing TaTME or LaTME for rectal cancer were selected. All patients were followed up until the first visit to the outpatient clinic after hospital discharge. Postoperative complications were classified according to the Clavien-Dindo classification and the comprehensive complication index (CCI). Propensity score matching was performed. Results In total, 220 patients were selected from the overall prospective multicentre cohort study. After propensity score matching, 48 patients from each group were compared. The median tumour height for TaTME was 10.0 cm (6.0-10.8) and for LaTME was 9.5 cm (7.0-12.0) (P = 0.459). The duration of surgery and anaesthesia were both significantly longer for TaTME (221 vs 180 min, P < 0.001, and 264 vs 217 min, P < 0.001). TaTME was not converted to laparotomy whilst surgery in five patients undergoing LaTME was converted to laparotomy (0.0% vs 10.4%, P = 0.056). No statistically significant differences were observed for Clavien-Dindo classification, CCI, readmissions, reoperations and mortality. The study showed that TaTME is a safe and feasible approach for rectal cancer resection. This new technique obtained similar postoperative morbidity to LaTME.
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 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...
Techniques in Coloproctology, 2018
Background Transanal total mesorectal excision (taTME) is a safe and effective technique. We have progressively developed a systematic approach in the single-surgeon setting. The aim of this study was to compare our early vs late single-surgeon taTME experience as well as present the technical and logistical modifications that were crucial to achieve successful implementation of a taTME program. Methods Review of prospectively collected data on 27 patients who had taTME in June 2015-September 2016 (early cohort) was included and compared with 43 patients who underwent taTME in October 2016-September 2017 (late cohort). Procedures were performed by a single-surgeon team at Health Sciences North (Sudbury, Ontario, Canada). Inclusion criteria were T1-3 or downstaged T4 mid-and low-rectal lesions. Cases of non-neoplastic disease were excluded. Outcomes assessed included mesorectal integrity, margin status, operative time, complications, morbidity, length of stay and 30-day readmission. Results A total of 70 cases were included. Patients were divided into early (27 patients, 14 males; mean age 60.74 ± 9.77 years) and late (43 patients, 29 males; mean age 63.48 ± 10.85 years) cohorts. During the early phase, procedural modifications including regular takedown of the splenic flexure, intra-corporeal division of the mesentery, liberal use of a Pfannenstiel incision for extraction, abundant washing of the surgical field and regular use of the ICG technology were progressively introduced. There was no mortality nor statistically significant difference between the early and late cohort in terms of morbidity (33.3 vs 39.4% p = 0.727), anastomotic leak (14.8 vs 4.6% p = 0.19), operating time (5.05 ± 1.26 vs 4.96 ± 1.14 h p = 0.755), length of stay (4.0 ± 2.54 vs 4.81 ± 3.63 days p = 0.394) and CRM negative margin (96.3 vs. 97.7% p = 0.999), and no incomplete specimens were obtained on either cohort. Conclusions This study confirms the safety and effectiveness of single-surgeon implementation of taTME technique. Technical challenges experienced in this setting were not obstacles for further refinement and to establish a tendency towards better outcomes. Overcoming technical challenges is possible, familiarity with taTME is slow yet progressive, and improvement tends to occur with experience.
Vojnosanitetski pregled, 2016
Background/Aim. In the last two decades there has been a significant progress in rectal cancer surgery. Preoperative radiotherapy, the introduction of staplers and largely improved surgical techniques have greatly contributed to better treatment outcomes, primarily by reducing the frequency of early surgical complications and the rate of local recurrence. The aim of this study was to compare operative and postoperative results in the treatment of rectal cancer between the two groups of surgeons ? those who are closely engaged in colorectal surgery and those who deal with these issues sporadically. Methods. This retrospective study included 146 patients who had underwent rectal cancer surgery at the Institute of Oncology of Vojvodina in the period from January 1, 2008 to December 31, 2010. The patients were divided into two groups, the group N1 of 101 patients operated on by trained colorectal surgeons, and the group N2 of 45 patients operated on by surgeons without training in total...