systematization and mediated results in 10 patients

(1)

w w w . j c o l . o r g . b r

Journal of

Coloproctology

Original Article

Tansanal total mesorectal excision (TaTME):

systematization and mediated results in 10 patients

Guilherme Inácio Bertoldo de Melo e Patriarca da Silva Neiva

^∗

, Fábio Alves Soares, Silvana Marques e Silva, Pedro Wilson Diniz Viana, Mário Nóbrega de Araújo Neto, Olane Marquez de Oliveira, Mauricio Cotrim Nascimento

HospitaldeBasedoDistritoFederal,UnidadedeColoproctologia,Brasília,DF,Brazil

a r t i c l e i n f o

Articlehistory:

Received18July2019 Accepted15September2019 Availableonline28October2019

Keywords:

TaTME

Totalmesorectalexcision Rectalcancer

Colorectalsurgery Transanalsurgery

a bs t r a c t

Background: Transanaltotalmesorectalexcisionisasurgicaltechniqueforminimallyinva- siveresectionoftherectumandperirectaltissues.Itisindicatedforpatientswithmedial anddistalrectumcancerconﬁnedtothemesorectalenvelope.Thisstudydescribesaseries ofpatientsundergoingtransanaltotalmesorectalexcision.

Methods:Tenpatientswereselectedtoundergotransanaltotalmesorectalexcisionusingthe SILS-Port® platform.Allpatientsincludedherehadmiddleorlowrectalcancer.Abdominal accessforproximalcolonmobilizationwasperformedbylaparoscopyinallcases.Asarule, in9ofthe10cases,thesurgicalspecimenwasremovedtransanally.

Results:Duringa41-monthperiod,10patientsunderwenttransanaltotalmesorectalexci- sionbasedoncurativeintent.Theﬁrstindicationfortransanaltotalmesorectumexcision wasmedialanddistalrectalcancer,locallyinvasiveandconﬁnedtothemesortalenvelope.

Themedianageofpatientswithrectalcanceratthetimeofsurgerywas61years(mean 59.4years,range22–78years),with80%(8)femaleand20%(2)male.Themediansurgical timewas305(mean314,range260–420).Themedianpostoperativelengthofstaywasﬁve days(averageof7.3days,intervalof3–23days).Therewasnopostoperativemortality.Surgi- calcomplicationsincludedpostoperativeileus(n=1),bladderparesis(n=1),andileostomy stenosis(n=1).Allpatientshadnegativesurgicalmarginsforneoplasiaandmorethan12 resectedlymphnodes.Thetumorswerebetween1and9cmfromtheanalmargin.

Conclusion:Totaltransanalmesorectalexcisionhasbeenshowntobeaviablemethodfor oncologicresectionoflocallyadvancedrectalcancerwithcurativeintent.

licenses/by-nc-nd/4.0/).

∗ Correspondingauthor.

E-mail:[email protected](G.I.Neiva).

https://doi.org/10.1016/j.jcol.2019.09.004

(2)

Excisãototaldomesorretoporviatransanal(TaTME):sistematizac¸ãoe resultadosmediatosemdezpacientes

Palavras-chave:

TaTME

Excisãototaldomesorreto Cancerretal

Cirurgiacolorretal Cirurgiatransanal

r e s u mo

Contexto: Aexcisãototaldomesorretoporviatransanaléumaaborgademcrânio-caudal paraa realizaçãoderessecção minimamenteinvasiva doretoetecidos perirretaisem monobloco.Éadequadaparapacientescomcâncerderetomédioedistalconfinadosao envelopemesorretal.Aquirelatamosumasériedepacientessubmetidosàexcisãototaldo mesorretoporviatransanal.

Métodos: Dezpacientes foramselecionadosparaserem submetidosà excisãototal do mesorreto por via transanal utilizando a plataforma SILS-Port®. Todos os pacientes eramportadoresdecâncerretaldelocalizac¸ãoextraperitoneal.Oacessoabdominalpara mobilizac¸ãodocólonproximal,emtodososcasos,foirealizadoporlaparoscopia.Como regra,aretiradadoespécimecirúrgico,emnovecasos,ocorreuporviatransanal.

Resultados: Duranteumperíodode41meses,10pacientesforamsubmetidosàexcisãototal domesorretoporviatransanalcomintençãocurativa.Aindicaçãoprimáriaparaexcisão totaldomesorretotransanalfoiocâncerderetomédioedistal,localmenteinvasor,mas confinadoaoenvelopemesorretal.Amedianadeidadedospacientescomcâncerdereto nomomentodacirurgiafoide61anos(médiade59,4anos,faixade22–78anos),sendo80%

(8)dosexofemininoe20%(2)dosexomasculino.Amedianadotempocirúrgicofoide305’

(médiade314’,intervalode260–420’).Amedianadotempodepermanênciapós-operatória foidecincodias(médiade7,3dias,intervalode3–23dias).Nãohouvemortalidadepós- operatória.Ascomplicac¸õescirúrgicasincluíramíleoparalítico(n=1),paresiavesical(n=1) eestenosedeileostomia(n=1).Todosospacientestiverammargenscirúrgicasnegativas paraneoplasiaemaisde12linfonodosressecados.Ostumoresdistavamde1a9cmda margemanal.

Conclusão: Aexcisãototaldomesorretotransanaldemonstrou-seummétodoviávelparaa ressecçãooncológicadecâncerderetolocalmenteavançadocomintençãocurativa.

´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/

licenses/by-nc-nd/4.0/).

Introduction

Colorectalcanceristhethirdmostcommontypeofcancerin theworld¹and,consideringonlytheextraperitonealcompart- ment,itpresentsuniquesurgicalchallenges.TotalMesorectal Excision(TME)isthegoldstandardforsurgicalmanagement ofrectalcancer.²Neoadjuvanttherapy,combinedwithquality surgical resection ofrectal cancer with neoplasia-free distaland circumferentialresection margins,can improvethe recurrencerateanddisease-freesurvival.^3,4Theseoncologi- calbeneﬁtswereprimarilyshownwithopensurgeryandare currentlyestablishedwithlaparoscopy.^4–6

Pelvic dissection and mobilization of the rectum and the entire mesorectal envelope can be a challenging pro- cedureduetopatient andtumorvariables.⁷ Male patients, obesepatients,anteriorlylocatedtumors,largetumorswith advanced T Stage, as well as instrumentation and pelvic exposurelimitations may affect dissection during open or laparoscopicTME.Inadequatedissectionincreasestheriskof surgicalmargininvolvement.^8,9 Althoughsomegroupshave successfullyusedtheroboticapproachtoreducetheserisks, thereisapaucityofdataonthesuperiorityofroboticsregard- ingcanceroutcomestodate.¹⁰

The need to overcome these challenges motivated surgeonstodevelopalternativetechniquesinordertosuc- cessfully perform rectal oncologic dissection.¹¹ TaTME is not a recent surgical approach, but rather a combination of established techniques, including Transanal Endoscopic Microsurgery(TEM),Transabdominal-Transanal(TATA)oper- ation,and Transanal minimally invasivesurgery(TAMIS).¹¹ The ﬁrst caseoflaparoscopy-guided TaTMEwas published in2010.¹² Sincethen,severalstudies haveshownthat this technique canbe safely performedand preserves the TME oncologicprinciples.^13–15Similarly,wereportourseriesof10 patientsundergoingTaTME,demonstratingthesafetyandvia- bilityofTaTMEinextraperitonealrectaltumors.

Methods

Between January 2015 and December 2018, 10 patients withhistologicaldiagnosisofrectaladenocarcinoma,located within10cmofthe anal margin, underwent TaTMEinour institution. Only onepatient did not undergo neoadjuvant therapy,asshepresentedwithStageIlesion,butwithindica- tionfortotalproctocolectomyduetoFamilialAdenomatous Polyposis(FAP).

(3)

Fig.1–Rectalclosureabovethepectinealline.

ThoracoabdominalComputedTomography(CT)andpelvic MagneticResonanceImaging(MRI) were routinely usedfor patientstaging.IntheStageIpatient,anorectalultrasound wasalsousedforassessmentofanalcanalmorphology.All subjectsunderwentcompletevideocolonoscopyexamination, withsynchronouslesionsfoundinonepatient.SerumCar- cinoembryonic Antigen (CEA) levels completed the staging process.

Anterogradecolonpreparationwith10%mannitolsolution andadequateantibioticprophylaxiswereusedinallpatients.

Inpatientsundergoingneoadjuvanttherapy,clinicalimag- ingandendoscopicrestagingwasperformedapproximately 8 weeks after its completion and surgery was performed between12and16weeksaftertheendofradiotherapy.

Allsurgeriesfollowedthesame standardization,andthe abdominalandtransanaltimeswereperformedbythesame teaminsuccession.Thecolorectalsurgeon(FAS)wasthesame forallproceduresandtheassistantshadthesametrainingor wereresidentinthespecialty.Abdominalsurgicaltimealways occurredbylaparoscopy,withamid-lateralapproach,respect- ingtheoncologicalparametersofresectionandreleasingthe splenicﬂexionofthecoloninallcases.Pelvicdissectionwas interruptedatthelevelofperitonealreﬂection.

Aftertheabdominaltime,thesurgicalﬁeldsand laparo- scopicmaterialwerechanged,andthepatientwasplacedin thelithotomyposition toinitiatethe transanaltime. Inall subjects,apurse-stringsuturewasperformedabouttwocen- timetersabovethe pectineallineunderdirectvision,using theportalincludedintheEEAHEM® staplerkit(Fig.1).Sub- sequently,theSILS^TM Port platform(MedtronicInc.,Dublin, Ireland)wasusedfortransanalaccess(Fig.2),combinedwith laparoscopicabdominalaccess.

A CO2 insufﬂation pneumopelvis was then made at a controlledpressureof12mmHg.Thismaneuverallowedthe delimitationofthe perirectalavascularplanes, whichwere dissectedupwardsandcircumferentially,freeingthesurgical specimen.

Afteracarefulreview ofhemostasis,the specimenwas removed transanally(Fig. 3),exceptin onecasewherethe tumorwasverylargeandhadtoberemovedbyalowtrans- verseabdominalincision(Pfannenstielincision).

In8casesit waspossibletoperformstapledanastomo- siswithEEATMHEM® 33mm–4.8mmstapler(MedtronicInc,

Fig.2–SILS^TMPortdeviceinserted.

Fig.3–Transanalsurgicalspecimenremoval.

Dublin,Ireland). Inthesecases, shortlyafter thespecimen removal, suture in the remnant colon bag was performed and the stapler warhead was fixed. The EEAHEM® anus- cope portal wasthen placedand fixedtothe skinand the distal stumppouch was sutured.Finally, the warhead was attached,followedbythestaplerclosure(Fig.4a–c),andthe pneumoperitoneumwasredone.Thepositionofthelowered colonwascheckedandafinalrevisionoftheabdominalcav- ity was performed, aswell asthe repairofthe ileum loop to make a protective ileostomy. Then, pneumoperitoneum was undone,staplingwasperformed, andstapled linewas checked,transanally,inordertomakereinforcementand/or hemostaticpointswhenevernecessary.

Finally,inallcasesinwhichtheanastomosiscouldbeper- formed,aloopileostomywasperformedintherightiliacfossa, whichwasmaintainedforthreemonthsaftertheprocedure.

Inonecasethatrequiredtheassociationofanintersphinc- tericdissectionandpartialen-blocresectionofthesphincter,a circumferentialincisionwithamonopolarelectrocauterywas performedalongthepectineallineanddissectionextending from theintersphincterspacetotheperirectalplanes,with subsequent placementofthe SILSport platform.For inter- sphinctericresection,aLoneStar® retractor(CooperSurgical, Trumbull, Connecticut, USA) wasalso used.In this case,a manualcoloanalanastomosiswasperformed.

(4)

Fig.4–(a)Staplercoupling;(b)Stapling;(c)Surgical specimen.

Results

Overa41-monthperiod,10patientsunderwentTaTMEwith curative intent.Themedian ageof patientsatthe time of surgerywas61years(mean59.4years,range22–78years),with 80%(8)beingfemale.Themediansurgicaltimewas305min (range260–420min).In8patients,astapledcolorectalanasto- mosiswasperformed,inonecase(P2)adeﬁnitiveileostomy wasperformedaftertotalproctocolectomy,asashortintesti- nalmesentery was observed, which madeit impossible to descendtheilealpouchforileoanalanastomosis.

Inonecase(P10)requiringintersphinctericresection,manualcoloanalanastomosiswasperformed.

The median postoperative length of stay was ﬁve days (mean 7.3 days, range 3–23 days). Surgical complications included paralytic ileus (n=1), bladder paresis (n=1), and ileostomystenosis(n=1).Onepatient (P2)had acomplica- tionduetoanestheticintervention(leftiliacarterythrombosis secondarytofemoralarterypunctureforinvasivebloodpres- suremonitoring–invasivebloodpressurecatheter),withthe longesthospitalstayintheseries.

Allpatientshaddistal,proximal,andcircumferentialmar- ginsfreeofneoplasiaandmorethan12lymphnodesresected insurgicalspecimens.

Tumors were 1–9cm from the anal margin. Pathological stagingranged from StageI toIII, with 60% ofthe lesions relatedtoparietalinvasionandclassiﬁedasT3lesions.

Meanbloodlosswasnotassessed,butnopatientrequired perioperativebloodtransfusion.

There werenocasesofconversiontoopensurgery, and onepatienthadileostomystenosisinthesixthpostoperative week,whichwasredone.

Table1showstheperioperativeandpostoperativeparam- etersofallpatients.

Discussion

In recent years, the treatment of lower rectal cancer has been modiﬁed in order to increase the rate of sphincter preservation.^16,17 Since the publication by Heald and Ryall,² TMEhasbeenacceptedworldwideasthe goldstan- dardsurgicaltechniqueforrectalcancerresection.Although the standardizationofTMEsurgeryiswell establishedand widespread, some studies still reportincomplete mesorec- tum after pathological examinationof rectal specimensin patientsundergoingrectalcancersurgeryperformedwiththis technique.^18,19 Even in experienced hands,rectal resection withTMEmaybeachallenge,especiallyinmalepatientswith narrowpelvis,obesepatients,andinlargetumors.^8,9,11

Under thesecircumstances,thedistalrectumdissection throughtheabdomen(bylaparotomyorlaparoscopy)isadif- ficulttask,withanincreasedriskofincompleteresectionand involvementofcircumferentialanddistalmargins.Themain difficultyliesintheexposureofthesurgicalfieldandplaneof dissection,whichisatanangletotheplaneofsurgicalview, ofteninaccessible.²⁰ Inthetransanalapproach,thisdissec- tionissimplifiedbecausethesurgeon’svisionisonthesame axis asthe lower-middle rectum, allowing resection under directvision,betteridentificationofthemesorectalanatomi- calplanes,andaccuratedeterminationofthedistalresection margin.²⁰

Inthisseries,weaddressedtheabdominalandtransanal approachtimeswiththesameteamduetotheunavailability ofequipmentandothersurgeonsthatwouldallowthesimul- taneousapproach,whichhasthebeneﬁtofshorteroperating time,earlyligationofthevascularpedicle,andearlyclamp- ingofthecolontopreventpneumocholon.Thedownsideis that itneedsmoreinvestmentinequipment andasecond trainedstaffavailable.Evenso,themediantimetosurgerywas 305min,similartothetimeinotherstudieswithconcomitant resection.^20–23

(5)

Table1–PerioperativeandpostoperativeparametersofpatientsundergoingTaTME.

Patient,gender, andage

Tumorlocation (distancefromanal margin)

Postoperative staging

Surgicaltime Complications Hospitalization (days)

P1/F,63a 6cm pT3N1 360min Adynamicileus 6

P2/F,22a 3cm pT2N0 420min Leftiliacarterythrombosis 23

P3/F,57a 7cm pT3N0 320min – 5

P4/F,72a 5cm pT2N0 300min – 6

P5/F,73a 7cm pT3N1 310min – 5

P6/F,56a 7cm pT2N0 290min – 5

P7/F,62a 4cm pT3N0 330min – 5

P8/F,78a 9cm pT3N0 270min – 4

P9/M,51a 8cm pT3N1 260min Ileostomystenosis 11

P10/M,60a 3cm pT1N0 280min Bladderparesis 3

Median61a 6,5cm – 305min – 5

Inthisstudy,wedemonstratedthattheuse ofthis new approachledtomortalityandmorbidityratesof0%and33%, respectively associated with the surgical procedure. These ﬁndingsareconsistentwiththemortalityandmorbidityrates followingrectal cancerresection reported inthe literature.

Inameta-analysisof23studiescomparingopenandlaparo- scopicresectionforrectalcancer(4539patients),Arezoetal.²⁴ reporteda1%mortalityrateinthelaparoscopicgroupand 2.4%intheopengroupandaglobalcomplicationrateof31.8%

inthelaparoscopicgroupand35.4%intheopengroup.Accord- ingtoTuechetal.²⁰andLeeetal.,²¹ thecumulativerateof postoperativecomplicationswasaround30%–35%.

Apointofconcerninlaparoscopicrectalsurgeryistherec- taltransectionstage,whichisquitedifﬁcultinlowerrectal lesionsandmayhindercanceroutcomeincasesofinadequate distalmargin,increasingthe likelihood oflocalrecurrence.

Itisnoteworthythat,inTaTME,theﬁrststepistoclosethe rectallumendistallytothetumor,thushavingdirectcontrol ofthe distalmargin. Inourseries, distaland circumferen- tialresectionmarginswereadequateinallpatients.^25–27This data,despitethe smallnumber ofcasesinourstudy,isin linewiththe ratesof88%and 75%reported inthestudies byMuratoreetal.²⁸(TaTME)andCOREANtrial(transabdomi- nalTEM),²⁹respectively.SixtypercentofourpatientshadT3 tumorsand wedidnotobserved anyT4tumors. Although advancedtumors(T4)arenotacontraindication toTaTME, thereisatendencytoavoidsuchanapproachinthosetypes oflesions,whichareassociatedwithahigherconversionrate andpositiveresectionmargins.^31,32

Thedehiscencerateofstapledormanualcoloanalanas- tomosisafterTEMrangesfrom5%to11%.^16,17Inthepresent seriestherewerenoreportsofsuchcomplication.Themedian lengthofhospitalstayafterTaTMEwasﬁvedaysandthere wasno30-daymortalityaftersurgery,similartootherstudies evaluated.^20,21,23

In our study, after TaTME procedure, no patient com- plainedofseverepostoperativefecalincontinence,evenafter intestinaltransitreconstructioninthe9caseswhereitwas possible.However,preoperativeandpostoperativefunctional assessmentwasnotsystematicallyperformedinthe study population.Previousmanometric analyzesofthe effectsof anal dilation after TEM indicated a decrease in sphincter tonerangingfrom2.5%to37%,comparedwithpreoperative

manometricdata,withcompletepostoperativerecoveryfrom clinicalcontinencewithin6–16weeks.³⁰

Weareawareofsomelimitationsofthestudy.Ourcase series has a small sample. However, TaTME has proven to be a safe, feasible and reproducible procedure, pro- viding good dissection quality and satisfactory oncologic results.

Conﬂicts of interest

Theauthorsdeclarenoconﬂictsofinterest.

references

1.WorldCancerResearchFund.ColorectalCancerStatistics.

http://www.wcrf.org/int/cancer-facts-ﬁgures/data-speciﬁc- cancers/colorectal-cancer-statistics.AccessedFebruary2, 2016.

2.HealdRJ,RyallRD.Recurrenceandsurvivalaftertotal mesorectalexcisionforrectalcancer.Lancet.1986;1:1479–82.

3.MERCURYStudyGroup.Diagnosticaccuracyofpreoperative magneticresonanceimaginginpredictingcurativeresection ofrectalcancer:prospectiveobservationalstudy.BMJ.

2006;333:779–83.

4.MartlingA,SingnomklaoT,HolmT,RutqvistLE,CedermarkB.

Prognosticsigniﬁcanceofbothsurgicalandpathological assessmentofcurativeresectionforrectalcancer.BrJSurg.

2004;91:1040–5.

5.JeongSY,ParkJW,NamBH,KimS,KangSB,LimSB,etal.

Openversuslaparoscopicsurgeryformidrectalorlow-rectal cancerafterneoadjuvantchemoradiotherapy(COREANtrial):

survivaloutcomesofanopen-label,non-inferiority, randomizedcontrolledtrial.LancetOncol.2014;15:767–74.

6.vanderPasMH,HaglindE,CuestaMA,FürstA,LacyAM,Hop WC,etal.ColorectalcancerLaparoscopicorOpenResectionII (COLORII)StudyGroup.Laparoscopicversusopensurgeryfor rectalcancer(COLORII):short-termoutcomesofa

randomised,phase3trial.LancetOncol.2013;14:210–8.

7.AraújoSE,SeidVE,BertonciniA,CamposFG,SousaAJr, NahasSC,etal.Laparoscopictotalmesorectalexcisionfor rectalcancerafterneoadjuvanttreatment:targeting sphincter-pre-servingsurgery.Hepatogastroenterology.

2011;58:1545–54.

8.VelthuisS,vandenBoezemPB,vanderPeetDL,CuestaMA, SietsesC.Feasibilitystudyoftransanaltotalmesorectal excision.BrJSurg.2013;100:828–31.

(6)

9. RouanetP,MourregotA,AzarCC,CarrereS,GutowskiM, QuenetF,etal.Transanalendoscopicproctectomy:an innovativeprocedurefordifﬁcultresectionofrectaltumorsin menwithnarrowpelvis.DisColonRectum.2013;56:

408–15.

10.HalabiWJ,KangCY,JafariMD,NguyenVQ,CarmichaelJC, MillsS,etal.Robotic-assistedcolorectalsurgeryintheUnited States:anationwideanalysisoftrendsandoutcomes.WorldJ Surg.2013;37:2782–90.

11.AraujoSE,CrawshawB,MendesCR,DelaneyCP.Transanal totalmesorectalexcision:asystematicreviewofthe experimentalandclinicalevidence.TechColoproctol.

2015;19:69–82.

12.SyllaP,RattnerDW,DelgadoS,LacyAM.NOTEStransanal rectalcancerresectionusingtransanalendoscopic microsurgeryandlaparoscopicassistance.SurgEndosc.

2010;24:1205–10.

13.deLacyAM,RattnerDW,AdelsdorferC,TasendeMM, FernándezM,DelgadoS,etal.Transanalnaturaloriﬁce transluminalendoscopicsurgery(NOTES)rectalresection:

“down-to-up”totalmesorectalexcision(TME)–short-term outcomesintheﬁrst20cases.SurgEndosc.2013;27:3165–72.

14.DumontF,GoéréD,HonoréC,EliasD.Transanalendoscopic totalmesorectalexcisioncombinedwithsingle-port laparoscopy.DisColonRectum.2012;55:996–1001.

15.LeroyJ,BarryBD,MelaniA,MutterD,MarescauxJ.No-scar transanaltotalmesorectalexcision:thelaststeptopure NOTESforcolorectalsurgery.JAMASurg.2013;148:226–30.

16.RullierE,DenostQ,VendrelyV,RullierA,LaurentC.Low rectalcancer:classiﬁcationandstandardizationofsurgery.

DisColonRectum.2013;56:560–7.

17.ParkJS,ChoiGS,JunSH,HasegawaS,SakaiY.Laparoscopic versusopeninterspinctericresectionandcoloanal

anastomosisforlowrectalcancer.AnnSurg.2011;254:941–6.

18.MaslekarS,SharmaA,MacdonaldA,GunnJ,MonsonJR, HartleyJE.Mesorectalgradespredictrecurrencesafter curativeresectionforrectalcancer.DisColonRectum.

2007;50:168–75.

19.BaikSH,KimNK,LeeKY,SohnSK,ChoCH,KimMJ,etal.

Factorsinﬂuencingpathologicresultsaftertotalmesorectal excisionforrectalcancer:analysisofconsecutive100cases.

AnnSurgOncol.2008;15:721–8.

20.TuechJJ,KarouiM,LelongB,DeChaisemartinC,BridouxV, ManceauG,etal.AsteptowardNOTEStotalmesorectal excisionforrectalcancerendoscopictransanalproctectomy.

AnnSurg.2015;261:228–33.

21.LeeGC,SyllaP.Shiftingparadigmsinminimallyinvasive surgery:applicationsoftransanalnaturaloriﬁcetransluminal

endoscopicsurgeryincolorectalsurgery.ClinColonRectal Surg.2015;28:181–93.

22.DeijenCL,TsaiA,KoedamTW,VeltcampHelbachM,Sietses C,LacyAM,etal.Clinicaloutcomesandcasevolumeeffectof transanaltotalmesorectalexcisionforrectalcancer:a systematicreview.TechColoproctol.2016;20:811–24.

23.FooDC,ChoiHK,WeiR,YipJ,LawWL.Transanaltotal mesorectalexcisionwithsingle-incisionlaparoscopyfor rectalcancer.JSLS.2016;20,e2016.00007.

24.ArezzoA,PasseraR,ScozzariG,VerraM,MorinoM.

Laparoscopyforrectalcancerreducesshort-termmortality andmorbidity:resultsofasystematicreviewand

meta-analysis.SurgEndosc.2013;27:1485–502.

25.TargaronaEM,BalagueC,PernasJC,MartinezC,Berindoague R,GichI,etal.Canwepredictimmediateoutcomeafter laparoscopicrectalsurgery?Multivariateanalysisofclinical, anatomic,andpathologicfeaturesafter3-dimensional reconstructionofthepelvicanatomy.AnnSurg.

2008;247:642–9.

26.AtallahS,AlbertM,DeBeche-AdamsT,NassifG,Polavarapu H,LarachS.Transanalminimallyinvasivesurgeryfor totalmesorectalexcision(TAMIS–TME):astepwisedescription ofthesurgicaltechniquewithvídeodemonstration.Tech Coloproctol.2013;17:321–5.

27.Fernandez-HeviaM,DelgadoS,CastellsA,TasendeM, MomblanD,DíazdelGobboG,etal.Transanaltotal

mesorectalexcisioninrectalcancer:shorttermoutcomesin comparisonwithlaparoscopicsurgery.AnnSurg.

2015;261:221–7.

28.MuratoreA,MellanoA,MarsanicP,DeSimoneM.Transanal totalmesorectalexcision(taTME)forcancerlocatedinthe lowerrectum:short-andmid-termresults.EurJSurgOncol.

2015;41:478–83.

29.KangSB,ParkJW,JeongSY,NamBH,ChoiHS,KimDW,etal.

Openversuslaparoscopicsurgeryformidorlowrectalcancer afterneoadjuvantchemoradiotherapy(COREANtrial):

short-termoutcomesofanopen-labelrandomizedcontrolled trial.LancetOncol.2010;11:637–45.

30.HermanRM,RichterP,WalegaP,PopielaT.Anorectal sphincterfunctionandrectalbarostatstudyinpatients followingtransanalendoscopicmicrosurgery.IntColorectal Dis.2001;16:370–6.

31.RouanetP,MourregotA,AzarCC,CarrereS,GutowskiM, QuenetF,etal.Transanalendoscopicproctectomy:an innovativeprocedurefordifﬁcultresectionofrectaltumorsin menwithnarrowpelvis.DisColonRectum.2013;56:408–15.

32.BjørnMX,PerdawoodSK.Transanaltotalmesorectalexcision –asystematicreview.DanMedJ.2015;62:A5105.