Transanal total mesorectal excision: Towards standardization of technique

Table 1 Types of studies and patient selection for transanal total mesorectal excision

Author, year	Type of study	No. of patients	Median age (yr)	Gender ratio (M:F)	Median BMI (kg/m²)	Neoadjuvant therapy	Median distance from AV/DL (cm)
Zorron, 2010	Prospective	9	63 (range, 52-81)	5:4	NR	4/9	AV 7.5 (range, 4-12)
Dumont, 2012	Prospective	4	67 (range, 70-66)	4:0	23 (range, 22-25)	NR	AV 5.3 (range, 4-7)
de Lacy, 2013	Prospective	20	65 ± 10.21 (range, 44-77)	11:9	25 ± 3.8 (range, 19-33)	14/20	DL 6.5 ± 3.31 (range, 2-15)
Lacy, 2013	Prospective	3	73 (range, 71-75)	1:2	22 (range, 16-25)	2/3	9.7 (range, 9-10)
Rouanet, 2013	Prospective	30	65 (range, 43-82)	30:0	26 (range, 21-32)	29/30	AV Low rectum (0-5 cm) 20/30; Middle rectum (5-10 cm) 10/30; Upper rectum (10-15 cm) 0/30
Sylla, 2013	Prospective	5	49 ± 9.81	3:2	26 ± 2.3	2/5	AV 5.7 (range, 4-10)
Atallah, 2014	Prospective	20	57 (range, 36-73)	14:6	24 (range 18-41)	17/20	AV 5 (range 1-9)
Chen, 2014	Prospective	20	58 ± 10.11	11:9	25 ± 3	11/20	AV 5.9 ± 1.7 (range, 2-8)
Chouillard, 2014	Prospective	16	58 (range, 34-81)	6:10	28 (range, 21-38)	Yes	NR
Fernandez-Hevia, 2014	Prospective Comparative	37	65 ± 11.81	24:13	24 ± 3.6 (range, 18-31)	27/37	AV Middle rectum 8.1 ± 1.71; Low rectum 3.5 cm ± 1.21
Kneist, 2014	Prospective	6	56 (range, 45-65)	5:1	25 (range, 23-28)	4/6	DL 1.7 (range, 0-3)
Meng, 2014	Prospective	3	80 (range, 76-82)	2:1	NR	1/3	AV 4.3 (range, 4-5)
Tuech, 2014	Prospective	56	65 (range, 39-83)	41:15	27 (range, 20-42)	47/56	AV 4 (range, 0-5)
Velthuis, 2014	Prospective Case-Matched	25	64 (range, 49-86)	18:7	25 (range, 20-36)	25/25	AV 8 (range, 0-16)
Wolthuis, 2014	Prospective	7	65 (range, 38-87)	6:1	25 (range, 17-32)	NR	NR
Atallah, 2015	Retrospective	4	45 (range, 26-59)	3:1	31 (range, 21-38)	3/4	AV 3.3 (range, 1-4)
Gomez Ruiz, 2015	Prospective	5	53 (range, 38-67)	4:1	26 (range, 22-31)	4/5	AV 5 (range, 4-6)
Knol, 2015	Prospective	10	61 (range 36-70)	8:2	27 (range 22-34)	10/10	DL 2.9 ± 1.21
Muratore, 2015	Prospective	26	66 (range, 38-84)	16:10	26 (range, 17-38)	19/26	4.4 (range, 3-6)
Prochazka, 2015	Prospective	17	68 (range, 49-81)	11:6	28 (range, 22-32)	12/17	AV 6 (range, 3-8)

¹Values reported as the mean ± SD. AV: Anal verge; DL: Dentate line; NR: Not reported; M: Male; F: Female; BMI: Body mass index.

Table 2 Operative techniques reported for transanal total mesorectal excision

Author, year	Transanal first	Transanal platform	Pure NOTES	Number of laparoscopic ports	Splenic flexure mobilization	Specimen extraction	Anastomosis	Defunctioning stoma (loop ileostomy)
Zorron, 2010	Yes	TriPort	No	3	Yes	Transanal 7; transabdominal 2	Hand-sewn 1/9, hand-sewn J-pouch 3/9, stapled 5/9	Yes
Dumont, 2012	Yes	GelPOINT Path	No	GelPOINT	Yes	Transabdominal	Hand-sewn	Yes
de Lacy, 2013	Simultaneous	GelPOINT Path	No	3.2 ± 0.81 (range, 3-4)	NR	Transanal	Hand-sewn 13/20, stapled 7/20	16/20
Lacy, 2013	Simultaneous	GelPOINT Path	No	4	2/3	Transanal	Stapled	2/3
Rouanet, 2013	Not systematically	TEO proctoscope	No	NR	Yes	Transanal or transabdominal	Hand-sewn straight 12/30, hand-sewn J-pouch 18/30	Yes
Sylla, 2013	Simultaneous	TEO proctoscope	No	4 or 5	Yes	Transanal	Hand-sewn	Yes
Atallah, 2014	No	SILS™ Port or GelPOINT path	No	NR	Yes	NR	Hand-sewn straight 11/20, stapled 4/20	14/20
Chen, 2014	No or simultaneous	GelPOINT Path	No	GelPOINT + 1	4/20	Transanal or transabdominal	Hand-sewn 6/20, stapled 14/20	Loop colostomy 12/20, loop ileostomy 5/20
Chouillard, 2014	Yes	SILS™ Port or GelPOINT path	Yes (10/16)	GelPOINT	NR	NR	Hand-sewn	Loop ileostomy 4/16, permanent ileostomy 1/16, permanent colostomy 1/16
Fernandez-Hevia, 2014	Simultaneous	GelPOINT Path	No	4 or 5	14/37	Transanal 36; transabdominal 1	Hand-sewn 16/37, stapled 21/37	32/37
Kneist, 2014	No	SILS™ Port or GelPOINT path	No	3-5	Yes	Transanal	Hand-sewn J-pouch 2/6, hand-sewn E-E 2/6, hand-sewn S-E 1/6, stapled J-pouch 1/6	Yes
Meng, 2014	Simultaneous	TEM platform	No	5	Yes	Transabdominal	Stapled	NR
Tuech, 2014	Yes	SILS™ Port or GelPOINT path or Endorec®	No	4 or single port in future ileostomy site	NR	Transanal	Hand-sewn J-pouch 4/56, hand-sewn S-E 29/56, hand-sewn straight 13/56	Permanent colostomy 4/56, loop ileostomy 44/56
Velthuis, 2014	5/25	SILS™ Port or GelPOINT path	No	SILS™ Port	Yes	Transanal	Hand-sewn or stapled	Loop ileostomy 19/25, permanent colostomy 6/25
Wolthuis, 2014	Yes	GelPOINT Path	No	3	Yes	Transanal	Hand-sewn	Yes
Atallah, 2015	No	GelPOINT Path	No	NR	Yes	Transabdominal	Hand-sewn 3/4	Loop ileostomy 3/4, permanent ileostomy 1/4
Gomez Ruiz, 2015	No	Transanal access port proctoscope	No	4	Yes	Transanal	Hand-sewn straight 2/5, stapled 3/5	Yes
Knol, 2015	No	GelPOINT Path	No	4 or 5	8/10	Transanal 1; transabdominal 9	Hand-sewn 3/10, stapled 7/10	Yes
Muratore, 2015	Yes	SILS™ Port	No	3	Yes	Transanal	Hand-sewn straight 17/26, hand-sewn J-pouch 8/26	Yes
Prochazka, 2015	Yes	SILS™ Port or GelPOINT path or Endorec®	No	NR	Yes	Transanal	Hand-sewn	Yes

¹Values reported as the mean ± SD. E-E: End-to-end; NR: Not reported; S-E: Side-to-end.

Table 3 Operative outcomes after transanal total mesorectal excision

Author, year	Median duration of surgery (min)	Median blood loss (mL)	Postoperative morbidity	Median length of stay (d)	Median follow-up (mo)	NOS
Zorron, 2010	311 (range, 200-420)	96 (range, 20-250)	Anastomotic leakage 1/9	7 (range, 4-27)	NR	3
Dumont, 2012	360 (range, 270-460)	175 (range, 50-300)	Anastomotic leakage 1/4	13 (range, 10-21)	4.3 (range, 3-9)	4
de Lacy, 2013	234.7 ± 561 (range, 150-325)	45 ± 151 (range, 10-110)	Urinary retention 2/20, POI 1/20, high-output ileostomy 1/20	6.5 ± 3.11	NR	6
Lacy, 2013	143 (range, 125-155)	65 (range, 15-30)	High-output ileostomy 1/3	5 (range, 4-5)	NR	4
Rouanet, 2013	304 (range, 120-432)	NR	POI 2/30, transient urinary dysfunction 2/30	14 (range, 9-25)	21 (range, 10-41)	6
Sylla, 2013	274.6 ± 85.41	166 (range, 80-300)	POI 1/5, transient urinary dysfunction 2/5	5.2 ± 2.61	5.4 ± 2.31	5
Atallah, 2014	243 (range, 140-495)	153 (range 30-500)	SSI 2/20, Pelvic abscess 4/20, POI 4/20, Anastomotic leakage 1/20	4.5 (range, 3-24)	6 (range, 1-24)	6
Chen, 2014	200.8 ± 47.71	68 ± 1061	Urinary retention 3/20, pelvic abscess 2/20	8.85 ± 2.51	NR	6
Chouillard, 2014	265 (range, 155-440)	225 (range, 50-600)	SBO 2/14, pelvic abscess 1/16	10 (range, 4-29)	9 (range, 3-29)	6
Fernandez-Hevia, 2014	215 ± 601 (range, 120-360)	NR	Anastomotic leakage 2/37, haemorrhage 1/37, urinary retention 1/37, POI 4/37	6 (range, 3-17)	NR	8
Kneist, 2014	NR	NR	NR	NR	NR	3
Meng, 2014	NR	NR	No	NR	NR	2
Tuech, 2014	270 (range, 150-495)	NR	Anastomotic leakage 3/56, pelvic sepsis 3/56, transient urinary dysfunction 5/56	10 (range, 6-21)	29 (range, 18-52)	6
Velthuis, 2014	NR	NR	NR	NR	NR	8
Wolthuis, 2014	148 (range, 85-250)	49 (range, 0-150)	Pelvic haematoma 1/7	9 (range, 3-14)	6 (range, 2-14)	6
Atallah, 2015	376 (range, 40-409)	200 (range, 50-300)	High-output ileostomy 1/20, SSI 1/20	4 (range, 4-5)	9 (range, 6-12)	4
Gomez Ruiz, 2015	375 (range, 270-450)	76 (range, 25-120)	Anastomotic leakage 1/5	6 (range, 5-7)	NR	4
Knol, 2015	235 (range, 150-290)	220 (range, 65-480)	POI 1/10	6 (range, 5-9)	NR	4
Muratore, 2015	241 (range, 150-360)	NR	Urinary retention 1/26	7 (range 3-25)	18 (range, 16-30)	6
Prochazka, 2015	280 (range, 212-375)	200 (range, 40-900)	Anastomotic leakage 2/17, POI 2/17, UTI 1/17, SSI 1/17	9 (range, 6-30)	NR	4

¹Values reported as the mean ± SD. NR: Not reported; POI: Postoperative ileus; SBO: Small-bowel obstruction; SSI: Surgical site infection; UTI: Urinary tract infection.