| BackgroudAccording to the statistics of global malignant tumor data in 2020,the incidence of colorectal cancer ranks third among all malignant tumors,and the mortality rate ranks second.There are about 408000 new cases and about 196000 new deaths of colorectal cancer in China each year.Around 60% to 70% of colorectal cancers tend to be rectal cancers.We should pay great attention to the prevention and treatment of rectal cancer.In 1982,Heald put forward the concept of total mesorectal excision(TME),and greatly reduces the local recurrence rate and improves the long-term prognosis after rectal cancer surgery.Since the advent of minimally invasive surgery technology for more than 30 years,traditional laparoscopic total mesorectal excision(LTME)has been widely used,it has brought patients less trauma,less pain,faster postoperative recovery and other benefits.With the continuous innovation of minimally invasive surgical technology and concept,the advent of RTME(robotic total mesorectal excision)and TaTME(transanal total mesorectal excision)have brought innovation to the minimally invasive surgical treatment of rectal cancer.The purpose of this study is to compare RTME,TaTME and traditional LTME respectively,further defined the efficacy of RTME and TaTME for radical resection of rectal cancer,especially focus on their advantages and disadvantages,and to provided a clinical basis for the choice of radical resection of rectal cancer.Methods1.From July 1,2016 to March 31,2021,the clinical data of patients who underwent RTME or LTME for radical resection of rectal cancer in the general surgery department of Daping Hospital and 940 Hospital were retrospectively collected.Inclusion criteria:(1)Adenocarcinoma was diagnosis by Preoperative colonoscopy biopsy or postoperative pathological;(2)Laparoscopic or robotic TME surgery;(3)Radical surgical resection for rectal cancer;(4)The distance from the lower edge of the tumor to the anal margin was ≤15 cm.Exclusion criteria:(1)Preoperative examination found distant metastasis;(2)Recurrent rectal cancer;(3)Multiple primary intestinal malignant tumors.Patients who underwent robotic and laparoscopic were matched 1:1 by propensity score.The 30-day shor-term outcomes and the 3-year survival outcomes were compared between two groups.2.From August 1,2014 to July 31,2022,the clinical data of patients who underwent laparoscopic-assisted transabdominal or transanal total mesorectal excision in anus-preserving surgery for low rectal cancer were retrospectively collected at the general surgery department of Daping Hospital.Inclusion criteria:(1)Adenocarcinoma was diagnosis by Preoperative colonoscopy biopsy or postoperative pathological;(2)Laparoscopic or transanal minimally invasive combined with laparoscopic TME surgery;(3)Radical surgical resection for rectal cancer;(4)The distance from the lower edge of the tumor to the anal margin was≤7cm.Exclusion criteria:(1)Patients undergoing Miles or Hartmann surgery;(2)Patients undergoing open or robotic radical resection of rectal cancer;(3)Preoperative examination found distant metastasis;(4)Recurrent rectal cancer;(5)Multiple primary intestinal malignant tumors.Patients who underwent TaTME and LTME were matched 1:1 by propensity score.The 30-day short-term outcome and the 3-year,5-year survival outcomes were compared bteween two groups.Rusults1.A total of 1442 patients met inclusion criteria,of which 297 underwent RTME and1145 underwent LTME.Before case matching,there were more preoperative hypoproteinemia,less Hartmann surgery,and less preventive stoma in RTME group.After1:1 propensity score matching,297 patients were included in each group,and no statistical difference was found in baseline levels between two groups.The rate of overall postoperative complications in RTME group is 15.7%(CDC: Ⅱ12.4%,Ⅲa 1.1%,Ⅲb 1.1%,Ⅳa 1.1%,no IVb or V case was found),and in LTME group is20.1%(CDC: Ⅱ 14.6%,Ⅲa 0.4%,Ⅲb 2.9%,Ⅳa 1.5%,no Ⅳb case was found,Ⅴ 0.7%).The rate of severe complications(CDC: Ⅲa～Ⅴ)in RTME group is 3.3%,and in LTME group is 5.5%.There were no statistical differences between two groups in 30-day total complication rate,CDC and severe complication rate.Anastomotic leakage rate is lower in RTME group than LTME group(4.0% vs 8.9%,P=0.036).The incidence of other various complications were almost similar in two groups.Compared to LTME,RTME was associated with shorter postoperative length of stay(8.5 days vs 10.0 days,P﹤0.001),longer operative time(184min vs 170 min,P﹤0.001),higher in-patient cost((?) 89962 vs (?) 63866,P﹤0.001)and higher material cost((?) 36938 vs(?) 26187,P﹤0.001).Conversion rate,intraoperative blood transfusion rate,estimated blood loss,hospital length of stay,30-day readmission rate and 30-day reoperation rate revealed no significant differences in both groups.There was no differences in 3 year OS and DFS between two groups.2.A total of 526 patients met inclusion criteria,of which 149 underwent TaTME and377 underwent LTME.Before matching,TaTME was associated with larger BMI,lower ASA score,less preoperative CEA elevation,more neoadjuvant therapy,and lower proportion of stapler anastomosis.After 1:1 propensity score matching,133 patients were included in each group,and the less proportion of stapler anastomosis in TaTME group,the other baseline characteristics were similar between the two groups.The rate of overall postoperative complications in TaTME group is 34.6%(CDC: Ⅰ9.0%,Ⅱ 15.0%,Ⅲa 1.5%,Ⅲb 5.3%,Ⅳa 3.0%,no IVb case was found,Ⅴ 0.8%),and in LTME group is 42.1%(CDC: Ⅰ 12.8%,Ⅱ 17.3%,Ⅲa 2.3%,Ⅲb 5.3%,Ⅳa 3.8%,Ⅳb 0.8%,no Ⅴ case was found).The rate of severe complications(CDC: Ⅲa～Ⅴ)in TaTME group is10.5%,and in LTME group is 12.0%.There were no statistical differences between two groups in 30-day total complication rate,CDC and severe complication rate.There was no significant difference in various complications between the two groups.Compared with LTME,TaTME was associated with longer operation time(215 min vs150 min,P﹤0.001),shorter postoperative hospital stay(7.0 days vs 8.0 days,P﹤0.001),lower total hospitalization cost((?) 55901 vs (?) 76353,P﹤0.001)and material cost((?) 20274 vs (?) 35145 yuan,P ﹤ 0.001).There was no significant difference in conversion rate,intraoperative blood transfusion rate,estimated blood loss,hospital length of stay,30-day readmission,and 30-day reoperation between the two groups.No statistically significant difference in 3-year or 5-year OS,DFS and LR was found between TaTME and LTME groups.Conclusion1.Compared with traditional LTME,RTME has short term advantages in reducing the incidence of anastomotic leakage and shortening the postoperative length of stay.2.When compared to conventional laparoscopy,TaTME has the short-term advantages of shortening postoperative hospital stay,reducing total hospitalization costs and material costs in anus-preserving surgery for low rectal cancer,and is not found to increase the risk of local recurrence and special complications.3.In terms of oncological indicators,both RTME and TaTME can provide similar pathological results and survival outcomes to traditional LTME.4.As compared to conventional laparoscopy,both the RTME and TaTME have the disadvantage of longer operative times,while the RTME also has the issue of higher costs. |
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