Study On The Application Of Tatme In Middle And Low Rectal Cancer Surgery

Background and objective:Over the past twenty years,the quality of rectal cancer surgery was improved and the local recurrence rate of rectal cancer was decreased by the use of total mesentery resection(TME),laparoscopic surgery and exralevator abdominoperineal excision(ELAPE).However,there are still some problems in mid-low rectal cancer surgery need to be solved,including high positive rate of circumferential resection margin(CRM),high rate of conversion to laparotomy and permanent colostomy.And TME surgery is extremely difficult to be performed especially in patient with pelvic narrow,obesity,large tumor,prostate hypertrophy and other factors leading to "difficult pelvis".In recent years,positive exploration and discussion were made to improve the quality of TME surgery with low rectal cancer and Transanal TME(TaTME)has attracted much attention in the colorectal surgery field.Totally different from traditional “up to down” surgery path of laparoscopic surgery,TaTME was performed by "retrograde dissection" from the anal or distal rectal to proximal rectal based on single port platform.Current research shows that TaTME for mid-low rectal cancer is safe and feasible.TaTME is potentially a suitable option for patients with middle or low rectal cancer especially for patients with difficult pelvis.It has been reported that TaTME have lower rate of conversion to laparotomy and more sphincter retention compared to laparoscopic TME.However,high-level evidence-based medical researches of TaTME is still absent,and further clinical studies confirming that TaTME could be used as the standard of low rectal cancer surgery are needed.So we designed a single-center retrospective cohort study to investigate the safety and feasibility of TaTME in patients with rectal cancer and the application of TaTME in middle and low rectal cancer surgery.Method:Part ?: A single-center retrospective cohort study.123 patients with rectal cancer were enrolled in the cohort.All the patients were initially diagnosed by colonoscopy,and their biopsy results revealed rectal adenocarcinoma.And the distance of the edge of the tumour within 7cm in all patients.Cancer staging according to the 7th Edition of American Joint Committee on Cancer was from T1 to T3 and N0 to N2.They were divided into two groups according to the surgery method.Patients in TaTME group were treated with total mesenterectomy through anal endoscopy,and patients in LaTME group were treated with total mesenterectomy through laparoscopy.Two groups were compared with many factors including operation time,bleeding volume,rate of conversion to LAR(low anterior resection),mode of anastomosis,distance from the lower margin to tumor,CRM,postoperative first venting time,postoperative average hospitalization day,postoperative pathological stage,etc.During 3 years following up,local recurrence rate and overall survival were observed,and defecation function and quality of life in both groups were evaluated by scale score.Part ?: Retrospective analysis of clinical data of 6 patients with colorectal cancer treated with robotic TaTME(R-taTME)surgery.Observation of intraoperative and postoperative related indicators,and through follow-up,record the forward tumor metastasis,recurrence and survival conditions To investigate the evaluation and feasibility of R-taTME in patients with rectal cancer.Result:1.Comparison of TaTME group and LaTME group.There was no significant difference in age,gender,BMI,tumor diameter and height between the two groups(P>0.05),suggesting comparability.Intraoperative indicators showed that intraoperative blood loss in TaTME group were significantly lower than that in LaTME group,with statistically significant differences(P<0.05).In addition,1 patient in LaTME group had intraoperative blood transfusion,while it didn't occurred inTaTME group.There were 41 cases of stapler anastomosis in TaTME group and 19 cases of manual anastomosis.All cases in LaTME group were anastomotic by stapler(P<0.05).The conversion rate to laparotomy in the two groups was(0% vs 6.35%),with no statistically significant differences(P<0.05).Besides,there were no significant differences in the operation time,the distance between the anastomosis and the anal margin and the preventive ileostomy.Postoperative indicators showed that the first exhaust time,extubation time and hospital stays of postoperation in TaTME group were significantly lower than that in LaTME group,with statistically significant differences(P<0.05).The comparison of postoperative pathological indicators showed that the integrity of mesangectomy was significantly different between the two groups(P<0.05).The distance from the distal cutting edge of TaTME group was significantly lower than that of LaTME group(P<0.05).In the comparison of cutting edges between the two groups,there were no significant difference between proximal cutting edges,distal cutting edges and annular cutting edges(P>0.05).In addition,there were no significant differences in the length of surgical specimens,number of lymph node detection and positive number,TNM staging and histological type between the two groups(P>0.05).Among the complications of perioperative period,there were 6 cases of anastomotic fistula,2 cases of intestinal obstruction,1 case of urinary retention and 2 cases of anastomotic bleeding in TaTME group,a total of 11 cases.In the LaTME group,4 cases of anastomotic fistula and 1 case of abdominal hemorrhage occurred in a total of 7 cases.The incidence of anastomotic fistula in the two groups was 10.00% and 6.35%,respectively,and the total incidence of complications was 18.33% and 7.94%,respectively,with no significant difference or statistical significance(P>0.05).The effective follow-up numbers were 51 and 40,respectively,and there were no significant differences in complications,readmission rate,recurrence rate,metastasis rate and survival rate between the two groups(P>0.05).All functional scores of the two groups(Wexner score,IPSS score,IIEF-5 score,FSFI score and EORTC qlq-c30 score)showed that TaTME group was significantly better than LaTME group,with statistically significant differences(P<0.05).There was no significant difference in EORTC qlq-cr38 scores between the two groups(P>0.05).2.Surgical treatment of R-taTME.All patients underwent operation successfully,and no transabdominal or blood transfusion occurred.No severe complications or death occurred during the operation.The operative time was(245.8±24.2)min,the intraoperative docking time was(21.2±2.6)min,the total transanal mesenteric anatomy time was(72.3±15.2)min,the intraoperative blood loss was(86.7±59.9)ml,and the anastomotic height from the anal edge was(16.0±6.1)mm.The length of postoperative specimens was(177.0±33.3)mm,and the mesenteric integrity of postoperative specimens in 5 patients was complete,one was nearly complete,and the length of distal resection margin was(20.2±3.2)mm,and circumferential resection margin was negative.Postoperative pathological stages: 1 patient at pT0N0 stage,1 patient at pT1N0 stage,2 patients at pT2N0 stage,1 patient at pT4N1 stage,and 1 patient at pT3N0 stage.The first 5 patients with prophylactic ileostomy were all given water on the first day after the operation,followed by a clear diet on the second day after the operation,and all patients were given non-steroidal analgesics for venous pain.The pain score on the first day after the operation was 1-2 points,and all patients could get out of bed on the first day after the operation.In the first 5 cases,the drainage tube was removed 3 ~ 6 days after operation,and the hospital stay was 5 ~ 7 days.Grade B anastomotic fistula occurred in the 6th case on the 3rd day after the operation.After symptomatic treatment such as fasting,water and anti-infection,the patient resumed liquid diet and was discharged successfully on the 15 th day after the operation.No postoperative intraperitoneal bleeding,intestinal obstruction and other complications occurred.All the patients were followed up,and no local tumor recurrence or death occurred during the 5-19 months of postoperative follow-up.Conclusion:Compared with LaTME,TaTME can effectively reduce intraoperative blood loss,which is safer.And TaTME can shorten postoperative exhaust time,extubation time and postoperative hospitalization time,is conducive to recovery for patients.In addition,TaTME can improve the integrity of mesangial resection,without increasing the rate of cutting edge,incidence of intraoperative and postoperative complications.In terms of long-term indicators,TaTME significantly reduced the readmission rate,recurrence rate and metastasis rate in the future,but all functional scores of patients were significantly improved.It can be seen that TaTME is safe and feasible in the treatment of middle and low rectal cancer,and has obvious advantages in postoperative recovery.Moreover,R-taTME can expand the application scope of TaTME surgery and improve the therapeutic effect,so it is worth promoting its application.