Page 231 - Read Online
P. 231

Yap et al. Mini-invasive Surg 2019;3:3  I  http://dx.doi.org/10.20517/2574-1225.2018.57                                               Page 7 of 9


               appear to be high BMI and a previously irradiated pelvic field. In females, there is also a risk of vaginal

               injury during the anterior dissection with the subsequent development of a rectovaginal fistula. The same
               registry study reported a 0.3% rate of vaginal perforation.

               Long-term functional data is not yet readily available, although some short-term studies have been
                                    [27]
               published. Koedam et al.  published a prospective quality of life study on thirty patients that showed that
               at 6 months, TaTME and laparoscopic TME had similar postoperative functional outcomes. It must be noted
               that TaTME patients in this study had initial (1 month) significant decrease in quality of life, physical and
               social functioning, fatigue, general experienced pain, anal pain, low anterior resection syndrome and male
                                                                                 [28]
               sexual interest which appeared to recover.A second study by Pontallier et al.  also showed no functional

               difference in bowel habits or urologic function when TaTME was compared to laparoscopic TME.

               FUTURE DIRECTIONS
               The most pertinent piece of missing literature is a randomized control trial. The COLOR III trial is designed
               to fill this gap as a multicenter randomised clinical trial comparing TaTME vs. laparoscopic TME for mid
                                                                                                       [29]
               and low rectal cancer. Initially, the CRM rate was chosen as primary endpoint within a superiority design ;
               however, the trial was subsequently changed to a non-inferiority design with a clinically relevant primary
               endpoint of local recurrence rate. This trial is currently in the recruitment phase. However, publication of the
               recent ALaCaRT (Australasian Laparoscopic Cancer of the Rectum Trial) and ACOSOG (American College
               of Surgeons Oncology Group) Z6051 trials which examined successful achievement of TME both failed to
               show non-inferiority of laparoscopy compared to open surgery place some doubt to the use of laparoscopic
               TME as a gold standard [30,31] . The authors anticipate that due to this, the publication of COLOR III will not
               settle the oncological questions surrounding low rectal cancer surgical technique. Continuing information
               will come from the registry data and other case series, including 5-year oncological data.


               Developments in surgical equipment and in technology may fill the gap. Surgeons have started to attempt
                                                                                                       [32]
               a hybrid between TaTME with a robotics platform either for the transanal or intraperitoneal dissection .
               Of most interest is the use of a flexible TEMs platform which may alleviate the many ergonomic and access
               issues that a single port system such as TAMIS introduces. There have been unpublished reports that
               surgeons have started experimenting with this system in TaTME.

               Further research is needed to define whether TaTME will provide the perioperative, oncological and
               functional outcomes in low rectal cancer surgery. In addition, further development in the education of both
               surgeons and trainees is needed to spread this technique if it does prove valuable. It is likely that rather than
               prove to be a “silver bullet” solution, TaTME will prove another weapon in the armament of the modern
               colorectal surgeon in dealing with low rectal cancer.


               DECLARATIONS
               Authors’ contributions
               Concept and design, drafting the manuscript: Yap R, Monson J


               Availability of data and materials
               Not applicable.


               Financial support and sponsorship
               None.

               Conflicts of interest
               All authors declared that there are no conflicts of interest.
   226   227   228   229   230   231   232   233   234   235   236