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this study is limited by its single-institution nature, its lack of a control group, and its small sample size.
In addition, most TARD procedures were performed by a single surgeon (KF); therefore, the potential for
selection bias is significant. Our data must be interpreted in the context of these potential biases. Recently,
TaTME utilizing laparoscopic instruments has been developed as a novel alternative to intersphincteric
resection that provides solutions to many of the limitations of TARD, as it is performed under direct visu-
[50]
alization . We recommend that further studies should be performed to confirm that transanal surgery is
feasible and of benefit for Japanese and all Asian patients.

Using TARD under direct vision during laparoscopic and open SPR for LRC has no negative effects on on-
cologic outcomes. However, resection of the IAS should be avoided, where possible, to minimize anorectal
dysfunction after ISR. This approach is feasible for Japanese patients with LRC. Further studies that com-
pare TaTME utilizing laparoscopic instruments with conventional transabdominal TME are required to
fully understand the risks and benefits of this approach for the Japanese and greater Asian populations.

DECLARATIONS
Authors’ contributions
Conception and design of the study: Teramoto T
Collection and assembly of data: Shiokawa H, Ushigome M, Kaneko T, Kagami S, Koda T
Analysis and interpretation of data: Koike J

Availability of data and materials
The data is presented and kept by the author and is available for scrutiny.

Financial support and sponsorship
None.

Conflicts of interest
The authors declare that there are no conflicts of interest.

Ethical approval and consent to participate
The Ethics Committee of Toho University Omori Medical Center (No. 17-41) approved the study, which
was conducted in accordance with the Helsinki Declaration and the standards of the Ethics Committee.
Written informed consent was obtained from all patients in this study.

Consent for publication
Not applicable.

Copyright
© The Author(s) 2018.

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