LAUSR

Editor Transanal total mesorectal excision (TaTME) was developed as a surgical solution for a surgical problem. The lower third mesorectal dissection and transection of rectal cancers presents a significant technical challenge, particularly in the narrow android pelvis. It is this subset of male obese patients who record poor oncological outcomes and the cohort that have the most to gain from the TaTME approach. It was therefore logical to attempt part of the dissection from below using a perineal approach with advanced optics and existing dedicated instruments; a modern interpretation of the transanal transabdominal (TATA) procedure developed by Marks in the 1980s1. Although international registry data and select higher volume centres have published oncologically sound data, this has not been universal and the technique is now at a crossroads relating to oncological safety issues among others. Following the Norwegian moratorium on TaTME2, a further report by van Oostendorp and colleagues3 raises oncological concerns relating to the uptake of TaTME. The study focuses on the first 10 patients in each site with dissemination of TaTME proctorship programme across 12 sites. Five of these centres had zero local recurrence, but three had one local recurrence, two centres had two, and one had three local recurrences. Early multifocal local recurrences were observed in eight of 12 cases, and although some clear selection issues were noted in a few of these cases, many of the recurrences appeared technique focused. What is particularly concerning is that these recurrences happened despite an active proctorship programme. According to the IDEAL framework, this 2b exploration study offers a timely warning to closely audit outcomes during this stage of surgical innovation. In Australasia, uptake of TaTME was accompanied by one of the first formal proctorships in the world4. In assessing over 300 TaTME cases, the proctorship group observed a local recurrence rate of 2 per cent at a minimum of 2 years’ follow-up. These reassuring results are in keeping with large studies from the Netherlands and compare favourably with transabdominal techniques for rectal cancer5. The current international COLOR III trial randomizes patients to TaTME or laparoscopic approaches and should inform us of the long term outcomes on a larger scale. The heterogeneous outcomes reported from TaTME series suggest that selection and technique are crucial determinants in outcome. It also appears that the influence of the learning curve on these outcomes can be significant. Although the Australasian experience to date suggests acceptable oncological outcomes can be achieved if the learning curve is managed within a structured training and proctoring programme, van Oostendorp et al.’s study shows this is not universal. Further evidence from longer term follow-up and RCTs regarding oncological outcomes will be needed to help decide the role of TaTME in managing rectal cancer. However, it is already clear that training and dissemination in the TaTME technique will require careful monitoring and evaluation. Consideration may need to be given to enhancing training beyond short courses, perhaps with extended proctorships or dedicated fellowships including TaTME as a focus.