Further Proof of the Oncologic Safety of Transanal Total Mesorectal Excision.

In the manuscript titled “Local Recurrence and Disease-Free Survival After Transanal Total Mesorectal Excision: Results From the International TaTME Registry,” elsewhere in this issue, Roodbeen et al presented the largest series of transanal total mesorectal excision (taTME) cases published to date: 2,803 operations with a median follow-up of 24 months. This study was very well conducted and had excellent follow-up, and is critically important because of the constant evolution in the management schema of rectal cancer. Rectal cancer resection was traditionally associated with unacceptably high rates of local recurrence. Thanks to the pioneering work of Professor Richard J. Heald, the concept of TME was introduced. Surgeons around the world began to embrace the concept of achieving tumor-free circumferential resection margins with complete or near-complete mesorectal specimens. The debate shifted from the advisability, and in fact requirement, of TME when surgery with intent to cure was performed to how to best achieve that result. A combination of preoperative imaging allowing appropriate assignment of neoadjuvant chemoradiotherapy combined with a variety of surgical approaches became the work of multidisciplinary teams. The importance of the multidisciplinary team in the United States was ultimately codified by the launch in 2018 of the American College of Surgeons Commission on Cancer National Accreditation Program for Rectal Cancer. The surgical aspect of this dialogue has centered around methods of best achieving a circumferential resection margin free of tumor to produce a complete or near-complete TME specimen. Techniques have shifted from open surgery to a variety of minimally invasive platforms. During the 1990s and early 2000s, a variety of randomized controlled and other studies clearly demonstrated the oncologic acceptability of laparoscopic TME. Subsequent to those studies, other investigations, in turn,demonstratedequivalence between laparoscopic and robotic minimally invasive surgical techniques. The most newly introduced method of attempted surgical cure of rectal cancer is taTME. The common denominator among all of these types of minimally invasive surgery is to offer patients with rectal cancer the advantages of minimally invasive surgery; specifically, the well-known short-term benefits relative to recovery, which have been proven repeatedly over the last.30 years, along with the longer-term benefits, such as decreased rates of intra-abdominal adhesions and hernias, and, according to some studies, possibly even oncologic benefits. The reluctance of some surgeons to learn and/or implement laparoscopic rectal cancer surgery has been an impetus for the increased performance of robotic rectal cancer surgery. Whether minimally invasive rectal cancer surgery is performed by a robotic or a laparoscopic approach is immaterial, given that the outcomes are virtually identical in almost every published study. The goal is to ‘HELP’ our patients by keeping our Hands Extracorporeal during Laparoscopic and robotic Procedures. TaTME adds another potential method of operative access and rectal extirpation to help us meet this repeatedly proven outcome and afford patients the innumerable benefits of minimally invasive versus open surgery for rectal cancer. STEVEN D. WEXNER, MD, PhD(Hon)