title: Laparoscopic transanal abdominal transanal resection with sphincter preservation for rectal cancer in the distal 3 cm of the rectum after neoadjuvant therapy.
abstract: BACKGROUND
  This study reports the short- and long-term results for a prospective rectal cancer management program using laparoscopic radical transanal abdominal transanal proctosigmoidectomy with coloanal anastomosis (TATA) after neoadjuvant therapy.
  
  
  METHODS
  A prospective database included 102 rectal cancer patients treated with laparoscopic TATA from 1998 to 2008. Patients with distant metastasis at presentation, patients with a tumor more than 3 cm from the anorectal ring, and patients not undergoing neoadjuvant therapy were excluded, leaving 79 patients (54 men and 25 women) with a mean age of 59.2 years (range, 22-85 years) for this study. 13 patients completed neoadjuvant therapy before the original evaluation, and they are excluded from the report of initial clinical assessment. Before treatment, 50 patients were staged as T3 and 16 patients as T2. The mean level in the rectum superior to the anorectal ring was 1.2 cm (range, -0.5 to 3 cm). In terms of fixity, 31 of the tumors were mobile, 27 were tethered, and 8 showed early fixation. Ulceration was absent in 8 cases, minimal in 12 cases, superficial in 7 cases, moderate in 22 cases, and deep in 17 cases. The mean pretreatment tumor size tumor was 4.8 cm (range, 1.5-12 cm). The median external beam radiation was 5,400 cGy (range, 3,000-8,040 cGy), and 77 patients underwent chemotherapy.
  
  
  RESULTS
  The mean follow-up period was 34.2 months (range, 1.9-113.9 months). There were no perioperative mortalities. The conversion rate was 2.5%, and the mean largest incision length was 4.3 cm (range, 1.2-21 cm). For 84% of the patients, the incision was less than 6.0 cm, and 46% of the patients had no abdominal incision for delivery of the specimen. The mean estimated blood loss was 367 ml (range, 75-2,200 ml). All the patients had a temporary diverting stoma. The major morbidity rate was 11%, and the minor morbidity rate was 19%. The major complications included four full-thickness rectal prolapses with repair, one ischemic neorectum with successful reanastomosis, two bowel obstructions, and two failed anastomoses requiring stoma. The ypT stages included 22 complete responses, 12 cases of ypT1, 22 cases of ypT2, 23 cases of ypT3; 65 cases of ypN0, and 14 cases of ypN + (T3 = 7, T2 = 4, T1 = 3). The local recurrence rate was 2.5% (2/79), and the distant metastases rate was 10.1% (8/79). The KM5YAS rate was 97%. Overall, 90% of the patients lived without a stoma. Neorectal loss was due to positive margins or recurrence and was followed by abdominoperineal resection in three cases and ischemia in two cases. The condition of two patients was not reversed due to comorbidities, and one patient had a stoma secondary to bowel obstruction.
  
  
  CONCLUSIONS
  The study results indicate excellent local recurrence (2.7%) and 5-year survival rates without the need for permanent colostomy in patients with cancers in the distal one-third of the rectum. Laparoscopic total mesorectal excision (TME) with the TATA approach is safe and can be performed laparoscopically. Multi-institutional studies are required to establish the reproducibility of this promising approach.
authors.affiliation: Section of Colorectal Surgery, Lankenau Hospital and Institute for Medical Research, Wynnewood, PA, USA. marksj@mlhs.org
authors.forename: J
authors.initials: J
authors.lastname: Marks
authors.forename: B
authors.initials: B
authors.lastname: Mizrahi
authors.forename: S
authors.initials: S
authors.lastname: Dalane
authors.forename: I
authors.initials: I
authors.lastname: Nweze
authors.forename: G
authors.initials: G
authors.lastname: Marks
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001003:Anal Canal / Q000601:surgery*; D016099:Endoscopy, Gastrointestinal / Q000379:methods*; D005260:Female; D006801:Humans; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D011183:Postoperative Complications; D012004:Rectal Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D016019:Survival Analysis; D055815:Young Adult