Initiation of a transanal total mesorectal excision program at an academic training program: Evaluating patient safety and quality outcomes

BACKGROUND: Short-Term results have shown that transanal total mesorectal excision is safe and effective for patients with mid to low rectal cancers. Transanal total mesorectal excision is considered technically challenging; thus, adoption has been limited to a few academic centers in the United States. OBJECTIVE: The aim of this study is to describe outcomes after the initiation of a transanal total mesorectal excision program in the setting of an academic colorectal training program. DESIGN: This is a single-center retrospective review of consecutive patients who underwent transanal total mesorectal excision from December 2014 to August 2016. SETTING: This study was conducted at an academic center with a colorectal residency program. PATIENTS: Patients with benign and malignant diseases were selected. INTERVENTION: All transanal total mesorectal excisions were performed with abdominal and perineal teams working simultaneously. OUTCOME MEASURES: The primary outcomes measured were pathologic quality, length of hospital stay, 30-day morbidity, and 30-day mortality. RESULTS: There were 40 patients (24 male). The median age was 55 years (interquartile range, 46.7-63.4) with a median BMI of 29 kg/m2 (interquartile range, 24.6-32.4). The primary indication was cancer (n = 30), and tumor height from the anal verge ranged from 0.5 to 15 cm. Eighty percent (n = 24) of the patients who had rectal cancer received preoperative chemoradiation. The most common procedures were low anterior resection (67.5%), total proctocolectomy (15%), and abdominoperineal resection (12.5%). Median operative time was 380 minutes (interquartile range, 306-454.4), with no change over time. For patients with malignancy, the mesorectum was complete or nearly complete in 100% of the specimens. A median of 14 lymph nodes (interquartile range, 12-17) were harvested, and 100% of the rectal cancer specimens achieved R0 status. Median length of stay was 4.5 days (interquartile range, 4-7), and there were 6 readmissions (15%). There were no deaths or intraoperative complications. LIMITATIONS: This study's limitations derive from its retrospective nature and single-center location. CONCLUSIONS: A transanal total mesorectal excision program can be safely implemented in a major academic medical center. Quality outcomes and patient safety depend on a comprehensive training program and a coordinated team approach.