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Transanale totale mesorektale Exzision – eine kritische Standortbestimmung

Transanal total mesorectal excision—a critical appraisal

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A Kommentar to this article was published on 07 May 2019

Zusammenfassung

Einleitung

Die totale mesorektale Exzision (TME) ist internationaler Standard der Rektumkarzinomchirurgie. Ergänzend zur laparoskopischen TME (lapTME) wurde in den letzten Jahren die transanale TME (taTME) entwickelt, um die Rate an inkompletten TME-Präparaten, Konversionen sowie postoperativen Funktionsstörungen zu reduzieren. Trotz begrenzter Evidenz verbreitet sich diese Technik zunehmend und wird von vielen Kliniken bereits routinemäßig bei Rektumkarzinomen unterschiedlichster Höhenlokalisation angewendet. Ziel dieser Arbeit ist eine Bestandsaufnahme der Evidenz zur taTME und Bewertung im Vergleich zum Therapiestandard der anterioren Rektumresektion mit lapTME.

Methodik

Die Datenbanken PubMed und Medline wurden systematisch bezüglich Publikationen zur transanalen totalen mesorektalen Exzision (taTME) bzw. transanal minimally invasive surgery (TAMIS) analysiert. Relevante Arbeiten wurden selektioniert und weiterführende Recherchen anhand der Literaturverzeichnisse unternommen.

Ergebnisse

Insgesamt wurden 16 Studien mit 3782 Patienten identifiziert. Die taTME führt im Vergleich zur Standardtechnik nicht zu einer höheren Rate an kompletten TME-Präparaten. Eine Überlegenheit der taTME konnte weder für Komplikationsraten noch für funktionelle oder onkologische Ergebnisse nachgewiesen werden. Gravierende Komplikationen durch Präparation in inadäquaten Schichten wurden beobachtet. Die Anastomosenhöhe scheint nach taTME generell sphinkternäher zu liegen als nach anteriorer lapTME.

Schlussfolgerung

Unter Berücksichtigung der aktuellen Evidenz konnte für die taTME keine Überlegenheit im Vergleich zur anterioren lapTME gezeigt werden. Auch wenn die taTME einige potenzielle Vorteile aufweist, ist sie mit erheblichen Risiken behaftet. Sie sollte daher außerhalb klinischer Studien nur bei sorgfältig selektionierten Patienten mit sehr hoher Konversionswahrscheinlichkeit nach entsprechender Patientenaufklärung sowie nach intensivem strukturiertem Training des Operateurs zum Einsatz kommen.

Abstract

Introduction

Total mesorectal excision (TME) is the international standard for rectal cancer surgery. In addition to laparoscopic TME (lapTME), transanal TME (taTME) was developed in recent years to reduce the rate of incomplete TME, conversion to open surgery and postoperative functional impairment. Despite limited evidence, this technique is becoming increasingly more popular and is already routinely used by many hospitals for rectal cancer in varying tumor level locations. The aim of this review was to evaluate the taTME compared to anterior rectal resection with lapTME as the standard of care in rectal cancer surgery based on currently available evidence.

Method

The databases PubMed and Medline were systematically searched for publications on transanal total mesorectal excision (taTME) and transanal minimally invasive surgery (TAMIS). Relevant studies were selected and further research based on the reference lists was undertaken.

Results

A total of 16 studies analyzing 3782 patients were identified. The taTME does not lead to a higher rate of complete TME-resected specimens compared to the standard procedure. So far, superiority could not be demonstrated for complication rates or for functional or oncological results. Serious complications secondary to dissection in incorrect planes were observed. The anastomotic level generally seems to be closer to the sphincter after taTME versus anterior lapTME.

Conclusion

Considering current evidence, taTME failed to show superiority compared to conventional anterior lapTME. Although taTME has some potential advantages, it carries substantial risks. If performed outside of clinical trials, it should therefore only be used in carefully selected patients with a high possibility of conversion, following adequate patient informed consent and after intense and systematic training of the surgeon.

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Authors and Affiliations

  1. Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Hindenburgdamm 30, 12200, Berlin, Deutschland

    C. Holmer &  M. E. Kreis

  2. Klinikum Sindelfingen-Böblingen, Klinik für Allgemein‑, Viszeral- und Kinderchirurgie, Klinikverbund Südwest, Böblingen, Deutschland

    S. Benz

  3. Klinik für Allgemein- und Viszeralchirurgie, Department Chirurgie, Universitätsklinikum Freiburg, Freiburg, Deutschland

    S. Fichtner-Feigl

  4. Klinik für Allgemein- und Viszeralchirurgie, St. Elisabethen-Klinikum, Ravensburg, Deutschland

    E. C. Jehle

  5. Klinik für Allgemein- und Viszeralchirurgie, Theresienkrankenhaus, Mannheim, Deutschland

    P. Kienle

  6. Chirurgische Klinik, Universitätsklinikum Mannheim, Mannheim, Deutschland

    S. Post

  7. Klinik für Allgemein- und Viszeralchirurgie, Klinikum Ludwigsburg, Ludwigsburg, Deutschland

    T. Schiedeck

  8. Klinik und Poliklinik für Viszeral‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus der TU Dresden, Dresden, Deutschland

    J. Weitz

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  1. C. Holmer
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Correspondence to M. E. Kreis.

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Interessenkonflikt

C. Holmer, S. Benz, S. Fichtner-Feigl, E.C. Jehle, P. Kienle, S. Post, T. Schiedeck, J. Weitz und M.E. Kreis geben an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Holmer, C., Benz, S., Fichtner-Feigl, S. et al. Transanale totale mesorektale Exzision – eine kritische Standortbestimmung. Chirurg 90, 478–486 (2019). https://doi.org/10.1007/s00104-019-0945-x

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