Comparison of the transanal surgical techniques for local excision of rectal tumors: a network meta-analysis



In order to assess the various surgical modalities for local resection of rectal tumors, a systematic review of the current literature and a network meta-analysis (NMA) was designed and conducted.


The present study adhered to the PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions principles. Scholar databases (Medline, Scopus, Web of Science) were systematically screened up to 23/12/2019. A Bayesian NMA, implementing a Markov chain Monte Carlo analysis, was introduced for the probability ranking of the available surgical methods. Odds ratio (OR) and weighted mean difference (WMD) of the categorical and continuous variables, respectively, were reported with the corresponding 95% confidence interval (95%CI).


Overall, 16 studies and 2146 patients were introduced in our study. Transanal minimal invasive surgery (TAMIS) displayed the highest performance regarding the overall postoperative morbidity, the perioperative blood loss, the length of hospitalization, and the peritoneal violation rate. Transanal endoscopic microsurgery (TEM) was the most efficient modality for resecting an intact specimen. Although transanal local excision (TAE) had the highest ranking considering operative duration, it was associated with a significant risk for positive resection margins and tumor recurrence.


In conclusion, TEM and TAMIS display superior oncological results over TAE. Due to several limitations, validation of these results requires further RCTs of a higher methodological level.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4


  1. 1.

    Heald RJ, Santiago I, Pares O, Carvalho C, Figueiredo N (2017) The perfect total mesorectal excision obviates the need for anything else in the management of most rectal cancers. Clin Colon Rectal Surg 30:324–332.

    Article  Google Scholar 

  2. 2.

    Rullier E, Rouanet P, Tuech JJ, Valverde A, Lelong B, Rivoire M, Faucheron JL, Jafari M, Portier G, Meunier B, Sileznieff I, Prudhomme M, Marchal F, Pocard M, Pezet D, Rullier A, Vendrely V, Denost Q, Asselineau J, Doussau A (2017) Organ preservation for rectal cancer (GRECCAR 2): a prospective, randomised, open-label, multicentre, phase 3 trial. Lancet 390:469–479.

    Article  Google Scholar 

  3. 3.

    Shaikh I, Askari A, Ouru S et al (2015) Oncological outcomes of local excision compared with radical surgery after neoadjuvant chemoradiotherapy for rectal cancer: a systematic review and meta-analysis. Int J Color Dis 30:19–29.

    Article  Google Scholar 

  4. 4.

    Kauff DW, Roth YDS, Bettzieche RS, Kneist W (2020) Fecal incontinence after total mesorectal excision for rectal cancer-impact of potential risk factors and pelvic intraoperative neuromonitoring. World J Surg Oncol 18:12.

    Article  Google Scholar 

  5. 5.

    Pucciarelli S, Giandomenico F, De Paoli A et al (2017) Bowel function and quality of life after local excision or total mesorectal excision following chemoradiotherapy for rectal cancer. Br J Surg 104:138–147.

    CAS  Article  Google Scholar 

  6. 6.

    Sterk P, Shekarriz B, Günter S, Nolde J, Keller R, Bruch HP, Shekarriz H (2005) Voiding and sexual dysfunction after deep rectal resection and total mesorectal excision: prospective study on 52 patients. Int J Color Dis 20:423–427.

    Article  Google Scholar 

  7. 7.

    George D, Pramil K, Kamalesh NP, Ponnambatheyil S, Kurumboor P (2018) Sexual and urinary dysfunction following laparoscopic total mesorectal excision in male patients: a prospective study. J Minim Access Surg 14:111–117.

    Article  Google Scholar 

  8. 8.

    Smith FML, Ahad A, Perez RO, Marks J, Bujko K, Heald RJ (2017) Local excision techniques for rectal cancer after neoadjuvant chemoradiotherapy: what are we doing? Dis Colon Rectum 60:228–239.

    Article  Google Scholar 

  9. 9.

    Rouleau-Fournier F, Brown CJ (2019) Can less be more? Organ preservation strategies in the management of rectal cancer. Curr Oncol 26:S16–S23

    CAS  Article  Google Scholar 

  10. 10.

    Russo S, Anker CJ, Abdel-Wahab M, Azad N, Das P, Dragovic J, Goodman KA, Herman JM, Jones W III, Kennedy T, Konski A, Kumar R, Lee P, Patel NM, Sharma N, Small W, Suh WW, Jabbour SK (2019) Executive summary of the american radium society appropriate use criteria for local excision in rectal cancer. Int J Radiat Oncol Biol Phys 105:977–993

    Article  Google Scholar 

  11. 11.

    Montroni I, Ugolini G, Saur NM, Spinelli A, Rostoft S, Millan M, Wolthuis A, Daniels IR, Hompes R, Penna M, Fürst A, Papamichael D, Desai AM, Cascinu S, Gèrard JP, Myint AS, Lemmens VEPP, Berho M, Lawler M, de Liguori Carino N, Potenti F, Nanni O, Altini M, Beets G, Rutten H, Winchester D, Wexner SD, Audisio RA (2018) Personalized management of elderly patients with rectal cancer: expert recommendations of the European Society of Surgical Oncology, European Society of Coloproctology, International Society of Geriatric Oncology, and American College of Surgeons Commission on Cancer. Eur J Surg Oncol 44:1685–1702

    Article  Google Scholar 

  12. 12.

    São Julião GP, Celentano JP, Alexandre FA, Vailati BB (2017) Local excision and endoscopic resections for early rectal cancer. Clin Colon Rectal Surg 30:313–323.

    Article  Google Scholar 

  13. 13.

    Lai IL, You JF, Chern YJ, Tsai WS, Chiang JM, Hsieh PS, Hung HY, Yeh CY, Chiang SF, Lai CC, Tang RP, Chen JS, Hsu YJ (2019) Survival analysis of local excision vs total mesorectal excision for middle and low rectal cancer in pT1/pT2 stage and intermediate pathological risk. World J Surg Oncol 17:212.

    Article  Google Scholar 

  14. 14.

    Parks AG, Stuart AE (1973) The management of villous tumours of the large bowel. Br J Surg 60:688–695.

    CAS  Article  Google Scholar 

  15. 15.

    Kidane B, Chadi SA, Kanters S, Colquhoun PH, Ott MC (2015) Local resection compared with radical resection in the treatment of T1N0M0 rectal adenocarcinoma: a systematic review and meta-analysis. Dis Colon Rectum 58:122–140.

    Article  Google Scholar 

  16. 16.

    Veereman G, Vlayen J, Robays J, Fairon N, Stordeur S, Rolfo C, Bielen D, Bols A, Demetter P, D’hoore A, Haustermans K, Hendlisz A, Lemmers A, Leonard D, Penninckx F, van Cutsem E, Peeters M (2017) Systematic review and meta-analysis of local resection or transanal endoscopic microsurgery versus radical resection in stage i rectal cancer: a real standard? Crit Rev Oncol Hematol 114:43–52.

    Article  Google Scholar 

  17. 17.

    Han J, Noh GT, Cheong C, Cho MS, Hur H, Min BS, Lee KY, Kim NK (2017) Transanal endoscopic operation versus conventional transanal excision for rectal tumors: case-matched study with propensity score matching. World J Surg 41:2387–2394.

    Article  Google Scholar 

  18. 18.

    Buess G, Hutterer F, Theiss J et al (1984) A system for a transanal endoscopic rectum operation. Chirurg 55:677–680

    CAS  Google Scholar 

  19. 19.

    Christoforidis D, Cho H-M, Dixon MR, Mellgren AF, Madoff RD, Finne CO (2009) Transanal endoscopic microsurgery versus conventional transanal excision for patients with early rectal cancer. Ann Surg 249:776–782.

    Article  Google Scholar 

  20. 20.

    Langer C, Liersch T, Suss M et al (2003) Surgical cure for early rectal carcinoma and large adenoma: transanal endoscopic microsurgery (using ultrasound or electrosurgery) compared to conventional local and radical resection. Int J Color Dis 18:222–229.

    CAS  Article  Google Scholar 

  21. 21.

    Moore JS, Cataldo PA, Osler T, Hyman NH (2008) Transanal endoscopic microsurgery is more effective than traditional transanal excision for resection of rectal masses. Dis Colon Rectum 51:1021–1026.

    Article  Google Scholar 

  22. 22.

    Clancy C, Burke JP, Albert MR, O’Connell PR, Winter DC (2015) Transanal endoscopic microsurgery versus standard transanal excision for the removal of rectal neoplasms: a systematic review and meta-analysis. Dis Colon Rectum 58:254–261.

    Article  Google Scholar 

  23. 23.

    Mege D, Bridoux V, Maggiori L, Tuech JJ, Panis Y (2017) What is the best tool for transanal endoscopic microsurgery (TEM)? A case-matched study in 74 patients comparing a standard platform and a disposable material. Int J Color Dis 32:1041–1045.

    Article  Google Scholar 

  24. 24.

    Han Y, He Y, Lin M-B et al (2012) Local resection for rectal tumors: comparative study of transanal endoscopic microsurgery vs. conventional transanal excision - the experience in China. Hepatogastroenterology 59:2490–2493.

    Article  Google Scholar 

  25. 25.

    Al Bandar MH, Han YD, Razvi SA et al (2017) Comparison of trans-anal endoscopic operation and trans-anal excision of rectal tumors. Ann Med Surg 14:18–24.

    Article  Google Scholar 

  26. 26.

    Serra-Aracil X, Mora-Lopez L, Alcantara-Moral M, Caro-Tarrago A, Navarro-Soto S (2014) Transanal endoscopic microsurgery with 3-D (TEM) or high-definition 2-D transanal endoscopic operation (TEO) for rectal tumors. A prospective, randomized clinical trial. Int J Color Dis 29:605–610.

    Article  Google Scholar 

  27. 27.

    Thompson EV, Bleier JIS (2017) Transanal minimally invasive surgery. Clin Colon Rectal Surg 30:112–119.

    Article  Google Scholar 

  28. 28.

    Clermonts SHEM, van Loon YT, Wasowicz DK, Langenhoff BS, Zimmerman DDE (2018) Comparative quality of life in patients following transanal minimally invasive surgery and healthy control subjects. J Gastrointest Surg 22:1089–1097.

    Article  Google Scholar 

  29. 29.

    Plummer JM, Leake P-A, Albert MR (2017) Recent advances in the management of rectal cancer: no surgery, minimal surgery or minimally invasive surgery. World J Gastrointest Surg 9:139–148.

    Article  Google Scholar 

  30. 30.

    Kaymak Ş, Sinan H, Saydam M, Aktaş HH, Gecim E, Demirbas S (2019) Comparison of transanal minimally invasive surgery (TAMIS) and transanal endoscopic operations (TEO). Indian J Surg.

  31. 31.

    Van den Eynde F, Jaekers J, Fieuws S et al (2019) TAMIS is a valuable alternative to TEM for resection of intraluminal rectal tumors. Tech Coloproctol 23:161–166.

    Article  Google Scholar 

  32. 32.

    Lee L, Edwards K, Hunter IA, Hartley JE, Atallah SB, Albert MR, Hill J, Monson JR (2017) Quality of local excision for rectal neoplasms using transanal endoscopic microsurgery versus transanal minimally invasive surgery: a multi-institutional matched analysis. Dis Colon Rectum 60:928–935.

    Article  Google Scholar 

  33. 33.

    Ishikawa K, Arita T, Shimoda K, Hagino Y, Shiraishi N, Kitano S (2005) Usefulness of transanal endoscopic surgery for carcinoid tumor in the upper and middle rectum. Surg Endosc 19:1151–1154.

    CAS  Article  Google Scholar 

  34. 34.

    Melin AA, Kalaskar S, Taylor L, Thompson JS, Ternent C, Langenfeld SJ (2016) Transanal endoscopic microsurgery and transanal minimally invasive surgery: is one technique superior? Am J Surg 212:1063–1067.

    Article  Google Scholar 

  35. 35.

    Lebedyev A, Tulchinsky H, Rabau M, Klausner JM, Krausz M, Duek SD (2009) Long-term results of local excision for T1 rectal carcinoma: the experience of two colorectal units. Tech Coloproctol 13:231–236.

    Article  Google Scholar 

  36. 36.

    de Jong GM, Hugen N (2019) Minimally invasive transanal surgery is safe after incomplete polypectomy of low risk T1 rectal cancer: a systematic review. Color Dis 21:1112–1119.

    Article  Google Scholar 

  37. 37.

    Higgins JPT, Cochrane Collaboration (2019) Cochrane handbook for systematic reviews of interventions, 2nd edn. Wiley-Blackwell Publishing Ltd

  38. 38.

    Hutton B, Salanti G, Caldwell DM, Chaimani A, Schmid CH, Cameron C, Ioannidis JPA, Straus S, Thorlund K, Jansen JP, Mulrow C, Catalá-López F, Gøtzsche PC, Dickersin K, Boutron I, Altman DG, Moher D (2015) The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations. Ann Intern Med 162:777–784.

    Article  Google Scholar 

  39. 39.

    Goossen K, Tenckhoff S, Probst P, Grummich K, Mihaljevic AL, Büchler MW, Diener MK (2018) Optimal literature search for systematic reviews in surgery. Langenbeck's Arch Surg 403:119–129.

    Article  Google Scholar 

  40. 40.

    Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, Cates CJ, Cheng HY, Corbett MS, Eldridge SM, Emberson JR, Hernán MA, Hopewell S, Hróbjartsson A, Junqueira DR, Jüni P, Kirkham JJ, Lasserson T, Li T, McAleenan A, Reeves BC, Shepperd S, Shrier I, Stewart LA, Tilling K, White IR, Whiting PF, Higgins JPT (2019) RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 366:l4898.

    Article  Google Scholar 

  41. 41.

    Sterne JA, Hernán MA, Reeves BC et al (2016) ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 355:i4919.

    Article  Google Scholar 

  42. 42.

    Uhlmann L, Jensen K, Kieser M (2018) Hypothesis testing in Bayesian network meta-analysis. BMC Med Res Methodol 18:128.

    Article  Google Scholar 

  43. 43.

    Hozo SP, Djulbegovic B, Hozo I (2005) Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol 5:13.

    Article  Google Scholar 

  44. 44.

    Caricato M, Borzomati D, Ausania F, Tonini G, Rabitti C, Valeri S, Trodella L, Ripetti V, Coppola R (2006) Complementary use of local excision and transanal endoscopic microsurgery for rectal cancer after neoadjuvant chemoradiation. Surg Endosc 20:1203–1207.

    CAS  Article  Google Scholar 

  45. 45.

    de Graaf EJR, Burger JWA, van Ijsseldijk ALA et al (2011) Transanal endoscopic microsurgery is superior to transanal excision of rectal adenomas. Color Dis 13:762–767.

    Article  Google Scholar 

  46. 46.

    Winde G, Blasius G, Herwig R, Lügering N, Keller R, Fischer R (1997) Benefit in therapy of superficial rectal neoplasms objectivized: transanal endoscopic microsurgery (TEM) compared to surgical standards. Minim Invasive Ther Allied Technol 6:315–323.

    Article  Google Scholar 

  47. 47.

    Benson AB, Venook AP, Al-Hawary MM et al (2018) Rectal Cancer, Version 2.2018, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Cancer Netw 16:874–901.

    Article  Google Scholar 

  48. 48.

    Glynne-Jones R, Wyrwicz L, Tiret E et al (2017) Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 28:iv22–iv40.

  49. 49.

    Rai V, Mishra N (2016) Transanal approach to rectal polyps and cancer. Clin Colon Rectal Surg 29:65–70.

    Article  Google Scholar 

  50. 50.

    Ondhia M, Tamvakeras P, O’Toole P et al (2019) Transanal endoscopic microsurgery for rectal lesions in a specialist regional early rectal cancer centre: the Mersey experience. Color Dis 21:1164–1174.

    CAS  Article  Google Scholar 

  51. 51.

    Barendse RM, Dijkgraaf MG, Rolf UR, Bijnen AB, Consten ECJ, Hoff C, Dekker E, Fockens P, Bemelman WA, de Graaf EJR (2013) Colorectal surgeons’ learning curve of transanal endoscopic microsurgery. Surg Endosc 27:3591–3602.

    Article  Google Scholar 

  52. 52.

    Westrich G, Venturero M, Schtrechman G, Hazzan D, Khaikin M, Nissan A, Shapiro R, Segev L (2019) transanal minimally invasive surgery for benign and malignant rectal lesions: operative and oncological outcomes of a single center experience. J Laparoendosc Adv Surg Tech A 29:1122–1127.

    Article  Google Scholar 

  53. 53.

    Lee L, Kelly J, Nassif GJ, Keller D, Debeche-Adams TC, Mancuso PA, Monson JR, Albert MR, Atallah SB (2018) Establishing the learning curve of transanal minimally invasive surgery for local excision of rectal neoplasms. Surg Endosc 32:1368–1376.

    Article  Google Scholar 

  54. 54.

    Lopez-Picado A, Albinarrate A, Barrachina B (2017) Determination of perioperative blood loss: Accuracy or approximation? Anesth Analg 125:280–286.

    CAS  Article  Google Scholar 

  55. 55.

    Maslekar S, Pillinger SH, Sharma A, Taylor A, Monson JRT (2007) Cost analysis of transanal endoscopic microsurgery for rectal tumours. Color Dis 9:229–234.

    CAS  Article  Google Scholar 

  56. 56.

    Atallah S, Albert M, Larach S (2010) Transanal minimally invasive surgery: a giant leap forward. Surg Endosc 24:2200–2205.

    Article  Google Scholar 

  57. 57.

    Albert MR, Atallah SB, deBeche-Adams TC et al (2013) Transanal minimally invasive surgery (TAMIS) for local excision of benign neoplasms and early-stage rectal cancer: efficacy and outcomes in the first 50 patients. Dis Colon Rectum 56:301–307.

    Article  Google Scholar 

  58. 58.

    Hwang Y, Yoon YS, Bong JW, Choi HY, Song IH, Lee JL, Kim CW, Park IJ, Lim SB, Yu CS, Kim JC (2019) Long-term transanal excision outcomes in patients with t1 rectal cancer: comparative analysis of radical resection. Ann Coloproctol 35:194–201.

    Article  Google Scholar 

  59. 59.

    Arezzo A, Lo Secco G, Passera R, Esposito L, Guerrieri M, Ortenzi M, Bujko K, Perez RO, Habr-Gama A, Stipa F, Picchio M, Restivo A, Zorcolo L, Coco C, Rizzo G, Mistrangelo M, Morino M (2019) Individual participant data pooled-analysis of risk factors for recurrence after neoadjuvant radiotherapy and transanal local excision of rectal cancer: the PARTTLE study. Tech Coloproctol 23:831–842.

    CAS  Article  Google Scholar 

  60. 60.

    Oh BY, Yun H-R, Kim SH, Yun SH, Kim HC, Lee WY, Chun HK, Cho YB (2015) Features of late recurrence following transanal local excision for early rectal cancer. Dis Colon Rectum 58:1041–1047.

    Article  Google Scholar 

  61. 61.

    Helewa RM, Rajaee AN, Raiche I, Williams L, Paquin-Gobeil M, Boushey RP, Moloo H (2016) The implementation of a transanal endoscopic microsurgery programme: initial experience with surgical performance. Color Dis 18:1057–1062.

    CAS  Article  Google Scholar 

  62. 62.

    Caycedo-Marulanda A, Jiang HY, Kohtakangas EL (2017) Transanal minimally invasive surgery for benign large rectal polyps and early malignant rectal cancers: experience and outcomes from the first Canadian centre to adopt the technique. Can J Surg 60:416–423.

    Article  Google Scholar 

  63. 63.

    Marrosu A, Paliogiannis P, Ruggiu MW, Attene F, Trignano M, Scognamillo F (2013) Hybrid transanal endoscopic microsurgery: a novel approach to rectal neoplasm excision. Color Dis 15:e757–e759.

    CAS  Article  Google Scholar 

  64. 64.

    Spizzirri A, Coccetta M, Cirocchi R, la Mura F, Napolitano V, Bravetti M, Giuliani D, de Sol A, Pressi E, Trastulli S, di Patrizi MS, Avenia N, Sciannameo F (2010) Synchronous colorectal neoplasias: our experience about laparoscopic-TEM combined treatment. World J Surg Oncol 8:105.

    Article  Google Scholar 

Download references

Author information



Corresponding author

Correspondence to Ioannis Baloyiannis.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material


(DOCX 103 kb)


(DOCX 3641 kb)


(PDF 72 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Perivoliotis, K., Baloyiannis, I., Sarakatsianou, C. et al. Comparison of the transanal surgical techniques for local excision of rectal tumors: a network meta-analysis. Int J Colorectal Dis 35, 1173–1182 (2020).

Download citation


  • Transanal
  • Excision
  • Rectal
  • TAE
  • TEM
  • TEO
  • Network
  • Meta-analysis