Training and accreditation in transanal total mesorectal excision in the United States

Abstract

The current standard of care for the surgical treatment of rectal cancer is the total mesorectal excision (TME). While laparoscopic TME has improved short-term postoperative outcomes relative to open surgery, its adoption has remained low and conversion rates high due to the technical difficulties associated with operating in the pelvis, particularly for low rectal tumors in obese male patients. Transanal TME (taTME) utilizes a “bottom up” approach to the distal rectum and mesorectum that overcomes the limitations of an abdominal approach by improving exposure of the TME planes. The proposed benefits of taTME include a lower rate of incomplete TME specimen grade, lower rates of positive resection margins, and lower rates of conversion to open surgery, as well as a higher rate of sphincter preservation for tumors located ≤5 cm from the anal verge. Short-term outcomes of taTME have thus far affirmed the proposed benefits of the procedure. Preliminary long-term oncological results demonstrate that when performed in carefully selected patients by high-volume surgeons with expertise, taTME is safe with acceptable oncologic and functional outcomes. The training of colorectal surgeons in taTME in the United States is currently unregulated and no formal system of accreditation exists. A large number of surgeons who have attended taTME workshops have not performed the procedure, either due to lack of comfort or low case volume. As taTME is associated with a significant learning curve, the training curriculum and use of proctorship will be paramount to the development of a standardized training program in the United States.