Ann Surg Treat Res.  2021 Sep;101(3):167-180. 10.4174/astr.2021.101.3.167.

Meta-analysis of transanal versus laparoscopic total mesorectal excision for rectal cancer: a ‘New Health Technology’ assessment in South Korea

• Kwon SH
• Joo YI
• Kim SH
• Lee DH
• Baek JH
• Chung SS
• Shin JY
• Eun CS
• Kim NK

• KMID: 2519847
• DOI: http://doi.org/10.4174/astr.2021.101.3.167

Abstract

Purpose
Under the South Korea’s unique health insurance structure, any new surgical technology must be evaluated first by the government in order to consider whether that particular technology can be applied to patients for further clinical trials as categorized as ‘New Health Technology,’ then potentially covered by the insurance sometime later. The aim of this meta-analysis was to assess the safety and efficacy of transanal total mesorectal excision (TaTME) for rectal cancer, activated by the National Evidence-based Healthcare Collaborating Agency (NECA) TaTME committee.
Methods
We systematically searched Ovid-MEDLINE, Ovid-Embase, Cochrane, and Korean databases (from their inception until August 31, 2019) for studies published that compare TaTME with laparoscopic total mesorectal excision (LaTME). End-points included perioperative and pathological outcomes.
Results
Sixteen cohort studies (7 for case-matched studies) were identified, comprising 1,923 patients (938 TaTMEs and 985 LaTMEs). Regarding perioperative outcomes, the conversion rate was significantly lower in TaTME (risk ratio, 0.19; 95% confidence interval, 0.11–0.34; P < 0.001); whereas other perioperative outcomes were similar to LaTME. There were no statistically significant differences in pathological results between the 2 procedures.
Conclusion
Our meta-analysis showed comparable results in preoperative and pathologic outcomes between TaTME and LaTME, and indicated the benefit of TaTME with low conversion. Extensive evaluations of well-designed, multicenter randomized controlled trials are required to come to unequivocal conclusions, but the results showed that TaTME is a potentially beneficial technique in some specific cases. This meta-analysis suggests that TaTME can be performed for rectal cancer patients as a ‘New Health Technology’ endorsed by NECA in South Korea.

Keyword

Colorectal neoplasms; Laparoscopic total mesorectal excision; Meta-analysis; Systematic review; Transanal total mesorectal excision

Figure

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  Fig. 1 PRISMA diagram of the search strategy. TaTME, transanal total mesorectal excision; LaTME, laparoscopic total mesorectal excision.

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  Fig. 2 Forest plots of risk ratios and mean differences of perioperative outcomes. (A) Operative time, (B) intraoperative blood loss and, (C) conversion rate. A random-effect model was used for meta-analysis of operative time. Fixed-effects models were used for meta-analysis of intraoperative blood loss and conversion rate. Mean differences and risk ratios are shown with 95% confidence intervals (CIs). TaTME, transanal total mesorectal excision; LaTME, laparoscopic total mesorectal excision; SD, standard deviation; IV, inverse variance; df, degree of freedom.

• 

  Fig. 3 Forest plots of risk ratios and mean differences of perioperative outcomes. (A) Hospital stay, (B) readmission, and (C) reoperation. A random-effect model was used for meta-analysis of hospital stay. Fixed-effects models were used for meta-analysis of readmission and reoperation. Mean differences and risk ratios are shown with 95% confidence intervals (CIs). TaTME, transanal total mesorectal excision; LaTME, laparoscopic total mesorectal excision; SD, standard deviation; IV, inverse variance; df, degree of freedom.

• 

  Fig. 4 Forest plots of risk ratios of perioperative outcomes. (A) Major complications (Clavien-Dindo classification III–V), (B) anastomotic leakage, and (C) intestinal obstruction. Fixed-effects models were used for meta-analysis. Risk ratios are shown with 95% confidence intervals (CIs). TaTME, transanal total mesorectal excision; LaTME, laparoscopic total mesorectal excision; df, degree of freedom.

• 

  Fig. 5 Forest plots of risk ratios and mean differences of pathological outcomes. (A) Circumferential resection margin involvement, (B) length of circumferential resection margin, (C) distal resection margin involvement, (D) length of distal resection margin, (E) incompleteness of mesorectum, and (F) harvested lymph nodes. Random-effects models were used for meta-analysis of length of circumferential resection margin and distal resection margin. Fixed-effects models were used for meta-analysis of circumferential resection margin and distal resection margin involvement. Mean differences and risk ratios are shown with 95% confidence intervals (CIs). TaTME, transanal total mesorectal excision; LaTME, laparoscopic total mesorectal excision; SD, standard deviation; IV, inverse variance; df, degree of freedom.

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