Scott R. Steele, MD, MBA, Chairman of Colorectal Surgery at Cleveland Clinic talks about taTME and how it works.
Interview conducted by Ivanhoe Broadcast News in October 2018.
What is taTME, what does it stand for?
Dr. Steele: So taTME stands for Transanal Total Mesorectal Excision. It’s essentially removing the rectum and all of its lymph nodes from above (belly) and bottom (anus). The above part is typically performed by a minimally invasive approach such as laparoscopic surgery. The transanal portion is performed by freeing up the lower part of the rectum (closer to the anus) and together removing the rectum and its package of lymph nodes standard for cancer operations.
Can you explain what this technique is and how it is different than others?
Dr. Steele: The pelvis is a part of the body that has fixed bony structures around it. It leaves little room to work with surgical instruments. How do we get our instruments down the pelvis to take out the rectum, the cancer, and the lymph nodes? You can either do it through open techniques, which often times are required, but can also lead to longer recoveries. Through smaller incisions, the minimally invasive procedures traditionally use a laparoscopic procedure or robotic procedures. The transanal technique, taTME, literally takes that hardest part of the case – the last bit closer to the anus that you have to free up and remove to get rid of the cancer and the lymph nodes – and approaches it a different way. By going through the anus, you can help achieve good margins around the cancer to help ensure you get all of the cancer out and hopefully have less pain by using the natural opening of the body. It basically takes that toughest part of the procedure when performed from the abdomen alone and makes it a lot easier.
Why was there a need for this particular technique compared to prior techniques?
Dr. Steele: In the past, when you had cancers that are closer to the anus, it would relegate patients to having a permanent stoma (bag or colostomy). If you take a look from the ten-thousand-foot view, our goal with rectal cancer is to first make sure that we can get the cancer out with good margins. Yet, we are also trying to avoid patients having to wear a permanent stoma when it is appropriate, as well as help maintain the best function as possible. Using this technique helps us achieve each of these goals.
How does taTME reduce recurrence rates?
Dr. Steele: taTME doesn’t necessarily in and of itself reduce recurrence rates. But, it allows patients to avoid a permanent bag, and it improves on their overall recovery and decreases complications around the time of an operation associated with some more traditional approaches to rectal cancer. You still have to do the same operation, no matter if you do it open, laparoscopic, robotically or via taTME. What taTME allows us to basically do is to take those toughest cancers, those in patients that are closest to the anus or larger cancers, and it allows us to get them out safely and reestablish the bowel continuity so that patients don’t have to have a permanent bag.
How long has taTME been around?
Dr. Steele: taTME first got described back in 2010. It was originally described by a small group of people both here in the U.S. and over in Europe in a pig model, and then they had the first case performed in humans. But really it’s been for over the last couple of years that taTME has really taken off. Now there are more centers that perform it, but we’re probably one of the more high-volume centers that are experienced in this particular procedure.
Has it been used for other conditions besides rectal cancer?
Dr. Steele: It has, and we’re probably one of the few centers that use it more commonly for proctocolectomy and pouches for the treatment of inflammatory bowel disease, specifically with ulcerative colitis, or hereditary polyposis. In this procedure, we use the taTME approach to remove the rectum and then make a new rectum (i.e., pouch) so the patient doesn’t need to have a permanent stoma. It has also been used for patients who have complications from previous surgery to aid in faster recovery with a more minimally invasive approach.
What advantages does this technique offer?
Dr. Steele: Well, there are advantages to the surgeon, and there are advantages most importantly to the patient. For the surgeon, what we want to do is we want to make sure that we get the cancer out but also have good margins. For those tumors that are very low, taTME offers us the advantages of going from below and making sure we get those good margins under direct visualization. This is a lot easier to do when you’re looking straight at the lesion through the anus than when you are from above in the belly looking down upon it. For the patient, in association with our enhanced recovery protocol, the advantages are many. Less pain, faster gastrointestinal recovery, and avoidance of a permanent stoma allows patients to get back on their feet both functionally quicker, have a better quality of life, as well as achieving a great cancer outcome.
What would qualify someone to have taTME instead of other techniques?
Dr. Steele: There’s no set criteria in terms of who qualifies for taTME and who doesn’t. As a matter of fact, you can use a taTME approach even for patients that may require a permanent bag. The goal of taTME, or any surgical approach, is to make sure that we do the right operation and take care of the goals of the operation—whether for cancer or another disease process. In general, we are now using taTME for patients who may have the types of tumors that are very close to the anus. In addition, certain body habitus types (e.g., larger patients with a narrow pelvis) can make it more difficult to go from above alone, and taTME helps. Of course, you can use it on anybody’s habitus, but it probably has more advantages for patients who have a higher BMI.
When you said body habitus can you explain to us?
Dr. Steele: Yes, so patients who are overweight have a higher BMI–body mass index. Those are the patients that often times are difficult to operate on when you go from a top down approach – . from the belly and down into the pelvis. It’s just a mere fact that the visualization may not be as good. Using the taTME technique, we’re able to do the harder part, that part that’s way down in the pelvis and doing it first. With taTME, and starting from the anus, it’s under your direct visualization.
What are some risks? Are there certain patients this would not be a good option for?
Dr. Steele: Well, I think that there are two ways to answer that question. The first one is from the surgeon’s viewpoint. With any new technique, we need to make sure that first and foremost we’re doing the right thing for our patients, and that we have the experience and the expertise in order to do a certain technique. With any operation, there are risks associated with the operation, whether it is pain, bleeding, infection, not healing, etc. taTME carries these risks as well, as it is a surgical approach to perform a certain operation. Second, we want to make sure that our patients get the best possible functional outcomes. While there’s no patient that you wouldn’t necessarily consider for the procedure, we need to make sure that we’re having appropriate selection of patients. For example, someone with a cancer that is higher up in the sigmoid colon, an abdominal operation would be the preferred route, and taTME wouldn’t be a good option.
How is the recovery?
Dr. Steele: Well, the recovery with taTME is one of the benefits of it. Patients have faster recovery of their bowel function, they have lower complication rates, and, by using a minimally invasive procedure, typically their belly wakes up faster. This means they will need less pain medications and they’re able to get up and move around quicker. For example, we get our patients out of bed the night of surgery, and they can be sipping on liquids right after surgery. They’re up and walking around, and hopefully spending less time in the hospital and able to get home to their friends and family soon after the operation.
What are some precautions patients would have to take afterwards?
Dr. Steele: With every recovery from surgery, we want to make sure that patients have as smooth of a recovery as possible. In order to do this, there are some easy things that can be done that go a long way toward better healing. For example, simply getting patients up and walking around can help in avoiding blood clots, pneumonias, and getting the bowels going again. While taTME is a minimally invasive surgery, the actual operation itself is still often a fairly major operation. In addition, we want to make sure that patients have adequate pain control, but not experience all the potential side effects from these types of medications. What we use here is a multi-modality pain control regimen. We don’t rely heavily on narcotics, which tends to slow down the bowel function recovery, By using this multi-modality approach that emphasizes lesser narcotics, but still controlling their pain adequately, the bowels start to function again quicker, patients can eat sooner, they feel better faster, and they’re able to get home earlier.
How soon can someone return back to their regular routine?
Dr. Steele: Well, the regular routine may take a few weeks, there’s no question. What I try to tell all my patients is that, for that first few days, you’re going to know you had an operation, but nothing like in the past. The difference is that in years past, people would stay in bed for a while, wake up with tubes in their nose, not be able to eat, and rely on narcotics alone for pain control. Now, by using these techniques such as taTME, they’re out of bed the evening following their surgery. They’re up and showering the next day. They’re eating within a day or so a soft meal. We don’t regularly use tubes in the nose anymore, and as I said, narcotics are only one small part of the pain control regimen. All these things allow patients to get back in to their regular routine quicker, and have a much more straightforward recovery.
What impact would taTME have for patients?
Dr. Steele: I think the greatest impact is that patients can get an effective operation, whether for cancer or another disease process, which utilizes a minimally invasive procedure that allows them to get back to normal recovery quicker than ever. In addition, those patients with very low cancers that may have traditionally resulted in a permanent bag don’t have to get that any more. Along with a better functional recovery, we can hope to have the least amount of complications as possible.
When you say permanent bag for people, can you explain why someone would have a permanent bag?
Dr. Steele: Many people’s biggest fear in going into a bowel operation, specifically one on the colon or rectum, is getting a bag. Now, to clarify terminology, a stoma or ostomy is often called a bag. Stoma or ostomy means opening, in this case the bowel to the abdominal wall, and patients wear a bag to collect the output. Further, a colostomy is simply bringing the colon up to the skin, and an ileostomy is bringing the ileum up to the skin. You don’t use your bathroom as you traditionally would. Patients are very worried about that and often ask those questions: “What type of life am I going to have wearing a bag and what is it going to do to me, and will people hear it or will it smell?” These are great questions and completely understandable. There are several reasons a person may need to have a permanent bag. First, patients with a tumor that is next to where the muscles (i.e., sphincters) that allow us to control our continence (the ability to hold in gas, liquid stool, solid stool when you want to) may need to have a bag because you need to cut out those muscles to take out the tumor and get appropriate margins. Even taking out part of those muscles may cause some problems in certain patients. For some people, problems with continence may occur rarely, and in others, there would be loss of control. In the latter group, a permanent bag avoids the situation. Yet, taking out some or all of the muscles was the right thing to do for their cancer operation to make sure that they get good margins around that tumor. Other patients may go into an operation with problems already with continence, and taking out this part of the rectum, whether by taTME or any approach, can worsen these symptoms. Therefore a permanent stoma is needed, and ultimately will often improve a patient’s quality of life.
Can you talk about Annie’s case?
Dr. Steele: Annie was a special case. She had some symptoms, and despite being young and healthy and could have attributed these to other things, she went to the doctor to get checked. She underwent a colonoscopy where they found and removed a small lesion in her rectum. Unfortunately, it wasn’t just a pre-cancerous lesion (i.e., benign polyp); it was a true invasive cancer. The other thing is that the tumor was very low, close to the opening of the anus. In the past, and to be honest, even today in many centers, in order to remove this lesion, the lymph nodes and achieve adequate margins would have required a permanent colostomy. Annie and I had a lot of discussions about options and what would be best for her both from a cancer standpoint as well as for peace of mind. Annie is a young mom with a new family and all of a sudden, not only you’re talking about the shock of having cancer, but also you’re talking about potentially a complete lifestyle change by having to undergo a major surgery that may require a permanent bag. Annie is extremely active, tremendously successful, busy with her kids, hardworking with her profession and needs to take this into account when making decisions. She and I talked a lot about what surgery may entail, and whether or not she could avoid having a permanent bag. When I first examined her, I felt that by using this taTME technique, I could perform an effective cancer operation, and avoid a permanent stoma as well. I think that is an important point. Our first priority is always to ensure she receives the best possible cancer operation. After that, if possible, I would do my best to avoid giving her a permanent bag. I felt that in her case the best way to accomplish both goals was using the taTME approach. She underwent the procedure and she did great. Because of where her tumor was, she may occasionally have urgency to use the bathroom. That’s definitely gotten better, although it was probably a little worse during chemotherapy. However, she’s on the road to recovery. Where her function ultimately winds up has much more to do with where the tumor was and what we had to do to get it out, versus the technique itself.
Talking a little bit about still Annie’s case and how she was so young and going back to the trend in rectal cancer increasing in younger adults, why do you colon and rectal cancer mortality rates have increased?
Dr. Steele: I think that’s the ten-thousand dollar question, the “why” behind this increased trend of colorectal cancer in young patients. I don’t think that we know exactly why. Now, part of the reason could be that patients are much more cognizant of the symptoms, regardless of age, and they are willing to go get checked. That’s probably the biggest learning point out of all of this – if you have symptoms, whether it be pain or bleeding or a change in your bowel habits, don’t ignore them. Especially if you have a family history of any colon or rectal cancer, don’t ignore it. Go to a doctor and get evaluated for it. We know that cancer is multifactorial, such that lots of different things can play a role – from your underlying genes, your family history, the exposures that you have — whether environmental, how you live, or your diet. All of these things can come together and suggest why some people get cancer and others do not. Active research is ongoing looking at cancer in general, as well as in younger age patients. I’m proud to say a lot of that is being done here at Cleveland Clinic by people in our department. What I can say is that it appears to be a real phenomenon, and if you experience symptoms, it’s worth getting checked out.
What are some of the symptoms again?
Dr. Steele: Symptoms can be wide-ranging, and importantly, just because you have one does not mean you have cancer. However, you should get evaluated. These include changes in your bowel habits such as increasing constipation or thinning of the stools, as well as rectal bleeding or pain. Again, I recognize these are common symptoms and the vast majority of times, there will be a benign cause or a very straight forward reason for why the symptoms may occur. It could be simply that you’re not taking enough fiber or you need to drink more water, or you’ve got hemorrhoids or an anal fissure that can be easily managed. That said, just because the vast majority of times it is a benign reason for the symptoms, you should go to the doctor and get checked.
Is there anything else that you would like to add on the topic of taTME to treat rectal cancer?
Dr. Steele: I think that the take-home point is that no matter the surgical approach that we use, whether it is a taTME, open or minimally invasive procedures from above, you still have to have an effective cancer operation first and foremost. taTME absolutely provides us with some advantages for certain tumors in certain patients. However, you have to match the patient with the procedure, and have the experience and the expertise of the surgeon to be able to achieve a great outcome associated with being cancer free with a wonderful quality of life.
END OF INTERVIEW
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