EAES, ESCP, and ESGAR clinical practice guideline update on taTME for rectal cancer

Background: The EAES released guidelines on the role of taTME in the management of rectal cancer in 2022. Objective: To develop updated, evidence-informed recommendations to support clinicians involved in the management of taTME; to provide guidance for hospital managers, policymakers, and patients with low- and mid-rectal cancers. Methods: We performed a systematic review to identify randomized trials and matched nonrandomized studies comparing transanal total mesorectal excision (taTME) to laparoscopic TME (laTME) or robotic TME (roTME) in patients with low- and mid-rectal cancer. A panel of general and colorectal surgeons, a radiologist, a pathologist, and patient partners appraised the certainty of the evidence using GRADE. The panel developed recommendations using an evidence-to-decision framework during an in-person consensus meeting. We applied a Delphi survey to establish consensus. Results: The panel recommends taTME over laTME in patients with low- and selected mid-rectal cancers when access to surgeons with expertise in performing taTME in high-volume rectal cancer centers is available (strong recommendation). This recommendation applies to patients eligible for sphincter preservation who are at high risk for conversion to abdominoperineal resection, including male gender with BMI > 30 kg/m². The recommendation is supported by a reduction in 30-day major complications and disease recurrence at 2 years with taTME compared to laTME. When access to a surgeon with expertise in performing taTME is not available, the panel recommends against taTME over laTME (strong recommendation). Further, the panel suggests roTME as an alternative to taTME in patients with low- and selected mid-rectal cancers when access to surgeons with expertise in performing taTME is not available (conditional recommendation). Conclusion: We provide evidence-informed guidance on the role of taTME in the surgical management of patients with low- and mid-rectal cancers. Patients and surgeons should exercise shared-decision making to apply patient-tailored decisions when considering treatment options.