The transanal approach represents the newest option for restorative proctocolectomy (RPC), improving the technical steps of a complex operation and the surgical outcomes. Health-related quality of life for this type of patients is very important, considering their young age and life expectancy.
The technique was first described in human by the Barcelona team in 2015 after the initial animal and cadaveric experiences, with a first case series involving 16 cases8. Since then, we found in literature 5 single-case reports,,,,, 4 further case series ranging from 8 to 18 cases9,10,11,12 and three multicentric experiences, reporting partially overlapping cohorts of 9713, 62 and 10014 cases. Described cases vary in indication from IBD to FAP.
The transanal approach can be employed, both in cancer and IBD surgery, to overcome some limitations of the traditional minimally invasive techniques, thus allowing better visualization in the low pelvis and easier dissection of the distal 5 cm of the rectum.
Reported experiences agree that Ta-IPAA allows a better visualization of the distal 5 cm of rectum, making easier the identification of a < 2 cm rectal cuff and a more precise pelvic dissection.
Stapled anastomosis is considered the gold standard5 and the length of the rectal cuff is one major determinant of quality of life after operation. A cuff length > 2 cm is related to symptomatic inflammatory disease recurrence or neoplastic risk, while a complete mucosectomy requests a colo-anal hand-sewn anastomosis which is associated with poorer continence, lower anal resting pressures and permanent loss of the recto-anal inhibitory reflex with consequent night-time soiling.
Moreover, Ta-IPAA permits the identification of the site for rectal section and the realization of a transanal distal pursestring, avoiding multiple stapler firings for rectal stump closure and lowering the risk of anastomotic leakage.
This technique in IBD treatment was employed only by few expert surgeons; moreover solid data concerning long term functional outcomes are still restricted.
First functional data in a series of TaTME performed for rectal cancer showed preserved urinary and sexual function and low incidence and severity of LARS.
De Buck van Overstraeten A. et al.13 published short-term outcomes of 97 patients from 3 Institutions who underwent a single incision surgery combined with TaTME for ileoanal pouch construction, compared with 119 cases in which a trans-abdominal approach was employed. They demonstrated the safety of Ta-IPAA for UC and showed a lower rate of 90 days postoperative complications in ulcerative colitis, comparing Ta-IPAA to Trans-abdominal approach.
A more recent paper14 reported a multicentric experience evaluating the long-term outcomes of Ta-IPAA against Abd-IPAA in restorative proctocolectomy, in 100 vs 274 cases. It shows that there are no statistically significant differences between Ta-IPAA and Abd-IPAA considering quality of life and that Ta-IPAA is associated with higher quality of health and energy level. Furthermore, severe complication rate was significantly reduced, whereas anastomotic leak rate was non significantly lower with Ta-IPAA.