Surgical Innovation in Rectal Cancer

The management of rectal cancer has undergone a huge evolution over the last few decades with advances in radiation and chemotherapy regimens as well as surgical advances with new techniques being developed. Surgery still offers the best chance of cure, but also carries significant risks.

Our first Bowel Cancer UK/RCS Research Fellow, Marta Penna, is exploring a new surgical technique pioneered to overcome many of the challenges faced by surgeons operating on rectal cancer. Marta shares with us why she is undertaking this work and how it will hopefully benefit patients with rectal cancer:    

Why did you become a surgical research fellow?

Growing up as a child, I wanted to become a doctor in order to help people. As a doctor, I have taken care of patients offering the treatments we currently have available, and taking them through difficult times in their lives. Although the level of care may be very good, there is a drive to do better and improve outcomes for patients further. I am therefore undertaking a PhD to pursue specialised research training and hope that my research will translate into clinical practice, aiming to enhance patient treatment and outcomes.

Why have you focused your research on rectal cancer?

Over 41,200 new cases of bowel cancer are diagnosed every year; affecting 1 in 14 men and 1 in 19 women. Most of these cancers occur in the lower part of the bowel called the rectum. Surgery remains the gold standard treatment for rectal cancer with the greatest chance of cure. However, surgery in this area can be very challenging when surgeons only operate looking down from the abdomen, especially when an accurate dissection is needed down a narrow tight pelvis with a limited view. This has led to incomplete removal of the tumour and up to 70% of patients experiencing problems with their bowel, urinary and sexual function, affecting their quality of life. There is therefore a definite need for improvement.

What is your research about?

Transanal Total Mesorectal Excision (TaTME) is the latest advanced surgical operation pioneered to improve rectal cancer surgery. The aims of the technique are to achieve complete removal of the tumour and its lymph nodes, which will reduce the risk of cancer returning, whilst protecting important surrounding structures such as the pelvic nerves that control bowel, urinary and sexual function. This is achieved by operating on the bowel both from the top (abdominally) and from the bottom (transanally), rather than just the top. The bottom approach overcomes many of the restrictions posed by the top view, providing a better view of where to cut and less injury to surrounding structures.

My research has two main aspects: the first involves analysing data collected on the International TaTME database from 39 different countries worldwide, showing outcomes from this operation.  The second aspect involves carrying out a detailed systematic analysis, called observational clinical human reliability analysis, of 200 unedited TaTME videos in order to identify the optimal way to perform the technique avoiding errors and complications. Human reliability analysis is a human factor approach routinely used in many industries, such as nuclear power stations and aerospace, which acknowledges that people and systems are not error-proof. However, by understanding how errors and potential errors can occur, mitigation strategies can be put into place. We have applied the same concept to surgery. The mechanisms identified to reduce errors will become part of the training for surgeons learning TaTME.

What have you found so far?

The initial analysis of 720 cases of TaTME have shown very promising results with high rates of complete tumour removal and a complication rate similar to that seen from the abdominal approach. Given that these operations were performed during the early phases of a surgeon’s experience with this technique, the results should improve further. The detailed analysis of the videos will also generate useful technical tips and error-reducing strategies that can be used in training and clinical practice. The analysis of 50 videos has already generated a lot of useful information and valuable suggestions.

Why is this research important for bowel cancer patients?

My research aims to improve surgical performance by analysing difficult components of this rectal cancer operation and identifying mechanisms to avoid errors. By avoiding injury with more precise surgery and removing whole cancer, patients are likely to live longer with better long-term bowel, urinary and sexual function and less risk of cancer recurrence.     

What are the next steps for making sure the research is rolled out in practice?

Strategies to reduce errors during surgery identified from the initial 50 videos will be integrated into the national TaTME training initiative recently started in the UK and endorsed by the Association of Coloproctology of Great Britain and Ireland. Further technical recommendations and guidelines will be published and available to all surgeons undertaking and learning the technique. Further analysis of the international TaTME database will also focus on the longer term effects of the surgery.

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