The National Institute for Health and Care Excellence (NICE) has issued full guidance to the NHS in England, Wales, Scotland and Northern Ireland on transanal total mesorectal excision of the rectum, in March 2015.
Transanal total mesorectal excision (TaTME) can be used to treat malignant or benign disease of the rectum.
Malignant disease: The incidence of rectal cancer rises sharply with age. Symptoms include rectal bleeding and change in bowel habit, although the early stages may be asymptomatic. Treatment of rectal cancer depends on its stage which is conventionally assessed using Dukes’ classification system:
- stage A – confined to the lining of the rectum
- stage B – grown into the muscle wall
- stage C – spread to at least 1 lymph node in the area
- stage D – spread to another organ in the body.
Surgery is the main treatment modality for patients with locally confined disease. It involves resection of the affected part of the rectum, with or without preservation of the anus (and formation of a colostomy when preservation of the anus is not technically possible). Adjunctive radiotherapy and chemotherapy may also be used to reduce the risk of local recurrence and prevent metastatic disease.
Benign disease: Benign conditions that may lead to the need for resection of the rectum include ulcerative colitis and Crohn’s disease. Both are chronic conditions, characterised by periods of clinical relapse and remission.
Treatment depends on the severity and extent of the disease and is aimed at reducing the frequency and severity of recurrences. Drug therapy, including corticosteroids and immunosuppressive agents (such as azathioprine), usually controls the disease adequately. For more severe cases, treatment with a monoclonal antibody (such as infliximab) may be considered. Surgical removal of the affected areas may be necessary for severe cases that do not respond to medical treatment.
The OPCS-4 codes for transanal total mesorectal excision of the rectum are:
H33.8 Other specified excision of rectum
This guidance represents the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take this guidance fully into account, and specifically any special arrangements relating to the introduction of new interventional procedures. The guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
All problems (adverse events) related to a medicine or medical device used for treatment or in a procedure should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card Scheme.
Commissioners and/or providers have a responsibility to implement the guidance, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties. Providers should ensure that governance structures are in place to review, authorise and monitor the introduction of new devices and procedures.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.