Surgery · Medical Literature
[Correspondence] COLOR III: widespread TaTME dissemination demands a LAPCO-equivalent framework
Abstract
We read with great interest the short-term outcomes of transanal total mesorectal excision (TaTME) for mid and low rectal cancer in Jurriaan B Tuynman and colleagues’ COLOR III trial,1 and the accompanying Comment by Patricia Sylla.2 The reduction in conversion rates versus laparoscopic TME (1% vs 17%) is striking, and the similar operating times compared with robotic-assisted TME, alongside substantially lower capital and consumable costs, are noteworthy. We agree that TaTME represents a valuable technique for specialists.
Clinical relevance
In light of the compelling short-term outcomes reported in the COLOR III trial, should the widespread dissemination of transanal total mesorectal excision (TaTME) be governed by a structured, competency-based national training framework analogous to the UK's LAPCO programme? __SNAPSHOT__ {"studyDesign":"Correspondence letter (expert opinion / methodological commentary); not a primary research study. The letter comments on the short-term secondary outcome data of the COLOR III trial — an international, multicentre, open-label, phase 3 randomised controlled non-inferiority trial (NCT02736942).","setting":"Correspondence published in The Lancet Gastroenterology & Hepatology (2026-08-01); the underlying COLOR III trial was conducted at 28 hospitals globally.","sampleSize":"Not applicable for this correspondence. The underlying COLOR III trial enrolled n=1,035 analysable patients (TaTME: n=696; LapTME: n=339), randomised 2:1.","population":"The COLOR III trial enrolled patients aged ≥18 years with (y)cT1–3N0–2M0 rectal adenocarcinoma located ≤10 cm from the anal verge, eligible for curative-intent surgery, excluding T4 tumours and those with suspected involved CRM at baseline MRI.","intervention":"Transanal total mesorectal excision (TaTME) — a 'bottom-up' surgical approach in which the rectum and mesorectum are dissected transanally according to TME oncological principles.","comparator":"Laparoscopic total mesorectal excision (LapTME) — the established minimally invasive transabdominal standard.","primaryOutcome":"The COLOR III trial's primary endpoint (not yet reported) is 3-year local recurrence rate, assessed for non-inferiority. This correspondence addresses short-term secondary endpoints from the published interim report: conversion rate, 90-day morbidity, anastomotic leakage, specimen quality, and resection margin involvement.","followUp":"Short-term secondary outcomes (to 90 days post-operatively) are the focus of this correspondence. The primary endpoint (3-year local recurrence) remains under follow-up and has not yet been reported.","fundingSource":"Not reported in the correspondence. The COLOR III trial funding source is not reported in the abstract accessed."}
Key findings
This is a correspondence letter and does not present original data. The authors cite and contextualise the following key findings from the COLOR III short-term outcome report (Tuynman et al., The Lancet Gastroenterology & Hepatology, 2026): (1) Conversion to open surgery occurred in 1% of TaTME patients (4/696) versus 17% of LapTME patients (56/339), representing a markedly lower conversion rate with TaTME (OR 0.03, 95% CI 0.01–0.08); (2) 90-day complication rates were similar between groups (TaTME 20% vs. LapTME 18%; OR 1.22, 95% CI 0.90–1.64); (3) Major complications occurred in 11% (TaTME) versus 9% (LapTME) (OR 1.23, 95% CI 0.82–1.85); (4) Anastomotic leakage rates did not differ significantly (TaTME 10% vs. LapTME 8%; OR 1.32, 95% CI 0.83–2.08); (5) Macroscopically complete resection was achieved in 84% of TaTME specimens versus 86% of LapTME specimens; (6) Positive CRM occurred in 1% (TaTME) versus <1% (LapTME), and positive DRM in 1% versus <1%, respectively. No p-values were reported for the margin or specimen quality comparisons in the abstract. The correspondence authors additionally note, without providing original data, that TaTME operating times are similar to robotic-assisted TME and that its capital and consumable costs are substantially lower. NNT/NNH are not calculable from the correspondence itself. No novel adverse event data are presented.
Practice implications
This letter does not establish new clinical evidence; it is an expert commentary on the COLOR III short-term data. The authors endorse TaTME as a valuable technique for specialists, consistent with the COLOR III finding that TaTME achieves perioperative safety non-inferior to LapTME while dramatically reducing intraoperative conversions. However, the correspondence's central argument — its primary contribution — is that the striking reduction in conversion rate and anticipated broader adoption of TaTME must not proceed without a structured, competency-based training and accreditation framework, analogous to the UK's LAPCO (National Training Programme for Laparoscopic Colorectal Surgery) model. The LAPCO programme, which provided competency-based supervised training to specialist colorectal surgeons in England, demonstrated measurable improvements in adoption rates and reductions in 30- and 90-day mortality. The authors draw a direct parallel, arguing that TaTME — a technically demanding procedure with a significant learning curve — risks producing preventable patient harm if disseminated through unregulated channels. Importantly, this correspondence does NOT establish: (a) that any LAPCO-equivalent TaTME framework currently exists or is being implemented; (b) the oncological safety of TaTME, as the primary 3-year local recurrence endpoint of COLOR III remains pending; (c) the optimal case volume or assessment criteria for TaTME competency. The COLOR III participant population was drawn from high-quality, internationally credentialled trial centres with pre-trial video-based competency assessment and central MRI review — conditions that may not be replicable in routine practice. Only abstract-level data from the underlying trial were available for this summary; the full correspondence text was not accessible. __LIMITATIONS__ 1. As a correspondence letter, this paper does not present original data, conduct statistical analysis, or report a defined methodology; it cannot be critically appraised using standard research quality tools. 2. The clinical arguments rely exclusively on the short-term secondary outcomes of COLOR III; the definitive primary oncological endpoint (3-year local recurrence) has not been reported, so the oncological equivalence of TaTME versus LapTME remains unproven. 3. The COLOR III trial was conducted at highly selected, internationally credentialled centres with mandatory pre-trial competency assessment — a level of surgical quality assurance that may not reflect community or lower-volume practice, limiting generalisability. 4. The correspondence does not quantify the TaTME learning curve, define competency thresholds, or propose specific curricular content for the advocated training framework, limiting its immediate operational utility. 5. The claim regarding comparable operating times and lower costs versus robotic-assisted TME is stated without citation of primary data or original analysis in the abstract reviewed. 6. External evidence on TaTME learning curves suggests that 45–51 cases may be required to reach technical proficiency at high-volume centres, with local relapse rates as high as 14% during the first 10 cases at less experienced centres — key contextual data not discussed in this abstract. 7. The prior Norwegian national experience, in which TaTME was suspended due to unexpectedly high local recurrence rates in the early adoption phase, is an important historical precedent that contextualises the authors' call for structured training but is not cited in the abstract. 8. No patient-reported outcomes, functional outcomes, or health economic data are included. 9. Funding source and any conflict-of-interest declarations for the correspondence authors are not reported in the abstract. __BOTTOM_LINE_CATEGORY__ potentially_practice_informing __BOTTOM_LINE__ This expert correspondence, responding to the COLOR III short-term outcome data, makes a clinically important process-of-care argument: TaTME's compelling perioperative advantage — a 16-percentage-point absolute reduction in conversion to open surgery compared with LapTME — should not prompt unstructured widespread adoption given the technique's steep learning curve and associated risks during the acquisition phase. Clinicians and healthcare systems considering TaTME implementation should advocate for and require a formal, competency-based training and proctorship framework before permitting independent practice. Final judgement on whether TaTME should replace LapTME as the preferred minimally invasive approach must await the COLOR III primary endpoint: 3-year local recurrence rates, which remain under follow-up.