Previous transanal endoscopic microsurgery for rectal cancer represents a risk factor for an increased abdominoperineal resection rate

Endoscopic submucosal dissection versus endoscopic mucosal resection for the treatment of rectal lesions involving the dentate line

BACKGROUND

The ideal treatment of epithelial neoplastic rectal lesions involving the dentate line is a controversial issue. Piecemeal endoscopic mucosal resection (EMR) is the most commonly used resection technique, but it is associated with high recurrence rates. Endoscopic submucosal dissection (ESD) has been shown to be safe and effective for the treatment of rectal lesions, but evidence is lacking concerning its application close to the dentate line. The aim of our study is to compare ESD and EMR for the treatment of epithelial rectal lesions involving the dentate line.

METHODS

We identified all cases of endoscopic resections of rectal lesions involving the dentate line performed in two German high-volume centers between 2010 and 2022. Periinterventional and follow-up data were collected and retrospectively analyzed.

RESULTS

We identified 68 ESDs and 62 EMRs meeting our inclusion criteria. ESD showed a significant advantage in en bloc resection rates (89.7% vs. 9.7%; P = 0.001) and complete resection rates (72.1% vs. 9.7%; P = 0.001). The overall curative resection rate was similar between both groups (ESD: 92.6%, EMR: 83.9%; P = 0.324), whereas in the subgroup of low-risk adenocarcinomas ESD was curative in 100% of the cases vs. 14% in the EMR group (P = 0.002). There was one local recurrence after ESD (1,5%) vs. 16 (25.8%) after EMR (P < 0.0001), and the EMR patients required an average of three further interventions.

CONCLUSION

ESD is superior to EMR for the treatment of epithelial rectal lesions involving the dentate line and should be considered the treatment of choice.

Completion Surgery after Non-Curative Local Resection of Early Rectal Cancer

Background

The expanding indications of local - endoscopic and transanal surgical - resection of early rectal cancer has led to their increased popularity and inclusion in the treatment guidelines. The accuracy of the current diagnostic tools in identifying the low-risk T1 tumors that can be curatively treated with a local resection is low, and thus several patients require additional oncologic surgery with total mesorectal excision (TME). An efficient clinical strategy which avoids overtreatment and obstacle surgical procedures is under debate between different disciplines.

Summary

Completion surgery has comparable outcomes to primary surgery regarding perioperative morbidity and mortality but also recurrence rates and overall survival. However, local scarring in the mesorectum can make mesorectal excision technically challenging, especially after full-thickness resections, and has been associated with increased rates of permanent ostomy and worse quality of the TME specimen. This risk seems to be lower after muscle-sparing procedures like endoscopic submucosal dissection, which seem to show a benefit in comparison to full-thickness resections.

Key Messages

Completion surgery after non-curative local resection of gastrointestinal malignancies is safe and feasible. Full-thickness resection techniques can cause scarring of the mesorectum; therefore, muscle-sparing procedures should be preferred.

Local Excision for organ preservation in early REctal cancer with No Adjuvant treatment (LORENA Trial): prospective observational study protocol

INTRODUCTION

Local resection (LR) is an alternative to total mesorectal excision (TME) that avoids its associated morbidity to the detriment of oncological radicality in early stages of rectal cancer. There are several conditioning factors for the success of this strategy, such as poor prognosis histological factors (PPHF), involvement of resection margins, clinical under staging, or complications that may lead to the indication for radical surgery with TME.

PATIENTS AND METHOD

An international multicenter prospective observational open-label study has been designed. Consecutive patients diagnosed with early rectal cancer (cT1N0 on MRI +/- endorectal ultrasound) whose lower limit is a maximum of 2 cm proximal to the ano-rectal junction will be included. The primary objective of the study is to determine the overall prevalence of PPHF after LR and requiring TME or postoperative radio-chemotherapy.

DISCUSSION

The prevalence of PPHF conditioning the success of LR in early distal rectal cancer has been scarcely studied in the literature, and there are very few prospective data. Considering the increasing interest in the watch and wait strategy in rectal cancer and its possible application in early-stage tumors, it seems necessary to know this information. The results of this study will help guide clinical practice in patients with early distal rectal cancer. It will also provide quality information for the design of future comparative studies to improve organ preservation success in these patients.

TRIAL REGISTRATION NUMBER

NCT05927584.

Excision of malignant and pre-malignant rectal lesions by transanal endoscopic microsurgery in patients under 50 years of age

BACKGROUND

The most common technique for treating benign and early malignant rectal lesions is transanal endoscopic microsurgery (TEM). Local excision is an acceptable technique for high-risk and elderly patients, but there are hardly any data regarding young patients.

AIM

To describe TEM outcomes in patients under 50 years of age.

METHODS

We collected demographic, clinical, and pathological data from all patients under the age of 50 years who underwent the TEM procedure at Hasharon Rabin Medical Center from January 2005 to December 2018.

RESULTS

During the study period, a total of 26 patients under the age of 50 years underwent TEM procedures. Their mean age was 43.3 years. Eleven (42.0%) were male. The mean operative time was 67 min, and the mean tumor size was 2.39 cm, with a mean anal verge distance of 8.50 cm. No major intraoperative or postoperative complications were recorded. The median length of stay was 2 d. Seven (26.9%) lesions were adenomas with low-grade dysplasia, four (15.4%) were high-grade dysplasia adenomas, two were T1 carcinomas (7.8%), and three were T2 carcinomas (11.5%). No residual disease was found following endoscopic polypectomy in two patients (7.8%), but four (15.4%) had other pathologies. Surgical margins were negative in all cases. Local recurrence was detected in one patient 33 mo following surgery.

CONCLUSION

Among young adult patients, TEM for benign rectal lesions has excellent outcomes. It may also offer a balance between the efficacy of complete oncologic resection and postoperative quality of life in the treatment of rectal cancer. In some cases, it may be considered an alternative to radical surgery.

Completion Total Mesorectal Excision: A Case-Matched Comparison With Primary Resection

Objectives

The aim of this study was to compare the perioperative and oncological results of completion total mesorectal excision (cTME) versus primary total mesorectal excision (pTME).

Background

Early-stage rectal cancer can be treated by local excision alone, which is associated with less surgical morbidity and improved functional outcomes compared with radical surgery. When high-risk histological features are present, cTME is indicated, with possible worse clinical and oncological outcomes compared to pTME.

Methods

This retrospective cohort study included all patients that underwent TME surgery for rectal cancer performed in 11 centers in the Netherlands between 2015 and 2017. After case-matching, we compared cTME with pTME. The primary outcome was major postoperative morbidity. Secondary outcomes included the rate of restorative procedures and 3-year oncological outcomes.

Results

In total 1069 patients were included, of which 35 underwent cTME. After matching (1:2 ratio), 29 cTME and 58 pTME were analyzed. No differences were found for major morbidity (27.6% vs 19.0%; P = 0.28) and abdominoperineal excision rate (31.0% vs 32.8%; P = 0.85) between cTME and pTME, respectively. Local recurrence (3.4% vs 8.6%; P = 0.43), systemic recurrence (3.4% vs 12.1%; P = 0.25), overall survival (93.1% vs 94.8%; P = 0.71), and disease-free survival (89.7% vs 81.0%; P = 0.43) were comparable between cTME and pTME.

Conclusions

cTME is not associated with higher major morbidity, whereas the abdominoperineal excision rate and 3-year oncological outcomes are similar compared to pTME. Local excision as a diagnostic tool followed by completion surgery for early rectal cancer does not compromise outcomes and should still be considered as the treatment of early-stage rectal cancer.

Long-term results of minimally invasive transanal surgery for rectal tumors in 249 consecutive patients

PURPOSE

To delineate the long-term results of minimally invasive transanal surgery (MITAS) for selected rectal tumors.

METHODS

We analyzed data, retrospectively, on consecutive patients who underwent MITAS between 1995 and 2015, to establish the feasibility, excision quality, and perioperative and oncological outcomes of this procedure.

RESULTS

MITAS was performed on 243 patients. The final histology included 142 cancers, 47 adenomas, and 52 neuroendocrine tumors (NET G1). A positive margin of 1.6% and 100% en bloc resection were achieved. The mean operative time was 27.4 min. Postoperative morbidity occurred in 7% of patients, with 0% mortality. The median follow-up was 100 months (up to ≥ 5 years or until death in 91.8% of patients). Recurrence developed in 2.9% of the patients. The 10-year overall survival rate was 100% for patients with NET G1 and 80.3% for those with cancer. The 5-year DFS was 100% for patients with Tis cancer, 90.6% for those with T1 cancer, and 87.5% for those with T2 or deeper cancers. MITAS for rectal tumors ≥ 3 cm resulted in perioperative and oncologic outcomes equivalent to those for tumors < 3 cm.

CONCLUSION

MITAS is feasible for the local excision (LE) of selected rectal tumors, including tumors ≥ 3 cm. It reduces operative time and secures excision quality and long-term oncological outcomes.

The outcome of local excision of large rectal polyps by transanal endoscopic microsurgery

Introduction

Local excision of large rectal polyps can be an alternative for radical rectal resection with total mesorectal excision. We aim to report the functional and oncological outcomes of transanal endoscopic microsurgery (TEM) for patients with large rectal polyps.

Methods

All demographic and clinical data of patients who underwent TEM for rectal polyp of 5 cm or more at the Hasharon Hospital from 2005 to 2018 were retrospectively reviewed.

Results

Twenty-eight patients were included. The mean age was 66 years. The mean polyp size was 6.2 cm (range: 5-8.5 cm) with a mean distance of 8.3 cm from the anal verge. Peritoneal entry during TEM was observed in five patients and additional laparoscopy after the completion of the TEM was performed in four patients. There were no major perioperative complications. Seven patients had minor complications. Final pathology revealed T1 carcinoma in five patients and T2 carcinoma in three patients. Re-TEM was performed in one patient with involved margins with adenoma. After a median follow-up of 64 months, one patient had local recurrence.

Conclusion

TEM is an acceptable technique for the treatment of large polyps with minor complications and a reasonable recurrence rate. TEM may be considered regardless of the size of the rectal polyp.

Prognosis of Patients Over 60 Years Old With Early Rectal Cancer Undergoing Transanal Endoscopic Microsurgery – A Single-Center Experience

Aim

Transanal endoscopic microsurgery (TEM) is widely performed in early rectal cancer. This technique offers greater organ preservation and decreases the risk of subsequent surgery. However, postoperative local recurrence and distant metastasis remain challenges for patients with high-risk pathological factors. This single-center study reports the prognosis of early rectal cancer patients over 60 years old after TEM.

Methods

The data of the patients over 60 years old who underwent local anal resection were collected retrospectively. Moreover, the 5-year follow-up data were analyzed to determine the 5-year DFS and OS.

Results

47 early rectal cancer patients over 60 years old underwent TEM. There were 27 patients with high-risk factors and 20 patients without high-risk factors. Two patients underwent radical surgery after TEM and ten patients received adjuvant treatment. Local recurrence occurred in 7 patients, of which 4 underwent salvage surgery. The 5-year progression-free survival rate was 75.6%, which was lower in the high-risk patients group (69.6%) than in the non-high-risk patients group (83.3%) (P&gt;0.05). The 5-year OS was 90.2%, but there was no statistically significant difference between the two groups (high-risk patients 87.0%, non-high-risk patients 94.4%). Furthermore, there was no significant difference in DFS and OS between people over and under 70 years old.

Conclusion

Some high-risk factor patients over 60 years old do not have inferior 5-year DFS and OS to the non-high-risk patients. TEM is an option for old patients with high surgical risks. Even if postoperative pathology revealed high-risk factors, timely surgical treatment after local recurrence would be beneficial to improve the 5-year DFS and OS.

Completion Total Mesorectal Excision After Transanal Local Excision of Early Rectal Cancer: A Systematic Review and Meta-analysis

BACKGROUND

Completion total mesorectal excision is recommended when local excision of early rectal cancers demonstrates high-risk histopathological features. Concerns regarding the quality of completion resections and the impact on oncological safety remain unanswered.

OBJECTIVE

This study aims to summarize and analyze the outcomes associated with completion surgery and undertake a comparative analysis with primary rectal resections.

DATA SOURCES

Data sources included PubMed, Cochrane library, MEDLINE, and Embase databases up to April 2021.

STUDY SELECTION

All studies reporting any outcome of completion surgery after transanal local excision of an early rectal cancer were selected. Case reports, studies of benign lesions, and studies using flexible endoscopic techniques were not included.

INTERVENTION

The intervention was completion total mesorectal excision after transanal local excision of early rectal cancers.

MAIN OUTCOME MEASURES

Primary outcome measures included histopathological and long-term oncological outcomes of completion total mesorectal excision. Secondary outcome measures included short-term perioperative outcomes.

RESULTS

Twenty-three studies including 646 patients met the eligibility criteria, and 8 studies were included in the meta-analyses. Patients undergoing completion surgery have longer operative times (standardized mean difference, 0.49; 95% CI, 0.23-0.75; p = 0.0002) and higher intraoperative blood loss (standardized mean difference, 0.25; 95% CI, 0.01-0.5; p = 0.04) compared with primary resections, but perioperative morbidity is comparable (risk ratio, 1.26; 95% CI, 0.98-1.62; p = 0.08). Completion surgery is associated with higher rates of incomplete mesorectal specimens (risk ratio, 3.06; 95% CI, 1.41-6.62; p = 0.005) and lower lymph node yields (standardized mean difference, -0.26; 95% CI, -0.47 to 0.06; p = 0.01). Comparative analysis on long-term outcomes is limited, but no evidence of inferior recurrence or survival rates is found.

LIMITATIONS

Only small retrospective cohort and case-control studies are published on this topic, with considerable heterogeneity limiting the effectiveness of meta-analysis.

CONCLUSIONS

This review provides the strongest evidence to date that completion surgery is associated with an inferior histopathological grade of the mesorectum and finds insufficient long-term results to satisfy concerns regarding oncological safety. International collaborative research is required to demonstrate noninferiority.

REGISTRATION NO

CRD42021245101.

Transanal Local Excision of Rectal Cancer after Neoadjuvant Chemoradiation: Is There a Place for It or Should Be Avoided at All Costs?

Tumor response to neoadjuvant chemoradiation (nCRT) with tumor downsizing and downstaging has significantly impacted the number of patients considered to be appropriate candidates for transanal local excision (TLE). Some patients may harbor small residual lesions, restricted to the bowel wall. These patients, who exhibit major response ("near-complete") by digital rectal examination, endoscopic assessment, and radiological assessment may be considered for this approach. Although TLE is associated with minimal postoperative morbidity, a few clinical consequences and oncological outcomes must be evaluated in advance and with caution. In the setting of nCRT, a higher risk for clinically relevant wound dehiscences leading to a considerable risk for readmission for pain management has been observed. Worse anorectal function (still better than after total mesorectal excision [TME]), worsening in the quality of TME specimen, and higher rates of abdominal resections (in cases requiring completion TME) have been reported. The exuberant scar observed in the area of TLE also represents a challenging finding during follow-up of these patients. Local excision should be probably restricted for patients with primary tumors located at or below the level of the anorectal ring (magnetic resonance defined). These patients are otherwise candidates for abdominal perineal resections or ultra-low anterior resections with coloanal anastomosis frequently requiring definitive stomas or considerably poor anorectal function.

Rectal Sparing Approach After Neoadjuvant Therapy in Patients with Rectal Cancer: The Preliminary Results of the ReSARCh Trial

BACKGROUND

Rectum-preservation for locally advanced rectal cancer has been proposed as an alternative to total mesorectal excision (TME) in patients with major (mCR) or complete clinical response (cCR) after neoadjuvant therapy. The purpose of this study was to report on the short-term outcomes of ReSARCh (Rectal Sparing Approach after preoperative Radio- and/or Chemotherapy) trial, which is a prospective, multicenter, observational trial that investigated the role of transanal local excision (LE) and watch-and-wait (WW) as integrated approaches after neoadjuvant therapy for rectal cancer.

METHODS

Patients with mid-low rectal cancer who achieved mCR or cCR after neoadjuvant therapy and were fit for major surgery were enrolled. Clinical response was evaluated at 8 and 12 weeks after completion of chemoradiotherapy. Treatment approach, incidence, and reasons for subsequent TME were recorded.

RESULTS

From 2016 to 2019, 160 patients were enrolled; mCR or cCR at 12 weeks was achieved in 64 and 96 of patients, respectively. Overall, 98 patients were managed with LE and 62 with WW. In the LE group, Clavien-Dindo 3+ complications occurred in three patients. The rate of cCR increased from 8- to 12-week restaging. Thirty-three (94.3%) of 35 patients with cCR had ypT0-1 tumor. At a median 24 months follow-up, a tumor regrowth was found in 15 (24.2%) patients undergoing WW.

CONCLUSIONS

LE for patients achieving cCR or mCR is safe. A 12-week interval from chemoradiotherapy completion to LE is correlated with an increased cCR rate. The risk of ypT > is reduced when LE is performed after cCR.

Early salvage total mesorectal excision (sTME) after organ preservation failure in rectal cancer does not worsen postoperative outcomes compared to primary TME: systematic review and meta-analysis

IMPORTANCE

While oncological outcomes of early salvage total mesorectal excision (sTME) after local excision (LE) have been well studied, the impact of LE before TME on postoperative outcomes remains unclear. We aimed to compare early sTME with a primary TME for rectal cancer.

METHODS

Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines with the random-effects model were adopted using Review Manager Version 5.3 for pooled estimates.

RESULTS

We retrieved eleven relevant articles including 1728 patients (350 patients in the sTME group and 1438 patients in the TME group). There was no significant difference between the two groups in terms of mortality (OR = 0.90, 95%CI [0.21 to 3.77], p = 0.88), morbidity (OR = 1.19, 95%CI [0.59 to 2.38], p = 0.63), conversion to open surgery (OR = 1.34, 95%CI [0.61 to 2.94], p = 0.47), anastomotic leak (OR = 1.38, 95%CI [0.50 to 3.83], p = 0.53), hospital stay (MD = 0.23 day, 95%CI [- 1.63 to 2.10], p < 0.81), diverting stoma rate (OR = 0.69, 95%CI [0.44 to 1.09], p = 0.11), abdominoperineal resection rate (OR = 1.47, 95%CI [0.91 to 2.37], p = 0.11), local recurrence (OR = 0.94, 95%CI [0.44 to 2.04], p = 0.88), and distant recurrence (OR = 0.88, 95%CI [0.52 to 1.48], p = 0.62). sTME was associated with significantly longer operative time (MD = 25.62 min, 95%CI[11.92 to 39.32], p < 0.001) lower number of harvested lymph nodes (MD =  - 2.25 lymph node, 95%CI [- 3.86 to - 0.65], p = 0.006), and higher proportion of incomplete TME (OR = 0.25, 95%CI [0.11 to 0.61], p = 0.002).

CONCLUSIONS

sTME is not associated with increased postoperative morbidity, mortality, or local recurrence. However, the operative times are longer and yield a poor specimen quality.

Cost comparisons of endoscopic and surgical resection of stage T1 rectal cancer

Background and study aims  Management of T1 rectal cancer is complex and includes several resection methods, making cost comparisons challenging. The aim of this study was to compare costs of endoscopic and surgical resection and to investigate hypothetical cost scenarios for the treatment of T1 rectal cancer. Patients and methods  Retrospective population-based cost minimization study on prospectively collected data on T1 rectal cancer patients treated using endoscopic submucosal dissection (ESD), transanal endoscopic microsurgery (TEM), open, laparoscopic, or robotic resection, in Skåne County, Sweden (2011-2017). The hypothetical cost scenarios were based on the distribution of high-risk features of lymph node metastases in a national cohort (2009-2017). Results  Eighty-five patients with T1 RC undergoing ESD (n = 16), TEM (n = 17), open (n = 35), laparoscopic (n = 9), and robotic (n = 8) resection were included. ESD had a total 1-year cost of 5165 € and was significantly ( P  < 0.05) less expensive compared to TEM (14871€), open (21 453 €), laparoscopic (22 488 €) and robotic resection (26 562 €). Risk factors for lymph node metastases were seen in 68 % of 779 cases of T1 rectal cancers included in the national cohort. The hypothetical scenario of performing ESD on all T1 RC had the lowest total 1-year per patient cost compared to all other alternatives. Conclusions  This is the first study analyzing total 1-year costs of endoscopic and surgical methods to resect T1 rectal cancer, which showed that the cost of ESD was significantly lower compared to TEM and surgical resection. In fact, based on hypothetical cost scenarios, ESD is still justifiable from a cost perspective even when all high-risk cases are followed by surgery in accordance to guidelines.

Transanal endoscopic microsurgical submucosal dissection (TEM-ESD): A novel approach to the local treatment of early rectal cancer

BACKGROUND

Complete local resection is currently the treatment of choice for low-risk early rectal cancer; however, the ideal resection technique for such tumours is still debated. Transanal endoscopic microsurgical submucosal dissection (TEM-ESD) is a new technique which combines the ergonomic advantages of transanal endoscopic microsurgery (TEM) with the minimally invasive approach of endoscopic submucosal dissection (ESD). The aim of our study was to assess the feasibility, safety, and long-term outcomes of TEM-ESD in treating early rectal cancer.

MATERIALS AND METHODS

We retrospectively analysed all cases of rectal adenocarcinomas treated with TEM-ESD in Karlsruhe Municipal Hospital between 2012 and 2019, as well as the perioperative and follow-up data of the patients.

RESULTS

We identified 40 cases (19 low-risk and 21 high-risk carcinomas) matching our criteria. The median size of the lesions was 3.8 cm and the median operating time 48.5 min. En bloc resection was possible in all cases, while histologically complete resection was confirmed in 18 of 19 low-risk tumours and in 30 out of all lesions. The resection was curative in 19 cases. No scarring of the mesorectum was reported during the completion of total mesorectal excision for high-risk tumours. There was only 1 case of local recurrence among patients treated with curative intent, with an overall survival rate of 100% and a disease-free survival rate of 96% at both 2 and 5 years for these patients.

CONCLUSION

TEM-ESD is a safe and feasible therapeutic option for resecting early rectal cancer, offering very good long-term outcomes.

Transanal endoscopic microsurgical submucosal dissection: Are there advantages over conventional ESD?

INTRODUCTION

Transanal endoscopic microsurgical submucosal dissection (TEM-ESD) is a technique that has been recently described for the treatment of large rectal adenomas and early rectal cancer. The purpose of our study is to compare TEM-ESD with flexible endoscopic submucosal dissection (ESD) in an experimental, ex vivo porcine model.

MATERIAL AND METHODS

We used TEM-ESD and flexible ESD to resect a total of 100 standardized 4 × 4cm lesions in an ex vivo porcine stomach model, performing 50 resections with each technique. Total procedure time, en bloc resection rate, injuries of the muscularis propria, perforation rate and learning curve were analysed.

RESULTS

TEM-ESD was associated with a significantly shorter total procedure time in comparison to ESD (19 min vs. 33 min, p < .001). The rates of en bloc resection, injury of the muscularis propria layer, and perforation were the same in both groups. The learning curve of TEM-ESD was shallower than that of ESD.

CONCLUSION

TEM-ESD showed an advantage over ESD in terms of procedure time and learning curve, with similar en bloc resection rates and safety profile in our experimental model.

Long-term outcomes of patients with poor prognostic factors following transanal endoscopic microsurgery for early rectal cancer

AIM

Management of early rectal cancer following transanal microscopic anal surgery poses a management dilemma when the histopathology reveals poor prognostic features, due to high risk of local recurrence. The aim of this study is to evaluate the oncological outcomes of such patients who undergo surgery with total mesorectal excision (TME), receive adjuvant chemo/radiotherapy (CRDT/RT) or receive close surveillance only (no further treatment).

METHODS

We identified patients with poor prognostic factors-pT2 adenocarcinoma, poor differentiation, deep submucosal invasion (Kikuchi SM3), lymphovascular invasion, tumour budding or R1 resection margin-between 1 September 2012 and 31 January 2020 and report their oncological outcomes.

RESULTS

Of the 53 patients, 18 had TME, 14 had CRDT and 14 had RT; seven patients did not have any further treatment. The median follow-up was 48 months, 12 developed recurrence and six died. Overall, 5-year survival (OS) was 88.9% and disease-free survival (DFS) was 79.2%. Compared to the surgical group, in which there were eight recurrences and two deaths, there were zero recurrences or deaths in the CRDT group, log-rank test P = 0.206 for OS and P = 0.005 for DFS. The 5-year survival rates in the RT and surveillance only groups were OS 78.6%, DFS 85.7% and OS 71.5%, DFS 71% respectively. TME assessment in the surgical group revealed Grade 3 quality in seven of the 16 available reports.

CONCLUSION

These findings support the strategy of adjuvant CRDT as first line treatment for patients undergoing transanal endoscopic microsurgery for early rectal cancer with poor prognostic factors on initial histological assessment.

The impact of transanal local excision of early rectal cancer on completion rectal resection without neoadjuvant chemoradiotherapy: a systematic review

BACKGROUND

The impact of transanal local excision (TAE) of early rectal cancer (ERC) on subsequent completion rectal resection (CRR) for unfavorable histology or margin involvement is unclear. The aim of this study was to provide a comprehensive review of the literature on the impact of TAE on CRR in patients without neoadjuvant chemoradiotherapy (CRT).

METHODS

We performed a systematic review of the literature up to March 2020. Medline and Cochrane libraries were searched for studies reporting outcomes of CRR after TAE for ERC. We excluded patients who had neoadjuvant CRT and endoscopic local excision. Surgical, functional, pathological and oncological outcomes were assessed. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed.

RESULTS

Sixteen studies involving 353 patients were included. Pathology following TAE was as follows T0 = 2 (0.5%); T1 = 154 (44.7%); T2 = 142 (41.2%); T3 = 43 (12.5%); Tx = 3 (0.8%); T not reported = 9. Fifty-three percent were > T1. Abdominoperineal resection (APR) was performed in 80 (23.2%) patients. Postoperative major morbidity and mortality occurred in 22 (11.4%) and 3 (1.1%), patients, respectively. An incomplete mesorectal fascia resulting in defects of the mesorectum was reported in 30 (24.6%) cases. Thirteen (12%) patients developed recurrence: 8 (3.1%) local, 19 (7.3%) distant, 4 (1.5%) local and distant. The 5-year cancer-specific survival was 92%. Only 1 study assessed anal function reporting no continence disorders in 11 patients. In the meta-analysis, CRR after TAE showed an increased APR rate (OR 5.25; 95% CI 1.27-21.8; p 0.020) and incomplete mesorectum rate (OR 3.48; 95% CI 1.32-9.19; p 0.010) compared to primary total mesorectal excision (TME). Two case matched studies reported no difference in recurrence rate and disease free survival respectively.

CONCLUSIONS

The data are incomplete and of low quality. There was a tendency towards an increased risk of APR and poor specimen quality. It is necessary to improve the accuracy of preoperative staging of malignant rectal tumors in patients scheduled for TAE.

Management of Low Rectal Cancer Complicating Ulcerative Colitis: Proposal of a Treatment Algorithm

Simple Summary

This article expresses the viewpoint of the authors’ management of low rectal cancer in ulcerative colitis (UC). This subject suffers from a paucity of literature and therefore management decision is very difficult to take. The aim of this paper is to provide a structured approach to a challenging situation. It is subdivided into two parts: a first part where the existing literature is reviewed critically, and a second part in which, on the basis of the literature review and their extensive clinical experience, a management algorithm is proposed by the authors to offer guidance to surgical and oncological practices. This text adds to the literature a useful guide for the treatment of these complex clinical scenarios.

Abstract

Low rectal Carcinoma arising at the background of Ulcerative Colitis poses significant management challenges to the clinicians. The complex decision-making requires discussion at the multidisciplinary team meeting. The published literature is scarce, and there are significant variations in the management of such patients. We reviewed treatment protocols and operative strategies; with the aim of providing a practical framework for the management of low rectal cancer complicating UC. A practical treatment algorithm is proposed.

Rectal cancer: Watch-and-wait and continuing the rectal-preserving strategy with local excision for incomplete response or limited regrowth

BACKGROUND

Deferral of conventional surgery for rectal cancer after neo-adjuvant chemo-radiotherapy is gaining increasing interest, particularly for patients who are too frail to undergo major surgery but also those who wish to avoid the adverse effects of major surgery. We elected to undertake a pragmatic approach to include all comers in a cohort with the aim of reflecting the clinical outcomes for patients on a deferral from conventional rectal surgery pathway, treated with neo-adjuvant chemo-radiation (CRT) with or without selective local excision (LE) offered to those who failed to demonstrate a complete clinical response (cCR).

METHODS

Rectal cancer patients treated with neo-adjuvant CRT were stratified to a group of complete responders to CRT on a "watch and wait" (WW) pathway and a group who were treated with an additional local excision for persistent tumour.

RESULTS

Regrowth was noted in 26% (11/42) in the WW group after 2 years surveillance, disease free survival was 94.5% (80-99%) at 1 year and 74.9% (44-76.4%) at 3 years. Recurrence was noted in 45% (10/22) in the CRT + LE group, disease free survival at 1 and 3 years was 74% (53.4-88.1) and 66.2% (45.6-82.4) respectively.

CONCLUSION

A WW strategy for cCR is a viable pathway in the non-operative management of rectal cancer. We found the use of CRT + LE is a useful option for those who hope to avoid surgery but caution should be exercised due to substantially higher risk of recurrence.

Completion total mesorectal excision following transanal endoscopic microsurgery does not compromise outcomes in patients with rectal cancer

BACKGROUND

Transanal endoscopic microsurgery (TEM) represents a choice of treatment in patients with neoplastic lesions in the rectum. When TEM fails, completion total mesorectal excision (cTME) is often required. However, a concern is whether cTME increases the rate of abdominoperineal resections (APR) and is associated with higher risk of incomplete mesorectal fascia (MRF) resection. The aim of this study was to compare outcomes of cTME with primary TME (pTME) in patients with rectal cancer.

METHODS

This was a nationwide study on all patients with cTME from the Danish Colorectal Cancer Group database between 2005 and 2015. Patients with cTME were compared to patients with pTME after propensity score matching (matching ratio 1:2). Matching variables were age, gender, tumor distance from anal verge, American Society of Anesthesiologists (ASA) score and American Joint Committee on Cancer (AJCC) stage.

RESULTS

A total of 60 patients with cTME were compared with 120 patients with pTME. Patients with cTME experienced more intraoperative complications as compared to pTME patients (18.3% vs. 6.7%, p = 0.021). However, there was no difference in the rate of perforations at or near the tumor/previous TEM site (6.7% vs. 2.5%, p = 0.224), conversion to open surgery (p = 0.733) or 30-day morbidity (p = 0.86). On multivariate analysis, cTME was not a risk factor for APR (OR 2.49; 95% CI 0.95-6.56; p = 0.064) or incomplete MRF (OR 1.32; 95% CI 0.48-3.63; p = 0.596). There was no difference in the rate of local recurrence between cTME and pTME (5.2% vs. 4.3%, p = 0.1), distant metastases (6.8% vs. 6.8%, p = 1), or survival (p = 0.081). The mean follow-up time was 6 years.

CONCLUSION

In our study, the largest so far on the subject, we find no difference in postoperative short- or long-term outcomes between cTME and pTME.

Completion Surgery in Unfavorable Rectal Cancer after Transanal Endoscopic Microsurgery: Does It Achieve Satisfactory Sphincter Preservation, Quality of Total Mesorectal Excision Specimen, and Long-term Oncological Outcomes?

BACKGROUND

Unfavorable adenocarcinoma after transanal endoscopic microsurgery requires "completion surgery" with total mesorectal excision. The literature on this procedure is very limited.

OBJECTIVE

This study aims to assess the percentage of transanal endoscopic microsurgery that will require completion surgery.

DESIGN

This is an observational study with prospective data collection and retrospective analysis from patients who were operated on consecutively.

SETTINGS

The study was conducted at a single academic institution.

PATIENTS

Patients undergoing transanal endoscopic microsurgery from June 2004 to December 2018 who later required total mesorectal excision were included.

MAIN OUTCOME MEASURES

All the patients followed the same protocol: preoperative study, indication of transanal endoscopic microsurgery with curative intent, performance of transanal endoscopic microsurgery, and completion surgery indication 3 to 4 weeks after transanal endoscopic microsurgery.

RESULTS

Seven hundred seventy-four patients underwent transanal endoscopic microsurgery, 622 with curative intent (group I: adenoma, 517; group II: adenocarcinoma, 105). Completion surgery was indicated in 64 of 622 (10.3%) patients: group I, 40 of 517 (7.7%) and group II, 24 of 105 (22.9%). After applying exclusion criteria, completion surgery was performed in 55 patients (8.8%). Abdominoperineal resection was performed in 23 (45.1%); the initial lesion was within 6 cm of the anal verge in 19 of these 23 (82.6%). The clinical morbidity rate (Clavien Dindo> II) was 3 of 51 (5.9%). Total mesorectal excision was graded as complete in 42 of 49 (85.7%). The circumferential resection margin was tumor-free in 47 of 50 (94%). Median follow-up was 58 months. Local recurrence was recorded in 2 of 51 (3.9%) and systemic recurrence was recorded in 7 of 51 (13.7%); 5-year disease-free survival was 86%.

LIMITATIONS

The limitations are defined by the study's observational design and the retrospective analysis.

CONCLUSION

The indication of completion surgery after transanal endoscopic microsurgery is low, but is higher in the indication of adenocarcinoma. Compared with initial total mesorectal excision, completion surgery requires a higher rate of abdominoperineal resection, but has similar postoperative morbidity, total mesorectal excision quality, and oncological results. See Video Abstract at http://links.lww.com/DCR/B423.

CIRUGA COMPLEMENTARIA EN CNCER DE RECTO DESFAVORABLE DESPUS DE UNA TEM SE OBTIENE SATISFACTORIAMENTE PRESERVACIN DEL ESFNTER, CALIDAD DE MUESTRA DE ETM Y RESULTADOS ONCOLGICOS A LARGO PLAZO

ANTECEDENTES:El adenocarcinoma con evolución desfavorable luego de una de microcirugía endoscópica transanal (TEM) requiere "cirugía de finalización" con la excisión total del mesorecto. La literatura sobre este procedimiento es muy limitada.OBJETIVO:Evaluar el porcentaje de microcirugía endoscópica transanal que requerió cirugía completa.DISEÑO:Estudio observacional con recolección prospectiva de datos y análisis retrospectivo de pacientes operados consecutivamente.AJUSTES:El estudio se realizó en una sola institución académica.PACIENTES:Aquellos pacientes sometidos a microcirugía endoscópica transanal desde junio de 2004 hasta diciembre de 2018 que luego requirieron excisón toztal del mesorecto.PRINCIPALES MEDIDAS DE RESULTADO:Todos los pacientes siguieron el mismo protocolo: estudio preoperatorio, indicación de microcirugía endoscópica transanal con intención curativa, realización de microcirugía endoscópica transanal e indicación de cirugía complementaria 3-4 semanas después de la microcirugía endoscópica transanal.RESULTADOS:Setecientos setenta y cuatro pacientes fueron sometidos a microcirugía endoscópica transanal, 622 con intención curativa (grupo I, adenoma: 517, grupo II, adenocarcinoma: 105). la cirugía complementaria fué indicada en 64/622 (10.3%), grupo I: 40/517 (7.7%) y grupo II 24/105 (22.9%). Después de aplicar los criterios de exclusión, la cirugía complementaria se realizó en 55 pacientes (8,8%). La resección abdominoperineal fué realizada en 23 (45,1%); en 19 de estos casos 23 (82,6%) la lesión inicial se encontraba dentro los 6 cm del margen anal. La tasa de morbilidad clínica (Clavien-Dindo > II) fue de 3/51 (5,9%). La excisión total del mesorecto se calificó como completa en 42/49 (85,7%). El margen de resección circunferencial se encontraba libre de tumor en 47/50 (94%). La mediana de seguimiento fue de 58 meses. La recurrencia local se registró en 2/51 (3.9%) y la recurrencia sistémica en 7/51 (13.7%); La supervivencia libre de enfermedad a 5 años fue del 86%.LIMITACIONES:Todas definidas por el diseño observacional y el análisis retrospectivo del mismo.CONCLUSIÓN:La indicación de completar la cirugía después de una TEM es baja, pero es más alta cuando la indicación es por adenocarcinoma. En comparación con la excisión total del mesorecto inicial, la cirugía complementaria requiere una tasa más alta de resección abdominoperineal, pero tiene una morbilidad postoperatoria, una calidad de excisión total del mesorecto y resultados oncológicos similares. ConsulteVideo Resumen en http://links.lww.com/DCR/B423. (Traducción-Dr. Xavier Delgadillo).

Early-rectal Cancer Treatment: A Decision-tree Making Based on Systematic Review and Meta-analysis

Local excision (LE) has arisen as an alternative to total mesorectal excision for the treatment of early rectal cancer. Despite a decreased morbidity, there are still concerns about LE outcomes. This systematic-review and meta-analysis design is based on the "PICO" process, aiming to answer to three questions related to LE as primary treatment for early-rectal cancer, the optimal method for LE, and the potential role for completion treatment in high-risk histology tumors and outcomes of salvage surgery. The results revealed that reported overall survival (OS) and disease-specific survival (DSS) were 71%-91.7% and 80%-94% for LE, in contrast to 92.3%-94.3% and 94.4%-97% for radical surgery. Additional analysis of National Database studies revealed lower OS with LE (HR: 1.26; 95%CI, 1.09-1.45) and DSS (HR: 1.19; 95%CI, 1.01-1.41) after LE. Furthermore, patients receiving LE were significantly more prone develop local recurrence (RR: 3.44, 95%CI, 2.50-4.74). Analysis of available transanal surgical platforms was performed, finding no significant differences among them but reduced local recurrence compared to traditional transanal LE (OR:0.24;95%CI, 0.15-0.4). Finally, we found poor survival outcomes for patients undergoing salvage surgery, favoring completion treatment (chemoradiotherapy or surgery) when high-risk histology is present. In conclusion, LE could be considered adequate provided a full-thickness specimen can be achieved that the patient is informed about risk for potential requirement of completion treatment. Early-rectal cancer cases should be discussed in a multidisciplinary team, and patient's preferences must be considered in the decision-making process.

Outcomes of completion total mesorectal excision are not compromised by prior transanal minimally invasive surgery

AIM

Transanal minimally invasive surgery (TAMIS) is used increasingly often as an organ-preserving treatment for early rectal cancer. If final pathology reveals unfavourable histological prognostic features, completion total mesorectal excision (cTME) is recommended. This study is the first to investigate the results of cTME after TAMIS.

METHOD

Data were retrieved from the prospective database of the Elisabeth-TweeSteden Hospital. Completion TME patients were case matched with a control group of patients undergoing primary TME (pTME). Primary and secondary outcomes were surgical outcomes and oncological outcomes, respectively.

RESULTS

From 2011 to 2017, 20 patients underwent cTME and were compared with 40 patients undergoing pTME. There were no significant differences in operating time (238 min vs 226 min, P = 0.53), blood loss (137 ml vs. 158 ml, P = 0.88) or complications (45% vs 55%, P = 0.07) between both groups. There was no 90-day mortality in the cTME group. The mesorectal fascia was incomplete in three patients (15%) in the cTME group compared with no breaches in the pTME group (P = 0.083). There were no local recurrences in either group. In three patients (15%), distant metastases were detected after cTME compared with one patient (2.5%) in the pTME group (P = 0.069). After cTME patients had a 1- and 5-year disease-free survival of 85% compared with 97.5% for the pTME group (P = 0.062).

CONCLUSION

Completion TME surgery after TAMIS is not associated with increased peri- or postoperative morbidity or mortality compared with pTME surgery. After cTME surgery patients have a similar disease-free and overall survival when compared with patients undergoing pTME.

Transanal endoscopic microsurgery for rectal villous tumours: Can we rely solely on preoperative biopsies and the surgeon’s experience?

Background

Transanal endoscopic microsurgery has become the standard of treatment for rectal villous adenomas. However, the role of preoperative imaging for these lesions is not clear. The aim of this study was to compare the value of preoperative imaging and surgeon clinical staging in the preoperative evaluation of patients with rectal villous adenomas having transanal endoscopic microsurgery resection.

Methods

We conducted a single-centre comparative retrospective cohort study of patients who underwent transanal endoscopic microsurgery surgery for rectal villous adenomas from 2011 to 2013. The intervention was preoperative imaging versus surgeon clinical staging. The primary outcome was the accuracy of clinical staging by preoperative imaging and surgeon clinical staging according to the histopathologic staging.

Results

A total of 146 patients underwent transanal endoscopic microsurgery surgery for rectal villous adenomas. One hundred and twelve (76.7%) of those patients had no preoperative imaging while 34 patients (23.3%) had either endorectal ultrasound (22 patients) or magnetic resonance imaging (12 patients). Surgeon staging was accurate in 89.3% of cases whereas staging by endorectal ultrasound was accurate in 40.9% cases and magnetic resonance imaging was accurate in 0% of cases. In the imaging group, inaccurate staging would have led to unnecessary radical surgery in 44.0% of patients.

Conclusion

This study was subject to selection bias because of its retrospective nature and the limited number of patients with imaging. Patients with rectal villous tumours without invasive carcinoma on biopsies and without malignant characteristics on appearance in the judgment of an experienced colorectal surgeon might not benefit from preoperative imaging before undergoing transanal endoscopic microsurgery procedures.

Organ Preservation in cT2N0 Rectal Cancer After Neoadjuvant Chemoradiation Therapy: The Impact of Radiation Therapy Dose-escalation and Consolidation Chemotherapy

OBJECTIVE

To demonstrate the difference in organ-preservation rates and avoidance of definitive surgery among cT2N0 rectal cancer patients undergoing 2 different chemoradiation (CRT) regimens.

BACKGROUND

Patients with cT2N0 rectal cancer are more likely to develop complete response to neoadjuvant CRT. Organ preservation has been considered an alternative treatment strategy for selected patients. Radiation dose-escalation and consolidation chemotherapy have been associated with increased rates of response and may improve chances of organ preservation among these patients.

METHODS

Patients with distal and nonmetastatic cT2N0 rectal cancer managed by neoadjuvant CRT were retrospectively reviewed. Patients undergoing standard CRT (50.4 Gy and 2 cycles of 5-FU-based chemotherapy) were compared with those undergoing extended CRT (54 Gy and 6 cycles of 5-FU-based chemotherapy). Patients were assessed for tumor response at 8 to 10 weeks. Patients with complete clinical response (cCR) underwent organ-preservation strategy ("Watch and Wait"). Patients were referred to salvage surgery in the event of local recurrence during follow-up.

RESULTS

Thirty-five patients underwent standard and 46 patients extended CRT. Patients undergoing extended CRT were more likely to undergo organ preservation and avoid definitive surgical resection at 5years (67% vs 30%; P = 0.001). After development of a cCR, surgery-free survival is similar between extended and standard CRT groups at 5 years (78% vs 56%; P = 0.12).

CONCLUSIONS

Dose-escalation and consolidation chemotherapy leads to increased long-term organ-preservation rates among cT2N0 rectal cancer. After achievement of a cCR, the risk for local recurrence and need for salvage surgery is similar, irrespective of the CRT regimen.

Local excision followed by early radical surgery in rectal cancer: long-term outcome

Background

In rectal cancers, radical surgery should follow local excisions, in cases of unexpected, unfavorable tumor characteristics. The oncological results of this completion surgery are inconsistent.

This retrospective cohort study assessed the clinical and long-term oncological outcomes of patients that underwent completion surgery to clarify whether a local excision compromised the results of radical surgery.

Methods

Forty-six patients were included, and the reasons for completion surgery, intraoperative complications, residual tumors, local recurrences (LRs), distant metastases, and cancer-specific survival (CSS) were assessed. The results were compared to 583 patients that underwent primary surgery without adjuvant therapy, treated with a curative intention during the same time period.

Results

The median follow-up was 14.6 years. The reasons for undergoing completion surgery were positive resection margins (24%), high-risk cancer (30%), or both (46%). Intraoperative perforations occurred in 10/46 (22%) cases. Residual tumor in the rectal wall or lymph node involvement occurred in 12/46 (26%) cases. The risk of intraoperative perforation and residual tumor increased with the pT category. Intraoperative perforations did not increase postoperative complications, but they increased the risk of LRs in cases of intramural residual tumors (p = 0.003). LRs occurred in 2.6% of pT1/2 and 29% of pT3 tumors. Both the 5- and 10-year CSS rates were 88.8% (95% CI 80.0–98.6). Moreover, the LRs of patients with pT1/2 cancers were lower in patients with completion surgery than in patients with primary surgery.

Conclusions

Rectal wall perforations at the local excision site and residual cancer were the main risks for poor oncological outcomes associated with completion surgery. Local excisions followed by early radical surgery did not appear to compromise outcomes compared to patients with primary surgery for pT1/2 rectal cancer. Improvements in clinical staging should allow more appropriate selection of patients that are eligible for a local excision of rectal cancer.

Transanal Minimally Invasive Surgery for Local Excision of Benign and Malignant Rectal Neoplasia: Outcomes From 200 Consecutive Cases With Midterm Follow Up

OBJECTIVE

This study describes the outcomes for 200 consecutive transanal minimally invasive surgery (TAMIS) local excision (LE) for rectal neoplasia.

BACKGROUND

TAMIS is an advanced transanal platform that can result in high quality LE of rectal neoplasia.

METHODS

Consecutive patients from July 1, 2009 to December 31, 2015 from a prospective institutional registry were analyzed. Indication for TAMIS LE was endoscopically unresectable benign lesions or histologically favorable early rectal cancers. The primary endpoints were resection quality, neoplasia recurrence, and oncologic outcomes. Kaplan-Meier survival analyses were used to describe disease-free survival (DFS) for patients with rectal adenocarcinoma that did not receive immediate salvage radical surgery.

RESULTS

There were 200 elective TAMIS LE procedures performed in 196 patients for 90 benign and 110 malignant lesions. Overall, a 7% margin positivity and 5% fragmentation rate was observed. The mean operative time for TAMIS was 69.5 minutes (SD 37.9). Postoperative morbidity was recorded in 11% of patients, with hemorrhage (9%), urinary retention (4%), and scrotal or subcutaneous emphysema (3%) being the most common. The mean follow up was 14.4 months (SD 17.4). Local recurrence occurred in 6%, and distant organ metastasis was noted in 2%. Mean time to local recurrence for malignancy was 16.9 months (SD 13.2). Cumulative DFS for patients with rectal adenocarcinoma was 96%, 93%, and 84% at 1-, 2-, and 3-years.

CONCLUSIONS

For carefully selected patients, TAMIS for local excision of rectal neoplasia is a valid option with low morbidity that maintains the advantages of organ preservation.

Does transanal local resection increase morbidity for subsequent total mesorectal excision for early rectal cancer?

AIM

Local excision is recommended for early rectal cancer (pT1). Complementary total mesorectal excision (cTME) is warranted when bad pathological features are present. The impact of a prior local resection on the outcome remains unclear. The aim of this study was to assess if prior local excision increases the morbidity of a subsequent cTME compared with primary TME.

METHODS

From 2001 to 2016 all patients who underwent TME after local excision for rectal adenocarcinoma were studied. All were matched (1:1) with patients who underwent primary TME, without neoadjuvant radiochemotherapy. The matching factors included age, sex, body mass index, American Society of Anesthesiologists score and type of surgery. Short-term morbidity and pathological examination of the resected specimen were compared.

RESULTS

Forty-one patients were included (14 women, 34%, mean age 65 ± 11 years), comprising classic transanal excision (66%) and transanal endoscopic microsurgery (34%), and were matched to 41 patients who had primary TME. cTME was significantly longer (315 min ± 87 vs 275 min ± 58, P = 0.03). The overall morbidity was 48.8% in the local excision group vs 31.7% in the control group (P = 0.18). Surgical morbidity was 31.7% vs 26.8% (P = 0.8). Anastomotic related morbidity was similar (local excision 17% vs TME 14.6%, P = 0.84) and the mean length of stay was similar (14 days) in both groups. There was a tendency to a worse quality of mesorectal excision in the cTME group (17% vs 5%, P = 0.15).

CONCLUSION

Local excision prior to TME for early rectal cancer tends to increase overall morbidity and may worsen the quality of the mesorectal plane but should be considered as a surgical approach in select cases.

Short-term outcomes of transanal completion total mesorectal excision (cTaTME) for rectal cancer: a case-matched analysis

BACKGROUND

Local excision of early rectal tumors as a rectal preserving treatment is gaining popularity, especially since bowel cancer screening programs result in a shift towards the diagnosis of early stage rectal cancers. However, unfavorable histological features predicting high risk for recurrence within the "big biopsy" may mandate completion total mesorectal excision (cTME). Completion surgery is associated with higher morbidity, poorer specimen quality, and less favorable oncological outcomes compared to primary TME. Transanal approach potentially improves outcome of completion surgery for rectal cancer. The aim of this study was to compare radical completion surgery after local excision for rectal cancer by the transanal approach (cTaTME) with conventional abdominal approach (cTME).

METHODS

All consecutive patients who underwent cTaTME for rectal cancer between 2012 and 2017 were case-matched with cTME patients, according to gender, tumor height, preoperative radiotherapy, and tumor stage. Surgical, pathological, and short-term postoperative outcomes were evaluated.

RESULTS

In total, 25 patients underwent completion TaTME and were matched with 25 patients after cTME. Median time from local excision to completion surgery was 9 weeks in both groups. In the cTaTME and cTME groups, perforation of the rectum occurred in 4 and 28% of patients, respectively (p = 0.049), leading to poor specimen quality in these patients. Number of harvested lymph nodes was higher after cTaTME (median 15; range 7-47) than after cTME (median 10; range 0-17). No significant difference was found in end colostomy rate between the two groups. Major 30-day morbidity (Clavien-Dindo≥ III) was 20 and 32%, respectively (p = 0.321). Hospital stay was significantly longer after cTME.

CONCLUSION

TaTME after full-thickness excision is a promising technique with a significantly lower risk of perforation of the rectum and better specimen quality compared to conventional completion TME.

Is Previous Transanal Endoscopic Microsurgery for Early Rectal Cancer a Risk Factor of Worse Outcome following Salvage Surgery A Case-Matched Analysis

Introduction

Transanal endoscopic microsurgery (TEM) is a minimally invasive procedure which allows local excision of early-stage rectal cancer and can be used as an alternative treatment to radical surgery. Patients can undergo salvage total mesorectal excision (sTME) following TEM after finding of unfavourable histological features. This study aimed to compare results and possible complications of sTME following TEM and primary TME (pTME) procedures.

Methods

Between 2010 and 2017, early sTME was performed in 9 patients at the National Cancer Institute in Vilnius, Lithuania. These patients were compared with 18 patients who underwent pTME, matched according to gender, age, cancer stage, and operative procedure. Data were obtained from the patients' charts and reviewed prospectively. We recorded the demographics, tumour specifications, treatment, operation time, postoperative results complications, and oncological outcome. Fisher's exact test and student's T test was used to compare both groups.

Results

A total of 130 patients underwent TEM at our institution during the study period, of which 9 (6.92%) had to undergo sTME. The average age of the patients was 62.7 ± 7.07 years; 44.4% of the patients were male and 55.6% female. The average tumour size in the sTME group was 2.8 ± 1.05 cm (range 1.5-5) and 2.61 ± 1.36 cm (range 1-5) in the pTME group (p = 0.696). When comparing postoperative complications, statistically significant results were not found in either of the groups (p = 0.55). Operation time of pTME was significantly shorter on average, i.e. 43 min, compared to sTME (p < 0.0267). The average number of harvested lymph nodes was 12.44 ± 7.126 in the sTME and 12.5 ± 8.06 in the pTME group (p = 0.986). The circumferential resection margin (CRM) was negative in 92.6% (25/27) of specimens, while the CRM was positive in 2 cases (7.4%), both of which were from the sTME group. The average follow-up time was 22.8 months (8-80 months) for patients undergoing sTME and 19.33 months (2-88 months) for patients after pTME (p = 0.71).

Conclusions

TEM is a relatively safe method for treating patients with early rectal cancer without high-risk features. It can be used in exceptional cases with high-risk features when the patient is not fit for radical surgery.

Salvage TME following TEM: a possible indication for TaTME

BACKGROUND

Salvage surgery after transanal endoscopic microsurgery (TEM) has shown mixed results. Transanal total mesorectal excision (TaTME) might be advantageous in this population. The aim of this study was to assess the short-term oncologic and operative outcomes of salvage surgery after TEM, comparing TaTME to conventional salavge TME (sTME).

METHODS

Consecutive patients treated with salvage surgery after TEM were identified. Patients who underwent TaTME were compared to those who had conventional sTME. The primary outcome was the ability to perform an appropriate oncologic procedure defined by a composite outcome (negative distal margins, negative radial margins and complete or near complete mesorectum specimen).

RESULTS

During the study period, 41 patients had salvage surgery after TEM. Of those, 11 patients had TaTME while 30 patients had sTME. All patients in the TaTME group met the composite outcome of appropriate oncologic procedure compared to 76.7% for the conventional sTME group (p = 0.19). TaTME was associated with significantly higher rates of sphincter preservation (100 vs. 50%, p = 0.01), higher rates of laparoscopic surgery (100 vs. 23.3%, p < 0.001) and lower rates of conversion to open surgery (9.1 vs. 57%, p < 0.001). No difference was found in postoperative morbidity (36.3 vs. 36.7%, p = 0.77).

CONCLUSIONS

The present study demonstrates that for patients requiring salvage surgery after TEM, TaTME is associated with significantly higher rates of sphincter-sparing surgery when compared to conventional transabdominal TME while producing adequate short-term oncologic outcomes. Salvage surgery after TEM might be a clear indication for TaTME rather than conventional surgery.

Laparoscopic Total Mesorectal Excision Following Transanal Endoscopic Microsurgery for Rectal Cancer

BACKGROUND

Patients' selection for transanal endoscopic microsurgery (TEM) depends on diagnostic modalities; however, there are still some limitations in the preoperative diagnosis of rectal lesions, and in some reports, up to third of the adenomas resected by TEM were found to be adenocarcinoma; therefore, salvage radical resection (RR) remains necessary for achieving oncological resection. Salvage RR may encounter some technical problems as the violation of the mesorectum and the scar formation. In this study, we aimed to report the outcome in patients undergoing salvage RR in terms of morbidity and oncological results.

MATERIALS AND METHODS

Demographic and clinical data pertaining to patients undergoing RR following TEM between 2004 and 2014 were retrospectively collected.

RESULTS

One hundred forty one TEM were performed in the study period, 53 (38%) for malignant rectal lesions. Indication for TEM: 15 (28%) benign adenoma, 25 (47%) early rectal cancer, and 13 (25%) had clinical complete response after neoadjuvant radiochemotherapy. Ten (19%) patients had no residual tumor in TEM specimen, 15 (28%) had T1, and 2 of them underwent salvage low anterior resection (LAR). Ten (19%) had T2, 4 had LAR, and 1 had abdominoperineal resection (APR). Five (9%) had a T3, 3 underwent LAR, and 2 had APR. Among the 13 (25%) after chemo-radiotherapy (CRT), 4 had salvage AR. The time from TEM to RR was 47 days (range32-70). Of 16 salvage surgeries, 8 (50%) were laparoscopic. The median operative time was 210 minutes (range165-360). Five patients had protective ileostomy. Rectal perforation occurred in 2 (12%) patients; both had a posterior location, one after CRT. Two (12%) postoperative small-bowl obstruction and three wound infections occurred. There was no perioperative mortality in any of the patients who underwent RR. The final pathology was no residual disease in 9, T3N1 in 1, T3N0 in 3, T2N1 in 1, and T2N0 in 2 patients. Eight (50%) had adjuvant chemotherapy.

CONCLUSION

Laparoscopic total mesorectal excision following TEM seems to be safe, and with no negative impact of the completeness of the resection. The concern of intraoperative specimen perforation is real, and should be dealt with meticulous technique and careful dissection, particularly after CRT.

Does previous transanal excision for early rectal cancer impair surgical outcomes and pathologic findings of completion total mesorectal excision? Results of a systematic review of the literature

BACKGROUND

Transanal excision (TAE) is increasingly used in the treatment of early rectal cancer because of lower rate of both postoperative complications and postsurgical functional disorders as compared with total mesorectal excision (TME) OBJECTIVE: To compare in a meta-analysis surgical outcomes and pathologic findings between patients who underwent TAE followed by completion proctectomy with TME (TAE group) for early rectal cancer with unfavorable histology or incomplete resection, and those who underwent primary TME (TME group).

METHODS

The Medline and Cochrane Trials Register databases were searched for studies comparing short-term outcomes between patients who underwent TAE followed by completion TME versus primary TME. Studies published until December 2016 were included. The meta-analysis was performed using Review Manager 5.0 (Cochrane Collaboration, Oxford, UK).

RESULTS

Meta-analysis showed that completion TME after TAE was significantly associated with increased reintervention rate (OR=4.28; 95% CI, 1.10-16.76; P≤0.04) and incomplete mesorectal excision rate (OR=5.74; 95% CI, 2.24-14.75; P≤0.0003), as compared with primary TME. However there both abdominoperineal amputation and circumferential margin invasion rates were comparable between TAE and TME groups.

CONCLUSIONS

This meta-analysis suggests that previous TAE impaired significantly surgical outcomes and pathologic findings of completion TME as compared with primary TME. First transanal approach during completion TME might be evaluated in order to decrease technical difficulties.

Local Excision and Endoscopic Resections for Early Rectal Cancer

Radical surgery is considered as the standard treatment for rectal cancer. Transanal local excision has been considered an interesting alternative for the management of selected patients with rectal cancers for many decades. Different approaches had been considered for local excision, from endoscopic submucosal dissection to resections using platforms, such as transanal endoscopic microsurgery or transanal minimally invasive surgery. Identifying the ideal candidate for this approach is crucial, as a local failure after local excision is associated with poor outcomes, even for an initial early rectal tumor. In this article, the diagnostic tools and criteria to select patients for local excision, the different modalities used, and the outcomes are discussed.

The feasibility of laparoscopic rectal resection in patients undergoing reoperation after transanal endoscopic microsurgery (TEM)

BACKGROUND

The success of transanal endoscopic microsurgery (TEM) for early rectal cancer depends on proper indications and strict patient selection. When unfavorable pathologic features are identified after TEM operation, total mesorectal excision is recommended to minimize the risk of recurrence. In this study, data were collected in a retrospective series of patients to determine the results of laparoscopic reoperation after TEM.

METHODS

All patients underwent an accurate rectal-digital examination and clinical tumor staging by transanal endosonography, CT, and/or MRI. The histologic examination included an evaluation of the free margins, depth of tumor infiltration according to International Union Against Cancer guidelines, degree of tumor differentiation, and the presence of lymphovascular and perineural invasion. When a high-risk tumor was identified, reoperation was performed within 6 weeks from TEM. The patients were divided into two groups according to the procedure performed: laparoscopic anterior resection (LAR) or laparoscopic abdominal perineal amputation (LAPR).

RESULTS

Sixty-eight patients (5.3%) underwent reoperation: 38 underwent LAR and 30 underwent LAPR. The mean operative time was 148.24 min (± 35.8, p = 0.62). Meanwhile, the mean distance of the TEM scar from the anal verge differed statistically between the two groups (p = 0.003) and was statistically correlated with abdominal perineal amputation (p = 0.0001) in multivariate analysis. Conversion to open surgery was required in 6 patients (15.7%) in the LAR group and 3 patients (10%) in the LAPR group (p = 0.38). The histologic examination revealed residual cancer cells in 3 cases (3 pT2N0) and 1 case (1 pT3N0), respectively, and lymph node metastases in 4 cases. No residual neoplasms were detected in the remaining 60 cases (88.3%). After a mean follow-up of 108 months, the overall disease-free survival was 98% (95% CI 88-99%).

CONCLUSIONS

In our experience, reoperation after TEM using a laparoscopic approach is feasible and safe, with low conversion rates and optimal postoperative results.

New Strategies in Rectal Cancer

In recent years, our understanding of rectal cancer has improved, including how locally advanced disease responds to chemotherapy and radiation. This has led to new innovations and advances in the treatment of rectal cancer, which includes organ-preserving strategies for responsive disease, and minimally invasive approaces for the performance of total mesorectal excision/protectomyh for persistently advanced disease. This article discusses new strategies for rectal cancer therapy, including Watch and Wait, local excision, minimally invasive proctectomy, and transanal total mesorectal excision particularly in the setting of preoperative multimodality treatment.

Magnetic resonance imaging following neoadjuvant chemoradiation and transanal endoscopic microsurgery for rectal cancer

AIM

Full-thickness local excision after neoadjuvant chemoradiotherapy (CRT) for patients with rectal cancer and incomplete clinical response has been a treatment strategy for organ preservation. Follow-up of these patients is challenging since anatomic distortion and postoperative changes may be clinically indistinguishable from tumour recurrence. MRI may have a role in detecting recurrence. The aim of this study was to describe the MRI findings during follow-up in patients having local excision following CRT with and without local recurrence.

METHOD

The data were collected retrospectively from a single centre. Fifty-three patients with rectal cancer who had full-thickness local excision after neoadjuvant CRT and near-complete response were eligible for the study. Patients with local recurrence were treated by radical salvage surgery. The main outcome was local MRI assessment findings during follow-up.

RESULTS

Fifteen patients (five who developed local recurrence and 10 with no evidence of local recurrence) had MR images available for review and were included in the study. High signal intensity and thickening of the rectal wall were present in all patients with recurrent disease within the rectal wall. Overall, 80% of the patients with recurrence showed diffusion restriction. MRI mesorectal fascia status and circumferential resection margin showed agreement in all cases. A low signal intensity scar was seen in all patients without recurrent disease.

CONCLUSION

MRI shows high signal intensity and thickening of the rectal wall in recurrent disease in comparison to a low signal intensity fibrotic scar in non-recurrent disease. These findings may be useful in surveillance of these patients.

Hybrid transanal and total mesorectal excision after transanal endoscopic microsurgery for unfavourable early rectal cancer: a report of two cases

Completion total mesorectal excision (TME) is a rare but complex procedure after transanal endoscopic microsurgery for early rectal cancer with unfavourable final histology. Two cases are reported when completion TME was performed after upfront transanal partial mesorectal dissection. Intact non-perforated TME specimens with negative and adequate distal and circumferential margins were created. The quality of both total mesorectal excisions was complete and distal margins were sufficient. We believe that our technique might be a way of approaching completion TME after TEM, especially in cases of low rectal cancer.

Organ preservation with local excision or active surveillance following chemoradiotherapy for rectal cancer

BACKGROUND

Organ preservation has been proposed as an alternative to radical surgery for rectal cancer to reduce morbidity and mortality, and to improve functional outcome.

METHODS

Locally advanced non-metastatic rectal cancers were identified from a prospective database. Patients staged ⩾T3 or any stage N+ were referred for neoadjuvant chemoradiotherapy (CRT) (50-54 Gy and 5-fluorouracil), and were reassessed 6-8 weeks post treatment. An active surveillance programme ('watch and wait') was offered to patients who were found to have a complete endoluminal response. Transanal excision was performed in patients who were found to have an objective clinical response and in whom a residual ulcer measured ⩽3 cm. Patients were followed up clinically, endoscopically and radiologically to assess for local recurrence or disease progression.

RESULTS

Of 785 patients with rectal cancer between 2005 and 2015, 362 had non-metastatic locally advanced tumours treated with neoadjuvant CRT. Sixty out of three hundred and sixty-two (16.5%) patients were treated with organ-preserving strategies - 10 with 'watch and wait' and 50 by transanal excision. Fifteen patients were referred for salvage total mesorectal excision post local excision owing to adverse pathological findings. There was no significant difference in overall survival (85.6% vs 93.3%, P=0.414) or disease-free survival rate (78.3% vs 80%, P=0.846) when the outcomes of radical surgery were compared with organ preservation. Tumour regrowth occurred in 4 out of 45 (8.9%) patients who had organ preservation.

CONCLUSIONS

Organ preservation for locally advanced rectal cancer is feasible for selected patients who achieve an objective endoluminal response to neoadjuvant CRT. Transanal excision defines the pathological response and refines decision-making.

National Disparities in Surgical Approach to T1 Rectal Cancer and Impact on Outcomes

This study investigated disparities between patients who had local excision versus radical resection for T1 rectal cancer. A retrospective analysis was performed using the National Cancer Data Base, 2004 to 2011. Inclusion criteria consisted of patients with T1, N0 rectal adenocarcinoma that were <3 cm, well or moderately differentiated without perineural invasion. Patients were stratified based on local excision and radical surgery. The primary outcome was overall survival (OS). Secondary outcomes included 30-day mortality, unplanned readmission rates, and postoperative length of stay. A total of 2235 patients were identified; 1335 (59.7%) underwent local excision and 900 (40.3%) had radical surgery. Overall, radical surgery was associated with an improved 5-year OS rate compared to local excision (0.86 vs 0.78, P = 0.009), increased unplanned readmission (6.5% vs 2.7%, P < 0.001), and longer postoperative length of stay (6.9 days vs 3.1 days, P < 0.001). For patients who had local excision, insurance status was an independent predictor of OS. Compared to patients with private insurance, those with government plans or no insurance had poorer OS (hazard ratio = 1.77 and 17.45, respectively, P = 0.006). Further study is warranted to understand the reasons accounting for this disparity in surgical approach to T1 rectal cancer.