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Garoufalia Z, Rogers P, Meknarit S, Mavrantonis S, Aeschbacher P, Ray-Offor E, Emile SH, Gefen R, Dourado J, Horesh N, Wexner SD. Trans‑anal minimally invasive surgery (TAMIS) versus rigid platforms for local excision of early rectal cancer: a systematic review and meta-analysis of the literature. Surg Endosc 2024:10.1007/s00464-024-11065-6. [PMID: 39026004 DOI: 10.1007/s00464-024-11065-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 07/06/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Available platforms for local excision (LE) of early rectal cancer are rigid or flexible [trans‑anal minimally invasive surgery (TAMIS)]. We systematically searched the literature to compare outcomes between platforms. METHODS PRISMA-compliant search of PubMed and Scopus databases until September 2022 was undertaken in this random-effect meta-analysis. Statistical heterogeneity was assessed using I2 statistic. Studies comparing TAMIS versus rigid platforms for LE for early rectal cancer were included. Main outcome measures were intraoperative and short-term postoperative outcomes and specimen quality. RESULTS 7 studies were published between 2015 and 2022, including 931 patients (423 females); 402 underwent TAMIS and 529 underwent LE with rigid platforms. Techniques were similar for operative time (WMD 11.1, 95%CI - 2.6 to 25, p = 0.11), percentage of defect closure (OR 0.7, 95%CI 0.06-8.22, p = 0.78), and peritoneal violation (OR 0.41, 95%CI 0.12-1.43, p = 0.16). Rigid platforms had higher rates of short-term complications (19.1% vs 14.2, OR 1.6, 95%CI 1.07-2.4, p = 0.02), although no significant differences were seen for major complications (OR 1.41, 95%CI 0.61-3.23, p = 0.41). Patients in the rigid platforms group were 3-times more likely to be re-admitted within 30 days compared to the TAMIS group (OR 3.1, 95%CI 1.07-9.4, p = 0.03). Rates of positive resection margins (rigid platforms: 7.6% vs TAMIS: 9.34%, OR 0.81, 95%CI 0.42-1.55, p = 0.53) and specimen fragmentation (rigid platforms: 3.3% vs TAMIS: 4.4%, OR 0.74, 95%CI 0.33-1.64, p = 0.46) were similar between the groups. Salvage surgery was required in 5.5% of rigid platform patients and 6.2% of TAMIS patients (OR 0.8, 95%CI 0.4-1.8, p = 0.7). CONCLUSION TAMIS or rigid platforms for LE seem to have similar operative outcomes and specimen quality. The TAMIS group demonstrated lower readmission and overall complication rates but did not significantly differ for major complications. The choice of platform should be based on availability, cost, and surgeon's preference.
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Affiliation(s)
- Zoe Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - Peter Rogers
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | | | | | - Pauline Aeschbacher
- Department of General Surgery and Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, FL, USA
- Department for Visceral Surgery and Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Emeka Ray-Offor
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
- Department of Surgery, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria
| | - Sameh Hany Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura, Egypt
| | - Rachel Gefen
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
- Department of General Surgery, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Justin Dourado
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - Nir Horesh
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
- Department of Surgery and Transplantations, Sheba Medical Center, Ramat Gan, Israel
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA.
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Keller DS, Reif de Paula T, Ikner TP, Saidi H, Schoonyoung H, Marks G, Marks JH. Comparing advanced platforms for local excision of rectal lesions. Surg Endosc 2024; 38:3976-3983. [PMID: 38811430 DOI: 10.1007/s00464-024-10895-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 05/02/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Transanal surgery facilitates organ preservation in select patients with benign and early malignant rectal lesions to avoid the functional consequences of radical surgery. The transanal endoscopic microsurgery (TEM) platform created a standard for local excision with lower margin positivity and recurrence rates than traditional transanal excision. The single-port robot (SP r) presents a promising alternative transanal platform. The goal of this study was to compare perioperative and pathologic outcomes of TEM and SP r for excision of rectal lesions. METHODS A review of consecutive patients who underwent local excision of rectal lesions at a tertiary referral center from 1/2001 to 5/2022 was performed. Cases were stratified into TEM or SP rTAMIS in a 1:1 propensity score-matched cohort, adjusting for all baseline characteristics. Clinical, tumor-specific, and perioperative outcomes were compared using χ2, and Mann-Whitney U-tests. The main outcomes were oncologic quality measures, complications, and operative time. RESULTS Matching resulted 50 patients in each cohort. Groups had similar age, gender, body mass index, comorbidity, diagnosis, lesion characteristics, and neoadjuvant chemoradiation rates. There were no intraoperative complications in either cohort. Three SP rTAMIS cases were converted intraoperatively; there were no conversions in TEM. SP rTAMIS had significantly shorter operative times than TEM (mean 104 vs. 245, p = 0.027). The rates of positive distal margins (2% TEM, 0% SP rTAMIS) and piecemeal resection (4% TEM, 0% SP rTAMIS) were similar. SP rTAMIS had significantly lower postoperative morbidity rates than TEM (9% vs. 20%, p = 0.031). There was no mortality in either cohort. CONCLUSIONS SP robotics provided high-quality outcomes similar to TEM for local excision of rectal lesions. SP robotics had faster operative time with comparable clinical and oncologic outcomes to TEM. These early data are promising for expanding use of SP robotic platforms.
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Affiliation(s)
- Deborah S Keller
- Department of Surgery, Marks Colorectal Surgical Associates, Lankenau Medical Center, Lankenau Institute for Medical Research, Wynnewood, PA, 19096, USA
| | - Thais Reif de Paula
- Lankenau Medical Center, Lankenau Institute for Medical Research, Wynnewood, PA, 19096, USA
| | - Taylor P Ikner
- Lankenau Medical Center, Lankenau Institute for Medical Research, Wynnewood, PA, 19096, USA
| | - Hela Saidi
- Lankenau Medical Center, Lankenau Institute for Medical Research, Wynnewood, PA, 19096, USA
| | - Henry Schoonyoung
- Department of Surgery, Marks Colorectal Surgical Associates, Lankenau Medical Center, Lankenau Institute for Medical Research, Wynnewood, PA, 19096, USA
| | - Gerald Marks
- Department of Surgery, Marks Colorectal Surgical Associates, Lankenau Medical Center, Wynnewood, PA, 19096, USA
| | - John H Marks
- Department of Surgery, Marks Colorectal Surgical Associates, Lankenau Medical Center, Lankenau Institute for Medical Research, Wynnewood, PA, 19096, USA.
- Minimally Invasive Colorectal Surgical and Rectal Cancer Management Fellowship, Department of Surgery, Marks Colorectal Surgical Associates, Lankenau Medical Center, Lankenau Institute for Medical Research, Main Line Health, Medical Science Building, Suite 375, 100 East Lancaster Avenue, Wynnewood, PA, 19096, USA.
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Brunori A, Daca-Alvarez M, Pellisé M. pT1 colorectal cancer: A treatment dilemma. Best Pract Res Clin Gastroenterol 2023; 66:101854. [PMID: 37852711 DOI: 10.1016/j.bpg.2023.101854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 07/04/2023] [Accepted: 07/30/2023] [Indexed: 10/20/2023]
Abstract
The implementation of population screening programs for colorectal cancer (CRC) has led to a considerable increase in the prevalence pT1-CRC originating on polyps amenable by local treatments. However, a high proportion of patients are referred for unnecessary oncological surgeries without a clear benefit in terms of survival. Selecting the appropriate endoscopic resection technique in the moment of diagnosis becomes crucial to provide the best treatment alternative to each individual polyp and patient. For this, it is imperative to increase the optical diagnostic skill for differentiating pT1-CRCs and decide the appropriate initial therapy. En bloc resection is crucial to obtain an adequate histological specimen that might allow organ preserving therapeutic management. In this review, we address key challenges in T1 CRC management, explore the efficacy and safety of the available diagnostic and therapeutic approaches, and shed light on upcoming advances in the field.
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Affiliation(s)
- Angelo Brunori
- Gastroenterology and Digestive Endoscopy, Università degli Studi di Perugia, Italy
| | - Maria Daca-Alvarez
- Department of Gastroenterology Hospital Clinic de Barcelona, Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), Hospital Clinic of Barcelona, Centro de Investigación Biomédica en Red de EnfermedadesHepáticas y Digestivas (CIBERehd), Spain
| | - Maria Pellisé
- Department of Gastroenterology Hospital Clinic de Barcelona, Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), Hospital Clinic of Barcelona, Centro de InvestigaciónBiomé, dica en Red de EnfermedadesHepáticas y Digestivas (CIBERehd), Universitat de Barcelona, Barcelona, Spain.
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Theodoropoulos GE, Frountzas M, Karathanasis P, Doulami G, Michalopoulou V, Kimpizi D, Schizas D, Zografos GC. A Strict Patient Selection Protocol Could Be the Key to Success for Transanal Minimally Invasive Surgery (TAMIS). South Med J 2023; 116:490-495. [PMID: 37263612 DOI: 10.14423/smj.0000000000001570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVES In recent years, the local excision of benign rectal lesions or early-stage rectal cancers using minimally invasive surgical techniques has replaced radical interventions that caused impairment in patients' quality of life. The aim of the present study was to investigate the feasibility of transanal minimally invasive surgery (TAMIS), as well as its excision quality, its oncologic outcomes, and its impact on anorectal function. METHODS Patients who underwent TAMIS at a single colorectal unit of a tertiary university hospital from 2015 until 2020 for benign rectal lesions or early-stage malignant rectal lesions, along with unsuitable patients for radical interventions, were included in the present study. RESULTS Twenty-five patients underwent TAMIS for rectal lesions. Their median distance from the anal verge was 7 cm (range 4-12 cm) and their median size was 3.8 cm (range 2-6 cm). The median operative duration was 75 minutes (range 30-150 minutes) and the median hospitalization interval was 2 days (range 1-6 days). In addition, the negative resection rate was 100% and the recurrence rate was 4% during an average follow-up period of 30 months (range 3-36 months). Two patients (8%) presented short-term complications, and in 1 patient (4%) a hybrid technique was required. Seventeen patients (68%) reported moderate incontinence symptoms 6 weeks postoperatively that subsided in all patients 3 months postoperatively. CONCLUSIONS TAMIS seemed to be a feasible technique with adequate oncologic outcomes and high excision quality, which preserved patients' quality of life. The impact of TAMIS on anorectal function after neoadjuvant chemoradiotherapy for rectal cancer should be further investigated, however.
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Affiliation(s)
- George E Theodoropoulos
- From the Colorectal Unit, First Propaedeutic Department of Surgery, Hippocration General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Maximos Frountzas
- From the Colorectal Unit, First Propaedeutic Department of Surgery, Hippocration General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Panagiotis Karathanasis
- From the Colorectal Unit, First Propaedeutic Department of Surgery, Hippocration General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Georgia Doulami
- From the Colorectal Unit, First Propaedeutic Department of Surgery, Hippocration General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Victoria Michalopoulou
- From the Colorectal Unit, First Propaedeutic Department of Surgery, Hippocration General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Despina Kimpizi
- From the Colorectal Unit, First Propaedeutic Department of Surgery, Hippocration General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Dimitrios Schizas
- First Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - George C Zografos
- From the Colorectal Unit, First Propaedeutic Department of Surgery, Hippocration General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
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5
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Sailer M. [Transanal Tumor Resection: Indication, Surgical Technique and Management of Complications]. Zentralbl Chir 2023; 148:244-253. [PMID: 37267979 DOI: 10.1055/a-2063-3578] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Transanal resection procedures are special operations for the minimally invasive treatment of rectal tumours. Apart from benign tumours, this procedure is suitable for the excision of low-risk T1 rectal carcinomas, if these can be completely removed (R0 resection). With stringent patient selection, very good oncological results are achieved. Various international trials are currently evaluating whether local resection procedures are oncologically sufficient if there is a complete or near complete response after neoadjuvant radio-/chemotherapy. Numerous studies have shown that the functional results and the postoperative quality of life after local resection are excellent, especially considering the well-known functional deficits of alternative operations, such as low anterior or abdominoperineal resection.Severe complications are very rare. Most complications, such as urinary retention or subfebrile temperatures, are minor in nature. Suture line dehiscences are usually clinically unremarkable. Major complications comprise significant haemorrhage and the opening of the peritoneal cavity. The latter must be recognized intraoperatively and can usually be managed by primary suture. Infection, abscess formation, rectovaginal fistula, injury of the prostate or even urethra are extremely rare complications.
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Affiliation(s)
- Marco Sailer
- Klinik für Chirurgie, Agaplesion Bethesda Krankenhaus Bergedorf, Hamburg, Deutschland
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Robot-assisted TAMIS: a systematic review of feasibility and outcomes. Surg Endosc 2023; 37:3398-3409. [PMID: 36707419 PMCID: PMC9882737 DOI: 10.1007/s00464-022-09853-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 12/27/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND In the advancement of transanal local excision, robot-assisted transanal minimal invasive surgery is the newest development. In the confined area of the rectum, robot-assisted surgery should, theoretically, be superior due to articulated utensils, video enhancement, and tremor reduction, however, this has not yet been investigated. The aim of this study was to review the evidence reported to-date on experience of using robot-assisted transanal minimal invasive surgery for treatment of rectal neoplasms. METHODS A comprehensive literature search of Embase and PubMed from May to August 2021were performed. Studies including patients diagnosed with rectal neoplasia or benign polyps who underwent robot-assisted transanal minimal invasive surgery were included. All studies were assessed for risk of bias through assessment tools. Main outcome measures were feasibility, excision quality, and complications. RESULTS Twenty-five studies with a total of 322 local excisions were included. The studies included were all retrospective, primarily case-reports, -series, and cohort studies. The median distance from the anal verge ranged from 3.5 to 10 cm and the median size was between 2.5 and 5.3 cm. Overall, 4.6% of the resections had a positive resection margin. The overall complication rate was at 9.5% with severe complications (Clavien-Dindo score III) at 0.9%. CONCLUSION Based on limited, retrospective data, with a high risk of bias, robot-assisted transanal minimal invasive surgery seems feasible and safe for local excisions in the rectum.
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MRI-based radiomics to predict neoadjuvant chemoradiotherapy outcomes in locally advanced rectal cancer: A multicenter study. Clin Transl Radiat Oncol 2022; 38:175-182. [DOI: 10.1016/j.ctro.2022.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/12/2022] [Accepted: 11/14/2022] [Indexed: 11/18/2022] Open
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Devane LA, Daly MC, Albert MR. Transanal Endoscopic Platforms: TAMIS versus Rigid Platforms: Pros and Cons. Clin Colon Rectal Surg 2022; 35:93-98. [PMID: 35237103 PMCID: PMC8885160 DOI: 10.1055/s-0041-1742108] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Transanal endoscopic surgery encompasses the minimally invasive surgical techniques used to operate in the rectum under magnification while maintaining pneumorectum via a resectoscope or port. The view, magnification, and surgical precision afforded by these advanced transanal techniques have resulted in excellent specimen quality and low recurrence rates, especially compared with traditional transanal surgery. For rigid platforms, the surgeon operates through a rigid 4-cm diameter steel proctoscope of varying lengths that is clamped to the operating table with an articulating arm. Transanal minimally invasive surgery (TAMIS) is a newer flexible platform using a disposable port which "hooks" into the anorectal ring to remain in place. The cost-effectiveness and versatility of the TAMIS platform have resulted in its popularity and use in more advanced applications such as transanal total mesorectal excision. Ultimately, the choice of operating platform should be based on surgeon preference, patient characteristics, availability, and cost. The pros and cons of each platform will be discussed in this article.
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Affiliation(s)
- Liam A. Devane
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland
| | - Meghan C. Daly
- AdventHealth, Digestive Health and Surgical Institute, Department of Colorectal Surgery, Orlando, FL
| | - Matthew R. Albert
- AdventHealth, Digestive Health and Surgical Institute, Department of Colorectal Surgery, Orlando, FL,Address for correspondence Matthew R. Albert, MD AdventHealth, Digestive Health and Surgical Institute, Department of Colorectal Surgery2501 North Orange Ave, Orlando, FL 32804
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Lossius W, Stornes T, Bernstein TE, Wibe A. Implementation of transanal minimally invasive surgery (TAMIS) for rectal neoplasms: results from a single centre. Tech Coloproctol 2021; 26:175-180. [PMID: 34905132 PMCID: PMC8857095 DOI: 10.1007/s10151-021-02556-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 11/26/2021] [Indexed: 11/29/2022]
Abstract
Background Local excisions are important in a tailored approach to treatment of rectal neoplasms. In cases of low risk T1 local excision facilitates rectal-preserving treatment. Transanal minimally invasive surgery (TAMIS) is the most recent alternative developed for local excision. In this study we evaluate the results after implementing TAMIS as the routine procedure for local excision of rectal neoplasms. Methods All patients who underwent TAMIS from January 2016 to January 2020 at St. Olav’s University Hospital were included, and clinical, pathological and oncological data were prospectively registered. The primary endpoint was local recurrence, and the secondary endpoint was complications. Results There were 76 patients (42 men, mean age was 69 years [range 26–88 years]), The mean tumour level was 82 mm (range 20–140 mm) from the anal verge measured on rigid proctoscopy, and mean tumour size was 32 mm (range 8–73 mm). Three patients experienced complications needing intervention (Clavien–Dindo > 3A). Seventeen patients had rectal adenocarcinoma, 9 of whom underwent R0 completion total mesorectal excision (cTME). Fifty-five patients had an adenoma, 3 of whom developed recurrence (5.4%) within 12 months. All recurrences were treated successfully with a new TAMIS procedure. In addition, TAMIS was used in treatment of 2 patients with a neuroendocrine tumour, 1 patient with a haemangioma and 1 patient with a solitary rectal ulcer. Conclusions TAMIS surgery is associated with a low risk of complications and a low recurrence rate in rectal neoplasms. In cases of adenocarcinoma, R0 cTME surgery is feasible in the sub-group with high risk T1 and T2 tumours.
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Affiliation(s)
- W Lossius
- Department of Surgery, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway.
| | - T Stornes
- Department of Surgery, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - T E Bernstein
- Department of Surgery, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - A Wibe
- Department of Surgery, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
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Smits LJH, van Lieshout AS, Grüter AAJ, Horsthuis K, Tuynman JB. Multidisciplinary management of early rectal cancer - The role of surgical local excision in current and future clinical practice. Surg Oncol 2021; 40:101687. [PMID: 34875460 DOI: 10.1016/j.suronc.2021.101687] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/30/2021] [Accepted: 11/22/2021] [Indexed: 12/14/2022]
Abstract
The implementation of bowel cancer screening programs has led to a rise in the incidence of early rectal cancer. The combination of increased incidence and the growing interest in organ-sparing treatment options has led to an amplified importance of local excision techniques in treatment strategies for early rectal cancer. In addition, developments in new technologies of single-port surgery have popularized surgical techniques. Although local treatment of early rectal cancer seems promising, a multidisciplinary approach is necessary and awareness of the oncological robustness is warranted to enable shared decision-making. This review illustrates the position of surgical local excision in the treatment of early rectal cancer and reflects on its role in current and future clinical practice.
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Affiliation(s)
- Lisanne J H Smits
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, the Netherlands.
| | - Annabel S van Lieshout
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, the Netherlands
| | - Alexander A J Grüter
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, the Netherlands
| | - Karin Horsthuis
- Department of Radiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, the Netherlands
| | - Jurriaan B Tuynman
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, the Netherlands.
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Kim MJ, Lee TG. Transanal minimally invasive surgery using laparoscopic instruments of the rectum: A review. World J Gastrointest Surg 2021; 13:1149-1165. [PMID: 34754384 PMCID: PMC8554714 DOI: 10.4240/wjgs.v13.i10.1149] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 07/18/2021] [Accepted: 09/16/2021] [Indexed: 02/06/2023] Open
Abstract
Transanal minimally invasive surgery (TAMIS) was first described in 2010 as an alternative to transanal endoscopic microsurgery (TEM). The TAMIS technique can be access to the proximal and mid-rectum for resection of benign and early-stage malignant rectal lesions and also used for noncurative intent surgery of more advanced lesions in patients who are not candidates for radical surgery. TAMIS has a shorter learning curve, reduced device setup time, flexibility in instrument use, and versatility in application than TEM. Also, TAMIS shows similar results in a view of the operation time, conversion rate, reoperation rate, and complication to TEM. For these reasons, TAMIS is an easily accessible, technically feasible, and cost-effective alternative to TEM. Overall, TAMIS has enabled the performance of high-quality local excision of rectal lesions by many colorectal surgeons. As TAMIS becomes more broadly utilized such as pelvic abscess drainage, rectal stenosis, and treatment of anastomotic dehiscence, the acquisition of appropriate training must be ensured, and the continued assessment and assurance of outcome must be maintained.
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Affiliation(s)
- Myung Jo Kim
- Department of Surgery, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju 28644, South Korea
| | - Taek-Gu Lee
- Department of Surgery, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju 28644, South Korea
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Affiliation(s)
- A Arezzo
- Department of Surgical Sciences, University of Turin, c.so Dogliotti 14, 10126, Turin, Italy.
| | - G Gagliardi
- Department of Surgery, University of Illinois College of Medicine at Chicago, Chicago, IL, USA
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Chavda V, Siaw O, Chaudhri S, Runau F. Management of early rectal cancer; current surgical options and future direction. World J Gastrointest Surg 2021; 13:655-667. [PMID: 34354799 PMCID: PMC8316852 DOI: 10.4240/wjgs.v13.i7.655] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 04/13/2021] [Accepted: 06/16/2021] [Indexed: 02/06/2023] Open
Abstract
Rectal cancer is the second commonest cause of cancer death within the United Kingdom. Utilization of national screening programmes have resulted in a greater proportion of patients presenting with early-stage disease. The technique of transanal endoscopic microsurgery was first described in 1984 following which further options for local excision have emerged with transanal endoscopic operation and, more recently, transanal minimally invasive surgery. Owing to the risks of local recurrence, the current role of minimally invasive techniques for local excision in the management of rectal cancer is limited to the treatment of pre-invasive disease and low risk early-stage rectal cancer (T1N0M0 disease). The roles of chemotherapy and radiotherapy for the management of early rectal cancer are yet to be fully established. However, results of high-quality research such as the GRECCAR II, TESAR and STAR-TREC randomised control trials may highlight a wider role for local excision surgery in the future, when used in combination with oncological therapies. The aim of our review is to provide an overview in the current management of early rectal cancer, the surgical options available for local excision and the future multimodal direction of early rectal cancer treatment.
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Affiliation(s)
- Vijay Chavda
- Department of General Surgery, Leicester General Hospital, Leicester LE5 4PW, United Kingdom
| | - Oliver Siaw
- Department of General Surgery, Leicester General Hospital, Leicester LE5 4PW, United Kingdom
| | - Sanjay Chaudhri
- Department of General Surgery, Leicester General Hospital, Leicester LE5 4PW, United Kingdom
| | - Franscois Runau
- Department of General Surgery, Leicester General Hospital, Leicester LE5 4PW, United Kingdom
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Luglio G, Tropeano FP, Errico C, Esposito E, De Palma GD. Transanal minimally invasive approach for early giant rectal tumour - a video-vignette. Colorectal Dis 2021; 23:1603-1604. [PMID: 33768606 DOI: 10.1111/codi.15647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 03/06/2021] [Accepted: 03/11/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Gaetano Luglio
- Endoscopic Surgery Unit, Department of Surgical and Medical Gastrointestinal Disease, University of Naples Federico II, Via pansini 5, Naples, Napoli, Italy
| | - Francesca Paola Tropeano
- Endoscopic Surgery Unit, Department of Surgical and Medical Gastrointestinal Disease, University of Naples Federico II, Via pansini 5, Naples, Napoli, Italy
| | - Chiara Errico
- Endoscopic Surgery Unit, Department of Surgical and Medical Gastrointestinal Disease, University of Naples Federico II, Via pansini 5, Naples, Napoli, Italy
| | - Enrica Esposito
- Endoscopic Surgery Unit, Department of Surgical and Medical Gastrointestinal Disease, University of Naples Federico II, Via pansini 5, Naples, Napoli, Italy
| | - Giovanni Domenico De Palma
- Endoscopic Surgery Unit, Department of Surgical and Medical Gastrointestinal Disease, University of Naples Federico II, Via pansini 5, Naples, Napoli, Italy
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15
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Westwood E, Aryal K. Trans-anal minimally invasive surgical approach to remove a large rectal polyp - a video vignette. Colorectal Dis 2021; 23:564. [PMID: 33190375 DOI: 10.1111/codi.15442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 10/03/2020] [Accepted: 10/27/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Esther Westwood
- James Paget University Hospitals NHS Trust, Great Yarmouth, UK
| | - Kamal Aryal
- James Paget University Hospitals NHS Trust, Great Yarmouth, UK
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17
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Aguirre-Allende I, Enriquez-Navascues JM, Elorza-Echaniz G, Etxart-Lopetegui A, Borda-Arrizabalaga N, Saralegui Ansorena Y, Placer-Galan C. Early-rectal Cancer Treatment: A Decision-tree Making Based on Systematic Review and Meta-analysis. Cir Esp 2020; 99:89-107. [PMID: 32993858 DOI: 10.1016/j.ciresp.2020.05.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 05/27/2020] [Accepted: 05/30/2020] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Ignacio Aguirre-Allende
- Servicio de Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Hospital Universitario Donostia, Instituto Biodonostia, Spain.
| | - Jose Maria Enriquez-Navascues
- Servicio de Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Hospital Universitario Donostia, Instituto Biodonostia, Spain
| | - Garazi Elorza-Echaniz
- Servicio de Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Hospital Universitario Donostia, Instituto Biodonostia, Spain
| | - Ane Etxart-Lopetegui
- Servicio de Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Hospital Universitario Donostia, Instituto Biodonostia, Spain
| | - Nerea Borda-Arrizabalaga
- Servicio de Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Hospital Universitario Donostia, Instituto Biodonostia, Spain
| | - Yolanda Saralegui Ansorena
- Servicio de Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Hospital Universitario Donostia, Instituto Biodonostia, Spain
| | - Carlos Placer-Galan
- Servicio de Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Hospital Universitario Donostia, Instituto Biodonostia, Spain
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18
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Melstrom KA, Kaiser AM. Role of minimally invasive surgery for rectal cancer. World J Gastroenterol 2020; 26:4394-4414. [PMID: 32874053 PMCID: PMC7438189 DOI: 10.3748/wjg.v26.i30.4394] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/20/2020] [Accepted: 07/30/2020] [Indexed: 02/06/2023] Open
Abstract
Rectal cancer is one of the most common malignancies worldwide. Surgical resection for rectal cancer usually requires a proctectomy with respective lymphadenectomy (total mesorectal excision). This has traditionally been performed transabdominally through an open incision. Over the last thirty years, minimally invasive surgery platforms have rapidly evolved with the goal to accomplish the same quality rectal resection through a less invasive approach. There are currently three resective modalities that complement the traditional open operation: (1) Laparoscopic surgery; (2) Robotic surgery; and (3) Transanal total mesorectal excision. In addition, there are several platforms to carry out transluminal local excisions (without lymphadenectomy). Evidence on the various modalities is of mixed to moderate quality. It is unreasonable to expect a randomized comparison of all options in a single trial. This review aims at reviewing in detail the various techniques in regard to intra-/perioperative benchmarks, recovery and complications, oncological and functional outcomes.
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Affiliation(s)
- Kurt A Melstrom
- Division of Colorectal Surgery, Department of Surgery, City of Hope National Medical Center, Duarte, CA 91010-3000, United States
| | - Andreas M Kaiser
- Division of Colorectal Surgery, Department of Surgery, City of Hope National Medical Center, Duarte, CA 91010-3000, United States
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19
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Comparison of the transanal surgical techniques for local excision of rectal tumors: a network meta-analysis. Int J Colorectal Dis 2020; 35:1173-1182. [PMID: 32447481 DOI: 10.1007/s00384-020-03634-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/14/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND In order to assess the various surgical modalities for local resection of rectal tumors, a systematic review of the current literature and a network meta-analysis (NMA) was designed and conducted. METHODS The present study adhered to the PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions principles. Scholar databases (Medline, Scopus, Web of Science) were systematically screened up to 23/12/2019. A Bayesian NMA, implementing a Markov chain Monte Carlo analysis, was introduced for the probability ranking of the available surgical methods. Odds ratio (OR) and weighted mean difference (WMD) of the categorical and continuous variables, respectively, were reported with the corresponding 95% confidence interval (95%CI). RESULTS Overall, 16 studies and 2146 patients were introduced in our study. Transanal minimal invasive surgery (TAMIS) displayed the highest performance regarding the overall postoperative morbidity, the perioperative blood loss, the length of hospitalization, and the peritoneal violation rate. Transanal endoscopic microsurgery (TEM) was the most efficient modality for resecting an intact specimen. Although transanal local excision (TAE) had the highest ranking considering operative duration, it was associated with a significant risk for positive resection margins and tumor recurrence. CONCLUSIONS In conclusion, TEM and TAMIS display superior oncological results over TAE. Due to several limitations, validation of these results requires further RCTs of a higher methodological level.
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20
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Transanale Resektionsverfahren – heutiger Stellenwert. Chirurg 2020; 91:853-859. [DOI: 10.1007/s00104-020-01186-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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21
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Coratti F, Bisogni D, Montanelli P, Cianchi F. Transanal endoscopic operation for rectal lesion: a rapid initial experience. MINERVA CHIR 2020; 75:153-156. [PMID: 32083411 DOI: 10.23736/s0026-4733.20.08260-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND In recent decades, transanal surgery for rectal lesions has become a valid alternative treatment for the treatment of small lesions of the rectum. Significant benefits in terms of morbidity and mortality are confirmed. There are multiple platforms for transanal surgery but the TEO system® is one of the best known. METHODS Between November 2017 and July 2019, 25 patients with rectal lesions suitable to transanal treatment came to our observation. In all reported cases, full-thickness rectum resections were performed. Demographic, histopathological, surgical morbidity/mortality and clinical outcome in all patients who underwent TEO were retrospectively evaluated from a prospectively collected database. RESULTS For a period of less than 2 years, 25 rectal lesions were excised by TEO. Sixteen lesions (64%) were low (<4 cm), 7 (28%) were mid-rectal (4-8 cm) and 2 (8%) were in the proximal rectum (>8 cm). Postoperative complications included: 3 (12%) bleedings, and 8 (32%) post-polipectomy syndrome. CONCLUSIONS Our initial experience suggests TEO is safe and feasible. Full-thickness resection guarantees adequate deep margins. Moreover, the limited number of cases requires the development of adequate reference centers.
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Affiliation(s)
- Francesco Coratti
- Department of Digestive Surgery, Careggi University Hospital, Florence, Italy -
| | - Damiano Bisogni
- Department of Digestive Surgery, Careggi University Hospital, Florence, Italy
| | - Paolo Montanelli
- Department of Digestive Surgery, Careggi University Hospital, Florence, Italy
| | - Fabio Cianchi
- Department of Digestive Surgery, Careggi University Hospital, Florence, Italy
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22
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Spinelli A, Foppa C, Bemelman WA, Tanis PJ, Carvello M, Hompes R. Intermuscular surgical dissection for rectal lesions by transanal minimally invasive surgery - a video vignette. Colorectal Dis 2020; 22:228-229. [PMID: 31621152 DOI: 10.1111/codi.14875] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 09/30/2019] [Indexed: 02/08/2023]
Affiliation(s)
- A Spinelli
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Hospital, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - C Foppa
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Hospital, Milan, Italy
| | - W A Bemelman
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - P J Tanis
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M Carvello
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Hospital, Milan, Italy
| | - R Hompes
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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23
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Dapri G, Guevara A, Bascombe NA, Mbedi S, Longheval G. Transanal minimally invasive resection of a superior Houston's valve rectal adenoma - a video vignette. Colorectal Dis 2019; 21:1460-1461. [PMID: 31437343 DOI: 10.1111/codi.14825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 07/29/2019] [Indexed: 02/08/2023]
Affiliation(s)
- G Dapri
- Department of Gastrointestinal Surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, Université Libre de Bruxelles, Brussels, Belgium.,Laboratory of Anatomy, Faculty of Medicine and Pharmacy, University of Mons, Mons, Belgium
| | - A Guevara
- Department of Gastrointestinal Surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - N A Bascombe
- Department of Gastrointestinal Surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - S Mbedi
- Department of Anesthesia, Saint-Pierre University Hospital, Brussels, Belgium
| | - G Longheval
- Department of Gastroenterology and Endoscopy, Cliniques de l'Europe - St Elisabeth, Brussels, Belgium
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24
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Verrijssen AS, Guillem J, Perez R, Bujko K, Guedj N, Habr-Gama A, Houben R, Goudkade D, Melenhorst J, Buijsen J, Vanneste B, Grabsch HI, Bellezzo M, Paiva Fonseca G, Verhaegen F, Berbee M, Van Limbergen EJ. Microscopic intramural extension of rectal cancer after neoadjuvant chemoradiation: A meta-analysis based on individual patient data. Radiother Oncol 2019; 144:37-45. [PMID: 31710942 DOI: 10.1016/j.radonc.2019.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 09/05/2019] [Accepted: 10/01/2019] [Indexed: 01/04/2023]
Abstract
OBJECTIVE In selected rectal cancer patients with residual local disease following neoadjuvant chemoradiation (CRT) and the preference of an organ preservation pathway, additional treatment with dose escalation by endoluminal radiotherapy (RT) may ultimately result in a clinical complete response. To date, the widespread introduction of selective endoluminal radiation techniques is hampered by a lack of evidence-based guidelines that describe the radiation treatment volume in relation to the residual tumor mass. In order to convert an incomplete response into a complete one with additional treatment such as dose-escalation with endoluminal RT from a theoretical perspective, it seems important to treat all remaining microscopic tumor cells after CRT. In this setting, residual tumor extension beneath normal appearing mucosa (microscopic intramural spread - MIS) becomes relevant for accurate tumor volume and margin estimation. With the goal of providing evidence-based guidelines that define an appropriate treatment volume and patient selection, we present results from a meta-analysis based on individual patient data of studies that have assessed the extent or range of MIS of rectal cancers after neoadjuvant CRT. This meta-analysis should provide an estimate of the residual tumor volume/extension that needs to be targeted by any additional radiation therapy boost in order to achieve complete tumor eradication after initial incomplete or near-complete response following standard CRT. METHODS AND MATERIALS A PubMed search was performed. Additional articles were selected based on identification from reference lists. Papers were eligible when reporting MIS in patients who were treated by total mesorectal excision or local excision/transanal endoscopic microsurgery (TEM) after neo-adjuvant long-course CRT. The mean MIS was calculated for the entire group along with the 70th until 95th percentiles. Additional exploratory subgroup analyses were performed. RESULTS Individual patient data from 349 patients with residual disease from five studies were analyzed. 80% of tumors showed no MIS. In order to appropriately treat MIS in 95% of rectal cancer patients after CRT, a margin of 5.5 mm around the macroscopic tumor would suffice. An exploratory subgroup analysis showed that T-stage after CRT (ypT) and time interval between neoadjuvant CRT and surgery are significant factors predicting the extent of MIS (p < 0.001.) The group of ypT1 had the smallest MIS, followed by the ypT3-4 group, while the ypT2 group had the largest MIS (p < 0.001). Regarding time interval between CRT and surgery, a statistically significant difference was seen when comparing the three time-interval groups (less than 8 weeks, 8-12 weeks, and more than 12 weeks), where waiting more than 12 weeks after CRT resulted in the largest MIS (p < 0.0001). CONCLUSION Based on this meta-analysis, in order to treat the MIS for 95% of rectal cancer patients after CRT, a Clinical Target Volume (CTV) margin of 5.5 mm from the lateral most edge of the macroscopic tumor would suffice. 80% of tumors showed no MIS and would not require an extra CTV margin for treatment. These findings support the feasibility of localized radiotherapy boosts for dose-escalation to improve response among patients with incomplete response after standard CRT and can also be applied in the surgical setting.
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Affiliation(s)
- An-Sofie Verrijssen
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, The Netherlands.
| | - José Guillem
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, USA.
| | - Rodrigo Perez
- Angelita & Joaquim Gama Institute, Hosp. Oswaldo Cruz - R. Treze de Maio, São Paulo, Brazil.
| | - Krzysztof Bujko
- Department of Radiotherapy, Maria Sklodowska-Curie Memorial Cancer Center, Oddział w Gliwicach, Gliwice, Poland.
| | - Nathalie Guedj
- Department of Pathology, Beaujon Hospital, Clichy, France.
| | - Angelita Habr-Gama
- Angelita & Joaquim Gama Institute, Hosp. Oswaldo Cruz - R. Treze de Maio, São Paulo, Brazil.
| | - Ruud Houben
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, The Netherlands.
| | - Danny Goudkade
- Department of Pathology, Zuyderland Medisch Centrum, The Netherlands.
| | - Jarno Melenhorst
- Department of Surgery, Maastricht University Medical Center+, The Netherlands.
| | - Jeroen Buijsen
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, The Netherlands.
| | - Ben Vanneste
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, The Netherlands.
| | - Heike I Grabsch
- Department of Pathology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center+, The Netherlands; Division of Pathology and Data Analytics, Leeds Institute of Medical Research at St James's, University of Leeds, UK.
| | - Murillo Bellezzo
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, The Netherlands.
| | - Gabriel Paiva Fonseca
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, The Netherlands.
| | - Frank Verhaegen
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, The Netherlands.
| | - Maaike Berbee
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, The Netherlands.
| | - Evert J Van Limbergen
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, The Netherlands.
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25
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Feeney G, Sehgal R, Sheehan M, Hogan A, Regan M, Joyce M, Kerin M. Neoadjuvant radiotherapy for rectal cancer management. World J Gastroenterol 2019; 25:4850-4869. [PMID: 31543678 PMCID: PMC6737323 DOI: 10.3748/wjg.v25.i33.4850] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 07/28/2019] [Accepted: 08/07/2019] [Indexed: 02/06/2023] Open
Abstract
Thirty per cent of all colorectal tumours develop in the rectum. The location of the rectum within the bony pelvis and its proximity to vital structures presents significant therapeutic challenges when considering neoadjuvant options and surgical interventions. Most patients with early rectal cancer can be adequately managed by surgery alone. However, a significant proportion of patients with rectal cancer present with locally advanced disease and will potentially benefit from down staging prior to surgery. Neoadjuvant therapy involves a variety of options including radiotherapy, chemotherapy used alone or in combination. Neoadjuvant radiotherapy in rectal cancer has been shown to be effective in reducing tumour burden in advance of curative surgery. The gold standard surgical rectal cancer management aims to achieve surgical removal of the tumour and all draining lymph nodes, within an intact mesorectal package, in order to minimise local recurrence. It is critically important that all rectal cancer cases are discussed at a multidisciplinary meeting represented by all relevant specialties. Pre-operative staging including CT thorax, abdomen, pelvis to assess for distal disease and magnetic resonance imaging to assess local involvement is essential. Staging radiology and MDT discussion are integral in identifying patients who require neoadjuvant radiotherapy. While Neoadjuvant radiotherapy is potentially beneficial it may also result in morbidity and thus should be reserved for those patients who are at a high risk of local failure, which includes patients with nodal involvement, extramural venous invasion and threatened circumferential margin. The aim of this review is to discuss the role of neoadjuvant radiotherapy in the management of rectal cancer.
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Affiliation(s)
- Gerard Feeney
- Department of General/Colorectal Surgery, Galway University Hospital, Galway H91 YR71, Ireland
| | - Rishabh Sehgal
- Department of General/Colorectal Surgery, Galway University Hospital, Galway H91 YR71, Ireland
| | - Margaret Sheehan
- Department of Histopathology, Galway University Hospital, Galway H91 YR71, Ireland
| | - Aisling Hogan
- Department of General/Colorectal Surgery, Galway University Hospital, Galway H91 YR71, Ireland
| | - Mark Regan
- Department of General/Colorectal Surgery, Galway University Hospital, Galway H91 YR71, Ireland
| | - Myles Joyce
- Department of General/Colorectal Surgery, Galway University Hospital, Galway H91 YR71, Ireland
| | - Michael Kerin
- Department of General/Colorectal Surgery, Galway University Hospital, Galway H91 YR71, Ireland
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