Endoscopic posterior mesorectal resection after transanal local excision of T1 carcinomas of the lower third of the rectum

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.

Endoscopic full-thickness resection of early colorectal neoplasms using an endoscopic submucosal dissection knife: a retrospective multicenter study

Background and study aims  Endoscopic full-thickness resection allows resection of early gastrointestinal neoplasms not amenable to conventional endoscopic resection techniques, due to their location, presence of submucosal fibrosis, or suspected deep mural invasion. It is typically achieved using a dedicated over-the-scope device (full-thickness resection device or FTRD). The aim of our study was to evaluate the feasibility, safety, and clinical outcomes of endoscopic full-thickness resection using an endoscopic submucosal dissection (ESD) knife. Patients and methods  Consecutive patients who underwent full-thickness endoscopic resection at six tertiary care centers from August 2010 to June 2017 were retrospectively included. We conducted a comparative analysis of patient characteristics, technical success, adverse events, and time to discharge between patients treated by a full-thickness resection using an ESD knife. Results  Twenty-one procedures were performed using an ESD knife. En-bloc resection and R0 resection rates were 95.2 % and 65 %, respectively. Clinical symptoms of perforation occurred in 66.7 %. There was no need for surgery or additional endoscopic procedures. Conclusion  Endoscopic full-thickness resection of early colorectal neoplasms using an ESD knife might be feasible and safe. It allows complete resection of lesions with no limitation in size. The technique may be preferable to an other-the-scope resection device in lesions larger than 20 mm, and to surgery in selected cases of low-risk T1 colorectal carcinomas, non-lifting adenomas, submucosal tumors, or technically challenging lesion locations.

A modified sentinel lymph node technique combined with endoluminal loco-regional resection for the treatment of rectal tumours: a 14-year experience

AIM

After endoluminal loco-regional resection (ELRR) by transanal endoscopic microsurgey (TEM) the N parameter may remain undefined. Nucleotide-guided mesorectal excision (NGME) improves the lymph node harvest. The aim of the present study is to evaluate the long-term oncological results after ELRR with NGME.

METHOD

A total of 57 patients were enrolled over the period January 2001 to June 2015. All patients underwent ELRR by TEM. Prior to surgery, 99 m-technetium-marked nanocolloid was injected into the peritumoural submucosa. After removal of the specimen, the residual defect was probed to detect any residual radioactivity and 'hot' mesorectal fat was excised. All patients were included in a 5-year follow-up programme.

RESULTS

Significant radioactivity in the residual cavity was found in 28 out of 57 patients (49%). The mean number of lymph nodes harvest in irradiated and nonirradiated patients was 1.66 and 2.76, respectively. After 68.2 months' follow-up overall survival was 91.2%, disease-related mortality 3.5% and disease-free survival 89.5%. Two patients developed pulmonary metastases: one ypT3N0 patient underwent lung lobectomy after chemotherapy and one pT2N0 patient was managed with lung radiotherapy. Both patients are currently alive and disease-free at 48 months' follow-up. Two patients developed local recurrence 1 year after ELRR, both treated with neoadjuvant chemo-radiotherapy and total mesorectal excision. Comparing the present series with previous patients who did not undergo NGME, an increased number of harvested lymph nodes were observed, with a statistically significant difference (P = 0.0085).

CONCLUSION

NGME during ELRR improves the lymph node harvest and staging accuracy. The long-term results showed satisfactory local (3.5%) and distant (7%) recurrence rates.

Predictors for regional lymph node metastasis in T1 rectal cancer: a population-based SEER analysis

BACKGROUND

Local resection of early-stage rectal cancer significantly reduces perioperative morbidity compared with radical resection. Identifying patients at risk of regional lymph node metastasis (LNM) is crucial for long-term survival after local resection.

METHODS

Patients after oncological resection of T1 rectal cancer were identified in the Surveillance, Epidemiology, and End Results register 2004-2012. Potential predictors of LNM and its impact on cancer-specific survival were assessed in logistic and Cox regression with and without multivariable adjustment.

RESULTS

In total, 1593 patients with radical resection of T1 rectal cancer and a minimum of 12 retrieved regional lymph nodes were identified. The overall LNM rate was 16.3 % (N = 260). A low risk of LNM was observed for small tumor size (P = 0.002), low tumor grade (P = 0.002) and higher age (P = 0.012) in multivariable analysis. The odds ratio for a tumor size exceeding 1.5 cm was 1.49 [95 % confidence interval (CI) 1.06-2.13], for G2 and G3/G4 carcinomas 1.69 (95 % CI 1.07-2.82) and 2.72 (95 % CI 1.50-5.03), and for 65- to 79-year-old and over 80-year-old patients 0.65 (95 % CI 0.43-0.96) and 0.39 (95 % CI 0.18-0.77), respectively. Five-year cancer-specific survival for patients with LNM was 90.0 % (95 % CI 85.3-95.0 %) and for patients without LNM 97.1 % (95 % CI 95.9-98.2 %, hazard ratio = 3.21, 95 % CI 1.82-5.69, P < 0.001).

CONCLUSIONS

In this population-based analysis, favorable cancer-specific survival rates were observed in nodal-negative and nodal-positive T1 rectal cancer patients after primary radical resection. The predictive value of tumor size, grading and age for LNM should be considered in medical decision making about local resection.

Rectal cancer: An evidence-based update for primary care providers

Rectal adenocarcinoma is an important cause of cancer-related deaths worldwide, and key anatomic differences between the rectum and the colon have significant implications for management of rectal cancer. Many advances have been made in the diagnosis and management of rectal cancer. These include clinical staging with imaging studies such as endorectal ultrasound and pelvic magnetic resonance imaging, operative approaches such as transanal endoscopic microsurgery and laparoscopic and robotic assisted proctectomy, as well as refined neoadjuvant and adjuvant therapies. For stage II and III rectal cancers, combined chemoradiotherapy offers the lowest rates of local and distant relapse, and is delivered neoadjuvantly to improve tolerability and optimize surgical outcomes, particularly when sphincter-sparing surgery is an endpoint. The goal in rectal cancer treatment is to optimize disease-free and overall survival while minimizing the risk of local recurrence and toxicity from both radiation and systemic therapy. Optimal patient outcomes depend on multidisciplinary involvement for tailored therapy. The successful management of rectal cancer requires a multidisciplinary approach, with the involvement of enterostomal nurses, gastroenterologists, medical and radiation oncologists, radiologists, pathologists and surgeons. The identification of patients who are candidates for combined modality treatment is particularly useful to optimize outcomes. This article provides an overview of the diagnosis, staging and multimodal therapy of patients with rectal cancer for primary care providers.

Local resection compared with radical resection in the treatment of T1N0M0 rectal adenocarcinoma: a systematic review and meta-analysis

BACKGROUND

Local resection for early rectal cancer is thought to be less invasive but oncologically inferior to radical resection.

OBJECTIVE

The aim of this study was to compare local with radical resection in terms of oncologic control (survival and local recurrence), postoperative complications, and the need for a permanent stoma in adult patients with T1N0M0 rectal adenocarcinoma.

DATA SOURCES

Data were retrieved from Medline, Embase, Central, www.clinicaltrials.gov, and conference proceedings.

STUDY SELECTION

Two reviewers independently screened studies and assessed the risk of bias.

INTERVENTIONS

Local resection (transanal procedures, excluding endoscopic polypectomy) versus radical resection were considered.

MAIN OUTCOME MEASURES

The primary outcomes measured were overall survival, major postoperative complications, and the 'need for permanent stoma.'

RESULTS

: One randomized controlled trial and 12 observational studies contributed 2855 patients for analysis. The randomized controlled trial was inadequately powered. Observational study meta-analysis showed that local resection was associated with significantly lower 5-year overall survival (72 more deaths per 1000 patients; 95%CI 30-120). However, the transanal endoscopic microsurgery subgroup did not yield significantly lower overall survival than radical resection. Local resection was associated with higher local recurrence but with lower perioperative mortality (relative risk 0.31, 95% CI 0.14-0.71), major postoperative complications (relative risk 0.20, 95% CI 0.10-0.41), and need for a permanent stoma (relative risk 0.17, 95% CI 0.09-0.30). Findings were robust to sensitivity analyses. Meta-regression suggests that the higher overall survival associated with radical resection may be explained by increased use of local resection on tumors in the lower third of the rectum, which have poorer prognosis.

LIMITATIONS

This systematic review of nonrandomized studies had inherent biases that may persist despite our rigorous use of systematic review methodology and sensitivity analyses.

CONCLUSIONS

Local resection does not offer oncologic control comparable to radical surgery. However, this finding may be driven by the higher prevalence of cancers with poorer prognosis in local resection groups. Local resection is associated with lower postoperative complications, mortality, and the need for a permanent stoma. Local resection with transanal endoscopic microsurgery appears to offer oncologic control similar to that of radical resection while offering all the benefits of local resection.

Transanal endoscopic microsurgery combined with endoscopic posterior mesorectum resection in the treatment of patients with T1 rectal cancer - 3-year results

Introduction

Rectum-sparing transanal endoscopic microsurgery (TEM) is a well-established treatment for T1 rectal cancer (RC). However, it is associated with an increased rate of local recurrence in comparison with extended resection. In most cases this failure is linked to inappropriate case selection and the presence of clinically non-detectable metastases in the regional lymph nodes. Endoscopic posterior mesorectal resection (EPMR) makes it possible to remove the relevant lymphatic drainage of the lower third of the rectum in a minimally invasive way, which in turn can help in adequate tumor staging.

Aim

To evaluate the long-term clinical results and influence of combined TEM and EPMR treatment on the anorectal functions.

Material and methods

Ten consecutive patients with T1 RC were operated on using TEM and EPMR as a two-stage procedure between 2007 and 2009.

Results

After a median follow-up of 42.6 (range: 36–80) months, none of our patients complained of symptoms of incontinence apart from one female patient with gas incontinence diagnosed preoperatively. There was no statistically significant difference in basal anal pressure, squeeze anal pressure, high pressure zone length or fecal continence assessed using the Fecal Incontinence Severity Index before and in follow-up months after the procedure. Postoperative morbidity consisted of one hematoma formation and one male patient complaining about sexual dysfunction until 6 months postoperatively. There was no evidence of locoregional recurrence.

Conclusions

Endoscopic posterior mesorectal resection in combination with TEM appears to be safe, feasible and with no impact on the basic anorectal functions in the 3-year follow-up.

Perirectal Oncologic Gateway to Retroperitoneal Endoscopic Single-Site Surgery (PROGRESSS): a feasibility study for a new NOTES approach in a swine model

INTRODUCTION

A transanal, posterior, retrorectal approach has been demonstrated as a feasible natural orifice transluminal endoscopic surgery (NOTES) total mesorectal excision (TME) procedure. The aim was to assess the feasibility of a transrectal approach with a completely retroperitoneal mobilization of the left colon and mesenteric vessels in an acute porcine model.

MATERIALS AND METHODS

Eight pigs were used. A purse-string suture was made 3 cm above the anal sphincter. Next, the retroperitoneal, perirectal space was entered with an endoscope through a single (or twin) anterior lateral, transrectal viscerotomy. A retroperitoneal tunnel was created using pneumodissection or endoscopically guided dissection to the inferior mesenteric artery (IMA). The IMA was skeletonized and lymph nodes retrieved using the IsisScope or other instruments. The IMA was divided with the Ligasure, clips, or ligature performed with the IsisScope. The rectum was dissected transanally in the "Holy" plane. After achieving mobilization using a completely retroperitoneal approach, the peritoneal attachments were then divided and the rectosigmoid specimen exteriorized through the anus. An explorative laparoscopy was then performed to evaluate the quality of the mobilization.

RESULTS

The procedure was successfully completed and the IMA correctly identified and ligated in all cases. In all but one case, no further mobilization was possible, even by a laparoscopic approach.

CONCLUSIONS

Perirectal oncologic gateway to retroperitoneal endoscopic single-site surgery for left-sided colonic resections using both flexible and rigid surgical endoscopic platforms was feasible and reproducible in an acute porcine model. This technique might represent a step toward pure NOTES left-sided colorectal procedures.

A prospective analysis of patient outcome following treatment of T3 rectal cancer with neo-adjuvant chemoradiotherapy and transanal excision

BACKGROUND

Local excision is an alternative to anterior or abdomino-perineal resection in patients with early rectal cancer. In more advanced disease, neo-adjuvant therapy (CRXT) can result in significant disease regression such that local excision may be considered. The primary aim was to assess oncological outcome in patients with T3 rectal cancer treated with CRXT and local excision due to unsuitability for or aversion to anterior resection and stoma. The secondary aim was to examine oncological outcomes in patients treated in a similar way in the published literature.

METHODS

Between July 2006 and July 2009, patients with rectal cancer staged T3, N0/N1, M0 who were deemed unfit for or who refused anterior resection were offered long-course CRXT. Patients were restaged 8 weeks following completion. If there was a good response (regression grade 2 or 3 clinically and radiologically), full thickness transanal excision was performed. All patients were followed regularly (monthly CT abdomen/pelvis and annual endoscopy) to assess for recurrence of disease. A literature search of PubMed was performed to identify all prospective data available of T3 rectal cancers managed with CRXT and local excision.

RESULTS

Ten patients were treated over 3 years. Six patients had complete pathological response, while four patients had a partial response. The resection margins following local excision were clear in all. There was no local recurrence (median follow-up 24 months, range 9-42 months).

CONCLUSION

Neo-adjuvant chemoradiotherapy and local excision is an option in patients unfit for or averse to major surgical resection if there is a good response to CRXT.

Clinical impact of lymph node status in rectal cancer

Lymph node status at the time of diagnosis remains one of the principal indicators of prognosis in patients with rectal cancer. Involvement of loco-regional lymph nodes is relevant to surgical and clinical oncologists and continues to impact significantly upon local and systemic management strategies, in both neo-adjuvant and adjuvant settings. In this review, the clinical impact of lymph node status in the surgical management of rectal cancer is considered, with particular reference to the significance of lymphadenectomy and the potential implications for rectal tumours amenable to trans-anal excision. Current standards of care are reviewed and the extent to which the determination of lymph node status influences oncological decisions regarding neo-adjuvant and adjuvant therapies are discussed with areas of controversy highlighted.

Functional and clinical results of transanal endoscopic microsurgery combined with endoscopic posterior mesorectum resection for the treatment of patients with t1 rectal cancer

BACKGROUND

Rectum-sparing transanal endoscopic microsurgery (TEM) is a well-established treatment for T1 carcinomas of the rectum. However, it is associated with an increased rate of local recurrence compared with extended resection. In most cases, this failure is linked to the presence of clinically nondetectable metastases in the regional lymph nodes. Endoscopic posterior mesorectal resection (EPMR) makes it possible to remove the relevant lymphatic drainage of the lower third of the rectum in the minimally invasive way, which can help with adequate tumor staging. The study evaluated the influence of combined TEM and EPMR treatment on the anorectal functions of this group of patients.

METHODS

Six consecutive patients (3 women and 3 men; mean age, 71.3 years) with T1 cancer of the rectum were operated on using TEM in combination with EPMR as a two-stage procedure between 2007 and 2009.

RESULTS

After a median follow-up of 19 (range, 8-30) months, none of our patients complained of symptoms of incontinence during the postoperative period apart from one woman with gas incontinence, who was diagnosed preoperatively. There was no statistically significant difference in BAP, SAP, HPZL, or in fecal continence control assessed using the Fecal Incontinence Severity Index before and 1, 3, and 6 months after the procedure. We observed one case of intraoperative complication (perforation) and one case of minor postoperative complication (hematoma formation). There was no evidence of locoregional recurrence.

CONCLUSIONS

EPMR in combination with TEM seems to be safe, feasible, and with no impact on the basic anorectal functions.

Rectum-conserving surgery in the era of chemoradiotherapy

BACKGROUND

A complete pathological response occurs in 10-30 per cent of patients with locally advanced rectal cancer undergoing neoadjuvant chemoradiotherapy (CRT). The standard of care has been radical surgery with high morbidity risks and the challenges of stomata despite the favourable prognosis. This review assessed minimalist approaches (transanal excision or observation alone) to tumours with a response to CRT.

METHODS

A systematic review was performed using PubMed and Embase databases. Keywords included: 'rectal', 'cancer', 'transanal', 'conservative', 'complete pathological response', 'radiotherapy' and 'neoadjuvant'. Original articles from all relevant listings were sourced. These were hand searched for further articles of relevance. Main outcome measures assessed were rates of local recurrence and overall survival, and equivalence to radical surgery.

RESULTS

Purely conservative 'watch and wait' strategies after CRT are still controversial. Originally used for elderly patients or those who refused surgery, the data support transanal excision of rectal tumours showing a good response to CRT. A complete pathological response in the T stage (ypT0) indicates < 5 per cent risk of nodal metastases.

CONCLUSION

Rectal tumours showing an excellent response to CRT may be suitable for local excision, with equivalent outcomes to radical surgery. This approach should be the subject of prospective clinical trials in specialist centres.

Brachytherapy and local excision for sphincter preservation in T1 and T2 rectal cancer

PURPOSE

To report long-term results of brachytherapy after local excision (LE) in the treatment of T1 and T2 rectal cancer at risk of recurrence due to residual subclinical disease.

METHODS AND MATERIALS

Between 1989 and 2007, 32 patients undergoing LE and brachytherapy were followed prospectively for a mean of 6.2 years. Estimates of local recurrence (LR), disease-specific survival (DSS), and overall survival (OS) were generated. Treatment-related toxicity and the effect of known prognostic factors were determined.

RESULTS

There were 8 LR (3 T1, 5 T2), of which 5 were salvaged surgically. Median time to the 8 LR was 14 months, and the 5-year rate of local control was 76%. Although there have been 9 deaths to date, only 5 were from disease. Five-year DSS and OS rates were 85% and 78%, respectively. There were 4 cases of Grade 2-3 radionecrosis and 1 case of mild stool incontinence. The sphincter was preserved in 27 of 32 patients.

CONCLUSION

Local excision and adjuvant brachytherapy for T1 and T2 rectal cancer is an appealing treatment alternative to immediate radical resection, particularly in the frail and elderly who are unable to undergo major surgery, as well as for patients wanting to avoid a permanent colostomy.

Management of early rectal cancer

BACKGROUND

Early rectal cancer (ERC) is adenocarcinoma that has invaded into, but not extended beyond, the submucosa of the rectum (that is a T1 tumour). Local excision is curative for low-risk ERCs but for high-risk cancers such management is controversial.

METHODS

This review is based on published literature obtained by searching the PubMed and Cochrane databases, and the bibliographies of extracted articles.

RESULTS AND CONCLUSION

ERC presents as a focus of malignancy within an adenoma, as a polyp, or as a small ulcerating adenocarcinoma. Preoperative staging relies on endorectal ultrasonography and magnetic resonance imaging. Pathological staging uses the Haggitt and Kikuchi classifications for adenocarcinoma in pedunculated and sessile polyps respectively. Lymph node metastases increase with the Kikuchi level, with a 1-3 per cent risk for submucosal layer (Sm) 1, 8 per cent for Sm2 and 23 per cent for Sm3 lesions. Low-risk ERCs may be treated endoscopically or by a transanal procedure. Transanal excision or transanal endoscopic microsurgery may be inadequate for high-risk ERCs and adjuvant chemoradiotherapy may be appropriate. There is a low rate of recurrence after local surgery for low-risk ERCs but this increases to up to 29 per cent for high-risk cancers.

Local excision and endoscopic posterior mesorectal resection versus low anterior resection in T1 rectal cancer

Background

Rectum-preserving endoscopic posterior mesorectal resection (EPMR) removes the local lymph nodes in a minimally invasive manner and completes tumour staging after transanal local excision (TE). The aim of this study was to compare the morbidity and mortality of TE and EPMR with those of low anterior resection (LAR) in patients with T1 rectal cancer.

Methods

Between 1996 and 2006 EPMR was performed 6 weeks after TE in 18 consecutive patients with a T1 rectal cancer. Morbidity and mortality were recorded prospectively and compared with those in a group of 17 patients treated by LAR. Lymph node involvement and local recurrence rate were analysed in both groups.

Results

Two major and three minor complications were noted after EPMR, and four major and four minor complications after LAR (P = 0·402 for major and P = 0·691 for minor complications). Median number of lymph nodes removed was 7 (range 1–22) for EPMR and 11 (range 2–36) for LAR (P = 0·132). Two of 25 patients with a low-risk rectal cancer were node positive. No patient developed locoregional recurrence.

Conclusion

EPMR after TE is a safe option for T1 rectal cancer. This two-stage procedure has a lower morbidity than LAR and may reduce locoregional recurrence compared with TE alone.

Endoscopic posterior mesorectal resection as an option to combine local treatment of early stage rectal cancer with partial mesorectal lymphadenectomy

BACKGROUND AND AIMS

Low anterior resection and abdominoperineal resection with total mesorectal excision are the standard treatment in patients with low rectal cancer. Rectal resection remains a surgical intervention with considerable morbidity and long-term impairment of quality of life. Local excision of low rectal cancer is regarded as an alternative to radical surgery; however, occurrence of lymph node metastasis even in patients with highly differentiated early-stage rectal cancer may be underestimated.

PATIENTS AND RESULTS

In two patients with T1 rectal cancer, minimal-invasive partial excision of the mesorectum was performed after transanal excision of the tumor. The postoperative course was uneventful in both patients. Patients left the hospital on the fourth and fifth postoperative day without any complaints. In one patient, histo-pathological workup revealed a lymph node metastasis in the specimen.

DISCUSSION

The technique of "Endoscopic posterior mesorectal resection" represents an interesting option in the surgical treatment of rectal cancer, as it allows for the first time an organ preserving resection of local lymph nodes in the small pelvis. It may evolve as an efficient new staging procedure to identify patients with metastatic disease who may benefit from multimodal treatment or extended surgery.