Function and quality of life after transanal excision of rectal polyps and cancers

Transanal excision with adjuvant therapy for pT1N0 rectal tumors with high-risk features offers equivalent survival to radical resection: A National Cancer Database analysis

BACKGROUND

Current guidelines favor transabdominal radical resection (RR) over transanal local excision (TAX) followed by adjuvant therapy (TAXa) for pT1N0 rectal tumors with high-risk features. Comparison of oncologic outcomes between these approaches is limited, although the former is associated with increased postoperative morbidity. We hypothesize that such treatment strategies result in equivalent long-term survival.

METHODS

A retrospective cohort study was conducted using the National Cancer Database (2010-2016) to identify patients with pT1N0 rectal adenocarcinoma with high-risk features who underwent TAX or RR for curative intent. The primary outcome was 5-year overall survival (OS), evaluated with log-rank and Cox-proportional hazards testing.

RESULTS

A total of 1159 patients (age 67.4 ± 12.9 years; 56.6% male; 83.3% White) met study criteria, of which 1009 (87.1%) underwent RR and 150 (12.9%) underwent TAXa. Patients undergoing TAXa had shorter lengths of stay (RR = 6.5 days, TAXa = 2.7 days, p < 0.001). The 5-year OS was equivalent between groups. TAX without adjuvant therapy was associated with an increased risk of mortality (hazard ratio 1.81, 95% confidence interval 1.17-2.78, p = 0.01).

CONCLUSIONS

This is the largest study to demonstrate equivalent 5-year OS between TAXa and RR for T1N0 rectal cancer with high-risk features. These findings may guide the development of prospective, randomized trials and influence changes in practice recommendations for early-stage rectal cancer.

Transanal minimally invasive surgery using laparoscopic instruments of the rectum: A review

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.

Adjuvant chemoradiotherapy versus radical surgery after transanal endoscopic microsurgery for intermediate pathological risk early rectal cancer: A single-center experience with long-term surveillance

BACKGROUND

The choice of subsequent treatment for intermediate-risk rectal tumors after transanal endoscopic microsurgery between adjuvant chemoradiotherapy and total mesorectal excision is controversial. The present study aimed to compare survival and functional outcome between these 2 strategies.

METHODS

This retrospective study included intermediate-risk patients with early rectal cancer after transanal endoscopic microsurgery in our center between 2010 and 2017. Patients were divided into adjuvant treatment and total mesorectal excision groups. Intermediate risk was defined as pT1 with lymphovascular invasion, poor differentiation, or large diameter (3-5 cm) or pT2 with small diameter (<3 cm). The study was based on follow-up data on survival and results from distributed validated scales for functional outcome.

RESULTS

Postoperative overall survival and disease-free survival were comparable between the groups (P = .619 and P = .712, respectively). Pathological T stage was an independent risk factor for disease-free survival (hazard ratio 3.09, 95% confidence interval 1.66-4.18, P = .044). Anorectal symptoms, such as buttock pain, were significantly prevalent in the total mesorectal excision group (P = .030). In addition, the total mesorectal excision group presented with poorer bowel function, including stool urgency (P < .001), bowel frequency (P = .016), severity of low anterior resection syndrome (P = .039) and total low anterior resection syndrome score (P = .040). Except for a lower score of vaginal lubrication in the total mesorectal excision versus the adjuvant treatment group, sexual function was similar between the groups.

CONCLUSION

Similar to total mesorectal excision, adjuvant chemoradiotherapy is an alternative option for intermediate-risk early rectal cancer after transanal endoscopic microsurgery and is associated with similar survival outcomes and better bowel function.

Survival analysis of local excision vs total mesorectal excision for middle and low rectal cancer in pT1/pT2 stage and intermediate pathological risk

Background

Local excision (LE) is a feasible treatment approach for rectal cancers in stage pT1 and presents low pathological risk, whereas total mesorectal excision (TME) is a reasonable treatment for more advanced cancers. On the basis of the pathology findings, surgeons may suggest TME for patients receiving LE. This study compared the survival outcomes between LE with/without chemoradiation and TME in mid and low rectal cancer patients in stage pT1/pT2, with highly selective intermediate pathological risk.

Methods

This retrospective study included 134 patients who received TME and 39 patients who underwent LE for the treatment of intermediate risk (pT1 with poor differentiation, lymphovascular invasion, perineural invasion, relatively large tumor, or small-sized pT2 tumor) rectal cancer between 1998 and 2016.

Results

Overall survival (OS), disease-free survival (DFS), and cumulative recurrence rate (CRR) were similar between the LE (3-year DFS 92%) and TME (3-year DFS 91%) groups. Following subgrouping into an LE with adjuvant therapy group and a TME without adjuvant therapy group, the compared survival outcomes (OS, DFS, and CRR) were found not to be statistically different. The temporary and permanent ostomy rates were higher in the TME group than in the LE group (p < 0.001). Rates of early and late morbidity following surgery were higher in the TME group (p = 0.005), and LE had similar survival compared with TME.

Conclusion

For patients who had mid and low rectal cancer in stage pT1/pT2 and intermediate pathological risk, LE with chemoradiation presents an alternative treatment option for selected patients.

Anorectal Function and Quality of Life in Patients With Early Stage Rectal Cancer Treated With Chemoradiation and Local Excision

BACKGROUND

Little is known about anorectal function and quality of life after chemoradiation followed by local excision, which is an alternative to total mesorectal excision for selected patients with early rectal cancer.

OBJECTIVE

The purpose of this study was to prospectively assess anorectal function and health-related quality of life of patients with T2N0 rectal cancer who were treated with an alternative approach.

DESIGN

This was a prospective, phase II trial.

SETTINGS

The study was multicentric (American College of Surgeons Oncology Group trial Z6041).

INTERVENTIONS

Patients with stage cT2N0 rectal adenocarcinomas were treated with an oxaliplatin/capecitabine-based chemoradiation regimen followed by local excision.

MAIN OUTCOME MEASURES

Anorectal function and quality of life were assessed at enrollment and 1 year postoperatively with the Fecal Incontinence Severity Index, Fecal Incontinence Quality of Life scale, and Functional Assessment of Cancer Therapy-Colorectal Questionnaire. Results were compared, and multivariable analysis was performed to identify predictors of outcome.

RESULTS

Seventy-one patients (98%) were evaluated at enrollment and 66 (92%) at 1 year. Compared with baseline, no significant differences were found on Fecal Incontinence Severity Index scores at 1 year. Fecal Incontinence Quality of Life results were significantly worse in the lifestyle (p < 0.001), coping/behavior (p < 0.001), and embarrassment (p = 0.002) domains. There were no differences in the Functional Assessment of Cancer Therapy overall score, but the physical well-being subscale was significantly worse and emotional well-being was improved after surgery. Treatment with the original chemoradiation regimen predicted worse depression/self-perception and embarrassment scores in the Fecal Incontinence Quality of Life, and male sex was predictive of worse scores in the Functional Assessment of Cancer Therapy overall score and trial outcome index.

LIMITATIONS

Small sample size, relatively short follow-up, and absence of information before cancer diagnosis were study limitations.

CONCLUSIONS

Chemoradiation followed by local excision had minimal impact on anorectal function 1 year after surgery. Overall quality of life remained stable, with mixed effects on different subscales. This information should be used to counsel patients about expected outcomes.

Validation of the chinese version of the EORTC QLQ-CR29 in patients with colorectal cancer

AIM

To assess the validity and reliability of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Colorectal Cancer 29 (EORTC QLQ-CR29) in Chinese patients with colorectal cancer (CRC).

METHODS

From March 2014 to January 2015, 356 patients with CRC from four different hospitals in China were enrolled in the study, and all patients self-administered the EORTC QLQ-CR29 and the quality of life core questionnaire (EORTC QLQ-C30). Evaluation of the scores was based on the Karnofsky Performance Scale (KPS). The reliability and validity of the questionnaires were assessed by Cronbach’s α coefficient, the Spearman correlation test and Wilcoxon rank sum test.

RESULTS

The EORTC QLQ-CR29 showed satisfactory reliability (α > 0.7), although the urinary frequency and blood and mucus in stool dimensions had only moderate reliability (α = 0.608). The multitrait scaling analyses showed good convergent (r > 0.4) and discriminant validity. Significant differences were obtained for each item in the different KPS subgroups (KPS ≤ 80; KPS > 80). Body image and most single-item dimensions showed statistically significant differences in patients with a stoma compared with the rest of the patients.

CONCLUSION

The EORTC QLQ-CR29 exhibits high validity and reliability in Chinese patients with CRC, and can therefore be recommended as a valuable tool for the assessment of quality of life in these patients.

Transanal Endoscopic Microsurgery for Early Rectal Cancer: A Single-Center Experience

BACKGROUND

There is debate regarding the appropriate use of transanal endoscopic microsurgery for rectal cancer.

OBJECTIVE

This study analyzed our single-center experience with transanal endoscopic microsurgery for early rectal cancer.

DESIGN

Medical charts of patients who underwent transanal endoscopic microsurgery were reviewed to determine lesion characteristics, as well as operative and treatment characteristics. Complications and recurrences were recorded.

SETTINGS

The study was conducted at a single academic medical center.

PATIENTS

Patients with early stage cancer (T1 or T2, N0, and M0) of the rectum were included.

MAIN OUTCOME MEASURES

Local and overall recurrence and disease-specific survival were measured.

RESULTS

A total of 92 patients were analyzed. Median follow-up was 4.6 years. Negative margins were obtained in 98.9%. Length of stay was 1 day for 95.4% of patients. The complication rate was 10.9% (n = 10), including urinary retention at 4.3% (n = 4) and postoperative bleeding at 4.3% (n = 4). Preoperative staging included 54 at T1 (58.7%) and 38 at T2 (41.3%). Adjuvant therapy was recommended for all of the T2 and select T1 lesions with adverse features on histology. The final pathologic stages of tumors were ypT0 at 8.7% (n = 8), pT1 at 58.7% (n = 54), pT2 at 23.9% (n = 22), and ypT2 at 8.7% (n = 8). The 3-year local recurrence risk was 2.4% (SE = 1.7), and overall recurrence was 6.7% (SE = 2.9). There were no recurrences among patients with complete pathologic response to neoadjuvant therapy. Mean time to recurrence was 2.5 years (SD = 1.43). A total of 89.2% of patients with very low tumors underwent curative resection without a permanent stoma (33/37). The 3-year disease-specific survival rate was 98.6% (95% CI, 90.4%-99.8%), and overall survival rate was 89.4% (95% CI, 79.9%-94.6%).

LIMITATIONS

The study was limited by its single-center retrospective experience.

CONCLUSIONS

Transanal endoscopic microsurgery provides comparable oncologic outcomes to radical resection in properly selected patients with early rectal cancer. Sphincter preservation rates approach 90% even in patients with very distal rectal cancer.

Transanal minimally invasive surgery: initial experience and short-term functional results

BACKGROUND

Currently, the preferred method for local excision of rectal polyps is transanal endoscopic microsurgery, avoiding rectal resection. Transanal minimally invasive surgery is a relatively new technique using a disposable port in combination with conventional laparoscopic instruments. This method is less expensive as compared with transanal endoscopic microsurgery, relatively easy to learn, and available. Despite wide adoption of transanal minimally invasive surgery, to date only a few series on the implementation and use of this technique are reported, and detailed information on the effect of transanal minimally invasive surgery on fecal continence is not available.

OBJECTIVE

The purpose of this work was to prospectively assess the functional outcome after transanal minimally invasive surgery using the Fecal Incontinence Severity Index preoperatively and postoperatively.

DESIGN

This was a prospective cohort study.

SETTINGS

The study was conducted at a large teaching hospital.

PATIENTS

Patients included those who underwent transanal minimally invasive surgery between October 2011 and September 2013.

INTERVENTIONS

Transanal minimally invasive surgery was studied.

MAIN OUTCOME MEASURES

We measured postoperative surgical and functional results.

RESULTS

A total of 37 patients underwent transanal minimally invasive surgery during our study period. Short-term morbidity rate was 14%, and positive resection margins were reported in 6 cases (16%); in 1 of these patients, a local recurrence was observed. Overall, there was a significant decline in preoperative and postoperative Fecal Incontinence Severity Index scores (p = 0.02), indicating an improvement in anorectal function after transanal minimally invasive surgery for patients with impaired preoperative continence. Seventeen patients (49%) had impaired continence before transanal minimally invasive surgery (mean Fecal Incontinence Severity Index score = 21). Continence improved in 15 (88%) of these patients after surgery; no change was observed in 1 patient (6%), and continence further decreased in another. In addition, 18 patients (51%) had normal preoperative continence (Fecal Incontinence Severity Index score = 0), of which 83% had no change in functionality, and continence decreased in 3.

LIMITATIONS

No quality of life was measured.

CONCLUSIONS

Short-term functional results of transanal minimally invasive surgery for rectal polyps are excellent and comparable to functional results using the dedicated transanal endoscopic microsurgery equipment. More research on outcome after transanal minimally invasive surgery is needed to assess morbidity rates and oncologic clearance.

Pressing the nerve alters muscle fiber types of the peroneus longus in rats: preliminary evidence for external anal sphincteroplasty

Background

Studies have demonstrated that anal reconstruction with a gracilis graft pressing the dominant nerve could be used to treat fecal incontinence. However, the detailed mechanism by this remains unknown. Herein, we evaluated the alteration in muscle fiber types and contractility of the peroneus longus muscle in rats after pressing its dominant nerves.

Material/Methods

The rat soleus and peroneus longus were exposed during surgery. The superficial peroneal nerve was pressed so that the peroneus longus temporarily lost its innervation. The epimysium between the soleus and the peroneus longus was removed. The end point of the soleus was cut off and the epimysium of the contact surfaces of the soleus and the peroneus longus were sutured. Five months later, peroneus longus contractility was recorded by the myograph system, and types of muscle fibers were observed using the myosin ATPase staining method.

Results

The skeletal muscle fiber type underwent adaptive changes due to double innervations with both fast and slow muscle nerves. Compared with other groups, the percentage of type I fibers in the peroneus longus increased significantly in the group of rats with the pressure on the nerve and removal of the sarcolemma. The maximal contraction and relaxation time at the single twitch and complete tetanus of the peroneus longus were also increased.

Conclusions

Our results show that pressing dominant nerves alter the skeletal muscle fiber types of the peroneus longus, which lead to increased maximal contraction and relaxation time, and significantly improve the ability in resistance to fatigue in rats. This study provides a basis for future clinical studies for external anal sphincter reconstruction using gracilis grafts that are doubly innervated by pressing on its dominant nerve.

Anorectal and sexual functions after preoperative radiotherapy and full-thickness local excision of rectal cancer

AIMS

Local excision with preoperative radiotherapy may be considered as alternative management to abdominal surgery alone for small cT2-3N0 tumours. However, little is known about anorectal and sexual functions after local excision with preoperative radiotherapy. Evaluation of this issue was a secondary aim of our previously published prospective multicentre study.

METHODS

Functional evaluation was based on a questionnaire completed by 44 of 64 eligible disease-free patients treated with preoperative radiotherapy and local excision. Additionally, ex post, these results were confronted with those recorded retrospectively in the control group treated with anterior resection alone (N = 38).

RESULTS

In the preoperative radiotherapy and local excision group, the median number of bowel movements was two per day, incontinence of flatus occurred in 51% of patients, incontinence of loose stool in 46%, clustering of stools in 59%, and urgency in 49%; these symptoms occurred often or very often in 11%-21% of patients. Thirty-eight per cent of patients claimed that their quality of life was affected by anorectal dysfunction. Nineteen per cent of men and 20% of women claimed that the treatment negatively influenced their sexual life. The anorectal functions in the preoperative radiotherapy and local excision group were not much different from that observed in the anterior resection alone group.

CONCLUSIONS

Our study suggests that anorectal functions after preoperative radiotherapy and local excision may be worse than expected and not much different from that recorded after anterior resection alone. It is possible that radiotherapy compromises the functional effects achieved by local excision.

Transanal endoscopic microsurgery: impact on fecal incontinence and quality of life

BACKGROUND

Anal dilation during tumour excision with transanal endoscopic microsurgery (TEM) has caused concerns regarding postoperative anal function. We sought to determine whether TEM affects anorectal function and quality of life.

METHODS

All patients undergoing TEM between March 2007 and December 2008 were considered for inclusion. We excluded patients who were treated with subsequent radical resection, unavailable for interview or deceased. Patients were interviewed by phone to measure the preoperative and postoperative function using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire- Core 30 (EORTC QLQ-C30) and Core 38 (CR38) instruments, the Fecal Incontinence Severity Index (FISI) and the Fecal Incontinence Quality of Life (FIQL) questionnaires. Statistical analysis involved the Wilcoxon signed rank test and Spearman rank correlation coefficient.

RESULTS

Forty patients received TEM; 30 of them met all inclusion criteria and agreed to participate. The median age was 70 (42-93) years, and median follow-up time between the interview and the operation was 365 (55-712) days. Tumours excised included 19 adenomas, 8 carcinomas and 3 carcinoid tumours. The median distance from the tumour to the anal verge was 6.5 (2-13) cm. Median length of stay was 1 (0-12) day. For most aspects of quality of life, there were no detectable differences after surgery. The EORTC QLQ-C30 showed a significant improvement in diarrhea (27.8 v. 10, p = 0.002). The FIQL scores improved with surgery (3.59 v. 3.85, p = 0.020). There was no difference in pre- versus postoperative FISI scores (6.7 v. 6.3, p = 0.93).

CONCLUSION

Despite a large operating rectoscope, TEM improves quality of life related to fecal incontinence and does not have a negative impact on fecal continence.

Adaptation of quality of life module EORTC QLQ-CR29 for Polish patients with rectal cancer: initial assessment of validity and reliability

Heath related quality of life has been an important object of interest in the clinical practice, focused on assessment of treatment effects from patient's point of view, with particular emphasis placed on effect of treatment on daily patient functioning. Concept of health-related quality of life needs valid and reliable instruments.The aim of the study was to present the process of validation of a new version of EORTC QLQ-CR29 module in Polish patients suffering from rectal cancer.Material and methods. EORTC QLQ-CR29 module comprises 29 questions, and was adapted to Polish cultural conditions based on EORTC procedure. Data collected from 20 patients were analyzed, their agreement with theoretical and empirical structure was assessed. Convergent and discriminant validity were analyzed with multi trait scaling.Reliability was assessed with Cronbach alpha coefficient. Known group validity was assessed in terms of differences between men and women, and between stoma and non-stoma patients. Exact Mann-Whitney test was used. P values lower than 0.05 were considered significant.Results. Scales built on bases of empirical model of module had higher validity and reliability than those based on theoretical model.There were no significant differences between men and women in health-related quality of life. Significantly higher values were observed in non-stoma patients on body image scale and for leakage of stool item. Reversed relationship was observed in case of abdominal and buttocks pain, as well as embarrassment because of bowel movements.Conclusions. Module CR29 is a valid and reliable tool, which enables standardized measurement of treatment effects, suggested for use as main tool measuring impact of disease itself and applied treatment on health-related quality of life of rectal cancer patients.

Transanal endoscopic microsurgery is superior to transanal excision of rectal adenomas

AIM

Comparison of transanal excision (TE) and transanal endoscopic microsurgery (TEM) of rectal adenomas (RA) has rarely been performed.

METHOD

From 1990 to 2007, the results of TE (43 RA) and TEM (216 RA) were compared. Rectal adenomas were matched for diameter and distance from the anal verge.

RESULTS

Operation time was 47.5 min for TE and 35 min for TEM (P < 0.001). Morbidity was 10% after TE and 5.3% after TEM (P < 0.001). Negative resection margins were observed in 50% after TE and 88% after TEM (P < 0.001). Fragmentation of the excised specimen was observed in 23.8% after TE and 1.4% after TEM (P < 0.001). In cases of fragmentation, positive resection margins were observed more frequently. Recurrence was 28.7% after TE and 6.1% after TEM (P < 0.001). After TE, RA with a negative resection margin had a local recurrence rate of 0%, compared with 59.6% with a positive margin (P < 0.001), and after TEM these rates were 3.2 and 7.7% (P = 0.3), respectively.

CONCLUSION

Transanal endoscopic microsurgery is superior to transanal excision of RA.

Polymorphisms of GSTT1 and GSTM1 and increased micronucleus frequencies in peripheral blood lymphocytes in residents at an e-waste dismantling site in China

In the present study, we investigated whether genetic polymorphisms of metabolic enzymes in an exposed population were associated with genotoxic effects of the pollutants from e-waste in 58 subjects (the exposed) resided in a typical e-waste recycling site and 80 subjects (the controls) from a village away from the recycling site. Effects of genetic polymorphisms of glutathione S-transferases (GSTs) (GSTT1 and GSTM1) on the frequency of micronucleated binucleated cells (MNed BNC) in peripheral blood lymphocytes were evaluated. GSTM1 and GSTT1 were typed using PCR-restriction fragment length polymorphism methods. Cytogenetic alterations were evaluated using the cytokinesis-block micronucleus assay. The MNed BNC frequency was significantly higher in the exposed group (median: 4.0 per thousand, IQR: 2.0-7.0 per thousand) than in the control group (median: 1.0 per thousand, IQR: 0.0-2.0 per thousand, P < 0.01 for both comparisons); sera GST activities were also higher in the exposed subjects with either non-null GSTT1 (mean +/- SD: 20.27 +/- 6.43) or non-null GSTM1 (mean +/- SD: 19.71 +/- 4.89) than in the controls (mean +/- SD: 18.79 +/- 4.91 and 19.34 +/- 6.42, respectively, P < 0.05 for both). Although the increased MNed BNC frequencies among the exposed group may be associated with the co-exposure of various chemical pollutants in the environment, there was no statistical evidence of an association between GSTs genotypes and frequencies of micronuclei in the study population. Because this study size was small, the mechanism of genotoxic effects caused by exposure to e-waste needs to be further validated in larger studies.