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Baral JEM, Kouladouros K. Completion Surgery after Non-Curative Local Resection of Early Rectal Cancer. Visc Med 2024; 40:144-149. [PMID: 38873629 PMCID: PMC11166898 DOI: 10.1159/000538840] [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: 12/03/2023] [Accepted: 04/10/2024] [Indexed: 06/15/2024] Open
Abstract
Background The expanding indications of local - endoscopic and transanal surgical - resection of early rectal cancer has led to their increased popularity and inclusion in the treatment guidelines. The accuracy of the current diagnostic tools in identifying the low-risk T1 tumors that can be curatively treated with a local resection is low, and thus several patients require additional oncologic surgery with total mesorectal excision (TME). An efficient clinical strategy which avoids overtreatment and obstacle surgical procedures is under debate between different disciplines. Summary Completion surgery has comparable outcomes to primary surgery regarding perioperative morbidity and mortality but also recurrence rates and overall survival. However, local scarring in the mesorectum can make mesorectal excision technically challenging, especially after full-thickness resections, and has been associated with increased rates of permanent ostomy and worse quality of the TME specimen. This risk seems to be lower after muscle-sparing procedures like endoscopic submucosal dissection, which seem to show a benefit in comparison to full-thickness resections. Key Messages Completion surgery after non-curative local resection of gastrointestinal malignancies is safe and feasible. Full-thickness resection techniques can cause scarring of the mesorectum; therefore, muscle-sparing procedures should be preferred.
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Affiliation(s)
| | - Konstantinos Kouladouros
- Central Interdisciplinary Endoscopy, Department of Hepatology and Gastroenterology, Charité University Hospital Berlin – Campus Virchow Klinikum, Berlin, Germany
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Coco C, Delrio P, Rega D, Amodio LE, Pucciarelli S, Spolverato G, Belluco C, Lauretta A, Poggioli G, Rocco G, Bianco F, Marsanic P, Sica G, Tondolo V, Rizzo G. Completion total mesorectal excision after neoadjuvant radiochemotherapy and local excision for rectal cancer. Colorectal Dis 2024; 26:281-289. [PMID: 38131642 DOI: 10.1111/codi.16834] [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: 05/15/2023] [Revised: 09/10/2023] [Accepted: 11/18/2023] [Indexed: 12/23/2023]
Abstract
AIM Local excision (LE) in selected cases after neoadjuvant radiochemotherapy (RCT) for locally advanced rectal cancer in clinically complete or major responders has been recently reported as an alternative to standard radical resection. Completion total mesorectal excision (cTME) is generally performed when high-risk pathological features are found in LE surgical specimens. The aim of this study was to evaluate the incidence of residual tumour and lymph node metastases after cTME in patients previously treated by RCT + LE. The secondary aims were to quantify the rate of postoperative morbidity and mortality and to evaluate the long-term oncological outcome of this group of patients. METHODS All patients treated from 2007 to 2020 by LE for locally advanced rectal cancer with a clinically complete or major response to RCT who had a subsequent cTME for high-risk pathological factors (ypT >1 and/or TRG >2 and/or positive margins) were included in this multicentre retrospective study. Pathological data, postoperative short-term morbidity (classified according to Clavien-Dindo) and mortality and oncological long-term outcome after cTME were recorded in a database. Statistical analysis was performed using Wizard for iOS version 1.9.31. RESULTS A total of 47 patients were included in the study. The rate of R0 resection was 95.7%, and a sphincter-saving procedure was performed in 37 patients (78.7%), with a protective stoma rate of 78.4%. In 28 cases (59.6%), it was possible to perform a minimally invasive approach. A residual tumour (pT and/or pN) on cTME specimens was found in 21 cases (44.7%). The rate of lymph node metastases was 12.8%. The overall short-term (within 30 days) postoperative morbidity was 34%, but grade >2 postoperative complications occurred in only nine patients (19.1%), with a reoperation rate of 6.4%. No short-term postoperative deaths occurred. At a median follow-up of 57 months (range: 21-174), the long-term stoma-free rate was 70.2%, and the actuarial 5-year overall survival (OS), disease-free survival (DFS) and local control (LC) were 86.7%, 88.9% and 95.7%, respectively. CONCLUSION When patients exhibit high-risk pathological factors after RCT + LE, cTME should be suggested due to the high risk of residual tumour or lymph node involvement (44.7%). The results after cTME in terms of the rate of R0 resection, sphincter-saving procedure, postoperative morbidity and mortality and long-term oncological outcome seem to be acceptable and do not represent a contraindication to use LE as a first-step treatment in patients with major or complete clinical response after RCT.
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Affiliation(s)
- Claudio Coco
- U.O.C. Chirurgia Generale 2, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Paolo Delrio
- Department of Abdominal Oncology, Colorectal Surgical Oncology, Istituto nazionale Tumori - IRCCS "Fondazione G. Pascale", Naples, Italy
| | - Daniela Rega
- Department of Abdominal Oncology, Colorectal Surgical Oncology, Istituto nazionale Tumori - IRCCS "Fondazione G. Pascale", Naples, Italy
| | - Luca Emanuele Amodio
- U.O.C. Chirurgia Generale 2, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | - Gaya Spolverato
- UOC Chirurgia Generale 3, Azienda Ospedale-Università Padova, Padova, Italy
| | - Claudio Belluco
- Department of Surgical Oncology, CRO Aviano National Cancer Institute IRCCS, Aviano, Italy
| | - Andrea Lauretta
- Department of Surgical Oncology, CRO Aviano National Cancer Institute IRCCS, Aviano, Italy
| | - Gilberto Poggioli
- Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giuseppe Rocco
- Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesco Bianco
- General and Colorectal Surgery Unit, S. Leonardo Hospital/ASL-Na3-sud, Castellammare di Stabia, Italy
| | | | - Giuseppe Sica
- Department of General Surgery, University of Rome Tor Vergata, Rome, Italy
| | - Vincenzo Tondolo
- Digestive and Colo-Rectal Surgery Unit, Ospedale Isola Tiberina Gemelli Isola, Rome, Italy
| | - Gianluca Rizzo
- Digestive and Colo-Rectal Surgery Unit, Ospedale Isola Tiberina Gemelli Isola, Rome, Italy
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Rega D, Granata V, Romano C, Fusco R, Aversano A, Ravo V, Petrillo A, Pecori B, Di Girolamo E, Tatangelo F, Avallone A, Delrio P. Total mesorectal excision after rectal-sparing approach in locally advanced rectal cancer patients after neoadjuvant treatment: a high volume center experience. Ther Adv Gastrointest Endosc 2024; 17:26317745241231098. [PMID: 39044726 PMCID: PMC11265235 DOI: 10.1177/26317745241231098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 01/19/2024] [Indexed: 07/25/2024] Open
Abstract
Background In patient with a complete or near-complete clinical response after neoadjuvant treatment for locally advanced rectal cancer, the organ-sparing approach [watch & wait (W&W) or local excision (LE)] is a possible alternative to major rectal resection. Although, in case of local recurrence or regrowth, after these treatments, a total mesorectal excision (TME) can be operated. Method In this retrospective study, we selected 120 patients with locally advanced rectal cancer (LARC) who had a complete or near-complete clinical response after neoadjuvant treatment, from June 2011 to June 2021. Among them, 41 patients were managed by W&W approach, whereas 79 patients were managed by LE. Twenty-three patients underwent salvage TME for an unfavorable histology after LE (11 patients) or a local recurrence/regrowth (seven patients in LE group - five patients in W&W group), with a median follow-up of 42 months. Results Following salvage TME, no patients died within 30 days; serious adverse events occurred in four patients; 8 (34.8%) patients had a definitive stoma; 8 (34.8%) patients undergone to major surgery for unfavorable histology after LE - a complete response was confirmed. Conclusion Notably active surveillance after rectal sparing allows prompt identifying signs of regrowth or relapse leading to a radical TME. Rectal sparing is a possible strategy for LARC patients although an active surveillance is necessary.
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Affiliation(s)
- Daniela Rega
- Colorectal Surgical Oncology, Department of Abdominal Oncology, Istituto Nazionale Tumori-IRCCS “Fondazione G. Pascale”, Via Semmola 2, Naples 80131, Italy
| | - Vincenza Granata
- Radiology Division, Istituto Nazionale Tumori-IRCCS “Fondazione G. Pascale”, Naples, Italy
| | - Carmela Romano
- Experimental Clinical Abdominal Oncology, Department of Abdominal Oncology, Istituto
- Nazionale Tumori-IRCCS “Fondazione G. Pascale”, Naples, Italy
| | | | - Alessia Aversano
- Colorectal Surgical Oncology, Department of Abdominal Oncology, Istituto Nazionale Tumori-IRCCS “Fondazione G. Pascale”, Naples, Italy
| | - Vincenzo Ravo
- Radiation Therapy, Istituto Nazionale Tumori-IRCCS “Fondazione G. Pascale”, Naples, Italy
| | - Antonella Petrillo
- Radiology Division, Istituto Nazionale Tumori-IRCCS “Fondazione G. Pascale”, Naples, Italy
| | - Biagio Pecori
- Radioprotection and Innovative Technologies, Istituto Nazionale Tumori IRCCS Fondazione
- Pascale-IRCCS di Napoli, Naples, Italy
| | - Elena Di Girolamo
- Gastroenterology and Endoscopy Unit, Department of Abdominal Oncology, Istituto
- Nazionale Tumori-IRCCS “Fondazione G. Pascale”, Naples, Italy
| | - Fabiana Tatangelo
- Pathology and Cytopathology Unit, Department of Support to Cancer Pathways Diagnostics Area, Istituto Nazionale Tumori-IRCCS “Fondazione G. Pascale”, Naples, Italy
| | - Antonio Avallone
- Experimental Clinical Abdominal Oncology, Department of Abdominal Oncology, Istituto
- Nazionale Tumori-IRCCS “Fondazione G. Pascale”, Naples, Italy
| | - Paolo Delrio
- Colorectal Surgical Oncology, Department of Abdominal Oncology, Istituto Nazionale Tumori-IRCCS “Fondazione G. Pascale”, Naples, Italy
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Tribonias G, Komeda Y, Leontidis N, Anagnostopoulos G, Palatianou M, Mpellou G, Pantoula P, Manola ME, Paspatis G, Tzouvala M, Kashida H. Endoscopic intermuscular dissection (EID) for removing early rectal cancers and benign fibrotic rectal lesions. Tech Coloproctol 2023; 27:1393-1400. [PMID: 37773471 DOI: 10.1007/s10151-023-02862-7] [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: 04/07/2023] [Accepted: 09/13/2023] [Indexed: 10/01/2023]
Abstract
In the current era of screening colonoscopy and increasing incidence of early rectal cancer, interventional endoscopy moves toward resections in deeper planes than the submucosal layer. Several reports support the use of endoscopic intermuscular dissection (EID) instead of endoscopic submucosal dissection (ESD) for the removal of deeply invasive rectal submucosal cancers. The resection plane into the intermuscular space, the space between the longitudinal (external) and circular (internal) muscle layer, allows radical removal of rectal invasive submucosal cancers. Furthermore, the technique offers the potential for dissection of scarred and severe fibrotic lesions in the rectum by cutting deeper and performing a partial myectomy avoiding the narrow submucosal space. We present 23 cases of EIDs both for deeply invasive rectal cancers and benign rectal lesions. This is the first report in the literature of EID resections for malignant and benign disease, including cases of severely fibrotic rectal lesions.
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Affiliation(s)
- G Tribonias
- Gastroenterology Department, General Hospital of Nikaia - Piraeus "Agios Panteleimon", Mantouvalou D.3, Nikaia, 18454, Athens, Greece.
| | - Y Komeda
- Department of Gastroenterology and Hepatology, Kindai University, Osaka, Japan
| | - N Leontidis
- Gastroenterology Department, General Hospital of Nikaia - Piraeus "Agios Panteleimon", Mantouvalou D.3, Nikaia, 18454, Athens, Greece
| | - G Anagnostopoulos
- Gastroenterology Department, General Hospital of Nikaia - Piraeus "Agios Panteleimon", Mantouvalou D.3, Nikaia, 18454, Athens, Greece
| | - M Palatianou
- Gastroenterology Department, General Hospital of Nikaia - Piraeus "Agios Panteleimon", Mantouvalou D.3, Nikaia, 18454, Athens, Greece
| | - G Mpellou
- Gastroenterology Department, General Hospital of Nikaia - Piraeus "Agios Panteleimon", Mantouvalou D.3, Nikaia, 18454, Athens, Greece
| | - P Pantoula
- Pathology Department, General Hospital of Nikaia - Piraeus "Agios Panteleimon", Nikaia, Athens, Greece
| | - M-E Manola
- Gastroenterology Department, General Hospital of Nikaia - Piraeus "Agios Panteleimon", Mantouvalou D.3, Nikaia, 18454, Athens, Greece
| | - G Paspatis
- Gastroenterology Department, Venizeleio General Hospital, Heraklion, Crete, Greece
| | - M Tzouvala
- Gastroenterology Department, General Hospital of Nikaia - Piraeus "Agios Panteleimon", Mantouvalou D.3, Nikaia, 18454, Athens, Greece
| | - H Kashida
- Department of Gastroenterology and Hepatology, Kindai University, Osaka, Japan
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5
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Moons LMG, Bastiaansen BAJ, Richir MC, Hazen WL, Tuynman J, Elias SG, Schrauwen RWM, Vleggaar FP, Dekker E, Bos P, Fariña Sarasqueta A, Lacle M, Hompes R, Didden P. Endoscopic intermuscular dissection for deep submucosal invasive cancer in the rectum: a new endoscopic approach. Endoscopy 2022; 54:993-998. [PMID: 35073588 DOI: 10.1055/a-1748-8573] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The risk of lymph node metastasis associated with deep submucosal invasion should be balanced against the mortality and morbidity of total mesorectal excision (TME). Dissection through the submucosa hinders radical deep resection, and full-thickness resection may influence the outcome of completion TME. Endoscopic intermuscular dissection (EID) in between the circular and longitudinal part of the muscularis propria could potentially provide an R0 resection while leaving the rectal wall intact. METHODS In this prospective cohort study, the data of patients treated with EID for suspected deep submucosal invasive rectal cancer between 2018 and 2020 were analyzed. Study outcomes were the percentages of technical success, R0 resection, curative resection, and adverse events. RESULTS 67 patients (median age 67 years; 73 % men) were included. The median lesion size was 25 mm (interquartile range 20-33 mm). The rates of overall technical success, R0 resection, and curative resection were 96 % (95 %CI 89 %-99 %), 81 % (95 %CI 70 %-89 %), and 45 % (95 %CI 33 %-57 %). Only minor adverse events occurred in eight patients (12 %). CONCLUSION EID for deep invasive T1 rectal cancer appears to be feasible and safe, and the high R0 resection rate creates the potential of rectal preserving therapy in 45 % of patients.
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Affiliation(s)
- Leon M G Moons
- Department of Gastroenterology & Hepatology, UMC Utrecht, Utrecht, The Netherlands
| | | | - Milan C Richir
- Department of Surgery, UMC Utrecht, Utrecht, The Netherlands
| | - Wouter L Hazen
- Department of Gastroenterology & Hepatology, Elizabeth Tweesteden Ziekenhuis, Tilburg, The Netherlands
| | - Jurriaan Tuynman
- Department of Surgery, Amsterdam UMC, Amsterdam, The Netherlands
| | - Sjoerd G Elias
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Ruud W M Schrauwen
- Department of Gastroenterology & Hepatology, Bernhoven, Uden, The Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology & Hepatology, UMC Utrecht, Utrecht, The Netherlands
| | - Evelien Dekker
- Department of Gastroenterology & Hepatology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Philip Bos
- Department of Gastroenterology & Hepatology, Gelderse Vallei, Ede, The Netherlands
| | | | - Miangela Lacle
- Department of Pathology, UMC Utrecht, Utrecht, The Netherlands
| | - Roel Hompes
- Department of Surgery, Amsterdam UMC, Amsterdam, The Netherlands
| | - Paul Didden
- Department of Gastroenterology & Hepatology, UMC Utrecht, Utrecht, The Netherlands
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6
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Wyatt JNR, Powell SG, Altaf K, Barrow HE, Alfred JS, Ahmed S. Completion Total Mesorectal Excision After Transanal Local Excision of Early Rectal Cancer: A Systematic Review and Meta-analysis. Dis Colon Rectum 2022; 65:628-640. [PMID: 35143429 DOI: 10.1097/dcr.0000000000002407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Completion total mesorectal excision is recommended when local excision of early rectal cancers demonstrates high-risk histopathological features. Concerns regarding the quality of completion resections and the impact on oncological safety remain unanswered. OBJECTIVE This study aims to summarize and analyze the outcomes associated with completion surgery and undertake a comparative analysis with primary rectal resections. DATA SOURCES Data sources included PubMed, Cochrane library, MEDLINE, and Embase databases up to April 2021. STUDY SELECTION All studies reporting any outcome of completion surgery after transanal local excision of an early rectal cancer were selected. Case reports, studies of benign lesions, and studies using flexible endoscopic techniques were not included. INTERVENTION The intervention was completion total mesorectal excision after transanal local excision of early rectal cancers. MAIN OUTCOME MEASURES Primary outcome measures included histopathological and long-term oncological outcomes of completion total mesorectal excision. Secondary outcome measures included short-term perioperative outcomes. RESULTS Twenty-three studies including 646 patients met the eligibility criteria, and 8 studies were included in the meta-analyses. Patients undergoing completion surgery have longer operative times (standardized mean difference, 0.49; 95% CI, 0.23-0.75; p = 0.0002) and higher intraoperative blood loss (standardized mean difference, 0.25; 95% CI, 0.01-0.5; p = 0.04) compared with primary resections, but perioperative morbidity is comparable (risk ratio, 1.26; 95% CI, 0.98-1.62; p = 0.08). Completion surgery is associated with higher rates of incomplete mesorectal specimens (risk ratio, 3.06; 95% CI, 1.41-6.62; p = 0.005) and lower lymph node yields (standardized mean difference, -0.26; 95% CI, -0.47 to 0.06; p = 0.01). Comparative analysis on long-term outcomes is limited, but no evidence of inferior recurrence or survival rates is found. LIMITATIONS Only small retrospective cohort and case-control studies are published on this topic, with considerable heterogeneity limiting the effectiveness of meta-analysis. CONCLUSIONS This review provides the strongest evidence to date that completion surgery is associated with an inferior histopathological grade of the mesorectum and finds insufficient long-term results to satisfy concerns regarding oncological safety. International collaborative research is required to demonstrate noninferiority. REGISTRATION NO CRD42021245101.
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Affiliation(s)
- James N R Wyatt
- Department of Colorectal Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
- University of Liverpool, Liverpool, United Kingdom
| | - Simon G Powell
- Department of Colorectal Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
- University of Liverpool, Liverpool, United Kingdom
| | - Kiran Altaf
- Department of Colorectal Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Hannah E Barrow
- Department of Colorectal Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Joshua S Alfred
- Department of Colorectal Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Shakil Ahmed
- Department of Colorectal Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
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7
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Rutgers MLW, Bemelman WA, Khan JS, Hompes R. The role of transanal total mesorectal excision. Surg Oncol 2021; 43:101695. [PMID: 34924223 DOI: 10.1016/j.suronc.2021.101695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 12/02/2021] [Accepted: 12/11/2021] [Indexed: 11/28/2022]
Abstract
At inception, transanal total mesorectal excision (TaTME) was hypothesized to be a solution for several problems encountered in pelvic surgery, particularly for distal rectal cancer. The transanal part of the procedure is less hampered by patient related factors such as visceral obesity and a narrow bony pelvis and can thus overcome access and visualization problems encountered with a pure abdominal approach. Clearly, as for any new technique, a learning curve needs to be negotiated, ideally without unacceptable harm to patients. Once in experienced hands, TaTME might overcome challenges found in anatomically challenging rectal cancer patients as well as for other indications. The role of TaTME is not to replace, but rather complement its abdominal counterpart.
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Affiliation(s)
- Marieke L W Rutgers
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands.
| | - Willem A Bemelman
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - Jim S Khan
- Department of Colorectal Surgery, Queen Alexandra Hospital, Portsmouth Hospital University NHS Trust, Portsmouth, United Kingdom
| | - Roel Hompes
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
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8
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Long-term outcomes of transanal endoscopic microsurgery for clinical complete response after neoadjuvant treatment in T2-3 rectal cancer. Surg Endosc 2021; 36:2906-2913. [PMID: 34231071 DOI: 10.1007/s00464-021-08583-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 06/02/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Organ sparing by the transanal endoscopic microsurgery (TEM) procedure is a treatment for patients with locally advanced rectal cancer after chemoradiotherapy (CRT) and complete clinical response (cCR). AIMS To assess the surgical and long-term oncological outcomes of TEM for the treatment in T2-3 rectal cancer after CRT and cCR. METHODS This study was a retrospective review of a prospective database of patients with rectal cancer who underwent TEM after CRT and cCR from April 2011 to March 2020. RESULTS 52 patients underwent TEM during a period of 9 years. This group of patients included 27 females and 25 males. The median age was 62 (32-86) years, lesion size was 2.5 (1-4) cm, and lesion distance from the anal verge 7.3 (4-10) cm. Median operative time was 79.5 (25-120) min and hospital stay was 1 day (14 h-4 days). Morbidity rate was 13.5% and reoperation rate due to major complications was 3.8%. Final histological findings confirmed 34 (65.4%) patients with ypT0, 7 (13.5%), 6 (11.5%), and 5 (9.6%) patients with carcinoma ypT1, ypT2, and ypT3, respectively. After a median follow-up period of 86 (5-107) months, 1 (2.4%) patient had local recurrences and 3 (7.3%) distant metastases. The 5-year disease-free survival was 91.7% and 5-year overall survival 89.5%. CONCLUSION Our experience has shown significant rates of ypT0 and ypT1 associated with excellent long-term results. Performing TEM to treat T2-3N0 rectal cancer after CRT and cCR appears to be an oncologically safe and effective procedure.
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9
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The impact of transanal local excision of early rectal cancer on completion rectal resection without neoadjuvant chemoradiotherapy: a systematic review. Tech Coloproctol 2021; 25:997-1010. [PMID: 34173121 DOI: 10.1007/s10151-020-02401-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 12/28/2020] [Indexed: 12/24/2022]
Abstract
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.
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10
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Levic Souzani K, Bulut O, Kuhlmann TP, Gögenur I, Bisgaard T. Completion total mesorectal excision following transanal endoscopic microsurgery does not compromise outcomes in patients with rectal cancer. Surg Endosc 2021; 36:1181-1190. [PMID: 33629183 DOI: 10.1007/s00464-021-08385-2] [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: 10/01/2020] [Accepted: 02/09/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Transanal endoscopic microsurgery (TEM) represents a choice of treatment in patients with neoplastic lesions in the rectum. When TEM fails, completion total mesorectal excision (cTME) is often required. However, a concern is whether cTME increases the rate of abdominoperineal resections (APR) and is associated with higher risk of incomplete mesorectal fascia (MRF) resection. The aim of this study was to compare outcomes of cTME with primary TME (pTME) in patients with rectal cancer. METHODS This was a nationwide study on all patients with cTME from the Danish Colorectal Cancer Group database between 2005 and 2015. Patients with cTME were compared to patients with pTME after propensity score matching (matching ratio 1:2). Matching variables were age, gender, tumor distance from anal verge, American Society of Anesthesiologists (ASA) score and American Joint Committee on Cancer (AJCC) stage. RESULTS A total of 60 patients with cTME were compared with 120 patients with pTME. Patients with cTME experienced more intraoperative complications as compared to pTME patients (18.3% vs. 6.7%, p = 0.021). However, there was no difference in the rate of perforations at or near the tumor/previous TEM site (6.7% vs. 2.5%, p = 0.224), conversion to open surgery (p = 0.733) or 30-day morbidity (p = 0.86). On multivariate analysis, cTME was not a risk factor for APR (OR 2.49; 95% CI 0.95-6.56; p = 0.064) or incomplete MRF (OR 1.32; 95% CI 0.48-3.63; p = 0.596). There was no difference in the rate of local recurrence between cTME and pTME (5.2% vs. 4.3%, p = 0.1), distant metastases (6.8% vs. 6.8%, p = 1), or survival (p = 0.081). The mean follow-up time was 6 years. CONCLUSION In our study, the largest so far on the subject, we find no difference in postoperative short- or long-term outcomes between cTME and pTME.
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Affiliation(s)
- Katarina Levic Souzani
- Gastrounit - Surgical Division, Center for Surgical Research, Copenhagen University Hospital Hvidovre, Kettegaards Allé 30, 2650, Hvidovre, Denmark.
| | - Orhan Bulut
- Gastrounit - Surgical Division, Center for Surgical Research, Copenhagen University Hospital Hvidovre, Kettegaards Allé 30, 2650, Hvidovre, Denmark.,Institution of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Tine Plato Kuhlmann
- Department of Pathology, Herlev University Hospital, Copenhagen, Denmark.,Institution of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Danish Colorectal Cancer Group, Copenhagen, Denmark
| | - Ismail Gögenur
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Køge, Denmark.,Institution of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Danish Colorectal Cancer Group, Copenhagen, Denmark
| | - Thue Bisgaard
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Køge, Denmark.,Danish Colorectal Cancer Group, Copenhagen, Denmark
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Detering R, van Oostendorp SE, Meyer VM, van Dieren S, Bos ACRK, Dekker JWT, Reerink O, van Waesberghe JHTM, Marijnen CAM, Moons LMG, Beets-Tan RGH, Hompes R, van Westreenen HL, Tanis PJ, Tuynman JB. MRI cT1-2 rectal cancer staging accuracy: a population-based study. Br J Surg 2020; 107:1372-1382. [PMID: 32297326 PMCID: PMC7496930 DOI: 10.1002/bjs.11590] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 02/05/2020] [Accepted: 02/17/2020] [Indexed: 01/25/2023]
Abstract
Background Adequate MRI‐based staging of early rectal cancers is essential for decision‐making in an era of organ‐conserving treatment approaches. The aim of this population‐based study was to determine the accuracy of routine daily MRI staging of early rectal cancer, whether or not combined with endorectal ultrasonography (ERUS). Methods Patients with cT1–2 rectal cancer who underwent local excision or total mesorectal excision (TME) without downsizing (chemo)radiotherapy between 1 January 2011 and 31 December 2018 were selected from the Dutch ColoRectal Audit. The accuracy of imaging was expressed as sensitivity, specificity, and positive predictive value (PPV) and negative predictive value. Results Of 7382 registered patients with cT1–2 rectal cancer, 5539 were included (5288 MRI alone, 251 MRI and ERUS; 1059 cT1 and 4480 cT2). Among patients with pT1 tumours, 54·7 per cent (792 of 1448) were overstaged by MRI alone, and 31·0 per cent (36 of 116) by MRI and ERUS. Understaging of pT2 disease occurred in 8·2 per cent (197 of 2388) and 27·9 per cent (31 of 111) respectively. MRI alone overstaged pN0 in 17·3 per cent (570 of 3303) and the PPV for assignment of cN0 category was 76·3 per cent (2733 of 3583). Of 834 patients with pT1 N0 disease, potentially suitable for local excision, tumours in 253 patients (30·3 per cent) were staged correctly as cT1 N0, whereas 484 (58·0 per cent) and 97 (11·6 per cent) were overstaged as cT2 N0 and cT1–2 N1 respectively. Conclusion This Dutch population‐based analysis of patients who underwent local excision or TME surgery for cT1–2 rectal cancer based on preoperative MRI staging revealed substantial overstaging, indicating the weaknesses of MRI and missed opportunities for organ preservation strategies.
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Affiliation(s)
- R Detering
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - S E van Oostendorp
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, VU University, Amsterdam, the Netherlands
| | - V M Meyer
- Department of Surgery, Zwolle, the Netherlands
| | - S van Dieren
- Clinical Research Unit, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - A C R K Bos
- Department of Research, Netherlands Comprehensive Cancer Organization, Utrecht, the Netherlands
| | - J W T Dekker
- Department of Surgery, Reinier de Graaf Hospital, Delft, the Netherlands
| | - O Reerink
- Department of Radiotherapy, Isala Hospital, Zwolle, the Netherlands
| | | | | | - L M G Moons
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - R G H Beets-Tan
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - R Hompes
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | - P J Tanis
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - J B Tuynman
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, VU University, Amsterdam, the Netherlands
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Local excision following chemoradiotherapy in T2-T3 rectal cancer: current status and critical appraisal. Updates Surg 2019; 72:29-37. [PMID: 31621033 DOI: 10.1007/s13304-019-00689-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 10/10/2019] [Indexed: 12/18/2022]
Abstract
Local excision following chemoradiotherapy in rectal cancer is an organ-preserving procedure which aims at reducing morbidity and functional disorders associated with total mesorectal excision (TME) in selected patients. Although TME after chemoradiotherapy remains the gold standard for locally advanced mid and low rectal cancer, in the last years multicenter research trials have offered encouraging oncologic results which have allowed to preserve the rectum in patients with a pathologic complete response after chemoradiotherapy. A review of the available literature on this topic was conducted to define the state of the art of this conservative approach and to focus on the most controversial aspects concerning local excision performed after chemoradiotherapy, in particular tumor scatter and lymph node status, completion and salvage surgery, morbidity and quality of life. The analysis of these topics should be considered, in trial setting or in current practice, for their clinical implications. Oncologic outcomes of recent trials are encouraging for part of the patients presenting T2 rectal cancer; however, TME still remains the standard treatment in clinical practice. In such cases, local excision should include a surgical safety margin of at least 1 cm from the resection margin to achieve a true negative margin from residual tumor cells. The selection of the patients should be carefully performed and their consensus extremely detailed because TME is necessary in about 30% of cases. Failing that, morbidity and quality of life are negatively affected. However, about half of these patients refuse radical surgery (45%), thus undergoing only palliative care.
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Samalavicius NE, Dulskas A. Hybrid transanal and hand-assisted laparoscopic total mesorectal excision for unexpected low rectal cancer following transanal endoscopic microsurgery-a video vignette. Colorectal Dis 2019; 21:726-727. [PMID: 30920114 DOI: 10.1111/codi.14623] [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: 12/25/2018] [Accepted: 03/16/2019] [Indexed: 02/08/2023]
Affiliation(s)
- N E Samalavicius
- Department of Surgery, Klaipeda University Hospital, Klaipeda, Lithuania.,Faculty of Medicine, Department of Surgical Oncology, Clinic of Internal, Family Medicine and Oncology, Institute of Oncology, Vilnius University, Vilnius, Lithuania
| | - A Dulskas
- Faculty of Medicine, Department of Surgical Oncology, Clinic of Internal, Family Medicine and Oncology, Institute of Oncology, Vilnius University, Vilnius, Lithuania.,Faculty of Health Care, University of Applied Sciences, Vilnius, Lithuania.,Department of Surgical Oncology, National Cancer Institute, Vilnius, Lithuania
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Transanale totale mesorektale Exzision – eine sinnvolle Operationstechnik zur individualisierten Behandlung von Patienten mit Rektumkarzinom. COLOPROCTOLOGY 2019. [DOI: 10.1007/s00053-019-0362-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Coton C, Lefevre JH, Debove C, Creavin B, Chafai N, Tiret E, Parc Y. Does transanal local resection increase morbidity for subsequent total mesorectal excision for early rectal cancer? Colorectal Dis 2019; 21:15-22. [PMID: 30300969 DOI: 10.1111/codi.14445] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 07/30/2018] [Indexed: 02/06/2023]
Abstract
AIM Local excision is recommended for early rectal cancer (pT1). Complementary total mesorectal excision (cTME) is warranted when bad pathological features are present. The impact of a prior local resection on the outcome remains unclear. The aim of this study was to assess if prior local excision increases the morbidity of a subsequent cTME compared with primary TME. METHODS From 2001 to 2016 all patients who underwent TME after local excision for rectal adenocarcinoma were studied. All were matched (1:1) with patients who underwent primary TME, without neoadjuvant radiochemotherapy. The matching factors included age, sex, body mass index, American Society of Anesthesiologists score and type of surgery. Short-term morbidity and pathological examination of the resected specimen were compared. RESULTS Forty-one patients were included (14 women, 34%, mean age 65 ± 11 years), comprising classic transanal excision (66%) and transanal endoscopic microsurgery (34%), and were matched to 41 patients who had primary TME. cTME was significantly longer (315 min ± 87 vs 275 min ± 58, P = 0.03). The overall morbidity was 48.8% in the local excision group vs 31.7% in the control group (P = 0.18). Surgical morbidity was 31.7% vs 26.8% (P = 0.8). Anastomotic related morbidity was similar (local excision 17% vs TME 14.6%, P = 0.84) and the mean length of stay was similar (14 days) in both groups. There was a tendency to a worse quality of mesorectal excision in the cTME group (17% vs 5%, P = 0.15). CONCLUSION Local excision prior to TME for early rectal cancer tends to increase overall morbidity and may worsen the quality of the mesorectal plane but should be considered as a surgical approach in select cases.
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Affiliation(s)
- C Coton
- Department of Digestive and General Surgery, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
| | - J H Lefevre
- Department of Digestive and General Surgery, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
| | - C Debove
- Department of Digestive and General Surgery, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
| | - B Creavin
- Department of Colorectal Surgery, St Vincent's University Hospital, Dublin 4, Ireland
| | - N Chafai
- Department of Digestive and General Surgery, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
| | - E Tiret
- Department of Digestive and General Surgery, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
| | - Y Parc
- Department of Digestive and General Surgery, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
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