Outcomes of Closed Versus Open Defects After Local Excision of Rectal Neoplasms: A Multi-institutional Matched Analysis

Local Excision for Early Rectal Cancer

Local excision is an established treatment for significant benign rectal tumours and early-stage cancers. It provides cure for most patients with pT1 disease, with minimum impact on quality of life. It is particularly suitable for elderly or comorbid patients. Local excision is associated with a risk of local recurrence, and this may vary from 5 to 30%, as determined by pathological risk factors. Recurrent cancer may be challenging to manage, but this may be mitigated by early detection with intensive surveillance and the use of adjuvant radiotherapy. This approach offers a realistic option for organ preservation in carefully selected early-stage disease compared with primary treatment with radiotherapy or total neoadjuvant treatment.

Transanal full-thickness excision for rectal neoplasm: is it advisable to leave the defect open?

PURPOSE

After a full-thickness total wall excision of a rectal tumor, suturing the defect is generally recommended. Recently, due to various contradictory studies, there is a trend to leave the defects open. Therefore, this study aimed to determine whether leaving the defect open is an adequate management strategy compared with suturing it closed based on postoperative outcomes and recurrences.

METHODS

A retrospective review of our prospectively maintained database was conducted. Adult patients who underwent transanal surgery for rectal neoplasm in our institution from 1997 to 2019 were analyzed. Patients were divided into two groups: sutured (group A) or unsutured (group B) rectal defect. The primary outcomes were morbidity (early and late) and recurrence.

RESULTS

In total, 404 (239 men) patients were analyzed, 143 (35.4%) from group A and 261 (64.6%) from group B. No differences were observed in tumor size, distance from the anal verge or operation time. The overall incidence of complications was significantly higher in patients from group B, which nearly double the rate of group A. With a mean follow-up of 58 (range, 12-96) months, seven patients presented with a rectal stricture, all of them from group B.

CONCLUSIONS

We acknowledge the occasional impossibility of closing the defect in patients who undergo local excision; however, when it is possible, the present data suggest that there may be advantages to suturing the defect closed.

Short- and long-term outcomes in ypT2 rectal cancer patients after neoadjuvant therapy and local excision: a multicentre observational study

BACKGROUND

Although local excision (LE) after neoadjuvant treatment (NT) has achieved encouraging oncological outcomes in selected patients, radical surgery still remains the rule when unfavorable pathology occurs. However, there is a risk of undertreating patients not eligible for radical surgery. The aim of this study was to evaluate the outcomes of patients with pathological incomplete response (ypT2) in a multicentre cohort of patients undergoing LE after NT and to compare them with ypT0-is-1 rectal cancers.

METHODS

From 2010 to 2019, all patients who underwent LE after NT for rectal cancer were identified from five institutional retrospective databases. After excluding 12 patients with ypT3 tumors, patients with ypT2 tumors were compared to patients with ypT0-is-1 tumors). The endpoints of the study were early postoperative and long-term oncological outcomes.

RESULTS

A total of 177 patients (132 males, 45 females, median age 70 [IQR 16] years) underwent LE following NT. There were 46 ypT2 patients (39 males, 7 females, median age 72 [IQR 18.25] years) and 119 ypT0-is-1 patients (83 males, 36 females, median age 69 [IQR 15] years). Patients with pathological incomplete response (ypT2) were frailer than the ypT0-is-1 patients (mean Charlson Comorbidity Index 6.15 ± 2.43 vs. 5.29 ± 1.99; p = 0.02) and there was a significant difference in the type of NT used for the two groups (long- course radiotherapy: 100 (84%) vs. 23 (63%), p = 0.006; short-course radiotherapy: 19 (16%) vs. 17 (37%), p = 0.006). The postoperative rectal bleeding rate (13% vs. 1.7%; p = 0.008), readmission rate (10.9% vs. 0.8%; p = 0.008) and R1 resection rate (8.7% vs. 0; p = 0.008) was significantly higher in the ypT2 group. Recurrence rates were comparable between groups (5% vs. 13%; p = 0.15). Five-year overall survival was 91.3% and 94.9% in the ypT2 and ypT0-is-1 groups, respectively (p = 0.39), while 5-year cancer specific survival was 93.4% in the ypT2 group and 94.9% in the ypT0-is-1 group (p = 0.70). No difference was found in terms of 5-year local recurrence free-survival (p = 0.18) and 5-year distant recurrence free-survival (p = 0.37).

CONCLUSIONS

Patients with ypT2 tumors after NT and LE have a higher risk of late-onset rectal bleeding and positive resection margins than patients with complete or near complete response. However, long-term recurrence rates and survival seem comparable.

Endoscopic adventitial dissection of a rectal GI stromal cell tumor

Video 1Demonstration of endoscopic adventitial dissection.

Transanal Minimally-Invasive Surgery (TAMIS): Experience with No Closure of the Rectal Defect

Background In transanal minimally-invasive surgery (TAMIS), the closure of the rectal defect is controversial, and endoluminal suture is one of the most challenging aspects. The goal of the present study is to evaluate the short- and medium-term complications of a consecutive series of patients with extraperitoneal rectal injuries who underwent TAMIS without closure of the rectal defect.

Materials and Methods A prospective, longitudinal, descriptive study conducted between August 2013 and July 2019 in which all patients with extraperitoneal rectal lesions, who were operated on using the TAMIS technique, were consecutively included. The lesions were: benign lesions ≥ 3 cm; neuroendocrine tumors ≤ 2 cm; adenocarcinomas in stage T1N0; and adenocarcinomas in stage T2N0, with high surgical risk, or with the patients reluctant to undergo radical surgery, and others with doubts about complete remission after the neoadjuvant therapy. Bleeding, infectious complications, rectal stenosis, perforations, and death were evaluated.

Results A total of 35 patients were treated using TAMIS without closure of the defect. The average size of the lesions was of 3.68 ± 2.1 cm (95% confidence interval [95%CI]: 0.7 cm to 9 cm), their average distance from the anal margin was of 5.7 ± 1.48 cm, and the average operative time was of 39.2 ± 20.5 minutes, with a minimum postoperative follow-up of 1 year. As for the pathologies, they were: 15 adenomas; 3 carcinoid tumors; and 17 adenocarcinomas. In all cases, the rectal defect was left open.

The overall morbidity was of 14.2%. Two patients (grade II in the Clavien-Dindo classification) were readmitted for pain treatment, and three patients (grade III in the Clavien-Dindo classification) were assisted due to postoperative bleeding, one of whom required reoperation.

Conclusion The TAMIS technique without closure of the rectal defect yields good results, and present a high feasibility and low complication rate.

Long-term outcomes of open versus closed rectal defect after transanal endoscopic microscopic surgery

AIM

Management of the rectal defect after transanal endoscopic microsurgery (TEM) is a matter of debate. Data are lacking on long term outcomes and continence of patients with open or closed rectal defect. We sought to analyse these in a retrospective cohort study.

METHODS

Patients undergoing TEM via the Specialist Early Rectal Cancer (SERC) MDT between 2012 and 2019 were included from a prospectively maintained database. These were divided into two groups - open and closed, based on management of rectal defect. Patient demographics and outcomes, including pre- and postoperative oncological staging, morbidity, mortality, length of stay and faecal incontinence severity score (FISI) scores were assessed.

RESULTS

A total of 170 matched patients were included (70-open, 100-closed rectal defects). Short-term complications (bleeding, infection, urinary retention and infection, length of stay and pain) were 18.8% with no significant difference between the two groups (22% vs. 16%). Most of the defects were well healed upon endoscopic follow-up; more unhealed/sinus formation was noticed in the open group (p = 0.01); more strictures were encountered in the closed group (p = 0.04). Comparing the open and closed defect groups, there was no difference in the functional outcome of patients in those who developed sinus (p = 0.87) or stricture (p = 0.79) but a significant difference in post-TEMS FISI scores in those with healed scar, with those in closed rectal defect group with worsening function (p = 0.02).

CONCLUSION

There are pros and cons associated with both rectal defect management approaches. Long-term complications should be expected and actively followed up. Patients should be thoroughly counselled about these and possible deterioration in continence post-TEM.

A rare case of tined lead migration of InterStim device into the rectum with subsequent novel combined surgical-endoscopic removal technique

After the introduction of self-anchoring tined leads in 2002, lead migration after sacral neuromodulation (SNM) in the form of InterStim^TM (Medtronic, Minneapolis, MN) has been reduced; however, it remains a considerable complication of this otherwise low-risk procedure. As intestinal perforation through lead migration or primary incorrect positioning portrays a rarity and has been scarcely reported in the literature, no algorithm for explantation in such cases has been determined. We present a case of a young man with an SNM device implant (InterStim II^®) because of neurogenic urinary retention, who was admitted with inflammation, localized at the sacral lead insertion site. Our diagnostic algorithm revealed a tined lead electrode protruding into the rectum without concomitant abscess. We performed an interdisciplinary surgical approach combining regular incisions over the sacrum and buttocks for dissection of the lead and the implanted pulse generator, respectively, with an endoscopic transanal lead extraction. This method prevented further bacterial seeding in the surrounding tissues of the colon and, therefore, presacral abscess formation or sacral osteomyelitis. Combined surgical-endoscopic removal of the InterStim device is an effective and safe procedure that should be included in the armamentarium of urologists performing neuromodulation surgery in cases of intestinal perforation.

Transanal minimally invasive surgery (TAMIS) for rectal tumor: a case report and literature review

Transanal minimally invasive surgery (TAMIS) is mainly used for benign tumors of the rectum, but there are few reports on treating malignant tumors of the rectum with a large volume. The aim of this study was to evaluate the feasibility and safety of TAMIS for resection of rectal malignant tumors. A 57-year-old patient was pathologically diagnosed as rectal malignancy before surgery. Computed tomography (CT), magnetic resonance imaging (MRI), fludeoxyglucose-18F (18F-FDG), and endoscopic mucosal biopsy were performed to assess the tumor location and preoperative size. There were no contraindications in all preoperative examinations. We applied TAMIS technology to perform the operation on this patient, And the operative time, the amount of blood loss, the length of hospital stay, the cost of hospital stay, surgical complications, postoperative complications and other relevant data were all collected. The operation was successful, the operation time was 45 min, 10 mL of intraoperative blood loss, and the length of stay was 3 days, a tumor of a maximum diameter of 4 cm being completely removed. There were no related complications or recurrence during postoperative follow-up. The pathological results were tubular villous adenoma with low-grade intraepithelial neoplasia, and a focal area of high-grade intraepithelial neoplasia. The pathological stage was T1N0M0. At 3-month follow-up there were no signs of recurrence. The patient was followed up for 5 years after the operation and there was no tumor recurrence or metastasis in other parts and no other discomfort. TAMIS is less commonly used in rectal malignancies, especially for tumors with larger diameters. We successfully performed complete resection of a 4-cm rectal malignant tumor with TAMIS. Given its low risk, low cost, simple operation, and few complications, TAMIS can be used for more indications of rectum diseases.

Hybrid Robotic Transanal Minimally Invasive Surgery Approach to Large and Low-Lying Rectal Polyps

BACKGROUND

Transanal excision is the surgical treatment of choice for low-risk rectal pathology such as endoscopically unresectable polyps, very select early rectal cancers, as well as other benign and low-risk tumors. Robotic transanal minimally invasive surgery enhances the surgeon's ability to work in the confined space of the rectum and helps overcome the limitations of other modalities for transanal excision. Large lesions that extend to the dentate line and cannot be excised transanally impart a particular challenge. Herein, we describe a hybrid robotic transanal minimally invasive surgery approach for excising large rectal lesions that extend to the dentate line and cannot be excised by utilizing traditional transanal techniques.

TECHNIQUE

With the use of a standard transanal approach, the distal margin of the lesion is marked and lifted off of the internal sphincter muscle. The dissection is continued until above the anorectal ring, and a 5.5-cm transanal platform is introduced transanally. Insufflation with an 8-mm trocar is initiated and the robotic platform is docked transanally. A 1-cm circumferential proximal margin is marked, and the excision is continued robotically until en bloc resection of the lesion is completed. The defect is closed in a transverse fashion using barbed suture. For rare cases of circumferential or nearly circumferential full-thickness defects, interrupted barbed sutures are placed equidistant, the robot is undocked, the transanal platform is removed, and a handsewn coloanal anastomosis is performed allowing complete closure of the defect.

RESULTS

A hybrid robotic transanal minimally invasive surgery approach to large and low-lying rectal lesions is feasible and safe, and it has advantages over standard transanal excision including enhanced ergonomics, dexterity, and optics, as well as reduced rates of specimen fragmentation.

CONCLUSION

A hybrid robotic transanal minimally invasive surgery approach allows for complete resection of very large polyps, which would otherwise be extremely challenging with standard transanal approaches. See Video at http://links.lww.com/DCR/B231.

Should the rectal defect be sutured following TEMS/TAMIS carried out for neoplastic rectal lesions? A meta-analysis

INTRODUCTION

Management of the rectal defect following transanal endoscopic microsurgery (TEMS) or minimally invasive surgery (TAMIS) carried out for excision of neoplasm in the lower rectum is controversial. We aimed to extract evidence by carrying out a meta-analysis to compare the peri- and postoperative outcomes following rectal neoplasm excision carried out by TEMS and/or TAMIS, whereby the defect is either sutured or left open.

METHODS

A literature search of Ovid MEDLINE and EMBASE was performed. Full-text comparative studies published until November 2019, in English and of adult patients, whereby TEMS or TAMIS was undertaken for rectal neoplasms were included. The main outcome measures were postoperative bleeding, infection, operative time and hospital stay.

FINDINGS

Three studies (one randomised controlled trial and two comparative case series) yielded 555 cases (283 in the sutured group and 272 in the open group). The incidence of postoperative bleeding was higher and statistically significant (p = 0.006) where the rectal defect was left open following excision of the neoplasm (19/272, 6.99% vs 6/283, 2.12%). There was no statistical difference between the sutured and open groups regarding infection (p = 0.27; (10/283, 3.53% vs 5/272, 1.84%, respectively), operative time (p = 0.15) or length of stay (p = 0.67).

CONCLUSION

Suturing the rectal defect following excision of rectal neoplasm by TEMS/TAMIS reduces the incidence of postoperative bleeding in comparison to leaving the defect open. However, suturing makes the procedure slightly longer but there was no statistical difference between both groups when postoperative infection and length of hospital stay were compared.

A multi-centre randomized controlled trial of open vs closed management of the rectal defect after transanal endoscopic microsurgery

AIM

Transanal endoscopic microsurgery (TEM) is a technically challenging strategy that allows expanded indications for local excision of rectal lesions. Transluminal suturing is difficult, so open management of the resultant defect is appealing. Expert opinion suggests there is more pain when the defect is left open. The aim of this study was to determine if closure of the defect created during full thickness excision of rectal lesions with TEM leads to less postoperative pain compared to leaving the defect open.

METHOD

At the time of surgery, patients undergoing a full thickness TEM were randomized to sutured (TEM-S) or open (TEM-O) management of the rectal defect. At five Canadian academic colorectal surgery centres, experienced TEM surgeons enrolled patients ≥ 18 years treated by full thickness TEM. The primary outcome was postoperative pain measured by the visual analogue scale. Secondary outcomes included postoperative pain medication use and 30-day postoperative complications, including bleeding, infection and hospital readmission.

RESULTS

Between March 2012 and October 2013, 50 patients were enrolled and randomized to sutured (TEM-S, n = 28) or open (TEM-O, n = 22) management of the rectal defect. There was no difference between the two study groups in postoperative pain on postoperative day 1 (2.8 vs 2.6, P = 0.76), day 3 (2.8 vs 2.1, P = 0.23) and day 7 (2.8 vs 1.7, P = 0.10).

CONCLUSION

In this multicentre randomized controlled trial, there was no difference in postoperative pain between sutured or open defect management in patients having a full thickness excision with TEM.

Cirugía mínimamente invasiva transanal (TAMIS): técnica y resultados de la experiencia inicial

Antecedentes: la cirugía transanal endoscópica es un abordaje mínimamente invasivo recientemente descrito, que provee una exposición superior y permite el acceso a las lesiones del recto en toda su extensión. Además, provee un riesgo menor de compromiso de los márgenes de resección, menores tasas de recurrencia y una menor morbimortalidad en comparación con la escisión transanal convencional o las remociones endoscópicas. Objetivos: se pretende describir la experiencia inicial y los resultados con la cirugía transanal mínimamente invasiva (transanal minimally invasive surgery, TAMIS) en términos de resecciones completas y posibles complicaciones relacionadas con el procedimiento. Materiales y métodos: esta una serie de casos con un seguimiento prospectivo de los pacientes con TAMIS. Se analizaron los resultados de 27 pacientes intervenidos en varios centros de Medellín, Colombia, entre enero de 2012 y diciembre de 2016, realizados con cirugía laparoscópica monopuerto (single-port laparoscopic surgery, SILS) (21 casos) o el GelPOINT® Path (6 casos), junto con el apoyo de la óptica del laparoscopio (16 pacientes) y del endoscopio flexible (11 pacientes). Resultados: se realizaron 27 TAMIS en el mismo número de pacientes, 10 mujeres (37 %) y 17 hombres fueron evaluados. Se realizó un seguimiento a los pacientes durante aproximadamente 12 meses, en promedio 32 meses. La edad promedio fue de 68 años (52-83 años). El tamaño promedio del tumor fue de 5,3 cm (2-9 cm) y la distancia promedio desde el margen anal fue de 7 cm (5-9 cm) Las complicaciones posoperatorias se dieron en 6 casos (22 %) Una perforación rectal se corrigió por vía laparoscópica en el mismo acto quirúrgico y otra por la misma vía transanal. Una estenosis rectal se manejó con dilatación digital, y hubo un caso de sangrado rectal menor, uno de retención urinaria y un paciente presentó un cáncer rectal avanzado a los tres meses de la resección con margen microscópico positivo (4 %). No hubo reingresos. La mortalidad por la intervención fue nula. La patología operatoria reportó la presencia de adenoma de bajo grado en 3 casos (11 %), de alto grado en 11 (41 %), adenocarcinoma in situ en 6 (22 %), tumor neuroendocrino en 5 pacientes (18 %), 1 caso de fibrosis cicatricial (4 %) y 1 de leiomioma (4 %). Limitaciones: los resultados no son extrapolables a la población general debido al poco número de intervenciones y la ejecución limitada a solo dos autores. Conclusiones: en nuestra experiencia inicial, TAMIS es un procedimiento mínimamente invasivo con una baja morbilidad posoperatoria, es curativa para lesiones benignas y para pacientes seleccionados con cáncer temprano.

Assessing the safety and outcomes of repeat transanal endoscopic microsurgery

BACKGROUND

Transanal endoscopic microsurgery (TEM) is the treatment of choice for benign rectal tumors and select early rectal cancers. This surgical approach has become ubiquitous and surgeons are seeing recurrent lesions after TEM resection. This study aims to outline the safety and outcomes of repeat TEM when compared to primary TEM procedures.

METHODS

At St. Paul's Hospital, demographic, surgical, pathologic, and follow-up data for patients treated by TEM are maintained in a prospectively populated database. Two groups were established for comparison: patients undergoing first TEM procedure (TEM-P) and patients undergoing repeat TEM procedure (TEM-R).

RESULTS

Between 2007 and 2017, 669 patients had their first TEM procedure. Over this time frame, 57 of these patients required repeat TEM procedures, including 15 of these patients treated by 3 or more TEMs. Indications for repeat TEM included recurrence (78%), positive margins (15%), and metachronous lesions (7%). There were no differences between the groups in patient age, gender, or tumor histology. Compared to TEM-P, TEM-R had shorter operative times (38 vs. 52 min, p < 0.001), more distal lesions (5 vs. 7 cm, p < 0.004), and smaller lesions (3 vs. 4 cm, p < 0.0003). The TEM-R group had similar length of hospital stay (0.45 vs. 0.56 days, p = 0.65), rates of clear margins on pathology (81% vs. 88%, p = 0.09), and 30-day readmission rates (7% vs. 4%, p = 0.27) when compared to TEM-P group. TEM-R was more likely to be managed without suturing the surgical defect (72% vs. 32%, p < 0.0001). Repeat TEM was associated with similar post-operative complications as primary TEM graded on the Clavien-Dindo classification scale (Grade 1: 5% vs. 5%, Grade 2: 5% vs. 4%, Grade 3: 5% vs. 1%, p = 0.53). No 30-day mortality occurred in either group.

CONCLUSIONS

The St. Paul's Hospital TEM experience suggests repeat TEM is a safe and feasible procedure with similar outcomes as patients undergoing first TEM.

Local excision for rectal cancer: a minimally invasive option

Transanal excision (TAE) with conventional retractors and transanal endoscopic microsurgery (TEM) are two well established minimally invasive surgical options for the treatment of selected rectal cancers. TEM is nowadays considered the standard of care for the transanal excision of rectal tumors, since it is associated with significantly better quality of excision and lower rates of recurrence than TAE. When compared with rectal resection and total mesorectal excision, TEM has lower postoperative morbidity and better functional outcomes, with similar long-term survival rates in selected early rectal cancers. More recently, transanal minimally invasive surgery (TAMIS) has been developed as an alternative to TEM. Possible benefits of TAMIS are under evaluation.