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.

EP.TU.393Management of Suspicious Neoplastic Rectal Lesions in Octogenarians by a Specialist Early Rectal Cancer MDT

Aims

To assess management of early rectal cancers in octogenarians going through a regional Small and Early Rectal Cancer MDT observing oncological outcomes, morbidity, mortality and quality of life after treatment

Methods

Consecutive octogenarian patients treated via the SERC MDT between Dec 2013 and Dec 2019 were examined retrospectively from a prospectively maintained database. Patients underwent transanal endoscopic microsurgery (TEMS), endoscopic submucosal dissection (ESD), contact radiotherapy or hybrid combinations. Patient demographics were recorded and outcomes assessed including pre and post-operative oncological staging, morbidity, mortality, length of stay and FISI scores

Results

85 patients were assessed. 38 had TEMS, 40 had EMR, ESD or hybrid procedures and 7 had contact radiotherapy. Of the 38 patients who underwent TEMS, there was minor morbidity in 5 patients, one cancer recurrence and no cancer related mortality. FISI scores pre- and post-procedure were markedly different with deterioration in control of flatus and mucus, but no faecal incontinence. Of the 40 patients who underwent EMR, ESD or hybrid procedures, 2 had minor morbidity and 3 had adenocarcinomas detected requiring further treatment

Conclusions

Management of octogenarians with early rectal cancer via a specialist MDT provides a safe option with minimal morbidity and no mortality in a subgroup of patients who would otherwise constitute a high risk cohort for surgical intervention. A deterioration in continence in this group highlights the need for careful counselling of patients to achieve the optimal balance between oncological outcomes and quality of life

SP1.2.13Prediction of malignant progression of colorectal adenomatous polyps – A complete systematic review and meta-analysis

Aims

Only 5% of colorectal adenomas (CA) progress to cancer. Identifying these is highly relevant for colorectal cancer screening risk. Currently, no biomarkers exist that predict this malignant progression. We looked at the effectiveness of common genetic aberrations as potential biomarkers through systematic review and meta-analyses.

Methods

MEDLINE, EMBASE and Cochrane Library were searched to identify all studies that assessed p53, APC, p21, BRAF, MLH1, MSH2, CIMP and Kras mutations as prognostic markers in CA. Main outcome measure was the development of colorectal cancer.

Results

109 clinical studies were included. P53 mutation [DOR 8.37 (5.21-13.42), sensitivity 55% (52-58%), specificity 85% (83-87%), PLR 4.23 (2.60-6.88), NLR 0.57 (0.57-0.64), AUC 0.7532] was found to be superior to all other mutations. Mutations of APC [DOR 0.57 (0.16-2.01), sensitivity 19% (4-25%), specificity 71% (66-76%), PLR 0.71 (0.33-1.54), NLR 1.19 (0.84-1.69)], BRAF [DOR 0.38 (0.22-0.67), sensitivity 12% (11-14%), specificity 60% (58-62%), PLR 0.57 (0.38-0.84), NLR 1.27 (1.12-1.44)], Kras [DOR 1.22 (0.72-2.0), sensitivity 33% (30-37%), specificity 74% (71-76%), PLR 1.17 (0.81-1.68), NLR 0.94 (0.83-1.07)], MLH1 [DOR 2.48 (1.05-5.84), sensitivity 26% (23-30%), specificity 82% (79-84%), PLR 1.74 (0.95-3.19)], MSH2 [DOR 1.06 (0.53-2.13), sensitivity 22% (17-27%), specificity 88% (84-90%), PLR 1.03 (0.62-1.70), NLR 0.99 (0.91-1.07)] and CIMP [DOR 1.88 (0.25-13.88), sensitivity 30% (23-36%), specificity 76% (72-80%), PLR 1.31 (0.29-5.99), NLR 0.76 (0.40-1.45)] failed to demonstrate any advantage over p53.

Conclusions

p53 mutations effectively predict malignant progression in CA. Panel of biomarkers would be more suited for surveillance programme. This needs confirmation in prospective clinical trials with cost-efficiency analyses.

SP1.1.15Long-term Outcomes of Open Verses Closed Rectal Defect After Transanal Endoscopic Microscopic Surgery

Aims

Management of rectal defect after TEMS is a matter of debate. Data are lacking on the effect of these techniques on long term outcomes and continence of patients. We sought to analyse these in our patient cohort.

Methods

Patients who underwent TEMS between 2012 and 2019 were examined retrospectively from a prospectively maintained database. These were divided into two groups – open and closed rectal defect. Patient demographics were recorded and outcomes assessed including oncological staging, morbidity, mortality, length of stay and FISI scores.

Results

170 matched patients were included, with 70 patients in the open and 100 in the closed rectal defect group. Short-term complications were 18.8% with no significant difference between the two groups. 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). Overall, there was a significant difference in pre and post TEMS FISI scores in all three groups (p < 0.00001, p < 0.00001, p = 0.02). Comparing the open and closed defect groups, there was no difference in the functional outcome of patients in those who developed sinus or stricture but a significant difference in those with healed scar, with those in closed rectal defect group with worsening function (p = 0.02)

Conclusion

Both the approaches of rectal defect management are associated with pros and cons. Long term complications should be expected and actively followed up for. Patients should be thoroughly counselled about these and possible deterioration in continence post-TEMS

968 Delivering Human Factors and Non-Technical Skills Training Using Interactive Online Platforms in the COVID Era

Aim

To evaluate the impact and effectiveness of an interactive online human factors (HF) and non-technical skills (NTS) course delivered to Core Surgical Trainees during the COVID-19 pandemic

Method

A 1-day HF and NTS course was conducted online, using the Zoom platform, to Core Surgical Trainees in the North West. The course consisted of interactive lectures, small group teaching sessions, and self-directed learning with written reflections. Pre- and post-course surveys were administered, evaluating the participants’ awareness, knowledge and skills using a 5-part Likert scale, along with a multiple-choice assessment of knowledge. Statistical analysis was undertaken with significance considered at p < 0.05

Results

The course was attended by 63 CT1/2 participants, representing all surgical specialties. In the post-course evaluation, participants’ self-rating of awareness and knowledge for both HF and patient safety increased by between 10-20%. There was a significant increase in the mean post-course test score from 7.54 (SD ± 1.7) to 8.65 (SD ± 1.2) out of 10 (p < 0.0001). The course overall was rated relevant and useful (weighted averages 4.4 and 4.5 respectively)

Conclusions

To our knowledge, this is the first time a video conferencing platform has been used to deliver a live HF/NTS course. This study provides evidence supporting the use of such interactive online platforms in postgraduate surgical education. Training and professional development must continue, despite the evolving pressures from COVID-19. Embracing new methods of education delivery is required, with ongoing reporting and evaluation of education practice, sharing lessons learned and informing the evidence base in postgraduate surgical training during this time