Systematic review and meta-analysis of published trials comparing the effectiveness of transanal endoscopic microsurgery and radical resection in the management of early rectal cancer

A training programme for operating theatre personnel in transanal endoscopic operation procedures for local excision of rectal tumours

The transanal endoscopic operation (TEO) is a minimal access surgical procedure for the removal of benign and early malignant rectal tumours (Nieuwenhuis et al 2009). This surgery involves specialist equipment, set up and positioning by the perioperative team. We report on and evaluate the first ever TEO course designed specifically for theatre practitioners.

Local excision by transanal endoscopic surgery

Transanal endoscopic surgery (TES) consists of a series of anorectal surgical procedures using different devices that are introduced into the anal canal. TES has been developed significantly since it was first used in the 1980s. The key point for the success of these techniques is how accurately patients are selected. The main indication was the resection of endoscopically unresectable adenomas. In recent years, these techniques have become more widespread which has allowed them to be applied in conservative rectal procedures for both benign diseases and selected cases of rectal cancer. For more advanced rectal cancers it should be considered palliative or, in some controlled trials, experimental. The role of newer endoscopic techniques available has not yet been defined. TES may allow for new strategies in the treatment of rectal pathology, like transanal natural orifice transluminal endoscopic surgery or total mesorectal excision.

Low rectal cancer: Sphincter preserving techniques-selection of patients, techniques and outcomes

Low rectal cancer is traditionally treated by abdominoperineal resection. In recent years, several new techniques for the treatment of very low rectal cancer patients aiming to preserve the gastrointestinal continuity and to improve both the oncological as well as the functional outcomes, have been emerged. Literature suggest that when the intersphincteric resection is applied in T1-3 tumors located within 30-35 mm from the anal verge, is technically feasible, safe, with equal oncological outcomes compared to conventional surgery and acceptable quality of life. The Anterior Perineal PlanE for Ultra-low Anterior Resection technique, is not disrupting the sphincters, but carries a high complication rate, while the reports on the oncological and functional outcomes are limited. Transanal Endoscopic MicroSurgery (TEM) and TransAnal Minimally Invasive Surgery (TAMIS) should represent the treatment of choice for T1 rectal tumors, with specific criteria according to the NCCN guidelines and favorable pathologic features. Alternatively to the standard conventional surgery, neoadjuvant chemo-radiotherapy followed by TEM or TAMIS seems promising for tumors of a local stage T1sm2-3 or T2. Transanal Total Mesorectal Excision should be performed only when a board approved protocol is available by colorectal surgeons with extensive experience in minimally invasive and transanal endoscopic surgery.

The evolution of cancer surgery and future perspectives

Surgery is the oldest oncological discipline, dating back thousands of years. Prior to the advent of anaesthesia and antisepsis 150 years ago, only the brave, desperate, or ill-advised patient underwent surgery because cure rates were low, and morbidity and mortality high. However, since then, cancer surgery has flourished, driven by relentless technical innovation and research. Historically, the mantra of the cancer surgeon was that increasingly radical surgery would enhance cure rates. The past 50 years have seen a paradigm shift, with the realization that multimodal therapy, technological advances, and minimally invasive techniques can reduce the need for, or the detrimental effects of, radical surgery. Preservation of form, function, and quality of life, without compromising survival, is the new mantra. Today's surgeons, no longer the uneducated technicians of history, are highly trained medical professionals and together with oncologists, radiologists, scientists, anaesthetists and nurses, have made cancer surgeries routine, safe, and highly effective. This article will review the major advances that have underpinned this evolution.

Long-term outcome of local excision after preoperative chemoradiation for ypT0 rectal cancer

BACKGROUND

Local excision, as an alternative to radical resection for patients with pathological complete response (ypT0) after preoperative chemoradiation, is under investigation.

OBJECTIVE

The aim of the present study was to evaluate the long-term clinical outcome of a selected group of patients with ypT0 rectal cancer who underwent local excision with transanal endoscopic microsurgery as a definitive treatment.

PATIENTS

Between 1993 and 2013, 43 patients with rectal adenocarcinoma underwent complete full-thickness local excision with a transanal endoscopic microsurgery procedure after a regimen of chemoradiation. In all patients, rectal wall penetration was preoperatively assessed by endorectal ultrasound and/or magnetic resonance. Chemoradiation and transanal endoscopic microsurgery were indicated in patients refusing radical procedures or patients unfit for major abdominal procedures.

MAIN OUTCOME MEASURES

Patient characteristics, operative record, pathology report, and tumor recurrence were analyzed at a median follow-up of 81 months. The potential prognostic factors for recurrence, screened in univariate analysis, were analyzed by multivariate analysis by using the Cox regression model.

RESULTS

Thirteen patients (30.2%), without residual tumor in the surgical specimen (ypT0), were treated with transanal endoscopic microsurgery only. In this ypT0 group, 2 patients (15.4%) had postoperative complications: 1 bleeding and 1 suture dehiscence. Postoperative mortality was nil. No local and distal recurrences were observed, and no tumor-related mortality occurred. In 30 patients (69.8%), partial tumor chemoradiation response or the absence of tumor chemoradiation response was observed. In this group, recurrence occurred in 17 patients (56.7%).

LIMITATIONS

The study was limited by its retrospective nature, different protocols of chemoradiation and preoperative staging over time, and the small sample size.

CONCLUSIONS

Local excision with transanal endoscopic microsurgery can be considered a definitive therapeutic option in patients with rectal cancer treated with preoperative chemoradiation, when no residual tumor is found in the specimen. In this selected group, local excision offers excellent results in terms of survival and recurrence rates. In the presence of residual tumor, transanal endoscopic microsurgery should be considered as a large excisional biopsy (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A157).

Effects of different Chinese medicine treatments on postoperative relapse and metastasis of colorectal cancer: A non-interventional clinical study

AIM: To analyze the effects of three different Chinese medicine treatments, Fuzheng, Quxie and Fuzhengquxie, on postoperative relapse and metastasis of colorectal cancer (CRC).

METHODS: The data were collected on the basis of non-interventional clinical research. Life-table, Wilcoxon (Gehan) test and Cox proportional hazard model (multivariate analysis) were used to reveal the effect of Chinese medicine treatments on relapse and metastasis of postoperative CRC.

RESULTS: The results of life-table analysis and Wilcoxon (Gehan) test showed that there were significant correlations between DFS and TNM stage (P = 0.000), age (P = 0.045), histopathologic differentiation (P = 0.000), radiotherapy (P = 0.000) and Chinese medicine treatment (P = 0.001). The differences between Fuzheng vs control, Quxie vs control and Fuzhengquxie vs control were all statistically significant (P = 0.000, 0.005, 0.019, respectively). Cox multivariate analysis showed that TNM stage, age, histopathologic differentiation, radiotherapy and Chinese medicine treatment were all independent influencing factors, among which Chinese medicine treatment was a protective one. Pairwise comparisons of Fuzheng, Quxie and Fuzhengquxie revealed that there were no statistical differences (P > 0.05 for all) in the 3- and 5-year accumulative survival rates (YDFSR), however, the 10-YDFSR and median DFS were longer in the Quxie group than in the other two groups (47.00% vs 33.00%, 32.00%; 91.28 mo vs 44.84 mo, 52.45 mo; P < 0.05 for all).

CONCLUSION: The Chinese medicine treatments directed by therapeutic guidance of Fuzheng, Quxie and Fuzhengquxie can all inhibit postoperative relapse and metastasis of CRC. In the prevention of postoperative relapse and metastasis of CRC with Chinese medicine therapy, we do not have to limit to any of the three Chinese medicine treatments, but should focus on treatment based on syndrome differentiation. After patients achieve 5-year DFS, the appropriate application of Fuzheng therapy on the basis of syndrome differentiation and treatment may contribute to better long-term DFS.