Sphincter-sparing surgery for adenocarcinoma of the distal 3 cm of the true rectum: results after neoadjuvant therapy and minimally invasive radical surgery or local excision

Longitudinal Analysis of Local Recurrence and Survival After Transanal Abdominal Transanal Radical Proctosigmoidectomy for Low Rectal Cancer Treated With Neoadjuvant Chemoradiation Therapy

BACKGROUND

The transanal abdominal transanal radical proctosigmoidectomy was developed in 1984 as a sphincter preservation surgery in patients with low rectal cancers after preoperative radiation therapy. While serving as a catalyst for disruptive sphincter preservation surgery, it continues to be used and evolve. With the controversy over safety and local recurrence in other sphincter-preserving surgery, review of transanal abdominal transanal radical proctosigmoidectomy long-term oncologic outcomes is warranted.

OBJECTIVE

To assess local recurrence and survival after transanal abdominal transanal radical proctosigmoidectomy after neoadjuvant chemoradiation therapy.

DESIGN

Retrospective cohort study of a prospectively maintained database.

SETTINGS

Tertiary rectal cancer referral center.

PATIENTS

Patients with low adenocarcinoma (≤5 cm anorectal ring) receiving neoadjuvant chemoradiation therapy and then transanal abdominal transanal radical proctosigmoidectomy for curative resection between 1998 and 2021.

MAIN OUTCOME MEASURES

Local recurrence rates and overall survival rates.

RESULTS

Of 255 included patients, 67.8% were men (n = 173); the mean age was 58.7 years (SD 11.5) and the mean BMI was 27.1 (SD 5.4), with 50.2% (n = 128) having ASA class II and 49.8% (n = 127) having ASA class III/IV. The mean tumor size was 4.8 cm (SD 1.9), the majority of patients had clinical T3 disease (81.8%; n = 184), and 52.1% had nodal disease (n = 100). The median radiation dose was 5400 cGy, with 73.7% (n = 149) achieving good response and 90.2% (n = 230) receiving minimally invasive surgery. The complete total mesorectal excision rate was 94.3%, and 100% of patients (n = 255) had negative distal margins. The mean number of examined lymph nodes were 13.9 (SD 10.7). After a median follow-up of 55.4 months, 5.1% of patients (n = 13) developed local recurrence at a median time of 29.6 months. The 5-year overall survival was 84.1% (95% CI, 78.8-89.4).

LIMITATIONS

Retrospective review with risk of bias and lack of generalizability.

CONCLUSIONS

In this longitudinal study, the transanal abdominal transanal radical proctosigmoidectomy demonstrated excellent long-term locoregional control and survival in very low rectal cancers. The superior transanal abdominal transanal radical proctosigmoidectomy outcomes are durable over time, warranting expansion of the sphincter-preserving surgery technique. See Video Abstract .

ANLISIS LONGITUDINAL DE LA RECURRENCIA LOCAL Y LA SUPERVIVENCIA DESPUS DE LA PROCTOSIGMOIDECTOMA RADICAL TRANSANAL ABDOMINAL TATA PARA EL CNCER DE RECTO BAJO TRATADO CON QUIMIORRADIACIN NEOADYUVANTE

ANTECEDENTES:La proctosigmoidectomía radical transanal abdominal se desarrolló en 1984 como una cirugía de preservación del esfínter en cánceres de recto bajo después de la radiación preoperatoria. Si bien sirve como catalizador para la cirugía disruptiva de preservación del esfínter, continúa utilizándose y evolucionando. Con la controversia sobre la seguridad y la recurrencia local en otras cirugías que preservan el esfínter, se justifica la revisión de los resultados oncológicos a largo plazo de la proctosigmoidectomía radical transanal abdominal.OBJETIVO:Evaluar localmente después de Proctosigmoidectomía Radical Transanal Abdominal Transanal después de quimiorradiación neoadyuvante.DISEÑO:Estudio de cohorte retrospectivo de una base de datos mantenida de forma prospectiva.AJUSTES:Centro terciario de referencia para el cáncer de recto.PACIENTES:Adenocarcinoma bajo (=/ Collapse

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MESH Headings

• Humans
• Male
• Middle Aged
• Female
• Retrospective Studies
• Longitudinal Studies
• Neoadjuvant Therapy
• Rectal Neoplasms/surgery
• Adenocarcinoma/therapy
• Adenocarcinoma/pathology
• Neoplasm Staging

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Affiliation(s)

John H Marks Lankenau Medical Center, Lankenau Institute for Medical Research, Wynnewood, Pennsylvania
Thais Reif de Paula
Hela Saidi
Taylor P Ikner
Henry Schoonyoung
Gerald Marks
Deborah S Keller

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Long-term efficacy of transanal local excision versus total mesorectal excision after neoadjuvant treatment for rectal cancer: A meta-analysis

AIM

The purpose of this meta-analysis is to compare the long-term efficacy of transanal local excision (TLE) versus total mesorectal excision (TME) following neoadjuvant therapy for rectal cancer.

METHOD

The Web of Science, Pubmed, Medline, Embase, and the Cochrane Library were systematically searched for correlational research. The Newcastle-Ottawa Scale and the Cochrane risk of bias tool were used to assess the quality of cohort studies (CSs) and randomized controlled trials (RCTs), respectively. Statistically analyzed using RevMan5.4.

RESULT

A total of 13 studies, including 3 randomized controlled trials (RCTs) and 10 cohort studies (CSs), involving 1402 patients, were included in the analysis. Of these, 570 patients (40.66%) underwent TLE, while 832 patients (59.34%) underwent TME. In the meta-analysis of CSs, no significant difference was observed between the TLE group and TME group regarding 5-year overall survival (OS) and 5-year disease-free survival (DFS) (P > 0.05). However, the TLE group had a higher rates of local recurrence (LR) [risk ratio (RR) = 1.93, 95%CI (1.18, 3.14), P = 0.008] and a lower rates of 5-years local recurrence-free survival (LRFS) [hazard ratio (HR) = 2.79, 95%CI (1.04, 7.50), P = 0.04] compared to the TME group. In the meta-analysis of RCTs, there was no significant difference observed between the TLE group and TME group in terms of LR, 5-year OS, 5-year DFS, and 5-year disease-specific survival (P > 0.05).

CONCLUSION

After undergoing neoadjuvant therapy, TLE may provide comparable 5-year OS and DFS to TME for rectal cancer. However, neoadjuvant therapy followed by TLE may has a higher LR and lower 5-year LRFS compared to neoadjuvant therapy followed by TME, so patients should be carefully selected. Neoadjuvant therapy followed by TLE may be a suitable option for patients who prioritize postoperative quality of life. However, the effectiveness of this approach requires further research to draw a definitive conclusion.

Surgical, oncological, and functional outcomes of local and radical resection after neoadjuvant chemotherapy or chemoradiotherapy for early- and mid-stage rectal cancer: a systematic review and meta-analysis

BACKGROUND

Radical resection is typically the standard treatment for early- and mid-stage rectal cancer as local resection may result in a high rate of recurrence and risk of distant metastasis. A growing number of studies have shown that local excision after neoadjuvant chemotherapy or chemoradiotherapy can significantly reduce recurrence rates and is a feasible strategy to preserve the rectum as an alternative to conventional radical resection.

OBJECTIVE

This study aims to compare the efficacy of local resection after neoadjuvant chemotherapy or chemoradiotherapy with radical surgery for early- and mid-stage rectal cancer and to report the evidence-based clinical advantages of both techniques.

METHODS

Clinical trials comparing oncologic and perioperative outcomes of local and radical resection after neoadjuvant chemotherapy or chemoradiotherapy in patients with early- to mid-stage rectal cancer were searched in PubMed, Embase, Web Of Science, and Cochrane databases, and a total of 5 randomized controlled trials and 11 cohort study trials were included.

RESULTS

In terms of oncology and perioperative outcomes, there were no statistically significant differences between the radical resection group and the local resection group in terms of OS [HR = 0.99, 95%CI (0.85, 1.15), p = 0.858], DFS [HR = 1.01, 95%CI (0.64, 1.58), p = 0.967], distant metastasis rate [RR = 0.76, 95%CI (0.36,1.59), p = 0.464], and local recurrence rate [RR = 1.30, 95%CI (0.69, 2.47), p = 0.420]. However, there were significant differences in the outcomes of complications [RR = 0.49, 95% CI (0.33, 0.72), p < 0.001], length of hospital stays [WMD =  - 5.13, 95%CI (- 6.22, - 4.05), p < 0.001], enterostomy [RR = 0.13, 95%CI (0.05, 0.37), p < 0.001], operative time [- 94.31, 95%CI (- 117.26, - 71.35), p < 0.001], and emotional functioning score [WMD = 2.34, 95% CI (0.94, 3.74), p < 0.001].

CONCLUSION

Local resection after neoadjuvant chemotherapy or chemoradiotherapy may be an effective alternative to radical surgery in patients with early and middle rectal cancer.

Efficacy of PET/CT in diagnosis of regional lymph node metastases in patients with colorectal cancer: retrospective cohort study

Background

Endoscopic and transanal local resection without lymph node dissection are treatment options for patients with a low risk of lymph node metastasis; however, some patients might have undiagnosed lymph node metastases before surgery. This retrospective study aimed to evaluate the efficacy of preoperative PET/CT for diagnosing regional lymph node metastasis.

Methods

Patients who underwent curative resection with lymph node dissection for colorectal cancer at Osaka University between January 2012 and December 2015 were included. The cut-off values appropriate for diagnosing lymph node metastasis were calculated by way of a receiver operating characteristic (ROC) curves from maximum standard unit value (SUVmax) of main tumour, and lymph node short axis, and SUVmax of lymph node. The cut-off values of primary tumour SUVmax: 7, short-axis diameter of the lymph node at 7 mm, and lymph node SUVmax at 1.5 were set.

Result

A total of 541 patients were included. Regional lymph node metastases were confirmed in resected specimens from 187 patients (35 per cent). With a primary tumour SUVmax of 7 used as a cut-off value, the sensitivity and specificity of regional lymph node metastasis were 70.1 per cent and 45.5 per cent respectively. With a cut-off short-axis diameter of the regional lymph node of 7 mm, the sensitivity and specificity of regional lymph node metastasis were 75.2 per cent and 82.6 per cent respectively, and with a cut-off regional lymph node SUVmax of 1.5, the sensitivity and specificity of regional lymph node metastasis were 78.6 per cent and 96.8 per cent respectively. When the diagnostic criteria were defined by a lymph node short-axis diameter of 7 mm or SUVmax of 1.5, the sensitivity and specificity were 87.4 per cent and 81.8 per cent respectively.

Conclusion

Preoperative PET/CT is a useful modality for evaluating regional lymph node metastasis in patients with colorectal cancer.

Local resection versus radical resection for early-stage rectal cancer: a systematic review and meta-analysis

PURPOSE

The optimal surgical approach for early-stage rectal cancer remains controversial. Radical resection is considered to be the gold standard for rectal cancer treatment. More and more studies show that local resection can replace traditional radical resection in the treatment of early rectal cancer. This research aimed to compare the efficacy of local excision and radical surgery for early-stage rectal cancer and report the evidence-based clinical advantages of both techniques.

METHODS

The clinical trials comparing oncological and perioperative local and radical resection outcomes for early-stage rectal cancer were searched from 7 national and international databases.

RESULTS

Finally, 3 randomized controlled trials and 14 cohort studies were included. In terms of oncology and perioperative outcomes, there were no statistically significant differences between the radical resection group and the local resection group in terms of OS (HR = 1.05, 95% CI (0.98, 1.13), DFS [HR = 1.18, 95% CI (0.93, 1.48), p = 0.168), distant metastasis rate (RR = 1.04, 95% CI (0.49, 2.20), p = 0.928), and mortality rate (RR = 1.52, 95% CI (0.80, 2.91), p = 0.200). However, there were significant differences in the outcomes of complications (RR = 2.85, 95% CI (2.07, 3.92), p < 0.001), length of hospital stays (WMD = 5.41, 95% CI (3.94, 6.87), p < 0.001), stoma rate (RR = 7.69, 95% CI (2.39, 24.77), p = 0.001), local recurrence rate (RR = 0.48, 95% CI (0.27, 0.86), p = 0.013), operative time (WMD = 74.68, 95% CI (68.00, 81.36), p < 0.001), blood loss (WMD = 156.36, 95% CI (95.48, 217.21, p < 0.001), and adverse events (RR = 1.59, 95% CI (1.05, 2.41), p = 0.027).

CONCLUSION

Local excision may be a viable alternative to radical resection for early-stage rectal cancer, but higher quality clinical studies are needed to confirm this.

Clinical application of terminal ileum suspension in laparoscopic radical resection for low rectal cancer

Objectives

This paper introduces the surgical procedure of "terminal ileum suspension" in the radical resection for low rectal cancer patients and evaluates the possibility of its clinical application.

Methods

This paper retrospectively analyzed the data of patients with low rectal cancer who underwent "terminal ileum suspension" during radical resection of rectal cancer (Dixon) in our hospital, and introduces the specific surgical procedures and key points of "terminal ileum suspension". Observe the relevant conditions of patients during the operation, postoperative recovery and postoperative complications, and analyze the safety and feasibility of this operation ("terminal ileum suspension").

Results

The operation of all 8 patients went smoothly, and no anastomotic leakage, intestinal obstruction, and open diversion of suspended terminal ileum were found. The application of "terminal ileum suspension" in the operation of low rectal cancer has achieved ideal clinical effect, without increasing the rate of anastomotic leakage and rehospitalization, reducing the proportion of the secondary return operation, and reducing the pain of the patients.

Conclusion

"Terminal ileum suspension" is a safe, effective and feasible surgical method for laparoscopic radical resection of low rectal cancer, which can be applied in clinical practice.

A systematic review and meta-analysis of robotic-assisted transabdominal total mesorectal excision and transanal total mesorectal excision: which approach offers optimal short-term outcomes for mid-to-low rectal adenocarcinoma?

BACKGROUND

Resection of low rectal adenocarcinoma can be challenging in the narrow pelvis of male patients. Transanal total mesorectal excision (TaTME) appears to offer technical advantages for distal rectal tumours, and robotic-assisted transabdominal TME (rTME) was introduced in effort to improve operative precision and ergonomics. However, no study has comprehensively compared these approaches. The aim of the present study was to perform a systematic review of the literature to compare postoperative short-term outcomes in rTME and TaTME.

METHODS

A systematic online search (1974-July 2020) of MEDLINE, Embase, web of science and google scholar was conducted for trials, prospective or retrospective studies involving rTME, or TaTME for rectal cancer. Outcome variables included: hospital stay; operation duration, blood loss; resection margins; proportion of histologically complete resected specimens; lymph nodes; overall complications; anastomotic leak, and 30-day mortality.

RESULTS

Sixty-two articles met the inclusion criteria, including 37 studies (3835 patients) assessing rTME resection, 23 studies (1326 patients) involving TaTME and 2 comparing both (165 patients). Operating time was longer in rTME (309.2 min, 95% CI 285.5-332.8) than in TaTME studies (256.2 min, 95% CI 231.5-280.9) (p = 0.002). rTME resected specimens had a larger distal resection margin (2.62 cm, 95% CI 2.35-2.88) than in TaTME studies (2.10 cm, 95% CI 1.83-2.36) (p = 0.007). Other outcome variables did not significantly differ between the two techniques.

CONCLUSIONS

rTME provides similar pathological and short-term outcomes to TaTME and both are reasonable surgical approaches for patients with mid-to-low rectal cancer. To definitively answer the question of the optimal TME technique, we suggest a prospective trial comparing both techniques assessing long-term survival as a primary outcome.

Can transanal endoscopic microsurgery effectively treat T1 or T2 rectal cancer?A systematic review and meta-analysis

AIM

We aimed to compare the safety and oncological outcomes of transanal endoscopic microsurgery (TEM) and radical surgery (RS) for patients with T1 or T2 rectal cancer.

METHOD

We searched Pubmed, Embase, Cochrane Library databases for relevant studies comparing TEM with RS in rectal cancer published until April 2020. We focused on safety and oncological outcomes.

RESULTS

This meta-analysis included 3526 patients from 12 studies. Compared with RS, TEM had a shorter operative time (weighted mean difference [WMD] -110.02, 95% confidence interval [CI]: 143.98, -76.06), less intraoperative blood loss (WMD -493.63, 95% CI: 772.66, -214.59), lower perioperative morality (risk ratio [RR] 0.25, 95% CI: 0.06, 0.99), and fewer postoperative surgical complications (RR 0.23, 95% CI: 0.11,0.45). TEM was associated with more patients with a positive margin or a doubtfully complete margin than RS (RR 7.36, 95% CI: 3.66, 14.78). TEM was associated with higher local recurrence (RR 2.63, 95% CI: 1.60, 4.31) and overall recurrence (RR 1.60, 95% CI: 1.09, 2.36). TEM had a negative effect on 5-year overall survival (hazard ratio [HR] 1.51, 95% CI: 1.16, 1.96), especially in the T2 without neoadjuvant therapy (NAT) subgroup (HR 2.02, 95% CI: 1.32, 3.09), but in the subgroups of T1 or T2 with NAT before TEM, TEM did not yield a significantly lower overall survival than RS.

CONCLUSION

TEM seems appropriate for T1 rectal cancer with favourable histopathology. For patients with T2 rectal cancer, NAT before TEM may contribute to achieving oncological outcomes equivalent to that achieved with RS.

First clinical experience with single-port robotic transanal minimally invasive surgery (SP rTAMIS) for benign rectal neoplasms

BACKGROUND

The new da Vinci Single-Port (SP) robot is a single-arm four-channel robotic system well suited for endoluminal surgery. We report our initial experience performing SP robotic transanal minimally invasive surgery (SP rTAMIS) for rectal neoplasms.

METHODS

Under Institutional Review Board approval, two patients with rectal neoplasms were prospectively enrolled for elective SP rTAMIS. The primary endpoint was to report the safety and feasibility of successful procedure completion with the SP robot. Secondary endpoints included patient characteristics and perioperative metrics.

RESULTS

Both patients underwent successful SP rTAMIS resection of rectal neoplasms without intraoperative complications or conversions. The lesions were 4.0 cm and 3.0 cm in size, located 6 cm and 7 cm cephalad to the anorectal ring. Excisions were full thickness with no piecemeal extractions or specimen fragmentation. Estimated blood loss was 0 mL and 30 mL. The mean excised area was 13.4 cm² (22.7 cm² and 9.0 cm²). The mean docking time was 5.25 min (range 2-8 min) and mean console time was 122.5 min (98 min and 147 min). Patients tolerated a liquid diet on postoperative day (POD) 0 and were discharged on POD 1 after tolerating a low residue diet and having bowel function. Pathology showed two adenomas with negative margins. There was no immediate or delayed morbidity or mortality.

CONCLUSIONS

Our initial experience indicates that SP rTAMIS is a safe and feasible approach for local excision of rectal lesions. While SP rTAMIS is very promising, more experience with this approach is necessary to determine its widespread applicability.

Open transanal resection of low rectal stromal tumor following neoadjuvant therapy of imatinib mesylate: Report of 11 cases and review of literature

OBJECTIVE

The global burden of rectal gastrointestinal stromal tumor (GIST) is increasing. However, a limited number of reports hinder our ability to reach a definitive conclusion regarding the current treatment and prognosis. In this study, we outline our experience with open transanal resection of rectal GIST following neoadjuvant therapy with imatinib mesylate (IM).

PATIENTS AND METHODS

We retrospectively analyzed 11 patients with rectal GISTs treated with neoadjuvant IM therapy and open transanal resection between April 2011 and April 2017 in Shanghai Changzheng Hospital.

RESULTS

The patients had 400-600 mg/day IM once daily for a median of 7 months (range: 3-9 months). Tumor size, distance from the lower margin of the tumor to the anal verge (AV), mitotic rates and mutation analysis were assessed on pretreatment biopsy. After reassessment, all 11 patients underwent transanal R0 resection. With median follow-up of 28 months (range: 8-80 months), there was no tumor recurrence or metastasis.

CONCLUSION

Open transanal resection of rectal GIST after neoadjuvant treatment with IM has good surgical and survival outcomes.

Effect of oxaliplatin combined with 5-fluorouracil on treatment efficacy of radiotherapy in the treatment of elderly patients with rectal cancer

Efficacy of the combination of oxaliplatin, 5-fluorouracil and radiotherapy on rectal cancer in elderly patients was investigated. Seventy-three elderly patients with rectal cancer confirmed by histopathological examination were randomly divided into 3 groups: oxaliplatin group (25 cases): intravenous infusion of oxaliplatin; fluorouracil group (24 cases): intravenous infusion of fluorouracil; combination group (24 cases), intravenous infusion of oxaliplatin and fluorouracil. All patients were treated with radiotherapy, and efficacy and safety were evaluated after 2 courses of treatment. MTT assay was used to observe the inhibitory effects of the proliferation of human rectal cancer cells. Cell proliferation and sensitization ratios were compared. After 2 courses of treatment, there was no difference in complete remission (CR), partial remission (PR), stable disease (SD), progression disease (PD) and disease control rate (DCR). Remission rate (RR) was higher in the combination group than that in the oxaliplatin and the fluorouracil groups (P<0.05), and there was no difference between the oxaliplatin and the fuorouracil group (P>0.05). Incidence of neutropenia in the combination group was higher than that in the fluorouracil group (P<0.05). OD values of the combination group were lower than those of the oxaliplatin and the fluorouracil groups (P<0.05). Proliferation ability of SW837 cells of the combination group was significantly lower than that of the oxaliplatin and the fluorouracil groups (P<0.05). Intragroup comparison of sensitization ratio showed that sensitization ratios of three groups of cells at 24, 48 and 72 h were all higher than those at 12 h (P<0.05). The combination of oxaliplatin and 5-fluorouracil is safe and effective in the treatment of rectal cancer in elderly patients, and it can be used for sensitization of radiotherapy. So it should be popularized in clinical practices.

Long-term oncological outcomes of local excision versus radical resection for early colorectal cancer in young patients without preoperative chemoradiotherapy: a population-based propensity matching study

The incidence and mortality of colorectal carcinoma are rising in young adults. This population-based propensity matching study aimed to compare long-term oncological outcomes of local excision with radical resection for early localized colorectal cancer (CRC) in young patients without preoperative chemoradiotherapy. Patients under 45 years old with T1 colon or rectal adenocarcinoma who underwent local excision or radical resection were included from the Surveillance, Epidemiology, and End Results (SEER) database between 1998 and 2014. Survival curves were plotted using the Kaplan-Meier method. Cancer-specific survival (CSS) was compared using adjusted hazard ratios (HRs) between local excision and radical resection. After propensity score matching procedure, total of 1719 patients were included in the analysis, among which 573 treated with local excision and 1146 treated with radical resection. The median follow-up was 80 months (interquartile range(IQR): 37-132), with 1074 patients followed for ≥5 years and 508 patients followed for ≥10 years. Five-year CSS of local excision versus radical resection was 93.4% versus 96.7% for colon cancer and 96.6% versus 98.4% for rectal cancer. Ten-year CSS of local excision versus radical resection was 91.4% versus 94.0% for colon cancer and 92.8% versus 96.7% for rectal cancer. On multivariable analysis, compared with radical resection, local excision was not associated with inferior CSS for colon (HR 1.74, 95% CI: 0.92-3.29, P = 0.090) and rectal cancer (HR 2.16, 95% CI: 0.99-4.71, P = 0.052). There is no evidence of differential long-term oncological outcomes between local excision and radical resection. These findings supported clinical application of local excision for early colon and rectal cancer in young adults.

Value of endorectal ultrasonography in measuring the extent of mesorectal invasion and substaging of T3 stage rectal cancer

The present study aimed to determine the value of endorectal ultrasound (ERUS) and magnetic resonance imaging (MRI) for T3 rectal cancer, and substaging of T3 rectal cancer by measuring the extent of mesorectal invasion (EMI). The clinical data of patients with rectal cancer who were admitted to the general surgical department of Peking Union Medical College Hospital (Beijing, China) were reviewed and analyzed. Two ultrasound practitioners independently measured the EMI on ERUS, and a radiologist measured the EMI on MRI. The consistency of ERUS measurements between the two doctors was assessed using intraclass consistency (ICC) analysis. T3 stages were subdivided into T3a (EMI ≤5 mm) and uT3b (EMI >5 mm). The accuracy of MRI and ERUS in T3 rectal cancer, and T3 substaging of rectal cancer was assessed and compared according to the pathological results. The Bland-Altman scatter plot demonstrated good consistency between the ERUS measurement and pathology measurement. Furthermore, the consistency of the ERUS measurement between the two doctors was good (ICC, 0.9344; 95% confidence interval, 0.8789-0.9645). The diagnostic accuracies for T3 rectal cancer, for the two ultrasound doctors and for MRI were 86.9% (53/61), 85.2% (52/61), and 90.2% (55/61), respectively. The accuracy, sensitivity and specificity for the two individual ultrasound doctors in the substaging of T3 tumors were 79.1% (34/43), 66.7% (10/15), and 85.7% (24/28), compared with 67.4% (31/43), 60% (9/15), and 82.1% (23/28), respectively. The accuracy of MRI in the substaging of T3 tumors was 86.0% (37/43), which was not statistically higher compared with those of ERUS (P>0.05). In conclusion, ERUS is a valuable tool for measuring the EMI and substaging T3 rectal cancer, and thus, can be complementary to MRI in selecting the appropriate treatment for rectal cancer.

Long-term outcomes by a transanal approach to total mesorectal excision for rectal cancer

BACKGROUND

The challenge of performing a good total mesorectal excision (TME) dissection, particularly in the distal 1/3 of the rectum, has spurred interest in new techniques. Robotic surgery is advocated by some, and more recently, a "new" approach, the transanal total mesorectal excision, has been popularized to address this problem. While great interest in this technique exists, little long-term outcome data are available. We have been utilizing a transanal abdominal transanal approach to TME in order to facilitate the distal dissection, and here, we provide our long-term outcomes using this approach in the management of rectal cancer.

METHODS

From a prospectively maintained rectal cancer database, we identified 373 consecutive rectal cancers treated with sphincter preservation surgery through a combined transanal and abdominal approach to TME. Perioperative, pathological, and oncologic outcomes were analyzed.

RESULTS

Three hundred and seventy-three patients with rectal cancer underwent a transanally initiated TME with mean follow-up of 5.5 years. 91% of cancers were in the distal rectum. 68.9% were men and 53.2% of cancers were tethered or fixed on presentation. 97.7% received neoadjuvant radiotherapy (mean 5405 cGy, 5-fluorouracil based); average time from completion of neoadjuvant therapy to surgery was 11 weeks. 180 and 193 patients underwent completion of their operation through open and laparoscopic abdominal approaches. 96% of TME specimens were complete/near complete, 94% had a negative circumferential resection margin, and 98.6% had a negative distal margin. Perioperative morbidity and mortality rates were 13.4 and 0.3%. Overall local recurrence (LR), DM, and Kaplan-Meier 5-year actuarial survival were 7.4, 19.5, and 90%, respectively.

CONCLUSION

This is the first report of long-term data using a transanal approach to TME supporting this approach for rectal cancer. Our data with 5-year follow-up show that adequate distal and circumferential margins with very good-quality TME specimens, and a low risk for LR with excellent overall survival can be achieved using this technique. Our long-term results support the promising reports of early experiences in the literature.

Transanal Total Mesorectal Excision: A Novel Approach to Rectal Surgery

Less invasive approaches continue to be explored and refined for diseases of the colon and rectum. The current gold standard for the surgical treatment of rectal cancer, total mesorectal excision (TME), is a technically precise yet demanding procedure with outcomes measured by both oncologic and functional outcomes (including bowel, urinary, and sexual). To date, the minimally invasive approach to rectal cancer has not yet been perfected, leaving ample opportunity for rectal surgeons to innovate. Transanal TME has recently emerged as a safe and effective technique for both benign and malignant diseases of the rectum. While widespread acceptance of this surgical approach remains tempered at this time due to lack of long-term oncologic outcome data, short-term outcomes are promising and there is great excitement surrounding the promise of this technique.

Quality of Life and Functional Outcome After Transanal Abdominal Transanal Proctectomy for Low Rectal Cancer

BACKGROUND

Transanal abdominal transanal proctectomy is a sphincter-preserving procedure designed to avoid colostomy in patients with cancer in the distal third of the rectum. Oncologic outcomes of this procedure have been established. However, data regarding patient satisfaction and quality of life are scant.

OBJECTIVE

The purpose of this study was to evaluate the quality of life and functional outcomes of patients after transanal abdominal transanal proctectomy.

DESIGN

This is a cross-sectional study.

SETTINGS

The study was conducted at a tertiary referral colorectal center.

PATIENTS

Patients who underwent transanal abdominal transanal proctectomy were included and surveyed using the Fecal Incontinence Quality of Life Scale, the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30, the Quality of Life Questionnaire CR38 module, and a questionnaire designed by the authors to assess satisfaction with quality of life.

MAIN OUTCOME MEASURES

Quality of life, functional outcomes, and patient satisfaction were measured and compared by age, tumor level, and stage of the disease.

RESULTS

A total of 133 surveys were mailed, and 90 patients responded and were included in the study. Patient quality of life was not significantly different after surgery. Patients with more proximal tumors had better lifestyle, physical, and emotional scores. Older patients performed better on multiple levels, including coping, emotional, body image, future perspective, and digestive. Stage of disease had no impact on quality of life. Compared with reference values, patients who underwent transanal abdominal transanal proctectomy performed better on most of the components. All of patients preferred transanal abdominal transanal proctectomy over having a stoma based on their current anal sphincter function, and >97% of patients preferred transanal abdominal transanal proctectomy based on their current quality of life, sexual function, and level of activities.

LIMITATIONS

This study is limited by the lack of a comparison group and a potential selection bias.

CONCLUSIONS

Satisfaction with quality of life and functional outcomes is high after transanal abdominal transanal proctectomy. Older patients and those with more proximal tumors performed better. This patient population clearly preferred a sphincter-preserving option for treatment of their rectal cancer.

Local Excision Techniques for Rectal Cancer After Neoadjuvant Chemoradiotherapy: What Are We Doing?

BACKGROUND

Recent evidence shows that the majority of rectal cancers demonstrate occult tumor scatter after neoadjuvant chemoradiotherapy that can extend for several centimeters under adjacent normal-appearing mucosa beside the residual mucosal abnormality or scar.

OBJECTIVE

This systematic review aimed to determine all of the published selection criteria and technical descriptions for local excision to date with regard to this phenomenon.

DATA SOURCES

PubMed, MEDLINE, and Embase were searched using the following key words: rectal cancer, local excision, radiotherapy, and neoadjuvant.

STUDY SELECTION

Studies that assessed local excision of rectal cancer after neoadjuvant chemoradiotherapy were included. Duplicate series were excluded from final analysis.

INTERVENTION

All of the data points were tabulated and analyzed using Microsoft Excel.

MAIN OUTCOME MEASURES

Criteria for patient selection, surgical technique, clinical restaging, pathologic assessment, and indications for completion surgery were analyzed.

RESULTS

After exclusions, data from 25 studies that in total evaluated local excision in 1001 patients were included. Compared with the single accepted technique of total mesorectal excision, described techniques for local excision after neoadjuvant therapy demonstrate significant variability in many critical technical issues, such as marking/tattooing original tumor margins before neoadjuvant therapy, using pretreatment tumor size/stage as exclusion criteria, and specifically stating lateral excision margins. Where detailed, the majority of local recurrences occurred in patients with clear pathological margins, yet significant variation existed for pathological assessment and reporting, with few studies detailing R status and some not reporting margin status at all. Significant variability also existed for adverse tumor features that mandated completion surgery, and, importantly, many series describe patients refusing completion surgery where indicated.

LIMITATIONS

We were unable to perform meta-analysis because studies lacked sufficient methodologic homogeneity to synthesize.

CONCLUSIONS

The observations from this study prompt additional study, standardization of technique, and cautious use of local excision of rectal cancer in the setting of neoadjuvant chemoradiotherapy.

[Hybrid TAMIS total mesorectal excision. A new perspective in treatment of distal rectal cancer - Technique and results]

BACKGROUND

Transanal minimally invasive surgery (TAMIS) represents a promising technique for total mesorectal excision (TME) with respect to radicalness and preservation of function. There are only few publications in the literature describing results in patients with distal rectal cancer.

METHODS

Between May 2013 and March 2015, 24 selected patients with a rectal carcinoma < 6 cm from the anal verge underwent a laparoscopically assisted TAMIS TME (Hybrid-TAMIS TME) procedure. This prospective observational study was conducted to examine the safety of the technique and the quality of TME surgery in distal rectal cancer and to assess the short-term postoperative outcome.

RESULTS

The median age of patients (18 male and 6 female) at the time of surgery was 57 years (range 35-77 years) and 7 patients (29 %) had a body mass index (BMI) > 30 kg/m(2). Specimen excision was carried out transanally in 19 patients. Pathological grading of TME specimens was good in 22 (92 %) and moderate in 2 cases. After neoadjuvant radiochemotherapy a complete pathological remission was identified in five patients. The median distal resection margin was 7 mm (range 2-30 mm), the median circumferential resection margin was 6 mm (range <1 mm-30 mm) and in 2 patients the tumor was ≤ 1 mm from the positive circumferential margin. A colonic reservoir was created in 19 patients (79 %) and no 30-day mortalities occurred. Morbidity was 29 %, including 1 anastomotic leak, 2 hematomas and 1 neurogenic bladder.

CONCLUSION

Hybrid-TAMIS TME for distal rectal cancer is safe and can provide a sphincter-preserving high-quality TME in difficult cases. Studies with long-term follow-up assessing oncological and functional results are mandatory.

A Systematic Review of Local Excision After Neoadjuvant Therapy for Rectal Cancer: Are ypT0 Tumors the Limit?

BACKGROUND

Neoadjuvant therapy reduces local recurrence after radical surgery for rectal cancer with complete pathological response in 15% to 25% of patients. Radical surgery is associated with significant morbidity that may be avoided by local excision in selected cases.

OBJECTIVE

This systematic review aimed to determine the oncological outcomes and morbidity of local excision after neoadjuvant therapy.

DATA SOURCES

Data sources included MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials databases.

STUDY SELECTION

A systematic search of the databases using validated terms for rectal cancer, neoadjuvant therapy, and local excision was conducted.

INTERVENTIONS

Neoadjuvant therapy and local excision were the included interventions.

MAIN OUTCOME MEASURES

Pooled local recurrence, median survival, and pooled morbidity were measured.

RESULTS

Twenty unique studies were included (14 cohort, 5 comparative cohort, and 1 randomized controlled trial), describing 1068 patients. Patient choice, prohibitive comorbidity, good clinical response, and early stage disease were the most frequent indications for local excision. Pretreatment T2 and T3 tumors accounted for 46.4% and 30.7% of cases. Long-course treatment was administered in all of the studies, except to a cohort of 64 patients who received short-course radiotherapy. Pooled complete clinical response was 45.8% (95% CI, 31.4%-60.5%), and pooled complete pathological response was 44.2% (95% CI, 36.4%-52.0%). Median follow-up was 54 months (range, 12-81 months). ypT0 tumors had a pooled local recurrence rate of 4.0% (95% CI, 1.9%-6.9%) and a median disease-free survival rate of 95.0% (95% CI, 87.4%-100%). Pooled local recurrence and median disease-free survival rates for ypT1 tumors or higher were 21.9% (95% CI, 15.9%-28.5%) and 68.0% (58.3%-69.0%). Pooled incidence of complications was 23.2% (95% CI, 15.7%-31.7%), with suture-line dehiscence reported in 9.9% (95% CI, 4.8%-16.7%).

LIMITATIONS

Limitations included study quality, high risk of selection bias and detection bias in study designs, and limited sample sizes.

CONCLUSIONS

Local excision after neoadjuvant therapy should only be considered a curative treatment if complete pathological response is obtained. Given the high rate of local recurrence among incomplete responders, future studies should focus on predicting patients who will achieve complete pathological response.

Feasibility of transanal endoscopic total mesorectal excision for rectal cancer: results of a pilot study

Purpose

To evaluate the feasibility of transanal total mesorectal excision (TME) in patients with rectal cancer.

Methods

This study enrolled 12 patients with clinically node negative rectal cancer located 4–12 cm from the anal verge who underwent transanal endoscopic TME with the assistance of single port laparoscopic surgery between September 2013 and August 2014. The primary endpoint was TME quality; secondary endpoints included number of harvested lymph nodes and postoperative complications within 30 days (NCT01938027).

Results

The 12 patients included 7 males and 5 females, of median age 59 years and median body mass index 24.2 kg/m². Tumors were located on average 6.7 cm from the anal verge. Four patients (33.3%) received preoperative chemoradiotherapy. Median operating time was 195 minutes and median blood loss was 50 mL. There were no intraoperative complications and no conversions to open surgery. TME was complete or nearly complete in 11 patients (91.7%). Median distal resection and circumferential resection margins were 18.5 mm and 10 mm, respectively. Median number of harvested lymph nodes was 15. Median length of hospital stay was 9 days. There were no postoperative deaths. Six patients experienced minor postoperative complications, including urinary dysfunction in 2, transient ileus in 3, and wound abscess in 1.

Conclusion

This pilot study showed that high-quality TME was possible in most patients without serious complications. Transanal TME for patients with rectal cancer may be feasible and safe, but further investigations are necessary to evaluate its long-term functional and oncologic outcomes and to clarify its indications.

Current Status of Minimally Invasive Surgery for Rectal Cancer

Recent randomized controlled data have shown possible limitations to laparoscopic treatment of rectal cancer. The retrospective data, used as the basis for designing the trials, and which showed no problems with the technique, are discussed. The design of the randomized trials is discussed relative to the future meta-analysis of the recent data. The implications of the current findings on practice are discussed as surgeons try to adjust their practice to the new findings. The possible next steps for clinical and research innovations are put into perspective as new technology is considered to compensate for newly identified limitations in the laparoscopic treatment of rectal cancer.

Outcomes of neoadjuvant chemoradiotherapy in Japanese locally advanced rectal carcinoma patients

Background

We investigated the efficacy and prognosis of neoadjuvant chemoradiotherapy (NACRT) for Japanese locally advanced rectal carcinoma patients.

Methods

Fifty-seven patients diagnosed with cT3-4 or any cT/cN+ disease using enhanced computed tomography or magnetic resonance imaging from 2002 to 2014 were enrolled. The male/female ratio was 42/15, and the median age was 67 years. Ra/Rb/Rb-P/P was expressed by 6/35/14/2 patients. Histological tumor types were tub1/tub2/por/muc in 22/30/4/1 patients. For NACRT, radiotherapy doses were 40–50.4 Gy chemotherapy consisted of 5′-DFUR, capecitabine, or S1.

Results

All 57 patients received curative surgical treatment. The anal preservation rate was 65.0 %. The ypStage of 0/I/II/IIIa/IIIb was 7/10/25/11/4 cases. The histological antitumor effect (HATE) was ≥grade (G) 2 and G3 in 31 (54.4 %) and 7 (12.3 %) cases, respectively. Postoperative complications occurred in 17 patients and exceeded GIII (Clavien–Dindo classification) in four patients. Recurrence was observed in 19 patients; the primary local recurrence rate was 5.3 %. The 3-year relapse-free survival (RFS) and overall survival (OS) rates were 64.8 and 95.5 %, respectively; the 5-year RFS and OS rates were 60.2 and 61.0 %, respectively. In multivariate analysis, ypN+ was a high-risk factor for distant organ recurrence. As predictive factors regarding the efficacy of NACRT, a neutrophil concentration <70 % and a neutrophil/lymphocyte ratio <3.0 in peripheral blood prior to treatment indicated that NACRT would be significantly more effective.

Conclusions

NACRT was effective in reducing local recurrence but did not suppress distant organ recurrence in Japanese locally advanced rectal carcinoma patients. A further investigation of an extension of the NACRT regimen is required.

Transanal total mesorectal excision in rectal cancer: why, how and when

Down-to-up total mesorectal excision (TME) or transanal TME (taTME) has gained worldwide popularity. taTME is one of the most promising innovations of the last years in the field of gastrointestinal surgery. Due to the better view of the dissection planes even in difficult patients (i.e., narrow pelvis or low rectal cancer), taTME seems to achieve both better TME quality reducing the rate of incomplete TME and lower rates of positive circumferential resection margins. taTME has overall morbidity and anastomotic leak rates comparable with the up-to-down TME. Mid-term results of taTME seems to be comparable with those of the up-to-down approach but definitive conclusions cannot be drawn since the short follow-up and small cohort of patients of the present studies.

Transanal total mesorectal excision: Towards standardization of technique

AIM: To describe the role of Transanal total mesorectal excision (TaTME) in minimally invasive rectal cancer surgery, to examine the differences in patient selection and in reported surgical techniques and their impacts on postoperative outcomes and to discuss the future of TaTME.

METHODS: MEDLINE (PubMed), EMBASE, and The Cochrane Library were systematically searched through the 1^st of March 2015 using a predefined search strategy.

RESULTS: A total of 20 studies with 323 patients were included. Most studies were single-arm prospective studies with fewer than 100 patients. Multiple transanal access platforms were used, and the laparoscopic approach was either multi- or single port. The procedure was initiated transanally or transabdominally. If a simultaneous approach with 2 operating surgeons was chosen, the operative time was significantly reduced.

CONCLUSION: TaTME was also associated with better TME specimens and a longer distal resection margin. TaTME is thus feasible in expert hands, but the learning curve and safety profile are not well defined. Long-term follow-up regarding anal function and oncological outcomes should be performed in the future.

Transanal Endoscopic Microsurgery

Transanal endoscopic microsurgery (TEM) was developed by Professor Gerhard Buess 30 years ago at the dawn of minimally invasive surgery. TEM utilizes a closed proctoscopic system whereby endoluminal surgery is accomplished with high-definition magnification, constant CO2 insufflation, and long-shafted instruments. The end result is a more precise excision and closure compared to conventional instrumentation. Virtually any benign lesion can be addressed with this technology; however, proper patient selection is paramount when using it for cancer.

Natural-orifice transluminal endoscopic surgery

BACKGROUND

Natural-orifice transluminal endoscopic surgery (NOTES) represents one of the most significant innovations in surgery to emerge since the advent of laparoscopy. A decade of progress with this approach has now been catalogued, and yet its clinical application remains controversial.

METHODS

A PubMed search was carried out for articles describing NOTES in both the preclinical and the clinical setting. Public perceptions and expert opinion regarding NOTES in the published literature were analysed carefully.

RESULTS

Two hundred relevant articles on NOTES were studied and the outcomes reviewed. A division between direct- and indirect-target NOTES was established. The areas with the most promising clinical application included direct-target NOTES, such as transanal total mesorectal excision and peroral endoscopic myotomy. The clinical experience with distant-target NOTES, such as for appendicectomy and cholecystectomy, showed feasibility; however, NOTES-specific morbidity was introduced and this represents an important limitation.

CONCLUSION

NOTES experimentation in the preclinical setting has increased substantially. There has also been a significant increase in the application of NOTES in humans in the past decade. Enthusiasm for NOTES should be tempered by the risk of incurring NOTES-specific morbidity. Surgeons should carefully consider patient preferences regarding this new minimally invasive option, as opinions are not unanimously supportive of NOTES. As technical limitations are overcome, the clinical application of NOTES is predicted to increase. It is paramount that, when this complex technique is performed on humans, it is applied judiciously by appropriately trained experts with outcomes recorded in a registry.

Chemoradiation therapy for rectal cancer in the distal rectum followed by organ-sparing transanal endoscopic microsurgery (CARTS study)

BACKGROUND

This prospective multicentre study was performed to quantify the number of patients with minimal residual disease (ypT0-1) after neoadjuvant chemoradiotherapy and transanal endoscopic microsurgery (TEM) for rectal cancer.

METHODS

Patients with clinically staged T1-3 N0 distal rectal cancer were treated with long-course chemoradiotherapy. Clinical response was evaluated 6-8 weeks later and TEM performed. Total mesorectal excision was advocated in patients with residual disease (ypT2 or more).

RESULTS

The clinical stage was cT1 N0 in ten patients, cT2 N0 in 29 and cT3 N0 in 16 patients. Chemoradiotherapy-related complications of at least grade 3 occurred in 23 of 55 patients, with two deaths from toxicity, and two patients did not have TEM or major surgery. Among 47 patients who had TEM, ypT0-1 disease was found in 30, ypT0 N1 in one, ypT2 in 15 and ypT3 in one. Local recurrence developed in three of the nine patients with ypT2 tumours who declined further surgery. Postoperative complications grade I-IIIb occurred in 13 of 47 patients after TEM and in five of 12 after (completion) surgery. After a median follow-up of 17 months, four local recurrences had developed overall, three in patients with ypT2 and one with ypT1 disease.

CONCLUSION

TEM after chemoradiotherapy enabled organ preservation in one-half of the patients with rectal cancer.

Transanal total mesorectal excision (taTME) for cancer located in the lower rectum: short- and mid-term results

BACKGROUND

Laparoscopic trans-abdominal total mesorectal excision is technically demanding. Transanal Total Mesorectal Excision (taTME) is a new technique which seems to provide technical advantages. This study describes the results of taTME in a consecutive series of patients with low rectal cancer.

METHODS

From January 2012 to December 2013, a consecutive series of 26 patients with low rectal cancer underwent laparoscopic taTME with coloanal anastomosis. cT4 or Type II-III rectal cancer (according to Rullier's classification) were contraindications to taTME. After anal sleeve mucosectomy, the rectal wall was transected at the ano-rectal junction. A single-access multichannel port was inserted in the anal canal. taTME was performed from down to up until the sacral promontory posteriorly and the Pouch of Douglas anteriorly were reached. A laparoscopic trans-abdominal approach was used to complete the left colon mobilization.

RESULTS

Sixteen patients (61.5%) were male. The mean distance of the rectal cancer from the anal verge was 4.4 cm (range 3-6). Nineteen patients (73.1%) received long-course neoadjuvant radiotherapy. At final pathology, resection margins were negative in all the patients: the mean distal and radial resection margins were 19 mm and 11.2 mm, respectively. TME was complete in 23 patients (88.5%) and nearly complete in three. Postoperative mortality was 3.8%. The overall morbidity rate was 26.9% (7 patients): two patients (7.7%) had an anastomotic leakage (Dindo I-d). After a mean follow up of 23 months, no patients have developed a local recurrence.

CONCLUSIONS

laparoscopic taTME allow wide resection margins and good quality TME.