Assessing the safety and outcomes of repeat transanal endoscopic microsurgery

Oncological Outcomes of Transanal Endoscopic Surgery for the Surgical Management of T2 and T3 Rectal Cancer

BACKGROUND

Transanal endoscopic surgery is an organ-sparing treatment for early rectal cancer. Patients with advanced lesions are recommended for total mesorectal excision. However, some patients have prohibitive comorbidities or refuse major surgery.

OBJECTIVE

To assess the cancer outcomes of patients with T2 or T3 rectal cancers who received transanal endoscopic surgery as their sole surgical treatment.

DESIGN

This study used a prospectively maintained database.

SETTING

A tertiary hospital in Canada.

PATIENTS

Patients who underwent transanal endoscopic surgery for pathology-confirmed T2 or T3 rectal adenocarcinomas from 2007-2020 were included.

MAIN OUTCOME MEASURES

Disease-free survival and overall survival, stratified by tumor stage and reason for transanal endoscopic surgery.

RESULTS

Among the included 132 patients (T2, n = 96; T3, n = 36), average follow-up was 22 months. Twenty-eight decline oncologic resection, whereas 104 had preclusive comorbidities. Fifteen patients (11.4%) had disease recurrence (4 local, 11 metastatic). Three-year disease-free survival was 86.5% (95% CI, 77.1-95.9) for T2 and 67.9% (95% CI, 46.3-89.5) for T3 tumors. Mean disease-free survival was longer for T2 (75.0 mo; 95% CI, 67.8-82.1) compared to T3 cancers (50 mo; 95% CI, 37.7-62.3; p = 0.037). Three-year disease-free survival for patients who declined radical excision was 84.0% (95% CI, 67.1-100) versus 80.7% (95% CI, 69.7-91.7) in patients too comorbid for surgery. Three-year overall survival rate was 84.9% (95% CI, 73.9-95.9) for T2 and 49.0% (95% CI, 26.7-71.3) for T3 tumors. Patients who declined radical resection had similar 3-year overall survival (89.7%; 95% CI, 76.2-100) compared to patients who were unable to undergo excision because of medical comorbidities (98.1%; 95% CI, 95.6-100).

LIMITATIONS

Small sample, single institution, and surgeon experience.

CONCLUSIONS

Oncologic outcomes are compromised in patients treated by transanal endoscopic surgery for T2 and T3 rectal cancer. Transanal endoscopic surgery remains an option for informed patients who prefer to avoid radical resection. See Video Abstract at http://links.lww.com/DCR/C200 .

RESULTADOS ONCOLGICOS DE LA CIRUGA ENDOSCPICA TRANSANAL PARA EL MANEJO QUIRRGICO DEL CNCER DE RECTO T Y T

ANTECEDENTES:La cirugía endoscópica transanal es un tratamiento de conservación de órganos para el cáncer de recto en estadio temprano. A los pacisentes con lesiones avanzadas se les recomienda la escisión total del mesorrecto. Sin embargo, algunos pacientes tienen comorbilidades prohibitivas o rechazan una cirugía mayor.OBJETIVO:Evaluar los resultados del cáncer de pacientes con cáncer de recto T2 o T3 que recibieron cirugía endoscópica transanal como único tratamiento quirúrgico.DISEÑO:Este estudio utilizó una base de datos mantenida prospectivamente.ENTORNO CLINICO:Un hospital terciario en CanadáPACIENTES:Aquellos que se sometieron a cirugía endoscópica transanal por adenocarcinomas rectales T2 o T3 confirmados por patología de 2007-2020. Se excluyeron los pacientes cuya cirugía se realizó por recurrencia del cáncer o posteriormente fueron sometidos a resección radical.PRINCIPALES MEDIDAS DE VALORACIÓN:Supervivencia libre de enfermedad y supervivencia global, estratificada por estadio del tumor y motivo de la cirugía endoscópica transanal.RESULTADOS:Se incluyeron 132 pacientes (T2, n = 96; T3, n = 36). El seguimiento medio fue de 22 meses (DE ± 23,4). 104 pacientes tenían comorbilidades significativas, mientras que 28 rechazaron la resección oncológica. Quince pacientes (11,4%) tuvieron recurrencia de la enfermedad (4 locales, 11 metastásicos). La supervivencia libre de enfermedad a los tres años para los tumores T2 fue del 86,5 % (IC del 95%: 77,1-95,9) y del 67,9% (IC del 95%: 46,3-89,5) para los tumores T3. La supervivencia libre de enfermedad media fue más prolongada para los cánceres T2 (75,0 meses, IC del 95%: 67,8 a 82,1) en comparación con los cánceres T3 (50 meses, IC del 95%: 37,7 a 62,3, p = 0,037). La supervivencia sin enfermedad a los tres años para los pacientes que rechazaron la escisión mesorrectal total fue del 84,0% (IC del 95%: 67,1-100), mientras que los pacientes con demasiada comorbilidad médica para la cirugía tuvieron una supervivencia sin enfermedad a los tres años del 80,7% (IC del 95%: 69.7-91.7). La supervivencia general a los tres años fue del 84,9% (IC del 95%: 73,9 a 95,9) para los tumores T2 y del 49,0% (IC del 95%: 26,7 a 71,3) para los tumores T3. Los pacientes que rechazaron la resección radical tuvieron una supervivencia general similar a los tres años (89,7%, IC del 95%: 76,2-100), en comparación con los pacientes que no pudieron someterse a una escisión mesorrectal total debido a comorbilidades médicas (98,1%, IC del 95%: 95,6-100).LIMITACIONES:Muestra pequeña, institución única, experiencia del cirujano.CONCLUSIONES:Los resultados oncológicos están comprometidos en pacientes tratados con cirugía endoscópica transanal por cáncer de recto T2 y T3. Sin embargo, la cirugía endoscópica transanal sigue siendo una opción para pacientes informados que prefieren evitar la resección radical. Consulte Video Resumen en http://links.lww.com/DCR/C200 . (Traducción-Dr. Ingrid Melo ).

Prognosis of Patients Over 60 Years Old With Early Rectal Cancer Undergoing Transanal Endoscopic Microsurgery – A Single-Center Experience

Aim

Transanal endoscopic microsurgery (TEM) is widely performed in early rectal cancer. This technique offers greater organ preservation and decreases the risk of subsequent surgery. However, postoperative local recurrence and distant metastasis remain challenges for patients with high-risk pathological factors. This single-center study reports the prognosis of early rectal cancer patients over 60 years old after TEM.

Methods

The data of the patients over 60 years old who underwent local anal resection were collected retrospectively. Moreover, the 5-year follow-up data were analyzed to determine the 5-year DFS and OS.

Results

47 early rectal cancer patients over 60 years old underwent TEM. There were 27 patients with high-risk factors and 20 patients without high-risk factors. Two patients underwent radical surgery after TEM and ten patients received adjuvant treatment. Local recurrence occurred in 7 patients, of which 4 underwent salvage surgery. The 5-year progression-free survival rate was 75.6%, which was lower in the high-risk patients group (69.6%) than in the non-high-risk patients group (83.3%) (P>0.05). The 5-year OS was 90.2%, but there was no statistically significant difference between the two groups (high-risk patients 87.0%, non-high-risk patients 94.4%). Furthermore, there was no significant difference in DFS and OS between people over and under 70 years old.

Conclusion

Some high-risk factor patients over 60 years old do not have inferior 5-year DFS and OS to the non-high-risk patients. TEM is an option for old patients with high surgical risks. Even if postoperative pathology revealed high-risk factors, timely surgical treatment after local recurrence would be beneficial to improve the 5-year DFS and OS.

Transanal Endoscopic Microsurgical Submucosal Dissection for Recurrent Rectal Adenomas

BACKGROUND

The local resection of recurrent rectal adenomas is a technically challenging task associated with increased local recurrence rate. Transanal endoscopic microsurgical submucosal dissection (TEM-ESD) uses traction to better expose the fibrotic submucosal layer, and therefore, is a valuable alternative for the treatment of such lesions. The aim of our study was to assess the feasibility and outcomes of TEM-ESD for the resection of recurrent rectal adenomas.

METHODS

We retrospectively analysed all TEM-ESD procedures performed in the Karlsruhe Municipal Hospital between 2012 and 2021 and isolated all cases of recurrent adenomas. Subsequently, we matched these cases 1:1 to TEM-ESD cases for primary rectal adenomas according to the size, localization, and histological type of the lesions and compared the outcomes between the two groups.

RESULTS

We identified 19 cases matching our criteria. The median diameter of the lesions was 25 mm and the median operating time 39 min. Macroscopic en bloc resection was achieved in 100% of the cases and histological complete en bloc resection in 78.9%. There was 1 case of conservatively treated postoperative bleeding. After a median follow-up period of 36 months, there was one local recurrence. After comparing those findings to the outcomes of TEM-ESD for primary rectal lesions, we found no significant differences on total operating time, complete en bloc resection rates, adverse events, and local recurrence.

CONCLUSION

TEM-ESD is a feasible therapeutic option for the resection of recurrent rectal adenomas, offering short operating times as well as high en bloc resection and low recurrence rates.

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.