1
|
Binda C, Secco M, Tuccillo L, Coluccio C, Liverani E, Jung CFM, Fabbri C, Gibiino G. Early Rectal Cancer and Local Excision: A Narrative Review. J Clin Med 2024; 13:2292. [PMID: 38673565 PMCID: PMC11051053 DOI: 10.3390/jcm13082292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/03/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024] Open
Abstract
A rise in the incidence of early rectal cancer consequent to bowel-screening programs around the world and an increase in the incidence in young adults has led to a growing interest in organ-sparing treatment options. The rectum, being the most distal portion of the large intestine, is a fertile ground for local excision techniques performed with endoscopic or surgical techniques. Moreover, the advancement in endoscopic optical evaluation and the better definition of imaging techniques allow for a more precise local staging of early rectal cancer. Although the local treatment of early rectal cancer seems promising, in clinical practice, a significant number of patients who could benefit from local excision techniques undergo total mesorectal excision (TME) as the first approach. All relevant prospective clinical trials were identified through a computer-assisted search of the PubMed, EMBASE, and Medline databases until January 2024. This review is dedicated to endoscopic and surgical local excision in the treatment of early rectal cancer and highlights its possible role in current and future clinical practice, taking into account surgical completion techniques and chemoradiotherapy.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, 47121 Forlì, Italy; (C.B.); (M.S.); (L.T.); (C.C.); (E.L.); (C.F.M.J.); (G.G.)
| | | |
Collapse
|
2
|
Kimura CMS, Kawaguti FS, Horvat N, Nahas CSR, Marques CFS, Pinto RA, de Rezende DT, Segatelli V, Safatle-Ribeiro AV, Junior UR, Maluf-Filho F, Nahas SC. Magnifying chromoendoscopy is a reliable method in the selection of rectal neoplasms for local excision. Tech Coloproctol 2023; 27:1047-1056. [PMID: 36906661 DOI: 10.1007/s10151-023-02773-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 02/12/2023] [Indexed: 03/13/2023]
Abstract
PURPOSE Adequate staging of early rectal neoplasms is essential for organ-preserving treatments, but magnetic resonance imaging (MRI) frequently overestimates the stage of those lesions. We aimed to compare the ability of magnifying chromoendoscopy and MRI to select patients with early rectal neoplasms for local excision. METHODS This retrospective study in a tertiary Western cancer center included consecutive patients evaluated by magnifying chromoendoscopy and MRI who underwent en bloc resection of nonpedunculated sessile polyps larger than 20 mm, laterally spreading tumors (LSTs) [Formula: see text] 20 mm, or depressed-type lesions of any size (Paris 0-IIc). Sensitivity, specificity, accuracy, and positive and negative predictive values of magnifying chromoendoscopy and MRI to determine which lesions were amenable to local excision (i.e., [Formula: see text] T1sm1) were calculated. RESULTS Specificity of magnifying chromoendoscopy was 97.3% (95% CI 92.2-99.4), and accuracy was 92.7% (95% CI 86.7-96.6) for predicting invasion deeper than T1sm1 (not amenable to local excision). MRI had lower specificity (60.5%, 95% CI 43.4-76.0) and lower accuracy (58.3%, 95% CI 43.2-72.4). Magnifying chromoendoscopy incorrectly predicted invasion depth in 10.7% of the cases in which the MRI was correct, while magnifying chromoendoscopy provided a correct diagnosis in 90% of the cases in which the MRI was incorrect (p = 0.001). Overstaging occurred in 33.3% of the cases in which magnifying chromoendoscopy was incorrect and 75% of the cases in which MRI was incorrect. CONCLUSION Magnifying chromoendoscopy is reliable for predicting invasion depth in early rectal neoplasms and selecting patients for local excision.
Collapse
Affiliation(s)
- C M S Kimura
- Divisoin of Gastrointestinal Surgery, Instituto do Câncer do Estado de São Paulo, São Paulo, Brazil
- Department of Surgery, Stanford University School of Medicine, Stanford, USA
| | - F S Kawaguti
- Division of Endoscopy, Instituto do Câncer do Estado de São Paulo, Dr. Arnaldo Av, 251, 2nd Floor, São Paulo, Zip Code 01246-000, Brazil.
| | - N Horvat
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - C S R Nahas
- Divisoin of Gastrointestinal Surgery, Instituto do Câncer do Estado de São Paulo, São Paulo, Brazil
| | - C F S Marques
- Divisoin of Gastrointestinal Surgery, Instituto do Câncer do Estado de São Paulo, São Paulo, Brazil
| | - R A Pinto
- Divisoin of Gastrointestinal Surgery, Instituto do Câncer do Estado de São Paulo, São Paulo, Brazil
| | - D T de Rezende
- Division of Endoscopy, Instituto do Câncer do Estado de São Paulo, Dr. Arnaldo Av, 251, 2nd Floor, São Paulo, Zip Code 01246-000, Brazil
| | - V Segatelli
- Division of Pathology, Instituto do Câncer do Estado de São Paulo, São Paulo, Brazil
| | - A V Safatle-Ribeiro
- Division of Endoscopy, Instituto do Câncer do Estado de São Paulo, Dr. Arnaldo Av, 251, 2nd Floor, São Paulo, Zip Code 01246-000, Brazil
| | - U R Junior
- Divisoin of Gastrointestinal Surgery, Instituto do Câncer do Estado de São Paulo, São Paulo, Brazil
| | - F Maluf-Filho
- Division of Endoscopy, Instituto do Câncer do Estado de São Paulo, Dr. Arnaldo Av, 251, 2nd Floor, São Paulo, Zip Code 01246-000, Brazil
| | - S C Nahas
- Divisoin of Gastrointestinal Surgery, Instituto do Câncer do Estado de São Paulo, São Paulo, Brazil
| |
Collapse
|
3
|
Burghgraef TA, Rutgers ML, Leijtens JWA, Tuyman JB, Consten ECJ, Hompes R. Completion Total Mesorectal Excision: A Case-Matched Comparison With Primary Resection. ANNALS OF SURGERY OPEN 2023; 4:e327. [PMID: 37746593 PMCID: PMC10513327 DOI: 10.1097/as9.0000000000000327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 07/24/2023] [Indexed: 09/26/2023] Open
Abstract
Objectives The aim of this study was to compare the perioperative and oncological results of completion total mesorectal excision (cTME) versus primary total mesorectal excision (pTME). Background Early-stage rectal cancer can be treated by local excision alone, which is associated with less surgical morbidity and improved functional outcomes compared with radical surgery. When high-risk histological features are present, cTME is indicated, with possible worse clinical and oncological outcomes compared to pTME. Methods This retrospective cohort study included all patients that underwent TME surgery for rectal cancer performed in 11 centers in the Netherlands between 2015 and 2017. After case-matching, we compared cTME with pTME. The primary outcome was major postoperative morbidity. Secondary outcomes included the rate of restorative procedures and 3-year oncological outcomes. Results In total 1069 patients were included, of which 35 underwent cTME. After matching (1:2 ratio), 29 cTME and 58 pTME were analyzed. No differences were found for major morbidity (27.6% vs 19.0%; P = 0.28) and abdominoperineal excision rate (31.0% vs 32.8%; P = 0.85) between cTME and pTME, respectively. Local recurrence (3.4% vs 8.6%; P = 0.43), systemic recurrence (3.4% vs 12.1%; P = 0.25), overall survival (93.1% vs 94.8%; P = 0.71), and disease-free survival (89.7% vs 81.0%; P = 0.43) were comparable between cTME and pTME. Conclusions cTME is not associated with higher major morbidity, whereas the abdominoperineal excision rate and 3-year oncological outcomes are similar compared to pTME. Local excision as a diagnostic tool followed by completion surgery for early rectal cancer does not compromise outcomes and should still be considered as the treatment of early-stage rectal cancer.
Collapse
Affiliation(s)
- Thijs A. Burghgraef
- From the Department of Surgery, Meander Medical Centre, Amersfoort, the Netherlands
- Department of Surgery, University Medical Centre, Groningen, the Netherlands
| | - Marieke L. Rutgers
- Department of Surgery, Amsterdam University Medical Centre, location AMC, Amsterdam, the Netherlands
| | | | - Jurriaan B. Tuyman
- Department of Surgery, Amsterdam University Medical Centre, location VUmc, Amsterdam, the Netherlands
| | - Esther C. J. Consten
- From the Department of Surgery, Meander Medical Centre, Amersfoort, the Netherlands
- Department of Surgery, University Medical Centre, Groningen, the Netherlands
| | - Roel Hompes
- Department of Surgery, Amsterdam University Medical Centre, location AMC, Amsterdam, the Netherlands
| |
Collapse
|
4
|
Somashekhar SP, Saklani A, Dixit J, Kothari J, Nayak S, Sudheer OV, Dabas S, Goud J, Munikrishnan V, Sugoor P, Penumadu P, Ramachandra C, Mehendale S, Dahiya A. Clinical Robotic Surgery Association (India Chapter) and Indian rectal cancer expert group’s practical consensus statements for surgical management of localized and locally advanced rectal cancer. Front Oncol 2022; 12:1002530. [PMID: 36267970 PMCID: PMC9577482 DOI: 10.3389/fonc.2022.1002530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 09/16/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction There are standard treatment guidelines for the surgical management of rectal cancer, that are advocated by recognized physician societies. But, owing to disparities in access and affordability of various treatment options, there remains an unmet need for personalizing these international guidelines to Indian settings. Methods Clinical Robotic Surgery Association (CRSA) set up the Indian rectal cancer expert group, with a pre-defined selection criterion and comprised of the leading surgical oncologists and gastrointestinal surgeons managing rectal cancer in India. Following the constitution of the expert Group, members identified three areas of focus and 12 clinical questions. A thorough review of the literature was performed, and the evidence was graded as per the levels of evidence by Oxford Centre for Evidence-Based Medicine. The consensus was built using the modified Delphi methodology of consensus development. A consensus statement was accepted only if ≥75% of the experts were in agreement. Results Using the results of the review of the literature and experts’ opinions; the expert group members drafted and agreed on the final consensus statements, and these were classified as “strong or weak”, based on the GRADE framework. Conclusion The expert group adapted international guidelines for the surgical management of localized and locally advanced rectal cancer to Indian settings. It will be vital to disseminate these to the wider surgical oncologists and gastrointestinal surgeons’ community in India.
Collapse
Affiliation(s)
- S. P. Somashekhar
- Department of Surgical Oncology, Manipal Hospital, Bengaluru, Karnataka, India
- *Correspondence: S. P. Somashekhar,
| | - Avanish Saklani
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Jagannath Dixit
- Department of GI Surgery, HCG Hospital, Bengaluru, Karnataka, India
| | - Jagdish Kothari
- Department of Surgical Oncology HCG Hospital, Ahmedabad, Gujarat, India
| | - Sandeep Nayak
- Department of Surgical Oncology, Fortis Hospital, Bengaluru, Karnataka, India
| | - O. V. Sudheer
- Department of GI Surgery and Surgical Oncology, Amrita Institute of Medical Science, Kochi, Kerala, India
| | - Surender Dabas
- Department of Surgical Oncology, BL Kapur-Max Superspeciality Hospital, Delhi, India
| | - Jagadishwar Goud
- Department of Surgical Oncology, AOI Hospital, Hyderabad, Telangana, India
| | | | - Pavan Sugoor
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
| | | | - C. Ramachandra
- Director and Head, Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
| | - Shilpa Mehendale
- Director and Head, Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
| | - Akhil Dahiya
- Department of Clinical and Medical Affairs, Intuitive Surgical, California, CA, United States
| |
Collapse
|
5
|
Wyatt JNR, Powell SG, Altaf K, Barrow HE, Alfred JS, Ahmed S. Completion Total Mesorectal Excision After Transanal Local Excision of Early Rectal Cancer: A Systematic Review and Meta-analysis. Dis Colon Rectum 2022; 65:628-640. [PMID: 35143429 DOI: 10.1097/dcr.0000000000002407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Completion total mesorectal excision is recommended when local excision of early rectal cancers demonstrates high-risk histopathological features. Concerns regarding the quality of completion resections and the impact on oncological safety remain unanswered. OBJECTIVE This study aims to summarize and analyze the outcomes associated with completion surgery and undertake a comparative analysis with primary rectal resections. DATA SOURCES Data sources included PubMed, Cochrane library, MEDLINE, and Embase databases up to April 2021. STUDY SELECTION All studies reporting any outcome of completion surgery after transanal local excision of an early rectal cancer were selected. Case reports, studies of benign lesions, and studies using flexible endoscopic techniques were not included. INTERVENTION The intervention was completion total mesorectal excision after transanal local excision of early rectal cancers. MAIN OUTCOME MEASURES Primary outcome measures included histopathological and long-term oncological outcomes of completion total mesorectal excision. Secondary outcome measures included short-term perioperative outcomes. RESULTS Twenty-three studies including 646 patients met the eligibility criteria, and 8 studies were included in the meta-analyses. Patients undergoing completion surgery have longer operative times (standardized mean difference, 0.49; 95% CI, 0.23-0.75; p = 0.0002) and higher intraoperative blood loss (standardized mean difference, 0.25; 95% CI, 0.01-0.5; p = 0.04) compared with primary resections, but perioperative morbidity is comparable (risk ratio, 1.26; 95% CI, 0.98-1.62; p = 0.08). Completion surgery is associated with higher rates of incomplete mesorectal specimens (risk ratio, 3.06; 95% CI, 1.41-6.62; p = 0.005) and lower lymph node yields (standardized mean difference, -0.26; 95% CI, -0.47 to 0.06; p = 0.01). Comparative analysis on long-term outcomes is limited, but no evidence of inferior recurrence or survival rates is found. LIMITATIONS Only small retrospective cohort and case-control studies are published on this topic, with considerable heterogeneity limiting the effectiveness of meta-analysis. CONCLUSIONS This review provides the strongest evidence to date that completion surgery is associated with an inferior histopathological grade of the mesorectum and finds insufficient long-term results to satisfy concerns regarding oncological safety. International collaborative research is required to demonstrate noninferiority. REGISTRATION NO CRD42021245101.
Collapse
Affiliation(s)
- James N R Wyatt
- Department of Colorectal Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
- University of Liverpool, Liverpool, United Kingdom
| | - Simon G Powell
- Department of Colorectal Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
- University of Liverpool, Liverpool, United Kingdom
| | - Kiran Altaf
- Department of Colorectal Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Hannah E Barrow
- Department of Colorectal Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Joshua S Alfred
- Department of Colorectal Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Shakil Ahmed
- Department of Colorectal Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| |
Collapse
|
6
|
Berger NF, Sylla P. The Role of Transanal Endoscopic Surgery for Early Rectal Cancer. Clin Colon Rectal Surg 2022; 35:113-121. [PMID: 35237106 PMCID: PMC8885158 DOI: 10.1055/s-0041-1742111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Transanal endoscopic surgery (TES), which is performed through a variety of transanal endoluminal multitasking surgical platforms, was developed to facilitate endoscopic en bloc excision of rectal lesions as a minimally invasive alternative to radical proctectomy. Although the oncologic safety of TES in the treatment of malignant rectal tumors has been an area of vigorous controversy over the past two decades, TES is currently accepted as an oncologically safe approach for the treatment of carefully selected early and superficial rectal cancers. TES can also serve as both a diagnostic and potentially curative treatment of partially resected unsuspected malignant polyps. In this article, indications and contraindications for transanal endoscopic excision of early rectal cancer lesions are reviewed, as well as selection criteria for the most appropriate transanal excisional approach. Preoperative preparation and surgical technique for complications of TES will be reviewed, as well as recommended surveillance and management of upstaged tumors.
Collapse
Affiliation(s)
| | - Patricia Sylla
- Icahn School of Medicine at Mount Sinai, New York, New York,Division of Colon and Rectal Surgery, Department of Surgery, Mount Sinai Hospital, New York, New York,Address for correspondence Patricia Sylla, MD, FACS, FASCRS Division of Colon and Rectal Surgery, Department of Surgery, Mount Sinai Hospital5 East 98th Street, Box 1259, New York, NY 10029
| |
Collapse
|
7
|
Prior endoscopic resection does not affect the outcome of secondary surgery for T1 colorectal cancer, a systematic review and meta-analysis. Int J Colorectal Dis 2022; 37:273-281. [PMID: 34716475 DOI: 10.1007/s00384-021-04049-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/13/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND It remains unclear the effect of prior endoscopic resection (ER) on the secondary surgery (SS) for T1 colorectal cancer (CRC). This study aimed to compare the short- and long-term outcomes between primary surgery (PS) and ER followed by SS for T1 CRC. METHODS A systematic literature search was performed in PubMed and Ovid for studies comparing PS with ER followed by SS for T1 colorectal cancer. The last search was performed on 18 May 2021. The primary outcomes were surgical parameters and the secondary outcomes were survival indicators. The meta-analysis was performed with Review Manager Software (version 5.3). RESULTS A total of fifteen studies published between 2013 and 2021 with 4349 patients were included in this meta-analysis finally. No significant difference was observed between the two groups for operative time (P = 0.75, WMD = 3.16, 95%CI [-15.88, 22.19], I2 = 64%), blood loss (P = 0.86, WMD = 12.33, 95%CI [-122.99, 147.65], I2 = 95%), and postoperative complications (P = 0.59, OR = 0.93, 95%CI [0.71, 1.22], I2 = 0%). Besides, the two groups showed comparable survival outcomes, including overall recurrence rate (P = 0.15, OR = 0.78, 95%CI [0.56, 1.09], I2 = 23%) and 5-year overall survival (P = 0.76, OR = 0.86, 95%CI [0.33, 2.25], I2 = 0%). In the subgroup analysis for studies with propensity matching score or lesions located in the rectum, the results were not changed. CONCLUSION ER followed by SS is feasible for T1 CRC with high-risk factors. The prior ER would not bring additional adverse effects to the SS. More advanced tools should be developed to improve the diagnostic accuracy for the high-risk factors before treatment for T1 CRC.
Collapse
|
8
|
Smits LJH, van Lieshout AS, Grüter AAJ, Horsthuis K, Tuynman JB. Multidisciplinary management of early rectal cancer - The role of surgical local excision in current and future clinical practice. Surg Oncol 2021; 40:101687. [PMID: 34875460 DOI: 10.1016/j.suronc.2021.101687] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/30/2021] [Accepted: 11/22/2021] [Indexed: 12/14/2022]
Abstract
The implementation of bowel cancer screening programs has led to a rise in the incidence of early rectal cancer. The combination of increased incidence and the growing interest in organ-sparing treatment options has led to an amplified importance of local excision techniques in treatment strategies for early rectal cancer. In addition, developments in new technologies of single-port surgery have popularized surgical techniques. Although local treatment of early rectal cancer seems promising, a multidisciplinary approach is necessary and awareness of the oncological robustness is warranted to enable shared decision-making. This review illustrates the position of surgical local excision in the treatment of early rectal cancer and reflects on its role in current and future clinical practice.
Collapse
Affiliation(s)
- Lisanne J H Smits
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, the Netherlands.
| | - Annabel S van Lieshout
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, the Netherlands
| | - Alexander A J Grüter
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, the Netherlands
| | - Karin Horsthuis
- Department of Radiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, the Netherlands
| | - Jurriaan B Tuynman
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, the Netherlands.
| |
Collapse
|
9
|
Early salvage total mesorectal excision (sTME) after organ preservation failure in rectal cancer does not worsen postoperative outcomes compared to primary TME: systematic review and meta-analysis. Int J Colorectal Dis 2021; 36:2375-2386. [PMID: 34244857 DOI: 10.1007/s00384-021-03989-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/26/2021] [Indexed: 02/04/2023]
Abstract
IMPORTANCE While oncological outcomes of early salvage total mesorectal excision (sTME) after local excision (LE) have been well studied, the impact of LE before TME on postoperative outcomes remains unclear. We aimed to compare early sTME with a primary TME for rectal cancer. METHODS Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines with the random-effects model were adopted using Review Manager Version 5.3 for pooled estimates. RESULTS We retrieved eleven relevant articles including 1728 patients (350 patients in the sTME group and 1438 patients in the TME group). There was no significant difference between the two groups in terms of mortality (OR = 0.90, 95%CI [0.21 to 3.77], p = 0.88), morbidity (OR = 1.19, 95%CI [0.59 to 2.38], p = 0.63), conversion to open surgery (OR = 1.34, 95%CI [0.61 to 2.94], p = 0.47), anastomotic leak (OR = 1.38, 95%CI [0.50 to 3.83], p = 0.53), hospital stay (MD = 0.23 day, 95%CI [- 1.63 to 2.10], p < 0.81), diverting stoma rate (OR = 0.69, 95%CI [0.44 to 1.09], p = 0.11), abdominoperineal resection rate (OR = 1.47, 95%CI [0.91 to 2.37], p = 0.11), local recurrence (OR = 0.94, 95%CI [0.44 to 2.04], p = 0.88), and distant recurrence (OR = 0.88, 95%CI [0.52 to 1.48], p = 0.62). sTME was associated with significantly longer operative time (MD = 25.62 min, 95%CI[11.92 to 39.32], p < 0.001) lower number of harvested lymph nodes (MD = - 2.25 lymph node, 95%CI [- 3.86 to - 0.65], p = 0.006), and higher proportion of incomplete TME (OR = 0.25, 95%CI [0.11 to 0.61], p = 0.002). CONCLUSIONS sTME is not associated with increased postoperative morbidity, mortality, or local recurrence. However, the operative times are longer and yield a poor specimen quality.
Collapse
|
10
|
Ahmad NZ, Abbas MH, Abunada MH, Parvaiz A. A Meta-analysis of Transanal Endoscopic Microsurgery versus Total Mesorectal Excision in the Treatment of Rectal Cancer. Surg J (N Y) 2021; 7:e241-e250. [PMID: 34541316 PMCID: PMC8440057 DOI: 10.1055/s-0041-1735587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 07/22/2021] [Indexed: 11/23/2022] Open
Abstract
Background
Transanal endoscopic microsurgery (TEMS) has been suggested as an alternative to total mesorectal excision (TME) in the treatment of early rectal cancers. The extended role of TEMS for higher stage rectal cancers after neoadjuvant therapy is also experimented. The aim of this meta-analysis was to compare the oncological outcomes and report on the evidence-based clinical supremacy of either technique.
Methods
Medline, Embase, and Cochrane databases were searched for the randomized controlled trials comparing the oncological and perioperative outcomes of TEMS and a radical TME. A local recurrence and postoperative complications were analyzed as primary end points. Intraoperative blood loss, operation time, and duration of hospital stay were compared as secondary end points.
Results
There was no statistical difference in the local recurrence or postoperative complications with a risk ratio of 1.898 and 0.753 and
p
-values of 0.296 and 0.306, respectively, for TEMS and TME. A marked statistical significance in favor of TEMS was observed for secondary end points. There was standard difference in means of −4.697, −6.940, and −5.685 with
p
-values of 0.001, 0.005, and 0.001 for blood loss, operation time, and hospital stay, respectively.
Conclusion
TEMS procedure is a viable alternative to TME in the treatment of early rectal cancers. An extended role of TEMS after neoadjuvant therapy may also be offered to a selected group of patients. TME surgery remains the standard of care in more advanced rectal cancers.
Collapse
Affiliation(s)
- Nasir Zaheer Ahmad
- Department of Surgery, University Hospital Limerick, Limerick, Republic of Ireland
| | - Muhammad Hasan Abbas
- Department of Surgery, Russells Hall Hospital, NHS Trust, West Midlands, Dudley, United Kingdom
| | | | - Amjad Parvaiz
- Faculty of Health Sciences, University of Portsmouth, Portsmouth, England.,Department of Colorectal Surgery, Poole NHS Trust, Poole, United Kingdom
| |
Collapse
|
11
|
The impact of transanal local excision of early rectal cancer on completion rectal resection without neoadjuvant chemoradiotherapy: a systematic review. Tech Coloproctol 2021; 25:997-1010. [PMID: 34173121 DOI: 10.1007/s10151-020-02401-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 12/28/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND The impact of transanal local excision (TAE) of early rectal cancer (ERC) on subsequent completion rectal resection (CRR) for unfavorable histology or margin involvement is unclear. The aim of this study was to provide a comprehensive review of the literature on the impact of TAE on CRR in patients without neoadjuvant chemoradiotherapy (CRT). METHODS We performed a systematic review of the literature up to March 2020. Medline and Cochrane libraries were searched for studies reporting outcomes of CRR after TAE for ERC. We excluded patients who had neoadjuvant CRT and endoscopic local excision. Surgical, functional, pathological and oncological outcomes were assessed. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. RESULTS Sixteen studies involving 353 patients were included. Pathology following TAE was as follows T0 = 2 (0.5%); T1 = 154 (44.7%); T2 = 142 (41.2%); T3 = 43 (12.5%); Tx = 3 (0.8%); T not reported = 9. Fifty-three percent were > T1. Abdominoperineal resection (APR) was performed in 80 (23.2%) patients. Postoperative major morbidity and mortality occurred in 22 (11.4%) and 3 (1.1%), patients, respectively. An incomplete mesorectal fascia resulting in defects of the mesorectum was reported in 30 (24.6%) cases. Thirteen (12%) patients developed recurrence: 8 (3.1%) local, 19 (7.3%) distant, 4 (1.5%) local and distant. The 5-year cancer-specific survival was 92%. Only 1 study assessed anal function reporting no continence disorders in 11 patients. In the meta-analysis, CRR after TAE showed an increased APR rate (OR 5.25; 95% CI 1.27-21.8; p 0.020) and incomplete mesorectum rate (OR 3.48; 95% CI 1.32-9.19; p 0.010) compared to primary total mesorectal excision (TME). Two case matched studies reported no difference in recurrence rate and disease free survival respectively. CONCLUSIONS The data are incomplete and of low quality. There was a tendency towards an increased risk of APR and poor specimen quality. It is necessary to improve the accuracy of preoperative staging of malignant rectal tumors in patients scheduled for TAE.
Collapse
|
12
|
Koreli A, Briassoulis G, Sideris M, Philalithis A, Papagrigoriadis S. Transanal Endoscopic Microsurgery (TEMS) for Rectal Cancer: Patient Decision-making, Postoperative Experience and Quality of Life. In Vivo 2021; 35:1235-1245. [PMID: 33622926 DOI: 10.21873/invivo.12374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 01/22/2021] [Accepted: 01/27/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM Transanal endoscopic microsurgery (TEMS) is a form of minimally invasive surgery for selected rectal cancers. The aim of this study was to explore the factors affecting patients' decision-making concerning the choice of surgical treatment as well as to measure the Quality of Life (QoL) post-TEMS. PATIENTS AND METHODS Thirty-four patients with rectal cancer stage T1/T2-N0-M0 that underwent TEMS were studied. The questionnaires used included the Short Form SF12v2, Wexner Score (CCF-FIS) and the Sexual Function Questionnaire (SFQ). The patients' views on experience and treatment decision were obtained with a custom-designed questionnaire. Questionnaires were completed at a mean of 6.9 years following treatment. RESULTS The factors that influenced the patients' decisions were: experience satisfaction (p=0.003), postoperative bowel function (p<0.001), lower incontinence score (p=0.020) and agreement of TEMS experience with preoperative information (p=0.049). Treatment experience satisfaction was associated with family support (p=0.034) and agreement with preoperative information (p=0.047), better bowel function (p=0.026) and mental QoL (MCS) (p=0.003). CONCLUSION factors important to patients when reflecting on treatment experience are adequate and reliable information, a good QoL and the presence of family support. Clinicians should incorporate those parameters in their practice when assisting patients in making a surgical treatment choice and provide informed consent on TEMS for rectal cancer.
Collapse
Affiliation(s)
- Alexandra Koreli
- Medical School, University of Crete, Heraklion, Greece; .,Nursing Department, University of West Attica, Athens, Greece
| | | | | | | | | |
Collapse
|
13
|
Sensi B, Bagaglini G, Bellato V, Cerbo D, Guida AM, Khan J, Panis Y, Savino L, Siragusa L, Sica GS. Management of Low Rectal Cancer Complicating Ulcerative Colitis: Proposal of a Treatment Algorithm. Cancers (Basel) 2021; 13:cancers13102350. [PMID: 34068058 PMCID: PMC8152518 DOI: 10.3390/cancers13102350] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 04/29/2021] [Accepted: 05/05/2021] [Indexed: 01/04/2023] Open
Abstract
Simple Summary This article expresses the viewpoint of the authors’ management of low rectal cancer in ulcerative colitis (UC). This subject suffers from a paucity of literature and therefore management decision is very difficult to take. The aim of this paper is to provide a structured approach to a challenging situation. It is subdivided into two parts: a first part where the existing literature is reviewed critically, and a second part in which, on the basis of the literature review and their extensive clinical experience, a management algorithm is proposed by the authors to offer guidance to surgical and oncological practices. This text adds to the literature a useful guide for the treatment of these complex clinical scenarios. Abstract Low rectal Carcinoma arising at the background of Ulcerative Colitis poses significant management challenges to the clinicians. The complex decision-making requires discussion at the multidisciplinary team meeting. The published literature is scarce, and there are significant variations in the management of such patients. We reviewed treatment protocols and operative strategies; with the aim of providing a practical framework for the management of low rectal cancer complicating UC. A practical treatment algorithm is proposed.
Collapse
Affiliation(s)
- Bruno Sensi
- Minimally Invasive Surgery, Department of Surgery, Policlinico Tor Vergata, 00133 Rome, Italy; (G.B.); (V.B.); (D.C.); (A.M.G.); (L.S.); (G.S.S.)
- Correspondence: ; Tel.: +39-338-535-2902
| | - Giulia Bagaglini
- Minimally Invasive Surgery, Department of Surgery, Policlinico Tor Vergata, 00133 Rome, Italy; (G.B.); (V.B.); (D.C.); (A.M.G.); (L.S.); (G.S.S.)
| | - Vittoria Bellato
- Minimally Invasive Surgery, Department of Surgery, Policlinico Tor Vergata, 00133 Rome, Italy; (G.B.); (V.B.); (D.C.); (A.M.G.); (L.S.); (G.S.S.)
| | - Daniele Cerbo
- Minimally Invasive Surgery, Department of Surgery, Policlinico Tor Vergata, 00133 Rome, Italy; (G.B.); (V.B.); (D.C.); (A.M.G.); (L.S.); (G.S.S.)
| | - Andrea Martina Guida
- Minimally Invasive Surgery, Department of Surgery, Policlinico Tor Vergata, 00133 Rome, Italy; (G.B.); (V.B.); (D.C.); (A.M.G.); (L.S.); (G.S.S.)
| | - Jim Khan
- Colorectal Surgery Department, Queen Alexandra Hospital, Portsmouth NHS Trust, Portsmouth PO6 3LY, UK;
| | - Yves Panis
- Service de Chirurgie Colorectale, Pôle des Maladies de L’appareil Digestif (PMAD), Université Denis-Diderot (Paris VII), Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris (AP-HP), 100, Boulevard du Général-Leclerc, 92110 Clichy, France;
| | - Luca Savino
- Pathology, Department of Biomedicine and Prevention, Policlinico Tor Vergata, 00133 Rome, Italy;
| | - Leandro Siragusa
- Minimally Invasive Surgery, Department of Surgery, Policlinico Tor Vergata, 00133 Rome, Italy; (G.B.); (V.B.); (D.C.); (A.M.G.); (L.S.); (G.S.S.)
| | - Giuseppe S. Sica
- Minimally Invasive Surgery, Department of Surgery, Policlinico Tor Vergata, 00133 Rome, Italy; (G.B.); (V.B.); (D.C.); (A.M.G.); (L.S.); (G.S.S.)
| |
Collapse
|
14
|
Levic Souzani K, Bulut O, Kuhlmann TP, Gögenur I, Bisgaard T. Completion total mesorectal excision following transanal endoscopic microsurgery does not compromise outcomes in patients with rectal cancer. Surg Endosc 2021; 36:1181-1190. [PMID: 33629183 DOI: 10.1007/s00464-021-08385-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 02/09/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Transanal endoscopic microsurgery (TEM) represents a choice of treatment in patients with neoplastic lesions in the rectum. When TEM fails, completion total mesorectal excision (cTME) is often required. However, a concern is whether cTME increases the rate of abdominoperineal resections (APR) and is associated with higher risk of incomplete mesorectal fascia (MRF) resection. The aim of this study was to compare outcomes of cTME with primary TME (pTME) in patients with rectal cancer. METHODS This was a nationwide study on all patients with cTME from the Danish Colorectal Cancer Group database between 2005 and 2015. Patients with cTME were compared to patients with pTME after propensity score matching (matching ratio 1:2). Matching variables were age, gender, tumor distance from anal verge, American Society of Anesthesiologists (ASA) score and American Joint Committee on Cancer (AJCC) stage. RESULTS A total of 60 patients with cTME were compared with 120 patients with pTME. Patients with cTME experienced more intraoperative complications as compared to pTME patients (18.3% vs. 6.7%, p = 0.021). However, there was no difference in the rate of perforations at or near the tumor/previous TEM site (6.7% vs. 2.5%, p = 0.224), conversion to open surgery (p = 0.733) or 30-day morbidity (p = 0.86). On multivariate analysis, cTME was not a risk factor for APR (OR 2.49; 95% CI 0.95-6.56; p = 0.064) or incomplete MRF (OR 1.32; 95% CI 0.48-3.63; p = 0.596). There was no difference in the rate of local recurrence between cTME and pTME (5.2% vs. 4.3%, p = 0.1), distant metastases (6.8% vs. 6.8%, p = 1), or survival (p = 0.081). The mean follow-up time was 6 years. CONCLUSION In our study, the largest so far on the subject, we find no difference in postoperative short- or long-term outcomes between cTME and pTME.
Collapse
Affiliation(s)
- Katarina Levic Souzani
- Gastrounit - Surgical Division, Center for Surgical Research, Copenhagen University Hospital Hvidovre, Kettegaards Allé 30, 2650, Hvidovre, Denmark.
| | - Orhan Bulut
- Gastrounit - Surgical Division, Center for Surgical Research, Copenhagen University Hospital Hvidovre, Kettegaards Allé 30, 2650, Hvidovre, Denmark.,Institution of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Tine Plato Kuhlmann
- Department of Pathology, Herlev University Hospital, Copenhagen, Denmark.,Institution of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Danish Colorectal Cancer Group, Copenhagen, Denmark
| | - Ismail Gögenur
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Køge, Denmark.,Institution of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Danish Colorectal Cancer Group, Copenhagen, Denmark
| | - Thue Bisgaard
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Køge, Denmark.,Danish Colorectal Cancer Group, Copenhagen, Denmark
| |
Collapse
|
15
|
Aguirre-Allende I, Enriquez-Navascues JM, Elorza-Echaniz G, Etxart-Lopetegui A, Borda-Arrizabalaga N, Saralegui Ansorena Y, Placer-Galan C. Early-rectal Cancer Treatment: A Decision-tree Making Based on Systematic Review and Meta-analysis. Cir Esp 2020; 99:89-107. [PMID: 32993858 DOI: 10.1016/j.ciresp.2020.05.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 05/27/2020] [Accepted: 05/30/2020] [Indexed: 02/07/2023]
Abstract
Local excision (LE) has arisen as an alternative to total mesorectal excision for the treatment of early rectal cancer. Despite a decreased morbidity, there are still concerns about LE outcomes. This systematic-review and meta-analysis design is based on the "PICO" process, aiming to answer to three questions related to LE as primary treatment for early-rectal cancer, the optimal method for LE, and the potential role for completion treatment in high-risk histology tumors and outcomes of salvage surgery. The results revealed that reported overall survival (OS) and disease-specific survival (DSS) were 71%-91.7% and 80%-94% for LE, in contrast to 92.3%-94.3% and 94.4%-97% for radical surgery. Additional analysis of National Database studies revealed lower OS with LE (HR: 1.26; 95%CI, 1.09-1.45) and DSS (HR: 1.19; 95%CI, 1.01-1.41) after LE. Furthermore, patients receiving LE were significantly more prone develop local recurrence (RR: 3.44, 95%CI, 2.50-4.74). Analysis of available transanal surgical platforms was performed, finding no significant differences among them but reduced local recurrence compared to traditional transanal LE (OR:0.24;95%CI, 0.15-0.4). Finally, we found poor survival outcomes for patients undergoing salvage surgery, favoring completion treatment (chemoradiotherapy or surgery) when high-risk histology is present. In conclusion, LE could be considered adequate provided a full-thickness specimen can be achieved that the patient is informed about risk for potential requirement of completion treatment. Early-rectal cancer cases should be discussed in a multidisciplinary team, and patient's preferences must be considered in the decision-making process.
Collapse
Affiliation(s)
- Ignacio Aguirre-Allende
- Servicio de Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Hospital Universitario Donostia, Instituto Biodonostia, Spain.
| | - Jose Maria Enriquez-Navascues
- Servicio de Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Hospital Universitario Donostia, Instituto Biodonostia, Spain
| | - Garazi Elorza-Echaniz
- Servicio de Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Hospital Universitario Donostia, Instituto Biodonostia, Spain
| | - Ane Etxart-Lopetegui
- Servicio de Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Hospital Universitario Donostia, Instituto Biodonostia, Spain
| | - Nerea Borda-Arrizabalaga
- Servicio de Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Hospital Universitario Donostia, Instituto Biodonostia, Spain
| | - Yolanda Saralegui Ansorena
- Servicio de Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Hospital Universitario Donostia, Instituto Biodonostia, Spain
| | - Carlos Placer-Galan
- Servicio de Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Hospital Universitario Donostia, Instituto Biodonostia, Spain
| |
Collapse
|
16
|
O'Connell E, Galvin R, McNamara DA, Burke JP. The utility of preoperative radiological evaluation of early rectal neoplasia: a systematic review and meta-analysis. Colorectal Dis 2020; 22:1076-1084. [PMID: 32052545 DOI: 10.1111/codi.15015] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 02/05/2020] [Indexed: 12/12/2022]
Abstract
AIM The diagnostic role for preoperative imaging of clinically benign rectal adenomas is unclear. The objective of this systematic review and meta-analysis was to examine the diagnostic accuracy of preoperative imaging in distinguishing benign adenomas from rectal cancer. METHOD A systematic search was performed for all studies published that correlated staging of clinically benign rectal adenomas with endorectal ultrasound (ERUS) or MRI and histology. Imaging was compared with postoperative histology and data on the numbers of true positives, false positives, true negatives and false negatives were extracted. Summary estimates of sensitivity and specificity with 95% CIs were calculated using a bivariate random effects model. The QUADAS2 tool was used to determine the methodological quality of included studies. RESULTS Eleven studies describing 1511 patients were retrieved. A total of 1134 patients underwent local excision and 377 had a formal proctectomy. A benign rectal adenoma was diagnosed in 840 and 214 had a T1 rectal cancer. For confirming benign adenomas, the pooled sensitivity of ERUS was 0.81 (95% CI 0.69-0.89) and specificity was 0.85 (95% CI 0.68-0.93). For detecting occult T1 tumours, the pooled sensitivity of ERUS was 0.50 (95% CI 0.33-0.66) and specificity was 0.89 (95% CI 0.82-0.94). Quantitative analysis of MRI could not be performed due to insufficient studies. CONCLUSION This study demonstrates the limited accuracy of preoperative ERUS in distinguishing benign adenomas from T1 rectal cancer. Preoperative imaging must be interpreted with caution to prevent over-staging and unnecessary proctectomy. We propose that clinically benign lesions may undergo local excision, with subsequent management based on final histology.
Collapse
Affiliation(s)
- E O'Connell
- Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland
| | - R Galvin
- School of Allied Health, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - D A McNamara
- Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland.,Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - J P Burke
- Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland.,Royal College of Surgeons in Ireland, Dublin 2, Ireland
| |
Collapse
|
17
|
Nozawa H, Ishii H, Sonoda H, Emoto S, Murono K, Kaneko M, Sasaki K, Nishikawa T, Shuno Y, Tanaka T, Kawai K, Hata K, Ishihara S. Effects of preceding endoscopic treatment on laparoscopic surgery for early rectal cancer. Colorectal Dis 2020; 22:906-913. [PMID: 32072748 DOI: 10.1111/codi.14989] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 01/02/2020] [Indexed: 02/08/2023]
Abstract
AIM Endoscopic treatment for rectal cancer, such as endoscopic mucosal resection and endoscopic submucosal dissection, causes inflammation, oedema and fibrosis in the surrounding tissue. However, little is known about the effect of these endoscopic therapies on salvage laparoscopic rectal surgery. The objective of this retrospective cohort study was to analyse the effect of preceding endoscopic treatment on the outcomes of laparoscopic surgery for rectal cancer. METHOD We analysed 53 patients who underwent laparoscopic surgery for rectal cancer with clinical Tis or T1 at our department between May 2011 and June 2019. Data from 30 patients who underwent laparoscopic surgery after preceding endoscopic treatment (Group E + S) were compared with those of 23 patients who underwent laparoscopic surgery alone (Group S). RESULTS There was no significant difference between the groups with respect to preoperative details. The mean operative time tended to be longer in Group E + S, and the volume of intra-operative blood loss was greater in Group E + S than in Group S (median 63 ml vs 10 ml, P = 0.049). There were no significant differences between the groups in other surgical parameters or oncological outcomes. CONCLUSION Laparoscopic surgery after endoscopic treatment for rectal cancer may be difficult due to an increased risk of intra-operative bleeding. Long-term prognosis after surgery was not affected by preceding endoscopic treatment in rectal cancer.
Collapse
Affiliation(s)
- H Nozawa
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - H Ishii
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - H Sonoda
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - S Emoto
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - K Murono
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - M Kaneko
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - K Sasaki
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - T Nishikawa
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - Y Shuno
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - T Tanaka
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - K Kawai
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - K Hata
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | - S Ishihara
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| |
Collapse
|
18
|
Clermonts SHEM, Köeter T, Pottel H, Stassen LPS, Wasowicz DK, Zimmerman DDE. Outcomes of completion total mesorectal excision are not compromised by prior transanal minimally invasive surgery. Colorectal Dis 2020; 22:790-798. [PMID: 31943682 PMCID: PMC7497048 DOI: 10.1111/codi.14962] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 12/15/2019] [Indexed: 01/08/2023]
Abstract
AIM Transanal minimally invasive surgery (TAMIS) is used increasingly often as an organ-preserving treatment for early rectal cancer. If final pathology reveals unfavourable histological prognostic features, completion total mesorectal excision (cTME) is recommended. This study is the first to investigate the results of cTME after TAMIS. METHOD Data were retrieved from the prospective database of the Elisabeth-TweeSteden Hospital. Completion TME patients were case matched with a control group of patients undergoing primary TME (pTME). Primary and secondary outcomes were surgical outcomes and oncological outcomes, respectively. RESULTS From 2011 to 2017, 20 patients underwent cTME and were compared with 40 patients undergoing pTME. There were no significant differences in operating time (238 min vs 226 min, P = 0.53), blood loss (137 ml vs. 158 ml, P = 0.88) or complications (45% vs 55%, P = 0.07) between both groups. There was no 90-day mortality in the cTME group. The mesorectal fascia was incomplete in three patients (15%) in the cTME group compared with no breaches in the pTME group (P = 0.083). There were no local recurrences in either group. In three patients (15%), distant metastases were detected after cTME compared with one patient (2.5%) in the pTME group (P = 0.069). After cTME patients had a 1- and 5-year disease-free survival of 85% compared with 97.5% for the pTME group (P = 0.062). CONCLUSION Completion TME surgery after TAMIS is not associated with increased peri- or postoperative morbidity or mortality compared with pTME surgery. After cTME surgery patients have a similar disease-free and overall survival when compared with patients undergoing pTME.
Collapse
Affiliation(s)
- S. H. E. M. Clermonts
- Department of SurgeryETZ (Elisabeth‐TweeSteden) HospitalTilburgThe Netherlands,Department of SurgeryMaastricht University Medical CentreMaastrichtThe Netherlands
| | - T. Köeter
- Department of SurgeryETZ (Elisabeth‐TweeSteden) HospitalTilburgThe Netherlands
| | - H. Pottel
- Department of Public Health and Primary CareCatholic University LeuvenKortrijkBelgium
| | - L. P. S. Stassen
- Department of SurgeryMaastricht University Medical CentreMaastrichtThe Netherlands
| | - D. K. Wasowicz
- Department of SurgeryETZ (Elisabeth‐TweeSteden) HospitalTilburgThe Netherlands
| | - D. D. E. Zimmerman
- Department of SurgeryETZ (Elisabeth‐TweeSteden) HospitalTilburgThe Netherlands
| |
Collapse
|
19
|
Junginger T, Goenner U, Hitzler M, Trinh TT, Heintz A, Wollschläger D. Local excision followed by early radical surgery in rectal cancer: long-term outcome. World J Surg Oncol 2019; 17:168. [PMID: 31594546 PMCID: PMC6784329 DOI: 10.1186/s12957-019-1705-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 09/05/2019] [Indexed: 12/27/2022] Open
Abstract
Background In rectal cancers, radical surgery should follow local excisions, in cases of unexpected, unfavorable tumor characteristics. The oncological results of this completion surgery are inconsistent. This retrospective cohort study assessed the clinical and long-term oncological outcomes of patients that underwent completion surgery to clarify whether a local excision compromised the results of radical surgery. Methods Forty-six patients were included, and the reasons for completion surgery, intraoperative complications, residual tumors, local recurrences (LRs), distant metastases, and cancer-specific survival (CSS) were assessed. The results were compared to 583 patients that underwent primary surgery without adjuvant therapy, treated with a curative intention during the same time period. Results The median follow-up was 14.6 years. The reasons for undergoing completion surgery were positive resection margins (24%), high-risk cancer (30%), or both (46%). Intraoperative perforations occurred in 10/46 (22%) cases. Residual tumor in the rectal wall or lymph node involvement occurred in 12/46 (26%) cases. The risk of intraoperative perforation and residual tumor increased with the pT category. Intraoperative perforations did not increase postoperative complications, but they increased the risk of LRs in cases of intramural residual tumors (p = 0.003). LRs occurred in 2.6% of pT1/2 and 29% of pT3 tumors. Both the 5- and 10-year CSS rates were 88.8% (95% CI 80.0–98.6). Moreover, the LRs of patients with pT1/2 cancers were lower in patients with completion surgery than in patients with primary surgery. Conclusions Rectal wall perforations at the local excision site and residual cancer were the main risks for poor oncological outcomes associated with completion surgery. Local excisions followed by early radical surgery did not appear to compromise outcomes compared to patients with primary surgery for pT1/2 rectal cancer. Improvements in clinical staging should allow more appropriate selection of patients that are eligible for a local excision of rectal cancer.
Collapse
Affiliation(s)
- Theodor Junginger
- Department of General and Abdominal Surgery, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Ursula Goenner
- Department of General and Abdominal Surgery, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Mirjam Hitzler
- Department of General, Visceral and Vascular Surgery, Catholic Hospital, Mainz, Germany
| | - Tong T Trinh
- Department of Heart, Chest and Vascular Surgery, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Achim Heintz
- Department of General, Visceral and Vascular Surgery, Catholic Hospital, Mainz, Germany
| | - Daniel Wollschläger
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Centre of the Johannes Gutenberg-University, Langenbeckstr. 1, D 55131, Mainz, Germany.
| |
Collapse
|
20
|
Transanal Minimally Invasive Surgery for Local Excision of Benign and Malignant Rectal Neoplasia: Outcomes From 200 Consecutive Cases With Midterm Follow Up. Ann Surg 2019; 267:910-916. [PMID: 28252517 DOI: 10.1097/sla.0000000000002190] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE This study describes the outcomes for 200 consecutive transanal minimally invasive surgery (TAMIS) local excision (LE) for rectal neoplasia. BACKGROUND TAMIS is an advanced transanal platform that can result in high quality LE of rectal neoplasia. METHODS Consecutive patients from July 1, 2009 to December 31, 2015 from a prospective institutional registry were analyzed. Indication for TAMIS LE was endoscopically unresectable benign lesions or histologically favorable early rectal cancers. The primary endpoints were resection quality, neoplasia recurrence, and oncologic outcomes. Kaplan-Meier survival analyses were used to describe disease-free survival (DFS) for patients with rectal adenocarcinoma that did not receive immediate salvage radical surgery. RESULTS There were 200 elective TAMIS LE procedures performed in 196 patients for 90 benign and 110 malignant lesions. Overall, a 7% margin positivity and 5% fragmentation rate was observed. The mean operative time for TAMIS was 69.5 minutes (SD 37.9). Postoperative morbidity was recorded in 11% of patients, with hemorrhage (9%), urinary retention (4%), and scrotal or subcutaneous emphysema (3%) being the most common. The mean follow up was 14.4 months (SD 17.4). Local recurrence occurred in 6%, and distant organ metastasis was noted in 2%. Mean time to local recurrence for malignancy was 16.9 months (SD 13.2). Cumulative DFS for patients with rectal adenocarcinoma was 96%, 93%, and 84% at 1-, 2-, and 3-years. CONCLUSIONS For carefully selected patients, TAMIS for local excision of rectal neoplasia is a valid option with low morbidity that maintains the advantages of organ preservation.
Collapse
|
21
|
Coton C, Lefevre JH, Debove C, Creavin B, Chafai N, Tiret E, Parc Y. Does transanal local resection increase morbidity for subsequent total mesorectal excision for early rectal cancer? Colorectal Dis 2019; 21:15-22. [PMID: 30300969 DOI: 10.1111/codi.14445] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 07/30/2018] [Indexed: 02/06/2023]
Abstract
AIM Local excision is recommended for early rectal cancer (pT1). Complementary total mesorectal excision (cTME) is warranted when bad pathological features are present. The impact of a prior local resection on the outcome remains unclear. The aim of this study was to assess if prior local excision increases the morbidity of a subsequent cTME compared with primary TME. METHODS From 2001 to 2016 all patients who underwent TME after local excision for rectal adenocarcinoma were studied. All were matched (1:1) with patients who underwent primary TME, without neoadjuvant radiochemotherapy. The matching factors included age, sex, body mass index, American Society of Anesthesiologists score and type of surgery. Short-term morbidity and pathological examination of the resected specimen were compared. RESULTS Forty-one patients were included (14 women, 34%, mean age 65 ± 11 years), comprising classic transanal excision (66%) and transanal endoscopic microsurgery (34%), and were matched to 41 patients who had primary TME. cTME was significantly longer (315 min ± 87 vs 275 min ± 58, P = 0.03). The overall morbidity was 48.8% in the local excision group vs 31.7% in the control group (P = 0.18). Surgical morbidity was 31.7% vs 26.8% (P = 0.8). Anastomotic related morbidity was similar (local excision 17% vs TME 14.6%, P = 0.84) and the mean length of stay was similar (14 days) in both groups. There was a tendency to a worse quality of mesorectal excision in the cTME group (17% vs 5%, P = 0.15). CONCLUSION Local excision prior to TME for early rectal cancer tends to increase overall morbidity and may worsen the quality of the mesorectal plane but should be considered as a surgical approach in select cases.
Collapse
Affiliation(s)
- C Coton
- Department of Digestive and General Surgery, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
| | - J H Lefevre
- Department of Digestive and General Surgery, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
| | - C Debove
- Department of Digestive and General Surgery, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
| | - B Creavin
- Department of Colorectal Surgery, St Vincent's University Hospital, Dublin 4, Ireland
| | - N Chafai
- Department of Digestive and General Surgery, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
| | - E Tiret
- Department of Digestive and General Surgery, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
| | - Y Parc
- Department of Digestive and General Surgery, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
| |
Collapse
|
22
|
Koedam TWA, Veltcamp Helbach M, Penna M, Wijsmuller A, Doornebosch P, van Westreenen HL, Hompes R, Bonjer HJ, Sietses C, de Graaf E, Tuynman JB. Short-term outcomes of transanal completion total mesorectal excision (cTaTME) for rectal cancer: a case-matched analysis. Surg Endosc 2019; 33:103-109. [PMID: 29967991 PMCID: PMC6336745 DOI: 10.1007/s00464-018-6280-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 06/18/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND Local excision of early rectal tumors as a rectal preserving treatment is gaining popularity, especially since bowel cancer screening programs result in a shift towards the diagnosis of early stage rectal cancers. However, unfavorable histological features predicting high risk for recurrence within the "big biopsy" may mandate completion total mesorectal excision (cTME). Completion surgery is associated with higher morbidity, poorer specimen quality, and less favorable oncological outcomes compared to primary TME. Transanal approach potentially improves outcome of completion surgery for rectal cancer. The aim of this study was to compare radical completion surgery after local excision for rectal cancer by the transanal approach (cTaTME) with conventional abdominal approach (cTME). METHODS All consecutive patients who underwent cTaTME for rectal cancer between 2012 and 2017 were case-matched with cTME patients, according to gender, tumor height, preoperative radiotherapy, and tumor stage. Surgical, pathological, and short-term postoperative outcomes were evaluated. RESULTS In total, 25 patients underwent completion TaTME and were matched with 25 patients after cTME. Median time from local excision to completion surgery was 9 weeks in both groups. In the cTaTME and cTME groups, perforation of the rectum occurred in 4 and 28% of patients, respectively (p = 0.049), leading to poor specimen quality in these patients. Number of harvested lymph nodes was higher after cTaTME (median 15; range 7-47) than after cTME (median 10; range 0-17). No significant difference was found in end colostomy rate between the two groups. Major 30-day morbidity (Clavien-Dindo≥ III) was 20 and 32%, respectively (p = 0.321). Hospital stay was significantly longer after cTME. CONCLUSION TaTME after full-thickness excision is a promising technique with a significantly lower risk of perforation of the rectum and better specimen quality compared to conventional completion TME.
Collapse
Affiliation(s)
- T. W. A. Koedam
- 0000 0004 0435 165Xgrid.16872.3aDepartment of Surgery, VU University Medical Center, Boelelaan 1117, 1081 HV Amsterdam, The Netherlands ,Postbus 7075, 1007 MB Amsterdam, The Netherlands
| | - M. Veltcamp Helbach
- 0000 0004 0398 026Xgrid.415351.7Department of Surgery, Hospital Gelderse Vallei, Ede, The Netherlands
| | - M. Penna
- 0000 0004 0488 9484grid.415719.fDepartment of Colorectal Surgery, Churchill Hospital, Oxford, UK
| | - A. Wijsmuller
- 0000 0004 0435 165Xgrid.16872.3aDepartment of Surgery, VU University Medical Center, Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - P. Doornebosch
- 0000 0004 0501 4532grid.414559.8Department of Surgery, IJsselland Hospital, Capelle a/d IJssel, The Netherlands
| | - H. L. van Westreenen
- 0000 0001 0547 5927grid.452600.5Department of Surgery, ISALA Hospital, Zwolle, The Netherlands
| | - R. Hompes
- 0000 0004 0488 9484grid.415719.fDepartment of Colorectal Surgery, Churchill Hospital, Oxford, UK
| | - H. J. Bonjer
- 0000 0004 0435 165Xgrid.16872.3aDepartment of Surgery, VU University Medical Center, Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - C. Sietses
- 0000 0004 0398 026Xgrid.415351.7Department of Surgery, Hospital Gelderse Vallei, Ede, The Netherlands
| | - E. de Graaf
- 0000 0004 0501 4532grid.414559.8Department of Surgery, IJsselland Hospital, Capelle a/d IJssel, The Netherlands
| | - J. B. Tuynman
- 0000 0004 0435 165Xgrid.16872.3aDepartment of Surgery, VU University Medical Center, Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| |
Collapse
|
23
|
Radiologic Evaluation of Clinically Benign Rectal Neoplasms May Not Be Necessary Before Local Excision. Dis Colon Rectum 2018; 61:1163-1169. [PMID: 30113341 DOI: 10.1097/dcr.0000000000001168] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Local excision may be curative for benign and malignant rectal neoplasms. Because many early rectal cancers are discovered incidentally after local excision of clinically benign lesions, it is unclear whether preoperative imaging with transrectal ultrasound or MRI affects management. OBJECTIVE The purpose of this study was to determine the diagnostic characteristics and effect of preoperative imaging on the incidence of malignancy in benign rectal lesions undergoing local excision. DESIGN Prospective data from 2 institutions were included. Coarsened exact matching created a balanced cohort comparing imaging and no-imaging groups. SETTING The study was conducted at high-volume specialist referral hospitals. PATIENTS Adult patients undergoing local excision via transanal endoscopic surgery between 1997 and 2016 for clinically benign rectal neoplasms were included. INTERVENTION The study intervention included preoperative imaging with transrectal ultrasound and/or MRI. MAIN OUTCOME MEASURES We measured the incidence of malignancy and diagnostic accuracy of preoperative imaging. RESULTS A total of 620 patients were included (272 with preoperative imaging and 348 without). There were 250 patients undergoing transrectal ultrasound, and 24 patients undergoing MRI (2 patients underwent both). Transrectal ultrasound and MRI correctly identified malignant polyps in 50% (11/22) and 44% (8/18). Overall agreement for benign versus malignant polyps between preoperative imaging and final pathology was κ = 0.30 (95% CI, 0.18-0.41) for transrectal ultrasound and 0.29 (95% CI, 0.01-0.57) for MRI. In both the overall and unmatched cohorts, the incidence of malignancy, margin involvement, and proportion of patients requiring salvage surgery was similar. LIMITATIONS Data were obtained from 2 institutions with different equipment over a long time period. CONCLUSIONS Preoperative imaging did not accurately identify malignancy in clinically benign rectal lesions and did not affect the incidence of malignancy, margin involvement, or proportion of patients requiring salvage surgery. Therefore, preoperative imaging may not be necessary for clinically benign lesions undergoing local excision. See Video Abstract at http://links.lww.com/DCR/A695.
Collapse
|
24
|
Current Trends on the Status of Transanal Endoscopic Microsurgery. CURRENT COLORECTAL CANCER REPORTS 2018. [DOI: 10.1007/s11888-018-0406-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
25
|
Letarte F, Raval M, Karimuddin A, Phang PT, Brown CJ. Salvage TME following TEM: a possible indication for TaTME. Tech Coloproctol 2018; 22:355-361. [PMID: 29725785 DOI: 10.1007/s10151-018-1784-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 12/07/2017] [Indexed: 01/16/2023]
Abstract
BACKGROUND Salvage surgery after transanal endoscopic microsurgery (TEM) has shown mixed results. Transanal total mesorectal excision (TaTME) might be advantageous in this population. The aim of this study was to assess the short-term oncologic and operative outcomes of salvage surgery after TEM, comparing TaTME to conventional salavge TME (sTME). METHODS Consecutive patients treated with salvage surgery after TEM were identified. Patients who underwent TaTME were compared to those who had conventional sTME. The primary outcome was the ability to perform an appropriate oncologic procedure defined by a composite outcome (negative distal margins, negative radial margins and complete or near complete mesorectum specimen). RESULTS During the study period, 41 patients had salvage surgery after TEM. Of those, 11 patients had TaTME while 30 patients had sTME. All patients in the TaTME group met the composite outcome of appropriate oncologic procedure compared to 76.7% for the conventional sTME group (p = 0.19). TaTME was associated with significantly higher rates of sphincter preservation (100 vs. 50%, p = 0.01), higher rates of laparoscopic surgery (100 vs. 23.3%, p < 0.001) and lower rates of conversion to open surgery (9.1 vs. 57%, p < 0.001). No difference was found in postoperative morbidity (36.3 vs. 36.7%, p = 0.77). CONCLUSIONS The present study demonstrates that for patients requiring salvage surgery after TEM, TaTME is associated with significantly higher rates of sphincter-sparing surgery when compared to conventional transabdominal TME while producing adequate short-term oncologic outcomes. Salvage surgery after TEM might be a clear indication for TaTME rather than conventional surgery.
Collapse
Affiliation(s)
- F Letarte
- Department of Colorectal Surgery, St. Paul's Hospital Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - M Raval
- Department of Colorectal Surgery, St. Paul's Hospital Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - A Karimuddin
- Department of Colorectal Surgery, St. Paul's Hospital Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - P T Phang
- Department of Colorectal Surgery, St. Paul's Hospital Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - C J Brown
- Department of Colorectal Surgery, St. Paul's Hospital Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada. .,Division of General Surgery, Providence Health Care, Vancouver, Canada. .,Section of Colorectal Surgery, St. Paul Hospital, University of British Columbia (UBC), C310-1081 Burrard Street, Vancouver, V6Z 1Y6, Canada.
| |
Collapse
|
26
|
Issa N, Fenig Y, Gingold-Belfer R, Khatib M, Khoury W, Wolfson L, Schmilovitz-Weiss H. Laparoscopic Total Mesorectal Excision Following Transanal Endoscopic Microsurgery for Rectal Cancer. J Laparoendosc Adv Surg Tech A 2018; 28:977-982. [PMID: 29668359 DOI: 10.1089/lap.2017.0399] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Patients' selection for transanal endoscopic microsurgery (TEM) depends on diagnostic modalities; however, there are still some limitations in the preoperative diagnosis of rectal lesions, and in some reports, up to third of the adenomas resected by TEM were found to be adenocarcinoma; therefore, salvage radical resection (RR) remains necessary for achieving oncological resection. Salvage RR may encounter some technical problems as the violation of the mesorectum and the scar formation. In this study, we aimed to report the outcome in patients undergoing salvage RR in terms of morbidity and oncological results. MATERIALS AND METHODS Demographic and clinical data pertaining to patients undergoing RR following TEM between 2004 and 2014 were retrospectively collected. RESULTS One hundred forty one TEM were performed in the study period, 53 (38%) for malignant rectal lesions. Indication for TEM: 15 (28%) benign adenoma, 25 (47%) early rectal cancer, and 13 (25%) had clinical complete response after neoadjuvant radiochemotherapy. Ten (19%) patients had no residual tumor in TEM specimen, 15 (28%) had T1, and 2 of them underwent salvage low anterior resection (LAR). Ten (19%) had T2, 4 had LAR, and 1 had abdominoperineal resection (APR). Five (9%) had a T3, 3 underwent LAR, and 2 had APR. Among the 13 (25%) after chemo-radiotherapy (CRT), 4 had salvage AR. The time from TEM to RR was 47 days (range32-70). Of 16 salvage surgeries, 8 (50%) were laparoscopic. The median operative time was 210 minutes (range165-360). Five patients had protective ileostomy. Rectal perforation occurred in 2 (12%) patients; both had a posterior location, one after CRT. Two (12%) postoperative small-bowl obstruction and three wound infections occurred. There was no perioperative mortality in any of the patients who underwent RR. The final pathology was no residual disease in 9, T3N1 in 1, T3N0 in 3, T2N1 in 1, and T2N0 in 2 patients. Eight (50%) had adjuvant chemotherapy. CONCLUSION Laparoscopic total mesorectal excision following TEM seems to be safe, and with no negative impact of the completeness of the resection. The concern of intraoperative specimen perforation is real, and should be dealt with meticulous technique and careful dissection, particularly after CRT.
Collapse
Affiliation(s)
- Nidal Issa
- 1 Department of Surgery, Rabin Medical Center , Hasharon Hospital, Petach Tikva, Israel .,2 The Sackler School of Medicine, Tel-Aviv University , Tel Aviv, Israel
| | - Yaniv Fenig
- 3 Department of Surgery, Monmouth Medical Center , Long Branch, New Jersey
| | - Rachel Gingold-Belfer
- 2 The Sackler School of Medicine, Tel-Aviv University , Tel Aviv, Israel .,4 Department of Gastroenterology, Rabin Medical Center , Hasharon Hospital, Petach Tikva, Israel
| | - Muhammad Khatib
- 1 Department of Surgery, Rabin Medical Center , Hasharon Hospital, Petach Tikva, Israel .,2 The Sackler School of Medicine, Tel-Aviv University , Tel Aviv, Israel
| | - Wisam Khoury
- 5 Department of Surgery, Rambam Medical Center , Haifa, Israel
| | - Lea Wolfson
- 6 Department of Pathology, Rabin Medical Center , Hasharon Hospital, Petach Tikva, Israel
| | - Hemda Schmilovitz-Weiss
- 2 The Sackler School of Medicine, Tel-Aviv University , Tel Aviv, Israel .,4 Department of Gastroenterology, Rabin Medical Center , Hasharon Hospital, Petach Tikva, Israel
| |
Collapse
|
27
|
Eid Y, Alves A, Lubrano J, Menahem B. Does previous transanal excision for early rectal cancer impair surgical outcomes and pathologic findings of completion total mesorectal excision? Results of a systematic review of the literature. J Visc Surg 2018; 155:445-452. [PMID: 29657063 DOI: 10.1016/j.jviscsurg.2018.03.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Transanal excision (TAE) is increasingly used in the treatment of early rectal cancer because of lower rate of both postoperative complications and postsurgical functional disorders as compared with total mesorectal excision (TME) OBJECTIVE: To compare in a meta-analysis surgical outcomes and pathologic findings between patients who underwent TAE followed by completion proctectomy with TME (TAE group) for early rectal cancer with unfavorable histology or incomplete resection, and those who underwent primary TME (TME group). METHODS The Medline and Cochrane Trials Register databases were searched for studies comparing short-term outcomes between patients who underwent TAE followed by completion TME versus primary TME. Studies published until December 2016 were included. The meta-analysis was performed using Review Manager 5.0 (Cochrane Collaboration, Oxford, UK). RESULTS Meta-analysis showed that completion TME after TAE was significantly associated with increased reintervention rate (OR=4.28; 95% CI, 1.10-16.76; P≤0.04) and incomplete mesorectal excision rate (OR=5.74; 95% CI, 2.24-14.75; P≤0.0003), as compared with primary TME. However there both abdominoperineal amputation and circumferential margin invasion rates were comparable between TAE and TME groups. CONCLUSIONS This meta-analysis suggests that previous TAE impaired significantly surgical outcomes and pathologic findings of completion TME as compared with primary TME. First transanal approach during completion TME might be evaluated in order to decrease technical difficulties.
Collapse
Affiliation(s)
- Y Eid
- Department of digestive surgery, university hospital of Caen, avenue de la Côte-de-Nacre, 14033 Caen cedex, France
| | - A Alves
- Department of digestive surgery, university hospital of Caen, avenue de la Côte-de-Nacre, 14033 Caen cedex, France; Centre François-Baclesse, Normandie université, UNICAEN, CHU de Caen, Inserm UMR1086, 3, avenue du Général-Harris, 14045 Caen cedex, France
| | - J Lubrano
- Department of digestive surgery, university hospital of Caen, avenue de la Côte-de-Nacre, 14033 Caen cedex, France; Centre François-Baclesse, Normandie université, UNICAEN, CHU de Caen, Inserm UMR1086, 3, avenue du Général-Harris, 14045 Caen cedex, France
| | - B Menahem
- Department of digestive surgery, university hospital of Caen, avenue de la Côte-de-Nacre, 14033 Caen cedex, France; Centre François-Baclesse, Normandie université, UNICAEN, CHU de Caen, Inserm UMR1086, 3, avenue du Général-Harris, 14045 Caen cedex, France.
| |
Collapse
|
28
|
Bronzwaer MES, Musters GD, Barendse RM, Koens L, de Graaf EJR, Doornebosch PG, Schwartz MP, Consten ECJ, Schoon EJ, de Hingh IHJT, Tanis PJ, Dekker E, Fockens P. The occurrence and characteristics of endoscopically unexpected malignant degeneration in large rectal adenomas. Gastrointest Endosc 2018; 87:862-871.e1. [PMID: 29030001 DOI: 10.1016/j.gie.2017.09.046] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 09/24/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Large non-pedunculated rectal polyps are most commonly resected by endoscopic mucosal resection (EMR) or transanal endoscopic microsurgery (TEM). Despite pre-procedural diagnostics, unexpected rectal cancer is incidentally encountered within the resected specimen. This study aimed to compare the diagnostic assessment and procedural characteristics of lesions with and without unexpected submucosal invasion. METHODS A post-hoc analysis of a multicenter randomized trial (TREND study) was performed in which patients with a non-pedunculated rectal polyp of ≥3 cm without endoscopic suspicion of invasive growth were randomized between EMR and TEM. RESULTS Unexpected rectal cancer was detected in 13% (27/203) of patients; 15 after EMR and 12 after TEM. Most consisted of low-risk T1 cancers (78%, n = 18). There were no differences in the diagnostic assessment between lesions with and without unexpected submucosal invasion. Diagnostic biopsies revealed similar rates of high-grade dysplasia (28% [7/25] vs 18% [26/144]). When compared with EMR of adenomas, EMR procedures of unexpected cancers had a lower success rate of submucosal lifting (60% vs 93%, P < .001), were more often assessed as endoscopically incomplete (33% vs 10%, P = .01), and were more frequently terminated prematurely (60% vs 8%, P = .001). CONCLUSIONS Diagnostic assessment of large non-pedunculated rectal polyps revealed similar characteristics between unexpected cancers and adenomas. Unexpected cancers during EMR were non-lifting in 40%, endoscopically assessed as incomplete in 33%, and terminated prematurely in 60%. In treatment-naive patients, these factors should raise suspicion of malignancy and need discussion in a multidisciplinary team meeting for decision on further treatment strategies.
Collapse
Affiliation(s)
- Maxime E S Bronzwaer
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Gijsbert D Musters
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Renée M Barendse
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Lianne Koens
- Department of Pathology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Eelco J R de Graaf
- Department of Surgery, IJsselland Hospital, Capelle aan de Ijssel, the Netherlands
| | - Pascal G Doornebosch
- Department of Surgery, IJsselland Hospital, Capelle aan de Ijssel, the Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, the Netherlands
| | - Esther C J Consten
- Department of Surgery, Meander Medical Center, Amersfoort, the Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Pieter J Tanis
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| |
Collapse
|
29
|
Transanal endoscopic microsurgery for giant benign rectal tumours: is large size a contraindication? Int J Colorectal Dis 2017; 32:1759-1761. [PMID: 28963594 DOI: 10.1007/s00384-017-2910-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/26/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE The purpose of this study is to look at our early postoperative results, recurrence rates and need for further radical surgery in treating large (> 5 cm) rectal tumours by transanal endoscopic microsurgery (TEM). METHODS Patients who underwent TEM for rectal tumours greater than 5 cm were included. Tumour diameter was determined based on fresh specimen measurements. We recorded the demographics, operative details, final pathology, length of hospital stay, complications and recurrence rates. RESULTS Mean tumour size was 5.9 ± 1.5 cm. 68.4% of tumours (13/19) were in the middle part of the rectum. Three patients (15.8%) developed postoperative complications: two had postoperative bleeding (10.5%), one had wound dehiscence (5.3%). Three patients had involved margins (15.8%). After a median follow up of 25.2 months, there were two recurrences (10.5%). One patient developed rectal cancer 6 years after removal of rectal adenoma. CONCLUSION TEM is feasible and safe for the treatment of giant benign rectal tumours. It may be an alternative method for proctectomy in selected patients.
Collapse
|
30
|
The feasibility of laparoscopic rectal resection in patients undergoing reoperation after transanal endoscopic microsurgery (TEM). Surg Endosc 2017; 32:2020-2025. [PMID: 29052070 DOI: 10.1007/s00464-017-5898-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 09/17/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND The success of transanal endoscopic microsurgery (TEM) for early rectal cancer depends on proper indications and strict patient selection. When unfavorable pathologic features are identified after TEM operation, total mesorectal excision is recommended to minimize the risk of recurrence. In this study, data were collected in a retrospective series of patients to determine the results of laparoscopic reoperation after TEM. METHODS All patients underwent an accurate rectal-digital examination and clinical tumor staging by transanal endosonography, CT, and/or MRI. The histologic examination included an evaluation of the free margins, depth of tumor infiltration according to International Union Against Cancer guidelines, degree of tumor differentiation, and the presence of lymphovascular and perineural invasion. When a high-risk tumor was identified, reoperation was performed within 6 weeks from TEM. The patients were divided into two groups according to the procedure performed: laparoscopic anterior resection (LAR) or laparoscopic abdominal perineal amputation (LAPR). RESULTS Sixty-eight patients (5.3%) underwent reoperation: 38 underwent LAR and 30 underwent LAPR. The mean operative time was 148.24 min (± 35.8, p = 0.62). Meanwhile, the mean distance of the TEM scar from the anal verge differed statistically between the two groups (p = 0.003) and was statistically correlated with abdominal perineal amputation (p = 0.0001) in multivariate analysis. Conversion to open surgery was required in 6 patients (15.7%) in the LAR group and 3 patients (10%) in the LAPR group (p = 0.38). The histologic examination revealed residual cancer cells in 3 cases (3 pT2N0) and 1 case (1 pT3N0), respectively, and lymph node metastases in 4 cases. No residual neoplasms were detected in the remaining 60 cases (88.3%). After a mean follow-up of 108 months, the overall disease-free survival was 98% (95% CI 88-99%). CONCLUSIONS In our experience, reoperation after TEM using a laparoscopic approach is feasible and safe, with low conversion rates and optimal postoperative results.
Collapse
|
31
|
Samalavičius NE, Dulskas A, Petrulis K, Kilius A, Tikuišis R, Lunevičius R. Hybrid transanal and total mesorectal excision after transanal endoscopic microsurgery for unfavourable early rectal cancer: a report of two cases. Acta Med Litu 2017; 24:188-192. [PMID: 29217973 PMCID: PMC5709058 DOI: 10.6001/actamedica.v24i3.3553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 09/25/2017] [Indexed: 11/27/2022] Open
Abstract
Completion total mesorectal excision (TME) is a rare but complex procedure after transanal endoscopic microsurgery for early rectal cancer with unfavourable final histology. Two cases are reported when completion TME was performed after upfront transanal partial mesorectal dissection. Intact non-perforated TME specimens with negative and adequate distal and circumferential margins were created. The quality of both total mesorectal excisions was complete and distal margins were sufficient. We believe that our technique might be a way of approaching completion TME after TEM, especially in cases of low rectal cancer.
Collapse
Affiliation(s)
- Narimantas E. Samalavičius
- Clinic of Internal Diseases, Family Medicine and Oncology of Medical Faculty, Vilnius University, National Cancer Institute, Vilnius, Lithuania
- Department of Surgery Klaipėda University Hospital, Klaipėda, Lithuania
| | - Audrius Dulskas
- General and Abdominal Surgery and Oncology Department, National Cancer Institute, Vilnius, Lithuania
| | - Kęstutis Petrulis
- General and Abdominal Surgery and Oncology Department, National Cancer Institute, Vilnius, Lithuania
| | - Alfredas Kilius
- General and Abdominal Surgery and Oncology Department, National Cancer Institute, Vilnius, Lithuania
| | - Renatas Tikuišis
- General and Abdominal Surgery and Oncology Department, National Cancer Institute, Vilnius, Lithuania
| | - Raimundas Lunevičius
- General Surgery Department, Aintree University Hospital NHS Foundation Trust, University of Liverpool, Liverpool, United Kingdom
| |
Collapse
|
32
|
Organ preservation with local excision or active surveillance following chemoradiotherapy for rectal cancer. Br J Cancer 2016; 116:169-174. [PMID: 27997526 PMCID: PMC5243997 DOI: 10.1038/bjc.2016.417] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 10/27/2016] [Accepted: 11/21/2016] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Organ preservation has been proposed as an alternative to radical surgery for rectal cancer to reduce morbidity and mortality, and to improve functional outcome. METHODS Locally advanced non-metastatic rectal cancers were identified from a prospective database. Patients staged ⩾T3 or any stage N+ were referred for neoadjuvant chemoradiotherapy (CRT) (50-54 Gy and 5-fluorouracil), and were reassessed 6-8 weeks post treatment. An active surveillance programme ('watch and wait') was offered to patients who were found to have a complete endoluminal response. Transanal excision was performed in patients who were found to have an objective clinical response and in whom a residual ulcer measured ⩽3 cm. Patients were followed up clinically, endoscopically and radiologically to assess for local recurrence or disease progression. RESULTS Of 785 patients with rectal cancer between 2005 and 2015, 362 had non-metastatic locally advanced tumours treated with neoadjuvant CRT. Sixty out of three hundred and sixty-two (16.5%) patients were treated with organ-preserving strategies - 10 with 'watch and wait' and 50 by transanal excision. Fifteen patients were referred for salvage total mesorectal excision post local excision owing to adverse pathological findings. There was no significant difference in overall survival (85.6% vs 93.3%, P=0.414) or disease-free survival rate (78.3% vs 80%, P=0.846) when the outcomes of radical surgery were compared with organ preservation. Tumour regrowth occurred in 4 out of 45 (8.9%) patients who had organ preservation. CONCLUSIONS Organ preservation for locally advanced rectal cancer is feasible for selected patients who achieve an objective endoluminal response to neoadjuvant CRT. Transanal excision defines the pathological response and refines decision-making.
Collapse
|
33
|
Leong KJ, Evans J, Davies MM, Scott A, Lidder P. Transanal endoscopic surgery: past, present and future. Br J Hosp Med (Lond) 2016; 77:394-402. [PMID: 27388378 DOI: 10.12968/hmed.2016.77.7.394] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Transanal endoscopic surgery is a safe, established technique to remove lesions in the rectum via the anus. This article reviews its evolution, approaches, indications and evidence for its role in treating benign rectal polyps. The future of transanal endoscopic surgery in rectal cancer and inflammatory bowel disease is also explored.
Collapse
Affiliation(s)
- Kai J Leong
- Specialty Registrar in the Department of Colorectal Surgery, University Hospitals of Coventry and Warwickshire NHS Trust, Coventry CV2 2DX
| | - John Evans
- Consultant Colorectal Surgeon in the Department of Colorectal Surgery, Northampton General Hospital NHS Trust, Northampton
| | - Michael M Davies
- Consultant Colorectal Surgeon in the Department of Colorectal Surgery, University Hospital of Wales, Cardiff
| | - Adam Scott
- Consultant Colorectal Surgeon in the Department of Colorectal Surgery, Leicester General Hospital, University Hospitals of Leicester NHS Trust, Leicester
| | - Paul Lidder
- Consultant Colorectal Surgeon in the Department of Surgery, Royal Cornwall Hospitals NHS Trust, Cornwall
| |
Collapse
|
34
|
Transanal Endoscopic Microsurgery: Current and Future Perspectives. Surg Laparosc Endosc Percutan Tech 2016; 26:e46-9. [DOI: 10.1097/sle.0000000000000273] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
35
|
YEO SEUNGGU. Preoperative chemoradiotherapy followed by transanal local excision for T3 distal rectal cancer: A case report. Exp Ther Med 2016; 11:1465-1468. [PMID: 27073466 PMCID: PMC4812548 DOI: 10.3892/etm.2016.3065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Accepted: 12/21/2015] [Indexed: 12/15/2022] Open
Abstract
Local excision (LE) for rectal cancer is currently indicated for selected T1 stage tumors. However, preoperative chemoradiotherapy (CRT) for locally advanced rectal cancer not only improves local disease control, but also leads to a decrease in the stage and size of the primary mural tumor, along with a decrease in the risk of regional lymphadenopathy. The present study reports the outcome of a patient with T3N0M0 rectal cancer who was treated with LE following preoperative CRT. The distal pole of the tumor was located 2 cm from the anal verge. Preoperative pelvic radiotherapy of 50.4 Gy was administered in 28 fractions. Chemotherapy using 5-fluorouracil and leucovorin was administered during the first and last weeks of radiotherapy. The tumor response to CRT, was found to be marked at 7 weeks after CRT completion, and a complete response was presumed clinically. Transanal full-thickness LE was performed, and pathological examination revealed the absence of residual cancer cells. After 30 months of close follow-up, the patient was alive with no evidence of disease, and treatment-associated severe toxicities were not observed. Although a longer follow-up period is required, this case report suggests that LE may also be a feasible alternative treatment for T3 rectal cancer, which exhibits a marked response to preoperative CRT, particularly in elderly and comorbid patients contraindicated for radical surgery, or patients who are reluctant to undergo sphincter-ablation surgery.
Collapse
Affiliation(s)
- SEUNG-GU YEO
- Department of Radiation Oncology, Soonchunhyang University College of Medicine, Soonchunhyang University Hospital, Cheonan, Chungnam 31151, Republic of Korea
| |
Collapse
|
36
|
Abstract
A transanal approach to rectal polyp and cancer excision is often an appropriate alternative to conventional rectal resection, and has a lower associated morbidity. There has been a steady evolution in the techniques of transanal surgery over the past 30 years. It started with traditional transanal excision and was revolutionized by introduction of transanal endoscopic microsurgery in early 1980s. Introduction of transanal minimally invasive surgery made it more accessible to surgeons around the world. Now robotic platforms are being tried in certain institutions. Concerns have been raised about recurrence rates of cancers with transanal approach and success of subsequent salvage operations.
Collapse
Affiliation(s)
- Vinay Rai
- Colon and Rectum Surgery, University of New Mexico, New Mexico
| | - Nitin Mishra
- Colon and Rectum Surgery, Mayo Clinic College of Medicine, Arizona
| |
Collapse
|
37
|
Allaix ME, Arezzo A, Morino M. Transanal endoscopic microsurgery for rectal cancer: T1 and beyond? An evidence-based review. Surg Endosc 2016; 30:4841-4852. [DOI: 10.1007/s00464-016-4818-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 02/04/2016] [Indexed: 12/17/2022]
|
38
|
Quaresima S, Balla A, D’Ambrosio G, Bruzzone P, Ursi P, Lezoche E, Paganini AM. Endoluminal loco-regional resection by TEM after R1 endoscopic removal or recurrence of rectal tumors. MINIM INVASIV THER 2016; 25:134-40. [DOI: 10.3109/13645706.2016.1145125] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
39
|
Removal of gallstone from mesorectum after laparoscopic cholecystectomy - new indication for transanal endoscopic microsurgery technique. Wideochir Inne Tech Maloinwazyjne 2016; 10:580-3. [PMID: 26865896 PMCID: PMC4729735 DOI: 10.5114/wiitm.2015.56494] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 11/12/2015] [Indexed: 11/17/2022] Open
Abstract
Transanal endoscopic microsurgery (TEM) is a minimally invasive technique for local excision of benign and malignant neoplasms in the rectum. Indications for this technique are constantly changing and extending. The aim of this study is to describe a case of a unique and innovative application of this surgical technique. A 72-year-old patient was admitted to the Clinical Department of General and Colorectal Surgery for elective resection of a tumor located in the perianal area using the TEM surgical technique. In August 2005 the patient underwent laparoscopic cholecystectomy due to symptomatic cholecystitis. From March 2011 the patient complained about ongoing sharp pain in the perianal and presacral area. Computed tomography revealed two oval areas approximately 30 mm in size to the right of the sigmoido-rectal region communicating with the colon lumen. Subsequently diverticulitis was diagnosed. The TEM technique was uniquely used to successfully remove the gallstone from the 72-year-old patient's presacral area.
Collapse
|
40
|
Perez RO, Habr-Gama A, São Julião GP, Proscurshim I, Fernandez LM, de Azevedo RU, Vailati BB, Fernandes FA, Gama-Rodrigues J. Transanal Endoscopic Microsurgery (TEM) Following Neoadjuvant Chemoradiation for Rectal Cancer: Outcomes of Salvage Resection for Local Recurrence. Ann Surg Oncol 2015; 23:1143-8. [PMID: 26577119 DOI: 10.1245/s10434-015-4977-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Indexed: 12/25/2022]
Abstract
BACKGROUND Transanal endoscopic microsurgery (TEM) has been considered an alternative for selected patients with rectal cancer following neoadjuvant chemoradiation (CRT). Immediate total mesorectal completion for all patients with unfavorable pathological features would result in unnecessary protectomies in a significant proportion of patients. Instead, salvage total mesorectal excision (TME) could be restricted for patients developing local recurrence. The aim of the present study is to determine oncological outcomes of salvage resection for local recurrences following CRT and TEM. METHODS Consecutive patients undergoing TEM following neoadjuvant CRT for rectal cancer were reviewed. Patients with "near" complete response to CRT (≤3 cm; ycT1-2N0) were offered TEM. Salvage surgery was attempted in the event of a local recurrence. RESULTS A total of 53 patients were managed by CRT followed by TEM. Unfavorable pathological features were present in 36 patients (68 %). None of the patients underwent immediate completion TME. There were 12 patients who developed local recurrence resulting in a 2-year local recurrence-free survival of 77 % (95 % CI, 53-100 %). Of these patients, 9 developed exclusively local recurrences, and all had at least 1 unfavorable pathological feature in the specimen after TEM (100 %). Eight patients (8 of 9) underwent salvage resection (abdominoperineal resection [APR] in 87 %) with CRM+ in 7 of 8 patients (87 %). Four patients developed local re-recurrence after a median 36 months of follow-up. The 2-year local re-recurrence free survival was 60 %. CONCLUSIONS Salvage resection for local recurrence following CRT and TEM is associated with high rates of R1 resection (CRM+) and local re-recurrence. Immediate completion of TME should be considered for patients with unfavorable pathological features after TEM.
Collapse
Affiliation(s)
- Rodrigo Oliva Perez
- Angelita and Joaquim Gama Institute, São Paulo, Brazil. .,Colorectal Surgery Division, University of São Paulo School of Medicine, São Paulo, Brazil. .,São Paulo Branch, Ludwig Institute for Cancer Research, São Paulo, Brazil.
| | - Angelita Habr-Gama
- Angelita and Joaquim Gama Institute, São Paulo, Brazil.,University of São Paulo School of Medicine, São Paulo, Brazil
| | | | | | | | - Rafael Ulysses de Azevedo
- Angelita and Joaquim Gama Institute, São Paulo, Brazil.,University of São Paulo School of Medicine, São Paulo, Brazil
| | | | - Felipe Alexandre Fernandes
- Angelita and Joaquim Gama Institute, São Paulo, Brazil.,University of São Paulo School of Medicine, São Paulo, Brazil
| | - Joaquim Gama-Rodrigues
- Angelita and Joaquim Gama Institute, São Paulo, Brazil.,University of São Paulo School of Medicine, São Paulo, Brazil
| |
Collapse
|
41
|
Arezzo A, Bianco F, Agresta F, Coco C, Faletti R, Krivocapic Z, Rotondano G, Santoro GA, Vettoretto N, De Franciscis S, Belli A, Romano GM. Practice parameters for early rectal cancer management: Italian Society of Colorectal Surgery (Società Italiana di Chirurgia Colo-Rettale; SICCR) guidelines. Tech Coloproctol 2015; 19:587-93. [PMID: 26408174 DOI: 10.1007/s10151-015-1362-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 05/27/2015] [Indexed: 02/07/2023]
Abstract
The introduction of new technologies for diagnosis and screening programs led to an increasing rate of early detection of colorectal cancer. This, associated with the evolution of endoscopic techniques of local excision, led to the assessment of new strategies to reduce morbidity related to treatment, especially for early rectal cancer (ERC). Nevertheless, the definition of ERC and its staging and treatment algorithm are still under debate. The Italian Society of Colorectal Surgery developed practice guidelines to provide recommendations on the diagnosis, staging and treatment of ERC. A systematic review on the topic was performed by a multidisciplinary group of experts selected based on their clinical and scientific expertise in endoscopy, endoscopic ultrasound, magnetic resonance and surgery, with the aid of an external international audit.
Collapse
Affiliation(s)
- A Arezzo
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - F Bianco
- Department of Surgical Oncology, Istituto Nazionale Tumori "Fondazione G. Pascale"-IRCCS, Naples, Italy
| | - F Agresta
- Department of General Surgery, Ulss1 9 of the Veneto, Civic Hospital, Adria, TV, Italy
| | - C Coco
- Department of Surgical Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - R Faletti
- Department of Surgical Sciences, Radiology Institute, University Hospital City of Health and Science, Turin University, Turin, Italy
| | - Z Krivocapic
- Institute for Digestive Disease, Clinical Center of Serbia, University of Belgrade, Belgrade, Serbia
| | - G Rotondano
- Department of Gastroenterology, Maresca Hospital, Torre del Greco, NA, Italy
| | - G A Santoro
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - N Vettoretto
- Department of General Surgery, Montichiari Hospital, Civic Hospitals of Brescia, Brescia, Italy
| | - S De Franciscis
- Department of Surgical Oncology, Istituto Nazionale Tumori "Fondazione G. Pascale"-IRCCS, Naples, Italy
| | - A Belli
- Department of Surgical Oncology, Istituto Nazionale Tumori "Fondazione G. Pascale"-IRCCS, Naples, Italy
| | - G M Romano
- Department of Surgical Oncology, Istituto Nazionale Tumori "Fondazione G. Pascale"-IRCCS, Naples, Italy.
| | | |
Collapse
|
42
|
García-Flórez LJ, Otero-Díez JL. Local excision by transanal endoscopic surgery. World J Gastroenterol 2015; 21:9286-9296. [PMID: 26309355 PMCID: PMC4541381 DOI: 10.3748/wjg.v21.i31.9286] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 05/10/2015] [Accepted: 07/03/2015] [Indexed: 02/06/2023] Open
Abstract
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.
Collapse
|
43
|
Issa N, Murninkas A, Schmilovitz-Weiss H, Agbarya A, Powsner E. Transanal Endoscopic Microsurgery After Neoadjuvant Chemoradiotherapy for Rectal Cancer. J Laparoendosc Adv Surg Tech A 2015; 25:617-24. [PMID: 26258267 DOI: 10.1089/lap.2014.0647] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Radical rectal resection following neoadjuvant chemoradiation therapy (CRT) for locally advanced rectal cancer is accompanied by relatively high morbidity. Local excision of rectal cancer may be more appropriate for some frail patients with severe comorbidities. Transanal endoscopic microsurgery (TEM), consisting of local excision of selected rectal cancers, has been associated with low rates of postoperative complications. Because neoadjuvant CRT for rectal cancer may be associated with increased complications, the suitability of TEM following CRT is still unclear. In this study we aimed to assess the clinical outcomes of patients undergoing TEM following neoadjuvant CRT. PATIENTS AND METHODS This study retrospectively analyzed all patients undergoing TEM for malignant rectal tumor in our institution between 2004 and 2010. They were divided into those who received CRT (CRT group) and those without CRT (non-CRT group). Demographics and clinical data were compared. RESULTS Forty-four of 97 patients who underwent TEM were included: 13 CRT and 31 non-CRT. Age, comorbidities, and the duration of the procedure were similar for both groups. There were no significant group differences in tumor diameter (2.1 cm [range, 0.5-3.5 cm] and 2.9 cm [range, 0.5-4.2 cm], respectively; P=.125) or distance of the lower part of the tumor from the anal verge (6.7 cm [range, 5-10 cm] and 7.7 cm [range, 5-15 cm], respectively; P=.285). Two non-CRT patients had peritoneal entry, and 1 of them underwent protective ileostomy because of insecure rectal defect closure. One non-CRT patient underwent a re-operation for postoperative bleeding. The other perioperative complications were minor and included urinary retention requiring catheter placement (2 patients in each group), pulmonary edema (1 non-CRT patient), and pneumonia (1 non-CRT patient). All complications were managed conservatively. There was no wound disruption, major complication, or mortality in either group. CONCLUSIONS With proper patient selection, TEM can be performed safely following CRT, without major complication or increased postoperative morbidity.
Collapse
Affiliation(s)
- Nidal Issa
- 1 Department of Surgery B, Rabin Medical Center , Petah-Tikva, Israel .,2 Sackler School of Medicine, Tel-Aviv University , Tel Aviv, Israel
| | - Alejandro Murninkas
- 1 Department of Surgery B, Rabin Medical Center , Petah-Tikva, Israel .,2 Sackler School of Medicine, Tel-Aviv University , Tel Aviv, Israel
| | - Hemda Schmilovitz-Weiss
- 2 Sackler School of Medicine, Tel-Aviv University , Tel Aviv, Israel .,3 Department of Gastroenterology, Hasharon Hospital, Rabin Medical Center , Petah-Tikva, Israel
| | - Abed Agbarya
- 4 Oncology Community Unit, Northern District, Clalit Health Services , Nazareth, Israel
| | - Eldad Powsner
- 1 Department of Surgery B, Rabin Medical Center , Petah-Tikva, Israel .,2 Sackler School of Medicine, Tel-Aviv University , Tel Aviv, Israel
| |
Collapse
|
44
|
Putte DV, Nieuwenhove YV, Willaert W, Pattyn P, Ceelen W. Organ preservation in rectal cancer: current status and future perspectives. COLORECTAL CANCER 2015. [DOI: 10.2217/crc.15.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
With the introduction of population screening initiatives, more patients may be amenable to local, transanal excision (LE) of early-stage rectal cancer. The most important drawback of LE is the risk of understaging node-positive disease. The most powerful predictors of node-positive disease are lymphatic invasion, submucosal invasion depth and width, tumor budding and poor differentiation. Therefore, LE should be reserved for low-risk T1 tumors in those reluctant or unable to undergo major surgery. Neoadjuvant chemoradiation followed by LE for T2 tumors allows adequate local control, and is currently being compared with anterior resection alone in randomized trials. A mere watchful waiting approach has been proposed in clinical complete responders to chemoradiation. However, given the very poor accuracy of current imaging modalities to predict a true pathological complete response, this strategy should not be offered outside of well-controlled trials.
Collapse
Affiliation(s)
- Dirk Vande Putte
- Department of Gastrointestinal Surgery, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium
| | - Yves Van Nieuwenhove
- Department of Gastrointestinal Surgery, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium
| | - Wouter Willaert
- Department of Gastrointestinal Surgery, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium
| | - Piet Pattyn
- Department of Gastrointestinal Surgery, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium
| | - Wim Ceelen
- Department of Gastrointestinal Surgery, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium
| |
Collapse
|
45
|
Vaughan-Shaw PG, Wheeler JMD, Borley NR. The impact of a dedicated multidisciplinary team on the management of early rectal cancer. Colorectal Dis 2015; 17:704-9. [PMID: 25704245 DOI: 10.1111/codi.12922] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 12/31/2014] [Indexed: 12/13/2022]
Abstract
AIM Local excision of early rectal cancer (ERCa) offers comparable survival and reduced operative morbidity compared with radical surgery, yet it risks an adverse oncological outcome if performed in the wrong setting. This retrospective review considers the impact of the introduction of a specialist early rectal cancer multidisciplinary team (ERCa MDT) on the investigation and management of ERCa. METHOD A retrospective comparative cohort study was undertaken. Patients with a final diagnosis of pT1 rectal cancer at our unit were identified for two 12-month periods before and after the introduction of the specialist ERCa MDT. Data on investigations and therapeutic interventions were compared. RESULTS Nineteen patients from 2006 and 24 from 2011 were included. In 2006, 12 patients underwent MRI and four transrectal ultrasound (TRUS) examination, while in 2011, 18 and 20, respectively, received MRI and TRUS. In 2006 four patients underwent incidental ERCa polypectomy, with all having a positive resection margin leading to anterior resection. In 2011 only one case with a positive margin following extended endoscopic mucosal resection was identified. Definitive local excision without subsequent resection occurred in two patients in 2006 and in 16 in 2011. CONCLUSION The study demonstrates an improvement in preoperative ERCa staging, a reduction in margin positivity and an increase in the use of local excision following the implementation of a specialist ERCa MDT. The increased detection of rectal neoplasms through screening and surveillance programmes requires further investigation and management. A specialist ERCa MDT will improve management and should be available to all practitioners involved with patients with ERCa.
Collapse
Affiliation(s)
- P G Vaughan-Shaw
- Department of Colorectal Surgery, Cheltenham General Hospital, Cheltenham, UK
| | - J M D Wheeler
- Department of Colorectal Surgery, Cheltenham General Hospital, Cheltenham, UK
| | - N R Borley
- Department of Colorectal Surgery, Cheltenham General Hospital, Cheltenham, UK
| |
Collapse
|
46
|
Chow OS, Smith JJ, Gollub MJ, Garcia-Aguilar J. Transanal surgery for cT1 rectal cancer: Patient selection, technique, and outcomes. SEMINARS IN COLON AND RECTAL SURGERY 2015. [DOI: 10.1053/j.scrs.2014.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
47
|
Morino M, Risio M, Bach S, Beets-Tan R, Bujko K, Panis Y, Quirke P, Rembacken B, Rullier E, Saito Y, Young-Fadok T, Allaix ME. Early rectal cancer: the European Association for Endoscopic Surgery (EAES) clinical consensus conference. Surg Endosc 2015; 29:755-73. [DOI: 10.1007/s00464-015-4067-3] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 01/07/2015] [Indexed: 12/13/2022]
|
48
|
Baatrup G, Qvist N. Local resection of early rectal cancer. APMIS 2014; 122:715-22. [PMID: 25046201 DOI: 10.1111/apm.12292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2014] [Accepted: 06/14/2014] [Indexed: 12/15/2022]
Abstract
The introduction of the National Danish screening programme for colorectal cancer will result in the detection of more early rectal cancers (ERC), which may be considered for local excision. For the low risk≤T1 cancer, the oncological outcome at local excision in smaller patient series has shown similar results to conventional surgery, but with a significantly lower rate of serious complications, morbidity and mortality. The challenge is correct preoperative staging, and a meticulous systematic histopathological staging of the excised specimen to distinguish the low risk from high-risk cases, where rescue surgery may be considered. The establishment of a regional or national clinical database is necessary to improve the local treatment of ERC.
Collapse
Affiliation(s)
- Gunnar Baatrup
- Institute of Regional Health, Medical Faculty, University of Southern Denmark, Svendborg, Denmark; Department of Surgery A, Odense University Hospital, Svendborg, Denmark
| | | |
Collapse
|
49
|
Smart CJ, Cunningham C, Bach SP. Transanal endoscopic microsurgery. Best Pract Res Clin Gastroenterol 2014; 28:143-57. [PMID: 24485262 DOI: 10.1016/j.bpg.2013.11.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Revised: 09/14/2013] [Accepted: 11/23/2013] [Indexed: 02/07/2023]
Abstract
Transanal endoscopic microsurgery (TEMS) is a well established method of accurate resection of specimens from the rectum under binocular vision. This review examines its role in the treatment of benign conditions of the rectum and the evidence to support its use and compliment existing endoscopic treatments. The evolution of TEMS in early rectal cancer and the concepts and outcomes of how it has been utilised to treat patients so far are presented. The bespoke nature of early rectal cancer treatment is changing the standard algorithms of rectal cancer care. The future of TEMS in the organ preserving treatment of early rectal cancer is discussed and how as clinicians we are able to select the correct patients for neoadjuvant or radical treatments accurately. The role of radiotherapy and outcomes from combination treatment using TEMS are presented with suggestions for areas of future research.
Collapse
Affiliation(s)
- Christopher J Smart
- School of Cancer Studies, Academic Department of Surgery, Room 28, 4th Floor,Queen Elizabeth Hospital Edgbaston, Birmingham B15 2TH, UK.
| | - Chris Cunningham
- Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Headley Way, Headington, England OX3 9DU, UK.
| | - Simon P Bach
- School of Cancer Studies, Academic Department of Surgery, Room 28, 4th Floor,Queen Elizabeth Hospital Edgbaston, Birmingham B15 2TH, UK.
| |
Collapse
|
50
|
EURECCA colorectal: Multidisciplinary management: European consensus conference colon & rectum. Eur J Cancer 2014; 50:1.e1-1.e34. [DOI: 10.1016/j.ejca.2013.06.048] [Citation(s) in RCA: 298] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Accepted: 06/19/2013] [Indexed: 02/06/2023]
|