Is Previous Transanal Endoscopic Microsurgery for Early Rectal Cancer a Risk Factor of Worse Outcome following Salvage Surgery A Case-Matched Analysis

Abstract

Introduction: Transanal endoscopic microsurgery (TEM) is a minimally invasive procedure which allows local excision of early-stage rectal cancer and can be used as an alternative treatment to radical surgery. Patients can undergo salvage total mesorectal excision (sTME) following TEM after finding of unfavourable histological features. This study aimed to compare results and possible complications of sTME following TEM and primary TME (pTME) procedures. Methods: Between 2010 and 2017, early sTME was performed in 9 patients at the National Cancer Institute in Vilnius, Lithuania. These patients were compared with 18 patients who underwent pTME, matched according to gender, age, cancer stage, and operative procedure. Data were obtained from the patients' charts and reviewed prospectively. We recorded the demographics, tumour specifications, treatment, operation time, postoperative results complications, and oncological outcome. Fisher's exact test and student's T test was used to compare both groups. Results: A total of 130 patients underwent TEM at our institution during the study period, of which 9 (6.92%) had to undergo sTME. The average age of the patients was 62.7 ± 7.07 years; 44.4% of the patients were male and 55.6% female. The average tumour size in the sTME group was 2.8 ± 1.05 cm (range 1.5-5) and 2.61 ± 1.36 cm (range 1-5) in the pTME group (p = 0.696). When comparing postoperative complications, statistically significant results were not found in either of the groups (p = 0.55). Operation time of pTME was significantly shorter on average, i.e. 43 min, compared to sTME (p < 0.0267). The average number of harvested lymph nodes was 12.44 ± 7.126 in the sTME and 12.5 ± 8.06 in the pTME group (p = 0.986). The circumferential resection margin (CRM) was negative in 92.6% (25/27) of specimens, while the CRM was positive in 2 cases (7.4%), both of which were from the sTME group. The average follow-up time was 22.8 months (8-80 months) for patients undergoing sTME and 19.33 months (2-88 months) for patients after pTME (p = 0.71). Conclusions: TEM is a relatively safe method for treating patients with early rectal cancer without high-risk features. It can be used in exceptional cases with high-risk features when the patient is not fit for radical surgery.

Local Excision ± Chemoradiotherapy vs. Total Mesorectal Excision for Early Rectal Cancer: Case-Matched Analysis of Long-Term Results

“…Seventeen patients underwent chemoradiotherapy. We have excluded nine patients who had poor prognostic factors and underwent completion of TME ( 13 ).…”

“…We used a low anterior resection syndrome (LARS) score for bowel function assessment for at least 2 years following the procedure (10,11). Complications were graded by using Clavien-Dindo classification (12).…”

A Meta-analysis of Transanal Endoscopic Microsurgery versus Total Mesorectal Excision in the Treatment of Rectal Cancer

“…A TME after the recurrence of TEMS is known to have reasonably good results comparable to primary TME; however, the presence of distant metastasis or the complexity of a salvage procedure would generally have poor prognosis. 33 34 35 36 37 38 39 A recurrence after TEMS may require an abdominoperineal resection (APR) as the salvage procedure and in case of the recurrence involving other pelvic organs, it may become necessary to undertake a pelvic exenteration in which case the outcomes are even poorer. 40 The disastrous outcomes of a second salvage surgery highlight the importance of careful selection of cases for the primary TEMS.…”

Hybrid transanal and hand‐assisted laparoscopic total mesorectal excision for unexpected low rectal cancer following transanal endoscopic microsurgery‐a video vignette

“…Low anterior resection is very challenging in obese patients with low‐lying, large tumours, or in patients who have previously undergone either TEM or local excision . Only one randomized controlled trial comparing standard laparoscopic TME and laparoscopic TME with perineal dissection for low‐lying rectal cancer has been published, which reported a reduction of positive circumferential margin in the perineal dissection group .…”

“…Total mesorectal excision (TME) following transanal endoscopic microsurgery (TEM) might be challenging . For TME quality improvement, the transanal approach (TaTME) is proposed .…”