Local Excision of Rectal Cancer: Review of Literature

Abstract

In selected patients, local excision of rectal cancer may be an alternative to radical surgery such as abdominoperineal excision of the rectum or anterior resection. Local excision carries lower mortality and morbidity, without the functional disturbance or alteration in body image that can be associated with radical surgery. There are several techniques of local therapy for rectal cancer, with most experience being available in transanal excision. Transanal endoscopic microsurgery is also used but experience with this newer technique is limited. Patient selection is the most important factor in successful local excision, however specific criteria for selecting patients have not been universally accepted. Review of the published literature is difficult because of the variation in adjuvant therapy regimes and follow-up strategies, as well as results reported in terms of local recurrence and survival rates. There is increasing evidence to suggest that local excision should be restricted to patients with T1 stage rectal cancer without high-risk factors. The place for local excision in patients with T2 or high-risk T1 tumours requires prospective, randomised multi-centre trials comparing radical surgery with local excision, with or without adjuvant therapy.

Transanal endoscopic operation: a new proposal

“…It is a less invasive procedure that, according to its indication criteria, brings benefits in terms of rectal and canal anal functional preservation, morbid-mortality and costs. 1,2 Literature estimates reveal that 40 to 50 % of the primary rectal cancer will be presented without lymphonodal commitment (T1, T2, T3 -No) as soon as diagnosed 26,27 and that 15% of the patients considered cured show tumors limited to the rectal wall (T1 -T3 -No). 28 Every year, more than 7000 patients with rectal cancer are potentially cured by local excision as the only therapeutic method.…”

“…Also, there is no randomized prospective studies and there is a lot of variation concerning the adjuvant therapy indication. 1,2,14,16,17,19 Another relevant aspect for literature data comparison is the biological characterization of the tumor, i.e., interaction tumor-host, which might be inferred by the morphology, histology, size, localization and invasive stage. This is essential for the therapeutic results comparison in patients with similar disease stages.…”

“…In patients with high surgical risk, the LE shows smaller morbidity and mortality, with also less anorectal, urinary and sexual function alterations. [1][2][3] The most commonly used techniques for LE include the colonoscopy with polypectomy loops, conventional transanal excision (CTE), transanal endoscopic microsurgery (TEM) and the posterior access surgery. [4][5][6] For local rectal cancer surgical treatment, the TEM has been used since 1983 with positive results, low recurrence rates and less post-operation complications compared to conventional procedures.…”

“…However, specific criteria for these tumors selection are still not universally accepted. 2,[14][15][16][17] Some parameters are indicated as requisites for determination of which tumors are theoretically adequate for transanal LE: smaller than 4 cm, mobile, restricted to only one quadrant, placed up to 10 cm of the anorectal line, well differentiated, with no lymphovascular or lymphonodal invasion, and endoscopic, tomographic and nuclear magnetic resonance evaluations that demonstrate that lesions are T1, T2 with no metastatic lesions. 18 The results of local treatment of rectal cancer are of difficult interpretation because the literature brings retrospective analysis of heterogeneous groups of patients, with different surgical indications and adjuvant therapies, while it lacks prospective homogeneous studies.…”

Laparoscopic extraperitoneal rectal cancer surgery: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES)

“…This approach allows accurate assessment of histopathological parameters such as margin, differentiation, vascular involvement and depth of penetration [137,138].…”