Completion surgery vs. primary TME for early rectal cancer: a national study

Abstract

Purpose While local excision by transanal endoscopic microsurgery (TEM) or transanal minimally invasive surgery (TAMIS) is an option for low-risk early rectal cancers, inaccuracies in preoperative staging may be revealed only upon histopathological evaluation of the resected specimen, demanding completion surgery (CS) by formal resection. The aim of this study was to evaluate the results of CS in a national cohort. Method This was a retrospective analysis of national registry data, identifying and comparing all Norwegian patients who, without prior radiochemotherapy, underwent local excision by TEM or TAMIS and subsequent CS, or a primary total mesorectal excision (pTME), for early rectal cancer during 2000–2017. Primary endpoints were 5-year overall and disease-free survival, 5-year local and distant recurrence, and the rate of R0 resection at completion surgery. The secondary endpoint was the rate of permanent stoma. Results Forty-nine patients received CS, and 1098 underwent pTME. There was no difference in overall survival (OR 0.73, 95% CI 0.27–2.01), disease-free survival (OR 0.72, 95% CI 0.32–1.63), local recurrence (OR 1.08, 95% CI 0.14–8.27) or distant recurrence (OR 0.67, 95% CI 0.21–2.18). In the CS group, 53% had a permanent stoma vs. 32% in the pTME group (P = 0.002); however, the difference was not significant when adjusted for age, sex, and tumor level (OR 2.17, 0.95–5.02). Conclusions Oncological results were similar in the two groups. However, there may be an increased risk for a permanent stoma in the CS group.

Completion total mesorectal excision after neoadjuvant radiochemotherapy and local excision for rectal cancer

“…to 32.1% reported in the meta‐analysis of Eid et al. [11, 24, 25, 27–33]. In the present study, the integrity of the mesorectal fascia was not analysed; nevertheless, positivity of the circumferential resection margin was recorded in only two patients (positive CRM rate: 4.2%).…”

“…Even if cTME does not seem inferior to primary TME in terms of oncological outcome, cTME seems to be characterized by the same critical aspects. Several studies of cTME after LE for rectal cancer, both in previously irradiated and in not irradiated patients, reported a rate of APR and a rate of definitive stoma higher than after primary TME [25].…”

“…Another aspect of cTME is the incidence of postoperative morbidity, which is higher than that after primary TME, as reported by the largest series published in the literature. In patients not previously irradiated, the rate of postoperative morbidity after cTME ranged from 18.3% to 65%, with a rate of major morbidity (Clavien's > 2) ranging from 5.9% to 25% [11, 23, 25–27, 29–32].…”

“…Another important pathological aspect of cTME is the possibility of finding no residual cancer in the specimen and the consequent uselessness of the surgical operation performed. In a major series of nonirradiated patients, the prevalence of event ranged between 20% and 88.3%, and the mean prevalence of cTME specimens with no residual cancer was 50% [11, 24, 25, 27–33]. In a previously irradiated series, the rate of no residual cancer in the cTME specimen was 45.5% in the series of Pucciarelli et al.…”

Local full-thickness excision for sessile adenoma and cT1-2 rectal cancer: long-term oncological outcome

“…In these cases, additional treatment (completion TME surgery or adjuvant chemoradiotherapy and close surveillance) should be considered in the shared decision-making process. A recent study indicated that there is no oncological loss from performing local excision before completion of surgery; however, there may be an increased risk for a permanent stoma [ 23 ].…”