Does transanal local resection increase morbidity for subsequent total mesorectal excision for early rectal cancer?

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.

Completion Total Mesorectal Excision After Transanal Local Excision of Early Rectal Cancer: A Systematic Review and Meta-analysis

“…2). The pooled 30-day mortality rate from all 15 studies 8,11,30,31,[36][37][38][39][41][42][43][44][45][46]49 reporting this outcome was 0.71% and included 425 patients.…”

“…Piessen 2012 46 Morino 2013 11 Levic 2013 42 Dulskas 2019 32 Coton 2019 31 Levic 2021 43 Clermonts 2020 30…”

Local excision followed by early radical surgery in rectal cancer: long-term outcome

“…Moreover, the quality of the TME resection was not determined at the beginning of the TME era. In most patients, no residual tumor was detected in resected specimens; thus, the actual impact of poor mesorectal quality after a completion TME remains unknown [9]. Prognostically, the more important risk factor was an intraoperative perforation in the rectal wall, which was always documented.…”

“…A primary problem with this approach is the risk of intraoperative perforation at the local excision site, which might impact the surgical treatment and the outcome. It remains unclear whether an intraoperative perforation raises the risks of postoperative morbidity [8, 9] or the risk of requiring an APR [10, 11]. In addition, it is not clear whether intraoperative perforations compromise oncological outcomes.…”

Is transanal excision safe for a T1 rectal adenocarcinoma?

“…Coton C et al . present a retrospective review on the morbidity following a total mesorectal excision (TME) performed after local excision of a T1 rectal cancer for adverse pathologic features. An increasing number of patients with a T1 mid to low rectal lesion are being offered transanal excision in order to prevent the functional morbidity of a transabdominal TME including low anterior resection syndrome or permanent stoma with an abdominoperineal resection .…”