Short-term outcomes of transanal completion total mesorectal excision (cTaTME) for rectal cancer: a case-matched analysis

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.Keywords TAMIS · TaTME · Completion · Rectal surgery · Outcomes Early rectal cancer is increasingly treated with transanal minimal invasive surgery (TAMIS). With the implementation of population screening programs for colorectal cancer and longer life expectancy, the incidence of elderly patients being diagnosed with early rectal cancer increases. Rectal preserving therapy is appealing for these patients as radical rectal surgery has been correlated with higher colostomy rate, higher morbidity, and poorer functional outcomes [1][2][3][4][5][6][7][8]. Commonly used platforms for full-thickness local excision include transanal endoscopic microsurgery (TEM), transanal endoscopic operations (TEO) and the GelPoint® Path port which offer a safe and curative therapy when performed for large rectal adenomas and low-risk T1 carcinoma, including tumors smaller than 3 centimeters in size,

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

“…Seven of the included studies reported outcomes of patients who had undergone a form of neoadjuvant chemoradiotherapy (NACR). 11,30,34,36,39,46,47 Table 3 summarizes the use of both NACR and adjuvant chemoradiotherapy in included studies.…”

“…This cohort of patients has unfavorable histopathological characteristics, including R1 TAE resections, and some are likely to have residual cancer or involved LNs at the time of cTME. Seventeen studies 8,10,11,30,31,[33][34][35][36][37][38][39][40][42][43][44][45]…”

Comparison of Short-Term Clinical and Pathological Outcomes after Transanal versus Laparoscopic Total Mesorectal Excision for Low Anterior Rectal Resection Due to Rectal Cancer: A Systematic Review with Meta-Analysis

“…Previous meta-analyses regarding feasibility of TaTME included abdomino-perineal resection (APR) or Hartmann resections, which in our opinion may have biased the results, rendering them inconclusive, especially when analyzing postoperative morbidity and anastomotic leakage [ 28 , 30 , 31 ]. Thus, we decided to exclude the studies by Perdawood et al, Koedam et al, Velthuis et al, and Marks et al [ 32 , 33 , 34 , 35 ]. Zhang and Hu in their meta-analyses also included a randomized control trial by Denost et al, treating it as TaTME [ 28 , 31 ].…”

Transanal Local Excision of Rectal Cancer after Neoadjuvant Chemoradiation: Is There a Place for It or Should Be Avoided at All Costs?

“…Multiple studies have identified previous TLE (using endoscopic platforms) as a risk factor for worse TME specimen quality. 26 28…”