Abstract
PurposeWhile 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.MethodThis 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.ResultsForty-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).ConclusionsOncological results were similar in the two groups. However, there may be an increased risk for a permanent stoma in the CS group.
Highlights
Local excision (LE) is an appealing solution in early-stage rectal cancer (ERC), facilitating organ preservation, implying less postoperative morbidity and mortality, and offering better functional outcomes as compared with rectal resection [1,2,3]
While the present results indicate that there is no oncological loss from performing local excision before completion surgery, they may indicate that local excisions alter the completion TME from LAR to APR, and a particular discussion about this outcome should be held with patients before any strategy is chosen, especially in patients where the tumor level dictates that a primary low anterior resection is possible with 1–2 cm of distal margin
The mean time for completion surgery (CS) in this study was 5.7 weeks, and the results indicate that this was within a proper time frame, as advocated by others who have recommended completion within 6 weeks or when the wound after local excision has healed [19]
Summary
Local excision (LE) is an appealing solution in early-stage rectal cancer (ERC), facilitating organ preservation, implying less postoperative morbidity and mortality, and offering better functional outcomes as compared with rectal resection [1,2,3]. Conventional transanal excision has proven inferior to TEM with regard to the quality of resection (surgical margins, fragmentation of the specimen) and local recurrence [10, 11], and in Norway this technique has been replaced. International Journal of Colorectal Disease by TEM or transanal minimally invasive surgery (TAMIS), two techniques reported to have comparable outcomes [12]. The inaccuracies in preoperative staging, despite the use of EUS and MRI, will result in surgeons inadvertently performing local excision with TEM or TAMIS on high-risk early rectal cancer (i.e., cancers with invasion beyond T1sm or other high-risk features). A few studies have reported that oncological outcomes after LE and CS are comparable to those following primary TME surgery [18,19,20,21]
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