Exploring the role of minimally invasive treatment strategies in early rectal cancer: the significance of functional outcome and quality of life

Abstract

We read with interest the article by Lezoche et al. [1] on the outcome of transanal endoscopic microsurgery (TEM) for small nonadvanced low rectal cancers (SNALRC). The group describes their shortand long-term results with and without neoadjuvant chemoradiotherapy (nCRT) for cT2N0 and cT1N0 distal rectal cancer, respectively. The authors report a disease-free survival rate of 100 and 93% for cT1 and cT2 lesions, respectively, with low perioperative morbidity, supporting the role of nCRT and local excision for early-stage disease. This is encouraging after the high rates of local recurrence reported after local excision alone [2, 3]. The use of local excision after radiotherapy has raised concerns over wound healing [4]. In contrast to radical resection where the anastomosis consists of healthy bowel brought into the irradiated field, the repair after local excision includes the same irradiated bowel which one would expect to show poor potential for uncomplicated healing. Furthermore, the authors advocate an extensive local excision technique by removing not only the rectal wall but also the adjacent mesorectum, and one might expect this ‘‘radical’’ local excision to be associated with increased incidence of rectal wound complications. However, they report wound dehiscence in only 6.6% of patients, and only one patient required a temporary ileostomy for a perineal phlegmon. These results are in contrast with the high wound complication rates reported by Marks et al. [5] after neoadjuvant radiation therapy. Wound complication rates were 25.6% in their irradiated group and 0% for the nonirradiated group. Can the authors account for their impressive results regarding wound complications? Could it be that the extended dissection is the key to prevent any tension on the suture line and thus better healing, or perhaps patients developed symptoms (pain, urgency, and rectal discharge) after discharge from hospital leading to an underestimation of the problem? Lezoche and associates accurately describe their TEM technique, and even speculate that an extended resection of the tumour site with adjacent mesorectum is one of the factors related to their favourable oncological results [1]. Unfortunately, they do not provide the ypN0 status nor do they mention if any lymph nodes were retrieved within the perirectal mesorectum. It would be valuable to know if the histological analysis of the mesorectal tissue in any way influenced the postoperative strategy. Although it is well known that nCRT decreases the number of lymph nodes retrieved, there is still a risk of lymph node disease, as demonstrated by Bujko et al. [6, 7]. They reported a 5% risk of lymph node disease for ypT0 rectal cancer, 8% for ypT1, and 28% for ypT2 cancer. Finally, we would be interested if the authors can comment on the initial location of the rectal cancer in patients who suffered a local recurrence and subsequently underwent a salvage laparoscopic abdominoperineal resection. Were all lesions situated in the lower third or was the choice of the salvage procedure a consequence of the ‘‘radical TEM’’? The excellent results from this article will further increase the interest for local excision in early-stage rectal cancer patients as well as in those with more advanced disease who demonstrate a good clinical response to nCRT. R. Hompes N. Mortensen C. Cunningham Department of Colorectal Surgery, Oxford Radcliffe Hospitals, Oxford, UK