Abstract
BackgroundIn rectal cancers, radical surgery should follow local excisions, in cases of unexpected, unfavorable tumor characteristics. The oncological results of this completion surgery are inconsistent.This retrospective cohort study assessed the clinical and long-term oncological outcomes of patients that underwent completion surgery to clarify whether a local excision compromised the results of radical surgery.MethodsForty-six patients were included, and the reasons for completion surgery, intraoperative complications, residual tumors, local recurrences (LRs), distant metastases, and cancer-specific survival (CSS) were assessed. The results were compared to 583 patients that underwent primary surgery without adjuvant therapy, treated with a curative intention during the same time period.ResultsThe median follow-up was 14.6 years. The reasons for undergoing completion surgery were positive resection margins (24%), high-risk cancer (30%), or both (46%). Intraoperative perforations occurred in 10/46 (22%) cases. Residual tumor in the rectal wall or lymph node involvement occurred in 12/46 (26%) cases. The risk of intraoperative perforation and residual tumor increased with the pT category. Intraoperative perforations did not increase postoperative complications, but they increased the risk of LRs in cases of intramural residual tumors (p = 0.003). LRs occurred in 2.6% of pT1/2 and 29% of pT3 tumors. Both the 5- and 10-year CSS rates were 88.8% (95% CI 80.0–98.6). Moreover, the LRs of patients with pT1/2 cancers were lower in patients with completion surgery than in patients with primary surgery.ConclusionsRectal wall perforations at the local excision site and residual cancer were the main risks for poor oncological outcomes associated with completion surgery. Local excisions followed by early radical surgery did not appear to compromise outcomes compared to patients with primary surgery for pT1/2 rectal cancer. Improvements in clinical staging should allow more appropriate selection of patients that are eligible for a local excision of rectal cancer.
Highlights
A local excision is an alternative to radical surgery in patients with low-risk rectal carcinoma [1], and it is increasingly used when patients show good responses to chemoradiotherapy (CRT) [2]
Rectal cancer was located in the middle third of the rectum in most of these patients, but all tumors removed with transanal excision (TAE) were located in the lower third of the rectum
Our results suggested that performing completion surgery early after local excisions of pT1/2 rectal cancers with unfavorable tumor characteristics might not compromise the long-term oncological outcome
Summary
A local excision is an alternative to radical surgery in patients with low-risk rectal carcinoma [1], and it is increasingly used when patients show good responses to chemoradiotherapy (CRT) [2]. Junginger et al World Journal of Surgical Oncology (2019) 17:168 on radical surgery strategies and its results has been inconclusive, mainly because we lack large data sets and long follow-up periods. Radical surgery should follow local excisions, in cases of unexpected, unfavorable tumor characteristics. The oncological results of this completion surgery are inconsistent This retrospective cohort study assessed the clinical and long-term oncological outcomes of patients that underwent completion surgery to clarify whether a local excision compromised the results of radical surgery
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