Abstract
Background
Transanal endoscopic microsurgery (TEM) allows locally complete resection of early rectal cancer as an alternative to conventional radical surgery. In case of unfavourable histology after TEM, or positive resection margins, salvage surgery can be performed. However, it is unclear if the results are equivalent to primary treatment with total mesorectal excision (TME). The aim of this retrospective study was to determine whether there is a difference in outcome between patients who underwent early salvage resection with TME after TEM, and those who underwent primary TME for rectal cancer.
Methods
From 1997 to 2011, early salvage surgery with TME after TEM was performed in 25 patients in our institution. These patients were compared with 25 patients who underwent primary TME, matched according to gender, age (±2 years), cancer stage and operative procedure. Data were obtained from the patients’ charts and reviewed retrospectively. No patients received preoperative chemotherapy. Perioperative data and oncological outcome were analysed. The Mann–Whitney U-test and Fisher’s exact test were used to compare the results between the two groups.
Results
There was no significant difference between the two groups in median operating time (P = 0.39), median blood loss (P = 0.19) or intraoperative complications (P = 1.00). The 30-day mortality was 8 % (n = 2) among patients who underwent salvage TME after TEM, and no patients died in the primary TME group (P = 0.49). There was no significant difference between two groups of patients in the median number of harvested lymph nodes (P = 0.34), median circumferential resection margin (CRM) (P = 0.99) or the completeness of the mesorectal fascia plane. No local recurrences occurred among the patients with salvage TME, and there were 2 patients (8 %) with local recurrences among the patients with primary TME (P = 0.49). Distant metastasis occurred in one patient (4 %) after salvage TME and in 3 patients (12 %) with primary TME (P = 0.61). The median follow-up time was 25 months (3–126) for patients who underwent salvage TME and 19 months (3–73) for patients after primary TME.
Conclusions
No difference was found in outcome between patients with rectal cancer undergoing salvage TME after TEM, those undergoing primary TME. In selected patients, TEM can therefore be chosen as a primary treatment, since failure of treatment and subsequent conventional resection appears not to compromise the outcome.
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References
Heald RJ, Moran BJ, Ryall RD, Sexton R, MacFarlane JK (1998) Rectal cancer: the Basingstoke experience of total mesorectal excision 1978–1997. Arch Surg 133:894–899
De Graaf EJ, Doornebosch PG, Tollenaar RA et al (2009) Transanal endoscopic microsurgery versus total mesorectal excision of T1 rectal adenocarcinomas with curative intention. Eur J Surg Oncol 35:1280–1285
Palma P, Horisberger K, Joos A, Rothenhoefer S, Willeke F, Post S (2009) Local excision of early rectal cancer: is transanal endoscopic microsurgery an alternative to radical surgery? Rev Esp Enferm Dig 101:172–178
Lee W, Lee D, Choi S, Chun H (2003) Transanal endoscopic microsurgery and radical surgery for T1 and T2 rectal cancer. Surg Endosc 17:1283–1287
Baatrup G, Breum B, Qvist N et al (2009) Transanal endoscopic microsurgery in 143 consecutive patients with rectal adenocarcinoma: results from a Danish multicenter study. Colorectal Dis 11:270–275
Borschitz T, Heintz A, Junginger T (2006) The influence of histopathological criteria on the long-term prognosis of locally excised pT1 rectal carcinomas: results of local excision (transanal endoscopic microsurgery) and immediate reoperation. Dis Colon Rectum 49:1492–1506
Bach SP, Hill J, Monson JR et al (2009) Association of Coloproctology of Great Britain and Ireland Transanal Endoscopic Microsurgery (TEM) Collaboration. A predictive model for local recurrence after transanal endoscopic microsurgery for rectal cancer. Br J Surg 96:280–290
Serra Aracil X, Bombardó Juncá J, Mora López L et al (2009) Site of local surgery in adenocarcinoma of the rectum T2N0M0. Cir Esp 85:103–109
Baron PL, Enker WE, Zakowski MF, Urmacher C (1995) Immediate versus salvage resection after local treatment for early rectal cancer. Dis Colon Rectum 38:177–181
Borschitz T, Heintz A, Junginger T (2007) Transanal endoscopic microsurgical excision of pT2 rectal cancer: results and possible indications. Dis Colon Rectum 50:292–301
Friel CM, Cromwell JW, Marra C, Madoff RD, Rothenberger DA, Garcia-Aguilar J (2002) Salvage radical surgery after failed local excision for early rectal cancer. Dis Colon Rectum 45:875–879
Hahnloser D, Wolff BG, Larson DW, Ping J, Nivatvongs S (2005) Immediate radical resection after local excision of rectal cancer: an oncologic compromise? Dis Colon Rectum 48:429–437
Mellgren A, Sirivongs P, Rothenberger DA, Madoff RD, Garcia-Aguilar J (2000) Is local excision adequate therapy for early rectal cancer? Dis Colon Rectum 43:1064–1071
Rectal Cancer—A multidisciplinary approach to management. Edited by Giulio Aniello Santoro. 2011 InTech
Danish Colorectal Cancer Group (DCCG) Guidelines 4th edition 2009. http://www.dccg.dk/10_English/0010_English.html
Koebrugge B, Bosscha K, Ernst MF (2009) TEM for local excision of rectal lesions: is there a learning curve? Dig Surg 26:372–377
Morino M, Allaix ME, Caldart M, Scozzani G, Arezzo A (2011) Risk factors for recurrence after transanal endoscopic microsurgery for rectal malignant neoplasm. Surg Endosc 25:3683–3690
Ramirez JM, Aquilella V, Valencia J et al (2011) Transanal endoscopic microsurgery for rectal cancer. Long-term oncologic results. Int J Colorectal Dis 26:437–443
Winde G, Nottberg H, Keller R, Schmid KW, Bünte H (1996) Surgical cure for early rectal carcinomas (T1). Transanalendsc. Micro versus ant res. Dis Colon Rectum 39:969–976
Beets-Tan RG, Beets GL (2004) Rectal cancer: review with emphasis on MR imaging. Radiology 232:335–346
Bipat S, Glas AS, Slors FJ, Zwinderman AH, Bossuyt PM, Stoker J (2004) Rectal cancer: local staging and assessment of lymph node involvement with endoluminal US, CT, and MR imaging-a meta-analysis. Radiology 232:773–783
Lahaye MJ, Engelen SM, Nelemans PJ (2005) Imaging for predicting the risk factors–the circumferential resection margin and nodal disease–of local recurrence in rectal cancer: a meta-analysis. Semin Ultrasound CT MR 26:259–268
Doornebosch PG, Ferenschild FT, de Wilt JH, Dawson I, Tetterooo GW, de Graaf ES (2010) Treatment of recurrence after transanal endoscopic microsurgery (TEM) for T1 rectal cancer. Dis Colon Rectum 53:1234–1239
Middleton PF, Sutherland LM, Maddern GJ (2005) Transanal endoscopic microsurgery: a systematic review. Dis Colon Rectum 48:270–284
Bülow S, Christensen IJ, Iversen LH et al (2011) the Danish Colorectal Cancer Group. Intra-operative perforation is an important predictor of local recurrence and impaired survival after abdominoperineal resection for rectal cancer. Colorectal Dis 13:1256–1264
Eriksen MT, Wibe A, Syse A, Heffner J, Wiig JN (2004) Norwegian Rectal Cancer Group; Norwegian Gastrointestinal Cancer Group. Inadvertent perforation during rectal cancer resection in Norway. Br J Surg 91:210–216
Jörgren F, Johansson R, Damber L, Lindmark G (2010) Oncological outcome after incidental perforation in radical rectal cancer surgery. Int J Colorectal Dis 25:731–740
Jörgren F, Johansson R, Damber L, Lindmark G (2010) Risk factors of rectal cancer recurrence: population-based survey and validation of the Swedish Rectal Cancer Registry. Colorectal Dis 12:977–986
Balch GC, De Meo A, Guillem JG (2006) Modern management of rectal cancer: a 2006 update. World J Gastroenterol 12:3186–3195
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Levic, K., Bulut, O., Hesselfeldt, P. et al. The outcome of rectal cancer after early salvage TME following TEM compared with primary TME: a case-matched study. Tech Coloproctol 17, 397–403 (2013). https://doi.org/10.1007/s10151-012-0950-2
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DOI: https://doi.org/10.1007/s10151-012-0950-2