Retrospective Study
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World J Gastroenterol. Jul 28, 2014; 20(28): 9556-9563
Published online Jul 28, 2014. doi: 10.3748/wjg.v20.i28.9556
Treatment of rectal cancer by transanal endoscopic microsurgery: Experience with 425 patients
Mario Guerrieri, Rosaria Gesuita, Roberto Ghiselli, Giovanni Lezoche, Andrea Budassi, Maddalena Baldarelli
Mario Guerrieri, Roberto Ghiselli, Giovanni Lezoche, Andrea Budassi, Maddalena Baldarelli, Department of General Surgery, Università Politecnica delle Marche, 60126 Ancona, Italy
Rosaria Gesuita, Interdepartmental “Epidemilogia, Biostatistica e Informatica Medica (EBI)” Centre, Università Politecnica delle Marche, 60126 Ancona, Italy
Author contributions: Guerrieri M and Baldarelli M designated study and wrote article; Gesuita R made statistical analysis; Ghiselli R contributed to drafting the article; Lezoche G and Budassi A performed acquisition of data and follow-up.
Correspondence to: Mario Guerrieri, MD, Department of General Surgery, Università Politecnica delle Marche, Via Conca 71, 60126 Ancona, Italy. guerrieri.m@libero.it
Telephone: +39-71-5963084 Fax: +39-71-5963326
Received: September 27, 2013
Revised: April 2, 2014
Accepted: April 27, 2014
Published online: July 28, 2014
Abstract

AIM: To describe our experience in treating rectal cancer by transanal endoscopic microsurgery (TEM), report morbidity and mortality and oncological outcome.

METHODS: A total of 425 patients with rectal cancer (120 T1, 185 T2, 120 T3 lesions) were staged by digital rectal examination, rectoscopy, transanal endosonography, magnetic resonance imaging and/or computed tomography. Patients with T1-N0 lesions and favourable histological features underwent TEM immediately. Patients with preoperative stage T2-T3-N0 underwent preoperative high-dose radiotherapy; from 1997 those aged less than 70 years and in good general health also underwent preoperative chemotherapy. Patients with T2-T3-N0 lesions were restaged 30 d after radiotherapy and were then operated on 40-50 d after neoadjuvant therapy. The instrumentation designed by Buess was used for all procedures.

RESULTS: There were neither perioperative mortality nor intraoperative complications. Conversion to other surgical procedures was never required. Major complications (urethral lesions, perianal or retroperitoneal phlegmon and rectovaginal fistula) occurred in six (1.4%) patients and minor complications (partial suture line dehiscence, stool incontinence and rectal haemorrhage) in 42 (9.9%). Postoperative pain was minimal. Definitive histological examination of the 425 malignant lesions showed 80 (18.8%) pT0, 153 (36%) pT1, 151 (35.5%) pT2, and 41 (9.6%) pT3 lesions. Eighteen (4.2%) patients (ten pT2 and eight pT3) had a local recurrence and 16 (3.8%) had distant metastasis. Cancer-specific survival rates at the end of follow-up were 100% for pT1 patients (253 mo), 93% for pT2 patients (255 mo) and 89% for pT3 patients (239 mo).

CONCLUSION: TEM is a safe and effective procedure to treat rectal cancer in selected patients without evidence of nodal involvement. T2-T3 lesions require preoperative neoadjuvant therapy.

Keywords: Rectal cancer, Transanal endoscopic microsurgery, Chemoradiotherapy, Local excision, Downstaging

Core tip: The gold standard treatment for locally advanced rectal cancer, major surgery, is associated with a high incidence of definitive stoma. In the 1980s, Buess pioneered the removal of rectal lesions with full-thickness excision by transanal endoscopic microsurgery (TEM). It was subsequently demonstrated that T1-N0 lesions can be treated by TEM alone. However, neoadjuvant chemoradiotherapy can downstage T2-T3-N0 lesions and even elicit a complete response. In our experience, the local recurrence and survival rates of selected patients with local-advanced rectal cancer and no nodal involvement treated with neoadjuvant therapy and TEM do not differ significantly from patients treated by major surgery.