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Nucleotide-guided mesorectal excision combined with endoluminal locoregional resection by transanal endoscopic microsurgery in the treatment of rectal tumors: technique and preliminary results

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Abstract

Background

Endoluminal locoregional resection (ELRR) by transanal endoscopic microsurgery (TEM) is an alternative treatment option for T1N0 rectal cancer and for selected patients with small T2N0 rectal cancer after neoadjuvant radiochemotherapy (n-RCT). The N parameter may remain undefined after transanal surgery. This study aimed to evaluate the role of a modified sentinel lymph node technique to improve N staging that the authors named “nucleotide-guided mesorectal excision” (NGME).

Methods

The study enrolled 41 patients (24 men and 17 women) with a mean age of 70.5 years. Preoperative staging identified dysplasia with no suspicion for cancer at imaging (n = 8), dysplasia with suspected malignancy at imaging (n = 15), no suspicion of malignancy at imaging after n-RCT (n = 2), cT1N0 (n = 6), cT2N0 (n = 6), cT3N0 (n = 3), and cT3N1 (n = 1). The patients underwent ELRR by TEM with NGME. Before surgery, 99m-technetium-marked nanocolloid was injected into the peritumoral submucosa. After resection, the residual defect was probed to detect residual radioactivity. If present, hot mesorectal fat was excised.

Results

With NGME, the mesorectal lymph node harvest increased from 0 to 10. Lymph nodes were isolated in the specimen or in hot mesorectal fat of 20 patients, 8 of whom had undergone n-RCT. The mean lymph node harvest was 2.75 ± 3.01 (range 1–10) in the irradiated patients and 2.91 ± 1.62 (range 1–6) in the nonirradiated patients (p = 0.87). The average number of lymph nodes in the irradiated patients was higher than in a previous historical series.

Conclusions

The use of NGME during ELRR by TEM increases the lymph node harvest and may improve staging accuracy after transanal surgery.

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Acknowledgments

The authors are grateful to Prof. Annarita Vestri, Dipartimento di Sanità Pubblica e Malattie infettive, Facoltà di Farmacia e Medicina, Sapienza University of Rome, Italy, for statistical advice.

Disclosures

Emanuele Lezoche, Bernardina Fabiani, Giancarlo D’Ambrosio, Pietro Ursi, Andrea Balla, Giovanni Lezoche, Francesco Monteleone, and Alessandro M. Paganini have no conflicts of interest or financial ties to disclose.

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Authors and Affiliations

  1. Department of General Surgery, Surgical Specialties and Organ Transplantation “Paride Stefanini”, Sapienza University of Rome, Azienda Policlinico Umberto I, Viale del Policlinico 155, 00161, Rome, Italy

    Emanuele Lezoche, Bernardina Fabiani, Giancarlo D’Ambrosio, Pietro Ursi, Andrea Balla & Alessandro M. Paganini

  2. Department of General Surgery, University “Politecnica delle Marche”, Ancona, Italy

    Giovanni Lezoche

  3. Department of Radiological Sciences, Sapienza University of Rome, Rome, Italy

    Francesco Monteleone

Authors
  1. Emanuele Lezoche
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  2. Bernardina Fabiani
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  3. Giancarlo D’Ambrosio
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  4. Pietro Ursi
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  5. Andrea Balla
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  6. Giovanni Lezoche
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  7. Francesco Monteleone
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  8. Alessandro M. Paganini
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Correspondence to Alessandro M. Paganini.

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Lezoche, E., Fabiani, B., D’Ambrosio, G. et al. Nucleotide-guided mesorectal excision combined with endoluminal locoregional resection by transanal endoscopic microsurgery in the treatment of rectal tumors: technique and preliminary results. Surg Endosc 27, 4136–4141 (2013). https://doi.org/10.1007/s00464-013-3012-6

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  • DOI: https://doi.org/10.1007/s00464-013-3012-6

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