Abstract
Background
Transanal endoscopic microsurgery (TEM) represents a surgical option in the treatment of selected early rectal cancers. However, when definitive histopathology shows negative prognostic factors, rectal resection with total mesorectal excision (TME) is recommended to reduce the risk of recurrence. No studies have yet analyzed the impact of previous TEM on the perioperative outcomes of immediate laparoscopic TME (LTME) for rectal cancer. The aim of this study was to evaluate the perioperative outcomes of LTME after TEM for rectal cancer.
Methods
This study was a retrospective analysis of a prospective database. All patients undergoing LTME within 8 weeks after full-thickness TEM for rectal cancer between January 2001 and December 2011 were included. Each patient was matched on the basis of demographic and clinical characteristics with two patients undergoing primary LTME for rectal cancer during the same period. Age, gender, body mass index, tumor distance from the anal verge, tumor size, neoadjuvant chemoradiation, previous TEM, rectal wall defect size created during TEM, and intraoperative complications were included in a multivariate analysis to identify risk factors for abdominoperineal resection (APR).
Results
A total of 17 patients undergoing TEM followed by LTME were compared to 34 patients undergoing primary LTME. Mean operative time of LTME after TEM was significantly higher (206 vs. 188 min, P = 0.025). APR was more frequently performed after TEM [odds ratio (OR) 5.25, P = 0.028] and in male patients (OR 9.04, P = 0.034). On multivariate analysis, a previous TEM was the only independent predictor of APR (OR 4.13, P = 0.046). The incidence and severity of postoperative complications were similar in both groups. Mesorectum integrity was complete in all cases.
Conclusions
LTME after TEM is a challenging procedure, with a significantly higher risk of APR compared to primary LTME. Future improvements in preoperative patient selection for TEM are needed to reduce this risk.
Similar content being viewed by others
References
MacFarlane JK, Ryall RDH, Heald RJ (1993) Mesorectal excision for rectal cancer. Lancet 341:457–460
Heald RJ, Moran BJ, Ryall RDH, Sexton R, MacFarlane JK (1998) The Basingstoke experience of total mesorectal excision, 1978–1997. Arch Surg 133:894–899
Arezzo A, Passera R, Scozzari G, Verra M, Morino M (2012) Laparoscopy for rectal cancer reduces short-term mortality and morbidity: results of a systematic review and meta-analysis. Surg Endosc. doi:10.1007/s00464-012-2649-x
Morino M, Parini U, Allaix ME, Monasterolo G, Brachet Contul R, Garrone C (2009) Male sexual and urinary function after laparoscopic total mesorectal excision. Surg Endosc 23:233–240
Marijnen CAM, Kapiteijn E, van de Velde CJ, Martijn H, Steup WH, Wiggers T, Kranenbarg EK, Leer JW, Cooperative Investigators of the Dutch Colorectal Cancer Group (2002) Acute side effects and complications after short-term preoperative radiotherapy combined with total mesorectal excision in primary rectal cancer: report of a multicenter randomized trial. J Clin Oncol 20:817–825
Wallner C, Lange MM, Bonsing BA, Maas CP, Wallace CN, Dabhoiwala NF, Rutten HJ, Lamers WH, Deruiter MC, van de Velde CJ, Cooperative Clinical Investigators of the Dutch Total Mesorectal Excision Trial (2008) Causes of fecal and urinary incontinence after total mesorectal excision for rectal cancer based on cadaveric surgery: a study from the Cooperative Clinical Investigators of the Dutch total mesorectal excision trial. J Clin Oncol 26:4466–4472
Hendren SK, O’Connor BI, Liu M, Asano T, Cohen Z, Swallow CJ, Macrae HM, Gryfe R, McLeod RS (2005) Prevalence of male and female sexual dysfunction is high following surgery for rectal cancer. Ann Surg 242:212–223
Hoerske C, Weber K, Goehl J, Hohenberger W, Merkel S (2010) Long-term outcomes and quality of life after rectal carcinoma surgery. Br J Surg 97:1295–1303
Ho P, Law WL, Chan SC, Lam CK, Chu KW (2003) Functional outcome following low anterior resection with total mesorectal excision in the elderly. Int J Colorectal Dis 18:230–233
Huser N, Michalski CW, Erkan M, Schuster T, Rosenberg R, Kleeff J, Friess H (2008) Systematic review and meta-analysis of the role of defunctioning stoma in low rectal cancer surgery. Ann Surg 248:52–60
Morris E, Quirke P, Thomas JD, Fairley L, Cottier B, Forman D (2008) Unacceptable variation in abdominoperineal excision rates for rectal cancer: time to intervene? Gut 57:1690–1697
Buess G, Hutterer F, Theiss R, Böbel M, Isselhard W, Pichlmaier H (1984) Das System für die transanale endoskopische Rektumoperation. Chirurgie 55:677–680
Casadesus D (2009) Surgical resection of rectal adenoma: a rapid review. World J Gastroenterol 15(31):3844–3851
Bach SP, Hill J, Monson JR, Simson JN, Lane L, Merrie A, Warren B, Mortensen NJ, Association of Coloproctology of Great Britain and Ireland Transanal Endoscopic Microsurgery (TEM) Collaboration (2009) A predictive model for local recurrence after transanal endoscopic microsurgery for rectal cancer. Br J Surg 96:280–290
Morino M, Allaix ME, Caldart M, Scozzari G, Arezzo A (2011) Risk factors for recurrence after transanal endoscopic microsurgery for rectal malignant neoplasm. Surg Endosc 25:3683–3690
Allaix ME, Rebecchi F, Giaccone C, Mistrangelo M, Morino M (2011) Long-term functional results and quality of life after transanal endoscopic microsurgery. Br J Surg 98:1635–1643
Baron PL, Enker WE, Zakowski MF, Urmacher C (1995) Immediate vs. salvage resection after local treatment for early rectal cancer. Dis Colon Rectum 38:177–181
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
Borschitz T, Heintz A, Junginger T (2006) The influence of histopathologic 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
Lee WY, Lee WS, Yun SH, Shin SH, Chun HK (2007) Decision for salvage treatment after transanal endoscopic microsurgery. Surg Endosc 21:975–979
Smith LE, Ko ST, Saclarides T, Caushaj P, Orkin BA, Khanduja KS (1996) Transanal endoscopic microsurgery. Initial registry results. Dis Colon Rectum 39:S79–S84
Floyd ND, Saclarides TJ (2006) Transanal endoscopic microsurgical resection of pT1 rectal tumors. Dis Colon Rectum 49:164–168
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
Piessen G, Cabral C, Benoist S, Penna C, Nordlinger B (2012) Previous transanal full-thickness excision increases the morbidity of radical resection for rectal cancer. Colorectal Dis 14:445–452
Levic K, Bulut O, Hesselfeldt P, Bülow S (2012) The outcome of rectal cancer after early salvage TME following TEM compared with primary TME: a case-matched study. Tech Coloproctol. doi:10.1007/s10151-012-0950-2
Allaix ME, Arezzo A, Arolfo S, Caldart M, Rebecchi F, Morino M (2013) Transanal endoscopic microsurgery for rectal neoplasms: how I do it. J Gastrointest Surg 17:586–592
Morino M, Parini U, Giraudo G, Salval M, Brachet Contul R, Garrone C (2003) Laparoscopic total mesorectal excision: a consecutive series of 100 patients. Ann Surg 237:335–342
Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications. A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213
Allaix ME, Arezzo A, Cassoni P, Famiglietti F, Morino M (2012) Recurrence after transanal endoscopic microsurgery for large rectal adenomas. Surg Endosc 26:2594–2600
Marusch F, Ptok H, Sahm M, Schmidt U, Ridwelski K, Gastinger I, Lippert H (2011) Endorectal ultrasound in rectal carcinoma—do the literature results really correspond to the realities of routine clinical care? Endoscopy 43:425–431
Ashraf S, Hompes R, Slater A, Lindsey I, Bach S, Mortensen N, Cunningham C, Association of Coloproctology of Great Britain and Ireland Transanal Endoscopic Microsurgery (TEM) Collaboration (2012) A critical appraisal of endorectal ultrasound and transanal endoscopic microsurgery and decision-making in early rectal cancer. Colorectal Dis 14:821–826
Nivatvongs S, Nicholson JS, Rothenberger DA, Balcos EG, Christenson CE, Nemer FD, Schottler JL, Goldberg SM (1980) Villous adenomas of the rectum: the accuracy of clinical assessment. Surgery 87:549–551
Galandiuk S, Fazio VW, Jagelman DG, Lavery IC, Weakley FA, Petras RE, Badhwar K, McGonagle B, Eastin K, Sutton T (1987) Villous and tubulovillous adenomas of the colon and rectum. A retrospective review, 1964–1985. Am J Surg 153:41–47
Pigot F, Bouchard D, Mortaji M, Castinel A, Juguet F, Chaume JC, Faivre J (2003) Local excision of large rectal villous adenomas: long-term results. Dis Colon Rectum 46:1345–1350
Disclosures
Mario Morino, Marco Ettore Allaix, Simone Arolfo, and Alberto Arezzo have no conflicts of interest or financial ties to disclose.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Morino, M., Allaix, M.E., Arolfo, S. et al. Previous transanal endoscopic microsurgery for rectal cancer represents a risk factor for an increased abdominoperineal resection rate. Surg Endosc 27, 3315–3321 (2013). https://doi.org/10.1007/s00464-013-2911-x
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00464-013-2911-x