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The impact of transanal local excision of early rectal cancer on completion rectal resection without neoadjuvant chemoradiotherapy: a systematic review

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Abstract

Background

The impact of transanal local excision (TAE) of early rectal cancer (ERC) on subsequent completion rectal resection (CRR) for unfavorable histology or margin involvement is unclear. The aim of this study was to provide a comprehensive review of the literature on the impact of TAE on CRR in patients without neoadjuvant chemoradiotherapy (CRT).

Methods

We performed a systematic review of the literature up to March 2020. Medline and Cochrane libraries were searched for studies reporting outcomes of CRR after TAE for ERC. We excluded patients who had neoadjuvant CRT and endoscopic local excision. Surgical, functional, pathological and oncological outcomes were assessed. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed.

Results

Sixteen studies involving 353 patients were included. Pathology following TAE was as follows T0 = 2 (0.5%); T1 = 154 (44.7%); T2 = 142 (41.2%); T3 = 43 (12.5%); Tx = 3 (0.8%); T not reported = 9. Fifty-three percent were > T1. Abdominoperineal resection (APR) was performed in 80 (23.2%) patients. Postoperative major morbidity and mortality occurred in 22 (11.4%) and 3 (1.1%), patients, respectively. An incomplete mesorectal fascia resulting in defects of the mesorectum was reported in 30 (24.6%) cases. Thirteen (12%) patients developed recurrence: 8 (3.1%) local, 19 (7.3%) distant, 4 (1.5%) local and distant. The 5-year cancer-specific survival was 92%. Only 1 study assessed anal function reporting no continence disorders in 11 patients. In the meta-analysis, CRR after TAE showed an increased APR rate (OR 5.25; 95% CI 1.27–21.8; p 0.020) and incomplete mesorectum rate (OR 3.48; 95% CI 1.32–9.19; p 0.010) compared to primary total mesorectal excision (TME). Two case matched studies reported no difference in recurrence rate and disease free survival respectively.

Conclusions

The data are incomplete and of low quality. There was a tendency towards an increased risk of APR and poor specimen quality. It is necessary to improve the accuracy of preoperative staging of malignant rectal tumors in patients scheduled for TAE.

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Authors and Affiliations

  1. General Surgery Unit, University Hospital, Parma, Italy

    R. Zinicola & M. Giuffrida

  2. Department Molecular & Translational Medicine, University of Brescia, Brescia, Italy

    R. Nascimbeni

  3. General Surgery Unit, University Hospital, Perugia, Italy

    R. Cirocchi

  4. Department of Surgery, University of Illinois College of Medicine at Chicago, Chicago, IL, USA

    G. Gagliardi

  5. General Surgery Unit, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy

    N. Cracco

  6. Unit Neuroscience, Department of Medicine and Surgery, Centre of Robust Statistic, University of Parma, Parma, Italy

    G. Pedrazzi

  7. Colorectal Surgery, Biomedical Institute, Genoa, Italy

    G. A. Binda

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  1. R. Zinicola
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Zinicola, R., Nascimbeni, R., Cirocchi, R. et al. The impact of transanal local excision of early rectal cancer on completion rectal resection without neoadjuvant chemoradiotherapy: a systematic review. Tech Coloproctol 25, 997–1010 (2021). https://doi.org/10.1007/s10151-020-02401-8

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