Local excision for early rectal cancer: transanal endoscopic microsurgery and beyond

The goal of treatment for early stage rectal cancer is to optimize oncologic control while minimizing the long-term impact of treatment on quality of life. The standard of care treatment for most stage I and II rectal cancers is radical surgery alone, specifically total mesorectal excision (TME). For early rectal cancers, this procedure is usually curative but can have a substantial impact on quality of life, including the possibility of permanent colostomy and the potential for short and long-term bowel, bladder, and sexual dysfunction. Given the morbidity associated with radical surgery, alternative approaches to management of early rectal cancer have been explored, including local excision (LE) via transanal excision (TAE) or transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS). Compared to the gold standard of radical surgery, local procedures for strictly selected early rectal cancers should lead to identical oncological results and even better outcomes regarding morbidity, mortality, and quality of life.     

Advances in Rectal Cancer Surgery

Surgical resection is the cornerstone of curative intent therapy for rectal cancer. The introduction of the concept of total mesorectal excision (TME) led to significant decreases in local recurrence. However, TME carries substantial morbidity. The advent of transanal endoscopic techniques, such as transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS), has allowed patients with early-stage disease to be managed with local excision and avoid the morbidity of TME. Advances in surgery such as laparoscopy, robotic surgery, and transanal approaches have also broadened the options for achieving TME. However, there is significant debate within the literature regarding the optimal approach and oncologic outcomes of these modalities.     

Management of Early (T1 or T2) Rectal Cancer

Early stage rectal cancers (T1/T2) are being found more commonly due to increasing compliance with population screening guidelines. Patient selection is the most important element in advising local excision versus standard transabdominal resection with total mesorectal excision (TME). Determining the best strategy for an individual patient relies on accurate histologic assessment (a surrogate of biologic behavior), accurate clinical staging (endorectal ultrasound or MRI), and accurate assessment of patient procedural risk. It is important to review the histology for high-risk features associated with occult lymph node metastasis as this portends a higher local recurrence rate. Since the local recurrence rate following local excision for T2 rectal cancer is high, it has been our practice to offer these patients proctectomy with TME unless the patient has a poor performance status, is unwilling to proceed, or is part of a clinical trial. We limit transanal resection to well-selected patients with T1 lesions without high-risk histologic features (lymphovascular invasion, poor grade, or deep submucosal invasion). Factors such as patient procedural preference and comorbidities may influence this decision but it is on a case by case basis. Local excision can be accomplished with conventional transanal procedures; however, newer techniques such as transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS) may have less specimen fragmentation and improved R0 resection rates. Neoadjuvant chemoradiation may add further benefit for maximizing local control but is associated with local wound problems including bleeding and infection. Adherence to a strict surveillance program after local excision allows clinicians to salvage recurrence as early as possible. In a multidisciplinary fashion, the surgeon, pathologist, gastroenterologist, and patient need to make informed decisions about risk and benefit when determining the best individualized care for the patient.     

Local therapy for rectal cancer.

In selected patients with early rectal cancer, local therapy is an effective alternative to radical resection and offers minimal morbidity and the avoidance of a colostomy. Several techniques are described: transanal excision, dorsal approaches (York-Mason or Kraske procedures), transanal endoscopic microsurgery, endocavitary radiation, and transanal fulguration. Among these, transanal excision is favored for the low rate of complications, promising outcomes, and ability to secure tissue for pathology. Patients with T1 lesions with favorable histologic features may undergo local excision alone, while those with T2 lesions require adjuvant chemoradiation. The data currently available do not support the use of local therapy with curative intent for tumors that are advanced (T3 or T4), poorly differentiated, or have other negative pathologic characteristics. In carefully selected patients for local excision, local recurrence and survival rates are similar to traditional radical resection. Following local excision, patients require close observation for recurrence. Most patients with local recurrence can be salvaged by radical resection, though the long-term outcome is unknown.     

Transanale endoskopische Mikrochirurgie (TEM)

Local excision of rectal tumors was primarily carried out for adenomas or with a palliative intention. Over a course of more than 20 years local surgery has increasingly become established for early (T1) carcinomas. Among several local resection procedures, the less traumatizing transanal approach has become most accepted as compared to more aggressive techniques. The transanal endoscopic microsurgical (TEM) technique is most widely used. For ‘low risk’T1 carcinomas low local recurrence rates are primarily reported, and both the tumor characteristics and the quality of the resection are relevant prognostic factors. For ‘high risk’T1 or T2 carcinomas, high recurrence rates have to be expected. Among additional measures, immediate conventional radical re-operating is superior to adjuvant chemoradiotherapy. In addition, awaiting salvage surgery of local recurrences provides inferior oncological outcomes. Interestingly, favorable results have been obtained with neoadjuvant chemoradiotherapy of T2–3 rectal cancers and first studies consistently showed low recurrence rates.     

腔镜直线切割吻合器用于T1期中低位直肠癌经肛门局部切除术的疗效及安全性

目的:探讨应用腔镜直线切割吻合器（endoscopic linear cutters,ENDOPATH）行经肛门局部切除术治疗T1期中低位直肠癌的疗效和安全性。方法:回顾性分析2011年01月至2017年12月我院收治的92例T1期中低位直肠癌患者的临床资料。根据手术方式分为经肛门局部切除术组（TAE组）与直肠癌传统根治术组（根治术组）。TAE组使用腔镜直线切割吻合器行经肛门全层局部切除术,共39例;根治术组按全直肠系膜切除原则行传统根治术,共53例(包括16例Miles手术和37例Dixon手术)。对两组患者的一般资料、术中及术后相关指标及预后情况进行比较。结果:TAE组和根治术组患者在性别、年龄、肿瘤病理分型、肿瘤大小、距肛缘距离方面对比分析,无显著性差异（P＞0.05）,两组资料有可比性。两组患者在手术时间［（TAE组:(37.74±10.66)min,根治术组:(117.66±41.78)min］、术后住院时间［TAE组:(6.85±1.06)天,根治术组:(10.70±1.72)天］、术中出血量［TAE组:(30.21±2.97)mL,根治术组:(78.96±12.65)mL］、术后并发症发生率（TAE组:2.56%,根治术组:43.39%）方面差异均有统计学意义（P＜0.01)。两组患者的3年无病生存率均为100.00%,两组患者3年内均无复发,相比较无统计学差异（P＞0.05）。两组患者的生存质量评分［TAE组:(90.31±3.82)分,根治术组:（71.59±6.33）分］差异有统计学意义（P＜0.01)。结论:与传统根治术相比,应用腔镜直线切割吻合器对T1期中低位直肠癌行经肛门局部切除术同样安全有效。应用腔镜直线切割吻合器行经肛门局部切除术创伤小、并发症少、恢复快,患者术后生活质量等方面明显优于根治术。应用腔镜直线切割吻合器行经肛门局部切除术可作为早期无淋巴转移的中低位直肠癌患者优先选择的一种术式。     

Transanal total mesorectal excision (TaTME) for rectal cancer: Step by step description of the surgical technique for a two-teams approach

Interest in transanal total mesorectal excision (TaTME) is growing worldwide due to the application of minimally invasive techniques to rectal cancer surgery while maintaining adequate oncologic outcomes.This article presents the standardised and refined technique after performing more than 300 operations at Hospital Clinic of Barcelona.     

Minimally invasive treatment of colorectal cancer

It may be widely interpreted that minimally invasive treatment of colorectal cancer includes endoscopic mucosal resection, transanal endoscopic microsurgery (TEM), laparoscopic surgery and open reduction-surgery as well as adjuvant treatments such as chemotherapy, radiotherapy and thermotherapy. With the development of medical technology and instruments, we have now a wide and new range of choices for each cancer stage of patients. However, it is not yet clear that minimally invasive treatment necessarily leads to better results in survival and recurrent rates of the patients, as compared with conventional surgery. We should therefore take into full consideration the lingering problems in selecting the new therapies. In this paper, we show the strong and weak points of laparoscopic surgery, TEM, right hemi-colectomy preserving Bauhin's valve and adjuvant radiotherapy for lower rectal cancer, and discuss ongoing problems.     

Systematic review analysis of robotic and transanal approaches in TME surgery- A systematic review of the current literature in regard to challenges in rectal cancer surgery

Several patients' and pathological characteristics in rectal surgery can significantly complicate surgical loco regional tumor clearance. The main factors are obesity, short tumor distance from anal verge, bulky tumors, and narrow pelvis, which have been shown to be associated to poor surgical results in open and laparoscopic approaches. Minimally invasive surgery has the potential to reduce perioperative morbidity with equivalent short- and long-term oncological outcomes compared to conventional open approach. Achilles' heel of laparoscopic approaches is conversion to open surgery. High risk for conversion is evident for patients with bulky and low tumors as well as male gender and narrow pelvis. Hence, patient's characteristics represent challenges in rectal cancer surgery especially in minimally invasive approaches. The available surgical techniques increased remarkably with recently developed and implemented improvements of minimally invasive rectal cancer surgery. The controversial discussions about sense and purpose of these novel approaches are still ongoing in the literature.Herein, we evaluate, if latest technical advances like transanal approach or robotic assisted surgery have the potential to overcome known challenges and pitfalls in rectal cancer surgery in demanding surgical cases and highlight the role of current minimally invasive approaches in rectal cancer surgery.     

Low rectal cancer: Sphincter preserving techniques-selection of patients,techniques and outcomes

Low rectal cancer is traditionally treated by abdominoperineal resection. In recent years, several new techniques for the treatment of very low rectal cancer patients aiming to preserve the gastrointestinal continuity and to improve both the oncological as well as the functional outcomes, have been emerged. Literature suggest that when the intersphincteric resection is applied in T1-3 tumors located within 30-35 mm from the anal verge, is technically feasible, safe, with equal oncological outcomes compared to conventional surgery and acceptable quality of life. The Anterior Perineal PlanE for Ultra-low Anterior Resection technique, is not disrupting the sphincters, but carries a high complication rate, while the reports on the oncological and functional outcomes are limited. Transanal Endoscopic MicroSurgery (TEM) and TransAnal Minimally Invasive Surgery (TAMIS) should represent the treatment of choice for T1 rectal tumors, with specific criteria according to the NCCN guidelines and favorable pathologic features. Alternatively to the standard conventional surgery, neoadjuvant chemo-radiotherapy followed by TEM or TAMIS seems promising for tumors of a local stage T1sm2-3 or T2. Transanal Total Mesorectal Excision should be performed only when a board approved protocol is available by colorectal surgeons with extensive experience in minimally invasive and transanal endoscopic surgery.     

Laparoscopic intersphincteric resection for low rectal cancer

The goal of this review is to outline some of the important surgical issues surrounding the management of patients with low rectal cancer submitted to laparoscopic intersphincteric resection (ISR). Surgery for rectal cancer continues to develop towards the ultimate goals of improved local control and overall survival, maintaining quality of life, and preserving sphincter, genitourinary, and sexual function. Nevertheless, all progress in the development of oncologic therapy (i.e., radiation and chemotherapy), radical surgical removal of the tumour is the only chance for permanent cure of rectal cancer. Beside this main objective, the preservation of faecal continence is the second-most important goal to reach an acceptable quality of life with preservation of sphincter function. Information concerning the depth of tumour penetration through the rectal wall, lymph node involvement, and presence of distant metastatic disease is of crucial importance when planning a curative rectal cancer resection. Preoperative staging is used to determine the indication for neoadjuvant therapy as well as the indication for local excision versus radical cancer resection. In appropriate patients, minimally invasive procedures, such as local excision, TEM, and laparoscopic resection with ISR allow for improved patient comfort, shorter hospital stays, and earlier return to preoperative activity level. Data from small, non-randomized studies evaluating laparoscopic ISR suggest that this procedure is feasible by experienced surgeons. A literature search identified five studies [Uchikoshi F, Nishida T, Ueshima S, Nakahara M, Matsuda H. Laparoscope-assisted anal sphincter-preserving operation preceded by transanal procedure. Tech Coloprocto 2006;10:5-9; Bretagnol F, Rullier E, Couderc P, Rullier A, Saric J. Technical and oncological feasibility of laparoscopic total mesorectal excision with pouch coloanal anastomosis for rectal cancer. Colorectal Disease 2003;5:451-3; Rullier E, Sa Cunha A, Couderc P, Rullier A, Gontier R, Saric J. Laparoscopic intersphincteric resection with coloplasty and coloanal anastomosis for mid and low rectal cancer. British Journal of Surgery 2003;90:445-51; Watanabe M, Teramoto T, Hasegawa H, Kitajima M. Laparoscopic ultralow anterior resection combined with per anum intersphincteric rectal dissection for lower rectal cancer. Diseases of the Colon and Rectum 2000;43(Suppl. 10):S94-7; Miyajima N, Yamakawa T. Laparoscopic surgery for early rectal carcinoma. Nippon Geka Gakkai Zasshi 1999;100:801-5]. The aim was to find those studies that documented potential clinical application of laparoscopic ISR. These studies concluded that a laparoscopic approach can be considered in most patients with low rectal cancer in which laparoscopic ISR represents a feasible alternative to conventional open surgery. Hopefully, randomized controlled trials, which utilize these alternative procedures, will in future determine the results of laparoscopic ISR in terms of sphincter function, faecal continence, disease free and overall survival. The reviewed studies concluded that high quality and less invasive surgery could be achieved if ISR and laparoscopic surgery were combined.     

早期中低位直肠癌经肛门切除的疗效分析

目的:探讨早期中低位直肠癌经肛门局部切除术的临床应用价值。方法:回顾性分析2012年至2015年期间我院收治的112例早期中低位直肠癌患者,分为经肛门局部切除组（n=52）和根治性切除组（n=60）。术后标本行常规免疫组化病理检测,同时对比两组患者的各种临床病理特征。结果:两组患者肿瘤大小、肿瘤距肛缘距离比较差异无统计学意义（P＞0.05）;术后住院天数、术中出血量、术后并发症发生率及手术时间比较差异有统计学意义（P＜0.05）。结论:早期中低位直肠癌经肛门切除与根治性手术比较治疗效果相当,但操作更简便易行,创伤小,恢复快、并发症少、术后生活质量高,具有一定优势,特别是内镜切割吻合器的联合应用,使得该术式更简便易行,在具有适应征患者中可以推广。     

Local Excision for Rectal Carcinoma

Local excision is an alternative approach to radical proctectomy for rectal cancer, but from an oncologic standpoint, it is a compromise, and its role remains controversial. Careful patient selection is essential because local excision is generally considered only for early rectal cancer with no evidence of nodal metastasis, parameters that can be predicted by clinical examination, and various radiologic modalities with variable accuracy. In this review, we present the literature evaluating the oncologic adequacy of local excision, including transanal endoscopic microsurgery and the results of salvage surgery after local excision. An overview of local excision in the context of perioperative adjuvant therapies is included. Finally, we suggest a treatment algorithm for local excision in rectal cancer.     

Minimally Invasive Surgery for Rectal Cancer: Current Trends

Purpose of the Review

The literature regarding minimally invasive surgical approaches to rectal adenocarcinoma is reviewed, and techniques introduced over recent decades are assessed for oncological and patient-centered outcomes.

Recent Findings

Total mesorectal excision (TME) is the gold standard for surgical treatment of rectal adenocarcinoma, and while laparoscopic TME is safe and feasible, with acceptable oncologic outcomes, its non-inferiority with regard to completeness of TME specimen when compared to open surgery could not be established in two recent randomized trials. Long-term follow-up for these trials is pending with regard to ultimate oncologic outcomes. Robotic TME is also safe and feasible when performed by experienced surgeons, but has high costs, and results of the only randomized trial comparing the technique to laparoscopy are yet to be published. Laparoscopic and robotic approaches appear to offer short-term benefits in patient recovery and quality of life. The latest innovation is transanal TME (TaTME). This is performed at select centers, and early on, has been associated with acceptable resection quality and short-term outcomes. Organ-preserving transanal and endoscopic resections for early-stage disease have acceptable results, and a non-operative/watch-and-wait strategy may be appropriate in selected patients with a complete clinical response.

Summary

There are multiple surgical options for rectal adenocarcinoma, depending on patient and disease characteristics. In the appropriate setting, minimally invasive approaches to TME offer short-term benefits to patients and acceptable oncologic results. Organ-preserving strategies in selected patients may avoid morbidity associated with radical resection.

     

低位直肠癌新辅助治疗达到almost-cCR（near-cCR）的缩小手术和根治术疗效的对照研究

目的:总结低位直肠癌行新辅助治疗原发肿瘤达到almost-cCR(almost-clinical complete response）后，比较缩小手术和根治术两种术式的优缺点。方法:回顾性分析2013年1月至2018年10月间，辽宁省肿瘤医院大肠科收治的局部晚期低位直肠癌经新辅助治疗原发肿瘤达到almost-cCR（near-cCR）的共35例患者的临床和病理资料。采用Kaplan-Meier法绘制生存曲线。结果:35例病人中，缩小手术组共纳入9例患者，根治术组共纳入26例患者。缩小手术组未出现术后并发症，根治术组3例患者出现术后并发症，发生率11.5%。缩小手术组1年和2年无复发生存率均为100%。根治术组1年和2年无复发生存率分别为96.1%和88.4%。缩小手术组中位DFS和OS均为32.1个月。根治术组中位DFS和OS分别为43.2个月和39.6个月。结论:对于低位直肠癌新辅助治疗达到almost-cCR（near-cCR）的病人，缩小手术组可以取得不亚于根治术组的临床疗效。并且减少手术创伤，改善近期疗效和远期预后。     

Sphincter preservation in rectal cancer

Opinion statement Distal rectal cancer poses two challenges to the oncologist: local tumor control and sphincter preservation. The abdominoperineal resection (APR), long considered the standard treatment of tumors with a distal edge located up to 6 cm from the anal verge, provides local control in many patients but results in sphincter loss with a permanent colostomy. This is a critical limitation. Consequently, there has been significant interest in sphincter-conserving approaches, frequently combining chemoradiation with surgery. These approaches have evolved along two fronts. For patients with small rectal cancers confined to the rectal wall, local excision techniques with and without chemoradiation may offer comparable local control and survival rates as an APR and preserve sphincter function. For patients with larger and more invasive tumors of the distal rectum where local excision is inappropriate, preoperative chemoradiation promotes tumor regression and may facilitate a resection sparing the sphincter with a coloanal anastomosis. Preliminary results from single institution studies appear promising. In both these settings (favorable and more invasive rectal cancer), chemoradiation is employed to compensate for the limitations of the sphincter-preserving surgical technique. In local excision procedures, the excision margins are invariably small, and the mesorectum (lymphatics, soft tissue) surrounding the tumor is not excised. For patients undergoing resection with coloanal anastomosis, there are narrow radial and distal surgical margins. With these approaches of chemoradiation and sphinctersparing surgery, satisfactory local control and survival with avoidance of colostomy are possible for many patients with distal rectal cancer.     

President’s Address

In breast cancer surgery, there has been a major shift toward less invasive local treatment: from extended or radical mastectomy to modified radical mastectomy, from modified radical mastectomy to breast conserving therapy, and from routine axillary lymph node dissection to sentinel lymph node biopsy. Many breast surgeons have experienced an evolutionary progression of surgical management of breast cancer. However, there is an increasing demand for minimally invasive and non-surgical treatment methods for patients with small breast cancer. Radiofrequency (RF) ablation is the most promising among non-surgical ablation techniques in the treatment of breast cancer, although it is still in the investigative stage. Nevertheless, surgery still plays an integral role in the treatment of breast cancer, because local therapy is important for enhancing survival in the presence of systemic therapy. In clinical practice, surgical oncologists must individualize treatments, selecting a surgical or non-surgical procedure that provides the best local control, does not compromise the chances of cure, and achieves the best cosmetic results.     

The management of rectal cancer in the elderly

INTRODUCTION: The majority of patients with rectal cancer are elderly. Due to the increasingly aging population the number of people with colorectal cancer is increasing. As medical advances in the areas of local therapy, radiation therapy, and surgical technique, such as, laparoscopy are made more elderly patients are offered various types of treatment for rectal cancer. As the number of treatment options increase, the debate on how to treat elderly patients' with rectal cancer intensifies. METHODS: A Medline search using "rectal cancer," "elderly," "local therapy," "radical surgery," and "radiation therapy" as key words was performed for English-language articles. Further references were obtained through cross-referencing the bibliography cited in each work. DISCUSSION: Numerous treatment options exists for elderly patients with rectal cancer. These range from transanal local excision to radical surgery. The best treatment option for a certain elderly patient is multifactorial and includes tumor stage, operative curability, preoperative functioning of the patient, patient comorbidities, quality of life goals, and patient preference. CONCLUSION: Age, taken as an independent variable, is not a contraindication to any specific type of therapy, including radical surgery with primary anastomsis. Patients' who meet the criteria for local resection should undergo this procedure. However, for tumors which are not amenable to local resection, these patients should be considered for radical surgery if this provides the best chance for cure. Elderly patients who can tolerate a major operation, and have good preoperative sphincter function should undergo a resection with primary anastomosis.     

Surgery for gynecologic malignancies.

The surgical management of invasive and preinvasive gynecologic malignancies continues to evolve at a brisk pace. Several good techniques are available for the treatment of preinvasive cervical disease, including cryotherapy, loop electrocautery excision, laser therapy, and standard knife conization. The use of radical surgery for early invasive cervical cancer has been extended to older women, and complications have been minimized. There has been a significant trend toward more conservative surgery in the management of invasive vulvar cancer. The new surgical staging system for endometrial cancer has generated much controversy. The importance of thorough surgical staging for ovarian cancer is clear, and our understanding of the role of cytoreduction has increased. The role of new techniques, including operative laparoscopy, is being defined in the management of gynecologic cancers.     

Recent advances in colorectal cancer surgery

Recent advances in colorectal cancer surgery have been made in improving the cure rate after surgery, the preservation of postoperative function, and the development of minimally invasive procedures. Indication for wide lymph node dissection in rectal cancer surgery is now limited to a smaller number of cases. Functional outcome is being improved thanks to the introduction of autonomic nerve preserving operations as well as the increasing number of sphincter preserving operations. Laparoscopic colectomy for cancer has been practiced for 7-8 years, and the advantages and disadvantages of this procedure are being clarified. Transanal endoscopic microsurgery (TEM) is a minimally invasive surgery for rectal tumors in early stages. The procedure is now overtaking the posterior surgical approach, which is used less and less in recent years. Future goals in colorectal cancer surgery are further improvements in the cure rate and the functional results. Minimally invasive surgery may become the established procedure after a careful assessment of its cure rate compared to the open surgical procedure.