Transanal endoscopic microsurgery in the treatment of patients with benign neoplasms and early rectal cancer

Introduction. Transanal endoscopic microsurgery (tem) is a method that allows the specialists to clearly visualize a tumor and bimanually remove the tumor using a set of special instruments. For a number of patients with a good tumor response to chemoradiation therapy (crt), tem is used as an advanced biopsy technique for tumor verification. The purpose of the study was to analyze the results of tem performed at a. Tsyb mrrc. Material and methods. Between 2015 and 2020, 64 patients (men – 42.2 % and women – 57.8 %) underwent tem. Forty patients had rectal cancer and 25 patients had benign rectal tumors. The indication for tem in patients with rectal cancer was the evidence of tis-t1 tumor by postoperative examination findings (mri and endosonography). Eleven patients with stage ii–iii rectal cancer received chemoradiation therapy. The indication for performing tem after rt in patients with rectal cancer was a good tumor response (mri trg1- 2). For statistical processing, commercial biomedical packages prism 3.1 and instat (graphpad software, inc., san diego, usa) were used. The significance of the differences between the indicators was assessed using the pearson χ2 test. Differences were considered significant if the p value was less than 0.05. Results. The median duration of surgery was 110 minutes (30–385). The volume of blood loss did not exceed 40 ml. Postoperative complications were observed in 15 cases (23.4 %). Grade 3 complications according to the clavien-dindo classification were observed in 5 (7.8 %) cases. Postoperative complications occurred more frequently in patients after crt (10.7 and 18.2 %; p=0.603), however, the differences were not statistically significant. At a median follow-up of 18 months (7–30), local relapses developed in 6 out of 26 (23 %) patients who underwent surgery alone. There were no signs of local recurrence in patients with adenocarcinomas after neoadjuvant chemotherapy and rectal adenomas. When comparing patients with the depth of tumor invasion tis-t1sm2 and t1sm3-t2, local relapses occurred in 1 of 21 (4.7 %) and 5 of 12 (41.6 %) cases, respectively (p=0.015). Conclusion. The analysis of the results of tem interventions in patients with rectal neoplasms allows us to conclude that this method of treatment is a priority for patients with benign rectal neoplasms and early rectal cancer. The method can also be used after rt or crt in patients with tumor invasion ≥t1sm3, provided a complete or almost complete tumor response to the treatment.

Completion surgery vs. primary TME for early rectal cancer: a national study

Purpose While local excision by transanal endoscopic microsurgery (TEM) or transanal minimally invasive surgery (TAMIS) is an option for low-risk early rectal cancers, inaccuracies in preoperative staging may be revealed only upon histopathological evaluation of the resected specimen, demanding completion surgery (CS) by formal resection. The aim of this study was to evaluate the results of CS in a national cohort. Method This was a retrospective analysis of national registry data, identifying and comparing all Norwegian patients who, without prior radiochemotherapy, underwent local excision by TEM or TAMIS and subsequent CS, or a primary total mesorectal excision (pTME), for early rectal cancer during 2000–2017. Primary endpoints were 5-year overall and disease-free survival, 5-year local and distant recurrence, and the rate of R0 resection at completion surgery. The secondary endpoint was the rate of permanent stoma. Results Forty-nine patients received CS, and 1098 underwent pTME. There was no difference in overall survival (OR 0.73, 95% CI 0.27–2.01), disease-free survival (OR 0.72, 95% CI 0.32–1.63), local recurrence (OR 1.08, 95% CI 0.14–8.27) or distant recurrence (OR 0.67, 95% CI 0.21–2.18). In the CS group, 53% had a permanent stoma vs. 32% in the pTME group (P = 0.002); however, the difference was not significant when adjusted for age, sex, and tumor level (OR 2.17, 0.95–5.02). Conclusions Oncological results were similar in the two groups. However, there may be an increased risk for a permanent stoma in the CS group.

Local Excision ± Chemoradiotherapy vs. Total Mesorectal Excision for Early Rectal Cancer: Case-Matched Analysis of Long-Term Results

Background: Our aim was to compare the bowel function and oncologic outcomes following these two treatment modalities.Materials and methods: This was a single-center study with 67 patients included between 2009 and 2018. A total of 32 patients underwent total mesorectal excision (TME) group and 35 transanal local excisions (LE) ± chemoradiation. We performed a case-matched analysis: we matched the patients by age, cancer stage, and comorbidities. Duration of operation, postoperative complications, length of hospital stay, and long-term functional and oncological outcomes were compared. We calculated oncological outcomes using Kaplan–Meier Cox diagrams. In addition, we used a low anterior resection syndrome (LARS) score for the bowel function assessment.Results: Mean operation time in the LE group was 58.8 ± 45 min compared with the TME group that was 121.1 ± 42 min (p = 0.032). Complications were seen in 5.7% in LE group and 15.62% in TME group (p = 0.043). ~85.2% of the patients had no LARS in LE group compared with 54.5% in TME group (p = 0.018). Minor LARS was 7.4% in LE group compared with 31.8% in TME group (p = 0.018); major LARS was 7.4 and 13.7%, respectively (p = 0.474). Hospital stay was 2.77 days in LE group compared with 9.21 days in TME group (p = 0.036). The overall survival was 68.78 months in LE group compared with 74.81 months in TME group (p = 0.964).Conclusion: Our results of a small sample size showed that local excision ± chemoradiation is a rather safe method for early rectal cancer compared with gold standard treatment. In addition, better bowel function is preserved with less postoperative complications and shorter hospital stays.

TP7.2.9 Natural orifice surgery in early rectal cancer; is it the way forward?

Aims Transanal-endoscopic microsurgery (TEMS) for early rectal cancer is an attractive alternative to radical surgery. With proper patient selection, it is possible to achieve acceptable oncological outcomes with fewer complications. We aim to study the outcomes following TEMS for suspicious or proven rectal cancers performed in our unit. Method We performed a retrospective analysis of prospectively collected data between May-17 and Oct-20. The patients’ details, tumour specific data, short term outcomes, and recurrences were recorded. Results A total of 45 patients with early rectal cancer (M = 29, F = 15) were included in this study. With1 exclusion due to intraoperative rectal perforation, 44 were available for further analysis. Eleven had a diagnosis of cancer at the time of surgery, an additional 11 patients were confirmed on final histology, and 22 were benign. Final histology showed: T1=14, T2=4, T3=3 &Tx=1. The majority (68%) had clear resection margins (R1=3, R2=1, Rx = 3). Twelve patients went on to have further treatment. Seven had resectional surgery (AR = 5, APR=2) for unfavorable histology (2), residual disease (3), or recurrence (2). The other 5(23%) received chemotherapy+/-radiotherapy (unfit/patients’ choice) for unfavorable. Histology (3) or residual disease (2). Conclusion With judicious patient selection, it is possible to offer a less invasive option with acceptable oncological and patient related outcomes for suspicious and proven malignant rectal lesions. The majority of patients (84%) were able to avoid radical surgery or stoma, thereby reducing the associated morbidity. Whilst this is a single institution study, we believe with available expertise this could be widely replicated.

EP.TU.393Management of Suspicious Neoplastic Rectal Lesions in Octogenarians by a Specialist Early Rectal Cancer MDT

Aims To assess management of early rectal cancers in octogenarians going through a regional Small and Early Rectal Cancer MDT observing oncological outcomes, morbidity, mortality and quality of life after treatment Methods Consecutive octogenarian patients treated via the SERC MDT between Dec 2013 and Dec 2019 were examined retrospectively from a prospectively maintained database. Patients underwent transanal endoscopic microsurgery (TEMS), endoscopic submucosal dissection (ESD), contact radiotherapy or hybrid combinations. Patient demographics were recorded and outcomes assessed including pre and post-operative oncological staging, morbidity, mortality, length of stay and FISI scores Results 85 patients were assessed. 38 had TEMS, 40 had EMR, ESD or hybrid procedures and 7 had contact radiotherapy. Of the 38 patients who underwent TEMS, there was minor morbidity in 5 patients, one cancer recurrence and no cancer related mortality. FISI scores pre- and post-procedure were markedly different with deterioration in control of flatus and mucus, but no faecal incontinence. Of the 40 patients who underwent EMR, ESD or hybrid procedures, 2 had minor morbidity and 3 had adenocarcinomas detected requiring further treatment Conclusions Management of octogenarians with early rectal cancer via a specialist MDT provides a safe option with minimal morbidity and no mortality in a subgroup of patients who would otherwise constitute a high risk cohort for surgical intervention. A deterioration in continence in this group highlights the need for careful counselling of patients to achieve the optimal balance between oncological outcomes and quality of life