Retrospective Cohort Study
Copyright ©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Oct 27, 2024; 16(10): 3114-3122
Published online Oct 27, 2024. doi: 10.4240/wjgs.v16.i10.3114
Local excision of early rectal cancer: A multi-centre experience of transanal endoscopic microsurgery from the United Kingdom
Ahmed Farid, Matthew Tutton, Prem Thambi, TS Gill, Jim Khan
Ahmed Farid, Department of General Surgery, Oncology Center Mansoura University, Cairo 11432, Egypt
Matthew Tutton, Department of Colorectal Surgery, East Suffolk and North Essex NHS Trust, Colchester CO1 1AA, Essex, United Kingdom
Prem Thambi, Department of Colorectal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth PO6 3LY, Hampshire, United Kingdom
TS Gill, Department of Surgery, University Hospital of North Tees, Stockton on Tees TS18-TS21, Darlington, United Kingdom
Jim Khan, Department of General Surgery, Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Portsmouth PO6 3LY, Hampshire, United Kingdom
Author contributions: Khan J, Tutton M, Thambi P, Gill T did the conceptualization, methodology and data collection; Fareed A did the analysis, investigation, and writing; Khan J edited the original draft and revised the manuscript; All authors read and approved the final manuscript.
Institutional review board statement: This study was reviewed and approved by Portsmouth Hospitals University NHS Trust review board, IRAS No. 293129.
Informed consent statement: Not Applicable as retrospective database review.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
Data sharing statement: All data used was extracted from a prospective research database and already had ethical approval (IRAS No. 293129). The project was registered with the R&D department at Portsmouth Hospitals University NHS Trust.
STROBE statement: The authors have read the STROBE Statement—a checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-a checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Jim Khan, FCPS, Professor, Surgical Oncologist, Department of General Surgery, Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Southwick Hill Road, Cosham, Portsmouth PO6 3LY, Hampshire, United Kingdom. mkhan702@aol.com
Received: June 9, 2024
Revised: July 25, 2024
Accepted: September 3, 2024
Published online: October 27, 2024
Processing time: 109 Days and 12.5 Hours
Abstract
BACKGROUND

Total mesorectal excision remains the gold standard for the management of rectal cancer however local excision of early rectal cancer is gaining popularity due to lower morbidity and higher acceptance by the elderly and frail patients.

AIM

To investigate the results of local excision of rectal cancer by transanal endoscopic microsurgery (TEMS) approach carried out at three large cancer centers in the United Kingdom.

METHODS

TEMS database was retrospectively reviewed to assess demographics, operative findings and post operative clinical and oncological outcomes. This is a retrospective review of the prospective databases, which included all patients operated with TEMS approach, for early rectal cancer (Node-negative T1-T2), selected T3 in unfit/frail patients.

RESULTS

Two hundred and twenty-two patients underwent TEMS surgery. This included 144 males (64.9%) and 78 females (35.1%), Median age was 71 years. The median distance of the tumours from the anal verge 4.5 cm. Median tumour size was 2.6 cm. The most frequent operative position of the patient was lithotomy (32.3%), Full-thickness rectal wall excision was done in 204 patients. Median operating time was 90 minutes. Average blood loss was minimal. There were two 90-day mortalities. Complete excision of the tumour with free microscopic margins by > 1mm were accomplished in 171 patients (76.7%). Salvage total mesorectal excision was performed in 42 patients (19.8%). Median disease-free survival was 65 months (range: 3-146 months) (82.8%), and median overall survival was 59 months (0-146 months).

CONCLUSION

TEMS provides a promising option for early rectal cancers (Large adenomas-cT1/cT2N0), and selected therapy-responding cancers. Full-thickness complete excision of the tumour is mandatory to avoid jeopardising the oncological outcomes.

Keywords: Local excision; Transanal endoscopic microsurgery; Early rectal cancer; Rectum preservation; Rectum saving

Core Tip: In this multi-centre study, Trans-anal endoscopic microsurgery was employed in 222 patients of early rectal cancers (T1-T2/early T3, N0), with acceptable oncologic outcomes and morbidity. The main independent factor of survival was the completeness of local excision, while completion total mesorectal excision did not offer a survival benefit. The limitations of this study were the heterogenicity of the data, its retrospective analysis, and the non-comparative design to the total mesorectal excision, which is the standard of care. However, this rectum preservation strategy can be a substitute in selected patients, especially in the evolving era of precision medicine.