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Transanal Total Mesorectal Excision by Transanal Endoscopic Microsurgery as an Alternative to Abdominoperineal Resection for Rectal Cancer
Vol. 221, No. 4S1, October 2015
Transanal Total Mesorectal Excision by Transanal Endoscopic Microsurgery as an Alternative to Abdominoperineal Resection for Rectal Cancer Emanuele Lezoche, MD, FACS, Hon. FASCRS, Andrea Balla, MD, Silvia Quaresima, MD, Giancarlo D’Ambrosio, MD, Mario Guerrieri, MD, Giovanni Lezoche, MD, Alessandro M Paganini, MD, PhD, FACS Sapienza University, Rome, Italy; Universita` Politecnica delle Marche, Ancona, Italy INTRODUCTION: Transanal total mesorectal excision (taTME) by transanal endoscopic microsurgery (TEM) with a modified rectoscope has been proposed as an alternative technique to abdominoperineal resection (APR) for ultralow advanced rectal cancer. METHODS: All patients underwent long-course neoadjuvant radiochemotherapy (n-RCT). The incision line by TEM starts at the dentate line. The modified rectoscope provides 360-degree dissection following the mesorectal plane. The abdominal step is performed by laparoscopy, with coloanal anastomosis and ileostomy. RESULTS: Since October 2008, taTME has been performed in 25 patients with ultralow rectal cancer. Mean tumor diameter was 4.5 cm (range 3-7 cm). Mean operative time was 220 minutes (range 120-315 minutes). Final staging was: ypT3N2 (1), ypT3N1 (2), ypT3N0 (4), ypT2(m)N1 (1), ypT2N1 (1), ypT2N0 (7), ypT1N0 (3), ypT0N0 (6). All tumors were located up to 1 cm from the dentate line at admission, before n-RCT. Postoperative complications included anastomotic leakage (4) and urinary retention (2). Mean hospital stay was 8 days (range 5-25 days). One patient underwent salvage abdominoperineal resection for positive margins. One local recurrence (4%) was observed at a mean follow-up of 26 months (range 1-74 months). One patient developed liver metastases at 25 months. All other patients are disease free. CONCLUSIONS: The modified TEM rectoscope provides optimal exposure of the anal canal, which can be resected together with the internal sphincter fibers. This technique may be a possible alternative to APR. A larger patient series, at least a 5-year follow-up, a randomized trial design, and functional data are required for more definitive conclusions. Transanal vs Laparoscopic Total Mesorectal Excision for Rectal Cancer: Comparison of the 2-Year Follow-up Francisco B de Lacy, MD, Maria Fernandez-Hevia, MD, Gabriel Dı´az del Gobbo, MD, Marta Jime´nez-Toscano, MD, PhD, Raquel Bravo, MD, Dulce Mombla´n, MD, Salvadora Delgado, MD, PhD, Antonio M Lacy, MD, PhD, FASCRS(Hon) Hospital Clinic of Barcelona, Barcelona, Spain INTRODUCTION: Transanal total mesorectal excision (TaTME) has recently gained popularity as an alternative for the treatment of rectal cancer. Reports published to date demonstrate that it is a safe and feasible technique, with comparable short-term oncologic outcomes. The aim of this study is to present the results of the 2-year follow-up analysis of TaTME patients. METHODS: Two-year outcomes were analyzed from 2 previously described cohorts of patients (37 prospectively registered patients
Scientific Forum Abstracts
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with middle or low rectal cancer treated by TaTME assisted by laparoscopy, compared with a retrospective cohort of consecutive patients treated by laparoscopic TME). Overall survival (OS), local and distant metastasis, disease-free survival (DFS), and recurrence time were included. Initial stage IV and T4 cases were excluded from the analysis. RESULTS: With a median follow-up of 29.7 months, general OS was 89.6%. No differences were found between laparoscopic and transanal groups in terms of OS (90.3% vs 88.9%, respectively; p¼0.638). There were no differences in local recurrence (9.7% vs 8.6%, respectively; p¼0.876) or distant recurrence (22.6% vs 11.4%, respectively; p¼0.225). The 2-year overall DFS rate was 80.3%, and no differences in DFS were found between groups (74.2% vs 85.7%, respectively; p¼0.240). Recurrence time for the laparoscopy group was 12.26.6 months, and for the transanal group was 11.97.3 months (p¼0.629). CONCLUSIONS: This analysis suggests that TaTME is an oncologically safe alternative for management of rectal cancer. Further studies with longer follow-up are warranted. Variability of Rectal Cancer Surgical Quality in the United States Sarah J Atkinson, MD, Nicholas H Osborne, MD, Bradley R Davis, MD, FACS, Daniel E Abbott, MD, FACS, Shimul A Shah, MD, MHCM, FACS, Ian M Paquette, MD, FACS University of Cincinnati, Cincinnati, OH; University of Michigan, Ann Arbor, MI INTRODUCTION: Positive resection margin in rectal cancer surgery is associated with increased tumor recurrence and decreased survival. We hypothesized that the rates of positive resection margin after surgery for rectal cancer vary substantially across hospitals in the US, even when controlling for case-mix differences. METHODS: Patients treated with oncologic resection for stage I-III rectal cancer were selected from the 1998-2010 National Cancer Database. Logistic regression was used to determine patient and tumor factors associated with positive margin (R1 or R2) resection. Hierarchical regression models were used to calculate risk-adjusted positive margin rates and hospital level variability in positive margin rates. Reliability adjustment using Empirical Bayes models was used to decrease the chance that hospital outcomes were observed due to random variation. RESULTS: A total of 126,188 patients were treated at 1,444 hospitals. The mean overall risk-adjusted positive margin rate was 6.9%. Hospitals were ranked based on their respective rates of margin positivity, and substantial variation in hospital performance was present. When case-mix and hospital volume differences were factored into the model, hospital variability in margin positivity rates increased by 15.2%, suggesting that variation in surgical quality exists. CONCLUSIONS: After rectal cancer resections, margin positivity rates vary substantially in the United States, even when adjusting for differences in case-mix and hospital volume. These results support standardization of surgical technique and pathologic assessment as part of a broader national quality improvement initiative.
Transanal Total Mesorectal Excision by Transanal Endoscopic Microsurgery as an Alternative to Abdominoperineal Resection for Rectal Cancer Emanuele Lezoche, MD, FACS, Hon. FASCRS, Andrea Balla, MD, Silvia Quaresima, MD, Giancarlo D’Ambrosio, MD, Mario Guerrieri, MD, Giovanni Lezoche, MD, Alessandro M Paganini, MD, PhD, FACS Sapienza University, Rome, Italy; Universita` Politecnica delle Marche, Ancona, Italy INTRODUCTION: Transanal total mesorectal excision (taTME) by transanal endoscopic microsurgery (TEM) with a modified rectoscope has been proposed as an alternative technique to abdominoperineal resection (APR) for ultralow advanced rectal cancer. METHODS: All patients underwent long-course neoadjuvant radiochemotherapy (n-RCT). The incision line by TEM starts at the dentate line. The modified rectoscope provides 360-degree dissection following the mesorectal plane. The abdominal step is performed by laparoscopy, with coloanal anastomosis and ileostomy. RESULTS: Since October 2008, taTME has been performed in 25 patients with ultralow rectal cancer. Mean tumor diameter was 4.5 cm (range 3-7 cm). Mean operative time was 220 minutes (range 120-315 minutes). Final staging was: ypT3N2 (1), ypT3N1 (2), ypT3N0 (4), ypT2(m)N1 (1), ypT2N1 (1), ypT2N0 (7), ypT1N0 (3), ypT0N0 (6). All tumors were located up to 1 cm from the dentate line at admission, before n-RCT. Postoperative complications included anastomotic leakage (4) and urinary retention (2). Mean hospital stay was 8 days (range 5-25 days). One patient underwent salvage abdominoperineal resection for positive margins. One local recurrence (4%) was observed at a mean follow-up of 26 months (range 1-74 months). One patient developed liver metastases at 25 months. All other patients are disease free. CONCLUSIONS: The modified TEM rectoscope provides optimal exposure of the anal canal, which can be resected together with the internal sphincter fibers. This technique may be a possible alternative to APR. A larger patient series, at least a 5-year follow-up, a randomized trial design, and functional data are required for more definitive conclusions. Transanal vs Laparoscopic Total Mesorectal Excision for Rectal Cancer: Comparison of the 2-Year Follow-up Francisco B de Lacy, MD, Maria Fernandez-Hevia, MD, Gabriel Dı´az del Gobbo, MD, Marta Jime´nez-Toscano, MD, PhD, Raquel Bravo, MD, Dulce Mombla´n, MD, Salvadora Delgado, MD, PhD, Antonio M Lacy, MD, PhD, FASCRS(Hon) Hospital Clinic of Barcelona, Barcelona, Spain INTRODUCTION: Transanal total mesorectal excision (TaTME) has recently gained popularity as an alternative for the treatment of rectal cancer. Reports published to date demonstrate that it is a safe and feasible technique, with comparable short-term oncologic outcomes. The aim of this study is to present the results of the 2-year follow-up analysis of TaTME patients. METHODS: Two-year outcomes were analyzed from 2 previously described cohorts of patients (37 prospectively registered patients
Scientific Forum Abstracts
S39
with middle or low rectal cancer treated by TaTME assisted by laparoscopy, compared with a retrospective cohort of consecutive patients treated by laparoscopic TME). Overall survival (OS), local and distant metastasis, disease-free survival (DFS), and recurrence time were included. Initial stage IV and T4 cases were excluded from the analysis. RESULTS: With a median follow-up of 29.7 months, general OS was 89.6%. No differences were found between laparoscopic and transanal groups in terms of OS (90.3% vs 88.9%, respectively; p¼0.638). There were no differences in local recurrence (9.7% vs 8.6%, respectively; p¼0.876) or distant recurrence (22.6% vs 11.4%, respectively; p¼0.225). The 2-year overall DFS rate was 80.3%, and no differences in DFS were found between groups (74.2% vs 85.7%, respectively; p¼0.240). Recurrence time for the laparoscopy group was 12.26.6 months, and for the transanal group was 11.97.3 months (p¼0.629). CONCLUSIONS: This analysis suggests that TaTME is an oncologically safe alternative for management of rectal cancer. Further studies with longer follow-up are warranted. Variability of Rectal Cancer Surgical Quality in the United States Sarah J Atkinson, MD, Nicholas H Osborne, MD, Bradley R Davis, MD, FACS, Daniel E Abbott, MD, FACS, Shimul A Shah, MD, MHCM, FACS, Ian M Paquette, MD, FACS University of Cincinnati, Cincinnati, OH; University of Michigan, Ann Arbor, MI INTRODUCTION: Positive resection margin in rectal cancer surgery is associated with increased tumor recurrence and decreased survival. We hypothesized that the rates of positive resection margin after surgery for rectal cancer vary substantially across hospitals in the US, even when controlling for case-mix differences. METHODS: Patients treated with oncologic resection for stage I-III rectal cancer were selected from the 1998-2010 National Cancer Database. Logistic regression was used to determine patient and tumor factors associated with positive margin (R1 or R2) resection. Hierarchical regression models were used to calculate risk-adjusted positive margin rates and hospital level variability in positive margin rates. Reliability adjustment using Empirical Bayes models was used to decrease the chance that hospital outcomes were observed due to random variation. RESULTS: A total of 126,188 patients were treated at 1,444 hospitals. The mean overall risk-adjusted positive margin rate was 6.9%. Hospitals were ranked based on their respective rates of margin positivity, and substantial variation in hospital performance was present. When case-mix and hospital volume differences were factored into the model, hospital variability in margin positivity rates increased by 15.2%, suggesting that variation in surgical quality exists. CONCLUSIONS: After rectal cancer resections, margin positivity rates vary substantially in the United States, even when adjusting for differences in case-mix and hospital volume. These results support standardization of surgical technique and pathologic assessment as part of a broader national quality improvement initiative.