Operative Standards for Cancer Surgery by Program American College of Surgeons Clinical Research;Katz Matthew;

Author:Program, American College of Surgeons Clinical Research;Katz, Matthew;
Language: eng
Format: epub
Publisher: Wolters Kluwer

Key Question: Local Excision

In patients with early rectal cancer, does local excision affect recurrence, survival, and quality of life relative to proctectomy?

INTRODUCTION

Like so many issues in the management of rectal cancer, the most appropriate treatment of early stage tumors continues to be controversial185–187 and sometimes even contentious. For patients with early rectal cancer, both local excision and proctectomy are accepted treatments, but the precise indications and the relative trade-offs for any given patient may be difficult to evaluate.188,189 On the one hand, proctectomy assures a wide surgical margin and provides for excision and histopathologic examination of the mesorectal lymph nodes.190 Patients may be staged with confidence and receive adjuvant therapy as appropriate. Further, the risk of local recurrence should be exceedingly small in the setting of early stage disease, thereby simplifying posttreatment follow-up and surveillance.191

However, proctectomy is a major abdominal operation with potential for perioperative morbidity or need for temporary or permanent intestinal stoma. There is an appreciable risk for anastomotic leak or adverse functional outcomes that may transform the temporary fecal diversion into a lifelong ostomy. Quality of life can be affected with urinary, sexual, and bowel dysfunction.157 Laparoscopic and robotic approaches along with advanced sphincter-saving techniques have reduced the short-term impact of surgery and have decreased the rate of permanent colostomies; however, it seems inappropriate to describe a proctectomy as “minimally invasive,” irrespective of the access approach chosen for radical excision, considering the incidence of potential functional impairments.

In comparison with proctectomy, local excision is associated with a lower incidence of major complications and less short- and long-term disability.192 Newer transanal endoscopic surgical approaches to local excision (e.g., TEM or TAMIS with the use of conventional laparoscopic instrumentation through a transanal access port) have made TAE far more precise with less fragmentation of the surgical specimen and have decreased the rate of local recurrence relative to standard TAE.85,133–140 The rectal reservoir is preserved, yielding a superior functional outcome. However, one must acknowledge the very real risk of occult positive lymph nodes, resulting in undertreatment, because of both incomplete resection and missed opportunity for referral for adjuvant therapy.193,194

An alternative approach to decrease the risk or impact of undertreatment is to incorporate adjuvant or neoadjuvant chemoradiotherapy when tumors are identified as high-risk early cancers.184,195–199 However, the oncologic efficacy of this approach remains uncertain, and adjuvant and/or neoadjuvant therapy may substantially increase the complication rate associated with local excision as well as impair functional outcome.200–202 Furthermore, the risk of local recurrence is higher with local excision than with proctectomy, resulting in the need for more frequent and potentially costly follow-up.145,203

Based on these concerns, we sought to address the following overarching question: In patients with early rectal cancer, does local excision affect recurrence, survival, and quality of life relative to proctectomy? A systematic review of the published literature was performed with the aim of answering the following specific questions:

1. Compared with patients who undergo radical excision of rectal adenocarcinoma, do patients who undergo local excision experience fewer postoperative complications?

2. Compared with the resected

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