title: Transanal endoscopic microsurgery for residual rectal cancer after neoadjuvant chemoradiation therapy is associated with significant immediate pain and hospital readmission rates.
abstract: BACKGROUND
  Transanal endoscopic microsurgery may represent appropriate diagnostic and therapeutic procedure in selected patients with distal rectal cancer following neoadjuvant chemoradiation. Even though this procedure has been associated with low rates of postoperative complications, patients undergoing neoadjuvant chemoradiation seem to be at increased risk for suture line dehiscence. In this setting, we compared the clinical outcomes of patients undergoing transanal endoscopic microsurgery with and without neoadjuvant chemoradiation.
  
  
  METHODS
  Thirty-six consecutive patients were treated by transanal endoscopic microsurgery at a single institution. Twenty-three patients underwent local excision after neoadjuvant chemoradiation therapy for rectal adenocarcinoma, and 13 patients underwent local excision without any neoadjuvant treatment for benign and malignant rectal tumors. Chemoradiation therapy included 50.4 to 54 Gy and 5-fluorouracil-based chemotherapy. All patients underwent transanal endoscopic microsurgery with primary closure of the rectal defect. Complications (immediate and late) and readmission rates were compared between groups.
  
  
  RESULTS
  Overall, median hospital stay was 2 days. Immediate (30-d) complication rate was 44% for grade II/III complications. Patients undergoing neoadjuvant chemoradiation therapy were more likely to develop grade II/III immediate complications (56% vs 23%; P = .05). Overall, the 30-day readmission rate was 30%. Wound dehiscence was significantly more frequent among patients undergoing neoadjuvant chemoradiation therapy (70% vs 23%; P = .03). Patients undergoing neoadjuvant chemoradiation therapy were at significantly higher risk of requiring readmission (43% vs 7%; P = .02).
  
  
  CONCLUSIONS
  Transanal local excision with the use of endoscopic microsurgical approach may result in significant postoperative morbidity, wound dehiscence, and readmission rates, in particular, because of rectal pain secondary to wound dehiscence. In this setting, the benefits of this minimally invasive approach either for diagnostic or therapeutic purposes become significantly restricted to highly selected patients that can potentially avoid a major operation but will still face a significantly morbid and painful procedure.
authors.affiliation: Angelita & Joaquim Gama Institute, São Paulo, Brazil. rodrigo.operez@gmail.com
authors.forename: Rodrigo Oliva
authors.initials: RO
authors.lastname: Perez
authors.forename: Angelita
authors.initials: A
authors.lastname: Habr-Gama
authors.forename: Guilherme Pagin
authors.initials: GP
authors.lastname: São Julião
authors.forename: Igor
authors.initials: I
authors.lastname: Proscurshim
authors.forename: Arceu
authors.initials: A
authors.lastname: Scanavini Neto
authors.forename: Joaquim
authors.initials: J
authors.lastname: Gama-Rodrigues
mesh_terms: D000970:Antineoplastic Agents / Q000627:therapeutic use*; D001938:Brazil / Q000453:epidemiology; D003082:Colectomy / Q000009:adverse effects* / Q000379:methods; D003113:Colonoscopy / Q000009:adverse effects* / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D009367:Neoplasm Staging; D010149:Postoperative Pain / Q000453:epidemiology / Q000209:etiology* / Q000628:therapy; D010359:Patient Readmission / Q000639:trends*; D011446:Prospective Studies; D018714:Radiotherapy, Adjuvant; D012004:Rectal Neoplasms / Q000188:drug therapy / Q000532:radiotherapy / Q000601:surgery*
chemical_list: D000970:Antineoplastic Agents