title: Unexpected rectal cancer after TEM: outcome of completion surgery compared with primary TME.
abstract: BACKGROUND
  Transanal endoscopic microsurgery (TEM) has gained wide-spread acceptance as a safe and useful technique for the resection of rectal adenomas and selected T1 malignant lesions. If the lesion appears >T1 rectal cancer after resection with TEM, a completion TME resection is recommended. The aim of this study was to investigate the results of TME surgery after TEM for rectal cancer.
  
  
  METHODS
  In four tertiary referral hospitals for TEM, all patients with completion TME surgery after initial TEM were selected. All eligible patients who were treated with 5 × 5 Gy radiotherapy followed by TME surgery from the Dutch TME trial were selected as reference group. A multivariate logistic regression model was used to calculate odds ratio's (OR) for colostomies and for colo- and ileostomies combined. Local recurrence and survival rates were compared in hazard ratio's (HR) using the multivariate Cox proportional hazard model.
  
  
  RESULTS
  Fifty-nine patients were included in the TEM-COMPLETION group and 881 patients from the TME trial. In the TEM-COMPLETION group, 50.8% of the patients had a colostomy compared to 45.9% in the TME trial, OR 2.51 (p < 0.006). There is no significant difference when ileo- and colostomies are analyzed together. In the TEM-COMPLETION group, 10.2% developed a local recurrence compared to 5.2% in the TME trial, HR 6.8 (p < 0.0001).
  
  
  CONCLUSIONS
  Completion TME surgery after TEM for unexpected rectal adenocarcinoma results in more colostomies and higher local recurrence rates compared to one stage TME surgery preceded with preoperative 5 × 5 Gy radiotherapy. Pre-operative investigations must be optimized to distinguish malignant and benign lesions and prevent avoidable local recurrence and colostomies.
authors: Netherlands Cancer Institute, Surgery Department, The Netherlands. Electronic address: willem@vangijn.com.
authors: W
authors: W
authors: van Gijn
authors: V
authors: V
authors: Brehm
authors: E
authors: E
authors: de Graaf
authors: P A
authors: PA
authors: Neijenhuis
authors: L P S
authors: LP
authors: Stassen
authors: J W A
authors: JW
authors: Leijtens
authors: C J H
authors: CJ
authors: Van De Velde
authors: P G
authors: PG
authors: Doornebosch
mesh_terms: D000328:Adult; D000368:Aged; D001003:Anal Canal; D003125:Colostomy / Q000706:statistics & numerical data*; D019583:Dose Fractionation, Radiation; D016099:Endoscopy, Gastrointestinal / Q000009:adverse effects; D007172:Erectile Dysfunction / Q000209:etiology / Q000517:prevention & control; D005242:Fecal Incontinence / Q000209:etiology / Q000517:prevention & control; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007081:Ileostomy / Q000706:statistics & numerical data*; D016015:Logistic Models; D008297:Male; D008866:Microsurgery; D008875:Middle Aged; D015999:Multivariate Analysis; D009364:Neoplasm Recurrence, Local / Q000175:diagnosis* / Q000453:epidemiology / Q000401:mortality / Q000517:prevention & control; D009367:Neoplasm Staging; D009426:Netherlands / Q000453:epidemiology; D016017:Odds Ratio; D016016:Proportional Hazards Models; D018714:Radiotherapy, Adjuvant; D012004:Rectal Neoplasms / Q000175:diagnosis* / Q000453:epidemiology / Q000401:mortality / Q000601:surgery*; D016019:Survival Analysis; D016896:Treatment Outcome
keywords: Preoperative staging; Rectal cancer; TEM surgery; TME surgery