title: Completion surgery following transanal endoscopic microsurgery: assessment of quality and short- and long-term outcome.
abstract: OBJECTIVE
  Patients with unfavourable pathology after transanal endoscopic microsurgery (TEM) should be offered completion surgery (CS) if appropriate. The aim of this retrospective cohort study was to assess the short-term outcome and long-term oncological results of CS and identify factors compromising the quality of resection specimens.
  
  
  METHODS
  Data were retrieved and analysed on patients who underwent CS from a comprehensive national TEM database (1992-2008) and the institutional prospective database from the Oxford University Hospitals (2008-2011).
  
  
  RESULTS
  There were 36 patients eligible for analysis. Postoperative complications occurred in 19 and were minor (grade I-II) in 13 and major (grade III-V) in six patients. The quality of the resected specimen was graded as good in 23 (64%), moderate in six (16.6%) and poor in seven (19.4%). Full-thickness excision by TEM (P = 0.03), an interval to CS greater than 7 weeks (P = 0.05) and distally located lesions (P = 0.04) were associated with increased risk for an inferior surgical specimen. Overall survival after CS was 91% at 1 year and 83% at 5 years. Patients with a 'good' TME specimen had significantly improved disease-free survival compared with patients with an 'inferior' specimen (100 vs 51%, P = 0.001).
  
  
  CONCLUSIONS
  Patients having full-thickness TEM excision, distally placed lesions and a long interval (> 7 weeks) to CS were likely to have an inferior TME specimen. The results confirm that CS after TEM does not negatively influence local recurrence and survival, but the reduced disease-free survival in patients with an inferior specimen is of concern.
authors.affiliation: Department of Colorectal Surgery, Oxford University Hospitals, Oxford, UK.
authors.forename: R
authors.initials: R
authors.lastname: Hompes
authors.forename: R
authors.initials: R
authors.lastname: McDonald
authors.forename: C
authors.initials: C
authors.lastname: Buskens
authors.forename: I
authors.initials: I
authors.lastname: Lindsey
authors.forename: N
authors.initials: N
authors.lastname: Armitage
authors.forename: J
authors.initials: J
authors.lastname: Hill
authors.forename: A
authors.initials: A
authors.lastname: Scott
authors.forename: N J
authors.initials: NJ
authors.lastname: Mortensen
authors.forename: C
authors.initials: C
authors.lastname: Cunningham
mesh_terms: D000230:Adenocarcinoma / Q000473:pathology* / Q000556:secondary / Q000601:surgery*; D000236:Adenoma / Q000473:pathology* / Q000601:surgery*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016063:Blood Loss, Surgical; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D008207:Lymphatic Metastasis; D008297:Male; D008866:Microsurgery / Q000009:adverse effects; D008875:Middle Aged; D018365:Neoplasm, Residual; D017063:Outcome Assessment, Health Care; D011183:Postoperative Complications; D011351:Proctoscopy; D012004:Rectal Neoplasms / Q000473:pathology* / Q000601:surgery*; D012007:Rectum / Q000473:pathology; D012189:Retrospective Studies; D015996:Survival Rate; D013997:Time Factors; D000267:Tissue Adhesions / Q000209:etiology
keywords: Cancer; completion surgery; rectum; recurrence; transanal endoscopic microsurgery (TEM)