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Comparative Study
. 2024 Sep 3;8(5):zrae103.
doi: 10.1093/bjsopen/zrae103.

Short-term outcomes after primary total mesorectal excision (TME) versus local excision followed by completion TME for early rectal cancer: population-based propensity-matched study

Annabel S van Lieshout  1   2 , Lisanne J H Smits  1   2 , Julie M L Sijmons  2   3   4 , Susan van Dieren  2   4 , Stefan E van Oostendorp  5 , Pieter J Tanis  4   6 , Jurriaan B Tuynman  1
Affiliations
Comparative Study

Short-term outcomes after primary total mesorectal excision (TME) versus local excision followed by completion TME for early rectal cancer: population-based propensity-matched study

Annabel S van Lieshout et al. BJS Open. .

Abstract

Background: Colorectal cancer screening programmes have led to a shift towards early-stage colorectal cancer, which, in selected cases, can be treated using local excision. However, local excision followed by completion total mesorectal excision (two-stage approach) may be associated with less favourable outcomes than primary total mesorectal excision (one-stage approach). The aim of this population study was to determine the distribution of treatment strategies for early rectal cancer in the Netherlands and to compare the short-term outcomes of primary total mesorectal excision with those of local excision followed by completion total mesorectal excision.

Methods: Short-term data for patients with cT1-2 N0xM0 rectal cancer who underwent local excision only, primary total mesorectal excision, or local excision followed by completion total mesorectal excision between 2012 and 2020 in the Netherlands were collected from the Dutch Colorectal Audit. Patients were categorized according to treatment groups and logistic regressions were performed after multiple imputation and propensity score matching. The primary outcome was the end-ostomy rate.

Results: From 2015 to 2020, the proportion for the two-stage approach increased from 22.3% to 43.9%. After matching, 1062 patients were included. The end-ostomy rate was 16.8% for the primary total mesorectal excision group versus 29.6% for the local excision followed by completion total mesorectal excision group (P < 0.001). The primary total mesorectal excision group had a higher re-intervention rate than the local excision followed by completion total mesorectal excision group (16.7% versus 11.8%; P = 0.048). No differences were observed with regard to complications, conversion, diverting ostomies, radical resections, readmissions, and death.

Conclusion: This study shows that, over time, cT1-2 rectal cancer has increasingly been treated using the two-stage approach. However, local excision followed by completion total mesorectal excision seems to be associated with an elevated end-ostomy rate. It is important that clinicians and patients are aware of this risk during shared decision-making.

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Figures

Fig. 1
Fig. 1
Flow chart of patient selection DICA, Dutch Institute for Clinical Auditing; TME, total mesorectal excision.
Fig. 2
Fig. 2
Number of surgical procedures for cT1–2 rectal cancer per year in the Netherlands TME, total mesorectal excision.
Fig. 3
Fig. 3
Number of surgical procedures for cT1–2 rectal cancer per year in the Netherlands relative to the national incidence (all stages, stages 2–4, and stage 1) TME, total mesorectal excision.
Fig. 4
Fig. 4
Distribution of different surgical procedures for cT1–2 rectal cancer over time: primary TME versus local excision followed by completion TME versus surgical local excision only TME, total mesorectal excision.
Fig. 5
Fig. 5
Distribution of the one-stage approach and the two-stage approach for cT1–2 rectal cancer over time TME, total mesorectal excision.
See this image and copyright information in PMC

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