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. 2024 Oct;40(5):451-458.
doi: 10.3393/ac.2023.00899.0128. Epub 2024 Sep 19.

The impact of short-course total neoadjuvant therapy, long-course chemoradiotherapy, and upfront surgery on the technical difficulty of total mesorectal excision: an observational study with an intraoperative perspective

Cheryl Xi-Zi Chong  1 , Frederick H Koh  1 , Hui-Lin Tan  1 , Sharmini Su Sivarajah  1 , Jia-Lin Ng  1 , Leonard Ming-Li Ho  1 , Darius Kang-Lie Aw  1 , Wen-Hsin Koo  2 , Shuting Han  2 , Si-Lin Koo  2 , Connie Siew-Poh Yip  3 , Fu-Qiang Wang  3 , Fung-Joon Foo  1 , Winson Jianhong Tan  1
Affiliations

The impact of short-course total neoadjuvant therapy, long-course chemoradiotherapy, and upfront surgery on the technical difficulty of total mesorectal excision: an observational study with an intraoperative perspective

Cheryl Xi-Zi Chong et al. Ann Coloproctol. 2024 Oct.

Abstract

Purpose: Total neoadjuvant therapy (TNT) is becoming the standard of care for locally advanced rectal cancer. However, surgery is deferred for months after completion, which may lead to fibrosis and increased surgical difficulty. The aim of this study was to assess whether TNT (TNT-RAPIDO) is associated with increased difficulty of total mesorectal excision (TME) compared with long-course chemoradiotherapy (LCRT) and upfront surgery.

Methods: Twelve laparoscopic videos of low anterior resection with TME for rectal cancer were prospectively collected from January 2020 to October 2021, with 4 videos in each arm. Seven colorectal surgeons assessed the videos independently, graded the difficulty of TME using a visual analog scale and attempted to identify which category the videos belonged to.

Results: The median age was 67 years, and 10 patients were male. The median interval to surgery from radiotherapy was 13 weeks in the LCRT group and 24 weeks in the TNT-RAPIDO group. There was no significant difference in the visual analog scale for difficulty in TME between the 3 groups (LCRT, 3.2; TNT-RAPIDO, 4.6; upfront, 4.1; P=0.12). A subgroup analysis showed similar difficulty between groups (LCRT 3.2 vs. TNT-RAPIDO 4.6, P=0.05; TNT-RAPIDO 4.6 vs. upfront 4.1, P=0.54). During video assessments, surgeons correctly identified the prior treatment modality in 42% of the cases. TNT-RAPIDO videos had the highest recognition rate (71%), significantly outperforming both LCRT (29%) and upfront surgery (25%, P=0.01).

Conclusion: TNT does not appear to increase the surgical difficulty of TME.

Keywords: Minimally invasive surgical procedures; Neoadjuvant therapy; Radiotherapy; Rectal neoplasms; Surgical difficulty.

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Conflict of interest statement

Conflict of interest

Frederick H. Koh is an Editorial Board member of Annals of Coloproctology, but was not involved in the reviewing or decision process of this manuscript. No other potential conflict of interest relevant to this article was reported.

Figures

Fig. 1.
Fig. 1.
The RAPIDO (Rectal Cancer and Preoperative Induction Therapy Followed by Dedicated Operation) protocol. SCRT, short-course radiotherapy; CAPOX, capecitabine and oxaliplatin; FOLFOX, fluorouracil, leucovorin, and oxaliplatin; TME, total mesorectal excision.
See this image and copyright information in PMC

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