Does Total Neoadjuvant Therapy Impact Surgical Precision in Total Mesorectal Excision? A Nationwide Survey of the Experiences of Expert Surgeons

Abstract

Background: The treatment of locally advanced rectal cancer (LARC) has steadily progressed over the past four decades, with recent focus shifting towards total neoadjuvant therapy (TNT). This survey aims to elucidate the perceived surgical challenges faced by Austrian colorectal surgeons performing total mesorectal excision (TME), focusing on the increased complexity and surgical difficulty introduced by intensified treatment regimens.

Methods: A comprehensive survey was conducted among Austrian colorectal surgeons to explore various aspects of managing and performing TME following TNT. The survey included questions on the general management of LARC within their institutions and utilized a five-point Likert scale to assess the respondents' perceptions and experiences regarding surgical precision and post-operative morbidity associated with TNT.

Results: A total of 31 surgeons (54% response rate) completed the survey. Regarding multidisciplinary therapy preferences, 56% of respondents preferred conventional neoadjuvant therapy regimens, with 32% favoring chemoradiotherapy and 24% opting for short-course radiotherapy, while 31% chose TNT. The majority of respondents (65%) reported quality differences in tissue dissection during TME following TNT, with 57% experiencing difficulties in identifying tissue planes and 47% noting increased tissue fragility. Increased bleeding was reported by 32% of respondents. In cases of regrowth after a watch-and-wait approach, 64% observed quality changes in tissue dissection, and 47% noted tissue fragility.

Conclusions: The survey results indicate that TNT impairs surgical precision due to changes in tissue quality and challenges in identifying surgical planes. Given the critical importance of surgical precision in achieving low local recurrence rates in mid-to-low LARC, these challenges could significantly impact patient outcomes. Further prospective studies are required to elucidate the extent of these effects.

Keywords: TME; TNT; neoadjuvant chemoradiotherapy; rectal cancer; surgical precision; total mesorectal excision; total neoadjuvant therapy.

Figure 1

Phases of development in locally advanced rectal cancer treatment over the past 40 years. Key studies and local recurrence rates (y-axis) are shown. CRT = Chemoradiotherapy, EORTC = European Organisation for Research and Treatment of Cancer, MRC = Medical Research Council, RT = Radiotherapy, TME = total mesorectal excision, TNT = total neoadjuvant therapy, and ** = Trans-Tasman Radiation Oncology Group.

Figure 2

Item I.2: How many primary rectal cancer cases are presented in your hospital per year?

Figure 3

Item I.5: The following neoadjuvant therapy concepts for patients with advanced rectal cancer are offered at surveyed hospitals. Percentages are calculated relative to the total number of participants (n = 31), reflecting the proportion of respondents selecting each option in a multiple-choice format.

Figure 4

Item II.2 and III.2: When do you generally operate on patients with residual tumors after CNT vs. TNT? Multiple answers possible. CNT = conventional neoadjuvant therapy, TNT = total neoadjuvant therapy.

Figure 5

Item II.3 and III.3: What surgical technique did you prefer for your most recent CNT vs. TNT patients? CNT = conventional neoadjuvant therapy, TNT = total neoadjuvant therapy.

Figure 6

Item II.4 and III.4: Do you routinely create a protective stoma after CNT vs. TNT? CNT = conventional neoadjuvant therapy, TNT = total neoadjuvant therapy.

Figure 7

Item IV.1: What experiences have you had during TME after TNT? TME = total mesorectal excision, TNT = total neoadjuvant therapy.

Figure 8

Item IV.2: Have you noticed any significant changes in TME quality (according to Mercury I–III) after TNT? TME = total mesorectal excision, TNT = total neoadjuvant therapy.

Figure 9

Item IV.3: What experiences have you had regarding anastomotic insufficiency after TNT? TNT = total neoadjuvant therapy.

Figure 10

Item IV.4: Have you observed increased wound healing issues after abdominoperineal excision following TNT? TNT = total neoadjuvant therapy.

Figure 11

Item V.1–V.4: Personal experiences during a rectal resection after TNT in the regrowth scenario under watch-and-wait strategy. TNT = total neoadjuvant therapy.

Figure 12

Item IV.1–IV.4: Subgroup analysis of personal experiences during a rectal resection after total neoadjuvant therapy (TNT) (Scenario 1). The figure compares responses from surgeons in high-volume (left) and low-volume (right) centers regarding their personal experiences during rectal resection after TNT without complete clinical remission (Scenario 1, N = 28). Responses are presented as percentages across five Likert scale categories: “Strongly Disagree”, “Disagree”, “Neutral”, “Agree”, and “Strongly Agree”. Observed trends highlight variations in perceptions of challenges such as difficulty in surgical plane identification, increased bleeding, tissue fragility, and the quality of total mesorectal excision (TME) following TNT compared to conventional neoadjuvant therapy (CNT).

Figure 13

Item V.1–V.4: Subgroup analysis of personal experiences during a rectal resection after total neoadjuvant therapy (TNT) (Scenario 2). The figure compares responses from surgeons in high-volume (left) and low-volume (right) centers regarding their personal experiences during rectal resection after regrowth under a watch-and-wait strategy (Scenario 2, N = 17). Responses are presented as percentages across five Likert scale categories: “Strongly Disagree”, “Disagree”, “Neutral”, “Agree”, and “Strongly Agree”. Trends highlight variations in perceived challenges such as tissue fragility, increased bleeding, anastomotic insufficiencies, and overall surgical quality following TNT.