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Page 2 of 6 Levic-Souzani et al. Mini-invasive Surg 2018;2:25 I http://dx.doi.org/10.20517/2574-1225.2018.35

The best management for early rectal cancer is still controversial. In terms of oncological results, local
excision of early rectal cancer (pT1) by TEM has equivalent outcomes to radical resection [10,11,13,14] . Due to
abovementioned advantageous attributes, the use of TEM for early rectal cancer is now considered a vi-
able option in selected patients, and may be offered to patents with lesions pre-operatively staged as T1N0,
with tumor diameter < 4 cm involving less than 30% of the rectal wall circumference, and no histological
risk factors [16-20] . Preoperative staging with endoscopic rectal ultrasound (ERUS) and magnetic resonance
imaging (MRI) of rectal lesions aid in decision making of selection for local treatment or radical resection.
However, understaging is not uncommon [9,21-25] . Furthermore, unexpected malignancy is reported in 18%-
43% of preoperatively assumed benign lesions in the rectum [9,26-28] .

Early completion proctectomy (CP) is recommended in cases when the TEM specimen shows non-radical
resection, low tumor differentiation or lymphovascular invasion, because of the increased risk of recur-
rence and lymph node metastasis in such cases. Some concerns have been raised regarding early CP. There
may be increased morbidity due to two procedures being performed in the same area within a short period
of time. The healing and scar formation and mesorectal fibrosis from the previous TEM procedure may
disrupt the normal tissue planes and compromise the operative field. This may increase the difficulty dur-
ing dissection in CP, and result in higher perforation rates, poor resection quality, prolonged operative
time and higher conversion rates. The fibrotic scarring following TEM procedure may also contribute to
tissue retraction and binding of the previous tumor site to the pelvic floor, which may lead to an increased
abdominoperineal excision (APE) rate. We aim to review the available literature regarding controversial is-
sues with early completion proctectomy following TEM.

OVERALL MORBIDITY AND APE RATE
Overall morbidity following rectal cancer surgery is about 40%, regardless of approach (open or laparo-
[29]
scopic) . A concern with CP is that a previous operation in the rectum by TEM may influence surgical
dissection plans, resulting in an increased risk for local complications. Regarding morbidity rates following
CP, the results vary among studies, and interpretation is limited by small study samples and methodologi-
[30]
cal issues. In a study reported by Piessen et al. , 14 consecutive patients who underwent full thickness
TAE and subsequent radical resection, were matched and compared with 25 patients with primary radical
resection. There was no significant difference in overall morbidity (64.3% vs. 32%, P = 0.112). However, a
higher rate of surgical complications was shown in the TAE group (57.1% vs. 20%, P = 0.048). The frequency
of specific surgical site complications, including anastomotic leakage and pelvic abscess, was also higher in
the TAE group (42.8% vs. 8%, P = 0.032). The study cohort consisted of patients with preoperative chemo-
or radiation therapy (5/14 patients in the TAE group), and the defect in the rectal wall was left unsutured in
all patients, which may have contributed to the higher local compliactions. Although not fully investigated
yet, the non-sutured defect at the TEM site may weaken the rectal wall and result in higher risk of perfora-
tion during CP.

[31]
In contrast, Morino et al. didn’t find any difference in the incidence of complications. They compared
17 patients with laparoscopic total mesorectal excision (LTME) after TEM with 34 patients undergoing
primary TME and found that the results on rate of intraoperative complications and conversion to open
surgery did not differ significantly (5.9% vs. 8.8%, P = 0.854, and 5.9% vs. 5.9%, P = 0.528, respectively).
There was, however, a significantly longer operating time in the TEM group (206 min vs. 188 min, P = 0.025).
[32]
Although there were only 25 patients in each group, the study by Levic et al. is the largest comparative
study on early CP up to date. Twenty-five patients with early CP were matched and compared with 25 pa-
tients with primary TME. There was no difference in intra- or postoperative complications, operating time
or estimated blood loss between the two groups. Only a minority of the patients in both groups were oper-