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Levic-Souzani et al. Mini-invasive Surg 2018;2:25 I http://dx.doi.org/10.20517/2574-1225.2018.35 Page 3 of 6

ated with laparoscopy, hence it is therefore not possible to say whether previous TEM had an influence on
conversion rates.

The fibrotic changes in the mesorectum and granulation tissue surrounding the previous TEM site is also
a concern following CP, because of potentially higher APE rates. Although recognized among surgeons,
[33]
there is still a lack of evidence on the subject in the literature. Hompes et al. reported a 14% APE rate in a
[30]
study consisting of 36 patients with CP. Piessen et al. didn’t find any difference in rate of sphincter saving
procedures performed. One of the matching factors was, however, the procedure type. Likewise, there was
[32]
no difference in the APE rate in the study by Levic et al. , although the control group was also matched
[31]
based on procedure type. Morino et al. performed matching based on gender, age, American Society of
Anesthesiologist (ASA) score, body mass index (BMI), tumor size, and tumor distance from the anal verge.
A significantly higher APE rate was observed in the CP group (41.2% vs. 11.7%, P = 0.028). Following mul-
tivariate analysis, previous TEM was the only independent predictor for APE (OR 4.13, 95%CI 1.09-15.55, P
[31]
[34]
= 0.046) . In a study by van Gijn et al. where 59 patients with CP were compared with 881 patients from
the TME-trial (with preoperative radiotherapy) the results showed a higher rate of colostomies in patients
with previous TEM (OR 2.51, 95%CI 1.30-4.86, P = 0.006). The TEM group had, however, a higher rate of
Hartmann procedures, but the same rate of APE.

PATHOLOGICAL FINDINGS
Another concern with CP after TEM may be pathologic findings and completeness of the mesorectal fascia
(MRF). The risk of poorer quality of the mesorectum may be due to the scar formation and mesorectal fi-
brosis from the previous TEM, as previously mentioned. In Morino’s study, where a higher rate of APE was
reported, no difference was seen in the integrity of the mesorectum, with preserved integrity in all patients
[32]
[31]
included in the study . Likewise, although there were incomplete pathological data on all patients, Levic et al.
didn’t find any difference in the number of patients with nearly complete or complete MRF (11 vs. 16 pa-
tients, P = 0.31). The perforation rate at or near the previous TEM site was, however, 20% in the CP group.
[30]
Piessen et al. reported major difference in completeness of the mesorectum. The MRF was complete in
only 4/25 with previous full-thickness TAE vs. 24/25 in the group with primary TME (P < 0.001). Further-
more, tearing of the rectal wall down to the mucosa occurred was more frequent in the group with CP (35.7%
vs. 0%, P = 0.009). Again, it is worth to mention that the defect after the full thickness excision was left un-
sutured in all patients, which may have had an influence on these figures. None of the studies comparing
[32]
CP with primary TME showed difference in the circumferential margin involvement rate (Levic et al. : 4%
[31]
[30]
in both groups; Morino et al. : 0% in both groups; Piessen et al. : 14% vs. 4%).
ONCOLOGICAL RESULTS
The reported high perforation rates during CP lead to worries regarding survival in these patients, as iatro-
genic rectal perforation is one of the most important risk factors for both local and distant recurrence and
impaired survival [35-37] . Results regarding long-term oncological results in patients with CP are, however,
[38]
very limited. Borschitz et al. ’s study on 21 patients with CP following TEM showed low rates of both lo-
cal recurrence and distant metastases (6%). The 5-year disease-free survival (DFS) was 75% in patients with
[33]
T1R0, and 93% in patients with T1/R1 or those with “high risk factors”. Similarly, Hompes et al. reported
good survival rates with 1-year DFS of 91% and 5-year DFS of 83%. Local recurrence occurred in 3% (1/36)
and distant metastases in 14% (5/36). However, only one study comparing CP with primary TME has re-
[32]
ported oncological results . There was no difference in rate of local recurrence between CP and primary
TME (0% vs. 8%, P = 0.49), or rate of distant metastases (4% vs. 12%, P = 0.26). Cumulative survival rates
were not reported. The median follow-up time was 25 and 19 months, respectively. The remaining two
studies comparing CP with primary TME only reported short-term results, and oncological data is there-
fore unfortunately lacking from these studies [30,31] .