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Page 4 of 6 Levic-Souzani et al. Mini-invasive Surg 2018;2:25 I http://dx.doi.org/10.20517/2574-1225.2018.35

WHEN TO PERFORM EARLY COMPLETION SURGERY
Whether the time between TEM and CP as an influence on outcomes is not known. The precise definition
of “early” and the time frame in which CP should be performed is unclear. Most studies report outcomes
[32]
after CP perform surgery within 6-8 weeks of TEM. Levic et al. defined “early” as CP within 12 weeks of
[39]
TEM. The median time to CP was 37 days with a range between 14 and 90 days. Similarly, Issa et al. had
[30]
[34]
a median time of 47 days to CP (range 32-70) and Piessen et al. 37 days (range 7-120). van Gijn et al.
reported longer interval of 15 weeks to the completion of TME, due to logistic reasons, but the decision of
CP was made immediately after the TEM results. In Morino’s study only patients with laparoscopic TME
[40]
[31]
within 8 weeks of TEM were included, with a median of 40 days . Hahnloser et al. had even shorter
criteria, and performed CP following TAE within 30 days, with median time of 7 days. So far only a few
[33]
studies have reported outcomes based on the time frame to CP. Hompes et al. found that poor quality
specimen was more frequent after an interval from TEM to CP of more than 7 weeks. The median time to
[31]
CP was 2 months with range between 0.5 to 8.7 months. However, Morino et al. didn’t find any differ-
ence in outcomes among patients operated within 30 days of TEM or more than 30 days after TEM.

FUTURE ASPECTS
Minimal invasive surgery has gained an increasing interest, especially in the field of rectal surgery. The
transanal approach of rectal dissection is gaining wider use and acceptance, and the first randomized trial
[41]
comparing taTME with laparoscopic TME is currently ongoing . The advantages of trans-anal TME
(taTME) include better visualization and possibility of approaching the lesion from below. This may have
benefits for patients in need for CP following TEM. Approaching the lesion from below may limit the
traction on the scarred tissue and thereby possibly reducing the risk of perforation and other surgical site
[42]
complications. So far, only one study has reported outcomes of patients with CP by taTME. Letarte et al.
reported results on 41 patients with CP following TEM, of which 11 were operated by taTME and 30 with
conventional TME. The patients with taTME had significantly less intraoperative blood loss (205 mL vs.
365 mL, P = 0.04). More interestingly, there was lower rate of conversion to open surgery (9.1% vs. 57%, P <
0.001) and higher sphincter preserving rates (100% vs. 50%, P = 0.01) despite of the significantly lower dis-
tance of tumor from the anal verge in the taTME group.

CONCLUSION
Completion proctectomy following TEM appears safe. Nevertheless, there seems to be an increased risk
for intraoperative rectal perforation, which the operating surgeon needs to be aware of. The possible higher
incidence of APE following TEM needs to be investigated in larger studies. The drawback in the current
literature is the small series reporting outcome of CP following TEM. The published studies on the subject
have different methodological approaches, and limited number of patients, which increases the risk of type
II error. In order to further investigate whether there is a higher risk of APE and morbidity (particularly
rectal perforation, which may influence survival) it is necessary to conduct more studies with higher num-
ber of patients, especially those comparing CP with primary TME.

DECLARATIONS
Authors’ contributions
Substantial contribution to conception and design, and acquisition of data, and analysis and interpretation
of data: Levic-Souzani K, Bulut O
Drafting the article and revising it critically for important intellectual content: Levic-Souzani K, Bulut O
Giving the final approval of the version to be submitted and any revised version: Levic-Souzani K, Bulut O

Availability of data and materials
Not applicable.