Servicio de Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Hospital Universitario Donostia, Instituto Biodonostia, Spain.
Servicio de Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Hospital Universitario Donostia, Instituto Biodonostia, Spain.
Cir Esp (Engl Ed). 2021 Feb;99(2):89-107. doi: 10.1016/j.ciresp.2020.05.035. Epub 2020 Sep 29.
Local excision (LE) has arisen as an alternative to total mesorectal excision for the treatment of early rectal cancer. Despite a decreased morbidity, there are still concerns about LE outcomes. This systematic-review and meta-analysis design is based on the "PICO" process, aiming to answer to three questions related to LE as primary treatment for early-rectal cancer, the optimal method for LE, and the potential role for completion treatment in high-risk histology tumors and outcomes of salvage surgery. The results revealed that reported overall survival (OS) and disease-specific survival (DSS) were 71%-91.7% and 80%-94% for LE, in contrast to 92.3%-94.3% and 94.4%-97% for radical surgery. Additional analysis of National Database studies revealed lower OS with LE (HR: 1.26; 95%CI, 1.09-1.45) and DSS (HR: 1.19; 95%CI, 1.01-1.41) after LE. Furthermore, patients receiving LE were significantly more prone develop local recurrence (RR: 3.44, 95%CI, 2.50-4.74). Analysis of available transanal surgical platforms was performed, finding no significant differences among them but reduced local recurrence compared to traditional transanal LE (OR:0.24;95%CI, 0.15-0.4). Finally, we found poor survival outcomes for patients undergoing salvage surgery, favoring completion treatment (chemoradiotherapy or surgery) when high-risk histology is present. In conclusion, LE could be considered adequate provided a full-thickness specimen can be achieved that the patient is informed about risk for potential requirement of completion treatment. Early-rectal cancer cases should be discussed in a multidisciplinary team, and patient's preferences must be considered in the decision-making process.
局部切除术 (LE) 已成为治疗早期直肠癌的全直肠系膜切除术的替代方法。尽管发病率降低了，但仍存在对 LE 结果的担忧。本系统评价和荟萃分析设计基于“PICO”过程，旨在回答三个与 LE 作为早期直肠癌主要治疗方法、LE 的最佳方法以及高风险组织学肿瘤的完成治疗和挽救性手术结果的潜在作用相关的问题。结果表明，LE 报告的总生存率 (OS) 和疾病特异性生存率 (DSS) 分别为 71%-91.7%和 80%-94%，而根治性手术分别为 92.3%-94.3%和 94.4%-97%。对国家数据库研究的进一步分析显示，LE 后 OS（HR：1.26；95%CI，1.09-1.45）和 DSS（HR：1.19；95%CI，1.01-1.41）较低。此外，接受 LE 的患者发生局部复发的风险明显更高（RR：3.44，95%CI，2.50-4.74）。对可用的经肛门手术平台进行了分析，发现它们之间没有显著差异，但与传统经肛门 LE 相比，局部复发减少（OR：0.24；95%CI，0.15-0.4）。最后，我们发现接受挽救性手术的患者生存结果较差，当存在高风险组织学时，有利于完成治疗（放化疗或手术）。总之，如果能够获得全层标本并且患者了解潜在的完成治疗的风险，LE 可以被认为是足够的。早期直肠癌病例应在多学科团队中进行讨论，并且在决策过程中必须考虑患者的偏好。
