Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands.
BJS Open. 2024 Sep 3;8(5). doi: 10.1093/bjsopen/zrae103.
BACKGROUND: Colorectal cancer screening programmes have led to a shift towards early-stage colorectal cancer, which, in selected cases, can be treated using local excision. However, local excision followed by completion total mesorectal excision (two-stage approach) may be associated with less favourable outcomes than primary total mesorectal excision (one-stage approach). The aim of this population study was to determine the distribution of treatment strategies for early rectal cancer in the Netherlands and to compare the short-term outcomes of primary total mesorectal excision with those of local excision followed by completion total mesorectal excision. METHODS: Short-term data for patients with cT1-2 N0xM0 rectal cancer who underwent local excision only, primary total mesorectal excision, or local excision followed by completion total mesorectal excision between 2012 and 2020 in the Netherlands were collected from the Dutch Colorectal Audit. Patients were categorized according to treatment groups and logistic regressions were performed after multiple imputation and propensity score matching. The primary outcome was the end-ostomy rate. RESULTS: From 2015 to 2020, the proportion for the two-stage approach increased from 22.3% to 43.9%. After matching, 1062 patients were included. The end-ostomy rate was 16.8% for the primary total mesorectal excision group versus 29.6% for the local excision followed by completion total mesorectal excision group (P < 0.001). The primary total mesorectal excision group had a higher re-intervention rate than the local excision followed by completion total mesorectal excision group (16.7% versus 11.8%; P = 0.048). No differences were observed with regard to complications, conversion, diverting ostomies, radical resections, readmissions, and death. CONCLUSION: This study shows that, over time, cT1-2 rectal cancer has increasingly been treated using the two-stage approach. However, local excision followed by completion total mesorectal excision seems to be associated with an elevated end-ostomy rate. It is important that clinicians and patients are aware of this risk during shared decision-making.
背景：结直肠癌筛查项目促使结直肠癌向早期阶段转移，在某些情况下，可以采用局部切除的方式进行治疗。然而，局部切除后行全直肠系膜切除术（两阶段方法）可能与原发性全直肠系膜切除术（一阶段方法）相比，结局较差。本项人群研究旨在确定荷兰早期直肠癌治疗策略的分布，并比较原发性全直肠系膜切除术与局部切除后行全直肠系膜切除术的短期结局。
方法：从荷兰结直肠审计中收集了 2012 年至 2020 年间荷兰接受单纯局部切除、原发性全直肠系膜切除术或局部切除后行全直肠系膜切除术的 cT1-2 N0xM0 直肠癌患者的短期数据。患者根据治疗组进行分类，并在多次插补和倾向评分匹配后进行逻辑回归。主要结局是造口率。
结果：从 2015 年至 2020 年，两阶段方法的比例从 22.3%增加到 43.9%。匹配后，纳入 1062 例患者。原发性全直肠系膜切除术组的造口率为 16.8%，局部切除后行全直肠系膜切除术组为 29.6%（P < 0.001）。原发性全直肠系膜切除术组的再次干预率高于局部切除后行全直肠系膜切除术组（16.7%对 11.8%；P = 0.048）。两组之间的并发症、转化率、转流造口、根治性切除术、再入院和死亡率均无差异。
结论：本研究表明，随着时间的推移，cT1-2 直肠癌症越来越多地采用两阶段方法进行治疗。然而，局部切除后行全直肠系膜切除术似乎与较高的造口率有关。在共同决策过程中，临床医生和患者都需要意识到这种风险。
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