Review
Outcomes following completion and salvage surgery for early rectal cancer: A systematic review

https://doi.org/10.1016/j.ejso.2017.10.212Get rights and content

Abstract

Objectives

To establish outcomes after completion and salvage surgery following local excision in literature published since 2005, to inform decision-making when offering local excision.

Background

Local excision of early rectal cancer aims to offer cure while maintaining quality of life through organ preservation. However, some patients will require radical surgery, prompted by unexpected poor pathology or local recurrence. Consistent definition and reporting of these scenarios is poor. We propose the term “salvage surgery” for recurrence after local excision and “completion surgery” for poor pathology.

Methods

Electronic databases were searched in February 2016. Studies since 2005 describing outcomes for radical surgery following local excision of rectal cancer were included. Pooled and average values were obtained.

Results

A total of 23 studies included 262 completion and 165 salvage operations. Most completion operations were done within 4 weeks; local recurrence rate was 5% and overall disease recurrence rate was 14%.

The majority of salvage operations for local recurrence were within 15 months of local excision, often following adjuvant treatment. Re-do local excision was used in 15%; APR was the most common radical procedure. Further local recurrence was uncommon (3%) but overall disease recurrence rate was 13%. Estimated 5-year survival was in the order of 50%.

Heterogeneity was high among the studies.

Conclusions

Patients undergoing local excision must be informed of risks and expected outcomes, but better data on completion and salvage surgery are required to achieve this.

Systematic review registration number

CRD42014014758.

Introduction

Four major goals exist in the treatment of a patient with rectal cancer: disease control, long-term survival, preservation of anal sphincter, urinary, and sexual functions, and maintenance or improvement in quality of life [1]. Historically, aside from improvements in neo-adjuvant treatment, surgical approaches mainly focused on radical oncological resection by either low anterior resection (LAR) or abdominoperineal excision (APE) even for early rectal cancer (ERC). More recently, local excision (LE) of ERC by either transanal endoscopic microsurgery (TEM) or transanal minimally-invasive surgery (TAMIS) has become an accepted treatment in selected patients, with the advantages of reduced post-operative morbidity and mortality, and less impairment of quality of life. The increase in LE has raised two particular issues. Firstly, current pre-operative staging is imperfect; histopathology may show cancers to be more advanced than anticipated and/or reveal unfavourable features, raising the question of whether and when a completion procedure should be undertaken. The second issue is how best to salvage the situation if local recurrence occurs. These two situations can be considered as ‘completion’ and ‘salvage’ surgery respectively.

However these terms are not consistently used in the current literature. We define ‘completion surgery’ as a procedure with curative intent undertaken on the basis of histopathology showing a more advanced cancer than anticipated. We use ‘salvage surgery’ for a surgical procedure with curative intent following the development of local recurrence. Some papers refer to completion surgery as ‘early salvage’; this is confusing as it does not sufficiently differentiate between the two different situations of a) performing more extensive surgery to remove the mesorectum and regional lymph nodes as part of the primary treatment strategy to reduce the risk of later recurrence, and b) dealing with local recurrence once it has occurred.

The literature on completion and salvage surgery is limited as these procedures are relatively rare; most series lack both a sufficient number of patients and adequate follow-up. Furthermore, historical data can be misleading due to different patient populations and poor definition. Our impression is that these techniques carry greater risk than is recognised in the literature, and therefore LE may be undertaken without adequate consideration of the potential consequences. As ERC and LE become more common, a good evidence base of outcomes is necessary to inform both surgeons and patients when deciding to proceed with further surgery. Our objective is to establish the outcomes after completion and salvage surgery in the recent literature to inform decision-making in this situation.

Section snippets

Methods

The review was registered with PROSPERO (number CRD42014014758) and published on the database on 4th November 2014.

Study selection

The PRISMA diagram is shown in Fig. 1. Only records providing specific outcome information for patients having completion and/or salvage surgery after LE of rectal cancer were included. A few studies included both completion and salvage surgery patients but only provided specific outcome information for the salvage surgery patients; completion surgery patients without outcome data in these studies were not included in this review.

In total, 23 cohort studies were included [3], [4], [5], [6], [7]

Completion surgery

Of the ten studies [4], [5], [6], [7], [10], [16], [17], [18], [19], [25] covering completion surgery, four [5], [6], [7], [25] looked specifically at completion surgery, although only two [5], [6] used this term; operations were otherwise referred to as early or immediate salvage, or just additional radical surgery.

Salvage surgery

Of the 15 studies covering salvage surgery, two [3], [24] focussed specifically on salvage surgery.

Discussion

Few studies involving completion surgery used this term. An important first step in generating usable data on outcomes after radical surgery following LE is international agreement about terminology. We propose the terms ‘completion’ and ‘salvage’ surgery. The Oxford group defined completion surgery as ‘surgery carried out after local excision to complete surgical treatment of the primary tumour. This is applied to patients with an inadequate or unclear resection margin following local

Conflicts of interest and source of funding

None declared.

Funding and support

Nil.

Author contribution

H Jones: study conception and design, analysis and interpretation of data, writing manuscript and final approval of version to be published.

C Cunningham: study conception and design, critical revision and final approval of version to be published.

G Nicholson: study conception and design, acquisition of data, drafting article and final approval of version to be published.

R Hompes: study conception and design, critical revision and final approval of version to be published.

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