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Transanal endoscopic microsurgery for the treatment of rectal cancer: comparison of wound complication rates with and without neoadjuvant radiation therapy



Neoadjuvant therapy for rectal cancer has led to improved tumor downstaging and higher complete pathologic response rates. At the same time, the introduction of transanal endoscopic microsurgery (TEM) technique has renewed interest in local excision of rectal cancer. There has been concern that radiation may make the more radical local excision with TEM unsuitable. Our study compared morbidity rates and wound complication rates for patients undergoing TEM and local excision with and without neoadjuvant radiation to determine whether this could be accomplished safely.


Data for all patients undergoing TEM are prospectively entered into a database. This database was queried for patients with rectal cancer undergoing TEM from November 1997 to June 2007. Of 64 patients identified, 2 were excluded because of previous radiation to the pelvis.


The study enrolled 62 patients with a final pathologic diagnosis of rectal cancer: 43 treated using neoadjuvant therapy with radiation (XRT) and 19 patients treated with TEM alone. The patients in the XRT group were 67 years of age (range, 29–86 years) and included 13 women. The patients in the non-XRT group were 66 years of age (range, 40–89 years) and included 8 women. Neither group had any mortalities. The overall morbidity rate was 33% for the XRT group and 5.3% for the non-XRT group, and this difference was statistically significant (p < 0.05). The wound complication rates were 25.6% for the XRT group (11 patients) and 0% for the non-XRT group (p = 0.015). Nine patients in the XRT group (82%) had minor wound separations, and two patients (18%) had major wound separation. Ten patients with wound separations were treated as outpatients and administered long-term oral antibiotics. One patient required additional surgery (diverting stoma).


Not unexpectedly, the wound complication rate was higher in the XRT group. However, 82% of those wounds were minor, and 91% were treated without any additional surgery or intervention. Although a significant concern, wound complications do not prohibit TEM treatment after neoadjuvant treatment.

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  1. 1.

    Trial Swedish Rectal Cancer (1997) Improved survival with preoperative radiotherapy in respectable rectal cancer. New Engl J Med 336:980–987

  2. 2.

    Crane CH, Skibber JM, Birnbaum EH, Feig BW, Singh AK, Delclos ME, Lin ED, Fleshman JW, Thames HD, Kodner IJ, Lockett MA, Picus J, Phan T, Chandra A, Janjan NA, Read TE, Myerson RJ (2003) The addition of continuous infusion 5-FU to preoperative radiation therapy increases tumor response, leading to increased sphincter preservation in locally advanced rectal cancer. Int J Radiation Biol Phys 57:84–89

  3. 3.

    Sauer R, Becker H, Hohenberger W, Rodel C, Wittekind C, Fietkau R, Martus P, Tschmelitsch J, Hager E, Hess CF, Karstens JH, Liesrch T, Schmidberger H, Raab R (2004) Preoperative versus postoperative chemoradiation for rectal cancer. N Engl J Med 351:1731–1740

  4. 4.

    Habr-Gama A, De Souza PMSB, Ribeiro U, Nadalin W, Gansl R, De Souza Jr AHS, Campos FG, Gama-Rodriques J (1998) Low rectal cancer: impact on radiation and chemotherapy on surgical treatment. Dis Colon Rectum 41:1087–1096

  5. 5.

    Janjan NA, Khoo VS, Abbruzzese J, Pazdur R, Dubrow R, Cleary KR, Allen PK, Lynch PM, Blober G, Wolff R, Rich TA, Skibber J (1999) Tumor downstaging and sphincter preservation with preoperative chemoradiation in locally advanced rectal cancer: the M.D. Anderson Cancer Center experience. Int J Rad Oncol Biol Phys 44:1027–1038

  6. 6.

    Kim CJ, Yeatman TJ, Coppola D, Trotti A, Williams B, Barthel JS, Dinwoodie W, Karl RC, Marcet J (2001) Local excision of T2 and T3 rectal cancers after downstaging chemoradiation. Ann Surg 234:352–359

  7. 7.

    Mellgren A, Sirivongs P, Rothenberger DA, Madoff RD, Garcia-Aguilar J (2000) Is local excision adequate therapy for early rectal cancer? Dis Colon Rectum 43:1064–1071

  8. 8.

    Stipa F, Burza A, Lucandri G, Ferri M, Pigazzi A, Ziparo V, Casula G, Stipa S (2006) Outcomes for early rectal cancer managed with transanal endoscopic microsurgery. Surg Endos 20:541–545

  9. 9.

    Marks G, Mohiuddin M, Masoni L, Montori A (1992) High-dose preoperative radiation as the key to extending sphincter-preservation surgery for cancer of the distal rectum. Surg Oncol Clin North Am 1:71–83

  10. 10.

    Lezoche E, Guerrieri M, Paganini A, Felicottir F, Di Pietrantonj F (1996) Is transanal endoscopic microsurgery (TEM) a valid treatment for rectal tumors? Surg Endos 10:736–741

  11. 11.

    Marks JH, Kawun UB, Mohiuddin M, Marks G (2008) High-dose preoperative radiation/chemoradiation and full-thickness local excision for select rectal cancers. Ann Surg Oncol, under review

  12. 12.

    Marks G, Mohiuddin M, Masoni L, Montori A (1992) High-dose preoperative radiation therapy as the key to extending sphincter-preservation surgery for cancer of the distal rectum. Surg Oncol Clin North Am 1:71–86

  13. 13.

    Stone HB, Coleman N, Anscher MS, McBride WH (2003) Effects of radiation on normal tissue: consequences and mechanisms. Lancet Oncol 4:529–536

  14. 14.

    Minsky BD, Cohen AM, Kemeny N, Enker WE, Kelsen DP, Reichman B, Satlz L, Sigurdson ER, Frankel J (1992) Combined modality therapy of rectal cancer: decreased acute toxicity with the preoperative approach. J Clin Oncol 10:1218–1224

  15. 15.

    Marks G, Mohiuddin M, Masoni L, Pecchioli L (1990) High-dose preoperative radiation and full-thickness local excision: a new option for patients with select cancers of the rectum. Dis Colon Rectum 33:735–739

  16. 16.

    Buess G, Mentges B, Manncke K, Starlinger M, Becker HD (1992) Technique and results of transanal endoscopic microsurgery in early rectal cancer. Am J Surg 163:63–70

  17. 17.

    Duek SD, Issa N, Hershko D, Krausz MM (2008) Outcome of transanal endoscopic microsurgery and adjuvant radiotherapy in patients with T2 rectal cancer. Dis Colon Rectum 51:379–384

  18. 18.

    Kreissler-Haag D, Schuld J, Lindemann W, Konig J, Hilderbrandt U, Schilling M (2008) Complications after endoscopic microsurgical resection correlate with location of rectal neoplasms. Surg Endos 22:612–616

  19. 19.

    Cataldo PA, O’Brien S, Osler T (2005) Transanal endoscopic microsurgery: a prospective evaluation of functional outcomes. Dis Colon Rectum 48:1366–1371

  20. 20.

    Araki Y, Isomoto H, Shirouzu K (2003) Video-assisted gasless transanal endoscopic microsurgery: a review of 217 cases of rectal tumors over the past 10 years. Dig Surg 20:48–52

  21. 21.

    Guerrieri M, Feliciotti F, Baldarelli M, Zenobi P, De Sanctis A, Lezoche G, Lezoche E (2003) Sphincter-saving surgery in patients with rectal cancer treated by radiotherapy and transanal endoscopic microsurgery: 10 years’ experience. Digest Liver Dis 35:876–880

  22. 22.

    Lezoche E, Guerrieri M, Paganini AM, Baldarelli M, De Sanctis A, Lezoche G (2005) Long-term results in patients with T2–3 N0 distal rectal cancer undergoing radiotherapy before transanal endoscopic microsurgery. Br J Surg 92:1546–1552

  23. 23.

    Caricato M, Borzomati D, Ausania F, Tonini G, Rabitti C, Valeri S, Trodella L, Ripetti V, Coppola R (2006) Complementary use of local excision and transanal endoscopic microsurgery for rectal cancer after neoadjuvant chemoradiation. Surg Endosc 20:1203–1207

  24. 24.

    Lezoche E, Guerrieri M, Paganini AM, Feliciotti F (2002) Long-term results of patients with pT2 rectal cancer treated with radiotherapy and transanal endoscopic microsurgery. World J Surg 26:1170–1174

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Correspondence to John H. Marks.

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Marks, J.H., Valsdottir, E.B., DeNittis, A. et al. Transanal endoscopic microsurgery for the treatment of rectal cancer: comparison of wound complication rates with and without neoadjuvant radiation therapy. Surg Endosc 23, 1081–1087 (2009).

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  • Neoadjuvant chemoradiation
  • Rectal cancer
  • Transanal endoscopic microsurgery