Abstract: Objective:To investigate the clinical outcomes of transanal local excision (LE) and transabdominal radical surgery (RS) for T1 rectal cancer with distance from anal verge (DAV) ≤8.0 cm, and analyze the prognostic factors after nonpalliative resection of T1 rectal cancer with DAV ≤8.0 cm.
Methods:The retrospective cohort study was conducted. The clinicopathological data of 82 T1 rectal cancer patients with DAV ≤8.0 cm who were admitted to the Fujian Medical University Union Hospital between December 2000 and December 2014 were collected. Among 82 patients, 42 undergoing transanal LE and 40 undergoing transabdominal RS were allocated into the LS and RS groups, respectively. Fortytwo patients in the LE group received transabdominal RS or postoperative adjuvant radiochemotherapy if results of postoperative pathological examination showed high risk. Observation indicators: (1) comparisons of surgical and postoperative situations between the 2 groups; (2) followup situations; (3) prognostic factors analysis after nonpalliative resection of T1 rectal cancer with DAV ≤8.0 cm. Followup using outpatient examination and telephone interview was performed to detect the defecation and sexual functions, survival and tumor recurrence up to January 2017. Measurement data with normal distribution were represented as ±s, and comparisons between groups were evaluated with an independent sample t test. Comparisons of count data were analyzed using the chisquare test or Fisher exact probability. The Kaplan Meier method was used for calculating overall survival rate and tumorfree rate, and survival was analyzed using the Logrank test. Multivariate analysis was done using the COX regression model.
Results:(1) Comparisons of surgical and postoperative situations between the 2 groups: all the 82 patients underwent successful surgery. Of 42 patients in the LE group, 28 underwent single transanal LE, 2 underwent additional transabdominal RS within 1 month postoperatively, 6 underwent postoperative adjuvant radiochemotherapy, 5 underwent postoperative adjuvant radiotherapy and 1 underwent postoperative adjuvant chemotherapy (didn′t complete course due to poor tolerance). Forty patients in the RS group underwent transabdominal anterior resection of rectum or combined with abdominal perineal resection for rectal cancer. DAV, operation time, volume of intraoperative blood loss, time of postoperative gastrointestinal function recovery, cases with pulmonary infection and duration of postoperative hospital stay were (4.9±1.3)cm, (65±33)minutes, (11±7)mL, (1.2±0.4)days, 0, (2.2±0.9)days in the LE group and (6.7±1.9)cm, (256±35)minutes, (65± 47) mL, (2.4±0.8)days, 6, (6.9±1.1)days in the RS group, respectively, with statistically significant differences (t=4.882, 12.448, 3.553, 4.025, x²=6.797, t=10.367, P<0.05). Cases with intraperitoneal infection, wound infection, urinary tract infection, inflammatory intestinal obstruction, anastomotic fistula, chyle leakage, rectovaginal fistula and positive surgical margin were 0, 0, 0, 0, 0, 0, 0, 1 in the LE group and 1, 0, 0, 1, 0, 2, 1, 0 in the RS group, respectively, with no statistically significant differences between the 2 groups (x²=1.063, 1.063, 2.153, 1.063, P>0.05). All patients with complications were cured by conservative treatment. (2) Followup situations: of 82 patients, 67 were followed up for defecation function (37 in the LE group and 30 in the RS group), 40 were followed up for sexual function (25 in the LE group and 15 in the RS group)， 76 were followed up for survival. Followup time was 1-145 months, with a median time of 31 months. Cases with fecal incontinence and sexual dysfunction were respectively 0, 0 in the LE group and 4, 3 in the RS group, showing statistically significant differences (x²=5.247, 5.405, P<0.05). Cases with 5year local recurrence, 5year overall survival rate and 5year tumorfree survival rate were respectively 1, 94.1%, 91.0% in the LE group and 0, 87.6%, 87.6% in the RS group, showing no statistically significant differences (x²=0.833, 2.313, 0.849, P>0.05). (3) Prognostic factors analysis after nonpalliative resection of T1 rectal cancer with DAV ≤8.0 cm: results of multivariate analysis showed that age was an independent factor affecting prognosis of T1 rectal cancer patients with DAV ≤8.0 cm after nonpalliative resection (RR=1.254, 95% confidence interval: 1.055-1.491, P<0.05).
Conclusions: Transanal LE in treatment of T1 rectal cancer patients with DAV ≤ 8.0 cm is consistent with RS in local control and long term prognosis, and the protection of defecation and sexual functions in LE is superior to that in RS. Age is an independent factor affecting prognosis of T1 rectal cancer patients with DAV ≤8.0 cm after nonpalliative resection.