P Terence Phang

Background: Total mesorectal excision is the standard of care for Stage-I rectal cancer. Despite major advances and increasing enthusiasm for modern endoscopic local excision (LE), uncertainty remains regarding its oncologic equivalence and safety relative to radical resection (RR).Methods: We performed a comprehensive search of major electronic databases, trial registries, and grey literature for randomized controlled trials (RCT) comparing LE versus RR with or without use of neo/adjuvant chemoradiotherapy. We used standard Cochrane Collaboration methodological procedures. Oncologic, surgical, and functional outcomes were sought and compared using a generic inverse variance and random-effects models, where appropriate.Results: Of eight potential studies, only three RCTs were complete and included in data synthesis with a combined total of 211 patients. Risk of bias was judged as unclear for oncologic outcomes across studies and high for surgical morbidity outcomes. Disease-free survival was comparable between LE versus RR (hazard ratio (HR) 1.48, (95% confidence interval (CI) 0.54 to 4.02; low-quality evidence, translating into 8.1% vs. 5.6% disease recurrence after LE and RR, respectively). Similarly, there was no difference between LE versus RR in cancer-related survival, local recurrence-free survival, or metastasis-free survival. There were no cases of 30-day mortality after any of the interventions. Risk of major postoperative complications was not significantly lower with LE (risk ratio 0.56, 95%CI 0.21 to 1.51; very low-quality evidence; corresponding to 5.2% for LE vs. 9.3% for RR). Very low-quality evidence suggested a non-significant trend for fewer minor postoperative complications after LE (risk ratio 0.53, 95% CI 0.28 to 1.03; very low-quality evidence; corresponding to 16.2% for LE vs. 30.6% for RR). One study reported 24% rate of definitive stoma only after RR. Data suggested shorter length of stay after LE. No objective data was available regarding sphincter function, quality of life or genitourinary function in any of the studies.Conclusion: Based on limited and low to very low-quality evidence, this review suggests an equal role for LE in terms of oncologic and operative outcomes in patients with early-stage rectal cancer. If further supported by more RCTs, LE has the potential to become the preferred approach in these patients.

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