Introduction
Transanal minimally invasive surgery (TAMIS) and endoscopic submucosal dissection (ESD) represent the two leading organ-preserving techniques for early rectal neoplasms. Despite growing adoption of both platforms, head-to-head comparative evidence remains scarce, methodologically heterogeneous, and largely derived from single-centre series. The optimal selection strategy based on lesion characteristics, perioperative outcomes, and oncological equivalence has yet to be defined in a balanced comparative cohort.
Aims & Methods
This retrospective multicentre study (2015–2023) compared technical, oncological, and safety outcomes between TAMIS and ESD in adults with rectal neoplasms ≥20 mm, high-grade dysplasia, or T1 adenocarcinoma (N0M0, <10 cm from the anal margin), excluding lesions with submucosal invasion ≥T2, active inflammatory bowel disease, or insufficient follow-up. Of 110 patients screened, 101 were eligible (53 TAMIS, 48 ESD). To address selection bias inherent to technique allocation, 1:1 propensity score matching (PSM) was applied incorporating age, sex, ASA class, lesion size, distance from the anal margin, Paris morphology, and preoperative histology, yielding 42 matched pairs. Primary endpoint was local recurrence at 24 months; secondary endpoints included R0 resection, en bloc resection, operative time, hospital stay, and complication rates (Clavien-Dindo classification). Recurrence-free survival was estimated by Kaplan–Meier analysis with log-rank testing.
Results
After PSM, groups were comparable in all baseline covariates (SMD <0.2). Median lesion size was 41±7 mm (ESD) and 46±12 mm (TAMIS). In the matched cohort, R0 resection rates were high and statistically equivalent (ESD 88% vs TAMIS 95%; OR 2.11, 95%CI 0.44–10.2; p=0.24), as were en bloc resection rates (ESD 90% vs TAMIS 93%; OR 1.55, 95%CI 0.38–6.2; p=0.69). TAMIS achieved significantly shorter operative time (97±14 vs 119±10 min; p<0.001), while ESD was associated with markedly reduced hospital stay (0.3±0.6 vs 2.2±2 days; p<0.001). Major complications were infrequent and comparable across groups: early haemorrhage (ESD 5% vs TAMIS 2%; p=1.0), perforation (ESD 5% vs TAMIS 10%; p=0.56), and readmission rates (ESD 0% vs TAMIS 7%; p=0.24). Local recurrence was low and equivalent between techniques (histological recurrence: ESD 7% vs TAMIS 5%; OR 1.54, 95%CI 0.2–9.7; log-rank p=0.25), with median follow-up of 33 months (ESD) and 65 months (TAMIS).
Conclusion
In this propensity score-matched multicenter analysis, TAMIS and ESD demonstrated equivalent oncological efficacy and safety profiles for selected early rectal neoplasms. ESD offered a significant advantage in hospital stay — supporting ambulatory or short-stay protocols — while TAMIS provided shorter operative time and technical advantages for more proximal lesions. These findings support an individualized, multidisciplinary approach guided by lesion location, morphology, and institutional expertise, rather than a universal algorithmic preference for either technique.
