Introduction

Radical resection in the rectum is associated with significant morbidity and poses a mortality risk, particularly in elderly or comorbid patients. Early or T1 rectal cancer is often curable and can be managed with local endoscopic resection techniques with reduced morbidity and negligible mortality. To establish a pathway for appropriate treatment of these early lesions through the multidisciplinary team (MDT), an early rectal cancer working party (ERCWP) was formed to evaluate management trends and outcomes within our hospital network. The ERCWP was multi-speciality comprising of gastroenterologists, colorectal surgeons and radiation oncologists.

Aims & Methods

A retrospective review was performed across four institutions that make up our network to identify all patients with a new diagnosis of localised (T1-T4,N0,M0) rectal or recto-sigmoid cancer between January 2015 and August 2023. Patients with confirmed adenocarcinoma staged as T1N0M0 or T2N0M0 were included in the analysis. Available electronic medical records from the time of index resection and all encounters for the following 12 months were reviewed. Patients were excluded if their treatment was completed at an outside institution. Patient outcomes were stratified by location of tumour (rectum / recto-sigmoid) and mode of resection (Endoscopic resection, Local surgical excision or Radical surgical resection). Major adverse events included any one of the following: ostomy, deep incisional site infection, abscess, wound dehiscence, pneumonia, sepsis, septic shock, acute renal failure, deep venous thrombosis, pulmonary embolus, stroke/cerebrovascular accident, myocardial infarction, ventilator >48 hours, still in hospital >30 days, cardiac arrest, reoperation, readmission and/or mortality.

Results

A total of 111 localized (T1/T2,N0) and 153 locally advanced (T3/T4,N0) lesions were newly diagnosed during the study period. 95/111 patients with localized disease were included (M=62/95, 65.3% F=33/95, 34.7%). Mean age was 67.8 years in the endoscopy group and 67.0 years in the radical surgical resection group. Mortality was 2.2% in the group of patients who had surgery (1/46). There was no mortality in patients who received endoscopic resection. Major adverse events were recorded in 16/46 (34.8%) of patients who underwent surgery. There were no major adverse events in patients who received endoscopic resection. Mean length of stay was 1.47 days in patients who had endoscopic resection and 10.2 days in patients who had radical resection. Mean length of stay was prolonged where there was a treatment related major adverse event (14.8 days, mean difference 9.8 days, p=<0.001). 78.5% (51/65) of the cohort with T1 cancer was low risk (well or moderately well differentiated and no lymphovascular invasion). Of the 16 patients with T1 rectal cancer who underwent definitive surgery, 15 (93.8%) were suitable for cure by en-bloc endoscopic excision. Following establishment of the ERCWP in 2020, there have been no cases of radical resection in the rectum for T1 cancer. For T1 cancer in the rectum, major adverse events were 5/34 (14.7%) pre ERCWP formation and 1/13 (7.7%) post ERCWP formation (p=<0.001).

Conclusion

Surgery carries a high risk of morbidity in patients with rectal cancer. Endoscopic resection carries a favourable risk profile and is currently being underutilised. Formation of a local expert group focusing on outcomes in T1 cancer can reduce unwarranted variation and similar groups should be formed at local institutions to optimise patient outcomes.