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Organ Preserving or Radical Surgery? A Systematic Review and Meta-Analysis of Transanal Local Excision Versus Total
Mahmood Al Dhaheri1, Reem Mubarak1, Ali Toffaha1
1Colorectal Surgery Unit, Hamad Medical Corporation, Doha, Qatar.
Background:
Total mesorectal excision (TME) is the standard surgical treatment for rectal cancer. Transanal local excision (TLE) after neoadjuvant chemoradiotherapy (nCRT) is an organ-preserving option, avoiding morbidity of TME. This study compared TLE versus TME following nCRT.
Methods:
We searched Medline, PubMed, Embase, Web of Science, Scopus, Cochrane databases, Google Scholar, and CINHAL to 30 April 2025. Eligible studies were adults with nonmetastatic mid or low rectal cancer treated with nCRT followed by TLE or TME. Outcomes included local recurrence, disease free survival (DFS), overall survival (OS), and postoperative complications. Risk of bias was assessed using Cochrane RoB 2 for randomized trials and Newcastle-Ottawa Scale (NOS) for cohorts.
Results:
Nineteen studies were included. TLE was associated with higher local recurrence in cohorts (RR = 1.823; 95% CI = 1.222-2.720; p = 0.003), but no difference in RCTs (RR = 1.248; 95% CI = 0.618-2.518; p = 0.537). DFS (HR = 1.121; p = 0.174) and OS (HR = 1.032; p = 0.830) did not differ. Postoperative morbidity was lower after TLE (RR = 0.429; p = 0.005).
Conclusion:
Strengths include robust search, study quality and number of patients, while heterogeneity in nCRT protocol, follow up, and complication reporting are limitations. Higher recurrence in TLE in cohorts but not in RCTs suggests safety of TLE when strict selection criteria are applied.
Registration:
PROSPERO CRD420251076513.
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