Minimally invasive approaches for early-stage rectal cancer: A comparative analysis from the TriNetX network

Minimally invasive approaches to manage early-stage rectal cancer have become popular, offering effective treatment with reduced morbidity. Among them, transanal endoluminal surgery (TES) and endoscopic submucosal dissection (ESD) are widely utilized, yet their comparative outcomes from large-scale real-world data remain limited.

We conducted a retrospective cohort study using the TriNetX United States Collaborative Network. Adults with T1 rectal cancer undergoing either TES or ESD were identified. Propensity score matching was performed on demographic and clinical variables. Primary outcomes included all-cause mortality, procedural complications, healthcare utilization, and local recurrence over a 10-year follow-up.

A total of 5138 patients were included within the two cohorts (2569 matched pairs). The TES cohort was associated with significantly lower mortality at 1 year (2.3 % vs. 10.1 %, HR = 0.21, p < 0.001) and 10 years (11.6 % vs. 27.1 %, HR = 0.41, p < 0.001). Procedural pain and thromboembolic events were significantly reduced across all time points in this cohort. Hospital readmissions at 1 month (3.4 % vs. 19.6 %, p < 0.001) and need for reintervention at 1 year (10.5 % vs. 17.0 %, p < 0.001) were also substantially lower. Rates of bleeding, infection, and perforation were comparable between both cohorts, while anal stenosis occurred less frequently in the TES cohort. Local recurrence was low (<10) for both cohorts.

TES was associated with lower all-cause mortality, fewer complications, and lower healthcare utilization when compared to ESD. These findings support patient-centered procedure selection based on lesion characteristics and institutional expertise while reflecting evidence-based guidelines for managing early-stage rectal cancer.