Anastomotic leakage after side-to-end anastomosis for rectal cancer: does leakage location matter?

AIM

To assess outcome according to location of anastomotic leakage (AL) after side-to-end stapler or manual low colorectal or coloanal anastomosis following laparoscopic total mesorectal excision (TME) for rectal cancer.

METHODS

All patients presenting with symptomatic or asymptomatic AL after TME and side-to-end low anastomosis for rectal cancer performed from 2005 to 2014 were identified from our prospective database. CT-scans with contrast enema were reviewed to assess location of AL origin.

RESULTS

Among 279 patients who underwent TME with side-to-end anastomosis from 2005 to 2014, 70 patients presented with AL and were included: 43 (61%) patients with AL on the circular anastomosis (CAL) were compared to 27 (39%) with AL on the transverse stapling line of the colonic stump (TAL). CAL and TAL were associated with similar rates of symptomatic AL (63% versus 48%, respectively; p=0.339), severe postoperative morbidity rate (33% versus 18%; p=0.313), and long-term outcomes, including definitive stoma rate (10 versus 11%; p=0.622), and major low anterior resection syndrome rate (56% vs 57%; p=0.961).

CONCLUSION

Our study showed that whatever the location of AL on a side-to-end low colorectal or coloanal anastomosis after TME for cancer, both short and long-term outcomes are similar. This article is protected by copyright. All rights reserved.

European Hernia Society guidelines on prevention and treatment of parastomal hernias

BACKGROUND

International guidelines on the prevention and treatment of parastomal hernias are lacking. The European Hernia Society therefore implemented a Clinical Practice Guideline development project.

METHODS

The guidelines development group consisted of general, hernia and colorectal surgeons, a biostatistician and a biologist, from 14 European countries. These guidelines conformed to the AGREE II standards and the GRADE methodology. The databases of MEDLINE, CINAHL, CENTRAL and the gray literature through OpenGrey were searched. Quality assessment was performed using Scottish Intercollegiate Guidelines Network checklists. The guidelines were presented at the 38th European Hernia Society Congress and each key question was evaluated in a consensus voting of congress participants.

RESULTS

End colostomy is associated with a higher incidence of parastomal hernia, compared to other types of stomas. Clinical examination is necessary for the diagnosis of parastomal hernia, whereas computed tomography scan or ultrasonography may be performed in cases of diagnostic uncertainty. Currently available classifications are not validated; however, we suggest the use of the European Hernia Society classification for uniform research reporting. There is insufficient evidence on the policy of watchful waiting, the route and location of stoma construction, and the size of the aperture. The use of a prophylactic synthetic non-absorbable mesh upon construction of an end colostomy is strongly recommended. No such recommendation can be made for other types of stomas at present. It is strongly recommended to avoid performing a suture repair for elective parastomal hernia. So far, there is no sufficient comparative evidence on specific techniques, open or laparoscopic surgery and specific mesh types. However, a mesh without a hole is suggested in preference to a keyhole mesh when laparoscopic repair is performed.

CONCLUSION

An evidence-based approach to the diagnosis and management of parastomal hernias reveals the lack of evidence on several topics, which need to be addressed by multicenter trials. Parastomal hernia prevention using a prophylactic mesh for end colostomies reduces parastomal herniation. Clinical outcomes should be audited and adverse events must be reported.

Circumferential margin involvement after total mesorectal excision for mid or low rectal cancer: are all R1 resections equal?

AIM

Our aim was to assess the prognostic influence of the circumferential resection margin (CRM) exact value after total mesorectal excision for mid or low rectal cancer.

METHODS

All patients (n = 321) who underwent total mesorectal excision from 2005 to 2013 were identified from a prospective database, including 49 (15%) who presented with a CRM ≤ 1 mm. Four groups were defined: group 1, CRM = 0 mm (n = 21); group 2, 0 < CRM ≤ 0.4 mm (n = 13); group 3, 0.4 < CRM ≤ 1 mm (n = 15); group 4, CRM > 1 mm (n = 272).

RESULTS

After a mean follow-up of 42 ± 26 months, locoregional recurrence rates were 8/21 (38%) in group 1, 3/13 (23%) in group 2, 0/12 (0%) in group 3 and 26/272 (10%) in group 4 (P < 0.001), leading to significantly impaired 3-year locoregional recurrence-free survival in group 1 (57% ± 13%) and group 2 (56% ± 15%) compared to group 3 (85% ± 10%, vs group 1, P = 0.021, vs group 2, P = 0.049) and to group 4 (89% ± 2%, vs group 1, P < 0.001, vs group 2, P < 0.001). In multivariate Cox analysis, a CRM ≤ 0.4 mm was identified as an independent factor impairing both locoregional recurrence-free survival (OR 3.14, 95% CI 1.53-6.46; P = 0.002) and disease-free survival (OR 2.15, 95% CI 1.28-3.63; P = 0.004).

CONCLUSION

Our study suggests that the prognosis after mid or low rectal cancer surgery was worse with a CRM ≤ 0.4 mm. The prognosis was similar in patients with a CRM > 0.4 mm or ≤ 1 mm and patients with an R0 resection.

Postoperative course of laparoscopic subtotal colectomy is affected by prolonged preoperative anti-TNF therapy in patients with acute colitis complicating inflammatory bowel disease

PURPOSE

The aim of medical treatment of severe acute colitis (SAC) complicating inflammatory bowel disease (IBD) is to avoid surgery, but in 20 to 50% of the cases, colectomy remains necessary. This study aimed to determine the impact of the different lines of medical therapy (i.e., steroids, anti-TNF, or ciclosporin) on postoperative course after laparoscopic subtotal colectomy for SAC complicating IBD.

METHODS

All the patients who underwent laparoscopic subtotal colectomy for SAC were included and divided into two groups: those who presented with postoperative morbidity (group A) and those with an uneventful postoperative course (group B). Preoperative physical, endoscopic and radiological data, and medical treatments were compared between groups.

RESULTS

From 2006 to 2015, 65 consecutive patients (32 males, median age = 35 [17-87] years) operated for SAC were included. Postoperative morbidity occurred in 19 patients (29%, group A) and was mainly represented by surgical morbidity (n = 15), including ileus (n = 9), stoma-related complications (n = 5), and intra-abdominal abscess (n = 4). Lichtiger score, endoscopic and radiological evaluations were similar between groups. Patients with morbidity had more frequently presented two previous episodes of SAC (26%) than those without (7%, p = 0.04). Duration of anti-TNF treatment was more frequently longer than 2 months in group A (67%) than that in group B (14%, p = 0.04). No significant differences between groups were noted regarding other preoperative medical treatments and number of lines therapy.

CONCLUSION

This study suggests that postoperative course after laparoscopic subtotal colectomy for SAC is affected by prolonged preoperative anti-TNF therapy, and in the case of recurrent SAC.

Peritoneal perforation is less a complication than an expected event during transanal endoscopic microsurgery: experience from 194 consecutive cases

BACKGROUND

Indications for transanal endoscopic microsurgery (TEM) have been extended to technically challenging tumors, which may be associated with an increased risk of peritoneal perforation (PP). The aim of the present study was to investigate the occurrence, management and outcome of PP in patients having TEM.

METHODS

All the patients who had TEM for rectal adenoma or adenocarcinoma in our unit were included. Patients in whom PP occurred (Group A) were compared to those without PP (Group B).

RESULTS

From 2007 to 2015, 194 TEM (116 men, median age 66 [range 21-100] years) were divided into Groups A (n = 28, 14%) and B (n = 166). The latter group included four patients, in whom a laparoscopy did not confirm suspicion of PP made during TEM. In 2 of 28 patients (7%), the diagnosis of PP was made postoperatively during reoperation for peritonitis. For the 26 other patients (93%), routine exploratory laparoscopy was performed with suture of the peritoneal defect on the pouch of Douglas in 24 cases and a rectal suture alone in 2 cases. Independent predictive factors for PP were: distance from the anal verge >10 cm (OR = 3.6), circumferential tumor (OR = 3.0) and anterior location (OR = 2.7). Hospital stay was significantly longer in Group A (7.5 [3-31] days) than in Group B (4 [1-38] days; p < 0.0001), whereas there was no significant difference regarding postoperative morbidity and recurrence rate.

CONCLUSIONS

Our results suggested that PP is not a very rare event during TEM, especially in anterior, circumferential and/or high rectal tumors. Laparoscopic treatment of PP is feasible and safe. The occurrence of PP is not associated with poor oncologic results.

Ileal Pouch-Anal Anastomosis for Dysplasia or Cancer Complicating Inflammatory Bowel Disease: Is Total Mesorectal Excision Always Mandatory? An Analysis of 36 Consecutive Patients

BACKGROUND AND AIMS

The extent of lymph node harvesting during surgery for colorectal neoplasm [dysplasia and/or cancer] complicating inflammatory bowel disease [IBD] is a matter of debate. This study aimed to assess the risk of invasive rectal cancer in patients undergoing ileal pouch-anal anastomosis [IPAA] for colonic neoplasm complicating IBD, and thus to clarify whether a systematic total mesorectal excision [TME] should be systematically performed, or not, in those patients.

METHODS

From 1998 to 2015, all patients who underwent IPAA for colorectal neoplasm complicating IBD were included. Patients with preoperatively known rectal cancer were excluded. Pathological results were compared with preoperative endoscopic results.

RESULTS

A totalof 36 patients [mean age 49 ± 14 years], comprising 10 women [31%] and 26 men [69%], underwent IPAA for colorectal neoplasm complicating IBD, with [n = 8; 22%] or without [n = 28; 78%] TME. Rectal cancer rate in pathological specimens was 0% [0/20] in patients with preoperatively known neoplasm only limited to the colon, 0% [0/8] among patients with preoperative rectal low-grade dysplasia, and 62% [5/8] among patients with preoperatively rectal high-grade dysplasia.

CONCLUSIONS

These results do not support systematic TME during IPAA for colonic neoplasm complicating IBD. Considering its association with postoperative sexual disorder, TME should be discussed only on a case-by-case basis.

Risk factors for prolonged postoperative ileus after laparoscopic sphincter-saving total mesorectal excision for rectal cancer: an analysis of 428 consecutive patients

BACKGROUND

Prolonged postoperative ileus (PPOI) is a common complication after colorectal resection but data regarding PPOI risk factors after laparoscopic rectal cancer surgery is lacking. This study aimed to identify risk factors for PPOI after laparoscopic sphincter-saving total mesorectal excision (TME) for cancer.

METHODS

All patients who underwent a laparoscopic sphincter-saving TME for cancer from 2005 to 2014 were identified from our prospective database. PPOI was defined as abdominal distension, nausea, and/or vomiting, requiring a nasogastric tube insertion, during the postoperative period.

RESULTS

Among 428 consecutive patients, 65 patients (15%) presented with POI. In multivariate analysis, male gender (Odds Ratio (OR) 2.3 [1.1-4.5]; p = 0.026, age >70 years (OR: 2.0 [1.1-4.0]; p = 0.037)], conversion to open approach (OR 4.9 [1.5-15.4]; p = 0.007), and intra-abdominal surgical site infection (OR 3.8 [1.9-7.5]; p < 0.001) were identified as independent risk factor for PPOI. PPOI risk was 5% in patients without any risk factor but raised to 11, 28, and 54% in patients with 1, 2, or ≥3 risk factors, respectively (p < 0.001).

CONCLUSION

PPOI is observed in 15% of the patients after laparoscopic sphincter-saving surgery for rectal cancer. We identified four independent factors for PPOI in multivariate analysis: male, gender, age >70, conversion to open approach, and intra-abdominal surgical site infection, leading to the construction of a simple and pragmatic predictive score. This score might help the surgeon to assess patient at risk of PPOI.

Is abdominal CT useful for the management of patients with severe acute colitis complicating inflammatory bowel disease? A study in 54 consecutive patients

AIM

To evaluate the contribution of CT for the management of patients with severe acute exacerbation of colitis (SAC) complicating inflammatory bowel disease (IBD); in particular, its contribution to surgical decision making.

METHOD

All patients who were admitted to our institution for SAC complicating IBD were divided into two groups: group A (those who received surgical treatment); and group B (those who received medical treatment). Admission CT results were compared between groups.

RESULTS

From 2006 to 2015, 54 patients [26 male; median age 39 (17-71) years] presenting with SAC were placed in either group A (n = 41; 76%) or group B (n = 13; 24%). Surgical patients in group A more frequently had altered general status (50 vs 17%; P = 0.01). Physical examination, Lichtiger score, endoscopic findings and laboratory results were similar between the groups. There was no significant difference in CT data between the groups with respect to extent of the colitis (pan-colitis in 54 and 69%, respectively, P = 0.35), median colonic thickness [10 (4-16) vs 8 (6-11) mm, P = 0.15], target enhancement (88 vs 77%, P = 0.38) and occurrence of toxic megacolon (2 vs 0%).

CONCLUSION

Admission CT is not helpful in surgical decision making in SAC.

Management of rectal cancer: the 2016 French guidelines

AIM

Rectal cancer is a malignant disease requiring multidisciplinary management. In view of the increasing number of studies published over the past decade, a comprehensive update is required to draw recommendations for clinical practice mandated by the French Research Group of Rectal Cancer Surgery and the French National Coloproctology Society.

METHOD

Seven questions summarizing the treatment of rectal cancer were selected. A search for evidence in the literature from January 2004 to December 2015 was performed. A drafting committee and a large group of expert reviewers contributed to validate the statements.

RESULTS

Recommendations include the indications for neoadjuvant therapy, the quality criteria for surgical resection, the management of postoperative disordered function, the role of local excision in early rectal cancer, the place of conservative strategies after neoadjuvant treatment, the management of synchronous liver metastases and the indications for adjuvant therapy. A level of evidence was assigned to each statement.

CONCLUSION

The current clinical practice guidelines are useful for the treatment of rectal cancer. Some statements require a higher level of evidence due to a lack of studies.

Anastomotic stenosis after coloanal, colorectal and ileoanal anastomosis: what is the best management?

AIM

To assess the results of treatment for colorectal (CRA), coloanal (CAA) or ileal pouch-anal (IPAA) anastomotic stenosis (AS).

METHOD

All patients operated on for AS from 1995 to 2014 were included. Success was defined as the absence of an additional surgical procedure for AS during 12 months after the last procedure and the absence of a stoma at the end of follow-up.

RESULTS

Fifty consecutive patients presenting with AS after CRA (n = 16, 32%), CAA (n = 18, 36%) or IPAA (n = 16, 32%), performed for colorectal cancer (n = 28, 56%), familial adenomatous polyposis (n = 5, 10%), inflammatory bowel disease (n = 8, 16%), diverticulitis (n = 4, 8%), benign colorectal neoplasia (n = 3, 6%) or other (n = 2, 4%) underwent a total of 99 procedures including digital (n = 14, 14%), instrumental (n = 38, 38%) or endoscopic dilatation (n = 5, 5%), transanal AS stricturoplasty (n = 9, 10%), transanal circular stapler resection (n = 11, 11%) or transabdominal redo-anastomosis (n = 22, 22%). Overall the per-procedure success rate was 53% (52/99). Success rates were 36% (5/14) for digital dilatation, 40% (15/38) for instrumental dilatation, 20% (1/5) for endoscopic dilatation, 64% (7/11) for circular stapler resection, 89% (8/9) for stricturoplasty and 73% (16/22) for transabdominal redo-anastomosis. After a mean follow-up of 46 months, 42/50 (84%) patients had treatment that was considered successful. Multivariate analysis identified redo-anastomosis [OR = 5.1 (95% CI: 1.4-18.7), P = 0.003] as the only independent prognostic factor for success.

CONCLUSION

AS should be managed according to a step-up strategy. Conservative procedures are associated with acceptable success rates. If these fail, transabdominal redo-anastomosis is associated with the highest probability of success.

Oncological impact of anastomotic leakage after laparoscopic mesorectal excision

BACKGROUND

The effect of anastomotic leakage on oncological outcomes after total mesorectal excision (TME) is controversial. This study aimed to assess the influence of symptomatic and asymptomatic anastomotic leakage on oncological outcomes after laparoscopic TME.

METHODS

All patients who underwent restorative laparoscopic TME for rectal adenocarcinoma with curative intent from 2005 to 2014 were identified from an institutional database. Asymptomatic anastomotic leakage was defined by CT performed systematically 4-8 weeks after rectal surgery, with no relevant clinical symptoms or laboratory examination findings during the postoperative course.

RESULTS

Of a total of 428 patients, anastomotic leakage was observed in 120 (28·0 per cent) (50 asymptomatic, 70 symptomatic). After a mean follow-up of 40 months, local recurrence was observed in 36 patients (8·4 per cent). Multivariable Cox regression identified three independent risk factors for reduced local recurrence-free survival (LRFS): symptomatic anastomotic leakage (odds ratio (OR) 2·13, 95 per cent c.i. 1·29 to 3·50; P = 0·003), positive resection margin (R1) (OR 2·41, 1·40 to 4·16; P = 0·001) and pT3-4 category (OR 1·77, 1·08 to 2·90; P = 0·022). Patients with no risk factor for reduced LRFS had an estimated 5-year LRFS rate of 87·7(s.d. 3·2) per cent, whereas the rate dropped to 75·3(4·3) per cent with one risk factor, 67(7) per cent with two risk factors, and 14(13) per cent with three risk factors (P < 0·001). Asymptomatic anastomotic leakage was not significantly associated with LRFS in multivariable analysis.

CONCLUSION

Symptomatic anastomotic leakage is a risk factor for disease recurrence in patients with rectal adenocarcinoma.

Colonic prolapse after intersphincteric resection for very low rectal cancer: a report of 12 cases

BACKGROUND

There are no published data concerning management of patients with exteriorized colonic prolapse (CP) after intersphincteric rectal resection (ISR) and side-to-end coloanal manual anastomosis (CAA) for very low rectal cancer. The aim of the present study was to report our experience in 12 consecutive cases of CP following ISR with CAA.

METHODS

From 2006 to 2014, all patients with very low rectal cancer who developed CP after ISR and CAA were reviewed. Demographic and surgical data, prolapse symptoms and treatment were recorded. Postoperative morbidity, functional outcomes and results after prolapse surgery were recorded.

RESULTS

Twelve out of 143 patients (8 %) who underwent ISR with side-to-end CAA for low rectal cancer presented CP: 7/107 ISR (7 %) with partial resection of the internal anal sphincter (IAS) and 5/36 ISR (14 %) with subtotal or total resection of the IAS (NS). CP was diagnosed after a median of 6 months (range 2-72 months) after ISR. All patients with CP suffered from pain and fecal incontinence. Median Wexner fecal incontinence score before surgery was 16.5 (range 12-20). Three patients refused reoperation. Nine patients underwent transanal surgery with prolapse resection (including colonic stump and side-to-end anastomosis) and new end-to-end CAA (with posterior myorraphy in 4 cases). After a median follow-up of 30 months (range 8-87 months), 3/9 patients (33 %) had CP recurrence: One with very poor function was treated by abdominoperineal resection and definitive stoma. The 2 others were successfully reoperated on transanally. Median Wexner fecal incontinence score after CP surgery was 9 (range 0-20). No CP recurrence was noted for the 6 other patients, and function improved in all cases. Thus, at the end of follow-up, 8/9 patients (89 %) had no recurrence after surgery.

CONCLUSIONS

We believe surgery must be attempted in these patients who develop CP after ISR with CAA for very low rectal cancer in order to improve function and symptoms. A transanal approach with CP resection and new end-to-end anastomosis appeared to be safe and effective. Larger studies are needed to confirm our results.

Is it time to rethink the rule of total mesorectal excision? A prospective radiological and pathological study in 49 consecutive patients with mid-rectal cancer

AIM

Total mesorectal excision (TME) after neoadjuvant chemoradiotherapy is the standard treatment for T3-T4 and/or N+ mid-rectal tumours, regardless of the exact tumour level. This leads to optimal oncological results but possible impaired functional results. Reducing rectal excision could reduce the functional drawbacks. This study prospectively assessed the risk of N+ or other mesorectal tumour deposit (OTD) below the tumour level by magnetic resonance imaging (MRI) performed after chemoradiotherapy and pathological examination of the TME specimen.

METHOD

Consecutive patients with mid-rectal cancer who underwent TME after chemoradiotherapy were included. A prospective evaluation by postchemoradiotherapy MRI and pathological examination was performed to assess the location of N+ nodes and/or OTDs.

RESULTS

Of 49 consecutive patients, 27 (55%) presented with nodes on postchemoradiotherapy MRI. However, only 12 nodes (size 2-4 mm) in 9 patients (18%) were under the tumour level. On pathological examination, 717 total lymph nodes were found, with 37 N+ and 22 OTD. According to the tumour level: (i) above tumour level, 21/453 nodes were N+ and 6 OTD; (ii) at tumour level, 16/166 nodes were N+ and 15 OTD; (iii) below tumour level, 0/98 nodes (0%) was N+ and only 1 OTD (2%) was noted at 2 cm below tumour level.

CONCLUSION

After chemoradiotherapy, N+ and/or OTD located under the level of the rectal cancer seems to be a very rare event. A postchemoradiotherapy MRI could help detect such patients. For others patients, conservation of the lower rectum with only a subtotal mesorectal excision could possibly improve function.

Effect of appendicectomy on colonic inflammation and neoplasia in experimental ulcerative colitis

Background

Ulcerative colitis (UC) promotes cancer, and can be ameliorated by early appendicectomy for appendicitis. The aim of the study was to explore the effect of appendicectomy on colitis and colonic neoplasia in an animal model of colitis and a cohort of patients with UC.

Methods

Five-week old IL10/Nox1DKO mice with nascent colitis and 8-week-old IL10/Nox1DKO mice with established colitis underwent appendicectomy (for experimental appendicitis or no appendicitis) or sham laparotomy. The severity and extent of colitis was assessed by histopathological examination, and a clinical disease activity score was given. From a cohort of consecutive patients with UC who underwent colectomy, the prevalence of appendicectomy and pathological findings were collected from two institutional databases.

Results

Appendicectomy for appendicitis ameliorated experimental colitis in the mice; the effect was more pronounced in the 5-week-old animals. Appendicectomy in the no-appendicitis group was associated with an increased rate of colonic high-grade dysplasia (HGD) or cancer compared with rates in sham and appendicitis groups (13 of 20 versus 0 of 20 and 0 of 20 respectively; P &lt; 0·001). Fifteen of 232 patients who underwent colectomy for UC had previously had an appendicectomy, and nine of these had colonic cancer or HGD. Thirty (13·8 per cent) of 217 patients with the appendix in situ had colonic neoplastic lesions. Multivariable analysis showed that previous appendicectomy was associated with colorectal neoplasia (odds ratio 16·88, 95 per cent c.i. 3·32 to 112·69).

Conclusion

Appendicectomy for experimental appendicitis ameliorated colitis. The risk of colorectal neoplasia appeared to increase following appendicectomy without induced appendicitis in a mouse model of colitis, and in patients with UC who had undergone appendicectomy.

Three-stage Laparoscopic Ileal Pouch-anal Anastomosis Is the Best Approach for High-risk Patients with Inflammatory Bowel Disease: An Analysis of 185 Consecutive Patients

BACKGROUND

There are very few studies and no consensus concerning the choice between two- and three-stage ileal pouch-anal anastomosis [IPAA] in inflammatory bowel diseases [IBD]. This study aimed to compare operative results between both surgical procedures.

METHODS

Only patients who underwent a laparoscopic IPAA for IBD were included. They were divided into two groups: two-stage [IPAA and stoma closure] [Group A] and three-stage IPAA [subtotal colectomy, IPAA, stoma closure] [Group B].

RESULTS

From 2000 to 2015, 185 patients (107 men, median age of 42 [range, 15-78] years) were divided into Groups A [n = 82] and B [n = 103]. Patients in Group B were younger than in Group A (39 [15-78] vs 43 [16-74] years; p = 0.019), presented more frequently with Crohn's disease [16% vs 5%; p < 0.04], and were more frequently operated in emergency for acute colitis [37% vs 1%; p < 0.0001]. Cumulative operative time and length of stay were significantly longer in Group B (580 [300-900] min, and 19 [13-60] days) than in Group A (290 [145-490] min and 10 [7-47] days; p < 0.0001). Cumulative postoperative morbidity, delay for stoma closure, and function were similar between the two groups. Long-term morbidity was similar between Group A [13%] and Group B [21%; p = 0.18].

CONCLUSIONS

Our study suggested that postoperative morbidity was similar between two- and three-stage laparoscopic IPAA. It suggested that the three-stage procedure is probably safer for high-risk patients [ie in acute colitis].

Is the benefit of laparoscopy maintained in elderly patients undergoing rectal cancer resection? An analysis of 446 consecutive patients

BACKGROUND

Several studies showed that age is significantly associated with impaired outcomes after open colorectal surgery. However, very few data exist on laparoscopic rectal cancer surgery in elderly patients. The aim of this study was to assess operative results of laparoscopic rectal cancer surgery according to age.

METHODS

From 2005 to 2014, 446 consecutive patients who underwent laparoscopic rectal cancer resection were identified from a prospective database. Five groups were defined: age <45 (n = 44), 45-54 (n = 80), 55-64 (n = 166), 65-74 (n = 95) and ≥75 years (n = 61).

RESULTS

Elderly patients presented significantly higher ASA score (p = 0.004), higher Charlson comorbidity index (p < 0.0001) and more frequent cardiovascular, pulmonary (p < 0.0001) and neurological (p = 0.03) comorbidities. Overall postoperative morbidity rate was similar between groups (34-35-37-43-43 %, p = 0.70). Medical morbidity slightly increased with age (14-9-14-19-26 %, p = 0.06), but there was no significant difference regarding clinical anastomotic leakage, surgical morbidity, major morbidity (Dindo ≥3), cardiopulmonary complications and length of hospital stay. In multivariate analysis, age was not an independent factor for postoperative morbidity, unlike ASA score ≥3 (p = 0.039), neoadjuvant radiotherapy/chemoradiotherapy (p = 0.034) and operative time ≥240 min (p = 0.013).

CONCLUSIONS

This study showed that laparoscopic rectal cancer resection might safely be performed irrespective of age.

Distal intramural and tumor spread in the mesorectum after neoadjuvant radiochemotherapy in rectal cancer: about 124 consecutive patients

This observational prospective study aimed to assess the distribution of intramural and mesorectal tumor spread in mid/low rectal cancer after neoadjuvant radiochemotherapy. Distribution of mesorectal metastatic lymph nodes (MLNs) and mesorectal extranodal cancer tissue (EX), according to the tumor location, were analyzed. Distal intramural tumor spread was also performed. A total of 1676 LNs, 135 MLNs, and 69 EX were detected on 124 consecutive surgical specimens. Forty-two patients (34%) had MLNs. Six patients (4.8%) were classified as ypN1c. Distal viable cancer spread was observed in 3 patients (2.4%), all with mid rectal carcinoma. Two patients (1.6%) presented distal direct intramural extension less than 1 cm; and 1 (0.8%), with EX localized no more than 2 cm from the lower edge of the tumor. MLNs (76%) and EX (94%) were preferentially localized in the peritumoral area and in the first 3 cm just above the tumor. No viable distal intramural or mesorectal spread was observed in low rectal carcinoma. Distal intramural and mesorectal cancer spread is a rare event after neoadjuvant RCT. These results suggest that the 1-cm distal margin recommended in patients with low rectal carcinoma could be reduced with insurance to obtain a negative distal margin. The knowledge of preferential localization of MLNs and EX would help the pathologist to improve patient's lymph node staging.

Is biological mesh interposition a valid option for complex or recurrent rectovaginal fistula?

AIM

Many surgical techniques are available for the treatment of rectovaginal fistula (RVF). There is hitherto little information on its treatment by biological mesh interposition. The aim of the present study was to analyse our results of RVF treatment using biological mesh interposition.

METHOD

Patients with RVF undergoing biological mesh interposition were identified. Success was defined by the absence of a diverting stoma and/or any vaginal discharge of faeces, flatus or mucous discharge.

RESULTS

Ten women [median age 39 (24.5-65) years] were included. Nine (90%) had recurrent RVF, and the median number of previous attempts at closure was 2.5 (0-8). The main cause of RVF was Crohn's disease (40%). All patients had faecal diversion. No intra-operative complications occurred from mesh interposition. Seven (70%) patients developed postoperative morbidity which was major (Dindo III) in two (20%). The primary success rate was 20% (2/10) but final success rate was achieved in 70% after reoperation with other procedures at 11.1 (2.7-13.1) months of follow-up.

CONCLUSION

The study has shown disappointing results with biological mesh interposition for RVF with a healing rate lower than achieved by gracilis muscle interposition.

Controversies in the management of early rectal cancer

Proctectomy with total mesorectal excision (TME) is the gold standard for rectal cancer surgical management, as it offers optimal oncologic results. However, this radical procedure is impaired by significant drawbacks, including temporary diverting stoma, risk of permanent stoma, high risk of postoperative morbidity, and long-term risk of postoperative bowel, urinary, and sexual disorders. These results led some authors to define "early rectal cancer" in an attempt to propose alternative strategies such as local excision in order to avoid radical surgery. Indeed, local surgery does not involve diverting stoma, has the advantage of sphincter-preservation even for very low rectal tumors, is associated with very good short-term results and accounts for a nearly nil long-term risk of bowel dysfunction or urogenital disorders. However, local excision, as opposed to TME, does not allow lymph node resection and staging. Its indication has therefore been the subject of debate. Finally, the recent description of organ preservation strategies, which concept lies in the avoidance of radical surgery, has recently been the subject of a high number of publications, including some poor-prognosis early rectal cancer. Recently, early rectal cancer has therefore become an intense field of research. In this review, we will assess described strategies and controversies regarding early rectal cancer management.

Is there a limit to transanal endoscopic surgery? A comparative study between standard and technically challenging indications among 168 consecutive patients

AIM

To assess the surgical outcome of transanal endoscopic surgery (TES) for rectal neoplasms in technically challenging indications.

METHOD

All patients who underwent TES for a rectal neoplasm from 2007 to 2014 were included. Technically challenging indications included a tumour with (i) diameter ≥ 5 cm, (ii) involving ≥ 50% of the rectal circumference and (iii) located ≥ 10 cm from the anal verge. Patients were divided into three groups according to how many of these features they had, as follows: Group 1, none; Group 2, one; Group 3, two or more.

RESULTS

Of the 168 patients (80 benign and 88 malignant tumours) included in the study, 73 (44%) were in Group 1, 46 (27%) in Group 2 and 49 (29%) in Group 3. There was no difference between Group 1 and Group 2 with regard to peritoneal perforation (P = 0.210), severe postoperative morbidity (P = 0.804), length of hospital stay (P = 0.444), incomplete resection (P = 0.441), piecemeal resection (P = 0.740), locoregional recurrence (P = 0.307) and long-term symptomatic rectal stenosis (P = 0.076). Conversely Group 3 showed significantly impaired results compared with Group 1 with regard to peritoneal perforation (P = 0.003), piecemeal resection (P = 0.005), incomplete resection (P = 0.025), locoregional recurrence (P = 0.035) and long-term symptomatic rectal stenosis (P < 0.001), but no difference in severe postoperative morbidity (P = 0.328).

CONCLUSION

Transanal endoscopic surgery for rectal neoplasms appears to be safe and effective, even in patients presenting with a technically challenging tumours. Although the short- and long-term outcomes after TES are worse in patients with highly challenging tumours, nevertheless the technique should still be considered in patients at high risk of requiring a proctectomy.