TaTME approach as a rescue during a laparoscopic TME for high rectal cancer. A case report.

INTRODUCTION AND IMPORTANCE: In the last years, transanal total mesorectal excision (TaTME) has been described in rectal cancer treatment, especially in challenging patients, difficulties in pelvic exposure and limitations of instrumentation improving not only dissection but also the preservation of autonomic pelvic nerves and the achievement of a restorative procedure. Here we report a case report of anterior laparoscopic rectal resection for adenocarcinoma of the high-mid rectum converted to transanal approach. CASE PRESENTATION: A 69-year-old male presented hepatic nodules during radiological follow-up for prostate cancer treated with radical prostatectomy and adjuvant radiotherapy (70 Gy). The biopsy of the lesion demonstrated the presence of a metastatic lesion of an adenocarcinoma, with suspected intestinal origin. Then, we perform an endoscopic examination, which showed the presence of a rectal lesion, which cause a bowel stenosis extended from the middle part to the upper part of the rectum. After chemoradiotherapy, an anterior rectal resection was performed. During surgery we could not perform the resection of the rectum due the thickness and fibrosis of the tissue, despite we used different branded mechanical stapler. So, we decided to complete the surgical treatment starting a TaTME procedure with resolution of the problem. CLINICAL DISCUSSION: TaTME is a relatively new technique that had already become a valid option in the treatment of low rectal cancer, and, nowadays, also in the treatment of inflammatory bowel disease. As reported in literature, this technique has a number of advantages, especially in narrow pelvis and it is very useful in low rectal surgery. CONCLUSION: This case report aims to describe the possible use of TaTME procedure as a rescue also when this approach is not the first choice.

Transanal proctocolectomy and ileal pouch-anal anastomosis (TaIPAA) for ulcerative colitis: medium term functional outcomes in a single centre.

BACKGROUND: Transanal dissection of the rectum has been recently introduced for ileal pouch-anal anastomosis (IPAA) in UC showing promising results. Thanks to the precise identification of the rectotomy site the risk of long rectal stump is avoided, and a single stapled anastomosis is performed easily. The aim of this study is to analyze our initial experience of transanal proctocolectomy and ileal pouch-anal anastomosis (TaIPAA), considering postoperative complications and medium-term functional outcomes. METHODS: Our Center has experienced the transanal approach for proctectomy and IPAA since August 2018. All patients underwent Enhanced Recovery After Surgery (ERAS) protocol. Postoperative complications occurring within 30 days after surgery were taken into consideration. Fecal continence, genito-urinary activity and global quality of life at 1 and 6 months after ileostomy reversal have been assessed. RESULTS: Until March 2019, 8 patients underwent transanal proctocolectomy and ileal pouch-anal anastomosis (TaIPAA). In all cases the laparoscopic approach was performed during the transabdominal phase; abdominal drainage was never used. At the time of the pouch construction a defunctioning loop ileostomy was created in all patients. Stoma closure was performed in all cases at a median time of 6 months after surgery. Postoperative complications occurred in only one patient, who showed rectal bleeding, not required a re-invertation. There were no cases of anastomotic leakage. Medium-term functional outcomes were determined prospectively using previously validated quality of life questionnaires (Cleveland Global Quality of Life). Fecal incontinence for liquid or solid stool, genitourinary and sexual functions were also investigated, showing comparable results with the literature data. CONCLUSIONS: In our experience, transanal proctocolectomy and ileal pouch-anal anastomosis provided good short and medium-term functional results in UC.

Topographic lymph node staging system shows prognostic superiority compared to the 8th edition of AJCC TNM in gastric cancer. A western monocentric experience.

INTRODUCTION: The current Tumor Node Metastasis staging system (TNM) for gastric cancer classifies the extent of lymph node metastasis based upon the number of lymph nodes involved. Choi et al. have recently proposed a new anatomical classification based upon the regionality of the involved nodes. This new classification seems to have a better predictive prognostic value than the traditional one. We investigated the prognostic role of the new anatomical based classification, reviewing our institutional gastric cancer database. METHODS: We performed a retrospective chart review of 329 patients who underwent gastrectomy at our Institution from 2003 to 2017. We excluded from data analysis any patient with distant metastases at the time of first diagnosis and or surgery, pathology other than adenocarcinoma, lymphadenectomy less than D2, impossibility to identify location of lymph nodes (LNs) on pathological report and neoadjuvant chemotherapy. The extent of D2 lymphadenectomy was defined according to Japanese Gastric Cancer Association criteria. LN metastasis were reclassified into three topographic groups (lesser, greater curvature, and extraperigastric nodes) and staged according to Choi. The new N stage was combined with the current pT according to the 8th edition of TNM and a new hybrid TNM stage was established. All patients were followed up until June 2019. The prognostic performance of the new stage and of the current anatomical numeric based system (TNM) was analyzed and assessed by the C-index, AIC and likelihood ratio χ2 value. RESULTS: In predicting both Overall Survival (OS) and Disease free Survival (DFS) the new N stage and the new TNM staging system had the highest C-index and likelihood ratio χ2 value and the lowest Akaike Information Criterion (AIC), showing a better accuracy and displaying a better prognostic performance. CONCLUSIONS: Our study is the first from the Western world to compare the new hybrid classification, based on the anatomical location of metastatic nodes, to the 8th of American Joint Committee on Cancer (AJCC) TNM staging system. Our findings on a small, monocentric sample suggest that hybrid topographic lymph node staging system is more accurate than TNM.

Prenatal diagnosis of haemoglobin disorders by cordocentesis at 12 weeks' gestation.

Prenatal diagnosis of haemoglobin disorders is accepted to be a useful procedure to avoid births of infants with homozygous diseases. Advances in sampling and molecular techniques, such as polymerase chain reaction (PCR) and chorionic villus sampling (CVS), have made earlier and safer first-trimester prenatal diagnosis possible. However, these procedures need previous studies of at-risk couples, which can be very time-consuming when a number of different beta-thalassaemia mutations occur in the region. We describe the possibility of making a first-trimester prenatal diagnosis by cordocentesis and fetal blood analysis at the 12th week of gestation. We found no statistically significant difference (p greater than 0.05) between beta/gamma values in fetuses at the 12th and 18th weeks of gestation. In seven affected fetuses aborted at the 12th week of gestation, the diagnosis was confirmed in all cases by PCR analysis. These findings suggest that early cordocentesis could be an alternative procedure to CVS and PCR analysis.

The risks of early cordocentesis (12-21 weeks): analysis of 500 procedures.

Five hundred cordocenteses were performed between 12 and 21 weeks. The indications were thalassaemia (386), rapid karyotyping (97), feto-maternal allo-immunization (10), rubella (6), and toxoplasmosis (1). One hundred and ten pregnancies underwent termination on the basis of the result, while 20 of the 370 pregnancies intended to continue were lost to follow-up. Amongst these were 16 fetal losses (4.3 per cent) and 22 premature deliveries (5.9 per cent); no other complications were reported. Four adverse prognostic factors were identified: (a) cord bleeding; (b) fetal bradycardia; (c) prolonged procedure time; and (d) anterior insertion of the placenta. There was no 'obvious' difference in fetal loss rate with advancing gestation until 19-21 weeks, when the risk of fetal loss decreased to 2.5 per cent.

First trimester fetal blood sampling.

The authors report 8 diagnostic cordocentesis performed at the end of the first trimester. The indication was thalassemia (5 cases) and karyotyping (3 cases). The technique requires that the operator holds both the probe and the needle (25 G X 90 mm); the fetal blood sample ranged between 0.25 and 0.35 cc, sufficient in all cases for the diagnosis. 1 pregnancy was terminated on the basis of the diagnostic result; no complications reported at a 3-weeks follow-up in the remaining 7 patients. The first trimester cordocentesis offers several advantages if compared to CVS, especially for thalassemia prenatal diagnosis; furthermore it opens new perspectives for intrauterine transplantations. More experience is required to assess the safety of the procedure.