Low Anterior Resection Syndrome After Transanal Total Mesorectal Excision: A Comparison With the Conventional Top-to-Bottom Approach.

BACKGROUND: Advances in sphincter-saving procedures improved the quality of life of patients with rectal cancer. However, many of them experienced functional disturbances after surgery, including low anterior resection syndrome. OBJECTIVE: The aim of this study was to evaluate the severity of low anterior resection syndrome after transanal total mesorectal excision and compare it with the conventional transabdominal, top-to-bottom, total mesorectal excision. DESIGN: This was a single-center, retrospective analysis. SETTINGS: The study was conducted at a tertiary academic institution. PATIENTS: This study analyzed patients who underwent total mesorectal excision for mid to low rectal cancer from January 2016 to April 2018. Cases were matched one-to-one according to the tumor height and history of pelvic irradiation using the propensity score. MAIN OUTCOME MEASURES: The primary outcome measured was the severity of low anterior resection syndrome and fecal incontinence at 3, 6, and 12 months after surgery or stoma reversal, whichever was later. RESULTS: There were 35 patients in each group after matching; 67.1% were male, and 41.4% had neoadjuvant radiotherapy. At 3 months, the median low anterior resection syndrome score was 37 after transanal total mesorectal excision, which was significantly higher than the conventional approach, 32 (p = 0.045). Apart from this, the low anterior resection syndrome score, severity grading, and the Wexner score were comparable at 6 and 12 months. LIMITATIONS: A difference between the 2 groups might not be detected because of the study's small sample size and because of its retrospective nature. CONCLUSIONS: A higher low anterior resection syndrome score was observed after transanal total mesorectal excision at the initial 3-month period, but such a difference was not observed thereafter. This study showed that both surgical techniques had similar anal and bowel functional outcomes in the long run. However, because of the limited case number and study design, further study is needed to prove this. See Video Abstract at http://links.lww.com/DCR/B146. SÍNDROME DE RESECCIÓN ANTERIOR BAJA DESPUÉS DE LA ESCISIÓN MESORRECTAL TOTAL TRANSANAL: UNA COMPARACIÓN CON EL ABORDAJE CONVENCIONAL DE SUPERIOR A INFERIOR: Los avances en los procedimientos para salvar esfínteres mejoraron la calidad de vida de los pacientes con cáncer rectal. Sin embargo, muchos de ellos sufrieron trastornos funcionales después de la cirugía, incluyendo el síndrome de resección anterior baja.El objetivo de este estudio fue evaluar la gravedad del síndrome de resección anterior baja después de la escisión mesorrectal total transanal y comparar con la escisión mesorrectal total convencional transabdominal, de arriba a abajo.El estudio se realizó en una institución académica terciaria.Este fue un análisis retrospectivo de un solo centro de pacientes que se sometieron a una escisión mesorrectal total por cáncer rectal medio a bajo desde enero de 2016 hasta abril de 2018. Los casos fueron emparejados uno a uno de acuerdo con la altura del tumor y los antecedentes de irradiación pélvica con puntaje de propensión.La gravedad del síndrome de resección anterior baja y la incontinencia fecal a los 3, 6 y 12 meses después de la cirugía o la reversión del estoma, lo que ocurriera más tarde.Hubo 35 pacientes en cada grupo después del emparejamiento. El 67.1% eran hombres. El 41,4% tenía radioterapia neoadyuvante. A los tres meses, la puntuación media del síndrome de resección anterior baja fue de 37 después de la escisión mesorrectal transanal total, que fue significativamente mayor que el enfoque convencional, 32 (p = 0.045). Aparte de esto, la puntuación baja del síndrome de resección anterior, la clasificación de gravedad y la puntuación de Wexner fueron comparables a los 6 y 12 meses.Es posible que no se detecte una diferencia entre los dos grupos debido al pequeño tamaño de la muestra del estudio. La naturaleza retrospectiva del estudio.Se observó una puntuación más alta en el síndrome de resección anterior baja después de la escisión mesorrectal total transanal en el período inicial de tres meses, pero dicha diferencia no se observó posteriormente. Este estudio mostró que ambas técnicas quirúrgicas tuvieron resultados similares de funcionamiento anal e intestinal a largo plazo. Sin embargo, debido al número limitado de casos y al diseño del estudio, es necesario realizar más estudios para demostrarlo. Consulte Video Resumen en http://links.lww.com/DCR/B146.

Clinical experience of positron-emission tomography in infective aortic disease.

Background Fluorine-18-fluorodeoxyglucose positron-emission tomography with computed tomography has revolutionized medical diagnosis by adding functional activity to anatomic imaging. We report our experience with this technique in patients with mycotic aortic pathology and aortic vascular graft infection. Methods We conducted a retrospective review of a prospective database of patients who underwent 18F-fluorodeoxyglucose positron-emission tomography with computed tomography for suspected infective aortic disease. From 2012 to 2016, 13 patients underwent 18F-fluorodeoxyglucose positron-emission tomography. Of these, 9 (69%) had a vascular graft infection (5 infrarenal aorta, 1 para-visceral, 2 descending, and 1 arch; 2 had previous open surgery and 7 had endovascular interventions) and 4 (31%) had a mycotic aneurysm (2 aortic arch, 1 infrarenal aorta, and 1 distal aorta and common iliac; 3 had endografts). The indications for imaging, location of pathology, 18F uptake, and clinical outcomes were analyzed. Results Eight (62%) patients had a single scan and 5 (38%) had serial scans performed. Among the 5 patients who had serial imaging, 3 showed decreased 18F uptake and 2 had increased uptake. Only one patient underwent subsequent endograft removal; the others were treated with lifelong antibiotics. There were 5 (38%) deaths on follow-up. Conclusion 18F-fluorodeoxyglucose positron-emission tomography with computed tomography could be a valuable adjunct in the diagnosis and surveillance of patients with aortic infection. Serial scans may be useful for monitoring disease activity and response to antibiotic therapy.

A systematic review and meta-analysis evaluating completeness and outcomes of robotic thyroidectomy.

OBJECTIVES/HYPOTHESIS: Despite immense interest, robotic-assisted thyroidectomy (RT) remains controversial in differentiated thyroid carcinoma (DTC). This systematic review and meta-analysis compared surgical completeness and/or oncological outcomes between RT and open thyroidectomy (OT) in low-risk DTC. STUDY DESIGN: Systematic review. METHODS: A systematic review was performed to identify studies that compared surgical completeness and/or oncological outcomes between RT and OT in DTC. Any study that compared at least one parameter relating to surgical completeness and/or oncological outcome for DTC was considered. Number of central lymph nodes (CLNs) retrieved during central neck dissection (CND), preablation stimulated thyroglobulin (sTg) level, radioiodine uptake on post-therapy scan, and locoregional recurrence (LRR) were examined. Meta-analysis was performed using a fixed or random-effects model depending on heterogeneity between studies. RESULTS: Ten studies were eligible. Of the 2,205 DTCs, 752 (34.1%) had RT, whereas 1,453 (65.9%) had OT. Relative to OT, RT had significantly fewer CLNs retrieved during CND (4.7 ± 3.2 vs. 5.5 ± 3.8, standardized mean difference [SMD] = -0.240, 95% confidence interval [CI]: -0.364 to -0.116, P < .001) and higher preablation sTg level (3.6 ± 6.7 ng/mL vs. 2.0 ± 5.0 ng/mL, SMD = 0.272, 95% CI: 0.022 to 0.522, P = .033). Interestingly, these differences were more evident in the robotic transaxillary approach (RTAA) than the robotic bilateral axillo-breast approach. After a mean follow-up of 17.7 months, no LRR was found in RT, whereas after 18.6 months, one LRR was found in OT. CONCLUSIONS: Relative to OT, total thyroidectomy by RTAA was associated with fewer CLNs retrieved and less-complete thyroid resection. However, using RTAA is unlikely to compromise the outcomes of low-risk DTC because of its inherently good prognosis.

Acute limb ischemia in cancer patients: should we surgically intervene?

BACKGROUND: Cancer patients have an increased risk of venous thromboembolic events. Certain chemotherapeutic agents have also been associated with the development of thrombosis. Reported cases of acute arterial ischemic episodes in cancer patients are rare. METHODS: Patients who underwent surgery for acute limb ischemia associated with malignancy in a university teaching hospital over a 10-year period were identified. Patient demographics, cancer type, chemotherapy use, site of thromboembolism, treatment and outcome were recorded. RESULTS: Four hundred nineteen patients underwent surgical intervention for acute arterial ischemia, 16 of these patients (3.8%) had associated cancer. Commonest cancer sites were the urogenital tract (n = 5) and the lungs (n = 5). Eight patients (50%) had been recently diagnosed with cancer, and four (25%) of these cancers were incidental findings after presentation with acute limb ischemia. Four patients (25%) developed acute ischemia during chemotherapy. The superficial femoral artery was the most frequent site of occlusion (50%), followed by the brachial (18%) and popliteal (12%) arteries. All patients underwent thromboembolectomy, but two (12%) patients subsequently required a bypass procedure. Six patients (37%) had limb loss, and in-patient mortality was 12%. Histology revealed that all occlusions were due to thromboembolism, with no tumor cells identified. At follow-up, 44% of patients were found to be alive after 1 year. CONCLUSION: Cancer and chemotherapy can predispose patients to acute arterial ischemia. Unlike other reports that view this finding as a preterminal event most appropriately treated by palliative measures, in this series, early diagnosis and surgical intervention enabled limb salvage and patient survival.

Endovascular repair of para-anastomotic aortoiliac aneurysms.

The purpose of this study is to evaluate the use of endovascular stent grafts in the treatment of para-anastomotic aneurysms (PAAs) as an alternative to high-risk open surgical repair. We identified all patients with previous open aortic aneurysm repair who underwent infrarenal endovascular aneurysm repair (EVAR) at our institution from June 1998 to April 2007. Patient demographics, previous surgery, and operative complications were recorded. One hundred forty-eight patients underwent EVAR during the study period and 11 patients had previous aortic surgery. Of these 11 redo patients, the mean age was 62 years at initial surgery and 71 years at EVAR. All patients were male. Initial open repair was for rupture in five (45%) patients. The average time between initial and subsequent reintervention was 9 years. All patients were ASA Grade III or IV. Fifty-five percent of the PAAs involved the iliac arteries, 36% the abdominal aorta, and 9% were aortoiliac. Ten patients had endovascular stent-grafts inserted electively, and one patient presented with a contained leak. Aorto-uni-iliac stent-grafts were deployed in seven patients, and bifurcated stent-grafts in four patients. A 100% successful deployment rate was achieved. Perioperative mortality was not seen and one patient needed surgical reintervention to correct an endoleak. Endovascular repair of PAAs is safe and feasible. It is a suitable alternative and has probably now become the treatment of choice in the management of PAAs.