A retrospective review of a large series of groin hernia patients operated with robotically assisted laparoscopic technique (R-TAPP).

We have reviewed the patient outcome and the feasibility of robotically assisted inguinal hernia repair (R-TAPP) from the first 4-years period after its introduction in our department in a Scandinavian Public Health hospital. A total of 226 hernia repairs were performed in 195 patients (31 bilateral hernias). 160 patients had primary hernias, whereas 35 had recurrent hernias. Of the recurrent hernias, three had recurred twice. The majority of the hernias were in the right groin (53.3%) and the lateral location was the most common (65.0%). The hernia was scrotal in 29 cases. The mean operation time was significantly reduced throughout the observation period for our cohort, i.e. from 81 to 57 min (p < 0.001). The operation time was 27 min faster (mean value) in unilateral vs bilateral hernias and 19 min faster (mean value) in primary vs residual hernias. There were no statistically significant differences in operation time between lateral and medial hernias, and no differences in operation time between the obese and normal-weight cases. We experienced four severe per-operative complications (4/226; 1.8%): two cases of abdominal wall bleeding subsequently undergoing intravascular coiling, one perforation of the urinary bladder and one perforation of small bowel that were both closed by direct suture intraoperatively. There were no conversions to laparoscopy or open procedure. One hernia recurred during the observation period. Our findings suggest that the R-TAPP procedure in a Scandinavian Public Health hospital's surgical department is both safe and feasible.

A critical appraisal of transanal minimally invasive surgery (TAMIS) in the treatment of rectal adenoma: a 4-year experience with 51 cases.

OBJECTIVE: The aim of this study was to describe feasibility, postoperative morbidity, and histological outcome of transanal minimally-invasive surgery (TAMIS) in patients with rectal adenoma. MATERIAL AND METHODS: All patients who underwent TAMIS at a single institution from December 2011 to December 2015 were retrospectively included in the study. Feasibility was based on tumor size, distance of tumor from the anal verge, operative time, and hospital stay. Thirty-day morbidity was defined by the revised Accordion Classification system. Histological outcome included microscopic resection margin status, specimen fragmentation status, and grading of dysplasia in rectal adenoma. RESULTS: A total of 51 patients with rectal adenoma underwent TAMIS. The median tumor diameter was 32 (4-60) mm and the median distance from the anal verge 8 (3-14) cm. Median operative time was 40 (13-116) min and median length of hospital stay was 1 (0-25) days. Overall morbidity was 12% (four grade 1, one grade 2, and one grade 3 complications). 22% had a positive resection margin, whereas 31% had an indefinable resection margin status mostly due to tissue fragmentation. Median follow-up time was 7 (0-40) months. CONCLUSIONS: TAMIS is a challenging surgical technique for treatment of rectal adenoma. Our initial experience among 51 patients resulted in a high proportion of positive resection margins and a high fragmentation rate. The role of TAMIS in the treatment of rectal adenoma is to be defined through comparative studies.

Adaptation of trustworthy guidelines developed using the GRADE methodology: a novel five-step process.

BACKGROUND: Adaptation of guidelines for use at the national or local level can facilitate their implementation. We developed and evaluated an adaptation process in adherence with standards for trustworthy guidelines and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, aiming for efficiency and transparency. This article is the first in a series describing our adaptation of Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines for a Norwegian setting. METHODS: Informed by the ADAPTE framework, we developed a five-step adaptation process customized to guidelines developed using GRADE: (1) planning, (2) initial assessment of the recommendations, (3) modification, (4) publication, and (5) evaluation. We developed a taxonomy for describing how and why recommendations from the parent guideline were modified and applied a mixed-methods case study design for evaluation of the process. RESULTS: We published the adapted guideline in November 2013 in a novel multilayered format. The taxonomy for adaptation facilitated transparency of the modification process for both the guideline developers and the end users. We excluded 30 and modified 131 of the 333 original recommendations according to the taxonomy and developed eight new recommendations. Unforeseen obstacles related to acquiring a licensing agreement and procuring a publisher resulted in a 9-month delay. We propose modifications of the adaptation process to overcome these obstacles in the future. CONCLUSIONS: This case study demonstrates the feasibility of a novel guideline adaptation process. Replication is needed to further validate the usefulness of the process in increasing the organizational and methodologic efficiency of guideline adaptation.

The Prognostic Impact of Protein Expression of E-Cadherin-Catenin Complexes Differs between Rectal and Colon Carcinoma.

The E-cadherin-catenin complex provides cell-cell adhesion. In order for a carcinoma to metastasize, cancer cells must let go of their hold of neighboring cells in the primary tumor. The presence of components of the E-cadherin-catenin complex in 246 rectal adenocarcinomas was examined by immunohistochemistry and compared to their presence in 219 colon carcinomas. The expression data were correlated to clinical information from the patients' records. There were statistically significant differences in protein expression between the rectal and the colon carcinomas regarding membranous beta-catenin, gamma-catenin, p120-catenin, and E-cadherin, as well as nuclear beta-catenin. In the rectal carcinomas, there was a significant inverse association between the expression of p120-catenin in cell membranes of the primary tumors and the occurrence of local recurrence, while membranous protein expression of beta-catenin was inversely related to distant metastases.

Differences in protein expression and gene amplification of cyclins between colon and rectal adenocarcinomas.

Adenocarcinomas of rectum and colon may be different with regard to the cellular biological basis for cancer development. A material of 246 rectal cancers removed surgically at Akershus University Hospital in the years 1992-2000 was investigated and was compared to a material of 219 colon cancers operated on at Akershus University Hospital during the years 1988, 1990 and 1997-2000. There were highly significant differences between the rectal and the colon cancers in the protein expression of cyclin D1, cyclin D3, cyclin E, nuclear beta-catenin, and c-Myc and in gene amplification of cyclin A2, cyclin B1, cyclin D1, and cyclin E. Gene amplification and protein expression in the rectal cancers correlated significantly for the cyclins B1, D3, and E. A statistically significant relation was observed between overexpression of cyclin A2 and local relapse of rectal carcinomas, as higher expression of cyclin A2 was associated with lower local recurrence rate.

Large-scale genomic instability in colon adenocarcinomas and correlation with patient outcome.

The purpose of this study was to evaluate the association between DNA content in colon adenocarcinomas using high-resolution image cytometry and patient outcome. Tumours from 219 patients operated for colon adenocarcinoma were analysed using high-resolution image cytometry. Proteins involved in cell cycle propulsion (cyclins A, D1, D3 and E) and cell proliferation (c-Myc and non-membranous beta-catenin) have previously been reported in the same cohort and were included in this study. The results were related to disease-free survival and to cancer-specific death. Patients with aneuploid tumours showed shorter relapse-free survival than patients with euploid tumours (univariate log-rank test, p = 0.004 and multivariate Cox regression model p = 0.009, HR 0.51, 95% CI 0.31-0.84). Also the risk of death from cancer was greater in patients with aneuploid tumours (log-rank test, p = 0.006 multivariate Cox regression model p = 0.014, HR 0.47, 95% CI 0.26-0.86). When analysing patients with Dukes stages A and B, nuclear expression of beta-catenin was highly significantly associated with both shorter relapse-free survival (p < 0.005, HR 5.0, 95% CI 1.6-15.5) and cancer-specific death (p = 0.036, HR 6.9, 95% CI 1.1-42.1). DNA content in colon adenocarcinomas measured by image cytometry is an independent predictor of prognosis in our patients operated for colon adenocarcinoma.

An increase in the number of adhesion proteins with altered expression is associated with an increased risk of cancer death for colon carcinoma patients.

BACKGROUND AND AIMS: Reduced expression of components of the cell-cell adhesive cadherin-catenin complex has been related to the invasive phenotype in many malignancies, but the prognostic value of altered expression of its separate components varies in colon cancer. Our objective was evaluation of the cadherin-catenin complex, considered as a functional unit, in colon carcinomas and its relationship to patient outcome. PATIENTS AND METHODS: Tumours from 206 patients operated for colon adenocarcinoma were analysed using immunohistochemistry of E-cadherin, alpha, beta, and gamma-catenins, and p120ctn. The sum of proteins with altered membranous expression was calculated as an overall adhesion score (ranging from 0 to 5) for each patient. The results were correlated with patient outcome. RESULTS: Of the tumours included in the analysis 0.5% had score 0, 4.9% had score 1, 13.6% had score 2, 31.6% had score 3, 33.0% had score 4, and 16.5% tumours had score 5. None of the proteins examined had individual, independent prognostic value. However, an increase in the number of proteins in the cadherin-catenin complex with altered expression was associated with an increased risk of cancer death (univariate P=0.002; multivariate P=0.007, HR 1.48, 95% CI 1.11-1.96). CONCLUSIONS: An increase in the number of adhesion proteins with altered expression in the primary tumour is associated with increasingly impaired prognosis for patients operated for colon carcinoma. The results reveal that the entire cadherin-catenin complex should be evaluated when assessing its prognostic value in the disease.

Expression of non-membranous beta-catenin and gamma-catenin, c-Myc and cyclin D1 in relation to patient outcome in human colon adenocarcinomas.

Non-membranous beta-catenin and gamma-catenin, c-Myc and cyclin D1 are key participants in the Wnt cell signalling pathway, in which aberrancies have been associated with malignant cell transformation. We assessed the independent prognostic value of these proteins in a clinical material. Tumours from a series of 162 patients operated on for Dukes' stage A, B and C colonic adenocarcinomas were analysed using semiquantitative immunohistochemistry and the results were related to patient outcome. Patients expressing nuclear beta-catenin in the primary tumour showed reduced survival compared to other patients (log rank p=0.028) and there was also an association with development of metastases follow-up (logistic regression p=0.024). Using multivariate analysis (Cox regression) co-expression of nuclear beta-catenin and c-Myc turned out to be the strongest marker of impaired prognosis (p=0.001, HR 5.26, 95% CI 1.93-14.36). Expression of non-membranous gamma-catenin, cyclin D1 and c-Myc alone failed to have independent prognostic significance in our study.