Transanal endoscopic microsurgery technique: an acceptable approach for retrorectal tumors.

INTRODUCTION: Retrorectal lesions (RRLs) are rare lesions that originate from the tissue present in the retrorectal space. The gold standard of care is complete resection regardless of pathology. The traditional approaches (anterior, posterior, and combined) are relatively well described. Transanal Endoscopic Microsurgery (TEM) is a minimally invasive technique offered as an alternative approach for RRLs. AIM: To evaluate the outcomes of patients diagnosed with RRL and treated by the TEM approach, especially postoperative complications, and the recurrence rate. METHODS: Patients with RRLs treated with the TEM technique in one medical center between 2000 and 2020 were identified. Their postoperative outcomes were compared with historical controls. RESULTS: Thirty-nine patients diagnosed with RRL were operated on using the TEM platform. Thirty-seven RRLs were benign, and two were malignant. Their median size (IQR) was 20 mm (15, 32.5). The median distance (IQR) from the anal verge was 50 mm (50, 72.5). The median operative time (IQR) was 48.5 min (41.75, 60). All, except one lesion, were completely resected. The median length of stay (IQR) was one day (1, 1 day). Postoperative complications were diagnosed in three patients, two of which resolved following a second operation. CONCLUSIONS: The implementation of TEM for the resection of RRLs demonstrated excellent overall results with acceptable complication and recurrence rate and represented a viable alternative surgical approach.

Rectal duplication cyst in adults treated with transanal endoscopic microsurgery.

Rectal duplication cyst is a rare entity that accounts for approximately 4% of all alimentary tract duplications. To the best of our knowledge, the presented cases are the first reports in the English literature of rectal duplication cyst resection by transanal endoscopic microsurgery. We present two patients; both are 41-year-old women with a palpable rectal mass. Workup revealed a submucosal posterior mass that was then resected by transanal endoscopic microsurgery. The pathology report described cystic lesions with squamous and columnar epithelium and segments of smooth muscle. These findings were compatible with rectal duplication cyst. Our limited experience showed good results with minimal morbidity and mortality for resection of rectal duplication cysts of limited size with no evidence of malignancy.

The effect of neoadjuvant Imatinib therapy on outcome and survival after rectal gastrointestinal stromal tumour.

AIM: The study aimed to characterize the pathological and clinical response of rectal gastrointestinal stromal tumours (GISTs) to neoadjuvant Imatinib. METHOD: The medical records of patients with rectal GISTs who were diagnosed and treated in five medical centres in Israel between January 2002 and January 2009 were retrospectively examined. Twelve patients who fulfilled the inclusion criteria of nonmetastatic rectal GIST for which preoperative neoadjuvant treatment with Imatinib was considered were suitable for enrollment. RESULTS: Of the 12 patients, nine received neoadjuvant treatment with Imatinib. The three patients who had immediate surgery were excluded. There were five men and four women with a median age of 63 years and a median follow up of 32 months. All tumours were located in the lower two-thirds of the rectum. One patient had a complete clinical response, six had a partial response and two had stable disease. Seven patients subsequently underwent surgery; six had an R0 resection and one had an R1 resection. Three patients had recurrence. There was no disease-related mortality. The reduction in both tumour size and mitotic activity during preoperative Imatinib therapy was significant. CONCLUSION: Preoperative Imatinib therapy can shrink large rectal GISTs, improving the chances of successful radical surgery and decreasing the risk of considerable morbidity.

Metastatic spinal cord compression as initial presentation of follicular thyroid carcinoma.

Follicular thyroid carcinoma, initially presenting as spinal cord compression due to metastatic lesions, is a less reported event. We present two cases of well-differentiated thyroid carcinoma that led to spinal cord compression. A thorough search of the literature revealed only five similar cases. We summarize the clinical characteristics of these cases, the therapeutic measures used, their outcome, and the prognosis.

[Nonsurgical treatment of gallstones].

Lately, nonoperative treatment is being used in high risk patients with gallbladder or bile duct stones. Procedures include oral dissolution, extracorporeal shock wave lithotripsy, mechanical lithotripsy, contact dissolution or extraction after papillotomy or via a T-tube tract. We review nonsurgical treatment of gallstones and present our experience in the treatment of 9 patients using combinations of the above-mentioned modalities.

[The seton in the treatment of trans-sphincteric anal fistulas].

In most patients anal fistulas are of the intersphincteric type (Parks' classification). Treatment consists of simple fistulotomy. 10% of those with an anal fistula have the more complicated trans-sphincteric type. The treatment of such a fistula by primary fistulotomy is associated with a high rate of incontinence. A technique to avoid this complication is the use of the seton for gradual transection of the sphincteric fibers. 21 of 53 patients with anal fistula had a trans-sphincteric fistula, and all of them were treated with setons. Hospital stay was 2 days and was followed by 2-4 outpatient visits. 17 patients (85%) underwent the procedure without any complications and were cured. 3 (15%) had minor problems with continence, of whom 2 required emergency operation. In no case did the fistula recur. We find that the use of the seton after partial fistulotomy for complicated anal fistulas reduces the rate of incontinence caused by sphincteric transection and has a very low recurrence rate.

[Extracorporeal shock wave lithotripsy for gallstones].

Biliary stone disease is common in most western societies, among whom gallstones are present in approximately 15-20% of adults. 40-60% of all persons with gallstones are asymptomatic, but 30-50% of them develop symptoms over a period of 2-5 years. For decades, cholecystectomy was the only solution. In the past decade new options, such as oral dissolution, direct dissolution, invasive endoscopy and lately lithotripsy and adjuvant treatment with oral dissolution agents, have become available. This paper summarizes the rationale of lithotripsy, its indications and complications, the impressive results of its use abroad and the authors' year of experience with 110 patients. Immediate fragmentation was achieved in 90.3%. Complete dissolution after 1 month was seen in 20%, after 3 months in 38.5% and after 6 months in 61.6%. After 1 year of treatment 85.8% of our patients were stone-free. Experience abroad, as well as our own, shows that lithotripsy and oral dissolution can be the treatment of choice in a selected group of patients with symptomatic gall stones.

Villous tumors of the stomach.

Four cases of gastric villous tumors are presented. The radiologic features of these rare tumors in the stomach are described. Their high propensity for malignancy as compared to villous adenoma of the colon is emphasized. In 2 of 4 of our patients the villous tumors were malignant. The radiologic picture of villous tumors of the stomach is characteristic enough to suggest the diagnosis.