Transanal Endoscopic Microsurgery (TEM) for Rectal Cancer: University Hospital of North Tees Experience.

Transanal endoscopic microsurgery (TEM) is a minimally invasive technique that is increasingly being used to treat early rectal cancer (T1/T2). We studied the outcomes of TEM for rectal cancer at our institution looking at the indication, recurrence rate, need for further radical surgery, 30-day and 12-month mortality and complication rate. We performed a retrospective analysis of prospectively collected data of cases between 2008 and 2012: 110 TEM procedures were performed during this period: 40 were confirmed rectal cancers and 70 were benign. We analysed the data for the 40 patients with confirmed rectal cancer. Thirty (75 %) of the subjects were male with a mean age of 71 ± 10 years (range 49-90 years) and 19 (48 %) patients were ASA 3 and 4. Nineteen (48 %) of cancers were pT1, eighteen (45 %) were pT2, two (5 %) were pT3 and one was yPT0. Mean specimen size was 66 ± 20 mm (range 33-120 mm) with a mean polyp size of 41 ± 24 mm (range 18-110 mm). The mean cancer size was 24 ± 13 mm (range 2-50 mm). Average distance from the anal verge was 70 ± 37 mm (range 10-150 mm), and the mean operating time was 72 ± 22 min (range 40-120 min), with an average blood loss of 28 ± 15 ml (range 10-50ml). Median hospital stay was 2 ± 1 days (range 1-7 days). Complete excision (R0) was achieved in 37 (93 %) patients. Minor post-operative complications included urinary retention in two and pyrexia in three patients. There were no 30-day or 12-month mortalities. Mean follow-up was 13 ± 11 months, range (3-40 months) Local recurrence occurred in two (5 %) patients, both underwent redo TEM. Twelve (30 %) patients underwent laparoscopic radical resections (seven AR and five APER) post-TEM. Post-operative histology confirmed pT0N0 in 7/12 patients. Three were lymph node-positive (T0N1), one was pT3N1 and the fifth was pT3N2. TEM is associated with quicker recovery, shorter hospital stay and fewer complications than radical surgery. It is a good alternative to radical surgery in early rectal cancer, especially for high-risk patients. Recurrent tumours can be treated with redo TEM.

Outcome of tumor-specific mesorectal excision for rectal cancer: the impact of laparoscopic resection.

OBJECTIVE: The study aimed to compare the outcomes of laparoscopic and open resection for rectal cancer in 1,063 consecutive cases in a single center. METHODS: We performed an analysis of 11 years of experience in rectal cancer surgery and compared the outcome of laparoscopic and open surgery. Multivariate and subgroup analysis was performed to look at the effect of the level of tumor and stage of disease on short-term outcomes like conversion rate, anastomotic leak rate, length of stay, complication rate, 30-day mortality, and long-term outcomes like local recurrence and survival. RESULTS: A total of 1,063 patients underwent rectal resection with 470 (44.2%) patients undergoing the laparoscopic approach. Groups were comparable in terms of age, sex, or co-morbidities, and the operating time was longer in the laparoscopic group (210 vs. 150 min; p value < 0.001). A conversion rate of 6.8% was noted, with an anastomotic leak rate of 3.87% in the open group and 2.97% in the laparoscopic group. The laparoscopic group had a lower blood loss (100 vs. 350 ml; p < 0.001), lower complication rates, and shorter length of stay (6 vs. 9 days). The local recurrence rate was comparable, and the laparoscopic approach had better overall and cancer-specific survival, even after adjusting for stages. The laparoscopic approach was an independent factor associated with better overall and cancer-specific survival on multivariate analysis. CONCLUSION: We confirmed the oncological safety of laparoscopic rectal cancer surgery. Laparoscopic surgery also showed superiority in the short-term and long-term outcomes of rectal cancer.

The prognostic value of transrectal ultrasound guided biopsy in patients over 70 years old with a prostate specific Antigen (PSA) level ≤ 15 ng/ml and normal digital rectal examination: a 10-year prospective follow-up study of 427 consecutive patients.

INTRODUCTION: As a urologist, it is common to review a patient above the age of 70 being referred to a prostate assessments clinic with an elevated PSA. We evaluate the prognosis of these patients clinically as there is no international consensus on the exact PSA cutoff level or a single international guideline as to when these patients should be offered a prostate biopsy. PATIENTS AND METHODS: On receiving ethic committee approval, we recruited 427 consecutive patients aged 70 years and above referred with a PSA of ≥ 4 ng/ml, from January 1996 to December 2000, into our study. All patients were assessed, examined with a digital rectal examination (DRE) of the prostate, and a subsequent prostate biopsy. We followed up on their histologic diagnosis for up to 10 years and analyzed their outcome. The main outcome measures were disease-free survival and overall survival, stratified according to the PSA level (≤ 15 vs. >15 ng/ml) and DRE findings (normal vs. sbnormal). RESULTS: There was a statistically significant difference in the overall survival (P value < 0.011) and disease specific survival (P value < 0.0001) of cancer patients with a PSA was >15 ng/ml and an abnormal DRE. However, in patients with a PSA ≤ 15 ng/ml and normal DRE, the incidence of cancer was low and they had no disease-specific or overall survival benefit. CONCLUSIONS: A policy of deferring prostate biopsy in patients with a PSA ≤ 15 ng/ml and normal DRE (Group A) would significantly decrease the need of unnecessary prostate biopsies. Within this group, patients did not have any survival advantage compared with those without cancer. We conclude that up to 20% of the prostate biopsies performed in this age group could have been avoided.

Rupture of an inferior epigastric artery pseudo-aneurysm following laparoscopic port insertion.

Laparoscopic port insertion is a potential cause of trauma to the inferior epigastric artery, resulting in pseudo-aneurysm formation. Treatment of pseudo-aneurysms includes thrombin injection, coil embolisation, embolisation with N-butyl cyanoacrylate, compression therapy or surgical excision and ligation. The authors present a case of pseudo-aneurysm caused by port insertion during laparoscopic sigmoid colectomy. The pseudo-aneurysm was identified using CT and Doppler ultrasound scans, but underwent spontaneous resolution with cessation of flow prior to intervention. The patient was therefore discharged, but he presented again as an emergency with rupture of a clinically infected pseudo-aneurysm and needed emergency surgical intervention.

Retrograde popliteal approach to common femoral vein stenosis in an intravenous drug user with hostile groin: a case report.

Intravenous (IV) drug abuse is a common problem in our society. One complication of this practice is venous stenosis, endovascular management of which can be technically challenging especially in patients with a hostile groin. We describe an ipsilateral retrograde popliteal approach in a 26-year-old IV drug user presenting with swelling of the left leg secondary to common femoral vein stenosis. This approach represents the next best method following failed contralateral/cross-bifurcation access and is a safe, convenient alternative offering a "straight run" at the lesion.

Colonic gallstones: a case report.

BACKGROUND: Colonic gallstone is an uncommon entity with high morbidity and mortality due to various reasons. It remains a diagnostic challenge because of delayed and non-specific presentations, especially in the elderly population, often with multiple co-morbidities. METHOD: We present a case of 81-year-old woman who had a large bowel obstruction due to colonic gallstone. RESULTS: Immediately after a cholecysto-colonic fistula was found by laporotomy, she underwent a single stage enterolithotomy, cholecystectomy and fistula closure. CONCLUSIONS: A single stage enterolithotomy, cholecystectomy and fistula closure is ideal for this condition. Various other surgical options in the literature are discussed.