Minimally invasive versus open total mesorectal excision for rectal cancer: Long-term results from a case-matched study of 633 patients.

BACKGROUND: This study compared the long-term oncologic outcomes of patients with rectal cancer who underwent either laparoscopic or robotic total mesorectal excision (TME) via minimally invasive surgery (MIS) to those patient who underwent open TME. METHODS: This study was a retrospective, case-control study; patients in the 2 groups were matched according to age, sex, MIS vs open operation, body mass index, tumor location, pathologic TNM stage (ie, tumor-node-metastasis), neoadjuvant treatment, and adjuvant treatment. RESULTS: A total of 633 patients (MIS, n = 211; open, n = 422) were assessed. The median follow-up period was 64 (2-124) months. Patient characteristics did not differ between the groups. Overall postoperative complication rates did not differ between the groups (16.0% [MIS]; 17.0% [open]; P = .76). Rates of the involvement of the circumferential resection margin did not differ between the groups (4.0% [MIS]; 5.0% [open]; P = .84). The 5-year overall survival, disease-specific survival, disease-free survival, and local recurrence rates were not different between the MIS and open groups (overall survival = 88.4% vs 85.3%, P = .23; disease-specific survival = 88.8% vs 87.4%, P = .53, disease-free survival = 80.7% vs 78.4%, P = .74; local recurrence = 5.7% vs 5.1%, P = .95). In subgroup analysis, no differences were found in terms of the long-term, oncologic outcomes, oncologic adequacy, and postoperative complications among 3 groups. CONCLUSION: We found no differences in the oncologic outcomes between MIS and open surgery, suggesting that MIS for rectal cancer is a safe option for rectal cancer that does not increase the risk of serious complications.

Safety of laparoscopic ventral rectopexy in the elderly: results from a nationwide database.

BACKGROUND: Laparoscopic ventral rectopexy is an established procedure in the treatment of posterior pelvic organ prolapse. It is still unclear whether this procedure can be performed safely in the elderly. OBJECTIVE: This study aimed to assess the effects of age on the outcome of laparoscopic ventral rectopexy performed for patients with pelvic organ prolapse. DESIGN: This study was a retrospective cohort analysis with data from a national registry. SETTINGS: The study was conducted in a tertiary care setting. PATIENTS: Patients undergoing laparoscopic ventral rectopexy were identified from discharge summaries. Patients were stratified according to age, including patients <70 (group A) and ≥ 70 (group B) years old. MAIN OUTCOME MEASURES: Variables analyzed included sex, age, diagnosis, associated pelvic organ prolapse, comorbidities, length of stay, complications (Clavien-Dindo scale), and mortality. RESULTS: Among 4303 patients (98.2% women) who underwent a laparoscopic ventral rectopexy, 1263 (29.4%) were >70 years old (mean age, 76.2 ± 5.0 years). Main diagnoses were vaginal vault prolapse (53.0% [group A] vs 47.0% [group B]; p value not significant) and rectal prolapse (17.7 vs 26.8%; p value not significant). Comorbidity was significantly increased in group B (mean length of stay, 5.6 ± 3.6 vs 4.7 ± 1.8 days; p < 0.001) and minor complications (8.4% vs 5.0%; p < 0.001) were significantly increased in group B, whereas major complications were not different (group A, 0.7%; group B, 0.9%; p = 0.40) after univariate analysis. Multivariate analysis found no significant differences between groups. The subgroup analysis of patients >80 years old (n = 299) showed no differences. Each group had 1 postoperative mortality. LIMITATIONS: Limitations of the study include its retrospective design, lack of prestudy power calculation, possible inaccuracy of an administrative database, and selection bias. CONCLUSIONS: Laparoscopic ventral rectopexy appears to be safe in select elderly patients.

A prospective evaluation of short-term and long-term results from colonic stenting for palliation or as a bridge to elective operation versus immediate surgery for large-bowel obstruction.

BACKGROUND: The efficacy and safety of self-expandable metallic stent (SEMS) placement as a bridge to elective surgery or definitive palliation versus emergency operation to treat colorectal obstruction is debated. This study aimed to evaluate the outcomes of patients with colorectal obstruction treated using different strategies. METHODS: Subjects admitted to the authors' department with colorectal obstruction (n = 134) were studied prospectively. They underwent endoscopic stenting as a bridge to elective surgery (SEMS group: n = 49) or for definitive palliation (n = 34). A total of 51 patients underwent immediate surgery without stenting (NO-SEMS). Treatment was decided by the senior on-call surgeon. RESULTS: Placement of SEMS was technically successful in 95.3 % and clinically successful in 98.7 % of cases. The short-term complications in the SEMS group were perforation (n = 1, 1.2 %), migration (n = 4, 4.9 %), occlusion (n = 4, 4.9 %), colon bleeding (n = 3, 3.7 %), and abdominal pain (n = 6, 7.4 %). The postoperative complication rate was 32.7 % in the SEMS group versus 60.8 % in the NO-SEMS group (P = 0.005), with a significant reduction in wound infections (26.5 vs 54.9 %; P = 0.004), abdominal abscess (14.3 vs 39.2 %; P = 0.006), respiratory morbidity (10.2 vs 37.3 %; P = 0.002), and intensive care treatment (10.2 vs 33.3 %; P = 0.007). The median postoperative hospital stay was 10 versus 15 days (P = 0.001). The in-hospital mortality rate in both groups was 2 %. Long-term follow-up evaluation showed less incisional hernia (6.3 vs 22.0 %; P = 0.04) and definitive stoma formation (6.3 vs 26.0 %; P = 0.01) in the SEMS group than in the NO-SEMS group, respectively. Kaplan-Meier survival curves showed a benefit for the SEMS group (log-rank test, 0.004). The long-term SEMS-related complication rate for the palliative patients was 43.8 %. The hospital readmission rate for SEMS complications was 34.4 %. Overall clinical success was 81.2 %. CONCLUSIONS: In case of colorectal obstruction, endoscopic colon stenting as a bridge to elective operation should be considered as the treatment of choice for resectable patients given the significant advantages for short- and long-term outcomes. Palliative stenting is effective but associated with a high rate of long-term complications.

Transanal radical endoscopic resection of the rectum on a swine model: a surviving model.

INTRODUCTION: This multimedia video is the second part of our study on transanal endoscopic radical resection of the rectum, which we have previously described (http://links.lww.com/DCR/A4). In this present study, we hypothesized that this procedure is not only technically feasible but also safe. MATERIALS AND SURGICAL TECHNIQUE: This procedure was performed on two swine as a surviving model. After radical resection of the rectum and primary anastomosis, the two swine were monitored in an animal holding area for a period of 1 week, and the anastomoses were inspected after that period. The lower rectum was transected, and retroperitoneal dissection was performed transanally using flexible endoscopic equipment to achieve high ligation of the caudal mesenteric vessels. After rectal resection, hand-sewn coloanal anastomosis was performed. DISCUSSION: Both swine had good postoperative outcomes, and the postoperative period was captured on video. Transanal radical endoscopic resection of the rectum is not only technically feasible, but it can can be safely performed on swine.

Transanal endoscopic microsurgery (TEM) for rectal tumor: the first French single-center experience.

OBJECTIVE: Transanal endoscopic microsurgery (TEM) allows complete local excision of rectal tumor, especially in the middle and upper part of the rectum, and provides an alternative to conventional surgery. This is a report of the first French single-center experience to assess the feasibility and postoperative results for rectal tumor excised by TEM. METHODS: From October 2007 to December 2008, 27 patients underwent TEM for excision of either rectal adenoma (n=19) or carcinoma (n=8). The median distance from the anal verge was 60mm (range: 10-140). RESULTS: TEM excision was performed in 26/27 patients. Intraoperative technical difficulties were recorded in two patients (peritoneal perforation and gas leakage, respectively). The morbidity rate was 22% (n=6), including two patients (7%) with major complications (delayed rectal bleeding) requiring readmission to hospital for both, and surgical hemostasis for one. R0 resection rates for adenoma and carcinoma were 84% and 75%, respectively. Immediate salvage surgery was performed in one patient because of a T2R1 carcinoma. At the time of the median follow-up at nine months (range: 2.5-17.5), no patient had experienced a recurrence. CONCLUSION: TEM is a safe and effective procedure with low morbidity for local rectal tumor resection. It allows local excision of benign tumors, especially those that are inaccessible to conventional local surgery resection, thereby avoiding radical surgery. In cases of carcinoma, its role in local surgery remains controversial and is yet to be defined.

Local excision of rectal tumours by transanal endoscopic microsurgery.

BACKGROUND: Transanal endoscopic microsurgery (TEM) allows locally complete excision of rectal tumours and provides an alternative to conventional surgery for benign tumours. However, its role in the curative treatment of invasive carcinoma is controversial. The aim of this study was to determine the morbidity and long-term results for rectal tumours excised by TEM. METHODS: Between February 1993 and January 2005, 200 patients underwent TEM for excision of adenomas (148) or carcinomas (52). The median tumour distance from the anal verge was 8 (range 1-16) cm. RESULTS: Mortality and morbidity rates were 0.5 and 14.0 per cent respectively. At a median follow-up of 33 (range 2-133) months, local recurrence had developed in 11 patients (7.6 per cent) with an adenoma. Histological examination of carcinomas revealed pathological tumour (pT) stage 1 in 31 patients, pT2 in 17 and pT3 in four. Immediate salvage surgery was performed in seven patients (13 per cent). At a median follow-up of 34 (range 1-102) months, eight patients (15 per cent) with carcinomas had developed local recurrence. The overall and disease-free 5-year survival rates for patients with carcinomas were 76 and 65 per cent respectively. CONCLUSION: TEM is an appropriate surgical treatment option for benign rectal tumours. For carcinomas, it is oncologically safe provided that resection margins are clear, but strict patient selection is required.