Robotic transanal total mesorectal excision: a pilot study

Background

The introduction of transanal minimally invasive surgery (TAMIS) in 2009 allowed colorectal surgeons to approach transanal access with a different perspective. This has lead to the development of TAMIS for total mesorectal excision (TME). We have previously described robotic transanal TME and here report our initial experience with the first three human cases performed at a single institution.

Methods

Three patients with distal rectal cancer were selective to undergo robotic transanal TME. All resections were carried out with intent to cure; they were performed by a single attending colorectal surgeon over an 11-month period.

Results

Three patients underwent robotic transanal TME. The average age was 45 years (range 26–59) with mean BMI of 32 kg/m² (range 21–38.5). The average tumor size was 2.5 cm. All lesions were located in the distal 5 cm of the rectum. In each case, the distal and circumferential resection margins were free of tumor. The resection quality of the mesorectal envelope was Grade I and Grade II. There was no major morbidity or mortality on short-term follow-up.

Conclusions

Robotic transanal TME is a new modality for en bloc rectal cancer surgery, and the technique is feasible. Further study is necessary to assess the benefit of this novel approach.     

Use of self-retaining barbed suture for rectal wall closure in transanal endoscopic microsurgery

Background

The aim of this study was to investigate the safety and efficacy of self-retaining barbed sutures in comparison with monofilament clip-fixated sutures for rectal wall closure in transanal endoscopic microsurgery.

Methods

Horizontal full-thickness wall defects (3.5 cm) of cattle rectal specimens were closed via transanal endoscopic microsurgery using a monofilament suture with clips at the end (Surgipro^® 2/0; Covidien, Mansfield, MA, USA, n = 25) or a self-retaining barbed suture (V-Loc? 180 3/0; Covidien, Mansfield, MA, USA, n = 25). The primary endpoint was the pneumatic leakage pressure of the suture line. As a secondary endpoint, suture time was evaluated.

Results

The median pneumatic leakage pressure for barbed sutures was 45.5 mbar (range 17–106 mbar) and 33.5 mbar (range 19–106 mbar) for monofilament sutures (p = 0.58). A pneumatic leak at a critical pressure below 25 mbar occurred in 3 cases with barbed sutures and in 7 cases with monofilament sutures (p = 0.29). Median suturing time [19:25 min:s (range 12:00–33:30) vs. 20:41 (17:00–28:33), p = 0.23] did not differ between the two groups.

Conclusions

Barbed sutures display the same bursting pressure as monofilament sutures and their use for rectal wall closure seems feasible.     

Perineal stapled prolapse resection (PSPR) in elderly patients for external rectal prolapse: early experience

Background

Full-thickness rectal prolapse in frail elderly patients is often treated by a perineal approach with considerable attendant morbidity. We report our preliminary results of the perineal stapled prolapse resection (PSPR) technique for resection of full-thickness external rectal prolapse using a new reloadable Contour^® Transtar? stapler (Ethicon Endo-Surgery) device.

Methods

Fourteen elderly high-risk patients with an external prolapse up to 10 cm in length were treated between April 2010 and October 2011, and operative factors, outcome and recurrence rates were assessed.

Results

There were no intraoperative difficulties and no perioperative morbidity. The median operating time was 35 min (range 25–45 min) with a median hospital stay of 3 days (range 3–5 days). Four patients developed early recurrence over a median follow-up of 32 months (range 25–41 months).

Conclusions

PSPR is safer, faster and easier to perform than other conventional perineal prolapse procedures and is suitable for elderly, high-risk patients for whom an abdominal approach under general anesthesia is not advisable.     

Transanal minimally invasive surgery for total mesorectal excision (TAMIS–TME): results and experience with the first 20 patients undergoing curative-intent rectal cancer surgery at a single institution

Background

Transanal TME is a new approach to performing minimally invasive rectal resection. It is particularly well suited for patients with locally advanced distal rectal cancer and obesity, where the abdominal approach is challenging. Transanal TME can be performed with either TAMIS or TEM. Here, we report our initial experience with transanal TME using TAMIS (TAMIS–TME).

Methods

Patients were selected to undergo transanal TME using the TAMIS platform (TAMIS–TME) primarily for malignant disease, but also for select cases of benign disease. Transanal TME defines a “bottom-up” approach to en bloc rectal cancer resection. Transanal TME requires abdominal access for proximal colonic mobilization and is often done in conjunction with a laparoscopic approach.

Results

During a 32-month period, 20 patients underwent TAMIS–TME with curative intent. The primary indication for transanal TME was distal, locally advanced rectal cancer. The median age of rectal cancer patients at the time of surgery was 57 years (range 36–73 years) with 30 % (6) female and 70 % (14) male. The median body mass index (BMI) measured was 24 kg/m² (range 18–41 kg/m²); this included six patients (30 %) with obesity (BMI ≥ 30 kg/m²). Mean operating time was 243 min (range 140–495 min) with blood loss averaging 153 ml. Postoperative length of stay averaged 4.5 days (range 3–24 days). There was no 30-day postoperative mortality. Surgical complications included wound infection (n = 2), pelvic abscess (n = 4), and prolonged ileus (n = 4). The anastomotic leak rate was 6.7 % (1/15). Of the 20 patients who underwent resection, 90 % (18/20) had negative margins. Pathologic grading of the TME specimen revealed that 85 % (17/20) of transanal TME specimens were found to have “completely” or “near-completely” intact mesorectal envelopes. Data collected during the 6-month median follow-up period revealed that only one patient had developed distant metastasis. There was no locoregional recurrence in any of the patients.

Conclusions

Transanal TME is a feasible method for oncologic resection of locally advanced mid- and distal-rectal cancer with curative intent. It has special application for patients with obesity and anatomic constraints such as a narrow male pelvis.     

Combined robotic transanal total mesorectal excision (R-taTME) and single-site plus one-port (R-SSPO) technique for ultra-low rectal surgery—initial experience with a new operation approach

Objective

Robot-assisted rectal surgery is gaining popularity, and robotic single-site surgery is also being explored clinically. We report our initial experience with robotic transanal total mesorectal excision (R-taTME) and radical proctectomy using the robotic single-site plus one-port (R-SSPO) technique for low rectal surgery.

Methods

Between July 2015 and March 2016, 15 consecutive patients with ultra-low rectal lesions underwent R-taTME followed by radical proctectomy using the R-SSPO technique by a single surgeon. The clinical and pathological results were retrospectively analyzed.

Results

The median operative time was 473 (range, 335–569) min, and the estimated blood loss was 33 (range, 30–50) mL. The median number of lymph nodes harvested was 12 (range, 8–18). The median distal resection margin was 1.4 (range, 0.4–3.5) cm, and all patients had clear circumferential resection margins. We encountered a left ureteric transection intraoperatively in one patient, and another patient required reoperation for postoperative adhesive intestinal obstruction. There was no 30-day mortality.

Conclusion

R-taTME followed by radical proctectomy using the R-SSPO technique for patients with low rectal lesions is technically feasible and safe without compromising oncologic outcomes. However, there were considerable limitations and a steep learning curve using current robotic technology.

     

Treatment of obstructed defecation syndrome due to rectocele and rectal intussusception with a high volume stapler (TST STARR-plus)

Background

In recent years, stapled transanal resection (STARR) has been adopted worldwide with convincing short-term results. However, due to the high recurrence rate and some major complications after STARR, there is still controversy about when the procedure is indicated. The aim of this study was to assess the safety, efficacy and feasibility of STARR performed with a new dedicated device for tailored transanal stapled surgery.

Methods

All the consecutive patients affected by obstructed defecation syndrome (ODS) due to rectocele or/and rectal intussusception, who underwent STARR with the TST STARR-Plus stapler, were included in a prospective study. Pain, Cleveland Clinic Score for Constipation (CCCS) and incontinence, patient satisfaction, number of hemostatic stitches, operative time, hospital stay and perioperative complications were recorded. Postoperative complications and recurrence were also reported.

Results

Forty-five consecutive patients (median age 50; range 24–79) were included in the study. Median resected volume was 15 cm³ (range 12–19 cm³) with a median height of surgical specimen of 5.6 cm (range 4.5–10 cm). The mean CCCS decreased from 17.26 (± 3.77) to 5.42 (± 2.78) postoperatively (p < 0.001). Patient satisfaction grade was excellent in 14 patients (31.1%), good in 25 (55.5%), sufficient in three (6.7%) and poor in three patients (6.7%). No major complications occurred. Five patients (11%) reported urgency after 30 days and two patients (4%) after 12 months. The Cleveland Clinic Incontinence score did not significantly change. At a median follow-up of 23 months (range 12–30 months), only three patients (6.7%) reported recurrent symptoms of obstructed defecation comparable to those reported at baseline.

Conclusions

TST STARR-Plus seems to be safe and effective for the treatment of ODS due to rectocele and rectal intussusception, and technical improvement could reduce the risk of some complications. However, careful patient selection is still the best means of preventing complications.

     

Laparoscopic sphincter-preserving surgery (intersphincteric resection) after neoadjuvant imatinib treatment for gastrointestinal stromal tumor (GIST) of the rectum

Background

Gastrointestinal stromal tumors (GISTs) of the rectum are rarely found, and radical surgery such as abdominoperineal resection would be necessary for large rectal GIST. On the other hand, therapy for GIST has changed significantly with the use of imatinib. Neoadjuvant imatinib therapy may reduce tumor size and may potentially prevent extended surgery. Moreover, when sphincter-preserving surgery is carried out laparoscopically, it can be performed as minimally invasive surgery with preservation of the anus.

Methods

From 2008 to 2011, five patients with rectal GIST were treated in our hospital. All patients received preoperative imatinib treatment (400 mg/day) and underwent laparoscopic sphincter-preserving surgery after 4–12 months of this treatment.

Results

Initial median tumor size was 31 mm (range, 24–88). At the time of operation, the median tumor size was 24 mm (range, 11–52). Sphincter-preserving surgery was performed in all patients. Three patients underwent laparoscopic intersphincteric resection (ISR), and two patients underwent transanal full-thickness local resection and recto-anal anastomosis following laparoscopic ISR. Macroscopically complete resection was achieved, and microscopically, the resection margin was not involved of residual tumors. The median duration of postoperative hospital stay was 16 days (range, 13–30). No recurrence occurred in all patients during 1 to 4 years.

Conclusions

The present study suggests that neoadjuvant imatinib therapy might be effective to prevent extended surgery for rectal GIST, and laparoscopic sphincter-preserving surgery is safe and technically feasible. We recommend a combination of neoadjuvant imatinib therapy and laparoscopic ISR for locally advanced rectal GIST.     

Short-term outcomes of local correction of stoma prolapse with a stapler device

Background

The aim of the present study was to classify the short-term outcomes of local correction of stoma prolapse with a stapler device.

Methods

The medical records of 11 patients undergoing local correction of stoma prolapse using a stapler device were retrospectively reviewed.

Results

No mortality or morbidity was observed after the surgery. Median operative time was 35 min (range 15–75 min), and blood loss was minimal. Median duration of follow-up was 12 months (range 6–55 months). One of the 11 patients had a recurrent stoma prolapse.

Conclusions

This technique can be a feasible, safe and minimally invasive correction procedure for stoma prolapse.     

Langzeitergebnisse nach transanaler Rektumwandresektion mittels Stapler bei der obstruktiven Defäkationsstörung

Background and Purpose

Rectocele and distal rectal intussusception are potential organic causes of obstructive defecation syndrome and can be corrected surgically once conservative treatment measures have been exhausted. Stapled transanal rectal resection (STARR procedure) was introduced as a new treatment approach. This study presents the first long-term results of this procedure.

Patients and Methods

A STARR procedure was performed in 19 patients (17 female, 2 male, age 53±12 years) between January 2003 and February 2007. The surgical indication was a severe, conservatively treated stool evacuation disorder secondary to symptomatic rectocele and/or distal intussusception.

Results

The mean follow-up period for all patients was 60±17 months (35–82 months). The defecation score (0–20 points) decreased from a preoperative 13.4±3.4 to 3.7±2.7 after 3 months and increased slightly to 4.8±3.6 by the time of the final follow-up examination. In 16 patients (84.2%), the obstructive defecation syndrome was significantly improved. These positive results were maintained also in the long term. Slight worsening of continence in terms of urge incontinence was reported by 6 patients (31.6%). The patients most affected were those with normal continence preoperatively. Procedure-related anal reoperations were required in 3 patients (15.8%)

Conclusion

Even in the long term, transanal rectal wall resection seems to be an effective therapy for obstructive defecation syndrome. However, it is associated with a substantial number of reoperations and of patients with persistent urge incontinence.     

Unselected rectal cancer patients undergoing low anterior resection with defunctioning ileostomy can be safely managed within an Enhanced Recovery Programme

Background

An increasing body of evidence supports the application of the Enhanced Recovery Programme (ERP) to colorectal surgery. Some institutions have reported an association between ERP failure and low rectal cancer surgery. We present the results that we achieved by applying the ERP to low anterior resections for tumours within 6 cm of the anal verge, with a view to determining the validity and safety of applying the ERP to this patient group.

Methods

A multimodal ERP, based on Kehlet’s model, was introduced in January 2007 and applied to all patients undergoing elective resections. Patients having a low anterior resection for a rectal cancer less than 6 cm from the anal verge between January 2007 and August 2011 were retrospectively identified from a prospectively maintained database. Individual patient record review was performed.

Results

Twenty consecutive patients (12 males) were identified. Median total postoperative length of stay (LOS), including readmission, was 8 days (mean 10.7, range 4–47 days), with 2 readmissions and no deaths. When surgery was uncomplicated, median LOS was 5 days (mean 5.8, range 4–12 days, n = 11), whereas LOS increased when a complication occurred, with a median of 12 days (mean 16.6, range 8–47 days, n = 9) [p = 0.001].

Conclusions

The ERP can safely be applied to this high-risk patient group. When no complication occurs, LOS of 5 days can be expected. When a complication is encountered, LOS is prolonged (12 days), but this is acceptable compared with the current national median LOS in the United Kingdom of 11 days for all rectal cancer surgery (at any height) with a stoma.     

Atypical indications for transanal endoscopic microsurgery to avoid major surgery

Background

Transanal endoscopic microsurgery (TEM) was originally designed for the removal of rectal tumors, principally incipient adenomas, and adenocarcinomas up to 20 cm from the anal verge. However, with the evolution of the technique and the increase in surgeons’ experience, new indications have emerged and TEM may now be used in place of other surgical procedures which are associated with higher morbidity. The aim of our study was to evaluate our group’s use of TEM or transanal endoscopic operations (TEO) for conditions other than rectal tumors.

Methods

An observational study of TEM (using Wolf equipment) or TEO (using Storz equipment) for indications other than excision of rectal tumors was conducted from June 2004 to July 2012.

Results

Four hundred twenty-four procedures were performed using TEM/TEO: removal of adenocarcinomas in 148 (34.9 %) patients, adenomas in 236 (55.7 %), post-polypectomy excision in 12 (2.8 %), removal of neuroendocrine tumors in 8 (1.9 %), and atypical indications in 20 (4.7 %). Atypical indications were pelvic abscess (3), benign rectal stenoses (2), rectourethral fistula after prostatectomy (3), gastrointestinal stromal tumor (3), endorectal condylomata acuminata (1), rectal prolapse (2), extraction of impacted fecaloma in the rectosigmoid junction (1), repair of traumatic and iatrogenic perforation of the rectum (2), and presacral tumor (3).

Conclusions

The use of TEM/TEO in atypical indications may benefit patients by avoiding surgical procedures associated with greater morbidity.     

Pure Natural Orifice Transluminal Endoscopic Surgery (NOTES) with a new elongated,curved Transanal Endoscopic Operation (TEO) device for rectosigmoid resection: a survival study in a porcine model

Background

Natural orifice transluminal endoscopic surgery (NOTES) has seen considerable new developments in its evolution to a platform for rectal and sigmoid resection, but to date no true single NOTES procedure has been convincing. This study investigates the safety and feasibility of a further developed transanal NOTES platform for single-access NOTES rectosigmoid resection.

Methods

Ten large female pigs, mean weight 99.3 kg [standard deviation (SD) 7 kg, range 85.1–112.6 kg], underwent transanal rectosigmoid resection. Five animals were included in an acute study group with immediate postoperative euthanization. A second group included five animals in a survival study. Transanal rectosigmoid resections were performed with an elongated and curved transanal endoscopic operation (TEO) device. Coloanal anastomosis was performed using the transanal circular stapler technique. Survival follow-up was at 7 and 28 days via colonoscopy under sedation.

Results

Single-access NOTES transanal rectosigmoid resection with coloanal anastomosis was performed in nine out of ten female pigs. Mean length of rectosigmoid specimens exteriorized was 18.7 cm (SD 2.9 cm, range 14–23 cm). Mean operating time was 124 min (SD 35.7 min, range 70–166 min). Within the survival group, no complications occurred during the monitoring phase. In one case, there was ascites and colitis at necropsy as well as fibrosis at the anastomosis site.

Conclusions

Pure transanal rectosigmoid resection is a feasible procedure. The approach via a single transanal access is demanding but viable with the elongated and curved TEO device. The newly developed scope offers an excellent view of the area cephalad to the promontory.

     

Factors associated with complete local excision of small rectal carcinoid tumor

Purpose

Although small rectal carcinoid tumors can be treated using local excision, complete resection can be difficult because tumors are located in the submucosal layer. We evaluate the factors associated with pathologically complete local resection of rectal carcinoid tumors.

Methods

Data were analyzed of 161 patients with 166 rectal carcinoid tumors who underwent local excision with curative intent from January 2001 to December 2010. A pathologically complete resection (P-CR) was defined as an en bloc resection with tumor-free lateral and deep margins. The study classified treatments into three categories for analysis: conventional polypectomy (including strip biopsy, snare polypectomy, and hot biopsy), advanced endoscopic techniques (including endoscopic mucosal resection with cap and endoscopic submucosal dissection), and surgical local excision (including transanal excision and transanal endoscopic microsurgery). We evaluated the P-CR rate according to treatment method, tumor size, initial endoscopic impression and the use of endoscopic ultrasound (EUS) or transrectal ultrasound (TRUS).

Results

The mean tumor size was 5.51?±?2.43 mm (range 2–18 mm) and all lesions were confined to the submucosal layer. The P-CR rates were 30.9, 72.0, and 81.8 % for conventional polypectomy, advanced endoscopic techniques, and surgical local excision, respectively. Univariate analysis showed that P-CR was associated with treatment method, use of EUS or TRUS, and initial endoscopic impression. Multivariate analysis showed that only treatment method was associated with P-CR.

Conclusion

Pathologically complete resection of small rectal carcinoid tumors was more likely to be achieved when using advanced endoscopic techniques or surgical local excision rather than conventional polypectomy.     

Long-term results of stapled transanal rectal resection (STARR) for obstructive defecation syndrome

Background

Rectocele and distal rectal intussusception are organic causes of obstructive defecation syndrome and can be corrected surgically once conservative treatment remedies have been exhausted. Stapled transanal rectal resection (STARR) procedure was introduced as a new treatment approach. This study presents the first long-term results of this procedure.

Patients and procedures

A STARR procedure was performed in 14 patients (two male, 12 female, age 53?±?12 years) between January 2003 and August 2005. The indication for surgery was a severe, conservatively treated stool evacuation disorder secondary to symptomatic rectocele and/or distal intussusception.

Results

The mean follow-up period was 68?±?10 (49–83) months. The defecation score (0–20 points) decreased from a preoperative 13.4?±?3.4 to 3.2?±?2.0 after 3 months and increased slightly to 4.7?±?3.4 by the time of the final examination. In 12 patients (85.7%), the obstructive defecation syndrome was significantly improved. These positive results were also maintained in the long-term. Five patients (38.5%) reported a slight worsening of continence in terms of urge incontinence. The most affected patients were those with preoperative normal continence. Procedure-related anal reoperations were required in two patients (14.3%).

Conclusion

Even in long-term, transanal rectal wall resection seems to be an effective therapy for obstructive defecation syndrome. However, it is associated with a substantial number of reoperations and in some patients with persistent urge incontinence.     

Combined NOTES total mesorectal excision and single-incision laparoscopy principles for conservative proctectomy: a single-centre study

Background

Surgery for low rectal cancer remains a challenge when a standard laparoscopic approach is used. Transanal endoscopic total mesorectal excision (TME) has been shown to be feasible and to be associated with a low conversion rate. Combining the transanal and transabdominal single-port approaches (with an abdominal single port implanted in the future stoma and extraction site) could allow TME with minimal wound trauma, low morbidity, and faster recovery. The aim of the current study was to assess the short- and mid-term results of this technique.

Methods

We conducted a prospective single-centre study of consecutive patients presenting with low rectal cancer requiring a conservative proctectomy with a manual coloanal anastomosis between January 2012 and April 2015.

Results

During the study period, 41 patients were recruited. Conversion to open surgery was required in only one patient (2.4%). The median operating time was 358.5 min (range 300–600 min). Partial intersphincteric resection was necessary for 15 patients (36.6%). The specimens were mostly extracted via the abdominal access (n = 34) without wound complications. The mean number of lymph nodes harvested was 12.7 (range 6–24 lymph nodes). Specimens were graded as complete (n = 31) or nearly complete (n = 10) in all of the patients, and the circumferential resection margin positivity was 4.9%. Intraoperative morbidity rate was 4.9%, and the 30-day morbidity rate was 24.4% (n = 10). Sixty per cent (n = 6) of the patients with 30-day morbidity were Dindo I–II. At a median follow-up of 29 months, overall and disease-free survival rates were 97.5 and 80.5%, respectively. The stoma-free survival rate was 95.1%.

Conclusions

Combining an endoscopic transanal TME and a single laparoscopic ileostomy-site proctectomy is a promising minimally invasive approach for the treatment of low rectal cancer.

     

Conservative treatment of intrarectal mesh migration after ventral laparoscopic rectopexy for rectal prolapse

Objective

Ventral rectopexy is a validated treatment for rectal prolapse with a low morbidity rate but a risk of intrarectal mesh migration. The purpose of this study was to report the results of local transanal mesh excision for intrarectal mesh migration after ventral rectopexy.

Methods

Between January 2004 and March 2011, 312 patients underwent laparoscopic ventral rectopexy in two hospitals. Six patients were treated for intrarectal mesh migration.

Results

Delay between ventral rectopexy and the onset of symptoms was 53 months (4–124 months). All patients have symptoms. Imaging revealed a pelvic abscess in two cases. Intrarectal mesh migration was confirmed by anorectoscopy or clinical examination. Five patients were only treated by local transanal partial mesh excision, and one required a colostomy. Morbidity and mortality were zero. The median hospitalization time was 5 days (3–8 days). After a median postoperative follow-up period of 9 months (1–40 months), one recurrence was observed 2 months after surgery.

Conclusion

Local transanal mesh excision for intrarectal mesh migration after laparoscopic ventral rectopexy is a feasible conservative treatment. This simple treatment produced a cure of the pelvic inflammation and closure of the fistula without compromising a more aggressive secondary treatment which was not necessary in our series.     

Tailored prolapse surgery for the treatment of haemorrhoids and obstructed defecation syndrome with a new dedicated device: TST STARR Plus

Objective

The aim of the study was to assess the safety, efficacy and feasibility of stapled transanal procedures performed by a new dedicated device, TST STARR Plus, for tailored transanal stapled surgery.

Methods

All the consecutive patients admitted to eight referral centres affected by prolapses with III-IV degrees haemorrhoids or obstructed defecation syndrome (ODS) with rectocele and/or rectal intussusception that underwent stapled transanal resection with TST STARR plus were included in the present study. Haemostatic stitches for bleeding of the suture line, specimen volume, operative time, hospital stay and perioperative complications were recorded.

Results

From 1 November 2012 to 31 March 2013, 160 consecutive patients (96 females) were enrolled in the study. In 94 patients, the prolapse was over the half of the circular anal dilator (CAD). The mean duration of the procedure was 25 min. The mean resected volume of the specimen was 13.3 cm³, the mean hospital stay was 2.2 days. In 88 patients (55 %), additional stitches on the suture line were needed (mean 2.1). Suture line dehiscence was reported in four cases, with intraoperative reinforcement. Bleeding was reported in seven patients (5 %). Urgency after 30 days was reported in one patient. No major complication occurred.

Conclusions

The new device seems to be safe and effective for a tailored approach to anorectal prolapse due to haemorrhoids or obstructed defecation.     

Rectal mucosal prolapse in males: surgery is effective for fecal incontinence but not for obstructed defecation

Background

The aim of this prospective study was to evaluate the functional outcome of transanal surgery in male patients suffering from fecal incontinence, soiling, and obstructed defecation associated with rectal mucosal prolapse.

Methods

All male patients who underwent transanal surgery (either stapled or Delorme mucosectomy) for rectal mucosal prolapse associated with fecal incontinence and obstructed defecation were prospectively enrolled in the study. The recruitment phase was 17 months (April 2011 to August 2012). Symptom evaluation was based on the validated scores preoperatively and 12 months after surgery (Wexner incontinence score and Wexner constipation score). The primary end point was “success,” which was defined as a 50 % reduction in symptoms. Using a decision-tree algorithm, patient groups with the highest and lowest chance of success were identified.

Results

Thirty-eight male patients (mean age 51 years) underwent transanal surgery for rectal mucosal prolapse. The predominant symptoms were fecal incontinence in 31 patients (82 %) and obstructed defecation in 7 (18 %). Stapled mucosectomy was performed in 34 patients and Delorme mucosectomy in 4 patients. No major morbidity occurred. Symptom resolution for soiling was 77 %, itching and mucus secretion were improved in 47 and 50 %, and bleeding resolved in 89 % of patients affected. Functional outcome was good in 90 % (28/31) of the patients with fecal incontinence but in only 28 % (2/7) for obstructed defecation. The Wexner incontinence score decreased significantly (11.1 vs. 3.9, p < 0.01), whereas the Wexner constipation score was not influenced (18.4 vs. 15.6, p > 0.05). Using a decision-tree algorithm, a success rate of 96 % was observed in patients with fecal incontinence associated with younger age (age <45 years) and no presence of fecal urgency prior to surgery.

Conclusions

Transanal stapled mucosectomy for rectal mucosal prolapse in males is effective for fecal incontinence, but not for obstructed defecation.     

Totally robotic rectal resection: an experience of the first 100 consecutive cases

Introduction

Robotic surgery provides an alternative option for a minimal access approach. It provides a stable platform with high definition three-dimensional views and improved access, which enhances the capabilities for precise dissection in a narrow surgical field. These distinctive features have made it an attractive option for colorectal surgeons.

Aim

The aim of this study was to present a standardised technique for single-docking robotic rectal resection and to analyse clinical outcomes of the first 100 robotic rectal procedures performed in a single centre between May 2013 and April 2015.

Method

Prospectively collected data related to 100 consecutive patients who underwent single-docking robotic rectal surgery was analysed for surgical and oncological outcomes.

Results

Sixty-six patients were male, the median age was 67 years (range-24–92). Eighteen patients had neo-adjuvant chemoradiotherapy whilst 23 patients had BMI >30. Procedures performed included anterior resection (n?=?74), abdominoperineal resection (n?=?10), completion proctectomy (n?=?9), restorative proctectomy with ileal pouch–anal anastomosis (IPAA) (n?=?5) and Hartmann’s procedure (n?=?2). The median operating time was 240 min (range-135–456), and median blood loss was 10 ml (range 0–200). There was no conversion or intra-operative complication. Median length of stay was 7 days (range, 3–48) and readmission rate was 12 %. Thirty-day mortality was zero. Postoperatively, two patients had an anastomotic leak whilst two had small bowel obstruction. The median lymph node harvest was 18 (range, 6–43).

Conclusion

The single-docking robotic technique should be considered as an alternative option for rectal surgery. This approach is safe and feasible and in our study it has demonstrated favourable clinical outcomes.

     

Transanal endoscopic microsurgery for giant benign rectal tumours: is large size a contraindication?

Purpose

The purpose of this study is to look at our early postoperative results, recurrence rates and need for further radical surgery in treating large (> 5 cm) rectal tumours by transanal endoscopic microsurgery (TEM).

Methods

Patients who underwent TEM for rectal tumours greater than 5 cm were included. Tumour diameter was determined based on fresh specimen measurements. We recorded the demographics, operative details, final pathology, length of hospital stay, complications and recurrence rates.

Results

Mean tumour size was 5.9 ± 1.5 cm. 68.4% of tumours (13/19) were in the middle part of the rectum. Three patients (15.8%) developed postoperative complications: two had postoperative bleeding (10.5%), one had wound dehiscence (5.3%). Three patients had involved margins (15.8%). After a median follow up of 25.2 months, there were two recurrences (10.5%). One patient developed rectal cancer 6 years after removal of rectal adenoma.

Conclusion

TEM is feasible and safe for the treatment of giant benign rectal tumours. It may be an alternative method for proctectomy in selected patients.