Endoscopic submucosal resection with an endoscopic variceal ligation device for the treatment of rectal neuroendocrine tumors

Background

Endoscopic resection is recommended for rectal neuroendocrine tumors <?1 cm in diameter; the three techniques (mucosal resection, submucosal dissection, and mucosal resection with variceal ligation device) of endoscopic resection of neuroendocrine tumor were reported; however, the optimal endoscopic technique remains unclear.

Purpose

We compared the efficacy and safety of three endoscopic rectal neuroendocrine tumor resection methods.

Methods

We retrospectively enrolled 52 patients with rectal neuroendocrine tumors treated by endoscopy at Aichi Medical University Hospital and Nagoya City University Hospital between May 2003 and June 2017. We compared clinical outcomes in three groups based on the endoscopic treatment method.

Results

Fifty-two patients underwent endoscopic rectal neuroendocrine tumor treatment (mucosal resection, 14; submucosal dissection, 19; mucosal resection with an endoscopic variceal ligation device, 19). In the endoscopic mucosal resection, submucosal dissection, and mucosal resection with variceal ligation device groups, R0 resection occurred in 50.0, 94.7, and 89.5%, respectively (mucosal resection vs. mucosal resection with variceal ligation device, p <?0.05; mucosal resection vs. submucosal dissection, p <?0.01), while the median procedure times were 6.5, 43, and 6.0 min, respectively (submucosal dissection vs. mucosal resection with variceal ligation device procedure times, p?<?0.01; mucosal resection vs. submucosal resection procedure times, p <?0.01). Postoperative bleeding occurred after endoscopic mucosal resection (1/14) and endoscopic submucosal dissection (4/19), but not after endoscopic mucosal resection with a ligation device.

Conclusion

Endoscopic mucosal resection with an endoscopic variceal ligation device was a safe, effective treatment for rectal neuroendocrine tumors.

     

Effect of preoperative chemotherapy on distal spread of low rectal cancer located close to the anus

Purpose

This study aimed to clarify the frequency of distal spread and the optimal distal margin after preoperative chemotherapy for advanced low rectal cancer.

Methods

The study included patients with advanced lower rectal cancer who received preoperative chemotherapy and underwent surgery during 2012–2015. We investigated the distal spread of tumor cells, defined as the distal distance from the intramucosal distal tumor edge to the farthest tumor cells located under the submucosal layer. Clinical characteristics were compared for distal spreads ≥?10 and <?10 mm, and risk factors for distal spread ≥?10 mm were investigated.

Results

Of the 71 patients, 42 (59%) showed distal spread. Distal spreads of 1–9, 10–19, and ≥?20 mm were observed in 27 (38%), 11 (15%), and 4 (6%) patients, respectively. Multivariate analysis revealed two independent risk factors for distal spread ≥?10 mm after preoperative chemotherapy. The first risk factor is the presence of different therapeutic effects between the mucosal and deeper layers (meaning that superficial tumor shrinkage was evident on colonoscopy, but little tumor shrinkage was evident on magnetic resonance imaging) (odds ratio, 11.6; 95% CI, 2.22–61.3). The second risk factor is poorly differentiated or mucinous adenocarcinoma (odds ratio, 8.86; 95% CI, 1.58–49.9).

Conclusion

A distal margin of 20 mm is required (10 mm is insufficient) for advanced lower rectal cancer patients who receive preoperative chemotherapy followed by surgery. Independent risk factors for distal spread ≥?10 mm include (1) the presence of different therapeutic effects between mucosal and deeper layers and (2) poorly differentiated or mucinous adenocarcinomas.

     

Initial experience with taTME in patients undergoing laparoscopic restorative proctocolectomy for familial adenomatous polyposis

Background

Transanal total mesorectal excision (taTME) is a minimally invasive technique which was developed to overcome the difficulties associated with the “top-down” pelvic dissection by enabling a “bottom-up” dissection in patients with mid- and low rectal cancer. While this technique was primarily designed to manage tumors in the mid- and lower rectum, its spectrum of indications has been broadened to include benign colorectal pathologies. The aim of the present study was to assess our initial experience with taTME in patients undergoing restorative proctocolectomy for familial adenomatous polyposis (FAP).

Methods

All consecutive patients (undergoing prophylactic restorative proctocolectomy with IPAA for FAP using taTME between April and October 2016 at our institution) were included in the study.

Results

There were 8 patients (6 females and 2 males). The median age was 19.5 years (range 16–31 years). In all cases, surgery was successfully completed using with taTME. No perioperative complications were recorded. A median of 5 bowel movements (range 4–6 bowel movements) with intermittent anti-diarrheal medication was recorded in all cases.

Conclusions

Our initial experience with 8 consecutive cases suggests taTME is safe and effective in patients undergoing prophylactic restorative proctocolectomy with IPAA for FAP.

     

Identification of Small Proteins and Peptides in the Differentiation of Patients with Intraductal Mucinous Neoplasms of the Pancreas,Chronic Pancreatitis and Pancreatic Adenocarcinoma

Background

There are a limited number of studies investigating the type of serum proteins capable of differentiating intraductal papillary mucinous neoplasms from benign or malignant diseases of the pancreas.

Aims

To select proteins able to differentiate intraductal papillary mucinous neoplasms from benign and malignant pancreatic disease using semiquantitative proteomics.

Methods

Serum samples were obtained from 74 patients (19 with type II intraductal papillary mucinous neoplasms, 8 with type I/III intraductal papillary mucinous neoplasms, 24 with chronic pancreatitis, 23 with pancreatic ductal adenocarcinomas) and 21 healthy subjects. Small proteins and peptides were assayed by matrix-assisted laser desorption/ionization for the detection of differentially abundant species possibly related to tumor onset. Serum pancreatic amylase, lipase, carcinoembryonic antigen and carbohydrate antigen 19-9 (CA 19-9) were also assayed.

Results

Twenty-six of 84 peaks detected were dysregulated (7 more abundant and 19 less abundant in the type II intraductal papillary mucinous neoplasms, p < 0.05). Of the differentially abundant peaks, 17 were commonly dysregulated (3 peaks more abundant and 13 less abundant in type II intraductal papillary mucinous neoplasms, and one at  m/z = 9961 at variance), indicating a protein fingerprint shared by types I/III and type II intraductal papillary mucinous neoplasms and pancreatic ductal adenocarcinomas.

Conclusions

These results suggest that our approach can be used to differentiate type II intraductal papillary mucinous neoplasms from type I/III neoplasms, and type II intraductal papillary mucinous neoplasms from pancreatic ductal adenocarcinomas.

     

Should we offer ventral rectopexy to patients with recurrent external rectal prolapse?

Background

For patients with rectal prolapse undergoing Ventral Rectopexy (VR), the impact of prior prolapse surgery on prolapse recurrence is not well described.

Purpose

The purpose of this study was to compare recurrence rates after VR in patients undergoing primary and repeat rectal prolapse repairs.

Design

This study is a prospective cohort study.

Methods

IRB-approved prospective data registry of consecutive patients undergoing VR for full-thickness external rectal prolapse between 2009 and 2015.

Main outcome measures

Rectal prolapse recurrence was defined as either external prolapse through the anal sphincters or symptomatic rectal mucosa prolapse warranting additional surgery. Preoperative and postoperative morbidity and functional outcomes were analyzed. Actuarial recurrence rates were calculated using the Kaplan-Meier method.

Results

A total of 108 VRs were performed during the study period. Seventy-two were primary and 36 repeat repairs. Seven cases were open, 23 laparoscopic, and 78 robotic. Six cases were converted from laparoscopic/robotic to open. In 63 patients, VR was combined with gynecological procedures. There were no statistical differences between primary or recurrent prolapse for the following: demographics, operative time, concomitant gynecologic procedures, complications, blood loss, and graft material type. Length of stay was longer in patients with a history of prior prolapse surgery (p = 0.01). Prolapse recurrence rates for primary repairs were reported at 1.4, 6.9, and 9.7% and for recurrent prolapse procedures 13.9, 25, and 25% at 1, 3, and 5 years (p = 0.13). Mean length of follow-up was similar between groups. Time to recurrence was significantly shorter in patients undergoing repeat prolapse surgery 8.8 vs 30.7 months (p = 0.03).

Conclusions

VR is a better option for patients undergoing primary rectal prolapse repair.

     

Robotic transanal surgery (RTAS) with utilization of a next-generation single-port system: a cadaveric feasibility study

Purpose

Transanal surgery remains both an innovative approach to rectal pathology and a demonstrated technical challenge. Improved technology using a single-port system robotic platform (SPS) offers a promising option for this surgery.

Methods

SPS robotic system was utilized to perform submucosal, full-thickness and cylindrical excision on four cadavers. Operative performance and surgeon fatigue were measured.

Results

On all types of resections, the SPS system performed well. There were no piecemeal or fragmented resections. Closure was judged to be good to excellent in all cases. Surgeon assessment of setup and performance of the SPS was excellent in all cases.

Conclusions

SPS robotic transanal surgery represents an exciting new option for transanal surgery.

     

Duodenum-preserving total pancreatic head resection for cystic neoplastic lesions in the head of the pancreas

Background/Purpose

Cystic neoplastic lesions of the pancreas are now found with increasing frequency. Duodenumpreserving pancreatic head resection with segmental resection of the duodenum has been introduced for the surgical treatment of inflammatory and neoplastic lesions. We report the following data from 15 patients treated surgically for cystic neoplastic lesions of the pancreas head.

Methods

Duodenum-preserving total pancreatic head resection (DPPHRt) with segmental resection of the duodenum (SD) was performed in eight patients, five with intraductal papillary mucinous neoplasm (IPMN), two with mucinous cystic neoplasm (MCN), and one with cystic endocrine neoplasm (EN). In four patients, a subtotal pancreatic head resection was performed, but recurrence of the IPMN lesion was observed in two patients. Ten patients suffered cystadenoma, three patients had a borderline lesion, and two patients had an in-situ carcinoma.

Results

Eight patients had a DPPHRt with SD resection, two patients had a resection of the uncinate process including segmental resection of the inferior duodenal segment, and one patient had a duodenum-and spleen-preserving total pancreatectomy. In four patients a DPPHR with subtotal pancreatic head resection was carried out. Postoperative local complications occurred in eight patients: there was a recurrence of the IPMN lesion in the remnant pancreatic head in two patients; and there was intraabdominal bleeding in one patient, pancreatic fistula in one patient, and delay of gastric emptying in four patients. Seven patients showed signs of acute pancreatitis. Hospital mortality was 0%, and postoperative length of hospital stay was 10. 4 days (range, 8–18 days).

Conclusions

Duodenum-preserving total pancreatic head resection for IPMN, MCN, serous cystadenoma (SCA), and cystic EN lesions is a safe and beneficial surgical procedure. Segmental resection of the duodenum was applied for an oncologically complete resection. In regard to long-term outcome, the procedure is, additionally, a pancreatic cancer preventive strategy.

     

Diagnostic Evaluation of Patients Presenting to Primary Care with Rectal Bleeding

Background

Rectal bleeding is a common, frequently benign problem that can also be an early sign of colorectal cancer. Diagnostic evaluation for rectal bleeding is complex, and clinical practice may deviate from available guidelines.

Objective

To assess the degree to which primary care physicians document risk factors for colorectal cancer among patients with rectal bleeding and order colonoscopies when indicated, and the likelihood of physicians ordering and patients receiving recommended colonoscopies based on demographic characteristics, visit patterns, and clinical presentations.

Design

Cross-sectional study using explicit chart abstraction methods.

Participants

Three hundred adults, 40–80 years of age, presenting with rectal bleeding to 15 academically affiliated primary care practices between 2012 and 2016.

Main Measures

1) The frequency at which colorectal cancer risk factors were documented in patients’ charts, 2) the frequency at which physicians ordered colonoscopies and patients received them, and 3) the odds of ordering and patients receiving recommended colonoscopies based on patient demographic characteristics, visit patterns, and clinical presentations.

Key Results

Risk factors for colorectal cancer were documented between 9% and 66% of the time. Most patients (89%) with rectal bleeding needed a colonoscopy according to a clinical guideline. Physicians placed colonoscopy orders for 74% of these patients, and 56% completed the colonoscopy within a year (36% within 60 days). The odds of physicians ordering recommended colonoscopies were significantly higher in patients aged 50–64 years of age than in those aged 40–50 years (OR?=?2.23, 95% CI: 1.04, 4.80), and for patients whose most recent colonoscopy was 5 or more years ago (OR?=?4.04, 95% CI: 1.50, 10.83). The odds of physicians ordering and patients receiving recommended colonoscopies were significantly lower for each primary care visit unrelated to rectal bleeding (OR?=?0.85, 95% CI: 0.75, 0.96).

Conclusions

Diagnostic evaluation of patients presenting to primary care with rectal bleeding may be suboptimal because of inadequate risk factor assessment and prioritization of patients’ other concurrent medical problems.

     

Selection of EMR and ESD for Laterally Spreading Lesions of the Colon

Introduction

Colonic laterally spreading lesions (LSL) are increasingly managed using endoscopic methods that comprise two main techniques: endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD).

Purpose of Review

In this review, we aimed to review the most recent literature on selection of the best endoscopic technique in the management of colonic LSL.

Recent Findings

EMR and ESD are complimentary techniques in the management of patients with colonic LSL.

Summary

EMR is safe and effective in most patients with LSL, except for cancers with submucosal invasion in whom R0 resection is favored.

     

Les lésions précancéreuses des carcinomes mucineux colorectaux: étude immunohistochimique et analytique de 53 cas

Aim

By studying 53 cases of mucinous colorectal carcinomas (MC), we tried to identify the possible type of precancerous lesion generating this tumor. Furthermore, we estimate the proportion of each type of cells (goblet cells or enterocytes) constituting the tumors we examined, in order to better understand the carcinogenetic pathways.

Materials and methods

It is a retrospective study of 53 cases of mucinous carcinomas. On macroscopic examination, we multiply prelevement between tumor and normal mucosa in order to increase the chance of finding the preneoplastic lesion. An interesting complementary immunohistochemical examination was performed for each tumor with a panel of antibodies: p53 and p21-ras markers of the loss of heterozygosity (LOH), and MLH1 and MSH2 main markers of the pathway of microsatellite instability MSI, as well as Muc1 and Muc2.

Results

Serrated crypt polyps (SCPs) and Peutz-Jeghers polyps (PPJs) degenerate in 100% of the cases studied into mucinous carcinomas. The cytology of preneoplastic lesions was similar to the tumor it had generated in 100% of our cases. The PPJs and SCPs generated the MC in 100% of cases. The MC preferentially followed the path of MSI.

Conclusion

The PPJs and SCPs constitute the preferential precancerous lesion of mucinous carcinomas. The main carcinogenetic way generating MC should be the MSI pathway.

     

Self-reported wellbeing and body image after abdominoperineal excision for rectal cancer

Purpose

Patients with low rectal cancer are often operated with an abdominoperineal excision (APE) rendering them a permanent stoma. The surgical procedure itself, the cancer diagnosis, and the permanent stoma might all affect quality of life. The aim of this study was to explore wellbeing and body image 3 years after APE in a population-based cohort of patients.

Methods

All patients with rectal cancer operated with an APE between 2007 and 2009 were identified using the Swedish ColoRectal Cancer Registry. A total of 545 patients answered a questionnaire 3 years after surgery. Two open-ended questions were analyzed with a mixed method design using both qualitative and quantitative content analysis. Main themes and sub-themes on wellbeing and body image were identified.

Results

Three main themes were identified: bodily limitations, mental suffering, and acceptance. Bodily limitations included other symptoms than stoma-related problems. A majority of patients expressed acceptance to their situation regardless of bodily limitations and mental suffering. However, 18 % did not describe any acceptance of their current situation.

Conclusions

Most patients expressed acceptance reflecting wellbeing 3 years after APE for rectal cancer. There is, however, a subset of patients (18 %) who describe bodily limitations and mental suffering without acceptance and who require further support. Many aspects of the portrayed bodily limitations and mental suffering could be prevented or treated.

Trial registration

NCT01296984.

     

Management of patients with rectal prolapse: the 2017 Dutch guidelines

Background

Rectal prolapse—both external rectal prolapse and internal rectal prolapse—is a disabling condition. In view of the overwhelming number of surgical procedures described for the treatment of rectal prolapse, a comprehensive update concerning the diagnostic and therapeutic pathway for this condition is required to draw recommendations for clinical practice. This initiative was commissioned by the Dutch Association for Surgery (Nederlandse Vereniging voor Heelkunde) as a multidisciplinary collaboration.

Methods

Nine questions outlining the diagnostic approach, conservative and surgical management of rectal prolapse were selected. A systematic literature search for evidence was then conducted in the Medline and Embase databases.

Results

Recommendations included diagnostic approach, methods to assess complaints of fecal incontinence and/or obstructive defecation and treatment options, both conservative and surgical. A level of evidence was assigned to each statement following the Grades of Recommendation Assessment, Development and Evaluation (GRADE) system.

Conclusions

These guidelines for clinical practice are useful in the diagnosis and treatment of rectal prolapse. There are many statements requiring a higher level of evidence due to a lack of studies.

     

Prophylactic pelvic drainage after rectal resection with extraperitoneal anastomosis: is it worthwhile? A meta-analysis of randomized controlled trials

Background

The role of prophylactic pelvic drainage in reducing the postoperative complication rate after rectal surgery remains unclear and controversial.

Objective

This review and meta-analysis of prospective randomized controlled trials was performed to determine whether drainage of the extraperitoneal anastomosis after rectal surgery impacts the postoperative complication rate.

Study eligibility criteria

Study eligibility criteria included randomized controlled trials comparing prophylactic pelvic drainage after rectal surgery.

Methods

The Medline and Cochrane Trials Register databases were searched for prospective randomized controlled trials comparing drainage versus no drainage after rectal surgery. Studies published until December 2016 were included. The meta-analysis was performed using Review Manager 5.0 (Cochrane Collaboration, Oxford, UK).

Results

Three randomized controlled trials involving 660 patients with extraperitoneal anastomosis after rectal surgery (330 with and 330 without prophylactic pelvic drains) were included. The overall mortality rate was 0.7% (2/267) in the drain group and 1.9% (5/261) in the no-drain group (P = 0.900). The anastomotic leakage rate was 14.8% (49/330) in the drain group and 16.7% (55/330) in the no-drain group (P = 0.370). The postoperative small bowel obstruction rate was significantly higher in the drain than no-drain group (50/267, 18.7% vs. 33/261, 12.6%; odds ratio, 1.61; 95% confidence interval, 1.00–2.60; P = 0.050).

Conclusions

Prophylactic use of pelvic drainage after extraperitoneal colorectal anastomosis has no impact on the incidence of anastomotic leakage or postoperative death. However, it significantly increases the rate of postoperative small bowel obstruction.

     

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.

     

Evaluation of the International Consensus Guidelines for the Surgical Resection of Intraductal Papillary Mucinous Neoplasms

Background

International consensus guidelines for intraductal papillary mucinous neoplasms (IPMNs) were revised in 2012.

Aims

We aimed to evaluate the clinical utility of each predictor in the 2006 and 2012 guidelines and validate the diagnostic value and surgical indications.

Methods

Forty-two patients with surgically resected IPMNs were included. Each predictor was applied to evaluate its diagnostic value.

Results

The 2012 guidelines had greater accuracy for invasive carcinoma than the 2006 guidelines (64.3 vs. 31.0%). Moreover, the accuracy for high-grade dysplasia was also increased (48.6 vs. 77.1%). When the main pancreatic duct (MPD) size ≥8 mm was substituted for MPD size ≥10 mm in the 2012 guidelines, the accuracy for high-grade dysplasia was 80.0%.

Conclusions

The 2012 guidelines exhibited increased diagnostic accuracy for invasive IPMN. It is important to consider surgical resection prior to invasive carcinoma, and high-risk stigmata might be a useful diagnostic criterion. Furthermore, MPD size ≥8 mm may be predictive of high-grade dysplasia.

     

Low anterior resection syndrome: a survey of the members of the American Society of Colon and Rectal Surgeons (ASCRS), the Spanish Association of Surgeons (AEC), and the Spanish Society of Coloproctology (AECP)

Background

Low anterior resection syndrome (LARS) is frequent following sphincter-sparing procedures for rectal cancer.

Objective

This study aims to assess surgeons’ awareness of LARS.

Design

This was a survey study.

Settings

Members of the American Society of Colon and Rectal Surgeons (ASCRS), the Spanish Association of Surgeons (AEC), and the Spanish Society of Coloproctology (AECP).

Participants

Three hundred thirty-four surgeons from the ASCRS and 150 from the Spanish Societies completed a 23-item electronic questionnaire.

Main outcome measures

Surgeons’ opinions regarding different aspects of LARS.

Results

The proportion of rectal cancer patients undergoing sphincter-sparing operations ranged between 71 and 90 %. Low anterior resection with end-to-end anastomosis was the most frequently cited procedure after mesorectal excision. More than 80 % of participants were recognized to be moderately or extremely aware of the condition, but regarding the method used to assess LARS, the majority relied on clinical manifestations. Around 35 % of surgeons considered that severe LARS developed in less than 40 % of patients. The most important factor related to defecatory function impairment in the surgeons’ opinion was the distance from the anal margin to anastomosis. Other factors thought to be involved were anastomotic leakage, preoperative radiation therapy, age, and postoperative radiotherapy, with similar percentages in the two groups of surgeons. Lifestyle changes and dietary measures associated with or without drug treatment was the modality of choice. The experience with transanal irrigation or sacral nerve stimulation was limited. It was considered that <30 % of patients chronically suffer from severe LARS with significant quality of life impairment.

Limitations

The limitations of this study are the international mix and expert status of the specialists.

Conclusions

The probability of patients suffering from LARS was underestimated despite reporting good knowledge of the syndrome. Validated methods for the assessment of LARS were rarely used. Deficient awareness regarding risk factors for LARS was documented. Knowledge of therapeutic options was also limited.

     

Mucosa-associated lymphoid tissue (MALT) variant of primary rectal lymphoma: a review of the English literature

Purpose

Primary rectal lymphoma (PRL) is the third most common cause of rectal cancer following adenocarcinoma (90–95 %) and carcinoid (5 %). The most common variant of PRL is the mucosa-associated lymphoid tissue (MALT) type. To date, no study has been able to recommend an optimal treatment algorithm for this rare disease. The aim of our study was to review the English literature on primary rectal MALT lymphoma.

Methods

A review of the English literature was conducted to identify articles describing the MALT variant of PRL.

Results

Fifty-one cases were identified. A complete response was achieved in 12 of 19 cases treated with Helicobacter pylori eradication therapy, 5 of 6 with radiation, 2 of 4 cases with chemotherapy, 2 of 4 with endoscopic resection, 6 of 8 cases with surgical resection, and all 8 with combination therapies. Cases failing initial therapies were responsive to various second-line treatments. Two cases spontaneously regressed with observation alone.

Conclusion

Complete regression of primary rectal MALT lymphoma was achieved using various therapeutic strategies, although the numbers of different treatment modalities are too small to draw definitive conclusions.

     

Prognostic impact of hospital volume on familial adenomatous polyposis: a nationwide multicenter study

Purpose

Many studies have shown that hospital volume is significantly associated with short- and long-term outcomes in various diseases, including cancer. However, there have been no reports discussing the relationship between hospital volume and familial adenomatous polyposis (FAP). This study aimed to clarify whether hospital volume affects short- and long-term outcomes in FAP patients.

Methods

We established a retrospectively collected database of FAP patients who underwent initial surgical treatment at 23 Japanese institutions during 2000–2012. Factors associated with short- and long-term outcomes were analyzed.

Results

The study cohort included 303 FAP patients. These patients were classified into tertile categories according to hospital volume: low (n = 31), middle (n = 72), and high volume (n = 200). The proportion of only adenoma/stage 0 was comparable among tertile categories. The adoption of operative procedure significantly differed among tertile categories; specifically, high-volume institutions preferred handsewn ileal pouch-anal anastomosis without diverting ileostomy (P < 0.001 and < 0.001, respectively). Nevertheless, the frequency of complications with Clavien-Dindo classification grade ≥ 3 was not significantly different among tertile categories. Functional results were acceptable in every category. Wexner scores were significantly lower in high-volume compared to low-volume institutions (P = 0.02). Multivariate analyses showed that UICC stage and hospital volume were significantly associated with overall survival (P = 0.04 and 0.03, respectively).

Conclusions

Hospital volume was significantly associated with short- and long-term outcomes in FAP patients.

     

Anastomotic leakage following low anterior resection for rectal cancer

Aim

Aim of this study is to present the incidence of anastomotic leakage after anterior resection for rectal cancer and to demonstrate the therapeutic approach for the treatment of this complication.

Patients and methods

Between 1990 and 2009, 170 patients underwent low anterior resection with total mesorectal excision (TME).

Results

A total of 14 (8.2%) anastomotic leaks were confirmed. Reoperation was carried out in six patients with major leaks. Eight patients with minor leaks were treated conservatively by nutritional support and antibiotic therapy.

Conclusion

The incidence of anastomotic leakage after anterior resection of the rectum for rectal cancer is relatively low.

     

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.