Rectal Excision Research Articles

TU4.2 Robotic surgery for colorectal cancer: a single-center experience

AimTo present our learning-curve data for patients that underwent robotic-assisted colorectal surgery (RCRS) at a large NE London DGH.MethodsWe report our data from 50 initial colorectal cancer resections, performed by two surgeons. We report the gender, age, histopathology, surgery performed, surgical time, conversion, post-operative complications, and hospital stay.ResultsThe first 50 patients who underwent RCRS between February 2020 and December 2021 for malignancy were included. Twenty-one were right hemicolectomies, 16 high anterior resection, 6 extended right hemicolectomies, 4 low anterior resections (including a planned robotic boari flap in 1 case by a trained urologist), 3 abdominoperineal excisions of rectum. The male to female ratio was 1:1 and the mean age was 65 (range: 22–85) years. The ASA class distribution was 4% ASA I, 64% ASA II, 32% ASA III.The median surgical time was 263 minutes (120–620) with median console time 136 minutes (50–540), the median hospital stay 5 days (range: 2–35) and a conversion rate of 6% (3/50 patients). The most common post-operative complications were ileus 4% (4/50), wound infection 6% (3/50), anastomotic leak 6% (3/50), and abscess formation 2% (1/50). 1 mortality occurred in a patient with an operated leak who contracted COVID-19. All patients underwent confirmed R0 resections with a negative CRM.ConclusionWe report our first 50 robotic cases for colorectal malignancy, showing that robotic-assisted surgery can be performed with low rates of conversion 3 cases (6%) and low rates of post-operative complications despite a challenging patient demographic and a sharp learning curve.

Management and Outcomes in Anal Canal Adenocarcinomas-A Systematic Review.

Simple SummaryAnal canal adenocarcinomas are a rare type of bowel cancer. For this reason, it is challenging to perform large studies in order to determine the optimal treatment strategy to achieve the best outcomes. Options for treatment include radiotherapy, chemotherapy and surgery. These treatments may be combined or used alone. Outcomes are regarded as survival after diagnosis and treatment, or the recurrence of the disease. There is no universal gold standard that exists, with wide variability in practice and therefore also in outcomes between institutions. Thus, by reviewing the body of literature on the subject matter, the hope is to establish a management algorithm that may be tested and refined going forward. This is the intention of this systematic review.(1) Background: Anal canal adenocarcinomas constitute 1% of all gastrointestinal tract cancers. There is a current lack of consensus and NICE guidelines in the United Kingdom regarding the management of this disease. The overall objective was to perform a systematic review on the multitude of practice and subsequent outcomes in this group. (2) Methods: The MEDLINE, EMBASE, EMCARE and CINAHL databases were interrogated between 2011 to 2021. PRISMA guidelines were used to select relevant studies. The primary outcome measure was 5-year overall survival (OS). Secondary outcome measures included both local recurrences (LR) and distant metastases (DM). The Newcastle–Ottawa Scale (NOS) was used to assess the quality of studies retrieved. The study was registered on PROSPERO (338286). (3) Results: Fifteen studies were included. Overall, there were 11,967 participants who were demographically matched. There were 2090 subjects in the largest study and five subjects in the smallest study. Treatment modalities varied from neoadjuvant chemoradiotherapy (CRT), CRT and surgery (CRT + S), surgery then CRT (S + CRT) and surgery only (S). Five-year OS ranged from 30.2% to 91% across the literature. LR rates ranged from 22% to 29%; DM ranged from 6% to 60%. Study heterogeneity precluded meta-analysis. (4) Conclusions: Trimodality treatment with neoadjuvant chemoradiotherapy (CRT) followed by radical surgery of abdominoperineal excision of rectum (APER) appeared to be the most effective approach, giving the best survival outcomes according to the current data.

Dermatofibrosarcoma protuberans of perianal region: a rare case report

Dermatofibrosarcoma protuberans (DFSP) is a rare locally aggressive slow growing soft tissue sarcoma with very low metastatic potential with high local recurrence rates. We presented a rare case of DFSP of left perianal region ulcerating into anal canal, we did wide excision with 3 cm margin along with abdominoperineal excision of rectum and permanent colostomy, defect is reconstructed with left pedicled antero-lateral thigh flap. DFSP has high chance of recurrence, it should be excised with at least 2-3 cm 3D margin and patient should be followed up for a long time.

Trends in General Surgery Resident Experience with Colorectal Surgery: An Analysis of the Accreditation Council for Graduate Medical Education Case Logs

Colorectal surgery is a core component of general surgery. The volume of colorectal surgery performed by general surgery residents throughout training has not been studied. This study aims to analyze trends observed in colorectal-specific case numbers logged by general surgery residents over 16 years. Case number data for general surgery residents was extracted from the publicly available, annually published Accreditation Council for Graduate Medical Education (ACGME) database from 2003 to 2019. Cases were categorized as open or laparoscopic colectomy/proctectomy, colectomy with ileoanal pull-thru, abdomino-perineal resection (APR), transanal rectal tumor excision (TRE), anorectal procedure, colonoscopy, and total colorectal cases. The average case numbers per category was calculated for each year. Linear regression analyzed trends in case categories for all residents and those logged as surgeon chief and junior residents. ACGME accredited general surgery residency programs. Not applicable. General surgery residents reported increased numbers of all, chief, and junior resident colorectal cases over the study period (124.5-173.7 cases/yr; 38.4-53.0 cases/yr; 86.4-120.6 cases/yr, all p = 0.00). Average cases for all, chief, and junior residents have increased for laparoscopic colectomy/proctectomy (4.6-26.4 cases/year; 2.7-12.9 cases/year; 2.0-13.5 cases/year, all p = 0.00), anorectal surgeries (26.7-37.7 cases/year; 5.4-9.9 cases/year; 21.3-27.8 cases/year, all p = 0.00), and colonoscopies (35.9-70.6 cases/year, p = 0.00; 6.6-14.1 cases/year, p = 0.01; 29.4-56.5 cases/year, p = 0.00). Average cases for all, chief, and junior residents have decreased for open colectomy/proctectomy (52.0-34.9 cases/year; 21.2-14.3 cases/year; 30.9-20.6 cases/year, all p = 0.00), APR (3.3-2.7 cases/year, p = 0.00; 1.8-1.3 cases/year, p = 0.00; 1.5-1.4 cases/year, p = 0.02), TRE (1.9-1.1 cases/year; 0.7-0.4 cases/year; 1.2-0.6 cases/year, all p = 0.00). Ileoanal pull-thru did not demonstrate a linear trend. The increase in exposure to colectomies/proctectomies, anorectal procedures and colonoscopies is encouraging, as these common colorectal operations will be encountered in general surgery practice. The observed low case numbers for TRE, APR, and ileoanal pull-thru suggest a need for specialized training.

Preoperative Imaging in Patients with Deep Infiltrating Endometriosis: An Important Aid in Predicting Depth of Infiltration in Rectosigmoid Disease

To determine the diagnostic accuracy of specialist-performed transvaginal ultrasound (TVUS) and pelvic magnetic resonance imaging (MRI) modalities in predicting depth of deep infiltrating endometriosis (DIE) of the rectosigmoid by comparison with histologic specimens obtained at surgery. A retrospective analysis, which met the Standards for Reporting of Diagnostic Accuracy Studies (2015) guidelines for a diagnostic accuracy study. Tertiary teaching hospital. A total of 194 cases who underwent preoperative discussion at the gynecologic endosurgery unit multidisciplinary meeting between January 2012 and December 2019 were eligible for inclusion. Retrospective assessment of the accuracy of TVUS and MRI in predicting histologic depth of rectosigmoid DIE after operative management. Al total of 135 surgeries were performed for DIE; 20 underwent a rectal shave, 14 had a disc/wedge resection, 38 an anterior/segmental resection, and 63 had no rectosigmoid surgery. Of the 52 patients with full-thickness rectal wall excision, all patients had at least one imaging modality available for review; 42 (81%) had both. At least one imaging modality was in agreement with histologic depth in 48 cases (92%) (sensitivity, 94%; specificity, 50%; positive predictive value [PPV], 97.9%; negative predictive value [NPV], 25.0%; area under the receiver operating curve, 0.720; 95% confidence interval, 0.229-1.000). When TVUS was assessed in isolation, the test remained sensitive for any rectal wall involvement (sensitivity, 93.6%; specificity, 50.0%; PPV, 97.8%; NPV, 25.0%; area under the receiver operating curve, 0.718; 95% confidence interval, 0.227-1.000). When only MRI was assessed, the test demonstrated both high sensitivity and specificity for rectal wall disease (sensitivity, 86.4%; specificity, 100%; PPV, 100%; NPV, 14.2). Specialist-performed TVUS and MRI are accurate in predicting depth of disease in rectosigmoid endometriosis. These modalities were similar in their diagnostic performance at assessing depth of rectal wall involvement, and their use is justified in the preoperative planning of these gynecologic surgeries.

Impact of the distal resection margin on local recurrence after neoadjuvant chemoradiation and rectal excision for locally advanced rectal cancer

We aimed to evaluate whether a short distal resection margin (< 1 cm) was associated with local recurrence in patients with locally advanced rectal cancer who underwent preoperative chemoradiotherapy. Patients with rectal cancer who underwent preoperative chemoradiotherapy followed by curative surgery were divided into two groups based on the distal resection margin (≥ 1 cm and < 1 cm). In total, 507 patients were analyzed. The median follow-up duration was 48.9 months. The 3-year local recurrence rates were 2% and 8% in the ≥ 1 cm and < 1 cm groups, respectively (P < 0.001). Multivariable analysis revealed that a distal resection margin of < 1 cm was a significant risk factor for local recurrence (P = 0.008). Subgroup analysis revealed that a distal resection margin of < 1 cm was not an independent risk factor for local recurrence in the ypT0–1 group. However, among patients with tumor stages ypT2–4, the cumulative 3-year incidences of local recurrence were 2.3% and 9.8% in the ≥ 1 cm and < 1 cm groups, respectively (P = 0.01). A distal resection margin of < 1 cm might influence local recurrence rates in patients with locally advanced rectal cancer undergoing preoperative chemoradiotherapy, especially in patients with tumor stages ypT2–4.

Forty-Year Experience Alleviating Postoperative Hirschsprung-Associated Enterocolitis by Complete Full-Thickness Posterior Rectal Cuff Excision. The Anorectal Line Eliminates Problematic Anastomoses.

Introduction: A modified pull-through (PT) distinguished by complete full-thickness removal of the posterior rectal cuff, initially developed as an open procedure in 1980, has been performed with laparoscopic assistance since 1997. Postoperative bowel dysfunction improved when the anatomic landmark for PT surgery was revised from the dentate line (DL) to the anorectal (or Herrmann's) line (ARL) in 2007. A 40-year (1980-2019) review of 153 consecutive rectal/rectosigmoid type Hirschsprung's disease (HD) patients is presented. Methods: Data for postoperative bowel dysfunction and Hirschsprung-associated enterocolitis (HAEC) classified according to the American Pediatric Surgical Association (APSA) scale were obtained retrospectively. Results: PT was open (n = 43) and laparoscopic (n = 110). Dissection was DL (n = 57) and ARL (n = 96). Over 40 years, 5/153 patients (3.3%) had postoperative obstructive symptoms (POS), and 10/153 patients (6.5%) had 13 episodes of postoperative HAEC; APSA grades were: I (n = 4); II (n = 8); and III: (n = 1) presenting with explosive diarrhea (10/13; 76.9%), fever (10/13; 76.9%), abdominal distension (9/13; 69.2%), or bloody stools/shock (1/13 with grade III; 7.7%). The grade III case had histologically-proven transitional zone PT. Postoperative HAEC developed in 3/5 (60.0%) POS+ patients and 7/148 (4.7%) POS- patients (P = .002). Symptom duration and treatment were not correlated with APSA grades. Conclusions: Complete full-thickness posterior rectal cuff excision and using the ARL reduced postoperative HAEC significantly in this series. Despite being anatomically distinct, the DL is inadequate as a precise landmark for PT surgery because it lacks functional relevance. The APSA scale could benefit from timely review to improve its clinical and prognostic value.

&#8220;Watch and wait&#8220; strategy in the treatment of patients with rectal carcinoma.

Innovative treatment strategies which do not involve oncosurgical radical rectal resection have been explored within the last decades in the management of patients with rectal carcinoma. Resection of the rectum with total mesorectal excision is burdened not only with significant postoperative morbidity, but also with symptoms of bowel, urinary and sexual dysfunctions, which can significantly affect patients quality of life. The aim of these alternative strategies is to preserve the anatomy and function of the rectum (so called organ preservation approach). This approach includes three innovative strategies: &#8220;watch and wait&#8221; strategy, neoadjuvant radiochemotherapy completed with transanal rectal carcinoma excision (or excision of the scar remaining after neoadjuvant therapy) and neoadjuvant radiochemotherapy of an early rectal carcinoma. So far, evidence supporting the organ preservation approach is highly insufficient in the available literature. There are no clear indication criteria for these strategies, no unequivocal criteria for complete clinical response detection and vague recommendations regarding an optimal neoadjuvant regimen or patients follow-up. Organ preservation approach is therefore considered to be an experimental treatment strategy, which should be offered only to patients within clinical trials with a high-quality design and very careful long-term follow-up. Patients considered for &#8220;watch and wait&#8221; must be informed properly about the benefits and drawbacks of the strategy including the risk of rectal carcinoma recurrence in 30% of the patients.

618 Management of Rectal Cancer in England And Wales. Is the Rate of Abdominoperineal Excision of Rectum Associated with The Pre-Operative Radiotherapy Rates?

Abstract Aim Rectal cancer treatment has improved over the years, but variations in practice remain. Abdominoperineal resection (APER) is associated with significant morbidity and pre-operative radiotherapy (RT) is only recommended for advanced rectal cancer. As such, APER and RT should be reserved for patients with an appropriate clinical need. The aim of the study is to evaluate the association between the rates of APER and RT, and whether any other factors are associated. Method Data on rectal cancer cases was extracted from National Bowel Cancer Audit 2019. Primary outcomes were: APER rate, RT rate. Pearson’s correlation coefficient was calculated. The means for APER and pre-operative radiotherapy were plotted on a four-quadrant matrix. The differences were analysed using Mann-Whitney U and Student T-test. Results 3,764 patients were included. A mean of 25% (95%CI: 10.3-14.9%) underwent APER and an average of 34% (95%CI: 30.5-36.8%) received RT. There was a weak positive correlation between rates of APER and RT (r = 0.356, p &amp;lt; 0.001). 43 (37%) trusts had proportions of both APER and RT below the overall mean, whilst 30 (26%) had both proportions above. No significant differences were found when comparing other variables between the high to low-rate trusts (p &amp;gt; 0.05). Conclusions There is a weak positive correlation between the proportion of rectal cancer patients undergoing APER and the proportion receiving RT in trusts across England and Wales. It is unknown whether this finding has a clinical significance and further analysis on trust/surgeon performance and patient demographics is needed, allowing for prevention strategies to be implemented.

Assessment of Circumferential Resection Margins (CRM) clearance in Conventional open Versus Laparoscopic Cancer Rectum Resection

Abstract Background Colon and rectal cancer represent the fourth commonest malignancy worldwide. Globally, colon and rectal cancer make up 9.4% and 10.1% in men and women of all cancers, respectively. Colon and rectal tumors are the third most common malignancy after breast and lung cancer, respectively. The main management of rectal cancer involves a multi-disciplinary team approach and an individually tailored treatment routine. Operative surgery remains the primary and definitive treatment for locally confined rectal adenocarcinoma and is the only historical and current treatment which allows for cure. Resection of the colon and rectal cancer can be done either by open surgical excision or laparoscopically. Aim of the work The objective is to compare the radicality of total mesorectal excision for rectal cancer in both open and laparoscopic surgery through the pathology report. Methods In this multicentric, prospective, comparative study, we included the pathologically established rectal cancer patients from 2 hospitals in Cairo, Egypt, Ain Shams University Hospitals and Maadi Military Hospital, Egypt between 2013 and 2016. The sample size was 40 patients divided into two groups; 20 patients for laparoscopic arm and 20 patients for the open trans-abdominal surgery. Inclusion criteria: histopathology confirmed rectal cancer, patients fit for operative resection, and with T1- T3 grades according to the preoperative evaluation. The exclusion criteria: Patients with T4 stage tumor, patients present as emergency cases and patients present with recurrence of the tumor and synchronous colonic tumors. Results The circumferential resection margins (CRM) of the mesorectum when examined pathologically after resection showed no difference between the two arms of the study with laparoscopic group specimens 3.18±1.16 mm mean, (SD) compared to 3.50±0.45 mm mean, (SD) in the open surgery group with no statistically significant difference. The longitudinal resection margins (LRM) was (5.50±1.98 mean, SD) in the laparoscopic group compared to (5.20±2.28 mean, SD) in the open conventional surgery group with no significant difference found between the two groups. Total operative time was significantly shorter in the trans-abdominal surgery group, while the hospital stay period was significantly shorter in the laparoscopy group. Laparoscopy group also showed significantly time before flatus passage, and the patients in the laparoscopy group started oral intake faster than open surgery group. Conclusion In our study, the radicality of the rectal cancer excision in both laparoscopic and traditional open surgery, showed non inferiority of the laparoscopic technique over open surgery Long-term clinical outcomes of overall survival and recurrence is the foremost parameters which should be taken in consideration for decision for laparoscopic surgery for rectal cancer. Additional follow-up results from the current trial are presently being developed, beside with records on other secondary end points, like cost effectiveness and quality of life.

Interposition of a biological mesh may not affect the rate of rectovaginal fistula after excision of large rectovaginal endometriotic nodules: a pilot study of 209 patients.

The aim of this work was to assess whether placement of a biological mesh (Permacol® ) between the vaginal and rectal sutures reduces the rate of rectovaginal fistula in patients with deep rectovaginal endometriosis. We report a retrospective, comparative study enrolling patients with vaginal infiltration of more than 3cm in diameter and rectal involvement in two centres. They benefited from complete excision of rectovaginal endometriotic nodules with or without a biological mesh placed between the vaginal and rectal sutures. The rate of rectovaginal fistula was compared between the two groups. Two hundred and nine patients were enrolled: 42 patients underwent interposition of biological mesh (cases) and 167 did not (controls). Ninety-two per cent of cases and 86.2% of controls had rectal infiltration more than 3cm in diameter. Cases underwent rectal disc excision more frequently (64.3% vs. 49.1%) and had a smaller distance between the rectal staple line and the anal verge (4.4±1.4cm vs. 6±2.9cm). Rectovaginal fistulas occurred in 4 cases (9.5%) and 12 controls (7.2%). Logistic regression analyses revealed no difference in the rate of rectovaginal fistula following the use of mesh (adjusted OR 1.6, 95% CI 0.3-9.5). A distance of less than 7cm between the rectal staple line and the anal verge was found to be an independent risk factor for the development of rectovaginal fistula (adjusted OR 15.1, 95% CI 1.7-132). Our results suggest that the placement of a biological mesh between the vagina and rectal sutures may not affect the rate of formation of postoperative rectovaginal fistula following excision of deep infiltrating rectovaginal endometriosis.

Megarectum: systematic histopathological evaluation of 35 patients and new common pathways in chronic rectal dilatation

AimsMegarectum is well described in the surgical literature but few contemporary pathological studies have been undertaken. There is uncertainty whether ‘idiopathic’ megarectum is a primary neuromuscular disorder or whether chronic...

Total neoadjuvant treatment versus standard chemoradiation to increase the sphincter preservation rate for distal locally advanced rectal cancer (TESS).

TPS3615 Background: Standard treatment of rectal cancer is neoadjuvant capecitabine chemotherapy with radiotherapy, followed by total mesorectal excision (TME). Total neoadjuvant treatment (TNT), a new concept, suggests organ preservation as an alternative to rectal excision in good responders after neoadjuvant chemoradiotherapy to decrease surgical morbidity and increase quality of life. RAPIDO and PRODIGE-23 trials showed that TNT strategy could improve the pathological complete response (pCR) rateand reduce the risk of distant metastasis. The objective of this trial is to increase the proportion of sphincter preservation rate for distal rectal cancer patients by optimizing tumor response, by using TNT regimen as compared to conventional chemoradiotherapy. TESS (clinicalTrials.gov, NCT03840239), a prospective, open label, multicenter, randomized phase 2 study, is underway. Methods: Main inclusion criteria include: cT3-4aNany or cTanyN+ rectal adenocarcinoma aged 18-70y; ECOG performance 0-1; distance≤5cm from anal verge. 168 patients will be randomized 1:1. Patients in the TNT group will receive 2 cycles of neoadjuvant chemotherapy Capeox (capecitabine + oxaliplation) before, during and after radiotherapy 50Gy/25 fractions, before TME (or other treatment decisions, such as watch and wait) and adjuvant chemotherapy capecitabine 2 cycles. Patients in the standard treatment group will receive neoadjuvant radiotherapy 50Gy/25 fractions combined with capecitabine 5 weeks before TME (or other treatment decisions, such as watch and wait), and adjuvant chemotherapy Capeox 6 cycles. Primary endpoint is the rate of sphincter preservation rate (absence of stoma). Secondary endpoints include: Ratio of sphincter preservation strategy; pathological complete response rate and tumor regression grade distribution; acute toxicity; surgical complications; long-term anal function; late toxicity; ECOG standard score; disease-free survival; overall survival. First site opened in January 24, 2019. Clinical trial information: NCT03840239.

Systematic Early Urinary Catheter Removal Integrated in the Full Enhanced Recovery After Surgery (ERAS) Protocol After Laparoscopic Mid to Lower Rectal Cancer Excision: A Feasibility Study.

PurposeEnhanced Recovery After Surgery (ERAS) programs advocate early urinary catheter removal after rectal cancer surgery; however, the optimal duration remains unclear. This study assessed the feasibility of the early urinary catheter removal protocol after rectal cancer surgery within an ERAS pathway and identified predictive factors for failure of this strategy.MethodsBetween March 2017 and October 2018, all unselected and consecutive patients who underwent rectal cancer resection and benefited from our ERAS program were included. Urinary complications (infection and retention) were prospectively recorded. Success was defined as catheter removal on postoperative day (POD) 3 without urinary complications.ResultsOf 135 patients (male, 63.7%; neoadjuvant chemoradiation, 57.0%; urology history, 17.8%), 120 had early urinary catheter removal with no complications (success rate, 88.9%), 8 did not have urinary catheter removal on POD 3 due to clinical judgment or prescription error, 5 experienced a urinary tract infection, and 2 had acute urinary retention. Obesity (odds ratio [OR], 0.16; P = 0.003), American Society of Anesthesiologists physical status classification > II (OR, 0.28; P = 0.048), antiaggregant platelet medication (OR, 0.12; P < 0.001), absence of anastomosis (OR, 0.1; P = 0.003), and prolonged operative time (OR, 0.21; P = 0.020) were predictive factors for failure. Conversely, optimal compliance with the ERAS program (OR, 7.68; P < 0.001), postoperative nonsteroidal anti-inflammatory drug use (OR, 21.71; P < 0.001), and balanced intravenous fluid therapy (OR, 7.87; P = 0.001) were associated with increased strategy success.ConclusionWithdrawal of the urinary catheter on POD 3 was successfully achieved after laparoscopic rectal resection and can be safely implemented in the ERAS program.

Robotic Transanal Surgery: A Novel Approach for Full-Thickness Rectal Excision.

Transanal excision of rectal lesions is a full thickness excision that is indicated in selected cases of early stage rectal cancer and in cases that have shown a major or complete clinical response after neoadjuvant chemoradiation. Complete clinical response includes also flat scar or teleangiectasia along with non palpable mass at digital exam and non visible lymphnodes at MRI.1 Full thickness excision is considered primarily as a radical excisionaI biopsy and it has the advantage (vs watch and wait approach) to provide a hystologic confirmation of the complete response. The excision of the tumor/scar and the suture of the rectal defect are technically demanding if performed with standard laparoscopic instruments because of the narrow working space. In order to overcome these difficulties we propose to use the daVinci® robotic platform. The robotic instruments are fully articulated at their tip and they allow the surgeon to easily operate within the lumen of the rectum and perform wrist like movements despite the narrow surgical space. The one limitation is represented by the cost of these procedures, so they should be reserved to selected, challenging cases (i.e. lesions of the mid-upper rectum and lesions that require extensive suture). The patients are either in lithotomy or prone position, depending on the site of the lesion. A gelpoint® system is inserted transanally in order to place the robotic trocars and the daVinci® system is then connected. The purpose of this video is to show the many advantages of the robotic platform in performing full thickness excisions and how the wrist like movements allow to perform transversal sutures thus minimizing the risk of stenosis of the rectum. See Video at http://links.lww.com/DCR/B515 .

Perineal hernia repair after abdominoperineal rectal excision with prosthetic mesh-a single surgeon experience.

Extralevator abdominoperineal excision for rectal cancer is associated with an increased incidence of perineal hernia. The purpose of this study was to determine clinical outcome following perineal hernia repair with prosthetic mesh by a perineal open approach. We present a case series of 10 patients who underwent 12 repairs of their hernia using a prosthetic mesh placed by a perineal open technique. Patients were identified from a prospectively maintained database and their case records were retrieved along with their imaging and analysed retrospectively. Perineal hernia incidence in our series is 10%. The median age was 73±5.9years. No gender predilection was found. The median time interval between extralevator abdominoperineal excision and surgical repair of perineal hernia was 25.3months. The surgical approach was perineal with the use of a double layer prosthetic mesh. The recurrence ratio was 30% (n=3). Overall morbidity was also 30% with no major complications (Clavien-Dindo I-II). Recurrence following primary repair was diagnosed in a median time interval of 28.3±16.57months. Two patients had repeat surgery to treat their recurrence. Our small series supports the use of a prosthetic mesh repair of perineal hernias through a perineal approach. It is safe and effective with complication rates similar to those previously reported.

Re-exploring the pelvic neuroanatomy from a new perspective and a potential guidance for TaTME: a "bottom-up" approach.

Neuro-anatomy of the perineum has gained renewed attention due to its significance in the transanal procedures for rectal cancer (eg TaTME). Surgeons embarking on this technique must have sophisticated knowledge and a precise anatomical understanding of the perineum before proceeding with this reversed rectal approach. We report anatomical observations deriving from a relevant experience in the colorectal surgery field. The collective multicenter experience of the present study is clinically relevant and based on the rectal and transanal resections performed in colorectal centers of excellence from Greece, UK, and Italy over the last 10years (2011-2020). From the original anatomical and intraoperative observations derived from collective cases operated by this multicenter group of colorectal surgical centers in three Europeancountries, data were retrieved and analyzed in collaboration with specialist researchers of human anatomy and interpreted for their clinical significance and potential use for preoperative planning and intraoperative guidance during TaTME. This descriptive article demonstrates in detail the neurogenic pathways encountered in the perineum and pelvic cavity during transanal procedures. Specific anatomical and topographic implications are also included serving as a guide for colorectal surgeons to perform a nerve-sparing procedure. transanal approach for rectal excision offers new insights into the complex pelvic and perineal neuroanatomy while the procedure itself remains a challenge for surgeons. Preoperative anatomical planning and 3D reconstruction may help in anticipating technical difficulties, resulting in more precise surgical dissections and decreased postoperative complications.

Molecular Features of Lymph Node Metastasis in T1/2 Colorectal Cancer from Formalin-Fixed Paraffin-Embedded Archival Specimens.

Histological risk factors for lymph node metastasis (LNM) in early-stage colorectal cancers (CRC) have been described, although the predictive utility of these factors varies. Improved LNM risk assessment based on findings in endoscopic colon and rectal excisions is necessary for optimal surgical management of CRC patients with pathologic T1- /T2-staged invasive depth (i.e., tumor not invading beyond the muscularis propria layer); as the current system is overly conservative, and results in many unnecessary radical surgeries. To identify molecular features in early CRC with elevated LNM potential, we carried out proteomic and gene expression profiling to compare T1 lymph node (LN) negative with T1/2 LN positive CRC tumors from formalin-fixed paraffin-embedded (FFPE) specimens. Using a data-independent acquisition mass spectrometry workflow, we detected over 7400 proteins and quantified over 4400 in all 21 specimens. Proteins from tumors with LN metastasis were enriched with effectors of epithelial-mesenchymal transition (EMT) and gene expression profiling confirmed activation of key transcription factors, SNAI1 and ZEB1, as well as a reduction in E-cadherin expression. Toward an implementation pathway, we investigated immunohistochemistry assays targeting four EMT-related proteins. While MS could reliably discern twofold protein abundance changes, we found the semiquantitative nature of IHC scoring limited confirmation of this degree of protein expression difference. This study demonstrated that EMT effectors are associated with locoregional metastasis in T1/T2 CRC and could be used to augment metastatic risk assessment, although further developments are required to enable routine implementation.

Evaluation of functional outcomes after disc excision of deep endometriosis involving low and mid rectum using standardized questionnaires: a series of 80 patients

The aim was to assess the functional outcome and quality of life in patients with low and mid rectal endometriosis who have undergone disc excision using a semicircular transanal staple device, a procedure we have named the Rouen technique. This was a retrospective study of patients undergoing the Rouen technique between October 2009 and November 2018. Preoperative and postoperative demographic and operative data were recorded prospectively (mean ± SEM). Postoperative complications were recorded using the Clavien-Dindo classification. Rectal function and quality of life were assessed by the low anterior resection syndrome (LARS) and Bowel Endometriosis Syndrome (BENS) scores respectively at ≥6months. The Rouen procedure was performed on 80 patients (29.7±4.3). The mean diameter of resected specimens was 57±10mm, and the height of the rectal suture from the anal verge was 4.6±1.2cm. The Clavien-Dindo complications were Clavien-Dindo 1 (leg compression), Clavien-Dindo 2 (urinary tract infection, bladder self-catheterization) and Clavien-Dindo 3b (bowel obstruction, rectovaginal fistula, pyelic dilation, colorectal stenosis after resection). A rectovaginal fistula (Clavien-Dindo 3b) developed in nine (11.3%) patients and their stoma could be reversed after 99-162days. The majority of patients (n=50, 62.5%) had normal postoperative rectal function with LARS score ≤20. However, minor (LARS≥21-29) and major rectal dysfunction (LARS≥30) was seen in 18 (22.5%) and 12 (15%) patients respectively. Quality of life as measured using the BENS score was normal (BENS score 0-8) in 51 (63.8%) patients, slightly reduced (BENS score 9-16) in 24 (30%) patients and in only five (6.3%) was this a major issue (BENS score>17). The development of a rectovaginal fistula was independently related to risk of major rectal dysfunction (adjusted OR 6.3, 95% CI 1.3-30.6). In our series of 80 patients with transmural low and mid rectal endometriosis disc excision using a semicircular staple device can result in good functional outcomes and quality of life and avoid the complexity and potential complications of a low anterior resection.

Survival after Laparoscopic Versus Open Curative Excision for Rectal Cancer

Background: Management of rectal cancer has been evolved over the past two decades with the introduction of total mesorectal excision (TME) and laparoscopic resection. Objective: This study aims to assess the difference in the long-term outcomes after laparoscopic and open resection for potentially curable, non-metastatic rectal cancer patients.Methods: This is a retrospective study which has been conducted in a single tertiary care center where the patients were recruited from the colorectal database of the Section of Colon and Rectal Surgery at King Faisal Specialist Hospital &amp; Research Centre (KFSH&amp;RC). It included all the patients who had non-metastatic rectal cancer and underwent laparoscopic or open curative resection regardless of their age or the comorbid status during the period from January 2012 – December 2015. We studied the long-term outcomes for those patients which included the completeness of resection of the tumor, overall 3-year survival, 3-year disease-free survival, local recurrence, and distal recurrence of cancer.Results:120 patients were included in this study, 69 of them were males and 51 were females. 86 (71.7%) of them underwent open surgery while 34 (28.3%) underwent laparoscopic surgery. After a mean follow-up of 32.4 months: 104 patients were alive, 7 deceased, and 9 were lost of follow-up. Local recurrence in the open approach (OA), and laparoscopic approach (LA) groups was 3/86 (3.5%) and 4/34 (11.8%) respectively. Distal recurrence occurred in 12/86 (14%) of OA and 5/34 (14.7%) of LA. Overall 3-years survival for OA and LA was 89% and 97% respectively and the 3-years disease-free survival was 49% and 57% respectively.Conclusion: Laparoscopic and open rectal excision were similar in their outcome.