Rigid Proctoscopy Research Articles

Exploring novel genetic and hematological predictors of response to neoadjuvant chemoradiotherapy in locally advanced rectal cancer.

Introduction: The standard treatment for locally advanced rectal cancer (LARC) is neoadjuvant chemoradiotherapy (nCRT). To select patients who would benefit the most from nCRT, there is a need for predictive biomarkers. The aim of this study was to evaluate the role of clinical, pathological, radiological, inflammation-related genetic, and hematological parameters in the prediction of post-nCRT response. Materials and methods: In silico analysis of published transcriptomics datasets was conducted to identify candidate genes, whose expression will be measured using quantitative Real Time PCR (qRT-PCR) in pretreatment formaline-fixed paraffin-embedded (FFPE) samples. In this study, 75 patients with LARC were prospectively included between June 2020-January 2022. Patients were assessed for tumor response in week 8 post-nCRT with pelvic MRI scan and rigid proctoscopy. For patients with a clinical complete response (cCR) and initially distant located tumor no immediate surgery was suggested ("watch and wait" approach). The response after surgery was assessed using histopathological tumor regression grading (TRG) categories from postoperative specimens by Mandard. Responders (R) were defined as patients with cCR without operative treatment, and those with TRG 1 and TRG 2 postoperative categories. Non-responders (NR) were patients classified as TRG 3-5. Results: Responders group comprised 35 patients (46.6%) and NR group 53.4% of patients. Analysis of published transcriptomics data identified genes that could predict response to treatment and their significance was assessed in our cohort by qRT-PCR. When comparison was made in the subgroup of patients who were operated (TRG1 vs. TRG4), the expression of IDO1 was significantly deregulated (p < 0.05). Among hematological parameters between R and NR a significant difference in the response was detected for neutrophil-to-monocyte ratio (NMR), initial basophil, eosinophil and monocyte counts (p < 0.01). According to MRI findings, non-responders more often presented with extramural vascular invasion (p < 0.05). Conclusion: Based on logistic regression model, factors associated with favorable response to nCRT were tumor morphology and hematological parameters which can be easily and routinely derived from initial laboratory results (NMR, eosinophil, basophil and monocyte counts) in a minimally invasive manner. Using various metrics, an aggregated score of the initial eosinophil, basophil, and monocyte counts demonstrated the best predictive performance.

Robotic transanal excision of rectal lesions: expert perspective and literature review

Transanal excision of benign lesions, moderately or well-differentiated rectal T1 adenocarcinomas is typically completed via transanal endoscopic microsurgery (TEM) or laparoscopic transanal minimally invasive surgery (TAMIS). Robotic platforms provide ergonomic comfort in an enclosed space, enhanced range of motion, and superior 3D visualization. This study sought to perform a literature review of robotic TAMIS (R-TAMIS) and provide expert commentary on the technique. A Pubmed literature search was performed. Study design, robot type, indication, techniques compared, surgical margins, conversion, complications, operative time, estimated blood loss, patient positioning, and defect closure were collected from included articles. Expert opinion on pre-operative planning, technical details, and possible pitfalls was provided, with an accompanying video. Twelve articles published between 2013 and 2022 were included. Five were case reports, three case series, two prospective cohort studies, one retrospective cohort study, and one Phase II trial. The Da Vinci Si (n = 3), Xi (n = 2), single port (n = 3) and flex robotic system (n = 2) were used. Five studies reported negative surgical margins, one reported positive margins, and six did not comment. Operating room time ranged from 45 to 552 min and EBL ranged from 0 to 100 mL. Patient positioning varied based on lesion location but included supine, prone, modified lithotomy, and prone jackknife positions. 11/12 studies reported defect closure, most commonly with V-Loc absorbable suture. We recommend pre-operative MRI abdomen/pelvis, digital rectal exam, and rigid proctoscopy; prone jackknife patient positioning to avoid collisions with robotic arms; and defect closure of full-thickness excisions with backhanded running V-Loc suture.

Long-term follow-up of HER2 overexpression in patients with rectal cancer after preoperative radiotherapy: A prospective cohort study.

BACKGROUNDThe role of HER2 overexpression in rectal cancer is controversial.AIMTo assess the role of HER2 overexpression in the long-term prognosis of rectal cancer.METHODSData from patients with locally advanced rectal cancer who underwent total mesorectal excision after short-course radiotherapy at Beijing Cancer Hospital between May 2002 and October 2005 were collected. A total of 151 tissue samples of rectal cancer were obtained using rigid proctoscopy before neoadjuvant radiotherapy, followed by immunohistochemistry and fluorescence in situ hybridisation to determine the patients’ HER2 expression status. Univariate and multivariate analyses of the associations between the clinicopathological factors and HER2 status were performed. Survival was estimated and compared using the Kaplan-Meier method based on HER2 expression status, and the differences between groups were verified using the log-rank test.RESULTSA total of 151 patients were enrolled in this study. A total of 27 (17.9%) patients were ultimately confirmed to be HER2-positive. The follow-up duration ranged from 9 mo to 210 mo, with a median of 134 mo. Distant metastasis and local recurrence occurred in 60 (39.7%) and 24 (15.9%) patients, respectively. HER2 positivity was significantly associated with the pre-treatment lymph node stage (pre-N) (P = 0.040), while there were no differences between HER2 status and age, sex, preoperative CEA levels (pre-CEA), T stage, and lympho-vascular invasion. In terms of prognosis, HER2 overexpression was correlated with distant metastasis (P = 0.002) rather than local recurrence (P > 0.05). The multivariate analysis demonstrated that elevated pre-CEA [P = 0.002, odds ratio (OR) = 3.277, 97.5% confidence interval (CI): 1.543-7.163], post N(+) (P = 0.022, OR = 2.437, 97.5%CI: 1.143-5.308) and HER2(+) (P = 0.003, OR = 4.222, 97.5%CI: 1.667-11.409) were risk factors for distant metastasis. The survival analysis showed that there were significant differences between rectal cancer patients in terms of disease-free survival (DFS) [hazard ratio: 1.69 (95%CI: 0.91-3.14); P = 0.048] and overall survival (OS) [1.95 (1.05-3.63); P = 0.0077].CONCLUSIONHER2 overexpression is a potential biomarker for predicting lymph node metastasis and distant metastasis, which are associated with worse long-term DFS and OS in rectal cancer patients with locally advanced disease.

Short-term clinical and functional results of rectal wall suture defect after transanal endoscopic microsurgery-a prospective cohort study.

Our goal was to assess the outcomes of rectal wall suture during the early and late periods after transanal endoscopic microsurgery (TEM) and long-term bowel function. Patients who underwent TEM for rectal neoplasms from May 2017 to March 2021 were prospectively included. A total of 70 patients were enrolled. Seven to 10days after TEM, clinical data were recorded, and digital rectal examination and rigid proctoscopy were performed. After at least 6months, bowel function was evaluated using low anterior resection syndrome (LARS) and Wexner questionnaires. Forty-five men with an average age of 67 ± 10.1 (40-85) were included. TEM sutures were recorded as intact in 48/70 (68%) and as dehiscent in 22/70 (32%). It did not have any significant clinical manifestation and was not related with longer postoperative stay or incidence of postoperative complications. Eight of 22 (36.4%) patients with suture dehiscence had per rectal bleeding or febrile temperature without any need for intervention or treatment. The only risk factor for wound dehiscence was a posteriorly located defect. In late postoperative period, there was no difference between groups in LARS or Wexner questionnaire (p value 0.72 and 0.85, respectively). Our study suggests that 1/3 of the patients' rectal wall defect after TEM will undergo dehiscence in early postoperative period and will not transfer to clinically significant manifestation (without a need of hospitalization or prolonging it). In late postoperative period, there is no difference in bowel function.

Implementation of transanal minimally invasive surgery (TAMIS) for rectal neoplasms: results from a single centre

BackgroundLocal excisions are important in a tailored approach to treatment of rectal neoplasms. In cases of low risk T1 local excision facilitates rectal-preserving treatment. Transanal minimally invasive surgery (TAMIS) is the most recent alternative developed for local excision. In this study we evaluate the results after implementing TAMIS as the routine procedure for local excision of rectal neoplasms.MethodsAll patients who underwent TAMIS from January 2016 to January 2020 at St. Olav’s University Hospital were included, and clinical, pathological and oncological data were prospectively registered. The primary endpoint was local recurrence, and the secondary endpoint was complications.ResultsThere were 76 patients (42 men, mean age was 69 years [range 26–88 years]), The mean tumour level was 82 mm (range 20–140 mm) from the anal verge measured on rigid proctoscopy, and mean tumour size was 32 mm (range 8–73 mm). Three patients experienced complications needing intervention (Clavien–Dindo > 3A). Seventeen patients had rectal adenocarcinoma, 9 of whom underwent R0 completion total mesorectal excision (cTME). Fifty-five patients had an adenoma, 3 of whom developed recurrence (5.4%) within 12 months. All recurrences were treated successfully with a new TAMIS procedure. In addition, TAMIS was used in treatment of 2 patients with a neuroendocrine tumour, 1 patient with a haemangioma and 1 patient with a solitary rectal ulcer.ConclusionsTAMIS surgery is associated with a low risk of complications and a low recurrence rate in rectal neoplasms. In cases of adenocarcinoma, R0 cTME surgery is feasible in the sub-group with high risk T1 and T2 tumours.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Colonic Volvulus and Acute Colonic Pseudo-Obstruction.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Colonic Volvulus and Acute Colonic Pseudo-Obstruction.

Contemporary diagnosis and management of traumatic rectal injuries

Abstract Rectal injuries are rare but potentially devastating injuries that are frequently associated with penetrating pelvic trauma or blunt pelvic fractures. Management principles for these injuries have gone through major paradigm shifts over time. Recently, large-scale civilian studies have been completed, providing valuable insight on best-practice strategies for contemporary trauma populations. The diagnosis of rectal injuries is accomplished with a combination of computed tomography (CT) scanning and rigid proctoscopy. Because the rectum is comprised of two distinct anatomic segments, the intra- and extraperitoneal rectum, management principles for rectal injuries are unique. Intraperitoneal rectal injuries are managed as colonic injuries, with small injuries primarily repaired and larger injuries resected. Extraperitoneal injuries are repaired primarily via a trans-anal approach, if feasible, and otherwise are managed with proximal diversion alone. Complications seen after rectal injuries include infection, strictures, and fistulae. The most provocative questions about rectal injuries that are currently unanswered relate to the possibility of nonoperative management for penetrating extraperitoneal rectal injuries and to the optimal timing of colostomy reversal after proximal diversion for extraperitoneal injuries.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Rectal Cancer.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Rectal Cancer.

Fundamentals of Anorectal Technical Skills: A Concise Surgical Skills Course.

Anorectal diseases, among the most common surgical conditions, are underrepresented in medical training. The Fundamentals of Anorectal Technical Skills course was developed to provide cost-effective formal training in diagnosis of common anorectal conditions and in commonly performed anorectal procedures using the theories of deliberative practice and perceptual and adaptive learning. First- through third-year general surgery and internal medicine residents and third- and fourth-year medical students participated in a course consisting of didactic instruction and hands on skills stations. The course covered common anorectal conditions, including internal and external hemorrhoids, fissures, condylomata, abscesses, fistula-in-ano, rectal prolapse, pilonidal disease, pruritis ani, and anal and rectal cancer, as well as common procedures such as anoscopy, excision of thrombosed external hemorrhoids, banding of internal hemorrhoids, rigid proctoscopy, incision and drainage of an abscess, administration of local anesthesia, and reduction of rectal prolapse. Before the course, participants completed a questionnaire consisting of demographics; previous anorectal experience, as measured by procedural case volume; confidence diagnosing and treating anorectal conditions; and a clinical knowledge multiple-choice quiz. Immediately following the course, participants took an additional survey reassessing their confidence and testing their clinical knowledge. This study was granted an educational exception by the Institutional Review Board at Walter Reed National Military Medical Center. Forty-three learners participated in this course. Forty-six percent of participants had not participated in any anorectal cases, 26% had participated in 1 to 5 cases, 17% had participated in 6 to 10 cases, 6% had been involved with 11 to15 cases, and 6% had been involved with more than 15 cases. For learners who had no prior experience, 1 to 5 prior cases, or 6 to 10 cases, there were statistically and educationally significant increases in confidence for all diagnoses and procedures. Additionally, there were statistically and educationally significant increases between pre-course and post-course quiz scores for learners who had no prior experience (7.8±2.0 vs. 11.8±2.5, P<0.01, Cohen's d=1.8) and for those who had only participated in 1 to 5 cases (11.0±3.7 vs. 14.2±2.0, P=0.04, Cohen's d=1.1). The changes in quiz scores for learners who previously had been involved with six or more cases were not statistically significant. This course provides a cost-effective training that significantly boosts learners' confidence in diagnosis of common anorectal procedures and confidence in performance of common anorectal procedures, in addition to improving objectively measured anorectal clinical knowledge.

Does Waiting Time from Diagnosis to Treatment Affect Outcome in Locally Advanced Rectal Cancer? Real World Data Analysis

Introduction: Rectal cancer is a common and lethal disease, with approximately 44,180 new cases of diagnosed annually in the United States and a five-year survival of 67% [1, 2]. The interval from diagnosis to chemoradiation treatment, or waiting time (WT), is considered to be an important quality indicator for cancer care and has been demonstrated to be associated with oncologic outcomes in various cancers [3, 4]. The current recommendation for pre-treatment staging evaluation includes rigid proctoscopy, PET CT, transrectal ultrasound (TRUS) and often rectal MRI. These diagnostic procedures may significantly postpone the start of treatment. We aim to examine the effect of WT on overall survival (OS) and disease free survival (DFS) of rectal cancer patients. Methods: Retrospective analysis was performed in a detailed database of patients with resectable primary rectal cancer who underwent chemoradiation between January 2000 and January 2019. Univariate and multivariate cox proportional hazard regressions were conducted in order to evaluate the effect of WT on oncological outcomes. Results: 387 patients were enrolled in our database; of them 297 patients were eligible by the inclusion criteria. Median WT was 6.3 weeks (IQR 4.3-8.7). Multivariate analysis showed adjusted Hazard Ratio (HR) for OS increases by 1.07 for each additional week of therapeutic delay in all age groups (p=0.025). Furthermore, focusing on the majority of patients in the age group 45 - 70 years, adjusted HR for OS increases by 1.12 for each additional week of therapeutic delay (p=0.011). Adjusted HR for DFS increases by 1.06 for each additional week of therapeutic delay in all age groups (p=0.045) and an increment by 1.09 for each additional week of therapeutic delay in age group 45-70 years (p=0.02). Conclusion: Prolonged WT leads to significant poorer overall survival in patients with primary rectal cancer who underwent chemoradiation and curative surgical treatment. This marks the importance of efficient diagnostic evaluation and clinical multidisciplinary decision making in a timeframe of 6 weeks in order to not jeopardize oncological outcomes.

Traumatic rectal injuries: Is the combination of computed tomography and rigid proctoscopy sufficient?

There are no clear guidelines for the best test or combination of tests to identify traumatic rectal injuries. We hypothesize that computed tomography (CT) and rigid proctoscopy (RP) will identify all injuries. American Association for the Surgery of Trauma multi-institutional retrospective study (2004-2015) of patients who sustained a traumatic rectal injury. Patients with known rectal injuries who underwent both CT and RP as part of their diagnostic workup were included. Only patients with full thickness injuries (American Association for the Surgery of Trauma grade II-V) were included. Computed tomography findings of rectal injury, perirectal stranding, or rectal wall thickening and RP findings of blood, mucosal abnormalities, or laceration were considered positive. One hundred six patients were identified. Mean age was 32 years, 85(79%) were male, and 67(63%) involved penetrating mechanisms. A total of 36 (34%) and 100 (94%) patients had positive CT and RP findings, respectively. Only 3 (3%) patients had both a negative CT and negative RP. On further review, each of these three patients had intraperitoneal injuries and had indirect evidence of rectal injury on CT scan including pneumoperitoneum or sacral fracture. As stand-alone tests, neither CT nor RP can adequately identify traumatic rectal injuries. However, the combination of both test demonstrates a sensitivity of 97%. Intraperitoneal injuries may be missed by both CT and RP, so patients with a high index of suspicion and/or indirect evidence of rectal injury on CT scan may necessitate laparotomy for definitive diagnosis. Diagnostic, level IV.

Anal and Perineal Injuries.

With increased use of explosive devices in warfare, anal trauma is often seen coupled with more complex pelviperineal injury. While the associated mortality is high, casualties that survive are often left with disabling fecal incontinence from damage to the anosphincteric complex. After resolution of the acute insult, the initial evaluation mandates a thorough physical exam, including endoscopic evaluation with rigid proctoscopy and flexible sigmoidoscopy, as well as adjunctive testing, specifically anal manometry and endoanal ultrasound. First-line therapy favors bulking agents and antidiarrheals, in conjunction with biofeedback, due to a minimal risk profile. Surgical options range from direct sphincter repairs to complex anosphincteric reconstruction with widely variable results. Most recently, burgeoning therapies in the treatment of fecal incontinence, including sacral nerve stimulation and magnetic anal sphincters, offer excellent alternatives with promising long-term outcomes. In summation, the goal of all interventions is the re-establishment of bowel continence, but, in its absence, permanent fecal diversion for devastating fecal incontinence is a reasonable option with excellent patient satisfaction scores.

Watchful Waiting After Complete Clinical Response Following Concurrent Chemoradiation for Rectal Adenocarcinoma

The standard of care for patients with locally advanced rectal cancer is neoadjuvant chemoradiation followed by surgery. However, some patients achieve a complete clinical response to neoadjuvant therapy. Increasing evidence has shown that such patients may be able to avoid surgery while achieving excellent functional and oncological outcomes 1. We retrospectively reviewed patients with rectal adenocarcinoma treated at Kaiser Permanente Los Angeles Medical Center from 2015 to 2016 who underwent neoadjuvant chemoradiation. Patients who achieved a complete clinical response based on strict criteria and who declined surgery were followed with watchful waiting. A complete clinical response on clinical exam was defined as the absence of mass or ulceration, and presence of flat mucosa or scar only. In addition, magnetic resonance imaging (MRI) showed no evidence of residual mass. Patients on watchful waiting were followed with MRI every 3-6 months for 2 years then every 6 months after for 5 years. Exam with rigid proctoscopy was performed every 3 months for 2 years and every 6 months up to 5 years. Local, regional, and distant recurrences were calculated using the Kaplan-Meier method, and statistical analysis was performed with R version 3.3.1. 238 patients were treated with neoadjuvant chemoradiation. Of these, 28 patients, including 2 patients treated prior to 2015, were followed with watchful waiting after achieving a complete clinical response by strict criteria (median age 67. 11% Stage I, 43% stage IIA, 4% stage IIIA, 36% stage IIIB, 7% stage IIIC). 13 patients on watchful waiting had negative repeat biopsy and 3 had local excisions negative for residual tumor. 16 patients (55%) received adjuvant chemotherapy. At a median follow up of 12 months, 3 patients developed local recurrence and were salvaged with surgery. The 12-month Kaplan-Meier rate of local control was 92%. No patients developed regional or distant recurrences. We observed a high rate of local, regional, and distant control among patients who achieved a complete clinical response to neoadjuvant chemoradiation and who were managed non-operatively with watchful waiting. Longer follow up will be needed to confirm our findings. Bibliography: 1. Appelt AL, Ploen J, Harling H, et al. High-dose chemoradiotherapy and watchful waiting for distal rectal cancer: a prospective observational study. The Lancet Oncology. 2015;16(8):919-927.

Water-Soluble Enema Prior to Ileostomy Closure in Patients Undergoing Low Anterior Resection: Is It Necessary?

BackgroundDiverting ileostomy is recommended in patients undergoing neoadjuvant chemoradiotherapy and low anterior resection for low-rectal cancer. Prior to ileostomy reversal, water-soluble enema is performed to assess the low colorectal anastomosis. The aim of this study was to assess whether performance of routine water-soluble enema prior to ileostomy takedown is necessary. Materials and MethodsAll mid-low rectal cancer patients who underwent low anterior resection with temporary diverting ileostomy after neoadjuvant chemoradiotherapy, between 2006 and 2013, were identified, retrospectively. The colorectal anastomosis prior to ileostomy takedown was evaluated by digital rectal exam, rigid proctoscopy, and water-soluble enema. The rectal exam and proctoscopy findings were compared to those of the water-soluble enema. The efficacy of routine water-soluble enema was assessed. ResultsThree hundred and twelve (184 male) patients (mean age 62.2 ± 17 years) met the inclusion criteria. Ten patients (3 %) experienced a contained anastomotic leak in the early postoperative period, of whom six had a positive intraoperative air leak test at the index operation. At follow-up, 12 patients (4 %) presented with anastomotic stricture, which was diagnosed by rectal exam and proctoscopy. In 11 of them, water-soluble enema showed anastomotic stricture. In terms of anastomotic defects, sinus was documented in two patients (0.6 %), yet digital rectal exam and proctoscopy were normal. No late septic complications related to the colorectal anastomosis after ileostomy closure were reported. The sensitivity of rectal exam, and proctoscopy for the diagnosis of anastomotic stricture was 100 %, while its negative predictive value for the diagnosis of anastomotic defect was 99 %. ConclusionRoutine water-soluble enema for the evaluation of colorectal anastomosis before ileostomy takedown does not provide additional information that changes patient management. The efficacy of this test in patients after neoadjuvant chemoradiotherapy and low anterior resection should be reassessed.

Review for the NCCN clinical guideline in oncology of rectal cancer on surgical treatment from 2005 to 2015

In 2005 NCCN clinical guideline in oncology of rectal cancer, it recommended four management principles of surgery. The surgeon should perform a rigid proctoscopy before initiating treatment, remove primary tumor with adequate margins, dissect draining lymphatics by total mesorectal excision, and restore organ integrity if possible. The principles of surgery has been updated four times until 2015. But it remained recommending that the surgeon should perform a rigid proctoscopy so that the surgeon can handle the size, the location and the region of the tumor and make the determination of an optimal treatment plan such as restoring anus or not. Throughout ten-year NCCN clinical guidelines, pursuing R0 resection and restoring organ integrity if possible are the basic principles for the surgical treatment of rectal cancer.

Transanal endoscopic microsurgery for early rectal cancer: single center experience.

IntroductionThe use of transanal endoscopic microsurgery (TEM) is increasing due to the ability to perform minimally invasive local treatment with large full-thickness local excision under improved vision.AimTo evaluate the initial experience with TEM for early rectal cancer in a single center.Material and methodsFrom February 2010 to November 2013 a total of 20 patients underwent TEM for early rectal cancer. Nine were women and 11 men, age range 39 to 88 years (median: 71 years). The postoperative surveillance protocol, which includes rigid proctoscopy, carcinoembryonic antigen (CEA) and endorectal ultrasound every 3 months during the first 2 years, was applied to all patients after TEM.ResultsFinal histology revealed 14 (70%) lesions to be T1 and 6 (30%) T2 cancers. There were no postoperative complications. All 6 patients in the pT2 group and those in the pT1 group with unfavorable histology were offered adjuvant chemoradiotherapy or immediate radical surgery. Patients were followed up from 2 to 35 months (median: 21 months). There was one local recurrence (5%) in a patient who refused to undergo abdominoperineal excision for T1 low rectal cancer, had unfavorable histology after TEM, and for which reason underwent postoperative chemoradiation. The patient had abdominoperineal resection 7 months after TEM (rpT2N0M0). One patient was lost to follow-up. The rest of the patients are alive and disease-free.ConclusionsIn our hands, TEM was an alternative to total mesorectal excision in patients with low-risk early rectal cancer. Further follow-up is necessary to evaluate recurrence and survival rates after TEM for patients with invasive rectal cancer.

The Case Files

The Case Files

Pushing the Limits of Local Excision for Rectal Cancer: Transanal Minimally Invasive Surgery for an Upper Rectal/Rectosigmoid Lesion

Transanal minimally invasive surgery (TAMIS) is an evolving technique for the local excision of early rectal cancers,1 particularly for mid-rectal lesions. The approach to upper rectal lesions is significantly more challenging and prone to complications. We demonstrate TAMIS for an upper rectal/rectosigmoid lesion, with transanal repair of an intraoperative rectal/rectosigmoid perforation. The patient is an elderly male in whom colonoscopy demonstrated a large polypoid lesion of the upper rectum/rectosigmoid colon. On rigid proctoscopy, the lesion was 4 cm in size and occupied 40 % of the rectal circumference, with distal extent at 14 cm from the anal verge. Endoscopic ultrasound was consistent with TisN0 disease. Multiple attempts at endoscopic mucosal resection were unsuccessful and the patient refused radical resection. The patient underwent TAMIS with a disposable transanal access port, using our previously published stepwise technique.2 RESULTS: The patient successfully underwent TAMIS. Intraoperatively, a small full-thickness perforation was created proximal to the excision site and was primarily repaired. A stepwise approach to excision and repair is described. Postoperatively, the patient had low-grade fevers for which he was treated empirically with antibiotics. The fevers resolved without further intervention. Pathologic examination revealed a 3.5 cm villous adenoma with focal high-grade dysplasia, negative margins, and two negative lymph nodes. On outpatient follow-up, the patient was symptom-free and had no fevers, pain, bleeding, fecal incontinence, or genitourinary functional deficits. He is disease-free 10 months from his procedure. TAMIS of upper rectal lesions is technically challenging, but can be accomplished safely in well-selected patients.

Intensity Modulated Radiation Therapy for Anal Canal Cancer: A Large Single Institution Experience

Intensity-modulated radiation therapy (IMRT) has the potential to increase dose conformality and reduce treatment-related morbidity in the treatment of gastrointestinal malignancies. This study sought to assess outcomes of patients with anal cancer treated with concurrent chemotherapy and IMRT in a single institutional series. One hundred forty-six consecutive patients with squamous cell carcinoma of the anal canal were treated definitively with chemotherapy (5-fluorouracil on days 1-4 and 29-32, and mitomycin-C on day 1 +/- day 29) and IMRT from 2007-2012 in a large integrated health system. All patients received radiation therapy and had follow-up at a single regional facility. After treatment, patients were closely followed with imaging studies, clinical exam, and rigid proctoscopy. Outcomes assessed were progression-free (PFS), cancer-specific (CSS), overall (OS), and colostomy-free survival (CFS), calculated using the Kaplan-Meier method. Toxicity was scored using CTCAE version 4. Median follow-up was 24 months (range, 1-60 months). Patient characteristics were as follows: median age was 69 years (range, 33-87 years); 71% were female; 18 patients (7%) were HIV positive. Stage distribution was: 4% (stage I), 46% (II), 13% (IIIA), and 37% (IIIB). Overall, 50% of primary tumors were T3 or T4 and 46% of patients had node positive disease. Median radiation dose was 5400 cGy to the primary tumor (range, 4200-6000 cGy; 3 patients received a dose higher than 5400 cGy) and 4400 cGy to uninvolved regional lymph nodes. At 2-years, PFS was 85%, CSS 89%, OS 89%, and CFS 90%. Overall, acute grade ≥3 non-hematologic toxicity was 37%. This included skin (28%) and GI (16%). Acute grade ≥3 hematologic toxicity was 47%, which included anemia (12%), leukopenia (38%), neutropenia (34%), and thrombocytopenia (21%). Treatment breaks were required in 28% of patients (median duration, 5 days). The median treatment length was 37 days. There were 3 treatment-related deaths; all were in patients who received 2 cycles of mitomycin-C. Late grade ≥3 toxicity was seen in 5% of patients and late grade ≥2 toxicity was 21%. To our knowledge, this is the largest reported experience in treating anal cancer with IMRT. This study demonstrates that IMRT can be effectively delivered in a large community-based health system, with good oncologic outcomes and low toxicity. In our series, clinical outcomes and toxicity rates compare favorably to historic, non-IMRT cohorts.

An unusual presentation of a rectal duplication cyst

INTRODUCTIONIntestinal duplications are rare developmental anomalies that can occur anywhere along the gastrointestinal tract. Rectal duplication cysts account for approximately 4% of all duplication cysts. They usually present in childhood with symptoms of mass effect, local infection or more rarely with rectal bleeding from ectopic gastric mucosa. PRESENTATION OF CASEA 26year old male presented with a history of bright red blood per rectum. On examination a mucosal defect with an associated cavity adjacent to the rectum was identified. This was confirmed with rigid proctoscopy and CT scan imaging. A complete transanal excision was performed. DISCUSSIONRectal duplication cysts are more common in pediatric patients. They more frequently present with symptoms of mass effect or local infection than with rectal bleeding. In adult patients they are a rare cause of rectal bleeding. Definitive treatment is with surgical excision. A transanal, transcoccygeal, posterior sagittal or a combined abdominoperineal approach may be used depending on anatomic characteristics of the duplication cyst. conclusionWe present a rare case of a rectal duplication cyst presenting in adulthood with rectal bleeding, managed with transanal excision.