Quality of life after transanal total mesorectal excision - our experience.

INTRODUCTION: Functional outcomes and quality of life (QoL) after transanal total mesorectal excision (TaTME) are very important factors in the evaluation of TaTME in comparison with other approaches to TME. The most common functional problems after resection of the rectum include bowel, urologic and sexual dysfunctions. In this study, we present our experience with QoL after TaTME; the results are compared with worldwide literature in the discussion. METHODS: QoL was assessed by a questionnaire. The total of 54 patients were analysed. A general questionnaire for oncological diseases was used - European Organisation for Research and Treatment of Cancer (EORTC)-QLQ-C30, together with EORTC-QLQ-CR29 - a specific questionnaire for colorectal cancer. The Low Anterior Resection Syndrome (LARS) score was also obtained in all patients. Mean follow-up was 42.65 months (range 9-91 months). RESULTS: The mean LARS score in patients undergoing TaTME was 30.7 while a major LARS was observed in 64.2% of those with LARS. Of all of the symptoms in the EORTC-QLQ-C30 survey, the most serious problems which affected patients undergoing TaTME were diarrhoea (30.25), fatigue (23.87) and insomnia (20.37). In the QLQ-CR29 survey the problems included flatulence (50.94), faecal incontinence (45.06) and stool frequency (35.19). The results of EORTC-QLQ-C30 and QLQ-CR29 are quite heterogeneous. CONCLUSION: In this study the QoL of patients with advanced rectal tumours (of whom 81.5% received neoadjuvant therapy) undergoing TaTME is comparable to results in the current literature. The most severe symptoms affecting QoL after TaTME are flatulence, faecal incontinence, and stool frequency. Other serious symptoms include fatigue and insomnia. LARS was recorded in 73.6% of patients undergoing TaTME, mostly a major LARS.

Our experience with transanal total mesorectal excision (TaTME) procedures in middle and distal rectal tumors.

INTRODUCTION: Transanal total mesorectal excision (TaTME) is a relatively new approach in surgical treatment of rectal cancer. There are no clear indications when to choose this strategy. It is a technically demanding procedure for the surgeon with a long learning curve, which should also be taken into account in evaluation of this method. The results of both oncological and postoperative complications must be properly evaluated to explore the benefit of TaTME. The aim of this study is to assess the potential benefit of TaTME compared to other alternatives in middle and distal rectal tumors. METHODS: Retrospective evaluation of patients undergoing TaTME procedure performed by one team of surgeons between October 2014 and June 2019. The authors analyzed demographic indicators of the group of patients, tumor characteristics, specimen quality, early postoperative complications and the possibility of stoma reversal. RESULTS: A total of 93 patients underwent TaTME procedure for middle and distal rectal cancer. Mean BMI was 27.6 (4.8). T3 or T4 tumor was found in 73 (78.5%) patients, 68 (73.1%) patients had positive lymph nodes and 12 (12.9%) patients were treated for synchronous metastatic rectal cancer. Neoadjuvant therapy was used in 80 (86%) patients. Conversion to open laparotomy was necessary in one case (1%). Stapled anastomosis was performed in 37 (39.7%) cases, handsewn in 56 (60.2%). A positive circumferential resection margin (CRM) was found in 10 (10.7%) cases. Distal resection margin (DRM) was positive in 3 (3.2%) patients. Pathological analysis showed a complete mesorectum in 18 patients (19.4%), nearly complete in 39 (41.9%) and an incomplete mesorectum in 36 (38.7%). Complications in the first 30 days after primary surgery were observed in 38 (40.8%) patients, mainly for anastomotic leak (19 patients, 20.4%). Reoperation was required in 7 (7.5%) patients. Permanent colostomy had to be performed in 4 (4.3%) cases. No patient died after surgery. CONCLUSION: In a selected group of patients it is possible to perform resection using this approach with acceptable postoperative morbidity and quality of the specimen. We used TaTME procedure in patients expected to have difficult TME due to obesity, size and distal localization of tumor. The incidence of conversion to open surgery was very low. Further studies for long term oncological outcomes are needed.

Acute abdomen in patients with Crohns disease case reports.

INTRODUCTION: Crohns disease (CD) as a chronic inflammatory disease can affect the entire digestive tract and therefore involves a wide range of symptoms and health problems. It often mimics other diseases of the digestive tract. In the case of acute abdomen in a patient with CD, it is necessary to approach it individually in cooperation with a gastroenterologist in order to reduce the extent of resection and to ensure fewer resections. CASE REPORTS: In our two case reports, we present patients with bowel obstruction and inflammatory acute abdomen. The first patient benefits from conservative treatment despite the presence of a bowel obstruction (resulting from inflammation) before subsequent surgical treatment. It is a relatively common acute complication of CD. The second patient, despite her ongoing pregnancy and the impossibility of using appropriate imaging techniques in the follow-up treatment, with regard to her clinical condition, requires an urgent surgical solution due to a fairly rare perforation to abdominal cavity. Key words: Crohns disease - surgery - acute abdomen - bowel obstruction - peritonitis.

Use of preperitoneal wound catheter for continuous local anaesthesia after laparoscopic colorectal surgery.

INTRODUCTION: The main cause of postoperative pain after abdominal surgery is the wound where laparotomy is made. Recently, laparoscopic procedures have become common in colorectal surgery. Although improving the tolerance of the surgery, postoperative pain management still remains a discussed problem. The use of an epidural catheter used to be generally recommended in the open surgery era; however, an ideal strategy for postoperative analgesic therapy after laparoscopy remains unclear. Reduced administration of opioid analgesic drugs after colorectal resection is a generally accepted goal. Preperitoneal catheter insertion for continuous local anaesthetic (LA) infusion in the wound after surgery is a simple alternative to other pain management methods. METHODS: Retrospective analysis of analgotherapy outcomes in patients undergoing laparoscopic colorectal resection procedures, divided in three patient groups according to the type of analgesia: Group 1: use of a catheter for local wound infusion (KAT) n=73; group 2: epidural analgesia (EPI) n=23; and control group 3 with combined parenteral and subcutaneous analgesia (CON) n=66. The main objective of this study was to analyse postoperative pain and the consumption of opioid analgesics in the first three days from the surgery and the incidence of any complications related to the analgesic therapy. RESULTS: Opioid consumption in KAT and EPI groups was significantly lower compared to CON in the first 72 hours from the surgery. The lowest postoperative pain was measured in the EPI group. Subjective perception of pain, measured using VAS, was not significantly different between the KAT and CON groups. In KAT patients, vomiting was statistically less frequent than in CON patients. There was no significantly different incidence of paralytic ileus in the KAT and CON groups and no paralytic ileus was observed in the EPI group. There was no increased incidence of SSI (surgical site infections) in the KAT group compared to the other groups. CONCLUSION: The use of the catheter was assessed as safe. Insertion and management of the catheter is unsophisticated, and we did not observe any complications in terms of application of the catheter or toxic side effects of the LA. The use of the catheter clearly reduced opioid administration in the postoperative period compared to the control group (CON) with combined parenteral and subcutaneous analgesics. The best pain control measured using the visual analog scale (VAS) was observed in the EPI group.

Results of minimally invasive esophagectomy for esophageal cancer performed after ischemic gastric conditioning

INTRODUCTION: Esophageal tumor resections are extensive procedures with high postoperative complication rates including anastomotic leak. An anastomotic leak occurs when microcirculation in the proximal gastric wall used for esophageal replacement is impaired. Preoperative occlusion of certain gastric vessels (ischemic gastric conditioning) may lead to changes in vascularization and can potentially reduce the occurrence and severity of anastomotic leak after esophageal resection. METHOD: This is a retrospective data analysis of patients with esophageal cancer operated on in the Department of Surgery at University Hospital in Brno after previous ischemic gastric conditioning. RESULTS: Preoperatively, IC was performed by means of a radiological method in 7 patients (embolisation of the left gastric artery). In another 68 patients, a diagnostic laparoscopy was performed and the left gastric artery was surgically divided. During the laparoscopy, a nutritional jejunostomy was performed to enhance nutrition supply in 44 patients with food intake issues due to a stenotizing tumor. In 15 cases, a biopsy from suspicious formations in the abdominal cavity was harvested. In 5 patients, the biopsies revealed malignant disease which had not been discovered with staging radiologic diagnostic methods. After radiological ischemic conditioning, spleen ischemia was found in 2 patients after esophageal resection, and therefore we did not continue to use this method. After surgical gastric ischemic conditioning, 39 mini-invasive esophageal resections were performed. 2 of the resected patients died after the operation (5.1%). Anastomotic leak was found in a total of 8 patients after the resection. In 6 patients with anastomotic leak, management was not complicated and no reoperation was needed. No patient had complete necrosis of the gastric conduit due to ischemia. CONCLUSION: Staging laparoscopy is a safe method beneficial for patients with esophageal cancer. It offers exploration of the abdominal cavity to rule out small peritoneal and liver metastases and nutritional jejunostomy for nutrition intake improvement can be done. Ischemic conditioning can also be performed during laparoscopy which may enhance vascularization of the gastric conduit used for esophageal replacement and, despite the fact that it does not reduce the incidence of anastomotic leak, it may reduce its severity. There are no exact recommendations about adequate time delay between ischemic conditioning and esophageal resection. Performing esophageal resection is not altered by previous ischemic gastric conditioning.

[Complete mesocolic excision during right hemicolectomy]. / Kompletní mezokolická excize u pravostranné hemikolektomie.

INTRODUCTION: Complete mesocolic excision (CME) ensures the removal of all sentinel and regional lymph nodes during colon cancer surgery. For right-sided hemicolectomy it is essential to dissect the wall of vena mesenterica superior, which increases the risk of injuring surrounding organs. So far, no randomized studies comparing long-term oncological results of standard right hemicolectomy and hemicolectomy with CME have been published. METHOD: 83 patients operated for colon carcinoma in 2014 and 2015 were included in this study, all of them undergoing right-sided hemicolectomy using laparotomy access. The standard procedure was done in 63 cases and hemicolectomy with CME was done in 20 cases. We compared the incidence of complications, and the characteristics and descriptions of obtained specimens evaluated by a pathologist for both groups. RESULTS: The operation times of right-sided hemicolectomies with CME was longer by 20 minutes on average. The incidence of postoperative complications was similar in both groups. Pancreatic fistula in the group of patients undergoing right-sided hemicolectomy with CME was an unusual complication; the fistula was healed through conservative treatment. Comparing the resecate parameters, we found no significant differences in the lengths of the resected terminal ileum. But the length of the resected colon was significantly longer for the CME technique (median 42 cm versus 22 cm). The incidence of lymph node metastases was similar in both groups. However, the total number of removed lymph nodes in the group with CME was significantly higher (median 23). CONCLUSION: Right-sided hemicolectomy with complete mesocolic excision offers the removal of more lymph nodes than the standard technique. The central vascular ligation technique elongates the operation time and may be associated with more intraoperative injuries. Introduction of the concept of complete mesocolic excision is derived from an effort to standardize the surgical technique for colon cancer resection.Key words: right-sided hemicolectomy complete mesocolic excision colon cancer lymphadenectomy.

[Transanal total mesorectal excision for low rectal cancer - first results]. / Transanální totální mezorektální excize pro karcinom distálního rekta - první výsledky.

INTRODUCTION: First experiences with laparoscopic low anterior resection with transanal mesorectal excision in patients with low and mid rectal cancer are referred. METHODS: During a 9 month period (between October 2013 and May 2014), 17 laparoscopically assisted rectal resections with transanal total mesorectal excision, hand-sewn colo-anal anastomosis and protective ileostomy were performed at two institutions (CHK FN Brno, CHO KOC Nový Jicín). There were 11 males and 6 females, with a mean age 68 years (range 49-81 years) in our cohort. The tumor was located 30-80mm from the anal verge (median 60 mm). RESULTS: A negative distal resection margin was achieved in all patients. The circumferential resection margin was positive in two cases. The TME quality was described as complete in 8 cases and nearly complete in 9 cases. Mean operative time was 280 min (range 212-375 min) with no intra-operative complications. Anastomotic leakage was observed in two patients (12%). Median length of postoperative hospital stay was 9 days with a range of 6-30 days, in case of anastomotic and wound complications. CONCLUSION: According to our first experience we evaluated this method as feasible and safe with satisfactory pathological outcomes. We cannot recommend exact indications yet. It is assumed that the transanal approach for total mesorectal excision should be indicated in obese patients with a narrow pelvis and voluminous prostate.Key words: total mesorectal excision transanal minimally invasive surgery.

[Transanal total mesorectal excision for rectal cancer - just a fashion trend?]. / Transanální totální mezorektální excize pro karcinom rekta - jen módní trend?

Transanal total mesorectal excision performed using equipment for transanal minimally invasive surgery is an innovative surgical technique introduced to facilitate this procedure and to reach better oncosurgical outcomes in patients with low rectal cancer. This article presents a brief summary of guidelines for treatment of patients with low rectal carcinoma. Up-to-date information about the principles of this new method, its modifications and contemporary indications is presented. Based on their own experience and literature resources, the authors inform about the advantages, limitations and unresolved issues of minimally invasive transanal mesorectal excision.

Utilization of Next Generation Sequencing in Analysis of Circulating MicroRNAs as Predictive Biomarkers for Patients with Locally Advanced Rectal Carcinoma.

BACKGROUND: MicroRNAs (miRNA) are short non-coding RNAs involved in post-transcriptional regulation of gene expression. MiRNAs are essential regulators of both physiological processes as of pathogeneses of many diseases, and their dysregulation was observed in many malignancies including rectal cancer. Circulating miRNAs presented in blood plasma could be potential candidates for non-invasive predictive biomarkers of the response of patients with locally advanced rectal cancer to chemoradiotherapy. Presented study aims to evaluate the potential of next-generation sequencing in the analysis of circulating miRNAs. MATERIAL AND METHODS: MiRNA expression profiles were done using samples of RNA isolated from blood plasma collected during TNM restaging and paired samples collected before initiation of neoadjuvant chemoradiotherapy. Sequencing libraries were prepared using kit which implements universal molecular indices that help to sensitively filter biological bias during data analysis. Sequencing data were processed by multidimensional biostatistical approaches. CONCLUSION: We identified specific miRNA profile enabling to distinguish the patients accordingly to their response to chemoradiotherapy. This work was supported by the Czech Ministry of Health grant No. 16-31765A. The authors declare they have no potential confl icts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers. Submitted: 22. 2. 2019 Accepted: 27. 2. 2019.

Comparison of cervical anastomotic leak and stenosis after oesophagectomy for carcinoma according to the interval of the stomach ischaemic conditioning.

Background Stomach preparation by ischaemic conditioning prior to oesophageal resection represents a potential method of reducing the risk of anastomotic complications. This study compares the results of the anastomotic complications of cervical anastomosis after oesophagectomy with a short interval after ischaemic conditioning (group S) and a long interval (group L). Methods Subjects undergoing oesophagectomy for carcinoma after ischaemic conditioning were divided into two groups. Group S had a median interval between ischaemic conditioning and resection of 20 days, while for group L the median interval was 49 days. Anastomotic leak and anastomotic stenosis in relation to the interval between ischaemic conditioning and actual resection were followed. Results After ischaemic conditioning, 33 subjects in total underwent surgery for carcinoma; 19 subjects in group S and 14 subjects in group L. Anastomotic leak incidence was comparable in both groups. Anastomotic stenosis occurred in 21% of cases in group S and 7% of cases in group L (not statistically significant). Conclusions A long interval between ischaemic conditioning and oesophagectomy does not adversely affect the postoperative complications. A lower incidence of anastomosis stenoses was found in subjects with a longer interval, however, given the size of our sample, the statistical significance was not demonstrated. Both groups seem comparable in surgical procedure course and postoperative complications.