Intracorporeal or extracorporeal ileocolic anastomosis after laparoscopic right colectomy: cost analysis of the Torino trial.

BACKGROUND: Intracorporeal (IIA) and extracorporeal anastomosis (EIA) are two well-established techniques for restoration of bowel continuity after laparoscopic right colectomy (LRC). Since no economic analysis comparing the two different anastomotic techniques has been performed yet, it is still unclear if IIA can reduce perioperative costs. The aim of the study was to compare costs of LRC with IIA or EIA for right-sided colon neoplasm. METHODS: This is a cost analysis of a single-institution double-blinded randomized controlled trial comparing the outcomes of LRC with IIA and LRC with EIA in patients with a right-sided colon neoplasm. All direct in-hospital costs related to patient's admission were recorded (intraoperative costs: operative room, surgical tools, blood units-postoperative costs: hospital stay, laboratory and microbiology analyses, diagnostic services, analgesic drugs and antibiotic therapy, blood units, reoperation-outpatient costs: post-discharge wound medications). This trial was registered with ClinicalTrials.gov, Number NCT03045107. RESULTS: A total of 140 patients were randomized and analyzed. Mean overall costs in the IIA group exceeded 349 € the mean overall costs of the EIA group (7926.87 ± 4617.23 € vs. 7577.45 ± 6131.17 €; P = 0.704). A mean extra charge of 608 € regarding total intraoperative costs was recorded in the IIA group (3058.84 ± 897.42 € vs. 2450.15 ± 558.90 €; P < 0.001). The cost of surgical instruments resulted in 542 € additional charge per patient in the IIA group compared to EIA group (1782.74 ± 541.26 € vs. 1240.55 ± 384.09 €; P < 0.001). The mean cost of operative room occupancy was comparable in IIA and EIA group: 1276.09 ± 514.94 € vs. 1209.60 ± 422.80 € (P = 0.405). No significant differences were observed in postoperative costs and in outpatient costs. CONCLUSION: This economic analysis showed that IIA and EIA after LRC had similar overall costs, even though there were intraoperative extra costs of IIA.

Current status on the adoption of high energy devices in Italy: An Italian Society for Endoscopic Surgery and New Technologies (SICE) national survey.

BACKGROUND: In the past three decades, different High Energy Devices (HED) have been introduced in surgical practice to improve the efficiency of surgical procedures. HED allow vessel sealing, coagulation and transection as well as an efficient tissue dissection. This survey was designed to verify the current status on the adoption of HED in Italy. METHODS: A survey was conducted across Italian general surgery units. The questionnaire was composed of three sections (general information, elective surgery, emergency surgery) including 44 questions. Only one member per each surgery unit was allowed to complete the questionnaire. For elective procedures, the survey included questions on thyroid surgery, lower and upper GI surgery, proctologic surgery, adrenal gland surgery, pancreatic and hepatobiliary surgery, cholecystectomy, abdominal wall surgery and breast surgery. Appendectomy, cholecystectomy for acute cholecystitis and bowel obstruction due to adhesions were considered for emergency surgery. The list of alternatives for every single question included a percentage category as follows: " < 25%, 25-50%, 51-75% or > 75%", both for open and minimally-invasive surgery. RESULTS: A total of 113 surgical units completed the questionnaire. The reported use of HED was high both in open and minimally-invasive upper and lower GI surgery. Similarly, HED were widely used in minimally-invasive pancreatic and adrenal surgery. The use of HED was wider in minimally-invasive hepatic and biliary tree surgery compared to open surgery, whereas the majority of the respondents reported the use of any type of HED in less than 25% of elective cholecystectomies. HED were only rarely employed also in the majority of emergency open and laparoscopic procedures, including cholecystectomy, appendectomy, and adhesiolysis. Similarly, very few respondents declared to use HED in abdominal wall surgery and proctology. The distribution of the most used type of HED varied among the different surgical interventions. US HED were mostly used in thyroid, upper GI, and adrenal surgery. A relevant use of H-US/RF devices was reported in lower GI, pancreatic, hepatobiliary and breast surgery. RF HED were the preferred choice in proctology. CONCLUSION: HED are extensively used in minimally-invasive elective surgery involving the upper and lower GI tract, liver, pancreas and adrenal gland. Nowadays, reasons for choosing a specific HED in clinical practice rely on several aspects, including surgeon's preference, economic features, and specific drawbacks of the energy employed.

Long-term oncologic outcomes following anastomotic leak after anterior resection for rectal cancer: does the leak severity matter?

BACKGROUND: The evidence regarding the impact of anastomotic leak (AL) after anterior resection (AR) for rectal cancer on oncologic outcomes is controversial, and there are no data about the prognostic relevance of the International Study Group of Rectal Cancer (ISREC) AL classification. The aim was to evaluate the oncologic outcomes in patients with AL after AR for rectal cancer. The prognostic value of the ISREC AL grading system was also investigated. METHODS: It is a retrospective analysis of a prospectively collected database including all patients undergoing curative elective AR for rectal cancer (April 1998-September 2013). AL severity was defined according to the ISREC criteria. A multivariable analysis was performed to identify predictors of poor survival. RESULTS: A total of 532 patients underwent curative AR (69% laparoscopic) for rectal cancer. The overall AL rate was 7.9%: 15 grade B and 27 grade C ALs. With a median follow-up of 80 (range 12-266) months, 5-year overall survival (OS) was 67.2% in patients with AL and 86.5% in those without AL (P = 0.001). Five-year disease-free survival (DFS) was 50.5% and 80.3%, respectively (P < 0.001). Local recurrence and distant metastases developed more frequently in AL patients (P < 0.05). Grade B AL and no administration or delay of adjuvant chemotherapy were independent predictors for poorer OS and DFS. Grade B AL independently affected also the administration of adjuvant chemotherapy. Circulating C-reactive protein levels at 2 weeks after AL treatment were higher in grade B than grade C patients (P = 0.006) and in patients with tumor relapse (P = 0.011). CONCLUSION: AL after curative AR for rectal cancer and impaired use of adjuvant chemotherapy are associated with poor survival. Postoperative systemic inflammation seems to be more sustained in grade B than that in grade C AL patients, with possible adverse impact on long-term survival.

Intraoperative air leak test reduces the rate of postoperative anastomotic leak: analysis of 777 laparoscopic left-sided colon resections.

BACKGROUND: The evidence supporting the use of the air leak test (ALT) after laparoscopic left-sided colon resection (LLCR) to test the colorectal anastomosis (CA) integrity aiming at reducing the rate of postoperative CA leakage (CAL) is not conclusive. The aim of this study was to challenge the use of ALT after elective LLCR. METHODS: It is a retrospective analysis of a prospectively collected database including all patients undergoing elective LLCR with primary CA and no proximal bowel diversion between January 1996 and June 2017. The decision to perform the ALT was based on the individual surgeon routine practice. A multivariate analysis was performed to identify independent risk factors for CAL. RESULTS: A total of 777 LLCR without proximal diversion were included in the analysis: the CA was tested in 398 patients (ALT group), while intraoperative ALT was not performed in 379 patients (No-ALT group). The two groups were similar in demographic characteristics, indication, and type of procedure. Intraoperative ALT was positive in 20 (5%) patients: a stoma was created in 14 (70%) patients, while 6 (30%) patients had a suture repair alone. Overall, postoperative CAL occurred in 32 patients (4.1%): the postoperative CAL rate was lower in ALT patients (2.5% vs. 5.8%, p = 0.025). A reoperation was needed in 87.5% of cases. No CAL occurred in the 20 patients with intraoperative positive ALT. Multivariate analysis showed that ASA score 3-4 (OR 5.39, 95% CI 2.53-11.51, p < 0.001) and male sex (OR 3.96, 95% CI 1.66-9.43, p = 0.002) were independent risk factors for postoperative CAL, while intraoperative ALT independently reduced the postoperative CAL rate (OR 0.40, 95% CI 0.18-0.88, p = 0.022). CONCLUSION: Intraoperative ALT allows to detect AL defects after LLCR that can be effectively managed intraoperatively, leading to a significant lower risk of postoperative CAL.

Analysis of Early and Long-Term Oncologic Outcomes After Converted Laparoscopic Resection Compared to Primary Open Surgery for Rectal Cancer.

BACKGROUND: Laparoscopic rectal resection (LRR) for cancer is a challenging procedure, with conversion to open surgery being reported in up to 30% of cases. Since only a few studies with short follow-up have compared converted LRR and open RR (ORR), it is unclear if conversion to open surgery should be prevented by preferring an open approach in those patients with preoperatively known risk factors for conversion. The aim of this study was to compare early postoperative outcomes and long-term survival after completed LRR, converted LRR or ORR for non-metastatic rectal cancer. METHODS: A prospective database of consecutive curative LRRs and ORRs for rectal cancer was reviewed. Patients undergoing LRR who required conversion (CONV group) were compared with those who had primary open rectal surgery (OPEN group) and completed LRR (LAP group). A multivariate analysis was performed to identify predictors of poor survival. RESULTS: A total of 537 patients were included in the study: 272 in the LAP group, 49 in the CONV group and 216 in the OPEN group. There were no significant differences in perioperative morbidity, mortality and length of hospital stay between the three groups. Five-year overall survival and disease-free survival rates did not significantly differ between LAP, CONV and OPEN patients: 83.9 versus 77.8 versus 81% (P = 0.398) and 74.5 versus 62.9 versus 72.7% (P = 0.145), respectively. Similar 5-year OS and DFS rates were observed between patients who had converted LRR for locally advanced tumor or for non-tumor-related reasons: 81.2 versus 80.8% (P = 0.839) and 62.5 versus 63.7% (P = 0.970), respectively. Poor grade of tumor differentiation, lymphovascular invasion and a lymph node ratio of 0.25 or greater, but not conversion, were independently associated with poorer survival. CONCLUSION: Conversion to open surgery does not impair short-term outcomes and does not jeopardize 5-year survival in patients with rectal cancer when compared to primary open surgery.

Preoperative stoma site marking: a simple practice to reduce stoma-related complications.

BACKGROUND: To evaluate the incidence and identify the risk factors of stoma-related complications in a consecutive series of patients treated at a single institution. METHODS: For this retrospective analysis, the medical records of patients followed up at the stoma care centre of our institution over the last 16 years were reviewed. The primary end point was the incidence of stoma-related complications. Risk factors were tested using univariate and multivariate Cox proportional hazards models. RESULTS: Of a total of 1076 patients, 604 received a colostomy and 472 an ileostomy. In all, 1055 stoma-related complications were recorded in 797 patients. Univariate analysis identified the following risk factors for stoma-related complications: male sex (p = 0.032), emergency surgery (p = 0.010), open surgery (p < 0.001), and ileostomy creation (p = 0.004). Preoperative stoma site marking was noted to play a protective role (hazard ratio 0.739; 95% confidence interval 0.576-0.947; p = 0.017). Multivariate analysis confirmed male sex and ileostomy creation as risk factors (p = 0.030 and p = 0.013, respectively) and preoperative stoma site marking as an independent protective factor (p = 0.001). CONCLUSIONS: Stoma-related complications are quite common, especially when an ileostomy is present. Preoperative stoma site marking was noted to play a highly protective role not only in reducing the complication rate but also in improving the patients' quality of life.

Total mesorectal excision using a soft and flexible robotic arm: a feasibility study in cadaver models.

BACKGROUND: Sponsored by the European Commission, the FP7 STIFF-FLOP project aimed at developing a STIFFness controllable Flexible and Learn-able manipulator for surgical operations, in order to overcome the current limitations of rigid-link robotic technology. Herein, we describe the first cadaveric series of total mesorectal excision (TME) using a soft and flexible robotic arm for optic vision in a cadaver model. METHODS: TME assisted by the STIFF-FLOP robotic optics was successfully performed in two embalmed male human cadavers. The soft and flexible optic prototype consisted of two modules, each measuring 60 mm in length and 14.3 mm in maximum outer diameter. The robot was attached to a rigid shaft connected to an anthropomorphic manipulator robot arm with six degrees of freedom. The controller device was equipped with two joysticks. The cadavers (BMI 25 and 28 kg/m2) were prepared according to the Thiel embalming method. The procedure was performed using three standard laparoscopic instruments for traction and dissection, with the aid of a 30° rigid optics in the rear for documentation. RESULTS: Following mobilization of the left colonic flexure and division of the inferior mesenteric vessels, TME was completed down to the pelvic floor. The STIFF-FLOP robotic optic arm seemed to acquire superior angles of vision of the surgical field in the pelvis, resulting in an intact mesorectum in both cases. Completion times of the procedures were 165 and 145 min, respectively. No intraoperative complications occurred. No technical failures were registered. CONCLUSIONS: The STIFF-FLOP soft and flexible robotic optic arm proved effective in assisting a laparoscopic TME in human cadavers, with a superior field of vision compared to the standard laparoscopic vision, especially low in the pelvis. The introduction of soft and flexible robotic devices may aid in overcoming the technical challenges of difficult laparoscopic procedures based on standard rigid instruments.

Laparoscopic colon resection: To prep or not to prep? Analysis of 1535 patients.

BACKGROUND: Mechanical bowel preparation (MBP) before elective open colon resection does not reduce the rate of postoperative anastomotic leakage. However, MBP is still routinely used in many countries, and there are very limited data regarding the utility of preoperative MBP in patients undergoing laparoscopic colon resection (LCR). The aim of this study was to challenge the use of MBP before elective LCR. METHODS: It is a retrospective analysis of a prospectively collected database. All patients undergoing elective LCR with primary anastomosis and no stoma were included. Preoperative MBP with polyethylene glycol solution was used routinely between April 1992 and December 2004, and then it was abandoned. The early postoperative outcomes in patients who had preoperative MBP (MBP group) and in patients who underwent LCR without preoperative MBP (No-MBP group) were compared. RESULTS: From April 1992 to December 2014, 1535 patients underwent LCR: 706 MBP patients and 829 No-MBP patients. There were no differences in demographic data, indication for surgery and type of procedure performed between MBP and No-MBP group patients. The incidence of anastomotic leakage was similar between the two groups (3.4 vs. 3.6 %, p = 0.925). No differences were observed in intra-abdominal abscesses (0.6 vs. 0.8 %, p = 0.734), wound infections (0.6 vs. 1.4 %, p = 0.149), infectious extra-abdominal complications (1.8 vs. 3 %, p = 0.190), and non-infectious complications (6.1 vs. 6.8 %, p = 0.672). The overall reoperation rate was 4.6 % for MBP patients and 5 % for No-MBP patients (p = 0.813). CONCLUSION: The use of preoperative MBP does not seem to be associated with lower incidence of intra-abdominal septic complications after LCR.

Laparoscopic versus open resection for transverse colon cancer.

BACKGROUND: Previous large randomized controlled trials comparing laparoscopic (LR) and open resection (OR) for colon cancer have not specifically analyzed the outcomes in patients with transverse colon cancer. The aims of this study were to evaluate the feasibility and safety of LR transverse colon cancer resection and to compare our findings with the results available in the literature. METHODS: We performed a retrospective analysis of consecutive patients undergoing LR or OR for histologically proven adenocarcinoma of the transverse colon. RESULTS: A total of 123 patients were included in this study: 66 LR and 57 OR. Median operating time was similar in the two groups. Median blood loss was higher in the OR group, even though the difference was not statistically significant. The rate of conversion from LR to OR was 16.7 %. Return of bowel function occurred significantly earlier in the LR group. The incidence and severity of 30-day postoperative complications and mortality rates were similar in the two groups. The median hospital stay was significantly shorter in the LR group. There was a trend toward a greater number of lymph nodes harvested in the OR group than in the LR group, although the difference was not statistically significant. The time to first flatus and bowel movement was significantly earlier in the LR group. Five-year overall survival and disease-free survival rates were similar in the LR and OR groups (86.4 vs. 88.6 %, p = 0.770 and 80.4 vs. 77.3 %, p = 0.516, respectively). CONCLUSIONS: LR of transverse colon cancer is feasible and safe, with similar early short-term outcomes when compared to OR. Larger prospective comparative studies with long-term follow-up are needed to assess the oncological equivalence of the two approaches.

Laparoscopy for rectal cancer is oncologically adequate: a systematic review and meta-analysis of the literature.

BACKGROUND: This review of cancer outcomes is based on key literature searches of the medical databases and meta-analysis of short-term benefits of laparoscopy in rectal cancer treatment. METHODS: We carried out a systematic review of randomized clinical trials (RCTs) and prospective non-randomized controlled trials (non-RCTs) published between January 2000 and September 2013 listed in the MEDLINE and EMBASE databases (PROSPERO Registration number: CRD42013005076). The primary endpoint was clearance of the circumferential resection margin. Meta-analysis was performed using a fixed-effect model, and sensitivity analysis by a random-effect model; subgroup analysis was performed on subsets of patients with extraperitoneal cancer of the rectum. Relative risk (RR) and mean difference (MD) were used as outcome measures. RESULTS: Twenty-seven studies (10,861 patients) met the inclusion criteria; eight were RCTs (2,659 patients). The RCTs reported involvement of the circumferential margin in 7.9 % of patients who underwent laparoscopic and in 6.9 % of those undergoing open surgery; the overall RR was 1.00 (95 % confidence interval 0.73-1.35) with no heterogeneity. Subgroup analysis of patients with extraperitoneal cancer showed equivalent involvement of the circumferential margin in the two treatment groups. Although significantly more lymph nodes were retrieved in the surgical specimen after open surgery, the MD of -0.56 was of marginal clinical significance. The sensitivity and subgroup analyses revealed no other significant differences between laparoscopic and open surgery in the rate of R0 resections, distal margin clearance, mesorectal fascia integrity, or local recurrence at 5 years. CONCLUSIONS: Based on the evidence from RCTs and non-RCTs, the short-term benefit and oncological adequacy of laparoscopic rectal resection appear to be equivalent to open surgery, with some evidence potentially pointing to comparable long-term outcomes and oncological adequacy in selected patients with primary resectable rectal cancer.

Early rectal cancer: the European Association for Endoscopic Surgery (EAES) clinical consensus conference.

BACKGROUND: The last 30 years have witnessed a significant increase in the diagnosis of early-stage rectal cancer and the development of new strategies to reduce the treatment-related morbidity. Currently, there is no consensus on the definition of early rectal cancer (ERC), and the best management of ERC has not been yet defined. The European Association for Endoscopic Surgery in collaboration with the European Society of Coloproctology developed this consensus conference to provide recommendations on ERC diagnosis, staging and treatment based on the available evidence. METHODS: A multidisciplinary group of experts selected on their clinical and scientific expertise was invited to critically review the literature and to formulate evidence-based recommendations by the Delphi method. Recommendations were discussed at the plenary session of the 14th World Congress of Endoscopic Surgery, Paris, 26 June 2014, and then posted on the EAES website for open discussion. RESULTS: Tumour biopsy has a low accuracy. Digital rectal examination plays a key role in the pre-operative work-up. Magnification chromoendoscopy, endoscopic ultrasound and magnetic resonance imaging are complementary staging modalities. Endoscopic submucosal dissection and transanal endoscopic microsurgery are the two established approaches for local excision (LE) of selected ERC. The role of all organ-sparing approaches including neoadjuvant therapies followed by LE should be formally assessed by randomized controlled trials. Rectal resection and total mesorectal excision is indicated in the presence of unfavourable features at the pathological evaluation of the LE specimen. The laparoscopic approach has better short-term outcomes and similar oncologic results when compared with open surgery. CONCLUSIONS: The management of ERC should always be based on a multidisciplinary approach, aiming to increase the rate of organ-preserving procedures without jeopardizing survival.

Transanal endoscopic microsurgery after endoscopic resection of malignant rectal polyps: a useful technique for indication to radical treatment.

BACKGROUND: Management of malignant rectal polyps (MRPs) after endoscopic polypectomy (EP) is still debated. It is sometimes difficult to decide whether to simply follow-up (FU) or to treat such a removed lesion. Transanal endoscopic microsurgery (TEM) could have a role both in T staging and in treating MRPs after EP. METHODS: Patients who underwent a full-thickness TEM within 3 months after an EP between January 2008 and October 2012 were retrospectively analyzed. If post-TEM histology showed locally advanced rectal cancer, patients underwent a total mesorectal excision (TME) within 4-6 weeks. Patients without malignant disease or pT1sm1 cancers at post-TEM histology were followed up every 3 months for 2 years with clinical examination, flexible rectal endoscopy, and neoplastic markers monitoring. RESULTS: A total of 39 patients were included. Post-EP histology was adenocarcinoma in 27/39 cases (69.2 %) and adenoma in 12/39. Mean operative time was 64.2 min; no 30-day mortality occurred; 30-day morbidity was 2.7 % (rectal bleeding in 1/39 cases). Post-TEM histology showed a T2 cancer in 5/39 patients, four with and one without a previous cancer diagnosis, who were further treated by TME (four RARs and one APR) and are disease free with a mean FU of 24.2 months. Post-TEM histology showed adenoma in 10/39 cases and fibrosis in 24/39. These patients are disease free with a mean FU of 13 months. CONCLUSIONS: A full-thickness TEM after EP of MRPs can establish the presence of residual malignant disease and its depth of invasion, precisely defining the indication to TME. In event of benign post-EP histology, TEM must be performed in presence of macroscopic residual disease, in order to obtain an RO resection and finally exclude cancer, while, in absence of macroscopic residual disease, only close FU is required.

Which treatment for large rectal adenoma? Preoperative assessment and therapeutic strategy.

In the present review the authors discuss the standard ways of preoperative work-up for a suspected large rectal non-invasive lesion, comparing East and West different attitudes both in staging and treatment. Looking at the literature and analyzing recent personal data, neither pit-pattern classification, nor EUS, nor biopsy histology, nor lifting sign verification, nor digital examination allow a specificity of more than three fourth of such cases. The authors disquisition about which optimal treatment excludes a role for EMR for the impossibility to obtain a single en-bloc specimen, minimum requirement for a correct lateral and vertical margin assessment. For the same reason ESD should be preferred, although a recent meta-analysis of the literature defined that one fourth of patients undergoing ESD for a preoperatively assessed non-invasive large rectal lesion fail to receive an R0 en-bloc resection. This forces about 10% of patients treated by flexible endoscopy to undergo abdominal surgery, which is about fourfold higher than TEM. While awaiting further implementation of modern technologies both to improve staging and to reduce invasiveness, a full-thickness excision of the rectal wall by TEM still represents the standard treatment even for suspected benign diseases.

Implementation of an enhanced recovery after surgery protocol for colorectal cancer in a regional hospital network supported by audit and feedback: a stepped wedge, cluster randomised trial.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols are known to potentially improve the management and outcomes of patients undergoing colorectal surgery, with limited evidence of their implementation in hospital networks and in a large population. We aimed to assess the impact of the implementation of an ERAS protocol in colorectal cancer surgery in the entire region of Piemonte, Italy, supported by an audit and feedback (A&F) intervention. METHODS: A large, stepped wedge, cluster randomised trial enrolled patients scheduled for elective surgery at 29 general surgery units (clusters). At baseline (first 3 months), standard care was continued in all units. Thereafter, four groups of clusters began to adopt the ERAS protocol successively. By the end of the study, each cluster had a period in which standard care was maintained (control) and a period in which the protocol was applied (experimental). ERAS implementation was supported by initial training and A&F initiatives. The primary endpoint was length of stay (LOS) without outliers (>94th percentile), and the secondary endpoints were outliers for LOS, postoperative medical and surgical complications, quality of recovery and compliance with ERAS items. RESULTS: Of 2626 randomised patients, 2397 were included in the LOS analysis (1060 in the control period and 1337 in the experimental period). The mean LOS without outliers was 8.5 days during the control period (SD 3.9) and 7.5 (SD 3.5) during the experimental one. The adjusted difference between the two periods was a reduction of -0.58 days (95% CI -1.07, -0.09; p=0.021). The compliance with ERAS items increased from 52.4% to 67.3% (estimated absolute difference +13%; 95% CI 11.4%, 14.7%). No difference in the occurrence of complications was evidenced (OR 1.22; 95% CI 0.89, 1.68). CONCLUSION: Implementation of the ERAS protocol for colorectal cancer, supported by A&F approach, led to a substantial improvement in compliance and a reduction in LOS, without meaningful effects on complications. Trial registration number NCT04037787.

Previous transanal endoscopic microsurgery for rectal cancer represents a risk factor for an increased abdominoperineal resection rate.

BACKGROUND: Transanal endoscopic microsurgery (TEM) represents a surgical option in the treatment of selected early rectal cancers. However, when definitive histopathology shows negative prognostic factors, rectal resection with total mesorectal excision (TME) is recommended to reduce the risk of recurrence. No studies have yet analyzed the impact of previous TEM on the perioperative outcomes of immediate laparoscopic TME (LTME) for rectal cancer. The aim of this study was to evaluate the perioperative outcomes of LTME after TEM for rectal cancer. METHODS: This study was a retrospective analysis of a prospective database. All patients undergoing LTME within 8 weeks after full-thickness TEM for rectal cancer between January 2001 and December 2011 were included. Each patient was matched on the basis of demographic and clinical characteristics with two patients undergoing primary LTME for rectal cancer during the same period. Age, gender, body mass index, tumor distance from the anal verge, tumor size, neoadjuvant chemoradiation, previous TEM, rectal wall defect size created during TEM, and intraoperative complications were included in a multivariate analysis to identify risk factors for abdominoperineal resection (APR). RESULTS: A total of 17 patients undergoing TEM followed by LTME were compared to 34 patients undergoing primary LTME. Mean operative time of LTME after TEM was significantly higher (206 vs. 188 min, P = 0.025). APR was more frequently performed after TEM [odds ratio (OR) 5.25, P = 0.028] and in male patients (OR 9.04, P = 0.034). On multivariate analysis, a previous TEM was the only independent predictor of APR (OR 4.13, P = 0.046). The incidence and severity of postoperative complications were similar in both groups. Mesorectum integrity was complete in all cases. CONCLUSIONS: LTME after TEM is a challenging procedure, with a significantly higher risk of APR compared to primary LTME. Future improvements in preoperative patient selection for TEM are needed to reduce this risk.

Does conversion affect short-term and oncologic outcomes after laparoscopy for colorectal cancer?

BACKGROUND: Conversion of laparoscopic colorectal resection (LCR) for cancer has been associated with adverse short-term and oncologic outcomes. However, most studies have had small sample sizes and short follow-up periods. This study aimed to evaluate the impact of conversion to open surgery on early postoperative outcomes and survival among patients undergoing LCR for nonmetastatic colorectal cancer. METHODS: A prospective database of consecutive LCRs for nonmetastatic colorectal cancer was reviewed. Patients who required conversion (CONV group) were compared with those who had completed laparoscopic resection (LAP group). Only patients with a minimum 5-year follow-up period were included in the oncologic analysis. Kaplan-Meier curves were compared to analyze survival. A multivariate analysis was performed to identify predictors of poor survival. RESULTS: The conversion rate was 10.9%. The most common reason for conversion was a locally advanced tumor (48.4%). Conversion was associated with a significantly longer operative time and a greater blood loss. No differences were observed in terms of postoperative morbidity, mortality, or hospital stay between the CONV and LAP patients. During a median follow-up period of 120 months (range, 60-180 months), the CONV group had a significantly worse 5-year overall survival (OS) (79.4 vs 87.4%; p = 0.016) and disease-free survival (DFS) (65.4 vs 79.6%; p = 0.013). Univariate analysis showed that conversion to open surgery, postoperative complications, anastomotic leakage, pT4 cancer, stage 3 disease, and adjuvant chemotherapy were significant risk factors for OS and DFS. On multivariate analysis, pT4 cancer and a lymph node ratio (LNR) of 0.25 or greater were the only independent predictors of DFS and OS, whereas a LNR of 0.01 to 0.24 showed a trend that did not reach statistical significance. CONCLUSION: Conversion to open surgery per se is not associated with worse early postoperative outcomes and does not adversely affect long-term survival per se.

Does peritoneal perforation affect short- and long-term outcomes after transanal endoscopic microsurgery?

BACKGROUND: Peritoneal perforation (PP) is frequently reported as a complication of transanal endoscopic microsurgery (TEM). Nevertheless, these concerns have only rarely been addressed in the literature, with no mention of the long-term oncologic consequences of PP. METHODS: A prospective database was analyzed with the intent to evaluate the influence of PP on the short- and long-term outcomes for patients undergoing TEM. RESULTS: Peritoneal perforation occurred in 28 (5.8%) of 481 patients who underwent TEM for a rectal neoplasm. The conversion rate to abdominal surgery was 10.7% (3/28). All the conversions occurred during the first 100 TEM procedures (3/100 vs 0/381; p = 0.007). The postoperative morbidity rate was 3.6% (1/28), and the 30-day mortality was nil. Compared with the group of patients who had no peritoneal perforation, the PP group showed a significantly longer operating time (120 vs 60 min; p < 0.001) and a significantly longer hospital stay (6 vs 4 days; p = 0.003). Nevertheless, the global morbidity rate and the type of complications according to Dindo's classification were similar. In the multivariate analysis, the only independent predictor of PP was tumor distance from the anal verge (p = 0.010). During a median follow-up period of 48 months (range, 12-150 months), no liver or peritoneal metastases were detected in 13 patients with rectal cancer. CONCLUSIONS: Peritoneal perforation does not seem to affect short-term or oncologic outcomes for patients submitted to TEM with full-thickness resection for upper rectum neoplasms. The use of TEM to resect rectal lesions involving the intraperitoneal rectum may therefore represent an intermediate step toward the development of transrectal natural orifice translumenal endoscopic surgery (NOTES) techniques.