How to perform an anastomosis following a low anterior resection by transanal total mesorectal excision surgery: from top to bottom techniques.

AIM: The aim was to describe the range of possibilities and our group's clinical outcomes when performing different types of anastomosis during transanal total mesorectal excision (taTME). METHOD: A retrospective analysis was performed based on four taTME series from 2016 to 2021. Inclusion criteria were patients with rectal cancer in whom a sphincter-saving low anterior resection by taTME was performed. Four different techniques were employed for the anastomosis construction: (A) abdominal view, (B) transanal view, (C) hand-sewn coloanal anastomosis and (D) pull-through. Intra-operative and postoperative data were collected and compared. RESULTS: A total of 161 patients were included. Tumour height was lower in groups C and D (4 [3-5] vs. 7 [6-8] group A vs. 6 [5-7] group B, P = 0.000), requiring a hand-sewn anastomosis. A transanal extraction of the specimen was more commonly performed in groups C and D (over 60% vs. 30% in groups A and B, P = 0.000). The rate of temporary stoma was similar between groups A, B and C (ranging from 84% to 98%) but was significantly lower in group D (P = 0.000). The overall rate of complications was similar between groups; however, group D had longer length of stay (15 days vs. 5-6 in groups A, B and C, P = 0.026). CONCLUSION: Every type of anastomosis construction after a taTME procedure seems to be safe and feasible and should be chosen based on surgeon's experience, tumour height and the length of the rectal cuff after the rectal transection. Colorectal surgeons should be familiar with these techniques in order to choose the one that benefits each patient the most.

Oncological safety of transanal total mesorectal excision (TaTME) for rectal cancer: mid-term results of a prospective multicentre study.

BACKGROUND: There is no consensus regarding the gold standard technique for rectal cancer as Total Mesorectal Excision (TME) may be safely performed either by open or minimally invasive surgery. The laparoscopic approach, however, may carry technical difficulties. For this reason, a novel technique has emerged in the last decade combining a dual laparoscopic dissection (abdominal and transanal) to perform the TME technique (TaTME). When focusing on oncological outcomes, there is a lack of literature regarding mid-long term results. The aim of this study is to evaluate the mid-term oncological impact of TaTME for treating rectal cancer. METHODS: A prospective multicentre study was performed in four tertiary centres including consecutive patients who underwent TaTME for mid-low rectal cancer by the same group of experienced surgeons. The analysed data included pathological results on the quality of TME and mid-term oncological outcomes. RESULTS: In total, 173 patients were included throughout a study period of 6 years. Our series included 70% males and 68% of patients with neoadjuvant treatments. The median follow-up was 23 [15-37.5] months. Regarding pathological results, a complete TME was achieved in 72.8%, while circumferential and distal margins were affected in 1.4 and 1.1%, respectively. Five patients developed local recurrences (3%) and 8.1% presented distant disease during the follow-up. The 2-year disease-free survival and the overall survival rates were 88% and 95%, respectively. CONCLUSIONS: There is currently a lack of evidence in the literature regarding TaTME and oncological outcomes with no data available from randomized clinical trials. In the meantime, the reported results from different multicentre series are controversial. This study showed positive mid-term outcomes at 2 years of follow-up and supported notable oncological outcomes with TaTME. However, it must be emphasized that previous experience in minimally invasive and transanal surgeries is essential for surgeons before intending to perform TaTME.

The impact of SARS-CoV-2 infection on the surgical management of colorectal cancer: lessons learned from a multicenter study in Spain.

OBJECTIVE: the aim of the study was to analyze the management of colorectal cancer (CRC) patients diagnosed with CRC or undergoing elective surgery during the period of the SARS-CoV-2 pandemic. MATERIAL AND METHODS: a multicenter ambispective analysis was performed in nine centers in Spain during a four-month period. Data were collected from every patient, including changes in treatments, referrals or delays in surgeries, changes in surgical approaches, postoperative outcomes and perioperative SARS-CoV-2 status. The hospital's response to the outbreak and available resources were categorized, and outcomes were divided into periods based on the timeline of the pandemic. RESULTS: a total of 301 patients were included by the study centers and 259 (86 %) underwent surgery. Five hospitals went into phase III during the peak of incidence period, one remained in phase II and three in phase I. More than 60 % of patients suffered some form of change: 48 % referrals, 39 % delays, 4 % of rectal cancer patients had a prolonged interval to surgery and 5 % underwent neoadjuvant treatment. At the time of study closure, 3 % did not undergo surgery. More than 85 % of the patients were tested preoperatively for SARS-CoV-2. A total of nine patients (3 %) developed postoperative pneumonia; three of them had confirmed SARS-CoV-2. The observed surgical complications and mortality rates were similar as expected in a usual situation. CONCLUSIONS: the present multicenter study shows different patterns of response to the SARS-CoV-2 pandemic and collateral effects in managing CRC patients. Knowing these patterns could be useful for planning future changes in surgical departments in preparation for new outbreaks.

International validation of the low anterior resection syndrome score.

OBJECTIVE: The aims of this study were to investigate the convergent and discriminative validity and reliability of the low anterior resection syndrome (LARS) score in an international setting. BACKGROUND: The LARS score is a simple self-administered questionnaire measuring bowel dysfunction after rectal cancer surgery. The score is intended to be commonly used in international research and clinical practice in the future. Therefore, a thorough validation in an international setting is of utmost importance. METHODS: The LARS score was translated using methods in keeping with current international recommendations. A total of 801 patients operated for rectal cancer in Sweden, Spain, Germany, and Denmark completed the LARS score questionnaire, including an anchor question assessing the impact of bowel function on quality of life. A subgroup of 218 patients completed the LARS score twice. Data were analyzed per country. RESULTS: The LARS score has demonstrated a high convergent validity in terms of a high correlation between LARS score and quality of life (P < 0.001). Sensitivity ranged from 67.7% to 88.3% and specificity from 58.1% to 86.3%. The LARS score was able to discriminate between groups of patients differing with regard to radiotherapy, surgery, and age (P < 0.05). The score also demonstrated high reliability at test-retest with narrow limits of agreement and no statistically significant difference between scores at the first and second test. CONCLUSIONS: The Swedish, Spanish, German, and Danish versions of the LARS score have proven to be valid and reliable tools for measuring LARS in European rectal cancer patients.

Low anterior resection syndrome and quality of life: an international multicenter study.

BACKGROUND: An increasing number of patients are surviving a diagnosis of rectal cancer. The majority of the patients are treated with the sphincter-sparing surgical procedure low anterior resection, and 50% to 90% of these patients experience bowel dysfunction, known as the low anterior resection syndrome. No previous studies have investigated the association between the low anterior resection syndrome and quality of life in an international setting with the use of a validated instrument for the classification of the low anterior resection syndrome. OBJECTIVE: The aim of this study was to investigate the association between quality of life and the low anterior resection syndrome in European patients who have had rectal cancer. DESIGN: The study was designed as an international cross-sectional study involving 5 centers in 4 European countries. PATIENTS: All patients had undergone low anterior resection for rectal cancer, had no stoma, had no dissemination or recurrence at the time of the study, and were at least 16 months past surgery. INTERVENTIONS: The patients received by mail the Low Anterior Resection Syndrome Score and the quality-of-life questionnaire EORTC QLQ-C30. MAIN OUTCOME MEASURES: Eight subscales were selected to be the focus of this study: global quality of life; physical, role, emotional, and social functioning; fatigue; constipation; and diarrhea. RESULTS: A total of 796 patients were included, which corresponds to a response rate of 75.0%. In comparison with patients without low anterior resection syndrome, patients with major low anterior resection syndrome fared substantially worse in all selected subscales (difference ≥ 10 points, p < 0.01), with the exception of constipation. LIMITATIONS: The cross-sectional design prevents an evaluation of causality. CONCLUSIONS: The quality of life of patients who have had rectal cancer is closely associated with the severity of the low anterior resection syndrome. Therefore, it is important that clinicians and researchers focus on this syndrome to improve the prevention and the treatment of bowel dysfunction and the information given to patients.

The role of transanal compared to laparoscopic total mesorectal excision (taTME vs. lapTME) for the treatment of mid-low rectal cancer in obese patients: outcomes of a multicenter propensity-matched analysis.

To compare the rate of sphincter-saving interventions between transanal and laparoscopic Total Mesorectal Excision in this particular group of patients. A multicentre observational study was conducted using a prospective database, including patients diagnosed with rectal cancer below the peritoneal reflection and BMI ≥ 30 kg/m2, who underwent minimally invasive elective surgery over a 5-year period. Exclusion criteria were (1) sphincter and/or puborectalis invasion; (2) multi-visceral resections; (3) palliative surgeries. The study population was divided into two groups according to the intervention: transanal or laparoscopic total mesorectal excision. The primary outcome was the rate of sphincter-saving surgery. Secondary outcomes included conversion, postoperative complications, quality of the specimen, and survival. A total of 93 patients were included; 40 (43%) transanal total mesorectal excision were compared to 53 (57%) laparoscopic. In addition, 35 cases of transanal approach were case-matched with an equal number of laparoscopic approaches, based on gender, tumor's height, and neoadjuvant therapy. In both groups, 43% of the patients had low rectal cancer; however, the rate of sphincter-saving surgery was significantly higher in the transanal group (97% vs. 71%, p = 0.003). There were no conversions to open surgery in the transanal group, compared to 2 cases in the laparoscopic group (6%) (p = 0.246). The percentage of major complications was similar, including the rate of anastomotic leakage (10% transanal vs. 19% laparoscopic, p = 0.835). In our experience, higher percentages of sphincter-saving procedures and lower conversion rates are potential benefits of using the transanal approach in a complex surgical setting population of obese patients with mid-low rectal tumors when compared to laparoscopic.

[Post-surgical complications and mortality after two-stage coloanal anastomosis using the Turnbull-Cutait procedure]. / Complicaciones y mortalidad postoperatorias tras anastomosis coloanal en dos tiempos según técnica de Turnbull-Cutait.

INTRODUCTION: As colo-anal anastomoses continue to have a high risk of post-surgical dehiscence it is recommended to combine this with a protective stoma. The main purpose of this study was to determine the post-operative morbidity and mortality rate in patients operated on using the Turnbull-Cutait (T-C) technique with delayed colo-anal anastomosis without a protective ileostomy. MATERIAL AND METHODS: An observational study was conducted on 17 patients. The surgical indication was classified as "primary" (group I), and "secondary" (group II) when rescue was performed due to complications in the short to long-term after rectal resection. The surgical technique consisted of two stages: 1) low anterior resection, circumferential mucosectomy from the pectinate line, pulling the colon through the anal canal; 2) resection of the pull-through segment and colo-anal anastomosis between the fifth and tenth day. Demographic data, associated comorbidities, and ASA score were recorded, as well as post-surgical complications, post-surgical mortality, and technical failure (defined as performing a definitive stoma). RESULTS: The review consisted of 13 patients in group I and 4 in group II. Twelve patients were operated on due to rectal cancer, one patient due to a recto-vesico-vaginal fistula, two due to rescue of early complications (from the Emergency Department), and two were operated due to chronic complications after rectal resection. Six patients (35.3%) had one or more complications, three of them required new surgery. There were no postoperative deaths. CONCLUSIONS: The T-C could be a first option in cancer of the rectum, with no need for a protective ileostomy. It could be an alternative in urgent re-interventions of patients who have rectal surgery complications.

Rectal cancer treatment by transanal total mesorectal excision: Results in 100 consecutive patients. / Tratamiento del cáncer de recto mediante escisión completa del mesorrecto por vía transanal. Resultados en 100 pacientes consecutivos.

INTRODUCTION: The aim of this study is to describe and evaluate our clinical short-term surgical results of laparoscopic transanal total mesorectal excision. METHODS: Analysis of 100 consecutive patients with mid and lower rectal cancer who underwent transanal total mesorectal excision from November 2013 to September 2018. Main outcomes described are operative data, morbidities, mortality and quality of the specimen. A comparative analysis was done between gender and simultaneous vs. non simultaneous abdominal-perineal surgery. RESULTS: Mean patient age was 67 years (56-75), and 67% were male. On MRI, 50% were stage T3 tumors, and 52% had positive nodes. Mean distance of the tumor from anal verge was 4.9±1.3cm. A total of 58% underwent neoadjuvant treatment. Mean operative time was 262±40.7min; it was shorter in females (P<.001) and in simultaneous 2-field surgery. Median specimen distal free margin was 1.5cm (0.5-2.4). A total of 89% of the specimens were with complete mesorectum, with better results when a simultaneous approach was used (P=.047). The mean number of retrieved lymph-nodes was 15.2±11.6, and 26% of patients had positive nodes. Median length of stay was 5.5 days (4-8). Morbidities occurred in 36% of cases, and one patient died. CONCLUSIONS: According to our experience, laparoscopic transanal total mesorectal excision is safe and effective with adequate circumferential and distal free margins and high quality of the resected mesorectum specimen. Post-operative morbidity is acceptable, according to the current literature.

Characterization of odor emission on the working face of landfill and establishing of odorous compounds index.

Temporal variation (seasonal and daily) of odor emission on the working face of a large sanitary landfill in China was characterized through a 2 yearlong case study. Odor pollution was most serious in spring and autumn, while lower odor concentrations were detected in summer and winter. The daily fluctuation of odor concentration on the working face showed that 2:00am, 6:00am, 2:00pm and 10:00pm were the "most probable times" for odor pollution occurrence, which deserves focused attention in odor control projects. Correlations analysis found that 41% of the variance in odor concentrations can be explained by the chemical concentrations of odorous compounds. Moreover, the selection criteria for the index of odorous compounds were also established by evaluating the odor concentration, contribution to odor strength and the frequency of each compound present in all the samples. Ethyl alcohol, α-piene, hydrogen sulfide, dimethyl sulfide, limonene, methyl mercaptan, dimethyl disulfide, and diethyl sulfide comprise the index of odorous compounds on the working face of typical municipal solid waste landfill in China.

Tratamiento del cáncer de recto mediante escisión completa del mesorrecto por vía transanal. Resultados en 100 pacientes consecutivos / Rectal cancer treatment by transanal total mesorectal excision: Results in 100 consecutive patients

Introducción: El objetivo de este estudio es analizar los resultados quirúrgicos a corto plazo de la escisión completa del mesorrecto por vía transanal laparoscópica. Métodos: Análisis en 100 pacientes con cáncer de recto medio e inferior, intervenidos consecutivamente entre noviembre de 2013 y septiembre de 2018. Se describen los datos operatorios, la morbimortalidad y la calidad de la pieza quirúrgica. Se realiza un análisis comparativo entre sexos y la cirugía a uno y a 2 campos simultáneos. Resultados: La mediana de edad fue de 67 años (56-75), siendo el 67% varones. El 50% fueron tumores T3 y el 52% con afectación ganglionar, por RMN. La media de distancia al margen anal fue de 4,9 ± 1,3 cm. El 58% recibió neoadyuvancia. La media de tiempo quirúrgico fue de 262 ± 40,7 min, siendo menor en mujeres (p < 0,001) y en la cirugía simultánea a 2 campos (p = 0,008). La mediana de margen distal fue de 1,5cm (0,5-2,4). Se obtuvo un mesorrecto completo en el 89%, con mejores resultados en la cirugía a 2 campos (p = 0,047). La media de ganglios aislados fue de 15,2 ± 11,6. El 26% de los pacientes tuvieron afectación ganglionar. La mediana de estancia fue de 5,5 días (4-8). Hubo una morbilidad del 36% y un paciente falleció. Conclusiones: La escisión completa del mesorrecto por vía transanal laparoscópica es segura, consiguiendo un adecuado margen circunferencial y distal, con una alta calidad del mesorrecto. Ofrece una morbilidad aceptable para el tipo de intervención quirúrgica, según la literatura actual

Introduction: The aim of this study is to describe and evaluate our clinical short-term surgical results of laparoscopic transanal total mesorectal excision. Methods: Analysis of 100 consecutive patients with mid and lower rectal cancer who underwent transanal total mesorectal excision from November 2013 to September 2018. Main outcomes described are operative data, morbidities, mortality and quality of the specimen. A comparative analysis was done between gender and simultaneous vs. non simultaneous abdominal-perineal surgery. Results: Mean patient age was 67 years (56-75), and 67% were male. On MRI, 50% were stage T3 tumors, and 52% had positive nodes. Mean distance of the tumor from anal verge was 4.9 ± 1.3cm. A total of 58% underwent neoadjuvant treatment. Mean operative time was 262 ± 40.7 min; it was shorter in females (P < .001) and in simultaneous 2-field surgery. Median specimen distal free margin was 1.5 cm (0.5-2.4). A total of 89% of the specimens were with complete mesorectum, with better results when a simultaneous approach was used (P = .047). The mean number of retrieved lymph-nodes was 15.2 ± 11.6, and 26% of patients had positive nodes. Median length of stay was 5.5 days (4-8). Morbidities occurred in 36% of cases, and one patient died. Conclusions: According to our experience, laparoscopic transanal total mesorectal excision is safe and effective with adequate circumferential and distal free margins and high quality of the resected mesorectum specimen. Post-operative morbidity is acceptable, according to the current literature

A new approach for bone marrow-derived stem cells intrapancreatic autotransplantation in diabetic rats.

PURPOSE: A new technique for stem cells intrapancreatic autotransplantation in rats. BASIC PROCEDURES: Section of a femoral diaphysis and aspirations of the bone marrow in both femoral segments were performed. A Kirschner needle was placed into the femur. Cells were isolated in Ficoll gradients and preserved at 4-6 degrees C. The second day, cells were injected, via aortic celiac trunk, into the pancreas of the same rat. RESULTS: Femoral surgery were well tolerated. Intrapancreatic homing of the injected cells was suggested with methylene blue injection that stained the pancreas, and proved by labeled cells in pancreas sections. Cell counts after Ficoll isolation were 1 x 10(6) +/- 2 x 10(5) ES. CONCLUSIONS: A technique is described for stem cell autotransplantation in rats. First we obtain autologous bone marrow-derived stem cells. Second, we inject the cells in the pancreas of the donor rat. This approach can be applied to experimental diabetes and other pancreatic processes.

Complicaciones y mortalidad postoperatorias tras anastomosis coloanal en dos tiempos según técnica de Turnbull-Cutait / Post-surgical complications and mortality after two-stage coloanal anastomosis using the Turnbull-Cutait procedure

Introducción Las anastomosis coloanales siguen presentando un alto riesgo de dehiscencia postoperatoria razón por la que se recomienda la asociación de un estoma de protección. El principal objetivo de este estudio fue determinar la tasa de morbimortalidad postoperatoria en pacientes intervenidos según técnica de Turnbull-Cutait (T-C) con anastomosis coloanal diferida sin ileostomía de protección. Material y Método Estudio observacional sobre 17 pacientes. La indicación quirúrgica fue clasificada como «primaria» (grupo I) y «secundaria» (grupo II) cuando se realizó de rescate por complicaciones a corto o largo plazo de resección de recto. La técnica quirúrgica consta de dos tiempos: 1) resección anterior baja, mucosectomía circunferencial desde la línea pectínea, exteriorización del colon por canal anal; 2) sección del segmento exteriorizado y anastomosis coloanal entre el quinto y el décimo día. Se registraron datos demográficos, comorbilidades asociadas, ASA score, complicaciones postoperatorias, mortalidad postoperatoria y fracaso de la técnica, definido como la realización de un estoma definitivo. Resultados Se revisó a 13 pacientes en el grupo I y a 4 en el grupo II. Doce pacientes intervenidos por neoplasia de recto, una paciente por fístula recto-vesico-vaginal, 2 por rescate de complicaciones precoces (de urgencias) y 2 fueron operados por complicaciones crónicas tras resección de recto. Seis pacientes (35,3%) presentaron una o más complicaciones postoperatorias, tres de ellos requirieron reintervención. No hubo mortalidad postoperatoria. Conclusiones La técnica de T-C puede constituir una opción primaria en cáncer de recto sin necesidad de ileostomía de protección. Puede también ser una alternativa en re-intervenciones urgentes de pacientes que presenten complicaciones de cirugía de recto (AU)

Introduction As colo-anal anastomoses continue to have a high risk of post-surgical dehiscence it is recommended to combine this with a protective stoma. The main purpose of this study was to determine the post-operative morbidity and mortality rate in patients operated on using the Turnbull-Cutait (T-C) technique with delayed colo-anal anastomosis without a protective ileostomy. Material and methods An observational study was conducted on 17 patients. The surgical indication was classified as "primary" (group I), and "secondary" (group II) when rescue was performed due to complications in the short to long-term after rectal resection. The surgical technique consisted of two stages: 1) low anterior resection, circumferential mucosectomy from the pectinate line, pulling the colon through the anal canal; 2) resection of the pull-through segment and colo-anal anastomosis between the fifth and tenth day. Demographic data, associated comorbidities, and ASA score were recorded, as well as post-surgical complications, post-surgical mortality, and technical failure (defined as performing a definitive stoma). Results The review consisted of 13 patients in group I and 4 in group II. Twelve patients were operated on due to rectal cancer, one patient due to a recto-vesico-vaginal fistula, two due to rescue of early complications (from the Emergency Department), and two were operated due to chronic complications after rectal resection. Six patients (35.3%) had one or more complications, three of them required new surgery. There were no postoperative deaths. Conclusions The T-C could be a first option in cancer of the rectum, with no need for a protective ileostomy. It could be an alternative in urgent re-interventions of patients who have rectal surgery complications (AU)

Influencia del status en hierro en la atención y rendimiento intelectual de un colectivo de adolescentes espanoles / Influence of iron status on attention and intellectual performance of a population of Spanish adolescents

Dietetic, hematologic and biochemical data were used to asses the iron status of a group of 64 adolescents (37 males and 27 females), aged 15 to 18 (mean age 15.94 +/- 0.76 years), who study in a High School in the comunidad Aut onoma de Madrid. All were asked to keep a dietary record during 5 days, one of which had to be a sunday. Iron intake was estimated using the Food Composition Tables of the Instituto de Nutrici on (1990). The hematologic survey determined hemoglobin hematocrit mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), serum iron and serum ferritin. These data were correlated with the scores obtained in the attention and school capability test (AT), that gave information about the verbal (V), reasoning (R) and calculus (C) capabilities. There is a positive correlation between MCV (r = 0.2705), MCH (r = 0.3370) ferritin (r = 0.3383) and attention. MCV (r = 0.2995), MCH (r = 0.3998), MCHC (r = 0.3134) and ferritin (r = 0.3970) were also correlated with the speed capability shown on the attention test and the hemoglobin level was correlated with the calculus capability (r = 0.2905). The students who obtained higher scores in the school capability test had also better blood parameter values. This was statistically significant for serum ferritin in males students and for hemoglobin and MCHC in female students. 19.6 per cent of the adolescents had ferritin levels lower than 12 ng/ml. Their intelligence test scores were lower to those who had serum ferritin > or = 12 ng/ml.(ABSTRACT TRUNCATED AT 250 WORDS)