Transanal versus laparoscopic total mesorectal excision for mid and low rectal cancer (Ta-LaTME study): multicentre, randomized, open-label trial.

BACKGROUND: Transanal total mesorectal excision (TaTME) is a minimally invasive surgical technique that tries to avoid conversion to open surgery. However, specific intraoperative complications and local recurrences have cast some doubt on the suitability of the technique. The primary endpoint of the present study was a composite outcome of conversion surgery. Secondary objectives were to assess postoperative recovery, and pathological and oncological outcomes. METHODS: This was a prospective, multicentre, randomized, controlled open-label study of patients diagnosed with mid and low rectal adenocarcinoma who underwent laparoscopic TaTME or laparoscopic total mesorectal excision (LaTME). The TaTME technique comprised intracorporeal resection and anastomosis. Main outcomes were conversion to open surgery. Secondary outcomes were postoperative morbidity, mortality, pathological, oncological results, and survival. Modified intention-to-treat (mITT) and per-protocol analyses were performed. RESULTS: The study was conducted between April 2015 and May 2021. Patients were randomized to the LaTME (57 patients) or TaTME (59) group. Fifty patients from the LaTME group and 55 from the TaTME group were eligible for mITT analysis. The procedure was converted to open surgery in 11 patients (11 per cent): 10 (20 per cent) in the LaTME group and 1 (2 per cent) in the laparoscopic TaTME group (difference 18.8, 95 per cent c.i. 30 to 7; P = 0.003). No significant differences were found in terms of postoperative recovery and morbidity at 30 days; nor were there significant differences in anastomotic leakage, although it was less common in laparoscopic TaTME. With a median follow-up of 39 months, there were three instances of local recurrence (6.1 per cent) in the LaTME group and one (1.8 per cent) in the laparoscopic TaTME group (95 per cent c.i. 60 to 69; P = 0.3). Registration number: NCT02550769 (http://www.clinicaltrials.gov). CONCLUSION: The conversion rate was significantly lower in laparoscopic TaTME than in LaTME. At centres with experienced surgeons, laparoscopic TaTME can avoid conversion to open surgery.

Multicentre, prospective, randomized control non-inferiority trial of bladder catheter management in colon surgery.

AIM: Perioperative bladder catheterization is a controversial issue. Most current recommendations are based on data from open surgery extrapolated to enhanced recovery after surgery or fast-track programmes ranging between 24 and 48 h. The aim of this study is to provide a rationale for reducing catheterization time while at the same time avoiding acute urine retention (AUR), in patients undergoing scheduled laparoscopic colon surgery. METHOD: This is a multicentre, prospective, controlled, randomized non-inferiority study of bladder catheter management in patients undergoing scheduled laparoscopic colon surgery, randomized into two groups: experimental (with catheter removal immediately after surgery) and control (with catheter removal 24 h post-surgery). The main outcome will be the development of AUR, and secondary outcomes the development of urinary infection within the first 30 days and hospital stay. Demographic, surgical and pathological variables will also be evaluated, especially the development of adverse effects assessed according to the Clavien scale and the Comprehensive Complication Index. Following the literature, we assume an incidence of AUR of 11% and a margin of non-inferiority (delta) of 8% and estimate that a sample size of 208 patients per group will be required (with an estimated 10% of losses per group). CONCLUSIONS: In this study we try to demonstrate that the bladder catheter can be removed immediately after scheduled laparoscopic colon surgery, without increasing acute urine retention. This measure would offers the benefits of earlier mobilization and reduces catheter-related morbidity.

Prospective evaluation of bowel dysfunction after rectal cancer surgery.

PURPOSE: Bowel dysfunction after rectal cancer surgery may significantly affect the quality of life. Our study aimed to estimate the incidence and characterize the low anterior resection syndrome (LARS). METHODS: Prospective evaluation of patients treated with anterior resection for rectal cancer at two hospitals followed for 12 months after ileostomy reversal. The assessment was performed at baseline, after neoadjuvant treatment, and 1 month, 6 months, and 12 months after bowel transit reconstruction using several scores (Bristol scale, LARS score, Memorial Sloan Kettering bowel function instrument, Fecal Incontinence Quality of Life, EORTC-QLQ30, and a visual analogue scale). RESULTS: Of 205 patients diagnosed with rectal cancer, 78 were followed for 12 months after the exclusion criteria. "Major LARS" at 1 month, 6 months, and 12 months was 55.6%, 47.3%, and 34.6%, respectively. At 12 months, patients experienced significantly less diarrhea, higher LARS score, more percentage of "major LARS," and worse MSK-BFI score compared to baseline. Regarding the quality of life at 12 months, 77.7% of patients with "major LARS" reported impact according to the anchor question of the LARS score; all FIQL subscales were significantly lower; the overall EORTC-QLQ30 score and the functional subscales significantly correlated with the LARS and the MSK-BFI scores. CONCLUSIONS: Bowel dysfunction with an impact on the quality of life is common after rectal cancer surgery. The knowledge of the potential consequences of the treatments is essential to be able to provide patients with the best possible information.

Preoperative neutrophil-to-lymphocyte ratio behaves as an independent prognostic factor even in patients with postoperative complications after curative resection for gastric cancer.

PURPOSE: The aim of this study was to determine if the prognostic value of the preoperative neutrophil-to-lymphocyte ratio (NLR) could be modified by the presence of postoperative complications (POC) and their severity in patients with gastric adenocarcinoma resected with curative intent. METHODS: A retrospective study based on a prospective database of patients with resectable gastric adenocarcinoma treated with radical intention (R0) between January 1998 and February 2012. The primary endpoint was overall survival according to preoperative peripheral blood NLR and postoperative complications. Clinicopathological variables, preoperative blood tests, POC and its severity (Clavien-Dindo classification), type of POC (infectious or not infectious) and mortality were registered. A univariate and multivariate analysis (step forward Cox regression) was performed. The Kaplan-Meier method was used to assess overall survival. RESULTS: The 147 patients with gastric cancer who had undergone radical resection were included from an initial cohort of 209 patients. Univariant analysis: type of surgery, pT, pN, postoperative complications (Clavien-Dindo ≥ 3) and preoperative NLR ≥ 2.4 were significantly associated with survival (p < 0.05). Patients with POC showed worse long-term survival (p = 0.000), with no difference (p = 0.867) between infectious or non-infectious POC. NLR ≥ 2.4 was associated with infectious POC (p < 0.001). Patients with preoperative NLR ≥ 2.4 (p = 0.02) had a worse prognosis. Multivariate analysis: pN (p < 0.001), postoperative complications (p < 0.001) (HR 3.04; 95% CI: 1.97-4.70) and NLR ≥ 2.4 (p = 0.04) (HR = 1.55; 95% CI: 1.02-2.3) were independent prognostic factors. CONCLUSION: The preoperative inflammatory state of patients with gastric cancer measured by NLR behaves as an independent prognostic factor, even in patients with POC.

Signaling and Immunoresolving Actions of Resolvin D1 in Inflamed Human Visceral Adipose Tissue.

Persistent activation of the innate immune system greatly influences the risk for developing metabolic complications associated with obesity. In this study, we explored the therapeutic potential of the specialized proresolving mediator (SPM) resolvin D1 (RvD1) to actively promote the resolution of inflammation in human visceral adipose tissue from obese (Ob) patients. Using liquid chromatography-tandem mass spectrometry-based metabololipidomic analysis, we identified unbalanced production of SPMs (i.e., D- and E-series resolvins, protectin D1, maresin 1, and lipoxins) with respect to inflammatory lipid mediators (i.e., leukotriene B4 and PGs) in omental adipose tissue from Ob patients. In parallel, high-throughput transcriptomic analysis revealed a unique signature in this tissue that was characterized by overactivation of the IL-10 signaling pathway. Incubation of inflamed Ob visceral adipose tissues and human macrophages with RvD1 limited excessive activation of the IL-10 pathway by reducing phosphorylation of STAT proteins. Of interest, RvD1 blocked STAT-1 and its target inflammatory genes (i.e., CXCL9), as well as persistent STAT3 activation, without affecting the IL-10 anti-inflammatory response characterized by inhibition of IL-6, IL-1ß, IL-8, and TNF-α. Furthermore, RvD1 promoted resolution by enhancing expression of the IL-10 target gene heme oxygenase-1 by mechanisms dependent on p38 MAPK activity. Together, our data show that RvD1 can tailor the quantitative and qualitative responses of human inflamed adipose tissue to IL-10 and provide a mechanistic basis for the immunoresolving actions of RvD1 in this tissue. These findings may have potential therapeutic implications in obesity-related insulin resistance and other metabolic complications.

Endoscopic tattooing of early colon carcinoma enhances detection of lymph nodes most prone to harbor tumor burden.

BACKGROUND: Colorectal cancer (CRC) screening programs result in the detection of early-stage asymptomatic carcinomas suitable to be surgically cured. Lymph nodes (LN) from early CRC are usually small and may be difficult to collect. Still, at least 12 LNs should be analyzed from colectomies, to ensure a reliable pN0 stage. Presurgical endoscopic tattooing improves LN procurement. In addition, molecular detection of occult LN tumor burden in histologically pN0 CRC patients is associated with a decreased survival rate. We aimed to study the impact of presurgical endoscopic tattooing on the molecular detection of LN tumor burden in early colon neoplasms. METHODS: A prospective cohort study from a CRC screening-based population was performed at a tertiary academic hospital. LNs from colectomies with and without preoperative endoscopic tattooing were assessed by two methods, hematoxylin and eosin (HE), and RT-LAMP, to detect tumor cytokeratin 19 (CK19) mRNA. We compared the amount of tumor burden and LN yields from tattooed and non-tattooed specimens. RESULTS: HE and RT-LAMP analyses of 936 LNs were performed from 71 colectomies containing early carcinomas and endoscopically unresectable adenomas (8 pT0, 17 pTis, 27 pT1, 19 pT2); 47 out of 71 (66.2 %) were tattooed. Molecular positivity correlated with the presence of tattoo in LN [p < 0.001; OR 3.1 (95 % CI 1.7-5.5)]. A significantly higher number of LNs were obtained in tattooed specimens (median 17 LN vs. 14.5 LN; p = 0.019). CONCLUSIONS: Endoscopic tattooing enables the analysis of those LNs most prone to harbor tumor cells and improves the number of LN harvested.

Effect of transgastric natural orifice transluminal endoscopic surgery peritoneoscopy on abdominal organ microcirculation: an experimental controlled study.

BACKGROUND AND AIMS: On-demand insufflation during endoscopic peritoneoscopy causes wide variations in intra-abdominal pressure. Its effects on splanchnic microcirculation may differ from those of steady intra-abdominal pressure, because pressure characteristics affect crucial intravascular hemodynamic forces--pressure and shear--adapting flow to local metabolic needs. Our aim was to assess the effect of natural orifice transluminal endoscopic surgery (NOTES) peritoneoscopy on splanchnic microcirculatory blood flow. METHODS: Twenty-one swine were randomized to the following: cholecystectomy by transgastric NOTES (n = 8), cholecystectomy by standard laparoscopy (Lap) (n = 8), and a sham group (n = 5). During NOTES, CO2 was manually insufflated with a maximum allowed pressure of 30 mm Hg. In the Lap group, intra-abdominal pressure was maintained at 14 mm Hg. Systemic hemodynamics were measured, and microcirculatory blood flow was quantified by using colored microspheres. RESULTS: Mean intra-abdominal pressure was lower in NOTES than in the Lap group (P = .038). In both groups, cardiac index and preload remained unchanged, whereas systemic vascular resistances increased over time, with a lesser increase in the Lap group (2-way analysis of variance; P = .041). In pneumoperitoneum groups, microcirculatory blood flow decreased similarly in the renal medulla, stomach, small bowel, colon, and mesocolon by 30%, 45%, 34%, 32%, and 37%, respectively. In NOTES, there was a greater microcirculatory blood flow decrease in the renal cortex (NOTES 41% vs Lap 35%; P = .044) and mesentery (NOTES 44% vs Lap 38%; P = .041). CONCLUSIONS: These findings suggest that both types of pneumoperitoneum have similar physiologic effects on microcirculatory blood flow. However, on-demand pneumoperitoneum (NOTES group) caused a greater microcirculatory blood flow decrease in areas with low metabolic needs, redistributing blood flow toward metabolically active areas.

Ferric carboxymaltose reduces transfusions and hospital stay in patients with colon cancer and anemia.

PURPOSE: The purpose of the study was to evaluate the efficacy of preoperative intravenous (IV) ferric carboxymaltose (FCM) administration vs. no-IV iron in colon cancer (CC) anemic patients undergoing elective surgery with curative intention. METHODS: This was a multicenter, observational study including two cohorts of consecutive CC anemic patients: the no-IV iron treatment group was obtained retrospectively while FCM-treated patients were recorded prospectively. RESULTS: A total of 266 patients were included: 111 received FCM (median dose 1000 mg) and 155 were no-IV iron subjects. Both groups were similar in terms of demographic characteristics, tumor location, surgical approach, and intra-operative bleeding severity. The FCM group showed a significant lower need for red blood cell (RBC) transfusion during the study (9.9 vs. 38.7%; OR: 5.9, p < 0.001). In spite of lower hemoglobin levels at baseline diagnosis and lower transfusion rates in the FCM group, the proportion of responders was significantly higher with respect to the no-IV group both at hospital admission (48.1 vs. 20.0%, p < 0.0001) and at 30 days post-surgery (80.0 vs. 48.9%, p < 0.0001). The percentage of patients with normalized hemoglobin levels was also higher in the FCM group (40.0 vs. 26.7% at 30 days, p < 0.05). A lower number of reinterventions and post-surgery complications were seen in the FCM group (20.7 vs. 26.5%; p = 0.311). The FCM group presented a significant shorter hospital stay (8.4 ± 6.8 vs. 10.9 ± 12.4 days to discharge; p < 0.001). CONCLUSIONS: Preoperative ferric carboxymaltose treatment in patients with CC and iron deficiency anemia significantly reduced RBC transfusion requirements and hospital length of stay, reaching higher response rates and percentages of normalized hemoglobin levels both at hospital admission and 30 days post-surgery.

Pretreatment with endothelium-derived nitric oxide synthesis modulators on gastrointestinal microcirculation during NOTES: an experimental study.

BACKGROUND AND STUDY AIMS: On-demand endoscopic insufflation during natural orifice transluminal endoscopic surgery (NOTES) adversely affects microcirculatory blood flow (MBF), even with low mean intra-abdominal pressure, suggesting that shear stress caused by time-varying flow fluctuations has a great impact on microcirculation. As shear stress is inversely related to vascular diameter, nitric oxide (NO) production acts as a brake to vasoconstriction. OBJECTIVE: To assess whether pretreatment by NO synthesis modulators protects gastrointestinal MBF during transgastric peritoneoscopy. METHODS: Fourteen pigs submitted to cholecystectomy by endoscope CO2 insufflation for 60 min were randomized into 2 groups: (1) 150 mg/kg of N-acetyl cysteine (NAC, n = 7) and (2) 4 ml/kg of hypertonic saline 7.5 % (HS, n = 7), and compared to a non-treated NOTES group (n = 7). Five animals made up a sham group. Colored microspheres were used to assess changes in MBF. RESULTS: The average level of intra-abdominal pressure was similar in all groups (9 mmHg). In NOTES group microcirculation decrease compared with baseline was greater in renal cortex, mesocolon, and mesentery (41, 42, 44 %, respectively, p < 0.01) than in renal medulla, colon, and small bowel (29, 32, 34, respectively, p < 0.05). NAC avoided the peritoneoscopy effect on renal medulla and cortex (4 and 14 % decrease, respectively) and reduced the impact on colon and small bowel (20 % decrease). HS eliminated MBF changes in colon and small bowel (14 % decrease) and modulated MBF in renal medulla and cortex (19 % decrease). Neither treatment influenced mesentery MBF decrease. CONCLUSIONS: Both pretreatments can effectively attenuate peritoneoscopy-induced deleterious effects on gastrointestinal MBF.

Transanal total mesorectal excision in rectal cancer: short-term outcomes in comparison with laparoscopic surgery.

OBJECTIVE: The aim of this study was to compare short-term results obtained with transanal total mesorectal excision (TME) and laparoscopic surgery. BACKGROUND: Transanal TME appears as an alternative in the treatment of rectal cancer and other rectal disease. Natural orifices transluminal endoscopic surgery using the rectum as access in colorectal surgery is intuitively better suited than other access routes. METHODS: All consecutive patients with middle or low rectal cancer submitted to surgery were included into a prospective cohort and treated by transanal TME assisted by laparoscopy. They were compared with a retrospective cohort of consecutive patients of identical characteristics treated by laparoscopic TME in the immediate chronological period. RESULTS: Thirty-seven patients were included in both study groups. No differences were observed between them with respect to baseline characteristics, thus emphasizing the comparability of both cohorts. Surgical time was higher in the laparoscopy group (252 ± 50 minutes) than in the transanal group (215 ± 60 minutes) (P < 0.01). Moreover, coloanal anastomosis was performed less frequently (16% vs 43%, respectively; P = 0.01) and distal margin was lower (1.8 ± 1.2 mm vs 2.7 ± 1.7 mm, respectively; P = 0.05) in the laparoscopy group than in the transanal one. Although there was no significant difference in 30-day postoperative complication rate (laparoscopy, 51% vs transanal, 32%; P = 0.16), early readmissions were more frequent in the laparoscopy group than in the transanal one (22% vs 6%, respectively; P = 0.03). CONCLUSIONS: Evaluation of short-term outcomes demonstrated that transanal TME is a feasible and safe technique associated with a shorter surgical time and a lower early readmission rate.

Characterization of inflammation and fibrosis in Crohn's disease lesions by magnetic resonance imaging.

OBJECTIVES: Measurement of the component of fibrosis in Crohn's disease (CD) may have important therapeutic implications. The aim of this study was to characterize the Magnetic Resonance Imaging (MRI) findings that are differentially associated with the presence of fibrosis and those associated with inflammatory activity, using the pathological analysis of surgically resected intestinal lesions as reference standard. METHODS: MRI studies with identical imaging protocol of 41 CD patients who underwent elective bowel resection within 4 months before surgery were reviewed. MRI evaluated wall thickening, edema, ulcers, signal intensity at submucosa at 70 s and 7 min after gadolinium injection, stenosis, and pattern of enhancement in each phase of the dynamic study and changes on this pattern over time. Pathological inflammatory and fibrosis scores were classified into three grades of severity. RESULTS: In all, 44 segments from 41 patients were analyzed. The pathological intensity of inflammation was associated with the following MRI parameters: hypersignal on T2 (P=0.02), mucosal enhancement (P=0.03), ulcerations (P=0.01), and blurred margins (P=0.05). The degree of fibrosis correlated with the percentage of enhancement gain (P<0.01), the pattern of enhancement at 7 min (P<0.01), and the presence of stenosis (P=0.05). Using percentage of enhancement gain, MRI is able to discriminate between mild-moderate and severe fibrosis deposition with a sensitivity of 0.94 and a specificity of 0.89. CONCLUSIONS: MRI is accurate for detecting the presence of severe fibrosis in CD lesions on the basis of the enhancement pattern.

Minimal invasive surgery: NOSE and NOTES in ulcerative colitis.

BACKGROUND: In patients with ulcerative colitis (UC), laparoscopic pelvic dissection for IPAA is not always straightforward: often, a hand-assistance incision is used to complete the proctectomy, lengthening operative times. Hybrid NOSE and NOTES are emerging as an alternative approach to conventional laparoscopy. We believe that UC patients could benefit from this new hybrid approach in three ways: by easing the proctectomy as performed down to up, avoiding additional incisions and decreasing surgical times. We present the short-term outcomes of our series. METHODS: All patients with UC who required IPAA were enrolled in a single-arm prospective study (July 2011 to March 2014). A three-step procedure was performed. The first step: laparoscopic colectomy (with transanal removal of the colon) and temporary ileostomy. The second step: "down-to-up" proctectomy (with transanal removal of the rectum) and IPAA with a covering ileostomy. We combined simultaneously transanal and laparoscopic approach. The third step: ileostomy closure. Functional outcomes were assessed 3 months after third step. RESULTS: Eighteen patients were enrolled. Two patients are waiting to complete the second stage, and 16 underwent all surgical steps. Twelve have been evaluated with functional scores. For the first step, the mean operative time was 162.2 min (SD 40.5) and 170 min (SD 50.1) for the second one. The median hospital stay was 6 days (IQR 5-14.75) for the first step and 5.5 (IQR 5-9.75) for the second one. No major complications occurred. Twenty-four-hour defecation frequency was 5.5 per day (SD 1.7), 0.5 per night. Seventy-five percentage of patients may retain stools for more than 30 min; the mean value of Oresland score was 4.7 and Wexner score 1.4. CONCLUSIONS: This is a safe and feasible technique to treat UC patients with good short-term outcomes. Long-term outcomes and controlled trials are needed.

Preoperative chemotherapy in patients with intermediate-risk rectal adenocarcinoma selected by high-resolution magnetic resonance imaging: the GEMCAD 0801 Phase II Multicenter Trial.

BACKGROUND: The need for preoperative chemoradiation or short-course radiation in all T3 rectal tumors is a controversial issue. A multicenter phase II trial was undertaken to evaluate the efficacy and safety of neoadjuvant capecitabine and oxaliplatin combined with bevacizumab in patients with intermediate-risk rectal adenocarcinoma. METHODS: We recruited 46 patients with T3 rectal adenocarcinoma selected by magnetic resonance imaging (MRI) who were candidates for (R0) resection located in the middle third with clear mesorectal fascia and who were selected by pelvic MRI. Patients received four cycles of neoadjuvant capecitabine and oxaliplatin combined with bevacizumab (final cycle without bevacizumab) before total mesorectal excision (TME). In case of progression, preoperative chemoradiation was planned. The primary endpoint was overall response rate (ORR). RESULTS: On an intent-to-treat analysis, the ORR was 78% (n = 36; 95% confidence interval [CI]: 63%-89%) and no progression was detected. Pathologic complete response was observed in nine patients (20%; 95% CI: 9-33), and T downstaging was observed in 48%. Forty-four patients proceeded to TME, and all had R0 resection. During preoperative therapy, two deaths occurred as a result of pulmonary embolism and diarrhea, respectively, and one patient died after surgery as a result of peritonitis secondary to an anastomotic leak (AL). A 13% rate of AL was higher than expected. The 24-month disease-free survival rate was 75% (95% CI: 60%-85%), and the 2-year local relapse rate was 2% (95% CI: 0%-11%). CONCLUSION: In this selected population, initial chemotherapy results in promising activity, but the observed toxicity does not support further investigation of this specific regimen. Nevertheless, these early results warrant further testing of this strategy in an enriched population and in randomized trials.

Clinical markers of the hypercoagulable state by rotational thrombelastometry in obese patients submitted to bariatric surgery.

BACKGROUND: Metabolic and inflammatory disturbances associated with obesity are considered important trigger factors for venous thromboembolism (VTE). Identification of clinical markers indicating a hypercoagulability state could define a group of high-risk patients in the surgical setting. This study aimed to identify these markers using rotational thrombelastometry (ROTEM) analysis, an established method for hemostasis testing that can detect hyperfunctional stages of the clotting process. METHODS: From June to December 2010, this study investigated 109 consecutive obese patients (28 women and 22 men, mean age 46 years, body mass index 46.6 ± 7 kg/m(2)) with no history of VTE who were candidates for bariatric surgery. Preoperative clinical and metabolic characteristics and ROTEM analysis were recorded. Hypercoagulable risk was defined when patients showed a clot strength (G) of ≥11 dynes/cm(2). RESULTS: Of the 109 patients, 20 (18%) were hypercoagulable according to ROTEM analysis. Metabolic/inflammatory biomarkers such as leptin, C-reactive protein, fibrinogen levels, and platelet count were significantly higher in the high-risk patients. In the multivariate analysis, fibrinogen was an independent predictor of G ≥ 11 dynes/cm(2) [odds ratio (OR) 2.92, 95 % confidence interval (CI) 1.80-5.21, p = 0.023]. After adjustment to other data, only waist circumference affected the prediction [OR 4.42, 95 % CI 2.27-6.71, p = 0.009]. Receiver operating characteristic curve analysis showed that 3.95 g/l was the best cutoff point for fibrinogen predictability (sensitivity 100 %, specificity 41%). CONCLUSION: A hypercoagulability state in obese patients is associated with central obesity and high fibrinogen levels, which should be considered clinical hallmarks of this state. More aggressive perioperative prophylaxis for VTE should be recommended when these hallmarks are present in obese patients.

Laparoscopic-assisted total mesorectal resection through the transanal route.

One of the most controversial areas in laparoscopic approach is rectal cancer, not only because of the surgical technique but of the best approach to do it. The transanal approach arises like a new alternative for rectal cancer and other rectal pathologies due to solve some of the problems that we can find in conventional laparoscopic approach, mainly in low rectal cancer for the section of the rectum and distal margin. The first case of rectal cancer surgery by transanal approach was published in 2009. Since now, just a few series with a limited number of patients has been done with this technique. Among the different series there are differences, especially with the surgical technique (mainly with the transanal platform). Nowadays, the morbidity and postoperative outcomes have are comparable with the conventional approach. The oncological outcomes have no shown any differences, even long term results are not known at the moment (longer follow-up of 21 months). The results published in transanal approach surgery demonstrate the feasibility and safety of the procedure with an advantage in hostile pelvis (obese, narrow pelvis and males). Randomized studies are needed for long-term functional and oncological outcomes.

[Effects of gastric bypass on estimated cardiovascular risk in morbidly obese patients with metabolic syndrome]. / Efectos del bypass gástrico sobre el riesgo cardiovascular estimado.

INTRODUCTION: The major goal of surgical treatment in morbid obesity is to decrease morbidity and mortality associated with excess weight. In this sense, the main factors of death are cardiovascular disease and metabolic syndrome. The objective of this study is to evaluate the effects of gastric bypass on cardiovascular risk estimation in patients after bariatric surgery. MATERIAL AND METHODS: We retrospectively evaluated pre and postoperative cardiovascular risk estimation of 402 morbidly obese patients who underwent laparoscopic gastric bypass. The major variable studied is the cardiovascular risk estimation that is calculated preoperatively and after 12 months. Cardiovascular risk estimation analysis has been performed with the REGICOR Equation. REGICOR formulation allows calculating a 10 year risk of cardiovascular events adapted to the Spanish population and is expressed in percentages. RESULTS: We reported an overall 4.1±3.0 mean basal REGICOR score. One year after the operation, cardiovascular risk estimation significantly decreased to 2,2±1,6 (P<.001). In patients with metabolic syndrome according to ATP-III criteria, basal REGICOR score was 4.8±3.1 whereas in no metabolic syndrome patients 2.2±1.8. Evaluation 12 months after surgery, determined a significant reduction in both groups (metabolic syndrome and non metabolic syndrome) with a mean REGICOR score of 2.3±1.6 and 1.6±1.0 respectively. CONCLUSION: The results of our study demonstrate favorable effects of gastric bypass on the cardiovascular risk factors included in the REGICOR equation.

GLP-1 and the long-term outcome of type 2 diabetes mellitus after Roux-en-Y gastric bypass surgery in morbidly obese subjects.

OBJECTIVE: To evaluate the association between glucagon-like peptide 1 (GLP-1) secretion and the long-term (>2 years) outcome of type 2 diabetes mellitus (T2DM) after Roux-en-Y gastric bypass (RYGBP). METHODS: Cross-sectional study in 18 T2DM morbidly obese subjects who underwent RYGBP but differed in the long-term outcome of T2DM (remission: G1, n = 6; relapse: G2, n = 6; lack of remission: G3: n = 6). Groups were matched for their sex, age, and body mass index. The GLP-1, glucose, C-peptide, and glucagon responses to a standardized test meal (STM) were evaluated. Insulin secretion and insulin sensitivity were estimated from the STM and by frequently sampling intravenous glucose tolerance test (FSIVGTT). Dual-energy X-ray absorptiometry was used to assess body composition. RESULTS: Patients in G1 presented a lower area under the curve (AUC0-120) of glucose in response to the STM as compared with G2, and G3 (P < 0.01). In contrast, the AUC0-120 of GLP-1 (P = 0.884) and glucagon (P = 0.630) did not differ significantly among the 3 groups. Indices of insulin secretion adjusted by the prevailing insulin sensitivity derived from STM and FSIVGTT, demonstrated larger ß-cell function in subjects in G1 as compared with G2 or G3 (Disposition Index-STM, P = 0.005; DI-FSIVGTT, P = 0.006). Body composition and inflammatory markers did not differ significantly among the 3 study groups. CONCLUSIONS: Our data show that in subjects with T2DM an enhanced GLP-1 response to meal intake is not sufficient to maintain normal glucose tolerance in the long term after RYGBP. Our data suggest that ß-cell function is a key determinant of the long-term remission of T2DM after this bariatric surgery technique.

Minilaparoscopy-assisted transrectal low anterior resection (LAR): a preliminary study.

BACKGROUND: Natural orifice translumenal endoscopic surgery (NOTES) represents the evolution of surgery towards less invasive procedures. The feasibility of NOTES transrectal approach has increased its clinical applicability. This report describes a first series of minilaparoscopy-assisted transrectal low anterior resection with double purse-string end-to-end circular stapler anastomoses. METHODS: Between March and April 2012 three selected patients underwent transrectal minilaparoscopy-assisted natural orifice surgery total mesorectal excision for rectal cancer. All the oncologic principles of open/laparoscopic low anterior resection for rectal cancer were strictly fulfilled. Two patients underwent neoadjuvant treatment. Laparoscopic visualization and assistance was provided through one 10-mm umbilical port and two ports, one of which was used as stoma site (5 mm) and the other as a drain site (2 mm needle port). The specimen was transected transanally followed by the confection of double purse-string lateral/end-to-end anastomoses. There were no intraoperative complications. RESULTS: Mean operative time was 143 min. Oral intake was initiated on the second postoperative day. Patients were discharged home by day 5. The pathology unit confirmed that distal and circumferential margins were free of tumor invasion, and quality of mesorectum resection was reported satisfactory. One patient had to be readmitted because of severe dehydration due to increased ileostomy output. The patient was discharged at the third day after the readmission without renal failure. CONCLUSIONS: In this preliminary report, transrectal minilaparoscopy-assisted low anterior resection was feasible and safe. Lateral/end-to-end anastomoses can be considered an interesting alternative to the double-stapling technique. However, it is necessary to further study and develop these procedures, along with careful patient selection, before transrectal low anterior resection may be considered for routine clinical use.

Transanal natural orifice transluminal endoscopic surgery (NOTES) rectal resection: "down-to-up" total mesorectal excision (TME)--short-term outcomes in the first 20 cases.

BACKGROUND: The transanal minilaparoscopy-assisted natural orifice transluminal endoscopic surgery (NOTES) approach holds significant promise as a safe and less morbid alternative to conventional low anterior rectal resection. Previous reports have shown satisfactory short-term oncologic results. We evaluated the safety and short-term outcomes in rectal cancer subjects who underwent transanal minilaparoscopy-assisted natural orifice surgery total mesorectal excision (TME) rectal resection. METHODS: Twenty selected patients with rectal cancer were enrolled onto a prospective study of minilaparoscopy-assisted natural orifice surgery TME rectal resection. The study endpoints were safety of access (intra- or postoperative morbidity) and adequacy of oncological resection criteria; intact TME; distal and circumferential margins; and number of lymph nodes retrieved. RESULTS: All procedures were successfully completed with the transanal NOTES and minilaparoscopy technique. The mean age was 65 ± 10 years; 55% of patients were male; the mean body mass index was 25.3 ± 3.8 kg/m(2). Thirty-five percent of tumors were in the distal rectum, 50% in midrectum, and 15% in proximal rectum. Coloanal anastomoses were hand sewn in 65% and stapled in 35%. Mean operative time was 235 ± 56 min. There were no procedure-related complications. Pathologic analysis demonstrated negative distal and circumferential margins in all patients. An average of 15.9 ± 4.3 lymph nodes were retrieved. The mesorectal fascia was intact in all the specimens. CONCLUSIONS: This study demonstrates that transanal NOTES with minilaparoscopic assistance in the hands of a specialized team is safe; meets the oncologic requirements for high-quality rectal cancer surgery; and may offer advantages over pure laparoscopic approaches for visualizing and dissecting out the distal mesorectum. Minilaparoscopic assistance allows one to compensate for the limitations of current NOTES instrumentation to ensure the safety and adequacy of oncologic resection in these difficult cases. Careful patient selection, a specialized team, and long-term outcome evaluation are critical before this procedure can be considered for routine clinical use.

Transumbilical single-port sleeve gastrectomy: initial experience and comparative study.

BACKGROUND: Sleeve gastrectomy is gaining relevance in the surgical armamentarium against obesity. The transumbilical single port has proved to be an attractive and safe alternative for a variety of minimally invasive abdominal surgeries. The purpose of this study is to evaluate the initial results of a group of patients operated by single-port sleeve gastrectomy compared with a group operated by conventional laparoscopic technique. PATIENTS AND METHODS: We present a prospective cohort study of two groups of consecutive patients with body mass index (BMI) between 35 and 55 kg/m(2), with an indication of sleeve gastrectomy. In 20 patients, we used a transumbilical single-port (TUSP) technique; in 22 patients, we used the conventional laparoscopic (CL) technique. All surgeries were performed between June and December 2009 in the Gastrointestinal Surgery Department of Hospital Clínic, Barcelona. The same medical team, in a standardized fashion, carried out all surgeries. RESULTS: There were no differences between groups in body mass index (BMI), age, sex, number and type of comorbidities, or history of previous abdominal surgery. Operative time (79.2 min) was significantly higher in the TUSP group (p = 0.002) than in the CL group (54.1 min). There were no conversions to open surgery in any of the patients operated upon via CL, but one conversion to laparoscopic surgery, requiring the addition of three trocars, in the TUSP group. There were no significant differences in morbidity or hospital stay between the groups. Percentage excess weight loss and excess BMI loss at 3 and 6 months, as indexes for improvement and resolution of comorbidities associated with obesity, showed that there were no significant differences between the groups. CONCLUSIONS: Transumbilical single-port sleeve gastrectomy has proved to be safe, technically feasible, and reproducible, with results that are similar to those obtained with conventional laparoscopic surgery.