The outcome of transanal endoscopic microsurgery and adjuvant radiotherapy in patients with high-risk T1 rectal cancer.

Introduction: Transanal endoscopic microsurgery (TEM) is considered the technique of choice for adenoma and low-risk T1 rectal cancer. The adequacy of such treatment for high-risk T1 tumours, however, is still controversial. The aim of the study is to evaluate our results with local excision of high-risk T1 cancers. and Methods: Demographic, clinical data pertaining to patients undergoing TEM for T1 rectal cancer between 1999 and 2015 was retrospectively collected. Long-term outcomes were assessed for the entire cohort. Patients were classified into two groups: favourable and high-risk cancer features. Results: Three hundred and fifty-five TEM procedures were recorded in the study period. Forty-three patients were included in the present study. There were 20 females and 23 males, the median age was 69 ± 9. The median tumour distance from the anal verge was 6 cm (range 1-13 cm). Post-operative histopathology showed well/moderately differentiated T1 adenocarcinoma in 30 patients and poorly differentiated in 13. The overall survival for patients with favourable and high-risk features groups were 93.5% and 77%, respectively, while the local recurrence (LR) was 3.5% and 23.1%, respectively. Nine patients with high-risk features received adjuvant radiotherapy; one (11.1%) of them experienced LR. Conclusions: Local excision by TEM augmented by adjuvant radiotherapy may be a feasible alternative for selected patients with high-risk T1 rectal cancer. The addition of radiotherapy seems to decrease the rates of LR.

Frozen section examination may facilitate reconstructive surgery for mid and low rectal cancer.

BACKGROUND: Distal margin >1 cm provides an oncologic safety in low-lying rectal cancers. We evaluated the accuracy of frozen section (FS) examination in estimating distal margins, and its impact on intraoperative decision making regarding restorative proctectomy. METHODS: Retrospective study of patients who underwent surgery for adenocarcinoma of the mid or lower rectum during 2001-2010 and for whom a distal margin specimen was examined intraoperatively by FS, to confirm microscopically free margins. Intraoperative findings, and frozen and final paraffin section findings were retrieved from patient charts. A distal margin of ≤1 cm was compared with >1 cm, for free margins at final pathology and local recurrence (LR). The impact of a distal margin ≤5 mm was also assessed. The impact of FS on intraoperative decision making, in patients who did and did not receive preoperative chemoradiotherapy, was assessed. RESULTS: The mean age of the 63 patients studied was 66.4 ± 11.8 years, and median tumor distance from the anal verge 6 cm (range 1-10 cm). Seven patients underwent abdominoperineal resection, 54 anterior resection, and two Hartman procedures. FS sensitivity and specificity were 83% and 98%, respectively. Accuracy of FS was high for the 41 patients treated with preoperative chemoradiotherapy, and the 22 who were not. Distal margin >5 mm at FS examination ensured a free margin at final pathology. LR rate was comparable between patients with distal margin >10 mm and ≤10 mm, 8% vs 11%, P = 0.65. CONCLUSIONS: FS examination may help determine free distal margin and consequently, in selected cases, may facilitate a restorative procedure in patients with low rectal cancer.

Transanal endoscopic microsurgery for upper rectal tumors.

BACKGROUND: Compared with traditional rectal resection, transanal endoscopic microsurgery (TEM) is faster and safer. This retrospective study sought to assess the efficacy of TEM for lesions located in the upper rectum, ≥10 cm from the anal verge. METHODS: Data from all patients who underwent TEM for rectal lesions ≥10 cm from the anal verge between 2001 and 2010 at two medical centers in Israel were retrospectively analyzed. The study group comprised 96 patients (57 men, 39 women) who underwent 99 TEM procedures. Collected data included patient demographics, tumor characteristics, indications for surgery, operative findings and details, postoperative outcomes, and histopathologic findings. Long-term outcomes including local recurrence (LR) for benign lesions and LR and overall survival (OS) for malignant lesions were calculated. Categorical variables were calculated by frequency tables, and linear variables were represented by averages and standard deviation or median with the spread of variables. Survival and LR analysis was performed by Kaplan-Meier and Cox regression methods. RESULTS: The mean tumor distance from the anal verge was 11.3 ± 2 cm and the median tumor size was 2 cm. Early postoperative outcomes were favorable, and no early postoperative mortality was reported. The postoperative morbidity rate was 10%. For long-term outcomes, in the subgroup with benign lesions, after a median follow-up of 8.7 years, the LR rate was 5.1%. In the group with malignant lesions, LR and OS rates were 6.9 and 87%, respectively. CONCLUSIONS: TEM for upper rectal lesions is feasible and may be safe in selected cases. Low morbidity rate, shorter operative time and length of stay, no mortality events, and favorable long-term outcomes support the use of TEM for the treatment of lesions in the upper rectum.

The impact of preoperative stoma site marking on the incidence of complications, quality of life, and patient's independence.

BACKGROUND: Preoperative stoma site marking and counseling aim to improve patients' rehabilitation and adaptation to a new medical condition. Objective studies are needed to provide evidence of the impact of care by stoma therapists. Key quality indicators include patients' quality of life, independence, and complication rates as affected by the variable modes of stoma site marking and planning. OBJECTIVE: The aim of this study was to evaluate the impact of preoperative stoma site marking on patients' quality of life, independence, and complication rates. DESIGN: : A validated stoma quality-of-life questionnaire was used as the main assessment tool. Complications were noted on regular postoperative visits. SETTING: This is a single-center, clinical study. The study was conducted at the Rambam Health Care Campus in Haifa, Israel. Rambam Health Care Campus is a tertiary university hospital. PATIENTS: All patients who underwent an elective stoma creation between 2006 and 2008 were included. MAIN OUTCOME MEASURES: Evaluated parameters included demographics, stoma type, marking status, complication rates, quality of life, and independence parameters. RESULTS: : One hundred five patients (60 men and 45 women) were included, of whom 52 (49.5%) were preoperatively marked and 53 (50.5%) were not marked. Sixty stomas (57%) were permanent, and 45 (43%) stomas were temporary. The quality of life of patients whose stoma sites were preoperatively marked was significantly better than that of the unmarked patients (p < 0.05 in 18 of 20 items), their independence parameters were significantly better, and their complication rates significantly lower. All of these results were significant irrespective of the stoma type. CONCLUSIONS: Preoperative stoma site marking is crucial for improving patients' postoperative quality of life, promoting their independence, and reducing the rates of postoperative complications. The role of the enterostomal therapist is very important in the ostomates' pre- and postoperative care.

Long-term results of local excision for T1 rectal carcinoma: the experience of two colorectal units.

BACKGROUND: Local excision for early rectal cancer has low morbidity and good functional results. Its use is limited by the inability to assess regional lymph nodes and by the uncertainty of oncologic outcome. METHODS: We conducted a retrospective chart review of all patients who underwent local excision of early rectal cancer in two colorectal units between 1995 and 2007. The retrieved and analyzed data were patient age and gender, tumor size, tumor distance from the anal verge, tumor differentiation, and additional treatment. RESULTS: There were 42 patients with T1 rectal cancer: 24 underwent transanal endoscopic microsurgery and 18 had a transanal excision. The surgical margins were free of tumor in 39 patients (93%), they were involved by tumor in one (2%) and margin status was unclear in two (5%). Seven patients (16%) had postoperative complications. There was no postoperative mortality. The mean hospital stay was 67 h. Thirty-nine patients (93%) were followed up for 57 months (mean). Two patients had local recurrence, at 7 and 41 months post-surgery. They had a tumor that invaded into the lower third of the submucosa, sm3. Both received chemoradiotherapy, and underwent an abdominoperineal resection and a low anterior resection. One of them died of metastatic disease 13 months later and the other is alive with no evidence of disease. Another two patients had salvage low anterior resection, one for suspected local recurrence and one for lymphovascular invasion: the specimens were tumor free. Six patients died of unrelated causes. CONCLUSIONS: Local excision of early rectal cancer is a feasible and acceptable alternative to radical resection. It has low complication and recurrence rates and a short postoperative hospital stay.

Transanal endoscopic microsurgery for large benign rectal tumors; where are the limits?

INTRODUCTION: Local excision is the treatment of choice for large benign rectal lesions. Transanal endoscopic microsurgery is recommended. The excision of large lesions >4 cm has been previously described. We report our series of lesions >5 cm that have been excised via the transanal endoscopic microsurgery. METHODS: Patients who underwent transanal endoscopic microsurgery for rectal tumors, between the years 2002-2012, were identified. Patients with tumors greater than 5 cm consisted the study group. Tumor diameter was determined based on fresh specimen measurements. Data pertaining to patients and tumor characteristics, operative and histopathology findings, postoperative outcomes were collected. Local recurrence and effects on anal sphincter function were assessed. RESULTS: Twenty five patients (14 female) with mean age of 70.3 ± 10.1 years, met the inclusion criteria. The mean tumor size was 5.7 ± 0.9 cm. The median distance from anal verge was 8 cm (range 1-17). Preoperative biopsy of the rectal tumor revealed adenoma with/without dysplasia in 24 patients. Postoperative findings were adenoma with/without dysplasia in 20 patients, T1 rectal cancer in 4 patients and tail gut cyst in one patient. Free margins were documented in 17 patients, in 7 it was involved and in one patient it could not be determined. In 2 cases the procedure was discontinued. Except for nonspecific transient fever no postoperative complications were reported. After a median follow up of 24.2 months, the 3-year LR rate was 10.9%. CONCLUSION: TEM is feasible for the treatment of large benign rectal tumors. It may be an alternative method for proctectomy in selected patients with large rectal lesions.

Restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis and familial adenomatous polyposis: twenty years follow-up in 174 patients.

BACKGROUND: Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical procedure of choice for patients with ulcerative colitis and familial adenomatous polyposis. OBJECTIVES: To evaluate the long-term functional outcome of patients who underwent this surgical procedure. METHODS: We performed this observational study in 174 consecutive patients: 146 with UC and 28 with FAP. The patients, 91 males and 83 females with a mean age of 34.1+/-10.6 years (range 6-67 years), underwent the procedure between January 1984 and January 2004 (mean follow-up 64.8 months, range 1-240 months). The indications for surgery were intractable disease in 124 patients (71%), dysplasia in 36 (21%), severe bleeding in 8 (5%), and perforation in 6 (3%). RESULTS: A protective ileostomy was performed in 140 patients (96%) with UC and 12 (43%) with FAP. An urgent three-stage procedure was necessary in 14 patients (8.4%). A mucosal proctectomy was performed in 94 (54%), and a double stapling technique in 80 (46%). Mean length of hospital stay was 9.4+/-6.6 days (range 5-34 days, median 8). Complications included pelvic sepsis in 7 patients (4.2%), anastomotic leakage in 8 (4.8%), bowel obstruction in 22 (13.2%), incisional hernia in 12 (7.2%), anastomotic stenosis that usually responded to manual dilatation in 46 (27.6%), pouchitis in 106 (61%), recto-vaginal fistula in 3 (1.8%), retrograde ejaculation in 3 (1.8%), and impotence in 2 (1.2%). There was no mortality in this group of patients. The median number of bowel movements per 24 hours was six in UC patients and five in FAP patients, with at least one bowel movement during the night. Complete daytime and night-time continence was documented in 124 patients (71%). Overall satisfaction was 95%. CONCLUSIONS: Restorative proctocolectomy with ileal pouch-anal anastomosis confers a long-term good quality of life to both UC and FAP patients, and the majority of patients are fully continent with five to six bowel movements per day.

Transanal endoscopic microsurgery for rectal cancer.

BACKGROUND: Transanal endoscopic microsurgery has recently gained acceptance as an alternative minimally invasive surgical technique for the curative management of large rectal adenomas and selected early rectal carcinomas. OBJECTIVES: To analyze our 8 year experience using TEM for the management of rectal cancer. METHODS: Local resection by TEM was performed in patients with benign tumors and early rectal cancer. In addition, selected patients with T2 and T3 rectal cancers who were either medically unfit or unwilling to undergo radical surgery were also treated with this modality. Radical surgery was offered to all patients with incomplete tumor excision by TEM. RESULTS: Overall, 116 TEM operations for rectal tumors were carried out between 1995 and 2003, including 74 patients with rectal adenomas and 42 patients with rectal carcinomas. In 25 patients, TEM successfully removed all T1 tumors with clear tumor margins. Fourteen patients had T2 cancer and 3 of them (21%) required additional radical surgery due to incomplete excision. Local recurrence was observed in one patient with T2 cancer. There was no mortality. Major surgery or radiotherapy-related complications requiring additional surgical intervention was needed in five patients with T2 cancer. CONCLUSIONS: Local excision by TEM is a safe surgical procedure and should be offered to highly selected patients with early rectal cancer.

Outcome of transanal endoscopic microsurgery and adjuvant radiotherapy in patients with T2 rectal cancer.

PURPOSE: The use of transanal endoscopic microsurgery for local excision of rectal cancer has recently gained wide acceptance as a valid and safe alternative for the surgical treatment of T1 tumors. The adequacy of such treatment for T2 tumors, however, is still controversial. This study was designed to evaluate our results with local excision of T2 cancers. METHODS: Patients with T2 cancer admitted to our hospital between 1995 and 2005 were offered surgery by transanal endoscopic microsurgery if found medically unfit or were unwilling to undergo radical surgery. Patients who were preoperatively staged as T1 tumor but were found to be pathologically T2 also were included. RESULTS: Overall, we performed 59 transanal endoscopic microsurgery operations for rectal cancers, of which 21 were for T2 cancers. In 16 (76 percent) of the T2 patients, the tumors were completely removed with clear margins by transanal endoscopic microsurgery and no additional surgery was performed, except for 2 patients who developed radiation-induced complications. Radical surgery was performed in a second operation in five patients because of involved margins and residual disease was found in two. At a median follow-up of three years, all 12 patients who received local excision and radiotherapy remained disease free, whereas a 50 percent recurrence rate was observed in patients who refused adjuvant radiotherapy. CONCLUSIONS: The results of this study support the feasibility of transanal endoscopic microsurgery for the treatment of selected patients with T2 rectal cancer. The addition of radiotherapy may decrease the rates of early local recurrence. However, at present, this treatment strategy should not be routinely considered for patients who may undergo radical procedures.

The role of fine-needle aspiration and intraoperative frozen section in the surgical management of solitary thyroid nodules.

PURPOSE: We evaluated the role of intraoperative frozen section (FS) in the surgical management of solitary thyroid nodules, as its true value is a subject of some controversy. METHODS: We reviewed the records of 206 consecutive patients operated on for solitary thyroid nodules. All patients had undergone both preoperative fine-needle aspiration (FNA) and intraoperative FS. The diagnostic findings of FNA cytology and FS histology were compared with the final histological results. RESULTS: There were 61 patients with cancer and 145 with various benign conditions. The sensitivity and specificity of FNA were 78.1% and 96.5%, respectively, demonstrating an overall accuracy of 91.3%. The sensitivity, specificity, and accuracy rates for FS were 83.3%, 95.2%, and 91.7%, respectively. FS altered the operative decision in 14 patients, but correctly so in only 8 patients. Correlated with FNA cytology, the yield of FS in assisting in the intraoperative decision making was 1.8%, 3.4%, and 5.2% for benign, malignant, and suspicious cytology, respectively. CONCLUSIONS: When the results of FNA and FS are interpreted as either benign or malignant, both are highly accurate predictors of the pathological nature of the nodule. However, the findings of the present study do not support the use of FS in the surgical management of solitary thyroid nodules, regardless of FNA cytology.