Transanal total mesorectal excision (TaTME) with delayed coloanal anastomosis versus TaTME with immediate coloanal anastomosis and temporary diversion in middle and low rectal cancer.

BACKGROUND: Transanal total mesorectal excision (TaTME) avoids the difficulty of laparoscopic dissection of the lower part of the rectum. The need for stoma is associated with many stoma-related complications. The objective was to compare TaTME with immediate coloanal anastomosis and protective ileostomy (TaTME-IA) versus Turnbull-Cutait delayed coloanal anastomosis (TaTME-TC). METHODS: A retrospective cohort study included patients with low rectal cancer at least 1 cm above the top of the anal sphincter. Patients had either TaTME-IA or TaTME-TC. Primary outcome measures were anastomotic and stoma-related complications. Secondary outcomes included rate of permanent stomas, local recurrence, continence, and quality of life (QOL). RESULTS: TaTME-IA was done in 25 patients versus 20 who had TaTME-TC. TaTME-IA had significantly longer mean operative time (p = 0.04) and shorter length of stay (LOS) (4.5 vs. 11.4 days; p = 0.0001) compared to TaTME-TC. Anastomotic leak was reported in two patients of TaTME-IA versus one patient of TaTME-TC (p = 0.77). Anastomotic stenosis was reported in one patient in each group. No significant difference between groups as regard continence, local recurrence, and QOL. CONCLUSION: TaTME-TC is a safe option that can be offered for patients with low rectal cancer who refuse or are not amenable to a temporary stoma. Anastomotic complications were similar in both groups. LOS was much longer in TaTME-TC, however, it avoids stoma complications. Both groups had similar functional oncologic outcomes and QOL.

Multicenter validation of the PREDICT score for prediction of local recurrence after total mesorectal excision of rectal cancer.

BACKGROUND: Total mesorectal excision (TME) is the gold standard treatment for rectal cancer. Although TME has managed to decrease the rates of local recurrence after rectal cancer resection, local recurrence is still recorded at varying rates. The present study aimed to validate the PREDICT score in the prediction of local recurrence of rectal cancer after TME with curative intent. METHODS: This was a retrospective multicenter study on patients with nonmetastatic low or middle rectal cancer who underwent TME. The total PREDICT score was calculated for every patient and related to the onset of local recurrence. According to the final score, patients were allocated to one of three risk groups: low, moderate, and high, and the rates of local recurrence in each group were calculated and compared. RESULTS: The present study included 262 patients (50.4% males) with a mean age of 47.1 years. The overall local recurrence rate was 12.6%. 29.4% of patients were in the low-risk group, 63.7% in the moderate-risk group, and 6.9% in the high-risk group. The local recurrence rate was 3.9% (95% confidence interval [CI]: 0.8-10.9) in the low-risk group, 13.2% (95% CI: 8.4-19.3) in the moderate risk group, and 44.4% (95% CI: 21.5-69.2) in the high-risk group (p < 0.0001). The sensitivity of the PREDICT score was 72.7%, the specificity was 88.1%, and the accuracy was 86.3%. CONCLUSIONS: The PREDICT score had good diagnostic accuracy in the prediction of local recurrence after TME and a good discriminatory ability in the differentiation between patients at different risks to develop local recurrence.

Laparoscopic Ventral Rectopexy Versus Stapled Transanal Rectal Resection for Treatment of Obstructed Defecation in the Elderly: Long-term Results of a Prospective Randomized Study.

BACKGROUND: Obstructed defecation is a common complaint in coloproctology. Many anal, abdominal, and laparoscopic procedures are adopted to correct the underlying condition. OBJECTIVE: The purpose of this study was to compare long-term functional outcome, recurrence rate, and quality of life between laparoscopic ventral rectopexy and stapled transanal rectal resection in the treatment of obstructed defecation. DESIGN: This was a prospective randomized study. SETTING: This study was performed at academic medical centers. PATIENTS: Patients were included if they had obstructed defecation attributed to pelvic structural abnormalities that did not to respond to conservative measures. Exclusion criteria included nonrelaxing puborectalis, previous abdominal surgery, other anal pathology, and pudendal neuropathy. INTERVENTION: Patients were randomly allocated to either laparoscopic ventral rectopexy (group 1) or stapled transanal rectal resection (group 2). MAIN OUTCOME MEASURES: The primary outcome measures were improvement of modified obstructed defecation score and recurrences after ≥3 years of follow-up. Secondary outcomes were postoperative complications, continence status using Wexner incontinence score, and quality of life using Patient Assessment of Constipation-Quality of Life Questionnaire. RESULTS: The study included 112 patients (56 in each arm). ASA score II was reported in 32 patients (18 in group 1 and 14 in group 2; p = 0.12), whereas 3 patients in each group had ASA score III. Minor postoperative complications were seen in 11 patients (20%) of group 1 and 14 patients of group 2 (25%; p = 0.65). During follow-up, 3 patients had fecal urgency after stapled transanal rectal resection but no sexual dysfunction in either procedure. After 6 months, modified obstructed defecation score improvement >50% was reported in 73% versus 82% in groups 1 and 2 (p = 0.36). After a mean follow-up of 41 months, recurrences of symptoms were reported in 7% in group 1 versus 24% in group 2 (p = 0.04). Six months postoperation, perineal descent improved >50% in defecogram in 80% of group 1 versus no improvement in group 2. Quality of life significantly improved in both groups after 6 months; however a significant long-term drop (>36 months) was seen only in group 2. LIMITATIONS: Possible limitations of this study are the presence of a single operator and the absence of blindness of the technique for both patient and assessor. CONCLUSIONS: In elderly patients even with comorbidities, both laparoscopic ventral rectopexy and stapled transanal rectal resection are safe and can improve function of the anorectum in patients with obstructed defecation attributed to structural abnormalities. Laparoscopic ventral rectopexy has better long-term functional outcome, less complications, and less recurrences compared with stapled transanal rectal resection. Perineal descent only improves after laparoscopic ventral rectopexy. Stapled transanal rectal resection was shown not to be the first choice in elderly patients with obstructed defecation unless they had a medical contraindication to laparoscopic procedures. See Video Abstract at http://links.lww.com/DCR/A788.

Bilateral Posterior Tibial Nerve Stimulation in the Treatment of Rectal Evacuation Disorder: A Preliminary Report.

BACKGROUND: Posterior tibial nerve stimulation influences both motor and sensory pathways, as well as the central nervous system. Stimulation of posterior tibial nerve roots (L4 to S3) could improve stool evacuation through S3 and/or S2 stimulation. OBJECTIVE: This study aimed to assess the efficiency of bilateral posterior tibial nerve stimulation in the treatment of rectal evacuation disorder without anatomic obstruction. DESIGN: This was a prospective case series studying the treatment of patients with obstructed defecation by posterior tibial nerve stimulation. SETTING: The study was conducted at a tertiary referral academic medical center. PATIENTS: Patients with rectal evacuation disorder without anatomic obstruction who were failing maximal conservative treatments were included. INTERVENTION: Thirty minutes of bilateral transcutaneous posterior tibial nerve stimulation was applied 3 times weekly for each patient for 6 consecutive weeks. MAIN OUTCOME MEASURES: The primary end point was the change in the modified obstructed defecation score. Secondary end points were changes in rectal sensitivity volumes (urge to defecate volume and maximal tolerable volume) and quality of life using the Patient Assessment of Constipation-Quality of Life questionnaire. RESULTS: Thirty-six patients (25 women) completed the trial. The mean age of patients was 57.2 years (SD = 14.4 y). No adverse events were reported. Symptomatic successful outcome was reported in 17 patients (47%) and modified obstructed defecation score decreased over 6 weeks (mean decrease = 10 points (95% CI, 8.7-11.3 points); p < 0.0001). Patients with successful outcome (responders) had relatively lower preoperative modified obstructed defecation score compared with patients with unsuccessful outcome (nonresponders). In the successful group, there were significant improvement after 6 weeks in both Patient Assessment of Constipation-Quality of Life score (mean improvement = 43.0 points (95% CI, 35.2-50.7 points); p < 0.0001) and rectal sensitivity (significant reductions in urge to defecate volume (from 258.1 ± 21.2 to 239.6 ± 15.3; p < 0.0001) and maximal tolerable volume (from 304.5 ± 24.8 to 286.8 ± 19.7; p < 0.0001)). No significant change in Patient Assessment of Constipation-Quality of Life or rectal sensitivity was observed in the nonresponders. LIMITATIONS: The study was designed just to proof the concept, but small sample size is a limitation. Another limitation is the short duration of study of only 6 weeks. CONCLUSIONS: Current data showed that bilateral transcutaneous posterior tibial nerve stimulation can improve symptoms in a considerable percentage of patients with obstructed defecation without anatomic obstruction. The procedure is more effective in patients with a less-modified obstructed defecation score. Additional studies are needed to discover the predictive factors for success.

Changing operative strategy from abdominoperineal resection to sphincter preservation in T3 low rectal cancer after downstaging by neoadjuvant chemoradiation: a preliminary report.

OBJECTIVE: The objective of this study is to assess oncological outcome after changing operative strategy from abdominoperineal resection (APR) to sphincter preservation (SP) in T3 low rectal carcinomas downstaged by neoadjuvant chemoradiation (nCRT). PATIENTS AND METHODS: This was a prospective observational study performed at academic medical centers. Patients with T3 rectal carcinoma, (<1 cm from the top of anal sphincter) received long-course neoadjuvant chemoradiation. Decision before chemoradiation was APR in all patients. Patients who had successful downstaging were included in the study. Low anterior resection (LAR) was performed after 8-11 weeks from completion of nCRT. Follow-up duration ranged from 4 to 6 years. Salvage surgery was done for local recurrence when possible. The primary endpoint of the study was disease-free survival. Secondary endpoints were morbidity, mortality, continence, and oncologic results of salvage surgery after recurrence. RESULTS: LAR with colorectal or coloanal anastomosis were done in 9 and 36 patients, respectively. After a mean follow-up of 57 months (range 48-70), local recurrences was reported in 4 patients (8.8 %), one of them had also distant metastasis while 2 patients (4.4 %) had only distant metastasis. Disease-free and overall survival rates were 87 and 89 %, respectively. Three of 4 patients with local recurrence (the fourth had liver metastasis) underwent salvage APR with free safety margins. Follow-up after salvage surgery for 31, 33, and 37 months revealed no recurrences. Wexner continence score ≤4 was noted in 39 patients; while major incontinence (Wexner score >12) was noted in 2 patients. CONCLUSIONS: For selected patients of T3 low rectal cancer, changing operative strategy from APR to SP after downstaging by nCRT can be done in motivated patients with good sphincter function. Disease-free survival rates and continence are comparable to patients had APR and to previous publications with decision made before nCRT. With strict follow-up, early diagnosis of recurrence and salvage surgery with free resection margins can be achieved.

Ligation of intersphincteric fistula tract versus mucosal advancement flap in patients with high transsphincteric fistula-in-ano: a prospective randomized trial.

PURPOSE: The aim of this study was to compare the ligation of the intersphincteric fistula track with the mucosal advancement flap in the treatment of high transsphincteric anal fistulas. DESIGN AND SETTING: This was a prospective randomized study performed at academic medical centers. PATIENTS: Patients with transsphincteric anal fistulas involving the upper part of anal sphincter were included. INTERVENTION: Patients were randomly assigned to either ligation of intersphincteric fistula track or mucosal advancement flap. MAIN OUTCOME MEASURES: The primary end points of the study were fistula closure, recurrence within 1 year, and continence by using the Wexner score. Secondary end points were morbidity, postoperative pain with the use of the visual analog scale, and quality of life with the use of the Cleveland Global Quality of Life score. RESULTS: There were 70 patients (35 in each group). Mean age was 36.1 years in patients undergoing ligation of the intersphincteric fistula track vs 32.9 years in patients undergoing mucosal advancement flap (p = 0.33). Mean visual analog scale after 1 week was significantly higher in the mucosal advancement flap group than in the ligation of intersphincteric fistula track group (3.1 vs 4.8, p = 0.04), but no significant difference was found after 4 weeks. Primary healing was achieved in 33 patients undergoing ligation of the intersphincteric fistula track vs 32 patients undergoing mucosal advancement flap (p = 0.99). Mean healing time was 22.6 days in the ligation of intersphincteric fistula track group vs 32.1 days in mucosal advancement flap group (p = 0.01). After 1 year of follow-up, successful outcome was achieved in 26 patients (74.3%) undergoing ligation of intersphincteric fistula track and in 20 patients (65.7%) undergoing mucosal advancement flap (p = 0.58). No significant change in Wexner score occurred 4 weeks postoperatively. There was no significant difference between groups regarding Cleveland Global Quality of Life score (p = 0.5 and 0.07 after 4 and 12 weeks). LIMITATIONS: The short-term follow-up is a probable limitation. Although the sample size was calculated to detect difference with 80% power at a significance level of 5%, the negative result within this relatively small number of patients might have resulted from type II statistical error. CONCLUSIONS: In patients with high transsphincteric anal fistulas, both ligation of intersphincteric fistula track procedure and mucosal advancement flap have a similar long-term healing rate, recurrences, continence, and quality of life. However, ligation of the intersphincteric fistula track has the advantage of less postoperative pain.

Colorectal cancer surgery in portal hypertensive patients: does adjuvant oxaliplatin affect prognosis?

BACKGROUND: Oxaliplatin is used in adjuvant treatment of colorectal cancer and is associated with sinusoidal obstruction syndrome. Few data are available on its effects in patients in whom portal hypertension was diagnosed before cancer treatment. OBJECTIVE: Our aim was to investigate short- and long-term outcomes of surgery for colorectal cancer in patients with portal hypertension with or without cirrhosis, particularly regarding effects of adjuvant chemotherapy with oxaliplatin. DESIGN AND SETTING: This was a prospective cohort study performed at an academic medical center. PATIENTS: Patients with stage II or III colorectal cancer and portal hypertension who underwent curative resection were included. INTERVENTION: All patients received adjuvant chemotherapy with oxaliplatin (FOLFOX 4) or 5-fluorouracil and leucovorin. MAIN OUTCOME MEASURES: Potential predictive laboratory and clinical variables and postoperative (30-day) and long-term morbidity and mortality were recorded. RESULTS: Of 63 patients enrolled, 23 (37%) had a total of 82 postoperative complications; 5 patients (8%) died within 30 days postoperatively. Univariate analysis showed that severe portal hypertension, preoperative Child class B, low albumin, the presence of ascites, preoperative upper GI tract bleeding, and high intraoperative blood loss were linked to postoperative morbidity. Presence of postoperative infection (p = 0.004), presence of preoperative ascites (p = 0.01), high intraoperative blood loss (p = 0.02), and preoperative upper GI tract bleeding (p = 0.03) were significantly related to mortality. Of 58 patients receiving adjuvant chemotherapy, 20 received the oxaliplatin regimen and 38 received 5-fluorouracil/leucovorin without oxaliplatin. The median length of follow-up was 26 (range, 6-36) months. Kaplan-Meier analyses showed that patients who received oxaliplatin had higher cumulative incidences of newly developed esophageal varices (p = 0.002), GI tract bleeding (p = 0.02), and newly formed ascites (p = 0.03). Death occurred in 8 of 20 patients (40%) in the oxaliplatin group and in 5 of 38 patients (13%) in the 5-fluorouracil group. Kaplan-Meier estimates of mean survival time were 34.4 months (95% CI, 32.4-36.5) in the 5-fluorouracil/leucovorin group vs 29.9 months (95% CI, 26-33.7) in the oxaliplatin group, and patients receiving oxaliplatin had a significantly higher relative risk of death (HR = 2.98; 95% CI, 1.03-8.65). Cancer-specific mortality was not related to treatment type. LIMITATIONS: The study was limited by the relatively small sample size and lack of randomization, which may have led to selection bias in treatment regimens. CONCLUSIONS: Colorectal cancer surgery can be done safely in portal hypertensive patients with good hepatic function; however, higher mortality is expected in patients with compromised hepatic function reserve. Compared with adjuvant chemotherapy without oxaliplatin, oxaliplatin-based chemotherapy does not significantly reduce cancer-specific mortality and may increase overall morbidity and mortality. Therefore, oxaliplatin-based chemotherapy should be used with caution in patients who have portal hypertension, even in those with good liver function.

Rectal Cancer in Patients with Hereditary Nonpolyposis Colorectal Cancer Compared with Sporadic Cases: Response to Neoadjuvant Chemoradiation and Local Recurrence.

BACKGROUND: This study aimed to assess the effect of neoadjuvant chemoradiation (nCXRT) on tumor regression and oncologic outcome of middle and low rectal cancer in patients of hereditary nonpolyposis colorectal cancer (HNPCC) compared to sporadic cases. STUDY DESIGN: This was a retrospective cohort study that compared the outcomes of patients with HNPCC presenting with middle or low rectal cancer indicated for nCXRT vs patients with sporadic rectal cancer. All patients received long-course nCXRT followed by total mesorectal excision. Primary outcome was pathologic tumor regression grade (TRG) assessed after resection. Secondary outcomes included disease-free survival and overall survival. RESULTS: Fifty-eight patients with HNPCC (24 female) were included in the study matched with 58 patients with sporadic rectal cancer (out of 166 using propensity score matching). Patients with HNPCC and sporadic rectal cancer were matched regarding tumor pathology TNM stage and lymphovascular invasion. In the HNPCC group, 36 patients (62%) had tumor regression (TRG3 = 6 (10.3%); TRG2 = 12 (20.6%); TRG1 = 18 (31%)) compared to 52 patients (92%) who had tumor regression in the control group (TRG4 = 9; TRG3 = 15; TRG2 = 18; TRG1 = 10) (p < 0.0007). After a median follow-up of 48 months, survival analysis revealed higher local recurrence and lower overall survival in patients with HNPCC compared to patients with sporadic rectal cancer. CONCLUSIONS: Rectal cancer in patients with HNPCC showed poorer response to nCXRT and was followed by higher local recurrence and lower overall survival than patients with sporadic rectal cancer. Tumor regression was detected in <65% of patients with HNPCC compared to >90% of patients with sporadic rectal cancer, and none of patients with HNPCC had a complete response.

Ligation of intersphincteric fistula tract (LIFT) with or without injection of platelet-rich plasma (PRP) in management of high trans-sphincteric fistula-in-ano: Short-term outcomes of a prospective, randomized trial.

BACKGROUND: Success rate after ligation of the inter-sphincteric fistula tract ranges from 40% to 75%. Platelet-rich plasma is hypothesized to improve healing by slowly releasing growth factors. The objective of the study was to compare the efficacy and outcome of ligation of the inter-sphincteric fistula tract plus platelet-rich plasma local injection versus ligation of the inter-sphincteric fistula tract alone in the management of high trans-sphincteric anal fistula in regards to postoperative pain, time for healing, morbidity, fistula closure rate, recurrence, and quality of life. METHODS: This was a prospective randomized trial. Patients with trans-sphincteric anal fistulas involving >50% of anal sphincters were included. Patients were randomly assigned to either ligation of the inter-sphincteric fistula tract plus platelet-rich plasma or ligation of the inter-sphincteric fistula tract (49 in each group). The primary endpoints were successful complete fistula closure and duration needed for healing. Secondary endpoints were morbidity, recurrence after 1 year of follow-up, postoperative pain, and quality of life. RESULTS: Complete primary healing was recorded in 42 patients in the ligation of the inter-sphincteric fistula tract plus platelet-rich plasma group and 32 patients in the ligation of the inter-sphincteric fistula tract group, and the difference was statistically significant (P = .03). The mean time to complete healing after ligation of the inter-sphincteric fistula tract plus platelet-rich plasma was significantly shorter than after ligation of the inter-sphincteric fistula tract alone (15.7 ± 4 days vs 21.6 ± 5.4 days; P = .03). One year after complete healing of anal fistula, recurrence was recorded in 4/42 patients in the ligation of the inter-sphincteric fistula tract plus platelet-rich plasma group and 3/32 patients in the ligation of the inter-sphincteric fistula tract group with no statistically significant difference (P = .99). Patients in the ligation of the inter-sphincteric fistula tract plus platelet-rich plasma group had significantly lower pain scores after both 1 and 7 days. Quality of life and level of happiness were significantly better 1 month after ligation of the inter-sphincteric fistula tract plus platelet-rich plasma. CONCLUSION: Ligation of the inter-sphincteric fistula tract plus platelet-rich plasma for the treatment of high trans-sphincteric fistula-in-ano is a safe modality with significantly higher successful healing rate, shorter healing time, and less postoperative pain compared with ligation of the inter-sphincteric fistula tract alone. Ligation of the inter-sphincteric fistula tract plus platelet-rich plasma does not improve the rate of recurrence; however, it results in significantly higher short-term quality of life.

Regenerated oxidized cellulose reinforcement of low rectal anastomosis: do we still need diversion?

PURPOSE: The leak rate after low anterior resection is in the region of 10% to 15%. The highest risks of anastomotic leak are in anastomoses less than 5 cm from the anal verge. We evaluated the outcome of oxidized regenerated cellulose reinforcement of low rectal anastomosis. METHODS: The study group consisted of 108 patients with rectal cancer. Patients with low rectal cancer had low anterior resection with stapled straight low colorectal or coloanal anastomosis without proximal diversion. They were prospectively randomized to either oxidized regenerated cellulose reinforcement or no reinforcement. Data collected included age, sex, hemoglobin percentage, albumin level, histopathologic type of the tumor, anastomotic leak, and stricture. RESULTS: The mean age of patients was 56 years, and sex was matched in both groups. Clinical leak occurred in 6 of 38 cases (15.7%) in the group that did not undergo reinforcement versus 2 of 33 (6.1%) in the oxidized regenerated cellulose reinforcement group (P < .01). In the case of a leak, diversion was needed in 3 of 6 patients in the group that did not undergo reinforcement vs no patients in the oxidized regenerated cellulose reinforcement group (P = .05). Generalized peritonitis occurred in 3 patients in the group that did not undergo reinforcement versus no patients in the oxidized regenerated cellulose reinforcement group (P < .01). Length of stay was 4.8 days in the oxidized regenerated cellulose reinforcement group versus 5.9 days in the group that did not undergo reinforcement (P = .047), with no mortalities in either group. CONCLUSION: Oxidized regenerated cellulose reinforcement of low rectal anastomosis significantly decreases the risk of postoperative leak in low rectal anastomosis and may reduce the requirement for proximal diversion. Potential benefits include avoidance of a stoma, lower morbidity, shorter hospital stay, and a lower cost of care.

Disappointing long-term outcomes after stapled transanal rectal resection for obstructed defecation.

BACKGROUND: The aim of this study was to assess both short and long-term functional outcomes and the quality of life of patients treated with stapled transanal rectal resection (STARR) for obstructed defecation syndrome (ODS). METHODS: Forty-six patients with ODS as a result of rectocele and/or rectal intussusceptions were treated with STARR. Data collected included demographics, OR time, pain score using a visual analog scale (VAS), and complications. The study included defecographic assessment and anal manometry [urge-to-defecate volume (UTDV) and maximum tolerable volume (MTV)], both done preoperatively and 1 year postoperatively. A modified obstructed-defecation syndrome questionnaire (MODS), constipation quality of life (PAC-QOL) score, and CCF continence score were all recorded preoperatively and every 6 months during follow-up. RESULTS: Mean age of the patients was 48.4 years. Forty-five patients had mild postoperative pain (VAS = 1-2). Only one male patient had severe pain (VAS = 7). Three patients developed stenosis at the staple line 6 months after surgery and were dilated manually. Follow-up ranged from 18 to 48 months and the median follow-up was 42 months. The recurrence rate was 6.5% after 18 months, 10.8% after 36 months, and 13% after 42 months. Significant reduction in MTV and UTDV was recorded. MODS and PAC-QOL showed significant improvement after 6 months; this improvement was maintained for 18 months and then there was a rapid decline until the end of the follow-up period. CONCLUSIONS: STARR is a safe surgical procedure that effectively restores the anatomy and function of the anorectum in patients with ODS. This correction improves functional and QOL scores; however, a high rate of symptomatic recurrence and QOL score decline are expected after 18 months.

Randomized controlled trial between perineal and anal repairs of rectocele in obstructed defecation.

OBJECTIVE: The present study was designed to evaluate functional outcome of perineal repair with and without levatorplasty versus transanal repair of rectocele in obstructed defecation. METHODS AND PATIENTS: A total of 48 multiparous women with obstructed defecation caused by a rectocele were randomly allocated to three groups: transperineal repair with levatorplasty (TPR-LP; n = 16); transperineal repair without levatorplasty (TPR; n = 16); and transanal repair (TAR; n = 16). The study included defecographic assessment, anal manometry, symptom improvement, sexual function, and score on a function questionnaire. Assessments were done preoperatively and 6 months postoperatively. RESULTS: Defecography showed significant reduction in size of rectocele in all groups. Constipation improved significantly in both groups with transperineal repair but not in the group with transanal repair. Significant reductions in mean anal resting pressure, maximum reflex volume, and urge-to-defecate volume were observed only with the transperineal approach (with and without levatorplasty). Functional score improved significantly in the transperineal groups (with levatorplasty, P < 0.001; without levatorplasty, P < 0.01), but not in the transanal group (P = 0.142). Levatorplasty added to transperineal repair significantly improved the overall functional score compared with transperineal repair alone (P < 0.01) and transanal repair TAR (P < 0.001). CONCLUSIONS: Rectocele repair appears to improve anorectal function by improving rectal urge sensitivity. Transperineal repair of rectocele is superior to transanal repair in both structural and functional outcome. Levatorplasty improves functional outcome, but potential effects on dyspareunia should be discussed with the patient.

Day-case Limberg flap for recurrent pilonidal sinus: does obesity complicate the issue?

The purpose of this study was to analyze the long-term outcome of rhomboid excision with Limberg flap reconstruction (LF) as one-day surgery in treatment of recurrent pilonidal sinus (RPS). The effect of obesity on outcome will be addressed. Forty-nine patients with RPS were treated by rhomboid excision and LF as one-day surgery. Data collected included demographics, body mass index, operative time, flap ischemia, wound infection, length of hospital stay, time of complete healing, and recurrence. Patients' mean age was 33.4 years and mean number of previous operations was 3.4. Operative time ranged from 40 to 70 minutes. Two patients developed sterile seroma (4.1%) and two patients (4.1%) had wound infections. No wound dehiscence or flap ischemia was reported. All patients returned to normal activity within 7 days. No recurrences were reported after a mean follow-up of 32.1 months. Obesity significantly increased the operative time, however, it affected neither the postoperative outcome nor the long-term recurrence. Rhomboid excision and LF as one-day surgery is a safe and reliable method for treatment of RPS. It guarantees low morbidity, short hospital stay, short time off work, and carries low risk of recurrence, even in obese patients.

Laparoscopic Ventral Rectopexy Versus Laparoscopic Wells Rectopexy for Complete Rectal Prolapse: Long-Term Results.

BACKGROUND: There is no agreement about which laparoscopic rectopexy technique is best for treating complete rectal prolapse. Purpose was to compare functional outcome, the recurrence rate, and quality of life in patients treated with laparoscopic ventral rectopexy (LVR) versus the laparoscopic Wells rectopexy (LWR) for complete rectal prolapse. MATERIALS AND METHODS: A retrospective review of a prospectively maintained database of consecutive patients who presented with complete rectal prolapse. Patients were divided into two cohorts: first one had LVR and the other one had LWR. Exclusion criteria were previous major abdominal surgery, slow transit constipation, Hirschsprung's disease, inflammatory bowel disease, pregnancy, and patients on drugs that cause constipation. Patients were assessed preoperatively by clinical examination to evaluate constipation using the Wexner constipation scale (WCS), incontinence using the Wexner incontinence score (WIS), and quality of life using the gastrointestinal quality of life index (GIQOL). The primary outcome measures were disappearance of prolapse and recurrences. Secondary outcome parameters were operative time, complications, length of hospital stay, effect on perineal descent, functional outcome (constipation and continence), and quality of life. RESULTS: A total of 74 patients (mean age of 55 years) with complete rectal prolapse had LVR (n = 41) and LWR (n = 33). Sixty (81%) patients were females. Operative time was significantly longer in LVR (122 minutes versus 105 minutes; P = .001). Also, length of stay was significantly longer in LVR (4.5 days versus 3.7 days; P = .04). Recurrences were reported in 1 patient in each group. Perineal descent improved >50% in defecogram 6 months postoperatively in 79% in LVR versus 21% in LWR. In LVR, mean WCS decreased from 11.3 to 5.1 postoperatively (P < .0001), while in LWR it decreased from 8.9 to 6.9 (P = .11). Mean WIS decreased in LVR from 5.9 to 3.8, P = .01, while in LWR, it decreased from 6.6 to 2.8; P = .001. GIQOL improved from 74.4 to 124.9 in LVR and from 79.3 to 112.6 in LWR. The change in both groups was statistically significant (P = .0001). CONCLUSIONS: In this study, both LVR and LWR successfully and safely corrected the prolapse and prevented recurrence in patients after long-term follow-up. Operative time and hospital length of stay are significantly shorter in LWR. High incontinence scores and age >70 are potential predictors of bad continence postoperatively. LVR appears to be more suitable for patients with a high constipation score and abnormal perineal descent.

Temporary sacral nerve stimulation in patients with fecal incontinence owing to rectal hyposensitivity: a prospective, double-blind study.

BACKGROUND: Rectal hyposensitivity (RH) can lead to fecal incontinence (FI). Sacral nerve stimulation (SNS) is known to modulate rectal sensation, but no data about affecting FI owing to RH are available. This prospective study aimed to assess the therapeutic effect of temporary SNS on patients with FI owing to RH. METHODS: Twenty-four patients with FI owing to RH had temporary SNS (4 weeks on followed by 1 week off). Before SNS (baseline), after 4 weeks of stimulation (on), and at the end of the off week we recorded first constant sensation (FCS), defecatory desire volume (DDV), maximum tolerated volume (MTV), anal pressures, bowel diaries, Wexner incontinence score, and FI quality-of-life score (FIQOL). RESULTS: There were significant decreases in DDV and MTV during the on-treatment period (P < .0001); this decrease was not significant during the off period. FCS was not significantly affected by SNS. FI episodes significantly improved during the on period in 22 patients (from 5.3 to 1.1 per week; P < .0001) and mean Wexner incontinence score improved from 13.3 to 1.7 (P < .0001). Anal pressures (resting and squeeze) significantly increased during the on period but not during the off period. There was significant improvement in FIQOL during the on period only. CONCLUSION: SNS can be effective in restoring continence and improving QOL in patients with FI owing to RH. Improved continence might be related to improvement of rectal sensation and/or increased anal pressure. The washout effect of SNS on the continence score, DDV, and MTV after cessation of stimulation needs to be explained.

Is it safe to omit neoadjuvant chemo-radiation in mucinous rectal carcinoma?

BACKGROUND: Purpose was to compare the oncologic outcome of neoadjuvant chemoradiotherapy (nCXRT) versus postoperative chemoradiotherapy (pCXRT) for locally advanced mucinous rectal carcinoma (MRC) having curative total mesorectal excision (TME). METHODS: One hundred and two patients with MRC (T3-4 and/or N1-2) of middle and lower third rectum were included. Patients were non-randomly divided into 2 groups: Group A (N = 61) had nCXRT followed by total mesorectal excision (TME) after 8-11 weeks and Group B (N = 41) had TME followed by pCXRT. Primary end points were disease free survival (DFS) and overall survival (OS). Secondary endpoints were tumor regression grade (TRG) and morbidity. RESULTS: In group A, 29 patients had partial response after nCXRT, 26 patients showed no change and 6 patients had progression. TME was done in 55 patients in group A and 41 patients in group B. Six patients in group A turned to be unresectable after nCXRT due to progressive disease. Mean follow-up was 53 months. In patients received TME, Four-year DFS was higher in group A compared to group B yet not statistically significant (DFS 0.69 [95% CI 0.54-0.85] vs. 0.67 [95% CI 0.47-0.87]; P = 0.39). However, actuarial 4 years OS was comparable in both groups (0.72 [95% CI 0.59-0.91] vs. 0.70 [95% CI 0.55-0.88]; P = 0.46 in groups A and B respectively). Multivariate analysis revealed that age <40, and N2 were risk factors of recurrence. CONCLUSION: Whilst accepting that the numbers are small, there was no statistical difference in outcome (DFS and OS) between patients receiving pre- or post-operative chemo-radiotherapy. In most MRC patients, tumor regression is not significant after nCXRT and there is considerable possibility of tumor progression during nCXRT treatment. So, nCXRT should be used with close follow-up in MRC for early detection of possible tumor progression. If the patient cannot tolerate nCXRT, it is possibly safe to do surgery followed by pCXRT. Prospective study is needed to study the value of nCXRT in MRC.

Advantages of laparoscopic colectomy in older patients.

HYPOTHESIS: Few data describe the relative benefits of an expedited recovery program and laparoscopic technique in older vs younger patients undergoing colectomy. We compared short-term outcomes in age-matched cohorts of patients undergoing laparoscopic vs open segmental colectomy managed with the Controlled Rehabilitation With Early Ambulation and Diet program. DESIGN: Four age-matched cohorts of patients were compared: (1). patients 70 years or older undergoing laparoscopic colectomy (group 1), (2). those 70 or older undergoing open colectomy (group 2), (3). those younger than 60 undergoing laparoscopic colectomy (group 3), and (4). those younger than 60 undergoing open colectomy (group 4). METHODS: Data collected included age, sex, body mass index, Physiologic and Operative Severity Score for the Enumeration of Morbidity and Mortality, American Society of Anesthesiologists' score, estimated blood loss, operative duration in minutes, pathologic findings, type of segmental colectomy, complications, mortality, length of hospital stay, and 30-day readmission rate. RESULTS: Four hundred seventy-six patients fulfilled the inclusion criteria and had complete data available for collection (group 1, 50 patients; group 2, 123 patients; group 3, 181 patients; and group 4, 122 patients). Demographic data, operative procedures, and pathologic findings were similar among the cohorts. The mean +/- SEM length of hospital stay was significantly shorter with laparoscopic surgery in both age cohorts (group 1, 4.2 +/- 3.0 days; group 2, 9.3 +/- 7.6 days; group 3, 3.9 +/- 5.9 days; and group 4, 6.1 +/- 3.0 days). The mean +/- SEM direct hospital costs were significantly lower only with laparoscopic colectomy in the older cohorts. Using the Physiologic and Operative Severity Score for the Enumeration of Morbidity and Mortality, it was noted that group 2 experienced an observed rate of morbidity similar to that predicted. Conversely, groups 1, 3, and 4 had rates that were significantly lower than expected. Mean +/- SEM readmission rates were comparable in the older cohorts (group 1, 6.0%, and group 2, 6.5%) but significantly different in the younger cohorts (group 3, 9.4%, and group 4, 4.1%). CONCLUSIONS: The Controlled Rehabilitation With Early Ambulation and Diet program in combination with laparoscopic segmental colectomy can be safely performed in all age groups. The technique offers particular advantages to older patients because of reductions in length of hospital stay, morbidity and mortality rates, and direct cost of care.

Long-term prognostic value of mesorectal grading after neoadjuvant chemoradiotherapy for rectal cancer.

BACKGROUND: Mesorectal grading was reported to be a valuable prognostic factor in rectal cancer surgery. Previous studies were retrospective, and had short follow-up. OBJECTIVE: To assess the long-term influence of total mesorectal excision quality on disease recurrence in mid and low rectal cancer patients who received preoperative neoadjuvant chemoradiotherapy (CRT) and postoperative chemotherapy. METHODS: One hundred twenty-one patients with rectal cancer had either low anterior resection or abdominoperineal resection. All patients received neoadjuvant CRT and postoperative chemotherapy. Main outcome measures included TNM staging, involvement of the circumferential resection margin (ICRM), mesorectal grading, local and systemic recurrences were recorded. RESULTS: Follow-up was done for at least 5 years or up to disease recurrence whatever comes first. Mean follow-up time was 59.4 months. Twenty-nine patients had abdominoperineal resection and 92 had low anterior resection. About 7.5% had positive CRM which was significantly correlated with mesorectal grading. Grade 3 mesorectal specimens were obtained in approximately 60% of patients, 27% had grade 2, and only 13% had grade 1 (poor) mesorectal specimens. Poorer mesorectal grading increased with APR and lower rectal tumors. Recurrences occurred in 20% of patients (40% in the first 2 years, 32% in the 3rd year, and 28% in the 4th and 5th years); factors affecting recurrence included lymphovascular invasion, ICRM, and N stage. Mesorectal grading was not a valuable prognostic factor for recurrence unless it resulted in ICRM. Recurrences occurred earlier with poorer mesorectal grade, yet this was not statistically significant. CONCLUSIONS: Mesorectal grading is a pathologic description that reflects the quality of surgery. However, in patients who received neoadjuvant CRT and postoperative chemotherapy, grading had no long-term prognostic value regarding recurrences unless it resulted in ICRM.

Metastatic lymph node ratio in stage III rectal carcinoma is a valuable prognostic factor even with less than 12 lymph nodes retrieved: a prospective study.

BACKGROUND: The aim of this study was to assess the prognostic value of metastatic lymph node (LN) ratio (MLNR) in stage III rectal cancer and whether this prognostic value remains significant when <12 LNs are retrieved. METHODS: This prospective study included 115 patients with stage III rectal cancer from 2006 to 2010. All patients underwent neoadjuvant long-course chemoradiation, curative resection, and postoperative adjuvant therapy (5-fluorouracil and leucovorin). Data collected included demographics, tumor pathology, tumor-node-metastasis staging, number of LNs retrieved, MLNR, recurrence, and mortality. RESULTS: The mean number of examined LNs was 12.1, and the mean number of metastatic LNs was 3.5 (range, 1 to 19). The mean MLNR was .37 (range, 0 to 1.00). The mean duration of follow-up was 37 months (range, 24 to 63). Forty patients died during the follow-up period (overall mortality, 34.8%), only 31 because of cancer (cancer-specific mortality, 27%). Univariate analysis revealed that ypN stage, lymphovascular invasion, and follow-up duration were significantly associated with increased recurrence and decreased survival. Number of positive nodes and ypT stage significantly affected recurrence, with no effect on overall survival. Multivariate analysis proved that MLNR was the only independent risk factor for both mortality and recurrence. Prognostic capability was not affected by having <12 nodes retrieved. The best sensitivity and specificity of MLNR as a prognostic factor for both tumor recurrence and overall survival were achieved at a cutoff value of .375. CONCLUSIONS: MLNR is an independent prognostic factor for recurrence and survival after the resection of stage III rectal cancer, with high sensitivity and specificity in patients who received neoadjuvant chemoradiation and postoperative chemotherapy. The total number of LN retrieved did not affect the prognostic value of MLNR even if <12.

Does immunostaining effectively upstage colorectal cancer by identifying micrometastatic nodal disease?

PURPOSE: Measure the association between the incidence of primary tumor staining and the identification of mediastinal lymph node (MLN) using cytokeratins, NM23, DCC-positive tumors, and vascular endothelial growth factor (VEGF) expression in T(2) and T(3)/N(0) colorectal cancers. The impact of MLN on both recurrence and survival was assessed. MATERIALS AND METHODS: There were 153 CORC patients (T(2), T(3)/N(0)) selected from a prospectively accrued database. All patients had been staged by routine histopathology after a curative resection and no patients received adjuvant chemotherapy. The primary tumors (PT) were assessed with a panel of immunohistochemical stains (cytokeratin, DCC, Nm23, and VEGF). If the PT was positive, the regional nodes were assessed with that marker(s). For any positive tumor marker, all lymph nodes (LNs, mean of 12.6+/-4.2) were stained for this marker. RESULTS: Patient age ranged from 38 to 86 years with a mean age of 61.56+/-25.56 years. Mean follow-up was 72.1+/-32.4 months. Recurrence rate of the whole group was 19/153 (12.4%) and the mean time to recurrence was 37.6+/-23.6 months (15 to 77 months). Crude mortality was 39.9%, while the cancer specific mortality was 11.2% after the whole follow-up period. The relationship between PT staining and MLNs was: cytokeratin-PT 143 (93.5%)/MLN 9 (6.3%); NM23-PT 51 (33.3%)/MLN 3 (5.9%); DCC-PT 79 (53%)/MLN 3 (3.8%); and VEGF-PT 72 (47%)/MLN 4 (5.6%). Nineteen (12.4%) patients experienced tumor recurrence. No correlation exist between PT and/or MLN staining and either recurrence or survival. No patient with MLN with any stain experienced a recurrence. There was no advantage to using an individual stain or all four stains. CONCLUSION: Immunohistochemical stains for PT and focused analysis of regional nodes did not improve prediction of survival or recurrence. Sentinel LN evaluation and the provision of adjuvant chemotherapy in node-negative patients should be questioned and not be utilized outside of a research protocol.