Risk of complications and long-term functional alterations after local excision of rectal tumors with transanal endoscopic microsurgery (TEM).

INTRODUCTION: Transanal endoscopic microsurgery (TEM) is a consolidated technique for the excision of rectal tumors. However, many aspects relating to its morbidity, risk of functional alterations, and therapeutic outcomes are still unclear. The aim of this study was to assess the rate of morbidity and fecal incontinence after TEM, and to identify associated risk factors. METHODS: We prospectively recorded the clinical data of 157 patients who underwent TEM from 1996 to 2013. Among these, 89 patients answered a questionnaire for the assessment of fecal continence at a median follow-up time of 40 months. RESULTS: Intraoperative and postoperative TEM complication rates were 3.8 and 20.4%. The mortality rate was 0.6%. A distance from the anal verge of more than 6 cm correlated with a higher risk of perforation, while patients with cancer were more likely to have postoperative bleeding. Incontinence was reported by 32 (36%) patients, of which 7 (8%) experienced transitory symptoms only, while 25 (28%) reported persistent symptoms. We found a correlation between patients receiving preoperative radiotherapy (RT) and the development of fecal incontinence. The recurrence rate was 3% (1/32) in pT1, 80% (4/5) in pT2, and 100% (1/1) in pT3. After radiotherapy, 7% (1/9) showed a good response (pT0-1), and 18% (2/7) showed no response (pT2-3). CONCLUSIONS: TEM is associated with low morbidity but the risk of developing functional alterations is not negligible and should be discussed with the patient before the operation. Good oncological outcomes are possible for early invasive cancers and for selected advanced cancers following a good response to preoperative RT.

Preoperative staging of patients with rectal tumors suitable for transanal endoscopic microsurgery (TEM): comparison of endorectal ultrasound and histopathologic findings.

BACKGROUND: Accurate preoperative staging is the key to correct selection of rectal tumors for local excision. This study aims to assess the accuracy of endorectal ultrasound (ERUS) at our institution. PATIENTS AND METHODS: Retrospective analysis was carried out of patients treated by transanal endoscopic microsurgery (TEM) from 1996 to 2008. TEM was considered the treatment of choice for uT0-1/N0 lesions located between 2 and 12 cm from the anal verge. It was also proposed in selected uT2-3 patients. Preoperative staging was compared with histopathologic findings. RESULTS: Eighty-one patients (46 males, mean age 66 years) underwent TEM. Mean distance of the tumor from the anal verge was 6.6 cm (range 2-12 cm). ERUS staged 15 of 27 adenomas (55%) as uT1. Of 54 carcinomas, 5 were pT0 because TEM was performed to remove resection margins of a malign polyp already snared. Five of 19 pTis (26%) were overstaged uT1, while 7 of 17 pT1 (41%) were understaged. Overall, ERUS enabled distinction between early and advanced rectal lesion with 96% sensitivity and 85% specificity, giving accuracy of 94% (65/67). Thirteen patients had advanced lesions (eight pT2 and five pT3). Only in two of them (15%) was depth of invasion underestimated by ERUS (one uT0, one uT1) and thus was subsequent salvage surgery necessary. CONCLUSIONS: ERUS is useful to confirm the diagnosis of adenoma and predict depth of mural invasion in early rectal cancer. Differentiation between T0/is and T1 lesions remains challenging, however this does not usually influence surgical strategy.

Pneumatosis cystoides of the right colon: a possible source of misdiagnosis. Report of a case.

Pneumatosis cystoides intestinalis is a rare condition that can be located in any part of the gastrointestinal tract. It is usually associated with a wide variety of gastrointestinal or pulmonary diseases. The primitive form is much less frequent and usually involves the left colon. The pathogenesis of pneumatosis cystoides intestinalis is still unclear. The mechanical theory, which is the most accepted explanation, postulates that gas is forced into the bowel wall by breaks in the mucosa; this is more likely to occur when the intraluminal pressure is higher, as happens in obstructive conditions, during endoscopies, or during infections from gas-forming bacteria. Pneumatosis cystoides is often asymptomatic, representing an occasional finding during investigations for other abdominal conditions. Complications occur in about 3% of cases and include obstruction, intussusception, volvulus, haemorrhage and intestinal perforation. When presenting acutely or in association with other abdominal conditions the differential diagnosis is rarely a problem. More important is to diagnose asymptomatic primitive submucosal pneumatosis of the colon, in order to avoid unnecessary intestinal resections. The Authors present the case of a patient with pneumatosis coli who underwent laparotomy for a suspected colonic lipomatosis of the right colon.

Cigarette smoking and appendectomy: effect on clinical course of diverticulosis.

AIM: To investigate the effect of appendectomy and cigarette smoking on the clinical course of diverticulosis. MATERIALS AND METHODS: A retrospective case-control study of 207 consecutive patients (45.8% male mean age 64.0 years), 150 with asymptomatic diverticulosis, and 57 with acute diverticulitis. Diagnosis of diverticulosis was defined on the basis of clinical and colonoscopic criteria, diverticulitis was defined by means of clinical, colonoscopic and computerised tomography criteria. Logistic regression function was used to define the relationship between the dependent variable (diverticulitis) and several covariates: sex, age, body mass index, smoking habit, and history of appendectomy. RESULTS: According to the final model, the risk of diverticulitis was 4.94-fold higher (95% confidence interval: 1.98-12.37) in patients with a history of appendectomy with emergency resection, compared to patients not submitted to appendectomy or with a history of elective resection (P < 0.001); and 2.79-fold higher (95% confidence interval: 1.30-5.96) in smokers than in non-smokers (P = 0.008). The effects of the two determinants were found to be independent, thus the cumulative risk of diverticulitis was 13.78-fold higher for smokers with a history of emergency surgical treatment. CONCLUSION: Smoking and emergency appendectomy are important predictive factors for the clinical course of diverticulosis.