Low Anterior Resection Syndrome After Transanal Total Mesorectal Excision: A Comparison With the Conventional Top-to-Bottom Approach.

BACKGROUND: Advances in sphincter-saving procedures improved the quality of life of patients with rectal cancer. However, many of them experienced functional disturbances after surgery, including low anterior resection syndrome. OBJECTIVE: The aim of this study was to evaluate the severity of low anterior resection syndrome after transanal total mesorectal excision and compare it with the conventional transabdominal, top-to-bottom, total mesorectal excision. DESIGN: This was a single-center, retrospective analysis. SETTINGS: The study was conducted at a tertiary academic institution. PATIENTS: This study analyzed patients who underwent total mesorectal excision for mid to low rectal cancer from January 2016 to April 2018. Cases were matched one-to-one according to the tumor height and history of pelvic irradiation using the propensity score. MAIN OUTCOME MEASURES: The primary outcome measured was the severity of low anterior resection syndrome and fecal incontinence at 3, 6, and 12 months after surgery or stoma reversal, whichever was later. RESULTS: There were 35 patients in each group after matching; 67.1% were male, and 41.4% had neoadjuvant radiotherapy. At 3 months, the median low anterior resection syndrome score was 37 after transanal total mesorectal excision, which was significantly higher than the conventional approach, 32 (p = 0.045). Apart from this, the low anterior resection syndrome score, severity grading, and the Wexner score were comparable at 6 and 12 months. LIMITATIONS: A difference between the 2 groups might not be detected because of the study's small sample size and because of its retrospective nature. CONCLUSIONS: A higher low anterior resection syndrome score was observed after transanal total mesorectal excision at the initial 3-month period, but such a difference was not observed thereafter. This study showed that both surgical techniques had similar anal and bowel functional outcomes in the long run. However, because of the limited case number and study design, further study is needed to prove this. See Video Abstract at http://links.lww.com/DCR/B146. SÍNDROME DE RESECCIÓN ANTERIOR BAJA DESPUÉS DE LA ESCISIÓN MESORRECTAL TOTAL TRANSANAL: UNA COMPARACIÓN CON EL ABORDAJE CONVENCIONAL DE SUPERIOR A INFERIOR: Los avances en los procedimientos para salvar esfínteres mejoraron la calidad de vida de los pacientes con cáncer rectal. Sin embargo, muchos de ellos sufrieron trastornos funcionales después de la cirugía, incluyendo el síndrome de resección anterior baja.El objetivo de este estudio fue evaluar la gravedad del síndrome de resección anterior baja después de la escisión mesorrectal total transanal y comparar con la escisión mesorrectal total convencional transabdominal, de arriba a abajo.El estudio se realizó en una institución académica terciaria.Este fue un análisis retrospectivo de un solo centro de pacientes que se sometieron a una escisión mesorrectal total por cáncer rectal medio a bajo desde enero de 2016 hasta abril de 2018. Los casos fueron emparejados uno a uno de acuerdo con la altura del tumor y los antecedentes de irradiación pélvica con puntaje de propensión.La gravedad del síndrome de resección anterior baja y la incontinencia fecal a los 3, 6 y 12 meses después de la cirugía o la reversión del estoma, lo que ocurriera más tarde.Hubo 35 pacientes en cada grupo después del emparejamiento. El 67.1% eran hombres. El 41,4% tenía radioterapia neoadyuvante. A los tres meses, la puntuación media del síndrome de resección anterior baja fue de 37 después de la escisión mesorrectal transanal total, que fue significativamente mayor que el enfoque convencional, 32 (p = 0.045). Aparte de esto, la puntuación baja del síndrome de resección anterior, la clasificación de gravedad y la puntuación de Wexner fueron comparables a los 6 y 12 meses.Es posible que no se detecte una diferencia entre los dos grupos debido al pequeño tamaño de la muestra del estudio. La naturaleza retrospectiva del estudio.Se observó una puntuación más alta en el síndrome de resección anterior baja después de la escisión mesorrectal total transanal en el período inicial de tres meses, pero dicha diferencia no se observó posteriormente. Este estudio mostró que ambas técnicas quirúrgicas tuvieron resultados similares de funcionamiento anal e intestinal a largo plazo. Sin embargo, debido al número limitado de casos y al diseño del estudio, es necesario realizar más estudios para demostrarlo. Consulte Video Resumen en http://links.lww.com/DCR/B146.

How does lymph node yield affect survival outcomes of stage I and II colon cancer?

BACKGROUND: According to the American Joint Committee on Cancer staging for cancer of the colon, a minimum of 12 lymph nodes (LN) has to be sampled for accurate staging. This has bearing on the long-term prognosis and the need for adjuvant chemotherapy. The aim of this study was to revisit the association of lymph node yield and the long-term survival in patients with stages I and II, i.e. node-negative, colon cancer. METHOD: Consecutive patients who underwent elective or emergency curative resections for cancer of colon between the years 2003 and 2012 were retrospectively reviewed. Only patients with stage I or II diseases (AJCC 8th edition) were included. They were analysed in three groups, LN<12, LN12-19 and LN≥20. Their clinic-pathological characteristics were compared. The disease-free (DFS) and overall survival (OS) were estimated with the Kaplan-Meier method and compared with the log-rank test. RESULTS: There was a total of 659 patients included in the analysis. Twelve or more LN were found in 65.6% of the specimens. The mean follow-up was 83.9 months. LN≥20 had significantly better DFS (p = 0.015) and OS (p = 0.036), whereas LN<12 had similar DFS and OS when compared to LN12-19. The advantage in DFS and OS were mainly seen in those with stage II diseases. A lymph node yield of greater than 20 was one of the predictors of favourable DFS, hazard ratio 0.358; 95% CI 0.170-.756, p = 0.007. CONCLUSION: The lymph node yield had a significant association with survival outcomes. A lymph node yield of 20 or more was associated with better survival outcomes. On the other hand, lymph node yield less than 12 was not shown to have inferior survival outcomes when compared to those between 12 and 19.

Colonic perfusion assessment with indocyanine-green fluorescence imaging in anterior resections: a propensity score-matched analysis.

BACKGROUND: Colonic perfusion is crucial for anastomotic healing and this could be evaluated intraoperatively using indocyanine-green fluorescence imaging (ICG FI). The aim of this study was to ascertain whether the use of ICG FI resulted in the reduction of anastomotic complications, i.e. AL and anastomotic stricture. METHODS: Consecutive patients who underwent anterior resections or low anterior resections at our institution in the period from January 1st 2013 to December 31st 2018 were retrospectively reviewed. Surgery performed during the period from January 1st 2013 to December 31st 2015 did not involve the use of ICG FI (ICG-) while surgery during the period from January 1st 2016 to December 31st 2018 was performed with the use of ICG FI (ICG+). The anastomotic leakage rates of the two groups were compared after propensity score matching, taking into account the height of the anastomosis and any history of pelvic irradiation. RESULTS: There was a total of 258 and 317 patients who had surgery with and without ICG FI, respectively. There were 253 patients in each group after propensity score matching. The overall anastomotic leakage rate was 3.6% and 7.9% for ICG+ and ICG-, respectively, (p = 0.035). Subgroup analysis showed that the use of ICG FI was significantly associated with a lower anastomotic leakage rate in total mesorectal excision (TME), 4.7% versus 11.6%, p = 0.043, but not in non-TME resections, 3.5% versus 2.4%, (p = 0.612). ICG FI, together with sex and anastomotic height, were independent predictors of anastomotic leakage. CONCLUSIONS: The routine use of ICG FI was associated with a lower anastomotic leakage rate in anterior resections. The reduction in anastomotic leakage rate was mainly seen in TME.

Dietary changes adopted by Chinese colorectal cancer patients: A qualitative study.

OBJECTIVE: To explore influences on post-diagnosis dietary decision-making in colorectal cancer survivors (CRC) for future intervention development. METHODS: Individual semi-structured interviews were conducted with 30 CRC survivors. All interviews were recorded and transcribed verbatim for grounded theory analysis. RESULTS: Most CRC survivors interviewed reported making both short- and long-term changes post-diagnosis, influenced by physical symptoms and personal beliefs: short-term treatment-driven changes to facilitate recovery, manage treatment side-effects and avoid disruption in treatment; short-term 'patient role' driven changes heavily influenced by family members and cultural beliefs; long-term changes driven by residual symptoms and illness beliefs, including cancer causal attributions and beliefs about preventing future recurrences. Traditional Chinese medicinal (TCM) beliefs were influential in both short- and long-term dietary decision-making, which may explain why survivors focused on specific food items rather than food patterns. CONCLUSION: While our findings suggested that the majority of CRC survivors made dietary changes post-diagnosis, their dietary pattern and motivation may change over the course of their illness trajectory. Also, the types of changes made are often not consistent with existing dietary recommendations. It is necessary to consider illness perception and cultural beliefs when delivering dietary care or developing interventions for this population.

The impact of indocyanine-green fluorescence angiogram on colorectal resection.

BACKGROUND: Perfusion plays an important role in anastomotic healing. Indocyanine-green fluorescence angiogram allows objective bowel perfusion assessment. This study aimed to investigate the impact of perfusion assessment on intraoperative decision during left-sided colorectal resections. METHOD: This was a prospective, single-centre, observational study recruiting patients with left-sided colorectal resections. Perfusion of bowel segment was assessed with ICG fluorescence angiogram prior to resection and anastomosis intra-operatively. The planned transection site and the actual transection site after perfusion assessment were compared. The decision for diversion stoma was also evaluated. RESULTS: 110 patients with cancer of the sigmoid colon (29.1%) and rectum (70.9%) were recruited. Total mesorectal excision was performed in 51.8% of patients. The transection site was revised in 34.5% of cases: 30.9% more proximally and 3.6% more distally. The median distance between the intended and actual transection sites was 2 cm (range 1-17 cm). A proximal revision in the transection site was more likely seen in rectal cancers (p = 0.036, OR 3.58, 95% CI 1.09-11.78) and relatively under-perfused left colon (p = 0.036, OR 1.01, 95% CI 1.01-1.02). Three (2.7%) patients were spared from a diversion stoma. The overall anastomotic leakage rate was 5.5%. CONCLUSION: ICG fluorescence angiogram altered operative decisions in a significant proportion of cases. The impact on transection site was more pronounced in patients with rectal cancers and those with relatively under-perfused colon.

Sphincter-Preserving Surgery for Low Rectal Cancers: Incidence and Risk Factors for Permanent Stoma.

BACKGROUND: Advances in surgical techniques and paradigm changes in rectal cancer treatment have led to a drastic decline in the abdominoperineal resection rate, and sphincter-preserving operation is possible in distal rectal cancer. OBJECTIVE: The aim of this study is to evaluate the long-term incidence of permanent stoma after sphincter-preserving surgery for low rectal cancer and its corresponding risk factors. METHOD: From 2000 to 2014, patients who underwent sphincter-preserving low anterior resection for low rectal cancer (within 5 cm from the anal verge) were included. The occurrence of permanent stoma over time and its risk factors were investigated by using a Cox proportional hazards regression model. RESULTS: This study included 194 patients who underwent ultra-low anterior resection for distal rectal cancer, and the median follow-up period was 77 months for the surviving patients. Forty-six (23.7%) patients required a permanent stoma eventfully. Anastomotic-related complications and disease progression were the main reasons for permanent stoma. Clinical anastomotic leakage (HR 5.72; 95% CI 2.31-14.12; p < 0.001) and neoadjuvant chemoradiation (HR 2.34; 95% CI 1.12-4.90; p = 0.024) were predictors for permanent primary stoma. Local recurrence (HR 16.09; 95% CI 5.88-44.03; p < 0.001) and T4 disease (HR 11.28; 95% CI 2.99-42.49; p < 0.001) were predictors for permanent secondary stoma. The 5- and 10-year cumulative incidence for permanent stoma was 24.1 and 28.0%, respectively. CONCLUSION: Advanced disease, prior chemoradiation, anastomotic leakage and local recurrence predispose patients to permanent stoma should be taken into consideration when contemplating sphincter-preserving surgery.

Surgical management and outcome of rectal carcinoids in a university hospital.

BACKGROUND: Rectal carcinoids are an uncommon entity comprising only 1%-2% of all rectal tumors. Rectal carcinoids are frequently diagnosed during colonoscopy, but management after polypectomy is still controversial. The aims of this study were to review the surgical procedures for rectal carcinoids and to compare the outcomes of patients after different treatment modalities in a university hospital in Hong Kong. METHODS: All rectal carcinoids diagnosed between January 2003 and September 2012 were reviewed retrospectively, including clinicopathological characteristics, their management, and surgical outcomes. RESULTS: There were 54 patients with a median age of 60 years, and 32 were males (59.3%). All patients underwent colonoscopy, and the most had rectal bleeding (53.7%). Two patients were diagnosed incidentally in the surgical specimens of rectal tissues. Eighteen patients were diagnosed to have rectal carcinoids after snaring polypectomy, and no further intervention was required. Twenty-five patients had local resection either by means of transanal resection or transanal endoscopic operation. Radical resection was performed in seven patients in which one had T3N1 disease and the others did not have any lymph node metastasis. In the median follow-up of 30 months (10-108 months), there was no recurrence in the "incidental" or post-polypectomy group. However, two patients with transanal resection and two patients with radical resection developed hepatic metastases after 13-24 months post-treatment. The 5-year overall survival was 100% in patients having snaring polypectomy only, 83% for those with local resection, and 63% in patients who underwent radical surgery (p = 0.04). CONCLUSIONS: Our data suggested that that local resection was an effective treatment for small rectal carcinoids and generally brought about good oncological and surgical outcomes. For larger tumors, radical resection seemed to provide acceptable oncological outcomes. Regular surveillance with colonoscopy and endorectal ultrasound is highly recommended for high-risk patients for long-term management. By sharing our experience, we hope to provide more evidence on the management on rectal carcinoids which, together with evidence from further studies, may guide us in the long-term management of these patients in the future.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) for colorectal and appendiceal peritoneal metastases - The Hong Kong experience and literature review.

INTRODUCTION: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is increasingly used to treat peritoneal metastases from appendiceal or colorectal origin. We evaluate our institution's experience and survival outcomes with this procedure, and its efficacy in symptom relief. METHODS: This is a single-centre retrospective observational study on patients with peritoneal metastases (PM) from appendiceal neoplasm or colorectal cancer who underwent CRS/HIPEC in Queen Mary Hospital. Our primary endpoints were overall survival (OS) and morbidity and mortality of this procedure; secondary endpoints included disease-free survival (DFS) and symptom-free survival. RESULTS: Between 2006 and 2018, thirty CRS/HIPEC procedures were performed for 28 patients - 17 (60.7%) had appendiceal PM while 11 (39.9%) had colorectal PM. The median peritoneal cancer index was 20; complete cytoreduction was achieved in 83.3% patients. High-grade morbidity occurred in 13.3% cases. There was no 30-day mortality. Two-year OS were 71.6% and 50% for low-grade appendiceal PM and colorectal PM patients (p = 0.20). Complete cytoreduction improved OS (2-year OS 75.4% vs 20%, p = 0.04). Median DFS was 11.8 months. Median symptom-free duration was 36.8 months; patients with complete cytoreduction were more likely to remain asymptomatic (82.9% at 1 year, vs 60% in incomplete cytoreduction group, p < 0.01). 91.7% low-grade appendiceal PM patients and 58.4% colorectal PM patients remained asymptomatic at post-operative one year (p = 0.31). CONCLUSION: CRS/HIPEC is beneficial to appendiceal PM and selected colorectal PM patients - improving survival and offering prolonged symptom relief, with reasonable morbidity and mortality. Complete cytoreduction is key to realising this benefit.

A Randomized Controlled Trial Comparing Short-term Outcomes of Self-Gripping (Progrip) Mesh Versus Fibrin Sealant in Laparoscopic Total Extraperitoneal Hernioplasty.

BACKGROUND: There are no data comparing the use of self-gripping mesh with standard mesh in total extraperitoneal repair (TEP). In this prospective study we aim to study the incidence of chronic pain between Progrip (PG) and standard mesh fixed by fibrin sealant (FS). MATERIALS AND METHODS: Under Institutional Review Board approval, from April 2016 to May 2017, patients with primary unilateral or bilateral inguinal hernia eligible for TEP were recruited. Before mesh insertion they were randomized into PG or FS (Tisseel). Demographics, intraoperative, and postoperative data were recorded. Patients were followed up for at least 1 year. Visual Analog Scale was used to record pain scores. Primary outcome was the incidence of chronic pain at 3 months after surgery. RESULTS: One hundred fifty patients were randomized. Of the 150 patients (193 hernias), 76 were randomized to PG and 74 randomized to FS. Demographic data such as age, presence of comorbidities, smoking history, mean body mass index was comparable in both groups. Bilateral hernias occurred in 25 (32.9%) and 18 (24.3%) patients in PG and FS group, respectively. Mean mesh deployment time was 283.7 seconds (range, 140 to 720 s) in PG group and 301.9 seconds (range, 67 to 1006 s) in FS group (P=0.30). A total of 5 patients were lost at follow-up and they were excluded from subsequent data analysis. Seroma occurred in 15 (20.3%) and 16 (22.5%) patients in PG and FS group, respectively (P=0.45). Mean Visual Analog Scale at 2 weeks (cough) was highest at 1.05 and 1.02 in PG and FS group, respectively (P=0.62). Eight (12.3%) and 15 (23.4%) patients in PG and FG group, respectively, reported pain at 3-month follow-up (P=0.1). Of those who experienced pain, majority was mild pain which did not affect activities of daily living. At a mean follow-up of 13.1±5.4 months, no recurrence was detected. CONCLUSIONS: There was no significant difference in terms of chronic pain between PG and FS group. The use of PG is effective in TEP.

Inguinal canal angioleiomyoma: case report of a rare disease entity within inguinal canal.

BACKGROUND: Angioleiomyoma is an uncommon benign soft tissue tumor and originates from the vascular smooth muscle. It often causes pain and is rarely found in inguinal region. We present a rare case of inguinal canal angioleiomyoma of a female patient who suffered from right groin pain for 4 years and mimicking inguinal hernia clinically. PRESENTATION OF CASE: A 53-year-old Chinese female patient presented with 4-year history of right groin pain which was exacerbated by movement. Magnetic resonance imaging was performed in view of atypical presentation and absence of cough impulse. Inguinal canal was subsequently explored by open approach and the mass was found arising from the posterior wall of the inguinal canal and measured 5.2 cm × 3.8 cm. The posterior wall was repaired by Bassini approach after the mass was resected en-bloc. Inguinal pain was resolved and no hernia was found during follow-up. Pathology of the resected specimen confirmed angioleiomyoma with clear resection margins. CONCLUSION: This is the first report of a case of angioleiomyoma of the inguinal canal, which presents as a painful mass. Magnetic resonance imaging should be considered when presenting history and physical examination does not confirm with the diagnosis of inguinal hernia. After inguinal canal exploration, suture or mesh repair should be performed to prevent weakening of posterior wall leading to inguinal hernia.

Transanal Total Mesorectal Excision With Single-Incision Laparoscopy for Rectal Cancer.

BACKGROUND AND OBJECTIVES: There has been great enthusiasm for the technique of transanal total mesorectal excision. Coupled with this procedure, we performed single-incision laparoscopic surgery for left colon mobilization. This is a description of our initial experience with the combined approach. METHODS: Patients with distal or mid rectal cancer were included. The operation was performed by 2 teams: one team performed the single-incision mobilization of the left colon via the right lower quadrant ileostomy site, and the other team performed the total mesorectal excision with a transanal platform. RESULTS: During the study period, 10 patients (5 men) with cancer of the rectum underwent the surgery. The mean age was 62.2 ± 11.1 years, and the mean body mass index was 23.4 ± 3.2 kg/m(2). The tumor's mean distance from the anal verge was 5.1 ± 2.5 cm. The median operating time was 247.5 minutes (range, 188-462 minutes). The mean estimated blood loss was 124 ± 126 mL (range, 10-188 mL). Conversion to multiport laparoscopy was needed in one case (10%). Postoperative pain, as reflected by the pain score, was minimal. The mean number of lymph nodes harvested was 15.6 ± 3.8. All specimens had clear distal and circumferential radial margins. The overall complication rate was 10%. CONCLUSION: Our experience showed transanal total mesorectal excision with single-incision laparoscopy to be a feasible option for rectal cancer. Patients reported minimal postoperative pain. Further studies on the long-term outcome are warranted.

Breast carcinoma in Chinese women: does age affect treatment choice and outcome?

OBJECTIVE: Age is a known risk factor for breast cancer behaviour. We studied the relationship of age with clinical characteristics, tumour pathology, therapeutic options and outcome in an affluent Asian population. METHODS: From 2003 to 2008, data on newly diagnosed breast carcinoma patients under the care of the multidisciplinary breast cancer team based at a private hospital in Hong Kong were collected prospectively. Patients were divided into three groups: age < 40 years (group I), 41-69 years (group II), and ≥ 70 years (group III). RESULTS: There were 2,079 patients: 334 in group I, 1,538 in group II and 148 in group III. The clinical presentation and tumour stages were similar. Younger patients had higher tumour grading (p = 0.000) and more lymphovascular permeation (p = 0.011). For older patients, combination therapy was employed less frequently (p < 0.0005), and more radical resection with less reconstructive procedures were performed (p = 0.000). The 3-year disease-free survival was 97.8% and there was no difference between the three groups. CONCLUSION: Although breast cancer in younger Chinese patients was more aggressive pathologically, the differences between clinical presentation, tumour staging and survival were similar. Treatment strategies should follow the clinical condition of the patient rather than age alone.

Hereditary Colorectal Cancer Syndromes in Hong Kong: a Registry's Perspective.

Established in 1995, the Hereditary Gastrointestinal Cancer Registry aimed at cancer prevention due to hereditary colorectal cancer syndromes in Hong Kong through early detection, timely treatment, education and ongoing research. This article details the history, structure and work of the Registry. A summary is also provided on the results of various research work conducted by the Registry which facilitates the clinical management of hereditary colorectal cancer syndromes in Hong Kong Chinese families.