Quality of life after rectal cancer surgery: differences between laparoscopic and transanal total mesorectal excision.

BACKGROUND: Transanal total mesorectal excision (TaTME) is a safe alternative to laparoscopic TME for mid and low rectal cancer. TaTME allows improved visualization of the surgical planes and margins, and may potentially improve oncological outcomes. However, functional results after total mesorectal excision (TME) are variable and there are currently only a few published studies that include functional data related to the outcomes of TaTME. METHODS: Fifty-four consecutive patients were included in this study: one group included 27 patients who underwent laparoscopic low anterior and the other included 27 patients who underwent TaTME. All patients were asked to complete five questionnaires related to quality of life (QOL) and function [EQ-5D-3L, EORTC-QLQ C30, EORTC-QLQ C29, Low Anterior Resection Syndrome score (LARS), and International Prostate Symptom Score IPSS]. All TaTME patients were operated on at The Gelderse Vallei Hospital by a single surgeon and had a follow-up of at least 6.6 months. RESULTS: The EORTC-QLQ C30 and EQ-5D-3L questionnaires showed comparable outcomes in terms of QOL between the two groups. Almost all items evaluated by the EORTC-QLQ C29, including sexual outcomes, were similar between the two groups. One item concerning fecal incontinence, however, was scored worse for TaTME. There were no significant differences between the groups in terms of LARS symptoms or urinary function. CONCLUSIONS: Patients undergoing laparoscopic or transanal TME showed comparable functional and QOL outcomes. Although the TaTME technique is still evolving, this study indicates that this technique is a safe alternative to laparoscopic surgery in terms of functional outcomes for mid and low rectal cancers.

COLOR III: a multicentre randomised clinical trial comparing transanal TME versus laparoscopic TME for mid and low rectal cancer.

INTRODUCTION: Total mesorectal excision (TME) is an essential component of surgical management of rectal cancer. Both open and laparoscopic TME have been proven to be oncologically safe. However, it remains a challenge to achieve complete TME with clear circumferential resections margin (CRM) with the conventional transabdominal approach, particularly in mid and low rectal tumours. Transanal TME (TaTME) was developed to improve oncological and functional outcomes of patients with mid and low rectal cancer. METHODS: An international, multicentre, superiority, randomised trial was designed to compare TaTME and conventional laparoscopic TME as the surgical treatment of mid and low rectal carcinomas. The primary endpoint is involved CRM. Secondary endpoints include completeness of mesorectum, residual mesorectum, morbidity and mortality, local recurrence, disease-free and overall survival, percentage of sphincter-saving procedures, functional outcome and quality of life. A Quality Assurance Protocol including centralised MRI review, histopathology re-evaluation, standardisation of surgical techniques, and monitoring and assessment of surgical quality will be conducted. DISCUSSION: The difference in involvement of CRM between the two treatment strategies is thought to be in favour of the TaTME. TaTME is therefore expected to be superior to laparoscopic TME in terms of oncological outcomes in case of mid and low rectal carcinomas.

The Physical Workload of Surgeons: A Comparison of SILS and Conventional Laparoscopy.

BACKGROUND: As extensively reported in the literature, laparoscopic surgery has many advantages for the patient. Surgeons, however, experience increased physical burden when laparoscopic surgery is compared with open surgery. Single-incision laparoscopic surgery (SILS) has been said to further enhance the patient's benefits of endoscopic surgery. Because in this surgical technique only 1 incision is made instead of the 3 to 5, as in conventional laparoscopic surgery (CLS), it is claimed to further reduce discomfort and pain in patients. Yet little is known about its impact on surgeons. This study aims to contribute by indicating the possible differences in physical workload between single-incision laparoscopy and CLS. METHODS: A laparoscopic box trainer was used to simulate a surgical setting. Participants performed 2 series of 3 different tasks in the box: one in the conventional way, the other through SILS. Surface electromyography was recorded from 8 muscles bilaterally. Furthermore, questionnaires on perceived workload were completed. RESULTS: Differences were found in the back, neck, and shoulder muscles, with significantly higher muscle activity in the musculus (M) longissimus, M trapezius pars descendens, and the M deltoideus pars clavicularis. Questionnaires did not indicate any significant differences in perceived workload. CONCLUSION: Performing SILS versus CLS increases the objectively measured physical workload of surgeons particularly in the back, neck, and shoulder muscles.

Intra-abdominal bacterial contamination in TAMIS total mesorectal excision for rectal carcinoma: a prospective study.

BACKGROUND: Natural orifice transluminal endoscopic surgery (NOTES) is currently gaining a lot of attention. NOTES is expected to further reduce surgical trauma and improve patient care due to eliminating abdominal incisions. The interest in transrectal NOTES has grown slowly, because of concerns of bacterial contamination due to transection of the rectum at the start of the procedure. However, different studies already demonstrated that transanal TME (TaTME) can be performed without major complications. This prospective study focuses on the presence and clinical significance of peritoneal bacterial contamination after TaTME for rectal cancer. METHODS: Three bacterial cultures were taken at standardized locations from the pelvic area after completion of the TaTME procedure and before closure of the incisional wounds. The cultures were evaluated for bacterial count and species identification. Furthermore, C-reactive protein and white blood cell count were measured perioperatively, and postoperative complications were recorded. RESULTS: Twenty-three consecutive patients were included between July 2013 and December 2014. Thirty-nine percent (9/23) of the cultures showed gastrointestinal flora. Four of these patients (44 %) developed presacral abscesses. The remaining 61 % (14/23) of the cultures were negative. None of these patients developed infectious complications. CONCLUSION: Transanal TME procedures are associated with positive cultures in more than one-third of the patients. In these patients, postoperative locoregional infectious complications are more common.

Transanal versus traditional laparoscopic total mesorectal excision for rectal carcinoma.

BACKGROUND: After total mesorectal excision (TME) surgery, patients with an incomplete mesorectum have an increased risk of local and overall recurrence. With the introduction of laparoscopic TME, an improved quality of the specimen was expected. However, the quality-related results were comparable to the results after traditional open surgery. Transanal TME is a new technique in which the rectum is mobilised by using a single-port and endoscopic instruments through the so called 'down to up' procedure. This new technique potentially leads to an improved specimen quality. This study was designed to investigate the pathological quality of specimens after transanal (TME) and to compare these with specimens after traditional laparoscopic TME. METHODS: This matched case control study compared the specimens of a cohort of consecutive patients who underwent transanal TME with the specimens after traditional laparoscopic TME. The pathological quality of the mesorectum was determined by the definitions of Quirke as 'complete', 'nearly complete', or 'incomplete'. RESULTS: From June 2012 until July 2013, 25 consecutive patients underwent transanal TME because of a rectum carcinoma. Within the transanal TME group, 96% of the specimens had a complete mesorectum, while in the traditional laparoscopic group, 72% was deemed complete (p < 0.05). Other pathological characteristics, such as the circumferential resection margin, were comparable between the two groups. CONCLUSIONS: Transanal TME appears associated with a significant higher rate of completeness of the mesorectum. Further studies are necessary to evaluate this novel technique.

[Transanal total mesorectal excision: a new treatment option for rectal cancer]. / Transanale totale mesorectale excisie: een nieuwe behandeling voor het rectumcarcinoom.

The transanal total mesorectal excision (TME) for colorectal tumours is a new endoscopic approach in which the rectum is mobilized transanally from down-to-up using a flexible transanal single-access port. The advantage of this technique is that it could result in fewer conversions from laparoscopic to open procedures and consequently fewer complications and more radical resections. Standard endoscopic armamentarium is used for the transanal technique so that costs remain low. The length of the learning curve is expected to be comparable to other laparoscopic techniques, and is even shorter for an experienced laparoscopic surgeon. Additional research is needed to compare long-term oncological and clinical results of transanal TME to laparoscopic and open TME.

Single-incision and NOTES cholecystectomy, are there clinical or cosmetic advantages when compared to conventional laparoscopic cholecystectomy? A case-control study comparing single-incision, transvaginal, and conventional laparoscopic technique for cholecystectomy.

BACKGROUND: The aim of the present study was to compare the clinical and cosmetic results of transvaginal hybrid cholecystectomy (TVC), single-port cholecystectomy (SPC), and conventional laparoscopic cholecystectomy (CLC). Recently, single-incision laparoscopic surgery and natural orifice transluminal endoscopic surgery have been developed as minimally invasive alternatives for CLC. Few comparative studies have been reported. METHODS: Female patients with symptomatic gallstone disease who were treated in 2011 with SPC, TVC, or CLC were entered into a database. Patients were matched for age, body mass index, and previous abdominal surgery. After the operation all patients received a survey with questions about recovery, cosmesis, and body image. RESULTS: A total of 90 patients, 30 in each group, were evaluated. Median operative time for CLC was significantly shorter (p < 0.001). There were no major complications. Length of hospital stay, postoperative pain, and postoperative complications were not significantly different. The results for cosmesis and body image after the transvaginal approach were significantly higher. None of the sexually active women observed postoperative dyspareunia. CONCLUSIONS: Both SPC and TVC are feasible procedures when performed in selected patients. CLC is a faster procedure, but other clinical outcomes and complication rates were similar. SPC, and especially TVC, offer a better cosmetic result. Randomized trials are needed to specify the role of SPC and TVC in the treatment of patients with symptomatic gallstone disease.

[A smoker with progressive knee complaints]. / Een roker met progressieve knieklachten.

A 70-year-old smoker was referred for X-rays of both painful knees. Both femora showed signs of hypertrophic osteoarthropathy. Chest radiography demonstrated a tumour in the upper lobe of the right lung. The patient was diagnosed with hypertrophic pulmonary osteoarthropathy (Marie-Bamberger syndrome).

Hybrid transvaginal cholecystectomy, clinical results and patient-reported outcomes of 50 consecutive cases.

OBJECTIVE: The aim of this study was to report the clinical and cosmetic results of transvaginal hybrid cholecystectomy (TVC). BACKGROUND: Natural orifice transluminal endoscopic surgery (NOTES) has been developed as a minimal invasive alternative for conventional laparoscopic cholecystectomy. Although transvaginal NOTES procedures are becoming increasingly popular, data focussing on body image, cosmesis and sexual recovery are rare. METHODS: Our clinic started to perform the TVC in the beginning of 2011. Female patients with symptomatic gallstone disease that were treated between January 2011 and April 2012 with TVC were entered in a prospective database. All patients received a survey postoperative with questions about recovery, cosmesis and body image. RESULTS: Fifty consecutive patients were treated with a TVC. There were no major complications. Mean operative time was 61 min. In five patients (10 %), a conversion to another type of cholecystectomy was necessary. None of the sexually active women observed dyspareunia postoperative. The results for cosmesis and body image after the transvaginal approach were excellent. CONCLUSIONS: TVC is a safe and feasible procedure when performed on selected patients. The transvaginal route seems to result in excellent cosmetic outcomes without gynaecologic complications after short-term follow up. Randomised trials are needed to specify the role of TVC in the treatment of patients with symptomatic gallstone disease and to detect differences in cosmetic outcomes.

[Transanal single-port surgery for local excision of rectal tumours]. / Flexibele toegangspoort voor excisie rectumtumoren.

Transanal endoscopic microsurgery (TEM) is the technique of choice for rectum-preserving treatment of rectal tumours. However, the instruments are relatively expensive and TEM is a highly-complex technique. From 2010 a few case reports describing a new technique for local excision of rectal tumours using a single-access laparoscopic port have appeared. These single-access ports are flexible multichannel ports for transumbilical laparoscopic surgery. Even though not developed for transanal use these ports are ideal because of their shape and the material they are made from. Transanal surgery using a single-access port is a relatively simple procedure and does not require any investment in new instruments. This new technique will enable more surgeons to carry out transanal endoscopic surgery.

Comparison of short-term surgical outcomes after single-incision laparoscopic versus multiport laparoscopic right colectomy: a two-center, prospective case-controlled study of 100 patients.

BACKGROUND: Recent case studies have demonstrated the feasibility of single-incision laparoscopic colectomy (SILC). Few comparative studies for SILC and multiport laparoscopic colectomy (MLC) have been conducted. The aim of this case-controlled study was to compare the short-term surgical outcomes between SILC and MLC for right-sided colectomies. METHODS: Between January 2010 and February 2012, data from the first 50 consecutive patients that underwent right SILS at one of the two institutions were compared with a group of 50 consecutive patients that underwent right MLC in the same period. RESULTS: Median operative time was significantly shorter in SILC (97 vs. 112 min; p < 0.001). Between both groups, no statistically significant differences were found regarding number and nature of short-term complications, number of reoperations [4 (8%) vs. 6 (12%)], and mortality rate [1 (2%) vs. 2 (4%)]. Median postoperative hospital stay was 6 days for both groups. CONCLUSION: SILC is a safe and feasible procedure when performed by experienced laparoscopic surgeons. Length of hospital stay and overall complication rates are comparable with MLC. Until today, no clear advantages of SILC over MLC have been demonstrated. However, due to its smaller incisional trauma, SILC could be a major step in improving cosmetic outcomes.