The 2019 World Health Organization Classification of appendiceal, colorectal and anal canal tumours: an update and critical assessment.

The recently published 5th edition 2019 World Health Organization (WHO) Classification of Tumours of the Digestive System brings significant changes from the 2010 4th edition. An emphasis on uniformity in nomenclature and grading for tumours across all organ systems is a particular feature of the 5th edition blue book series that is reflected in the gastrointestinal tract (GIT) classification. For example, simplified two tiered grading is reinforced for preinvasive lesions throughout the GIT, with dysplasia at all sites now being considered either low or high grade. Similarly, a uniform approach to classification and grading of GIT neuroendocrine neoplasms has been consolidated, with an emphasis on distinguishing grade 3 neuroendocrine tumours from neuroendocrine carcinomas. In this review, we discuss and critically assess the important and sometimes controversial changes made to the classification of tumours of the lower GIT, comprising the colorectum, vermiform appendix and anal canal. The particularly controversial decision to endorse the term 'sessile serrated lesion' for lesions previously termed 'sessile serrated polyp/adenoma' is explored. The morphological, molecular, and clinical insights behind the substitution of the term 'goblet cell adenocarcinoma' for 'goblet cell carcinoid' are assessed. The evolution of the classification of appendiceal mucinous neoplasms is considered. Inflammatory bowel disease related dysplasia and its evolving subtypes, with major implications for pathologists in routine practice, is explained.

Transanal total mesorectal excision combined with laparoscopic dissection: perioperative results and assessment of the mesorectal quality. / Excisão total de mesorreto transanal combinada à dissecção laparoscópica: resultados perioperatórios e avaliação da qualidade do mesorreto.

OBJECTIVE: to assess the perioperative and postoperative results of transanal total mesorectal excision, as well as the quality of the specimens obtained by this technique. METHODS: we conducted a prospective, descriptive study in consecutive patients with rectal adenocarcinoma located up to 10cm from the anal verge, without distant metastasis, subjected or not to neoadjuvant chemoradiotherapy. We evaluated the presence of technical difficulties, conversion to open abdominal route, surgical time and intra and postoperative complications. Through histopathological analysis, we assessed the quality of the mesorectum, involvement of the proximal and distal margins and positivity of the circumferential, classifying quality of the mesorectum as complete, partially complete or incomplete resection. RESULTS: between December 2016 and May 2019, 41 patients underwent transanal total mesorectal excision, of which 75% were classified as clinical stage III, 13% clinical stage II and 12% clinical stage I. The average distance between the anal verge and the lower border of the tumor was 6.2cm. Forty percent of the tumors were in the anterior rectal wall and 17% were circumferential. The average operative time was 189 minutes. The average hospital stay was 4.6 days. There were no in-hospital deaths. Eighty-two percent of the specimens were classified as complete resection. CONCLUSION: transanal total mesorectal excision demonstrates adequate specimen quality and surgical margins, being associated with lower rates of perioperative complications, acceptable surgical time and short hospitalization.

OBJETIVO: avaliar os resultados perioperatórios e pós-operatórios relacionados à excisão total do mesorreto transanal, bem como, qualidade dos espécimes obtidos pela excisão total do mesorreto transanal através da análise histopatológica da qualidade do mesorreto, acometimento das margens proximal e distal e positividade da margem circunferencial. MÉTODOS: estudo prospectivo, descritivo, em pacientes consecutivos portadores de adenocarcinoma de reto localizados até 10cm da borda anal, sem metástase à distância, submetidos ou não à quimioterapia e radioterapia neoadjuvantes. Foram avaliados a presença de dificuldades técnicas, índice de conversão para via abdominal, tempo cirúrgico e intercorrências intra e pós-operatórias. A qualidade do mesorreto foi classificada em ressecção completa, parcialmente completa ou incompleta. RESULTADOS: entre dezembro de 2016 e maio de 2019, 41 pacientes foram submetidos à excisão total do mesorreto transanal, dos quais 75% foram classificados como estágio clínico III, 13% estágio clínico II e 12% estágio clínico I. A média de distância entre borda anal e borda inferior do tumor foi de 6,2cm. Quarenta por cento dos tumores encontravam-se na parede retal anterior e 17% foram classificados como circunferenciais. A média de tempo operatório foi de 189 minutos. A média de internação hospitalar foi de 4,6 dias. Não houve óbitos intra-hospitalares. Oitenta e dois por cento dos espécimes foram classificados como ressecção completa. CONCLUSÃO: a excisão total do mesorreto transanal demonstra adequada qualidade do mesorreto e adequadas margens cirúrgicas, estando associada a baixos índices de complicações perioperatórias, tempo cirúrgico aceitável e curto tempo de hospitalização.

Assessment of haemorrhoidal artery network using Doppler-guided haemorrhoidal artery ligation for haemorrhoids and pathogenesis implications.

BACKGROUND: Some authors, either with anatomical studies or Doppler laser flowmetric investigations have shown the blood flow to the posterior midline of the anus to be potentially deficient. This relative local ischaemia might explain pathogenesis of anal fissure, which is often located posteriorly. The aim of this study was to record the exact position of the distal branches of the superior rectal artery during Doppler-guided haemorrhoidal artery ligation-rectoanal repair (HAL-RAR) procedures with special reference to posterior distribution of the arteries. METHODS: All consecutive patients with symptomatic haemorrhoids who were treated with the HAL-RAR procedure between February 2008 and February 2014 in a single institution were included in the study. Number and position of Doppler-guided ligations were prospectively collected. Pearson's chi-squared test was used to compare artery locations. RESULTS: A total of 150 patients (75 women) with symptomatic haemorrhoids were included in the study. Median age was 53 years (range 23-83). A median of 10 ligations were placed per patient (range 3-18). A significantly lower number of cumulative arterial ligations was recorded in the posterior position (88 ligations overall, P = 0.025). CONCLUSIONS: The number of distal branches of the superior rectal artery that have been localized by the Doppler-guided HAL-RAR technique is lower at the posterior midline than in the other segments of the lower rectum. This is another evidence of the vascular deficiency at the posterior pole of the anal canal that might explain the pathogenesis of the anal fissure.

Assessment of the Heineke-Mikulicz anoplasty for skin level postoperative anal strictures and congenital anal stenosis.

INTRODUCTION: Acquired skin-level strictures following posterior sagittal anorectoplasty (PSARP) and some rare cases of congenital anal stenosis can be managed using a Heineke-Mikulicz like anoplasty (HMA). We hypothesized that this procedure was an effective, safe, and durable outpatient procedure in select patients. METHODS: We retrospectively reviewed all patients who underwent HMA for skin level strictures following PSARP or for certain congenital anal stenoses from 2014 to 2017. RESULTS: Twenty-eight patients (19 males, 9 females) with a mean age of 5.8 years (range 0.5-24.4) underwent HMA. Twenty-six had a prior PSARP, of which 18 were redo, and 8 were primary procedures. Two patients had congenital skin level anal stenosis. The mean follow up was 1.0 years (range 0.4-2.9). The average preprocedure anal size was Hegar 8, which after HMA increased 8 Hegar sizes to 16 (95% CI 7-9, p < 0.001). There were no operative complications. One patient restenosed and required a secondary procedure. CONCLUSION: HMA is a safe procedure for skin-level anal strictures following PSARP (primary and redo) and can also be used in some rare cases of congenital anal stenosis. Long-term follow up to determine the restricture rate is ongoing. A plan to do an HMA if a stricture develops may offer an alternative to routine anal dilations, particularly after a redo PSARP in an older child. TYPE OF STUDY: Case series. LEVEL OF EVIDENCE: Level IV.

Excisão total de mesorreto transanal combinada à dissecção laparoscópica: resultados perioperatórios e avaliação da qualidade do mesorreto / Transanal total mesorectal excision combined with laparoscopic dissection: perioperative results and assessment of the mesorectal quality

RESUMO Objetivo: avaliar os resultados perioperatórios e pós-operatórios relacionados à excisão total do mesorreto transanal, bem como, qualidade dos espécimes obtidos pela excisão total do mesorreto transanal através da análise histopatológica da qualidade do mesorreto, acometimento das margens proximal e distal e positividade da margem circunferencial. Métodos: estudo prospectivo, descritivo, em pacientes consecutivos portadores de adenocarcinoma de reto localizados até 10cm da borda anal, sem metástase à distância, submetidos ou não à quimioterapia e radioterapia neoadjuvantes. Foram avaliados a presença de dificuldades técnicas, índice de conversão para via abdominal, tempo cirúrgico e intercorrências intra e pós-operatórias. A qualidade do mesorreto foi classificada em ressecção completa, parcialmente completa ou incompleta. Resultados: entre dezembro de 2016 e maio de 2019, 41 pacientes foram submetidos à excisão total do mesorreto transanal, dos quais 75% foram classificados como estágio clínico III, 13% estágio clínico II e 12% estágio clínico I. A média de distância entre borda anal e borda inferior do tumor foi de 6,2cm. Quarenta por cento dos tumores encontravam-se na parede retal anterior e 17% foram classificados como circunferenciais. A média de tempo operatório foi de 189 minutos. A média de internação hospitalar foi de 4,6 dias. Não houve óbitos intra-hospitalares. Oitenta e dois por cento dos espécimes foram classificados como ressecção completa. Conclusão: a excisão total do mesorreto transanal demonstra adequada qualidade do mesorreto e adequadas margens cirúrgicas, estando associada a baixos índices de complicações perioperatórias, tempo cirúrgico aceitável e curto tempo de hospitalização.

ABSTRACT Objective: to assess the perioperative and postoperative results of transanal total mesorectal excision, as well as the quality of the specimens obtained by this technique. Methods: we conducted a prospective, descriptive study in consecutive patients with rectal adenocarcinoma located up to 10cm from the anal verge, without distant metastasis, subjected or not to neoadjuvant chemoradiotherapy. We evaluated the presence of technical difficulties, conversion to open abdominal route, surgical time and intra and postoperative complications. Through histopathological analysis, we assessed the quality of the mesorectum, involvement of the proximal and distal margins and positivity of the circumferential, classifying quality of the mesorectum as complete, partially complete or incomplete resection. Results: between December 2016 and May 2019, 41 patients underwent transanal total mesorectal excision, of which 75% were classified as clinical stage III, 13% clinical stage II and 12% clinical stage I. The average distance between the anal verge and the lower border of the tumor was 6.2cm. Forty percent of the tumors were in the anterior rectal wall and 17% were circumferential. The average operative time was 189 minutes. The average hospital stay was 4.6 days. There were no in-hospital deaths. Eighty-two percent of the specimens were classified as complete resection. Conclusion: transanal total mesorectal excision demonstrates adequate specimen quality and surgical margins, being associated with lower rates of perioperative complications, acceptable surgical time and short hospitalization.

Anal Fistulas in Severe Perineal Crohn's Disease: Mri Assessment in the Determination of Long-Term Healing Rates.

Background & Aims: The European Crohn's and Colitis Organization recommends magnetic resonance imaging (MRI) of anal fistulas to decide on the drug/surgery strategy. No evidence is available on the long-term impact of MRI features on fistula healing. The aim of this study was to evaluate the benefit of combined drug/surgery strategies for the treatment of perianal Crohn's fistulas based on MRI factors at referral. Methods: The clinical event (anal abscess, new fistula tract, cellulitis), therapeutic intervention (introduction/optimization of immunosuppressant/biologics, anal surgery, intestinal resection, stoma), and MRI data were prospectively recorded for patients with Crohn's disease (CD) and anal fistulas. Healing was defined by fulfilment of all the following conditions: no discharge or pain, closure of the external opening of the fistula, no visible internal opening, no abscess, and no subsequent draining seton or drainage procedure performed during at least 1 year of follow-up. Results: Seventy CD patients with anal fistulas and MRI evaluations were followed for 70 months. The cumulative rates of fistula healing were 25%, 40%, 50%, and 70% at 12, 24, 36, and 72 months, respectively. Severe, complex, branched, and high fistulas were associated with a less favorable outcome. Surgical closure of the tract improved the healing rates better than treatment with biologics or thiopurines. Male sex, A1 luminal phenotype, and anal ulceration at referral were independently associated with a higher healing rate. Conclusions: Therapeutic strategies for perianal fistulizing CD require robust anatomical and healing evaluations. Combined strategies using biologics to improve both drainage and secondary closure of the fistula tracts merit further study.

Patients with newly diagnosed cervical cancer should be screened for anal human papilloma virus and anal dysplasia: Results of a pilot study using a STELLA computer simulation and economic model.

BACKGROUND: Women with cervical cancer often have anal human papillomavirus (HPV) infection and anal dysplasia. However, effectiveness of anal HPV screening is unknown. METHODS: A dynamic model was constructed using STELLA. Populations are represented as "stocks" that change according to model rates. Initial anal cytology in new cervical cancer patients, dysplasia progression and regression, cost of treating high-grade squamous intraepithelial lesions (HSIL), and lifetime costs for anal cancer care were extrapolated from the literature. Local costs of anal HPV testing and cytology were obtained. Outcomes included anal cancer rates, anal cancer deaths, screening costs and cancer care. RESULTS: Benefits in the screened group included reduction in anal cancers after three years and anal cancer deaths after four years. After 10 years, predicted costs per anal cancer prevented and anal cancer deaths were $168,796 and $210,057 and were $98,631 and $210,057 at 20 years. Predicted costs per quality of life year saved at 10 and 20 years were $9785 and $1687. Sensitivity analysis demonstrated cost-effectiveness of screening for a variety of cure rates HSIL with electrocautery. CONCLUSION: Screening for anal HPV and treatment of anal HSIL in patients with cervical cancer is cost-effective, prevents anal cancer and reduces anal cancer deaths.

Uptake of Transanal Total Mesorectal Excision in North America: Initial Assessment of a Structured Training Program and the Experience of Delegate Surgeons.

BACKGROUND: Transanal total mesorectal excision is a new approach to curative-intent rectal cancer surgery. Training and surgeon experience with this approach has not been assessed previously in America. OBJECTIVE: The purpose of this study was to characterize a structured training program and to determine the experience of delegate surgeons. DESIGN: Data were assimilated from an anonymous, online survey delivered to attendees on course completion. Data on surgeon performance during hands-on cadaveric dissection were collected prospectively. SETTINGS: This study was conducted at a single tertiary colorectal surgery referral center, and cadaveric hands-on training was conducted at a specialized surgeon education center. MAIN OUTCOME MEASURES: The main outcome measurement was the use of the course and surgeon experience posttraining. RESULTS: During a 12-month period, eight 2-day transanal total mesorectal excision courses were conducted. Eighty-one colorectal surgeons successfully completed the course. During cadaveric dissection, 71% achieved a complete (Quirke 3) specimen; 26% were near complete (Quirke 2), and 3% were incomplete (Quirke 1). A total of 9.1% demonstrated dissection in the incorrect plane, whereas 4.5% created major injury to the rectum or surrounding structures, excluding the prostate. Thirty eight (46.9%) of 81 surgeon delegates responded to an online survey. Of survey respondents, 94.6% believed training should be required before performing transanal total mesorectal excision. Posttraining, 94.3% of surgeon delegates planned to use transanal total mesorectal excision for distal-third rectal cancers, 74.3% for middle-third cancers, and 8.6% for proximal-third cancers. The most significant complication reported was urethral injury; 5 were reported by the subset of survey respondents who had performed this operation postcourse. LIMITATIONS: The study was limited by inherent reporting bias, including observer and recall biases. CONCLUSIONS: Although this structured training program for transanal total mesorectal excision was found to be useful by the majority of respondents, the risk of iatrogenic injury after training remains high, suggesting that this training pedagogy alone is insufficient. See Video Abstract at http://links.lww.com/DCR/A335.

The assessment of local response using magnetic resonance imaging at 3- and 6-month post chemoradiotherapy in patients with anal cancer.

OBJECTIVES: To assess the use of MRI-determined tumour regression grading (TRG) in local response assessment and detection of salvageable early local relapse after chemoradiotherapy (CRT) in patients with anal squamous cell carcinoma (ASCC). METHODS: From a prospective database of patients with ASCC managed through a centralised multidisciplinary team, 74 patients who completed routine post-CRT 3- and 6-month MRIs (2009-2012) were reviewed. Two radiologists blinded to the outcomes consensus read and retrospectively assigned TRG scores [1 (complete response) to 5 (no response)] and related these to early local relapse (within 12 months) and disease-free survival (DFS). RESULTS: Seven patients had early local relapse. TRG 1/2 scores at 3 and 6 months had a 100 % negative predictive value; TRG 4/5 scores at 6 months had a 100 % positive predictive value. All seven patients underwent salvage R0 resections. We identified a novel 'tram-track' sign on MRI in over half of patients, with an NPV for early local relapse of 83 % at 6 months. No imaging characteristic or TRG score independently prognosticated for late relapse or 3-year DFS. CONCLUSIONS: Post-CRT 3- and 6-month MRI-determined TRG scores predicted salvageable R0 early local relapses in patients with ASCC, challenging current clinical guidelines. KEY POINTS: • Post-chemoradiotherapy MRI (3 and 6 months) helps local response assessment in ASCC. • The MRI-TRG system can be used reproducibly in patients with ASCC. • The TRG system facilitates patient selection for examination under anaesthesia and biopsy. • The use of MRI-TRG predicts for detection of salvageable early local relapses. • The TRG system allows for a standardised follow-up pathway.

Influence of Body Position on Anorectal Manometric Assessment in Functional Constipation.

Objective: To date, there have been no studies to evaluate the influence of posture on anorectal manometric measurements in patients with functional constipation. The present study aimed to compare differences in anorectal manometric measurements in constipated patients when performing the test in the lying and sitting positions. Material and Method: Anorectal manometry with a conventional solid state manometric catheter was performed in 30 constipated patients in both the lying and sitting positions. Anorectal manometric variables at rest and during attempted defecation with empty rectum were assessed in both positions. A colonic transit study using Sitzmarks radiopaque markers and a 50-mL water-filled balloon expulsion test was also performed in all patients. Patients exhibiting an abnormal manometric pattern of defecation in either the sitting or lying position proceeded to a simulated defecation test. The anorectal pressure parameters of resting and during attempted defecation of the both positions were compared. Results: The resting rectal pressure, maximum rectal straining pressure, and defecation index during attempted defecation were significantly higher in the sitting position than the lying position. A dyssynergic manometric pattern during attempted defecation with empty rectum was seen in 46% of the patients in the lying position, not significantly different from the 56% in the seated position (p = 0.58). Most patients (71%) who exhibited manometric dyssynergia with an empty rectum could relax their anal sphincter during the simulated defecation test. Only six (20%) constipated patients had abnormal dyssynergic anal sphincter contraction confirmed by a simulated defecation test. Conclusion: Body position affects the results of manometric measurements related to the defecation mechanism.

Defining the histopathological changes induced by nonablative radiofrequency treatment of faecal incontinence--a blinded assessment in an animal model.

AIM: Nonablative radiofrequency (RF) sphincter remodelling has been used to treat gastro-oesophageal reflux disease (GERD) and faecal incontinence (FI). Its mechanism of action is unclear. We aimed to investigate the histomorphological and pathophysiological changes to the internal and external anal sphincter (IAS and EAS) following RF remodelling. METHOD: An experimental FI model was created in 12 female pigs: eight underwent RF 6 weeks following induction of FI (FI+RF) and four were untreated (UFI). Four animals served as controls (CG). Two blinded pathologists examined all haematoxylin and eosin and trichrome stained slides. RESULTS: Compared with the UFI group, histological examination of the IAS in the FI+RF group demonstrated an increased smooth muscle (SM)/connective tissue ratio (77.2 vs 68.1%, P < 0.05) and increased collagen I compared with collagen III content (67.2 vs 54.9%, P < 0.001). The RF+FI group exhibited greater SM bundle thickness compared with the UFI group (SM width 486.93 vs 338.59 µm, P < 0.01; height 4384.4 vs 3321.0 µm, P < 0.05). The EAS of the FI+RF animals showed a significantly higher type I/II fibre ratio (33.5 vs 25.2%, P = 0.023) and fibre type I diameter (67.2 vs 59.7 µm, P < 0.001) compared with the UFI group. Post-RF manometry showed higher basal (18.8 vs 0 mmHg, P < 0.001) and squeeze (76.8 vs 12.4 mmHg, P < 0.05) anal pressures. After RF treatment, the number of interstitial cells of Cajal was significantly reduced compared with the UFI and CG groups [0.9 (FI+RF) vs 6.7 (UFI) vs 0.7 (CG) per mm(2) , P < 0.001]. CONCLUSION: In an animal model nonablative RF appeared to induce morphological changes in the IAS and EAS leading to an anatomical state reminiscent of normal sphincter structure.

Clinical and investigative assessment of constipation: a study from a referral center in western India.

INTRODUCTION: Constipation may be primary or secondary. Pathophysiologic subtypes of primary constipation are dyssynergic defecation (DD), slow (STC), and normal transit constipation (NTC). Clinical subtypes are functional constipation (FC) and constipation predominant IBS (C-IBS). AIMS: The objectives of this paper are to study the clinical profile, categorize and compare various subtypes of primary constipation, and to assess the success of biofeedback therapy (BFT) in a non-randomized, uncontrolled open-label study among patients with DD. MATERIAL AND METHODS: Consecutive constipation patients (April 2011 to December 2012) were evaluated. Patients <18 years and secondary constipation were excluded. FC and C-IBS were classified by Rome III module. All patients, after excluding secondary constipation, underwent anorectal manometry (ARM) with balloon expulsion test and colon transit study (CTS). Patients with DD were given BFT. RESULTS: Out of 128 patients, 23 %, 58 %, and 19 % had secondary constipation, FC, and C-IBS, respectively. Ninety-nine patients had primary constipation. Among those with primary constipation mean age was 53.5 (21-86) years, (77 % males). Forty-six, 15, and 40 had NTC, STC, and DD, respectively. Out of those with DD, 34 had paradoxical anal contraction and 6 had impaired rectal propulsion. FC and C-IBS were clinically and pathophysiologically similar except for abdominal pain. Patients with DD were more likely to have history of finger evacuation, straining, incomplete evacuation, sensation of anorectal obstruction than no DD. Sixty-nine percent of the patients with STC had ≤3 stools/week compared to 37 % with NTC (p-value 0.018). Thirty out of 40 (75 %) patients with DD underwent BFT but 20 completed ≥4 sessions. Seventy percent with ≥4 sessions had improved complete spontaneous bowel movements (CSBM). CONCLUSION: NTC was the most common subtype of primary constipation. Symptoms of finger evacuation, sensation of anorectal obstruction, incomplete evacuation, and straining were more prevalent in DD. ARM and CTS could easily identify patients with DD and STC.

Assessment of pubovisceral muscle defects and levator hiatal dimensions in women with faecal incontinence after vaginal delivery: is there a correlation with severity of symptoms?

AIM: We assessed pubovisceral muscle (PVM) defects, levator hiatal dimensions and anal sphincter defects using three-dimensional (3D) endovaginal and anorectal ultrasonography in women with previous vaginal delivery and faecal incontinence to determine the relationship between anatomic/functional findings and severity of faecal incontinence symptoms. METHOD: This was a prospective, observational study including 52 women with faecal incontinence symptoms who had undergone vaginal delivery. Asymptomatic nulliparous women (n = 17) served as controls to provide reference values for pelvic floor measurements. All participants underwent 3D endovaginal and anorectal ultrasonography. We used an ultrasound score to identify and quantify the extent of PVM defects and sphincter damage and to measure levator hiatal dimensions. Incontinence was assessed using the Cleveland Clinic Florida Incontinence Scoring System. RESULTS: Defects of the PVM were identified with 3D endovaginal ultrasonography in 27% of women with faecal incontinence who had undergone vaginal delivery. The incontinence score and the ultrasound score were significantly higher in women with a PVM defect. A significant, positive correlation was found between the incontinence score and the ultrasound score. The levator hiatal dimensions were significantly greater, and the positions of the anorectal junction and bladder neck were lower, in women who had undergone vaginal delivery than in nulliparous women. CONCLUSION: As determined by the 3D ultrasound score, severity of incontinence is related to the extent of damage of the PVM, as well as of the anal sphincters. Additionally, vaginal delivery results in enlargement of the levator hiatus and a lower position of the anorectal junction and bladder neck compared with nulliparous women.

Are colon and rectal surgeons ready to screen for anal dysplasia? Results of a survey on attitudes and practice.

BACKGROUND: Colorectal surgeons are ideal referral sources to screen for and treat high-grade anal dysplasia (high-grade squamous intraepithelial lesion [HSIL]) and anal cancer. Anal cytology and high-resolution anoscopy (HRA) using acetic acid and magnification are optimal methods for screening. We endeavored to determine US colorectal surgeons' attitudes and practices regarding HSIL screening. METHODS: An Internet-based survey with questions related to clinician demographics and attitudes and practices regarding anal dysplasia was sent to US members of the American Society of Colon and Rectal Surgeons. RESULTS: Of 1655 requests, 290 (18%) eligible participants responded. Most were white (83%), male (76%), board-certified colorectal surgeons (89%), and graduating medical school after 1990 (54%), almost all treated patients at risk for anal cancer and had read research on HSIL. Approximately one-third of respondents had performed anal cytology, and one-third had performed HRA. When evaluating patients for HSIL in surgery, only 31% use acetic acid with magnification. Of 99 participants who perform HRA, 46% were formally trained, 83% primarily do HRA primarily in the operating room, and 82% use acetic acid with magnification. Knowledge of HSIL risk factors was not associated with screening. Women, more recent graduates, and surgeons with higher percentages of HIV-infected patients were more likely to screen. Screening barriers included no training (52%), not a priority (23%), lack of evidence (21%), and cost (8%). CONCLUSIONS: American Society of Colon and Rectal Surgeons members responding to the survey by and large do not screen for anal dysplasia. Those that do are often not formally trained and use inadequate technique.

Anal sphincter repair with muscle progenitor cell transplantation: serial assessment with iron oxide-enhanced MRI.

OBJECTIVE: The purpose of this study was to assess homing of ultrasmall superparamagnetic iron oxide (USPIO)-labeled muscle progenitor cells in an experimental rabbit model of anal sphincter repair using MRI. MATERIALS AND METHODS: Twelve rabbits underwent external anal sphincterotomy and randomly received injection of either autologous muscle progenitor cells labeled with USPIO at a concentration of 4 mg/10(6) cells (experimental group) or saline (control group) at the site of sphincter damage. In vivo MRI, electromyography, and manometry were performed before, 1 hour after, and 1, 2, and 4 weeks after the injection. At the end time point, anal sphincter sections were obtained for histologic analysis. Semiquantitative analysis of fibrosis, desmin, iron, CD3, and CD68 was performed using two microscopic fields in two distinct regions of the sphincter according to either presence (zone I) or absence (zone II) of signal loss on the corresponding MR images. RESULTS: Labeling efficiency was 88.67% and did not influence cell viability. On follow-up images of the cell-transplanted rabbits, significant influence was reported at 1 hour, 1 and 2 weeks after transplantation. The maximum signal loss was detected at 1 hour (75.7%). Regenerating myofibers stained positively for desmin and mainly correlated to zone I on MR images. Clusters of iron-positive particles were detectable in the myofibers located mainly at the site of injection, which correlated well to zone I. Significant signal loss and Perls Prussian blue-positive area were not detected in the control group. Functional studies showed significant improvement in sphincter pressure and electrical activity in the experimental group after 4 weeks (p<0.001). CONCLUSION: Our results support the potential of iron oxide-enhanced MRI for serial monitoring of transplanted cells in an animal model of anal sphincter repair.

Transanal minimal invasive surgery with the Endorec(TM) trocar: a low cost but effective technique.

PURPOSE: Transanal endoscopic microsurgery (TEM) is a well-established surgical approach for local excision of benign adenomas and early-stage rectal cancer. This technique is expensive and associated with a long learning curve. To avoid these obstacles, we have developed an alternative approach using the Endorec(TM) trocar (Aspide, France), which combines the advantages of local transanal excision and single-port access. The aim of this study was to evaluate the feasibility of this technique. PATIENTS AND METHODS: Fourteen consecutive patients underwent transanal resection using Endorec trocar and standard laparoscopic instruments. A retrospective evaluation of the outcome of this technique was performed. RESULTS: Fourteen patients were successfully operated. Rectal lesions included adenoma in ten patients, T1 adenocarcinoma in three and one T2 adenocarcinoma not amenable for abdominal surgery. The average distal margin from the anal verge was 10 cm (range 5-17 cm), and the mean diameter was 3.5 cm (range 1-5 cm). Negative margins were obtained in 13 patients (92,8 %). Median operating time was 60 min (range 20-100). The excisional area was sutured in nine patients. Median postoperative stay was 4 days (range 1-13). Postoperative complications (21 %) included postoperative fever in one patient and two patients were readmitted with rectal blood loss 6 and 15 days postoperatively and were treated with conservative measures. CONCLUSIONS: Our current data show that transanal surgery using Endorec trocar is feasible and safe. Although long-term outcomes and definite indications should be yet evaluated, we believe that this new technique offers a promising alternative to TEM.

An MRI-based assessment of standard and extralevator abdominoperineal excision specimens: time for a patient tailored approach?

BACKGROUND: The extralevator abdominoperineal excision (ELAPE) has been proposed as oncologically superior to standard abdominoperineal excision (SAPE). However, little is known regarding comparative margins achieved in ELAPE and SAPE. The purpose of this study was to compare patterns of tissue removal between these two groups that can aid patient selection. METHODS: Twenty APE specimens, comprising 10 SAPEs and 10 ELAPEs, were selected randomly from a single UK centre. Transverse slices of pathological specimens were matched to corresponding axial MRI images obtained from conventional pelvic MRI imaging. Measurements from the muscularis propria to the resection margin [muscularis to margin (MTM) distance] were recorded by height (from anal verge) and quadrant for each surgical group. MTM distances achieved on histopathological assessment were also compared to MRI assessed distances necessary to achieve a clear CRM. RESULTS: ELAPE specimens had a greater mean MTM distance than for SAPE (7.75 vs. 5.61 mm, p = 0.02). ELAPE had significantly greater MTM distances in lateral and posterior quadrants (p < 0.05) than SAPE at 30-49 mm. There was no significant difference in mean anterior distances (1.57 vs. 1.16 mm, p = 0.507) with the smallest difference at a height of 60-69 mm. Two (2 %) of pathological MTM distances within ELAPE group failed to achieve the minimum MRI assessed distance compared with 30 (23 %) in the SAPE group, which had higher CRM positivity. CONCLUSIONS: ELAPE appears to confer oncological benefit over SAPE but with notable exceptions, including tumours located above and below the puborectalis sling and anteriorly at the level of prostate where exenteration may be more appropriate.

Safety assessment of myogenic stem cell transplantation and resulting tumor formation.

OBJECTIVES: To assess for stem cell migration to liver and lung after transplantation in injured rat anal sphincters. To evaluate histological findings of unanticipated ectopic foci of growth. METHODS: This is a prospective study involving 33 female virginal Sprague-Dawley rats. Anal sphincters were transected and repaired under sterile technique. Animals received injections of 5.0 × 10 myogenic stem cells (24 rats) or sham control (9 rats) and were killed on day 30. Liver and lung samples were obtained. Upon encountering abnormal foci of growth, further staining protocols were employed. Enzyme-linked immunosorbent assay studies evaluated stem cell media for in vitro growth factor secretion. RESULTS: No evidence of cell migration to liver or lung was found at the time of euthanasia in any study animal. Ectopic foci of growth were noted in 2 transplant rats. Further histological evaluations of these growths were consistent with benign tumors: no nuclear abnormalities and no evidence of proliferation at day 30. Enzyme-linked immunosorbent assay studies demonstrated positive secretion of vascular endothelial growth factor and insulin growth factor into the media of cultured rat myogenic stem cells. CONCLUSIONS: Whereas distant migration was not encountered in the liver or lung, 2 transplanted rats developed abnormal foci of growth, that is, tumors, from the external anal sphincter-raising further safety questions. Additional evaluation of these foci seemed benign. Possible explanations include cell trapping, stem cell overgrowth, and/or paracrine factors. The lack of cell migration supports that future investigation of safety parameters could focus locally.