Prediction of disease recurrence or residual disease after primary endoscopic resection of pT1 colorectal cancer-results from a large nationwide Danish study.

PURPOSE: Risk assessment of disease recurrence in pT1 colorectal cancer is crucial in order to select the appropriate treatment strategy. The study aimed to develop a prediction model, based on histopathological data, for the probability of disease recurrence and residual disease in patients with pT1 colorectal cancer. METHODS: The model dataset consisted of 558 patients with pT1 CRC who had undergone endoscopic resection only (n = 339) or endoscopic resection followed by subsequent bowel resection (n = 219). Tissue blocks and slides were retrieved from Pathology Departments from all regions in Denmark. All original slides were evaluated by one experienced gastrointestinal pathologist (TPK). New sections were cut and stained for haematoxylin and eosin (HE) and immunohistochemical markers. Missing values were multiple imputed. A logistic regression model with backward elimination was used to construct the prediction model. RESULTS: The final prediction model for disease recurrence demonstrated good performance with AUC of 0.75 [95% CI 0.72-0.78], HL chi-squared test of 0.59 and scaled Brier score of 10%. The final prediction model for residual disease demonstrated medium performance with an AUC of 0.68 [0.63-0.72]. CONCLUSION: We developed a prediction model for the probability of disease recurrence in pT1 CRC with good performance and calibration based on histopathological data. Together with lymphatic and venous invasion, an involved resection margin (0 mm) as opposed to a margin of ≤ 1 mm was an independent risk factor for both disease recurrence and residual disease.

Outcomes after transanal proctectomy with ileal pouch-anal anastomosis in adolescents.

PURPOSE: The aim of this study was to describe our initial surgical and functional outcomes of transanal ileal pouch anastomosis (Ta-IPAA) in adolescents. METHODS: A total of 16 adolescents' age ≤ 19 underwent consecutive Ta-IPAA on the indication ulcerative colitis (UC) or familiar adenomatous polyposis (FAP), between January 2018 and September 2022. Primary outcomes were postoperative complications. Secondary outcomes were conversion rates, intraoperative complications, length of hospital stay (LOS), morbidity within 30 days, surgical characteristics, and functional outcomes. RESULTS: Thirteen adolescents with UC and three with FAP underwent Ta-IPAA. The median age of UC patients was 16. They had a colectomy on the indication UC followed by a Ta-IPAA. Median operating time was 247 min, and there were no conversion or intraoperative complications. Median LOS was 7 days. No anastomotic leakage was observed, and three patients had complications within the first 30 days. Three had late complications. The median bowel movements were 5, and 50% had bowel movements during the night. Three children were operated on the indication FAP with proctocolectomy and Ta-IPAA. There were no conversion or intraoperative complications, and the median bowel movements was 4. CONCLUSION: Ta-IPAA approach in children seems to be feasible, safe and offers acceptable functional results.

Completion total mesorectal excision following transanal endoscopic microsurgery does not compromise outcomes in patients with rectal cancer.

BACKGROUND: Transanal endoscopic microsurgery (TEM) represents a choice of treatment in patients with neoplastic lesions in the rectum. When TEM fails, completion total mesorectal excision (cTME) is often required. However, a concern is whether cTME increases the rate of abdominoperineal resections (APR) and is associated with higher risk of incomplete mesorectal fascia (MRF) resection. The aim of this study was to compare outcomes of cTME with primary TME (pTME) in patients with rectal cancer. METHODS: This was a nationwide study on all patients with cTME from the Danish Colorectal Cancer Group database between 2005 and 2015. Patients with cTME were compared to patients with pTME after propensity score matching (matching ratio 1:2). Matching variables were age, gender, tumor distance from anal verge, American Society of Anesthesiologists (ASA) score and American Joint Committee on Cancer (AJCC) stage. RESULTS: A total of 60 patients with cTME were compared with 120 patients with pTME. Patients with cTME experienced more intraoperative complications as compared to pTME patients (18.3% vs. 6.7%, p = 0.021). However, there was no difference in the rate of perforations at or near the tumor/previous TEM site (6.7% vs. 2.5%, p = 0.224), conversion to open surgery (p = 0.733) or 30-day morbidity (p = 0.86). On multivariate analysis, cTME was not a risk factor for APR (OR 2.49; 95% CI 0.95-6.56; p = 0.064) or incomplete MRF (OR 1.32; 95% CI 0.48-3.63; p = 0.596). There was no difference in the rate of local recurrence between cTME and pTME (5.2% vs. 4.3%, p = 0.1), distant metastases (6.8% vs. 6.8%, p = 1), or survival (p = 0.081). The mean follow-up time was 6 years. CONCLUSION: In our study, the largest so far on the subject, we find no difference in postoperative short- or long-term outcomes between cTME and pTME.

Evaluation of midterm outcomes after Shone's complex surgery: Analysis of reoperation and mortality risk factors.

OBJECTIVE: The midterm results of patients who underwent biventricular repair surgery for Shone's complex were examined, and mortality and reoperation risk factors were evaluated. METHODS: This retrospective study included 34 patients with Shone's complex who underwent mitral valve (MV) surgery between 2005 and 2020. RESULTS: A total of 19 patients (56%) had coarctation, 10 (29%) patients had subaortic stenosis, 9 (26.5%) patients had a hypoplastic aortic arch (AA), and 9 (26.5%) patients had aortic valve (AV) stenosis. Twenty-four (70.6%) patients had bileaflet AV. Associated left-sided in-flow stenotic lesions included parachute MV in 19 (56%) patients and supramitral ring in 18 (53%) patients. The estimated freedom from reoperation rate on the 6th month, 1 year and 2 years after surgery was 84.4%, 79.5%, and 71.5%, respectively. The overall mortality rate was 20.6% (seven patients) with a median follow-up of 10 months (0-41). The estimated survival rate on the 6th month, 1 year, and 3 years after surgery was 83.8%, 79.4%, and 79.4 respectively. Bicuspid aortic valve (p = .017) (HR (95% CI) = 0.130 (0.025-0.695) and hammock mitral valve (p = .038) (HR (95% CI) = 11,008 (1,146->100) were associated with mortality. CONCLUSION: The presence of a bicuspid aortic valve hammock mitral valve might have an effect on negative effect on the outcome.

Short-term outcomes after transanal total mesorectal excision for rectal cancer in Denmark - a prospective multicentre study.

AIM: The aim of this study was to evaluate the short-term surgical and oncological outcomes after transanal total mesorectal excision (TaTME) for rectal cancer during the implementation phase of this procedure in Denmark. METHOD: This is a retrospective review of prospectively recorded data. Registration was initiated by the Scientific Council of the Danish Colorectal Cancer Group (DCCG.dk) in order to assess the quality of care during the implementation of TaTME. Pre-, intra- and postoperative data including early recurrences were recorded at the operating centres. RESULTS: From August 2016 to April 2019, 115 TaTME procedures were registered. Patients were predominantly male (74%) with mid-rectal (88%) tumours. The level of surgical complications was comparable to previous nationwide results. Anastomotic leakage occurred in 6/109 (5.5%). One urethral injury occurred. The plane of dissection was mesorectal in 60% of cases, intramesorectal in 28% and muscularis in 12%. Nonmicroradicality was seen in 8% (R1, 6%; R2, 2%). Four local recurrences occurred after a median of 23 months of follow-up. One of these was multifocal. CONCLUSION: In an implementation phase where patient selection is expected, surgical and oncological results after TaTME were comparable to those of other approaches reported in the literature.

Malignant colorectal polyps: endoscopic polypectomy and watchful waiting is not inferior to subsequent bowel resection. A nationwide propensity score-based analysis.

BACKGROUND AND AIMS: The optimal treatment of patients with malignant colorectal polyps is unsettled. The surgical dilemma following polypectomy is selecting between watchful waiting (WW) and subsequent bowel resection (SBR), but the long-term survival outcomes have not been established yet. This nationwide study compared survival of patients after WW or SBR. METHODS: Danish nationwide study with 100% follow-up of all patients with malignant colorectal polyps (the Danish Colorectal Cancer Group database) in a 10-year period from 2001 to 2011. All patients' charts and histological reports were individually reviewed. Survival rates were calculated with Cox proportional hazard model after propensity score matching. RESULTS: A total of 692 patients were included (WW, 424 (61.3%), SBR, 268 (38.7%)) with a mean follow-up of 7.5 years (3-188 months). Following propensity score matching, there was no significant difference in overall or disease-free survival (p = 0.344 and p = 0.184) or rate of local recurrence (WW, 7.2%, SBR, 2%, p = 0.052) or distant metastases (WW, 3.3%, SBR, 4.6%, p = 0.77). In the SBR group, there was no residual tumor or lymph node metastases in the resected specimen in 82.5% of the patients. CONCLUSION: Subsequent bowel resection may not be superior to endoscopic polypectomy and watchful waiting with regard to overall and disease-free survival in patients with malignant colorectal polyps.

Comparison of single-port and conventional laparoscopic abdominoperineal resection.

BACKGROUND: Within the last two decades, surgical treatment of colorectal cancer has changed dramatically from large abdominal incisions to minimal access surgery. In the recent years, single port (SP) surgery has spawned from conventional laparoscopic surgery. The purpose of this study was to compare conventional with SP laparoscopic abdominoperineal resection (LAPR) for rectal cancer. PATIENTS AND METHODS: This was a single-center non-randomised retrospective comparative study of prospectively collected data on 53 patients who underwent abdominoperineal resection for low rectal cancer; 41 with conventional laparoscopy and 12 with SP surgery. RESULTS: Patients' characteristics were in general comparable, but patients in the conventional laparoscopy-group had a significantly higher American Society of Anesthesiologists-score. The operative time was slightly shorter in the conventional laparoscopy-group, but no differences were found in oncological margins of the resected specimen, in length of stay or readmission rate. CONCLUSIONS: SP LAPR appeared to be safe and feasible in selected patients. Adequate oncologic resections can be performed with acceptable morbidity and mortality. Larger randomised controlled trials with longer follow-up are needed to determine the beneficial role of this new procedure.

Increased perirenal fat area is not associated with adverse outcomes after laparoscopic total mesorectal excision for rectal cancer.

INTRODUCTION: Intraabdominal visceral obesity may increase technical challenges during laparoscopic rectal resection and hypothetically therefore increase the risk of perioperative complications. The aim of this study was to analyze intraabdominal obesity by means of perirenal fat against risk of adverse outcomes in patients undergoing laparoscopic rectal cancer surgery. METHODS: This study was a single-institution retrospective analysis of consecutive patients undergoing laparoscopic total mesorectal surgery for rectal cancer between January 2009 and January 2013. Abdominal CT scans with intravenous contrast were assessed in a blinded manner to estimate the perirenal fat area (cm2). RESULT: A total of 195 patients were included (median age 70 years (range 27-87), 58 women and 137 men) for analysis. There was a moderate correlation between BMI and perirenal fat area (r = 0.499, p = 0.001). Perirenal fat area was not associated with any of the measured adverse outcomes. Patients with BMI ≥ 30 had significantly higher intraoperative blood loss (191 mL, p = 0.001). CONCLUSION: Perirenal fat area was not an important predictor of adverse outcomes in patients undergoing laparoscopic rectal cancer surgery.

Inadvertent Splenectomy During Resection for Colorectal Cancer Does Not Increase Long-term Mortality in a Propensity Score Model: A Nationwide Cohort Study.

BACKGROUND: Previous studies suggest that long-term mortality is increased in patients who undergo splenectomy during surgery for colorectal cancer. The reason for this association remains unclear. OBJECTIVE: The purpose of this study was to investigate the association between inadvertent splenectomy attributed to iatrogenic lesion to the spleen during colorectal cancer resections and long-term mortality in a national cohort of unselected patients. DESIGN: This was a retrospective, nationwide cohort study. SETTINGS: Data were collected from the database of the Danish Colorectal Cancer Group and merged with data from the National Patient Registry and the National Pathology Databank. PATIENTS: Danish patients with colorectal cancer undergoing curatively intended resection between 2001 and 2011 were included in the study. MAIN OUTCOME MEASURES: The primary outcome was long-term mortality for patients surviving 30 days after surgery. Secondary outcomes were 30-day mortality and risk factors for inadvertent splenectomy. Multivariable and propensity-score matched Cox regression analyses were used to adjust for potential confounding. RESULTS: In total, 23,727 patients were included, of which 277 (1.2%) underwent inadvertent splenectomy. There was no association between inadvertent splenectomy and long-term mortality (adjusted HR = 1.15 (95% CI, 0.95-1.40); p = 0.16) in the propensity score-matched model, whereas 30-day mortality was significantly increased (adjusted HR = 2.31 (95% CI, 1.71-3.11); p < 0.001). Inadvertent splenectomy was most often seen during left hemicolectomy (left hemicolectomy vs right hemicolectomy: OR = 24.76 (95% CI, 15.30-40.06); p < 0.001). LIMITATIONS: This study was limited by its retrospective study design and lack of detailed information on postoperative complications. CONCLUSIONS: Inadvertent splenectomy during resection for colorectal cancer does not seem to increase long-term mortality. The previously reported reduced overall survival after inadvertent splenectomy may be explained by excess mortality in the immediate postoperative period.

Pre-analytical variables of circulating cell-free nucleosomes containing 5-methylcytosine DNA or histone modification H3K9Me3.

AIM: To evaluate pre-analytical variables of circulating cell-free nucleosomes containing 5-methylcytosine DNA (5mC) or histone modification H3K9Me3 (H3K9Me3). MATERIALS AND METHODS: Six studies were designed to assess the possible influence of pre-analytical variables. Study 1: influence of stasis and contamination with white-cells and platelets. Study 2: influence of within-day variations. Study 3: influence of day-to-day variation. Study 4: influence of temperature during handling and storage, and of neoplastic disease. Study 5: influence of colonoscopy. Study 6: influence of the surgical trauma. 5mC and H3K9Me3 measurements were performed using enzyme-linked immunosorbent assays. RESULTS: Stasis, white-cell and platelet contamination, within-day variations, varying storage time before centrifugation, colonoscopy, and surgical trauma had no significant influence on levels of 5mC or H3K9Me3. Day-to-day variations of 12.7% and 11.5% (intra-individual) and 98.1% and 60.8% (inter-individual) were shown for 5mC and H3K9Me3, respectively. Levels of 5mC or H3K9Me3 were significantly higher in samples stored at room temperature until centrifugation compared to samples stored on ice. Patients with cancer had significantly lower levels of 5mC or H3K9Me3 compared to levels in healthy individuals. CONCLUSION: Levels of 5mC or H3K9Me3 appear stable in most pre-analytical settings if blood samples are stored at room temperature until centrifugation.

A Comparative Study of Single-Port Laparoscopic Surgery Versus Robotic-Assisted Laparoscopic Surgery for Rectal Cancer.

INTRODUCTION: Conventional laparoscopic surgery is the treatment of choice for many abdominal procedures. To further reduce surgical trauma, new minimal invasive procedures such as single-port laparoscopic surgery (SPLS) and robotic assisted laparoscopic surgery (RALS) have emerged. The aim of this study was to compare the early results of SPLS versus RALS in the treatment of rectal cancer. METHODS: We performed a retrospective analysis of prospectively collected data on patients who had undergone SPLS (n = 36) or RALS (n = 56) in the period between 2010 and 2012. Operative and short-term oncological outcomes were compared. RESULTS: The RALS group had fewer patients with low rectal cancer and more patients with mid-rectal tumors (P = .017) and also a higher rate of intraoperative complications (14.3% vs 0%, P = .021). The rate of postoperative complications did not differ (P = .62). There were no differences in circumferential resection margins, distal resection margins, or completeness of the mesorectal fascia. The RALS group had a larger number of median harvested lymph nodes (27 vs 13, P = .001). The SPLS group had fewer late complications (P = .025). There were no locoregional recurrences in either of the groups. There was no difference in median follow-up time between groups (P = .58). CONCLUSION: Both SPLS and RALS may have a role in rectal surgery. The short-term oncological outcomes were similar, although RALS harvested more lymph nodes than the SPLS procedure. However, SPLS seems to be safer with regard to intraoperative and late postoperative complications.

Determinants of recurrence after intended curative resection for colorectal cancer.

Despite intended curative resection, colorectal cancer will recur in ∼45% of the patients. Results of meta-analyses conclude that frequent follow-up does not lead to early detection of recurrence, but improves overall survival. The present literature shows that several factors play important roles in development of recurrence. It is well established that emergency surgery is a major determinant of recurrence. Moreover, anastomotic leakages, postoperative bacterial infections, and blood transfusions increase the recurrence rates although the exact mechanisms still remain obscure. From pathology studies it has been shown that tumors behave differently depending on their location and recur more often when micrometastases are present in lymph nodes and around vessels and nerves. K-ras mutations, microsatellite instability, and mismatch repair genes have also been shown to be important in relation with recurrences, and tumors appear to have different mutations depending on their location. Patients with stage II or III disease are often treated with adjuvant chemotherapy despite the fact that the treatments are far from efficient among all patients, who are at risk of recurrence. Studies are now being presented identifying subgroups, in which the therapy is inefficient. Unfortunately, only few of these facts are implemented in the present follow-up programs. Therefore, further research is urgently needed to verify which of the well-known parameters as well as new parameters that must be added to the current follow-up programs to identify patients at risk of recurrence.

The short-term outcomes of conventional and single-port laparoscopic surgery for rectal cancer: a comparative non-randomized study.

BACKGROUND: Single-port laparoscopic surgery (SPLS) has evolved as an alternative method to conventional laparoscopic surgery (CLS). The aim of this study is to evaluate the results of SPLS compared to CLS in the treatment of rectal cancer. MATERIAL AND METHODS: Prospectively collected data of patients who had undergone either CLS (n = 194) or SPLS (n = 36) for rectal cancer in the period between 2009 and 2012 were retrospectively analyzed. RESULTS: Median operative time was higher in patients with SPLS (p = 0.01), but the median operative blood loss was significantly lower (p = 0.006). No significant difference was found in intraoperative- (p = 0.14) or postoperative complication rate (p = 0.4) or 30-day mortality (p = 0.62). A tendency towards fewer late complications in the SPLS-group was seen (11.1% vs. 25.3%), but the difference was not significant (p = 0.084). CONCLUSION: SPLS for rectal cancer is a safe method in a selected group of patients. Further studies are needed to confirm the benefits of SPLS. Operative time is longer, but the intraoperative blood loss is reduced.

Effect of melatonin in patients with low anterior resection syndrome (MELLARS): a study protocol for a randomised, placebo-controlled, crossover trial.

INTRODUCTION: After rectal cancer surgery, a majority of patients suffer from sequelae known as low anterior resection syndrome (LARS). It is a collection of symptoms consisting of flatus and/or stool incontinence, evacuation frequency, re-evacuation and urgency. The circadian hormone, melatonin, has shown to possess anti-inflammatory properties, and in high doses, it reduces bowel movements. The aim of the study is to investigate if locally administered melatonin has an alleviating effect on LARS. Secondarily, the effect of melatonin on bowel movements, other patient-reported symptoms, quality of life, depression, anxiety, sleep disturbances, motilin levels and rectal mucosa histology will be examined. METHODS AND ANALYSIS: This is a randomised, placebo-controlled, double-blinded, two-period crossover trial. The participants are randomised to 28 days of 25 mg melatonin administered rectally via an enema daily (or placebo) followed by a 28-day washout and then 28 days of placebo (or melatonin). Three participants will be included in an internal feasibility test. They will receive 25 mg of melatonin daily for 28 days. Data from these participants will be used to assess the feasibility of the rectally administered melatonin and to analyse the course of recruitment and outcome measurements. Afterwards, 18 participants will be included in the crossover trial. The severity of the LARS symptoms will be evaluated using the LARS Score on the first and last day of each treatment period. ETHICS AND DISSEMINATION: The Regional Ethics Committee, the Danish Medicines Agency and the Data and Development Support in Region Zealand approved this study. The study will be performed according to the Helsinki II declaration. Written informed consent will be obtained from all participants. The results of the study will be submitted to peer-reviewed journals for publication and presented at congresses. TRIAL REGISTRATION NUMBERS: EudraCT Registry (2020-004442-11) and ClinicalTrial.gov Registry (NCT05042700).

Long-term outcomes after transanal total mesorectal excision for rectal cancer in Denmark: A prospective multicenter study from the late implementation phase.

PURPOSE: The aim of this study was to evaluate the long-term surgical and oncological outcomes after transanal total mesorectal excision (TaTME) for rectal cancer during an implementation phase on a national level. METHOD: This is a retrospective review of prospectively recorded data. Registration was initiated by the Danish Colorectal Cancer Group in order to assess the quality of care during the implementation of TaTME in Denmark. Data from four centers were pooled for simultaneous analysis. Short-term data was available from a prior study, and long-term data regarding recurrences, chemotherapy, and mortality was collected. RESULTS: From August 2016 to April 2019, 115 TaTME procedures were registered. Patients were predominantly male (n = 85, 74%) with mid-rectal (n = 88, 77%) tumors. The overall local recurrence rate was 7.8% (n = 9) of which six patients also had systemic recurrence. Mean long-term follow-up was 59.4 months, and median time to local recurrence was 24.9 months. Local recurrences occurred predominantly among initial implementation cases. The overall mortality rate was 13% (n = 15). Of the 17 patients with recurrence, 35% (n = 6) died and developed either solely distant recurrence (n = 2, 12%) or in combination with local recurrence (n = 4, 24%). CONCLUSION: We found acceptable long-term oncological results after TaTME during the implementation phase in Denmark. There was an accumulation of local recurrences in the early phase of the study which emphasizes the importance of thorough training and proctoring when starting the approach.

Changes in serum natriuretic peptide levels after percutaneous closure of small to moderate ventricular septal defects.

Background. B-type natriuretic peptide has been shown to be a very sensitive and specific marker of heart failure. In this study, we aimed to investigate the effect of percutaneous closure of ventricular septal defects with Amplatzer septal occluders on brain natriuretic peptide levels. Methods. Between 2008 and 2011, 23 patients underwent successfully percutaneous ventricular septal defect closure in 4 cardiology centers. Brain natriuretic peptide levels were measured in nine patients (4 male, mean ages were 25.3 ± 14.3) who underwent percutaneous closure with Amplatzer occluders for membranous or muscular ventricular septal defects were enrolled in the study. Brain natriuretic peptide levels were measured one day before and one month after the closure. Patients were evaluated clinically and by echocardiography one month after the procedure. Results. Percutaneous closures of ventricular septal defects were successfully performed in all patients. There was not any significant adverse event in patients group during followup. Decrease in brain natriuretic peptide levels after closure were statistically significant (97.3 ± 78.6 versus 26.8 ± 15.6, P = 0.013). Conclusion. Brain Natriuretic Peptide levels are elevated in patients with ventricular septal defects as compared to controls. Percutaneous closure of Ventricular Septal Defect with Amplatzer occluders decreases the BNP levels.

The implementation of a standardized approach to laparoscopic rectal surgery.

BACKGROUND AND OBJECTIVES: The purpose of this study was to audit our results after implementation of a standardized operative approach to laparoscopic surgery for rectal cancer within a fast-track recovery program. METHODS: From January 2009 to February 2011, 100 consecutive patients underwent laparoscopic surgery on an intention-to-treat basis for rectal cancer. The results were retrospectively reviewed from a prospectively collected database. Operative steps and instrumentation for the procedure were standardized. A standard perioperative care plan was used. RESULTS: The following procedures were performed: low anterior resection (n = 26), low anterior resection with loop-ileostomy (n = 39), Hartmann's operation (n = 14), and abdominoperineal resection (n = 21). The median length of hospital stay was 7 days; 9 patients were readmitted There were 9 cases of conversion to open surgery. The overall complication rate was 35%, including 6 cases (90/%) of anastomotic leakages requiring reoperation. The 30-day mortality was 5%. The median number of harvested lymph nodes was 15 (range, 2 to 48). There were 6 cases of positive circumferential resection margins. The median follow-up was 9 (range, 1 to 27) months. One patient with disseminated cancer developed port-site metastasis. CONCLUSIONS: The results confirm the safety of a standardized approach, and the oncological outcomes are comparable to those of similar studies.

Single-port access laparoscopic surgery for rectal cancer: initial experience with 10 cases.

BACKGROUND: Single-port access laparoscopic surgery is emerging as a method to improve the morbidity and cosmetic benefits of conventional laparoscopic surgery and minimize the surgical trauma. However, the feasibility of this procedure in rectal surgery has not yet been determined. OBJECTIVE: This study aimed to evaluate our initial experience using single-port access in laparoscopic rectal surgery. DESIGN: This investigation was designed as a prospective clinical study. SETTINGS: The study took place in a university hospital. PATIENTS: Ten patients with nonmetastatic rectal cancer underwent rectal resections. MAIN OUTCOME MEASURES: The main outcome measures are perioperative data including intraoperative and postoperative complications, pathological outcome, length of stay, and short-term follow-up. RESULTS: The median age of the patients was 67 (range, 49-83) and the median body mass index was 23.5 kg/m (range, 20-25 kg/m). Six patients had previously had abdominal surgery. The operations were 6 low anterior resections (4 receiving diverting ileostomy), 2 anterior resections, 1 Hartmann procedure, and 1 abdominoperineal resection. The median operative time was 229 minutes (range, 185-318), and blood loss ranged from 0 to 100 mL. In 2 cases, it was necessary to add an extra 5-mm port to deal with intraoperative complications. The median hospital stay was 7 days (range, 4-14). There were no anastomotic leaks and no mortality. All of the resection margins were clear, and the circumferential resection margin was a median of 11 mm (range, 2.5-25). The median number of lymph nodes examined was 14 (range, 3-20). LIMITATIONS: This study's limitations include the lack of registration of postoperative pain, immunological parameters, and long-term clinical and oncological outcome. The small sample size makes it difficult to ascertain complication and conversion rates. CONCLUSIONS: Single-port access laparoscopic surgery for rectal cancer can be performed safely in slim patients with a small tumor. This technique can be an alternative option for selected patients in the hands of skilled laparoscopic surgeons. Prospective comparative studies are needed to determine the role for this technique approach in the future.

Scandinavian surveillance follow-up programmes in patients with malignant colorectal polyps.

INTRODUCTION: Following endoscopic removal of malignant colorectal polyps, patients may undergo completion radical resection or surveillance. The optimal surveillance strategy remains unknown. This study included colorectal departments in Scandinavian countries with a focus on follow-up periods and examination modalities for patients with endoscopically removed malignant polyps with a resection margin > 1 mm. METHODS: This study was conducted as an internet-based survey. A questionnaire was sent to all Scandinavian surgical departments performing > 20 colorectal procedures annually. Questions differed between follow-up on rectal and colonic malignant polyps with presence or absence of histological risk factors. The follow-up period was defined as short (one year), intermediate (three years) or long (five years). RESULTS: The majority of the departments used a long (five years) (38-59%) or intermediate (three years) (26-38%) follow-up programme. In patients with rectal malignant polyps and presence of histological risk factors, a significant difference was observed in the use of endoscopy according to length of follow-up. No difference in the use of the different modalities was seen according to length of follow-up in patients with colonic malignant polyps. CONCLUSIONS: The follow-up on patients with endoscopically removed malignant polyps and a surveillance strategy varies both in terms of length and performed modalities. Future studies should compare long-term patient outcomes in departments employing different follow-up strategies. FUNDING: none. TRIAL REGISTRATION: not relevant.

Laparoscopic reversal of Hartmann's procedure.

INTRODUCTION: A change in procedure from open to laparoscopic reversal of Hartmann's colostomy was implemented at our department between May 2005 and December 2008. The aim of the study was to investigate if this change was beneficial for the patients. MATERIAL AND METHODS: The medical records of all patients who underwent reversal of a colostomy after a primary Hartmann's procedure during the period May 2005 to December 2008 were reviewed retrospectively in a case-control study. RESULTS: A total of 43 patients were included. Twenty-one had a laparoscopic and 22 an open procedure. The two groups matched with regard to age, sex, American Society of Anestheologists (ASA) score, body mass index and indication for Hartmann's operation. A significantly longer operation time was found for laparoscopic than for open surgery (median 285 versus 158 minutes, p < 0.001), but with less blood loss (median 100 versus 600 ml, p < 0.001), faster return of bowel function (median three versus four days, p < 0.01) and shorter postoperative hospitalization (median four versus six days, p < 0.01). No intraoperative complications occurred. One laparoscopic operation was converted (5%). There was no difference in postoperative complications between the two groups (10 versus 14%), and no anastomotic leaks. The total mortality was 2% as one patient died postoperatively after an open operation. CONCLUSION: It is possible for trained laparoscopic colorectal surgeons to perform laparoscopic reversal of Hartmann's procedure as safely as in open surgery and with a faster recovery, shorter hospital stay and less blood loss despite a longer knife time. It therefore seems reasonable to offer patients a laparoscopic procedure at departments which are skilled in laparoscopic surgery and use it for standard colorectal surgery.