Surgical and postoperative evaluations of rectal adenomas excised with a rigid proctoscope

Abstract Purpose This study presents the surgical and postoperative results achieved with a rigid proctoscope using the transanal endoscopic technique to excise rectal adenomas. The results are compared to the results obtained with other currently employed transanal techniques. Methods We investigated the medical records of patients who underwent transanal endoscopic operations from April 2000 to June 2018 at two tertiary referral centers for colorectal cancer. Results This study included 99 patients. The mean age was 65.3 ± 13.3 years. The average size of the adenomas was 4.6 ± 2.3 cm, and their average distance to the anal border was 5.6 ± 3.3 cm. The average operative time was 65.3 ± 41.7 min. In 48.5% of the operations, the specimen was fragmented, and in 59.6% of the cases, the microscopic margins were free. The rates of postoperative complications and relapse were 5% and 19%, respectively. The mean follow-up was 80 ± 61.5 months. Conclusions The described proctoscope proved to be a viable technique with results similar to other techniques, with the advantage that it allowed greater accessibility for surgeons. Therefore, its use could be implemented and become widespread in surgical practice.

Quality indicators for cervical cancer care in Japan / 부인종양

OBJECTIVE: We aimed to propose a set of quality indicators (QIs) based on the clinical guidelines for cervical cancer treatment published by The Japan Society of Gynecologic Oncology, and to assess adherence to standard-of-care as an index of the quality of care for cervical cancer in Japan. METHODS: A panel of clinical experts devised the QIs using a modified Delphi method. Adherence to each QI was evaluated using data from a hospital-based cancer registry of patients diagnosed in 2013, and linked with insurance claims data, between October 1, 2012, and December 31, 2014. All patients who received first-line treatment at the participating facility were included. The QI scores were communicated to participating hospitals, and additional data about the reasons for non-adherence were collected. RESULTS: In total, 297 hospitals participated, and the care provided to 15,163 cervical cancer patients was examined using 10 measurable QIs. The adherence rate ranged from 50.0% for ‘cystoscope or proctoscope for stage IVA’ to 98.8% for ‘chemotherapy using platinum for stage IVB’. Despite the variation in care, hospitals reported clinically valid reasons for more than half of the non-adherent cases. Clinically valid reasons accounted for 75%, 90.9%, 73.4%, 44.5%, and 88.1% of presented non-adherent cases respectively. CONCLUSION: Our study revealed variations in pattern of care as well as an adherence to standards-of-care across Japan. Further assessment of the causes of variation and non-adherence can help identify areas where improvements are needed in patient care.

Desarterialización hemorroidal transanal. Una nueva alternativa quirúrgica / Transanal hemorrhoidal dearterialization. A new surgical alternative

La desarterialización hemorroidal es una técnica desarrollada en la última década, que consiste en la ligadura de la arteria hemorroidal a través de un proctoscopio que contiene un Doppler, con la subsecuente pexia de la mucosa. Objetivo: Analizar la factibilidad de la generalización de este procedimiento, mencionando sus ventajas y posibles desventajas en la utilización del mismo. Métodos: Se realizó un estudio descriptivo en el cual se incluyeron 41 pacientes (20 masculinos y 21 femeninas) en edades entre 23 y 55 años, con hemorroides II, III sintomáticas y IV sin síntomas de defecación obstruida, intervenidos en el Servicio de Cirugía 2 del Hospital Domingo Luciani y en la Unidad de Colon, Recto y Ano del Centro Clínico Leopoldo Aguerrevere, desde junio de 2012 hasta marzo de 2014. La técnica consiste en la ligadura de las ramas terminales de las arterias hemorroidales en radiales 1, 3, 5, 7,9 y 11. El tiempo promedio del procedimiento fue de 39.26 minutos. El seguimiento de los pacientes se realizó a la semana, a los quince días, al mes y a los 3 meses, valorando satisfacción de la técnica en base a dolor, reducción del prolapso y complicaciones. Resultados: Se logró el seguimiento de 41 pacientes en consulta, el 48.8% con rango de edad entre 31-40 años, 61% con hemorroides III, 27% hemorroides II y el 12% hemorroides IV. Durante el procedimiento quirúrgico se realizaron 6 pexias en el 80.5%. Los plicomas se resecaron en todos los pacientes que lo presentaban. Los síntomas referidos en los primeros 7 días en forma individual o asociado a otro síntoma fueron tenesmo 68.3%, molestia perianal en 39%, dolor moderado en 21.9%, dolor intenso en 14.6%, dolor leve y sangrado en 9.7% y trombosis en 2.4%, igualmente 14.6% no refirieron ninguna sintomatología. Al relacionar la exéresis de los plicomas con el dolor perianal observamos dolor intenso en 15.4% de los pacientes a quienes se le retiraron los plicomas y en el 25% de los pacientes a quien no se le realizó exéresis. El grado de satisfacción de la técnica en el post operatorio inmediato es bueno en 39% y muy bueno en 34%, solo fue malo en 3%. Al aplicar una escala de visualización análoga del dolor se observa una tendencia progresiva en los controles sucesivos en EVA 0-1 19.5% a los 15 días, 78% a los 30 días y 85.3% a los 90 días. En los pacientes sometidos a manometría anorrectal se evidencio un incremento en las presiones de reposo. El 83% se reintegró a sus actividades habituales en promedio a las 3 semanas del postoperatorio. No se presentaron complicaciones mayores, el prolapso de algún paquete hemorroidal se presentó en el 29.4% de los pacientes. Conclusiones: THD es un método seguro, poco invasivo, con buenos resultados para el tratamiento de pacientes, bien seleccionados, con hemorroides II, III y IV. Se deben realizar futuros ensayos controlados comparando con otros procedimientos, para demostrar la ventaja real y definir las indicaciones adecuadas realizando pruebas fisiológicas, además de llevar un control a largo plazo(AU)

Hemorrhoid dearterialisation is a technique developed in the last decade, consisting of ligation of hemorrhoidal artery through a proctoscope which contains a Doppler, with the subsequent mucosal pexy. Objective: To analyze the feasibility of the generalization of this procedure, mentioning its advantages and possible disadvantages in the use of the same. Methods: We conducted a descriptive study which included 41 patients (20 male and 21 female) ages between 23 and 55 years, with II, symptomatic III and IV haemorrhoids without symptoms of obstructed defecation, operated in the service of Surgery 2 of the Hospital Domingo Luciani and Unit of Colon, Rectum and Anus at the Centro Clínico Leopoldo Aguerrevere, from June 2012 to March 2014. The technique involves the ligation of terminal branches of the hemorrhoidal arteries in radial 1, 3, 5, 7.9 and 11. The average time of the procedure was 39.26 minutes. The follow-up of the patients was carried out a week, fifteen days, a month and three months, assessing satisfaction of the technique based on pain, reduction of prolapse and complications. Results: Were follow-up 41 patients in consultation, the 48.8% with age range between 31-40 years, 61% with hemorrhoids III, 27% hemorrhoid II and 12% hemorrhoid IV. During the surgical procedure were 6 pexy the 80.5%. The plicomas be resected in all patients presenting with it. The symptoms referred to in the first 7 days individually or associated to other symptoms were tenesmus 68.3%, 39%, moderate in 21.9 pain perianal discomfort %, severe pain in 14.6%, bleeding and mild pain in 9.7% and thrombosis in 2.4%, also 14.6% not reported any symptoms. To relate the resection of plicomas with perianal pain it was observed severe pain in 15.4% of the patients resected to 25% of patients not resected. Immediate postoperative satisfaction was good at 39 % and very good at 34 %, it was just bad at 3 %. To apply a scale of analog display of pain there is a progressive tendency in the successive controls at 0-1 19.5% at 15 days, 30 days 78% and 85.3% at 90 days. In patients undergoing anorectal manometry were demonstrated an increase in resting pressures. 83% returned to their usual activities on average at 3 weeks of the postoperative period. There were no major complications, some package hemorrhoidal prolapse was presented at the 29.4% of the patients. Conclusions: THD is a safe method, minimally invasive, with good results in the treatment of well selected patients with hemorrhoids II, III and IV. Future controlled trials comparing with other procedures, to demonstrate the real advantage and define appropriate physiological indications, as well as to control long-term studies should be performed(AU)

Early Experience of Doppler-Guided Hemorrhoidal Artery Ligation and Rectoanal Repair (DG-HAL & RAR) for the Treatment of Symptomatic Hemorrhoids

PURPOSE: This study is to introduce our preliminary experience of the Doppler-guided hemorrhoidal artery ligation and Rectoanal repair (DG-HAL & RAR) as a new treatment for symptomatic or prolapsed hemorrhoids. METHODS: A Doppler probe incorporated proctoscope was inserted under the lithotomy position and the location of the hemorrhoidal artery was identified. The identified artery was ligated as a 'figure of eight' method with an absorbable suture into the submucosa. Then the prolapsed hemorrhoidal pile was lifted at the rectal mucosa by continuous suture to 5 mm above the dentate line and tied. The procedure was repeated at the 1, 3, 5, 7, 9, and 11 o'clock positions. We evaluated post-operative hospital stay, degree of pain, time to return to work, and recurrence. RESULTS: The patient's mean age was 50.2+/-15 years old and the mean follow-up time was 415+/-75 days. The constitution of the type of internal hemorrhoids was as follows: Grade II: 13, Grade III: 16, and Grade IV: 5. The mean operation time was 35 minutes and post-operative hospital stay was 1.4 days. The mean time it took to return to work was 1.8 days. There were no severe pains requiring injection of analgesics or other severe complications. So far, 2 patients have had recurrence of symptoms. CONCLUSION: The DG-HAL & RAR is a safe and less painful procedure. The DG-HAL & RAR is an effective alternative for the treatment of symptomatic or prolapsed hemorrhoids.

Diffusion weighted imaging combined with magnetic resonance conventional sequences for the diagnosis of rectal cancer / 中国医学科学院学报

<p><b>OBJECTIVE</b>To evaluate the clinical value of diffusion weighted imaging (DWI) combined with conventional sequences of magnetic resonance imaging (T1 and T2-weighted imaging) for the diagnosis of rectal cancer.</p><p><b>METHODS</b>DWI and conventional sequences were performed in 29 patients with endoscopically diagnosed rectal cancer and 15 patients without rectal cancer. Two doctors who were blind to the history of the patients interpreted the imaging findings. The sensitivity and specificity of conventional sequences with and without DWI were analyzed using receiver operating characteristic curve (ROC).</p><p><b>RESULTS</b>The areas under ROC were 0.915 and 0.930 for conventional sequences alone, and 0.990 and 0.994 for conventional sequences with DWI, respectively, indicating that although both of them were optimal methods for the diagnosis of rectal cancer, the accuracy of conventional sequences with DWI was significantly superior to that of conventional sequence alone (P < 0.05). The Kappa value was 0.850 for conventional sequences alone and 0.858 for DWI with conventional sequences.</p><p><b>CONCLUSION</b>DWI was necessary for the diagnosis of rectal cancer when performing conventional sequences.</p>

Transanal endoscopic operation: a new proposal / Operação transanal endoscópica: uma nova proposta

PURPOSE: The transanal procedure for rectal cancer surgery is one of the many techniques currently available. Different techniques for local excision of rectal tumors include: conventional transanal technique, posterior access surgery, therapeutic colonoscopy, transanal endoscopic surgery. METHODS: The aim of the present study is to describe a new method of transanal endoscopic resection, transanal endoscopic operation (TEO), and performed with the aid of a surgical proctoscope especially designed for this purpose and report the results obtained in 32 patients submitted to the TEO and to compare these results with those obtained with other techniques currently available. The average proportions of recurrence, post-operation complications and posterior resections were analyzed by means of a metanalysis. Data on the distance and size of rectal lesions, the operative timing and hospitalization time were distributed in graphs according to authors and techniques. RESULTS: The results were favorable and equivalent to those described in the literature. CONCLUSIONS: The surgical proctoscope specially designed for this study is efficient and has a low cost; the TEO is easily performed with the aid of this equipment; the final results were favorable and similar to those obtained with other available techniques for endoscopic transanal intestinal resection, which are of high cost and less availability.

INTRODUÇÃO: A operação cirúrgica por acesso transanal no tratamento do câncer retal é uma das várias técnicas utilizadas nessa terapêutica. Há várias técnicas de excisão local para os tumores retais: O método cirúrgico transanal convencional, acessos posteriores, colonoscopia terapêutica e operações transanais endoscópicas. O objetivo é apresentar um novo método de ressecção transanal endoscópica (Operação Transanal Endoscópica - OTE), realizada com um proctoscópio cirúrgico idealizado para o procedimento e divulgar os resultados obtidos em 32 pacientes submetidos a OTE e compará-los com as técnicas atualmente empregadas. MÉTODOS: Foram analisadas as proporções médias da recorrência, das complicações pós-operatórias e das ressecções posteriores por meio da técnica de metanálise. Para a distância e o tamanho das lesões retais, os tempos de operação e de hospitalização, foram feitos gráficos de acordo com o autor e a técnica. RESULTADOS: Os resultados foram favoráveis e equiparáveis aos trabalhos analisados. CONCLUSÃO: Concluiu-se que: O proctoscópio utilizado na OTE demonstrou ser eficaz e de baixo custo; 2 - A OTE mostrou-se factível; 3 - A análise dos resultados com a OTE foram satisfatórios e similares às outras técnicas de ressecções transanais endoscópicas que são de alto custo e pouco disponíveis em nosso meio.