Colorectal cancer with synchronous unresectable liver metastases: resecting the primary tumor improves survival.

PURPOSE: The optimal treatment strategy of patients affected by colorectal cancer (CRC) with synchronous unresectable liver metastases (SULM) is at present undefined. It is not known if a palliative primary tumor resection followed by chemotherapy could have a survival benefit compared to upfront chemotherapy (CT). The aim of the study is to analyze the safety and effectiveness of both therapeutic strategies in a group of patients treated at one institution. METHODS: A prospectively collected database was queried for patients affected by colorectal cancer with synchronous unresectable liver metastases between January 2004 and December 2018, defining and comparing 2 groups: patients treated by chemotherapy alone (group 1) vs patients who underwent primary tumor resection with or without a first line chemotherapy (group 2). The primary end point was Overall Survival (OS), estimated by the Kaplan-Meier method. RESULTS: One hundred sixty-seven patients were included: 52 in group 1 and 115 in group 2, median follow-up 48 months (range 25-126). A difference of 14 months in overall survival was observed between group 2 compared to group 1 (28 vs 14 months respectively; p < 0.001). Furthermore, overall survival increased in patients who underwent liver metastases resection (p < 0.001) or percutaneous radiofrequency ablation after surgery (p < 0.001). CONCLUSION: With the limits of a retrospective analysis, the study shows that surgical resection of the primary tumor has a significant impact on survival compared to chemotherapy alone. Randomized controlled trials are needed to confirm these data.

Minimally invasive adrenalectomy for large pheochromocytoma: not recommendable yet? Results from a single institution case series.

BACKGROUND: Minimally invasive adrenalectomy represents the treatment of choice of pheochromocytoma (PCC). For large or invasive PCCs, an open approach is currently recommended, in order to ensure complete tumor resection, prevent tumor rupture, avoid local recurrence, and limit perioperative hemodynamic instability. The aim of this study is to analyze perioperative outcomes of laparoscopic adrenalectomies (LAs) for large adrenal PCCs. METHODS: All consecutive LAs for PCC performed at a single institution between 1998 and 2020 were included. Two groups were defined: lesions larger (group 1) and smaller (group 2) than 5 cm. Short-term outcomes were compared in order to find any significant difference between the two groups. OUTCOMES: One hundred fourteen patients underwent LA during the study period: 46 for lesions larger and 68 for lesions smaller than 5 cm. No significant differences were found in patients' characteristics, median operative time, conversion rate, intraoperative hemodynamic and metabolic parameters, postoperative intensive care unit (ICU) admission rate, complications rate, and length of hospital stay. Long-term oncologic outcomes were similar, with a recurrence rate of 5.1% in group 1 vs 3.6% in group 2 (p = 1). CONCLUSION: Minimally invasive adrenalectomy seems to be safe and effective even in large PCC. The recommendation to prefer an open approach for large PCCs should probably be reconsidered.

Impact of COVID-19 outbreak on esophageal cancer surgery in Northern Italy: lessons learned from a multicentric snapshot.

Coronavirus Disease-19 (COVID-19) outbreak has significantly burdened healthcare systems worldwide, leading to reorganization of healthcare services and reallocation of resources. The Italian Society for Study of Esophageal Diseases (SISME) conducted a national survey to evaluate changes in esophageal cancer management in a region severely struck by COVID-19 pandemic. A web-based questionnaire (26 items) was sent to 12 SISME units. Short-term outcomes of esophageal resections performed during the lockdown were compared with those achieved in the same period of 2019. Six (50%) centers had significant restrictions in their activity. However, overall number of resections did not decrease compared to 2019, while a higher rate of open esophageal resections was observed (40 vs. 21.7%; P = 0.034). Surgery was delayed in 24 (36.9%) patients in 6 (50%) centers, mostly due to shortage of anesthesiologists, and occupation of intensive care unit beds from intubated COVID-19 patients. Indications for neoadjuvant chemo (radio) therapy were extended in 14% of patients. Separate COVID-19 hospital pathways were active in 11 (91.7%) units. COVID-19 screening protocols included nasopharyngeal swab in 91.7%, chest computed tomography scan in 8.3% and selective use of lung ultrasound in 75% of units. Postoperative interstitial pneumonia occurred in 1 (1.5%) patient. Recovery from COVID-19 pandemic was characterized by screening of patients in all units, and follow-up outpatient visits in only 33% of units. This survey shows that clinical strategies differed considerably among the 12 SISME centers. Evidence-based guidelines are needed to support the surgical esophageal community and to standardize clinical practice in case of further pandemics.

Surgically induced weight loss effects on sexual quality of life of obese men: a prospective evaluation.

BACKGROUND: Sexual difficulties are common among obese patients, but only a few research studies have examined the relationship between obesity and sexual quality of life (QoL). The aim of this study is to investigate the efficacy of bariatric surgery to improve sexual function and related quality of life in obese men. METHODS: Prospective study including consecutive male patients undergoing bariatric surgery procedures, both sleeve gastrectomy and Roux en Y gastric bypass, between 2013 and 2017. Anthropometric parameters, biochemical and hormonal assessment and QoL questionnaires [International Index of Erectile Function (IIEF), Sexual Desire Inventory (SDI), Short Form-36 (SF-36) health survey questionnaire] were collected before and 12 months after surgery. RESULTS: 44 male patients were recruited in the study. 40/44 (90.91%) underwent a SG and 4/44 a RYGB (9.09%). Median age was 43.45 years. Waist Circumference, Hip Circumference, body weight and body mass index significantly decreased 12 months after surgery, with a median weight loss of 49 kg and a median BMI difference of 14.28 kg/m2 12 months after surgery. Basal glycaemia, HbA1c, basal insulin, triglycerides, HDL cholesterol and CRP levels significantly decreased, while FSH, total testosterone and SHBG levels significantly increased. IEEF total score was significantly higher 12 months after surgery. Univariate analysis identified SHBG, estradiol and inhibin B levels, IIEF erectile function, IIEF intercourse satisfaction, IIEF total and SF-36 physical functioning scores as significant negative predictive factors of sexual improvement. None of them reached the statistical significance in the multivariate analysis. CONCLUSIONS: Sexual impairment in morbidly obese men represents an underestimated problem, with a high prevalence in the IIEF domains in our series. Bariatric surgery represents the most effective therapy of morbid obesity, having a tremendous impact on metabolic profile, sexual function and self-perceived QoL.

Long-term oncologic outcomes following anastomotic leak after anterior resection for rectal cancer: does the leak severity matter?

BACKGROUND: The evidence regarding the impact of anastomotic leak (AL) after anterior resection (AR) for rectal cancer on oncologic outcomes is controversial, and there are no data about the prognostic relevance of the International Study Group of Rectal Cancer (ISREC) AL classification. The aim was to evaluate the oncologic outcomes in patients with AL after AR for rectal cancer. The prognostic value of the ISREC AL grading system was also investigated. METHODS: It is a retrospective analysis of a prospectively collected database including all patients undergoing curative elective AR for rectal cancer (April 1998-September 2013). AL severity was defined according to the ISREC criteria. A multivariable analysis was performed to identify predictors of poor survival. RESULTS: A total of 532 patients underwent curative AR (69% laparoscopic) for rectal cancer. The overall AL rate was 7.9%: 15 grade B and 27 grade C ALs. With a median follow-up of 80 (range 12-266) months, 5-year overall survival (OS) was 67.2% in patients with AL and 86.5% in those without AL (P = 0.001). Five-year disease-free survival (DFS) was 50.5% and 80.3%, respectively (P < 0.001). Local recurrence and distant metastases developed more frequently in AL patients (P < 0.05). Grade B AL and no administration or delay of adjuvant chemotherapy were independent predictors for poorer OS and DFS. Grade B AL independently affected also the administration of adjuvant chemotherapy. Circulating C-reactive protein levels at 2 weeks after AL treatment were higher in grade B than grade C patients (P = 0.006) and in patients with tumor relapse (P = 0.011). CONCLUSION: AL after curative AR for rectal cancer and impaired use of adjuvant chemotherapy are associated with poor survival. Postoperative systemic inflammation seems to be more sustained in grade B than that in grade C AL patients, with possible adverse impact on long-term survival.

European association for endoscopic surgery (EAES) consensus statement on single-incision endoscopic surgery.

BACKGROUND: Laparoscopic surgery changed the management of numerous surgical conditions. It was associated with many advantages over open surgery, such as decreased postoperative pain, faster recovery, shorter hospital stay and excellent cosmesis. Since two decades single-incision endoscopic surgery (SIES) was introduced to the surgical community. SIES could possibly result in even better postoperative outcomes than multi-port laparoscopic surgery, especially concerning cosmetic outcomes and pain. However, the single-incision surgical procedure is associated with quite some challenges. METHODS: An expert panel of surgeons has been selected and invited to participate in the preparation of the material for a consensus meeting on the topic SIES, which was held during the EAES congress in Frankfurt, June 16, 2017. The material presented during the consensus meeting was based on evidence identified through a systematic search of literature according to a pre-specified protocol. Three main topics with respect to SIES have been identified by the panel: (1) General, (2) Organ specific, (3) New development. Within each of these topics, subcategories have been defined. Evidence was graded according to the Oxford 2011 Levels of Evidence. Recommendations were made according to the GRADE criteria. RESULTS: In general, there is a lack of high level evidence and a lack of long-term follow-up in the field of single-incision endoscopic surgery. In selected patients, the single-incision approach seems to be safe and effective in terms of perioperative morbidity. Satisfaction with cosmesis has been established to be the main advantage of the single-incision approach. Less pain after single-incision approach compared to conventional laparoscopy seems to be considered an advantage, although it has not been consistently demonstrated across studies. CONCLUSIONS: Considering the increased direct costs (devices, instruments and operating time) of the SIES procedure and the prolonged learning curve, wider acceptance of the procedure should be supported only after demonstration of clear benefits.

The use of 3D laparoscopic imaging systems in surgery: EAES consensus development conference 2018.

BACKGROUND: The use of 3D laparoscopic systems is expanding. The European Association of Endoscopic Surgery (EAES) initiated a consensus development conference with the aim of creating evidence-based statements and recommendations for the surgical community. METHODS: Systematic reviews of the PubMed and Embase libraries were performed to identify evidence on potential benefits of 3D on clinical practice and patient outcomes. Statements and recommendations were prepared and unanimously agreed by an international surgical and engineering expert panel which were presented and voted at the EAES annual congress, London, May 2018. RESULTS: 9967 abstracts were screened with 138 articles included. 18 statements and two recommendations were generated and approved. 3D significantly shortened operative time (mean difference 11 min (8% [95% CI 20.29-1.72], I2 96%)). A significant reduction in complications was observed when 3D systems were used (RR 0.75, [95 CI% 0.60-0.94], I2 0%) particularly for cases involving laparoscopic suturing (RR 0.57 [95% CI 0.35-0.90], I2 0%). In 69 box trainer or simulator studies, 64% concluded trainees were significant faster and 62% performed fewer errors when using 3D. CONCLUSION: We recommend the use of 3D vision in laparoscopy to reduce the operative time (grade of recommendation: low). Future robust clinical research is required to specifically investigate the potential benefit of 3D laparoscopy system on complication rates (grade of recommendation: high).

EAES and SAGES 2018 consensus conference on acute diverticulitis management: evidence-based recommendations for clinical practice.

BACKGROUND: Acute diverticulitis (AD) presents a unique diagnostic and therapeutic challenge for general surgeons. This collaborative project between EAES and SAGES aimed to summarize recent evidence and draw statements of recommendation to guide our members on comprehensive AD management. METHODS: Systematic reviews of the literature were conducted across six AD topics by an international steering group including experts from both societies. Topics encompassed the epidemiology, diagnosis, management of non-complicated and complicated AD as well as emergency and elective operative AD management. Consensus statements and recommendations were generated, and the quality of the evidence and recommendation strength rated with the GRADE system. Modified Delphi methodology was used to reach consensus among experts prior to surveying the EAES and SAGES membership on the recommendations and likelihood to impact their practice. Results were presented at both EAES and SAGES annual meetings with live re-voting carried out for recommendations with < 70% agreement. RESULTS: A total of 51 consensus statements and 41 recommendations across all six topics were agreed upon by the experts and submitted for members' online voting. Based on 1004 complete surveys and over 300 live votes at the SAGES and EAES Diverticulitis Consensus Conference (DCC), consensus was achieved for 97.6% (40/41) of recommendations with 92% (38/41) agreement on the likelihood that these recommendations would change practice if not already applied. Areas of persistent disagreement included the selective use of imaging to guide AD diagnosis, recommendations against antibiotics in non-complicated AD, and routine colonic evaluation after resolution of non-complicated diverticulitis. CONCLUSION: This joint EAES and SAGES consensus conference updates clinicians on the current evidence and provides a set of recommendations that can guide clinical AD management practice.

Safety of single-incision robotic cholecystectomy for benign gallbladder disease: a systematic review.

BACKGROUND: Multiport laparoscopic cholecystectomy (MLC) is the gold standard technique for cholecystectomy. In order to reduce postoperative pain and improve cosmetic results, the application of the single-incision laparoscopic cholecystectomy (SILC) technique was introduced, leading surgeons to face important challenges. Robotic technology has been proposed to overcome some of these limitations. The purpose of this review is to assess the safety of single-incision robotic cholecystectomy (SIRC) for benign disease. METHODS: An Embase and Pubmed literature search was performed in February 2017. Randomized controlled trial and prospective observational studies were selected and assessed using PRISMA recommendations. Primary outcome was overall postoperative complication rate. Secondary outcomes were postoperative bile leak rate, total conversion rate, operative time, wound complication rate, postoperative hospital stay, and port site hernia rate. The outcomes were analyzed in Forest plots based on fixed and random effects model. Heterogeneity was assessed using the I2 statistic. RESULTS: A total of 13 studies provided data about 1010 patients who underwent to SIRC for benign disease of gallbladder. Overall postoperative complications rate was 11.6% but only 4/1010 (0.4%) patients required further surgery. A postoperative bile leak was reported in 3/950 patients (0.3%). Conversion occurred in 4.2% of patients. Mean operative time was 86.7 min including an average of 42 min should be added as for robotic console time. Wound complications occurred in 3.7% of patients. Median postoperative hospital stay was 1 day. Port site hernia at the latest follow-up available was reported in 5.2% of patients. CONCLUSIONS: The use of the Da Vinci robot in single-port cholecystectomy seems to have similar results in terms of incidence and grade of complications compared to standard laparoscopy. In addition, it seems affected by the same limitations of single-port surgery, consisting of an increased operative time and incidence of port site hernia.

Preoperative stoma site marking: a simple practice to reduce stoma-related complications.

BACKGROUND: To evaluate the incidence and identify the risk factors of stoma-related complications in a consecutive series of patients treated at a single institution. METHODS: For this retrospective analysis, the medical records of patients followed up at the stoma care centre of our institution over the last 16 years were reviewed. The primary end point was the incidence of stoma-related complications. Risk factors were tested using univariate and multivariate Cox proportional hazards models. RESULTS: Of a total of 1076 patients, 604 received a colostomy and 472 an ileostomy. In all, 1055 stoma-related complications were recorded in 797 patients. Univariate analysis identified the following risk factors for stoma-related complications: male sex (p = 0.032), emergency surgery (p = 0.010), open surgery (p < 0.001), and ileostomy creation (p = 0.004). Preoperative stoma site marking was noted to play a protective role (hazard ratio 0.739; 95% confidence interval 0.576-0.947; p = 0.017). Multivariate analysis confirmed male sex and ileostomy creation as risk factors (p = 0.030 and p = 0.013, respectively) and preoperative stoma site marking as an independent protective factor (p = 0.001). CONCLUSIONS: Stoma-related complications are quite common, especially when an ileostomy is present. Preoperative stoma site marking was noted to play a highly protective role not only in reducing the complication rate but also in improving the patients' quality of life.

Cost analysis of laparoendoscopic rendezvous versus preoperative ERCP and laparoscopic cholecystectomy in the management of cholecystocholedocholithiasis.

BACKGROUND: Evidence from controlled trials and meta-analyses suggests that laparoendoscopic rendezvous (LERV) is preferable to sequential treatment in the management of common bile duct stones. MATERIALS AND METHODS: With this retrospective analysis of a prospective database that included consecutive patients treated for cholecystocholedocholithiasis at our institution between January 2007 and July 2015, we compared LERV with sequential treatment. The primary endpoint was global cost, defined as the cost/patient/hospital stay, and the secondary end points were efficacy and morbidity. Fisher's exact test or Mann-Whitney test was used. RESULTS: Of a total of 249 consecutive patients, 143 underwent LERV (group A) and 106 a two-stage procedure (group B). Based on an average cost of €613 for 1 day of hospital stay in the General Surgery Department, the overall median cost of treatment was €6403 for group A and €8194 for group B (p < 0.001). Operative time was significantly shorter (p < 0.001), and length of hospital stay was significantly longer for group B (p < 0.001). No mortality in either group was observed. The postoperative complications rate was significantly higher in group B than in group A (24.5 vs. 10.5%; p = 0.003). No significant difference in the postoperative pancreatitis rate or the number of patients with increased serum amylase at 24 h was observed in either group. CONCLUSION: Our study suggests that LERV is preferable to sequential treatment not only in terms of less morbidity, but also of lower costs accrued by a shorter hospital stay. However, the longer operative time raises multiple organizational issues in the coordination of surgery and endoscopy services.

Total mesorectal excision using a soft and flexible robotic arm: a feasibility study in cadaver models.

BACKGROUND: Sponsored by the European Commission, the FP7 STIFF-FLOP project aimed at developing a STIFFness controllable Flexible and Learn-able manipulator for surgical operations, in order to overcome the current limitations of rigid-link robotic technology. Herein, we describe the first cadaveric series of total mesorectal excision (TME) using a soft and flexible robotic arm for optic vision in a cadaver model. METHODS: TME assisted by the STIFF-FLOP robotic optics was successfully performed in two embalmed male human cadavers. The soft and flexible optic prototype consisted of two modules, each measuring 60 mm in length and 14.3 mm in maximum outer diameter. The robot was attached to a rigid shaft connected to an anthropomorphic manipulator robot arm with six degrees of freedom. The controller device was equipped with two joysticks. The cadavers (BMI 25 and 28 kg/m2) were prepared according to the Thiel embalming method. The procedure was performed using three standard laparoscopic instruments for traction and dissection, with the aid of a 30° rigid optics in the rear for documentation. RESULTS: Following mobilization of the left colonic flexure and division of the inferior mesenteric vessels, TME was completed down to the pelvic floor. The STIFF-FLOP robotic optic arm seemed to acquire superior angles of vision of the surgical field in the pelvis, resulting in an intact mesorectum in both cases. Completion times of the procedures were 165 and 145 min, respectively. No intraoperative complications occurred. No technical failures were registered. CONCLUSIONS: The STIFF-FLOP soft and flexible robotic optic arm proved effective in assisting a laparoscopic TME in human cadavers, with a superior field of vision compared to the standard laparoscopic vision, especially low in the pelvis. The introduction of soft and flexible robotic devices may aid in overcoming the technical challenges of difficult laparoscopic procedures based on standard rigid instruments.

Laparoscopic colon resection: To prep or not to prep? Analysis of 1535 patients.

BACKGROUND: Mechanical bowel preparation (MBP) before elective open colon resection does not reduce the rate of postoperative anastomotic leakage. However, MBP is still routinely used in many countries, and there are very limited data regarding the utility of preoperative MBP in patients undergoing laparoscopic colon resection (LCR). The aim of this study was to challenge the use of MBP before elective LCR. METHODS: It is a retrospective analysis of a prospectively collected database. All patients undergoing elective LCR with primary anastomosis and no stoma were included. Preoperative MBP with polyethylene glycol solution was used routinely between April 1992 and December 2004, and then it was abandoned. The early postoperative outcomes in patients who had preoperative MBP (MBP group) and in patients who underwent LCR without preoperative MBP (No-MBP group) were compared. RESULTS: From April 1992 to December 2014, 1535 patients underwent LCR: 706 MBP patients and 829 No-MBP patients. There were no differences in demographic data, indication for surgery and type of procedure performed between MBP and No-MBP group patients. The incidence of anastomotic leakage was similar between the two groups (3.4 vs. 3.6 %, p = 0.925). No differences were observed in intra-abdominal abscesses (0.6 vs. 0.8 %, p = 0.734), wound infections (0.6 vs. 1.4 %, p = 0.149), infectious extra-abdominal complications (1.8 vs. 3 %, p = 0.190), and non-infectious complications (6.1 vs. 6.8 %, p = 0.672). The overall reoperation rate was 4.6 % for MBP patients and 5 % for No-MBP patients (p = 0.813). CONCLUSION: The use of preoperative MBP does not seem to be associated with lower incidence of intra-abdominal septic complications after LCR.

Diagnosis and management of acute appendicitis. EAES consensus development conference 2015.

Unequivocal international guidelines regarding the diagnosis and management of patients with acute appendicitis are lacking. The aim of the consensus meeting 2015 of the EAES was to generate a European guideline based on best available evidence and expert opinions of a panel of EAES members. After a systematic review of the literature by an international group of surgical research fellows, an expert panel with extensive clinical experience in the management of appendicitis discussed statements and recommendations. Statements and recommendations with more than 70 % agreement by the experts were selected for a web survey and the consensus meeting of the EAES in Bucharest in June 2015. EAES members and attendees at the EAES meeting in Bucharest could vote on these statements and recommendations. In the case of more than 70 % agreement, the statement or recommendation was defined as supported by the scientific community. Results from both the web survey and the consensus meeting in Bucharest are presented as percentages. In total, 46 statements and recommendations were selected for the web survey and consensus meeting. More than 232 members and attendees voted on them. In 41 of 46 statements and recommendations, more than 70 % agreement was reached. All 46 statements and recommendations are presented in this paper. They comprise topics regarding the diagnostic work-up, treatment indications, procedural aspects and post-operative care. The consensus meeting produced 46 statements and recommendations on the diagnostic work-up and management of appendicitis. The majority of the EAES members supported these statements. These consensus proceedings provide additional guidance to surgeons and surgical residents providing care to patients with appendicitis.

Laparoscopic versus open resection for transverse colon cancer.

BACKGROUND: Previous large randomized controlled trials comparing laparoscopic (LR) and open resection (OR) for colon cancer have not specifically analyzed the outcomes in patients with transverse colon cancer. The aims of this study were to evaluate the feasibility and safety of LR transverse colon cancer resection and to compare our findings with the results available in the literature. METHODS: We performed a retrospective analysis of consecutive patients undergoing LR or OR for histologically proven adenocarcinoma of the transverse colon. RESULTS: A total of 123 patients were included in this study: 66 LR and 57 OR. Median operating time was similar in the two groups. Median blood loss was higher in the OR group, even though the difference was not statistically significant. The rate of conversion from LR to OR was 16.7 %. Return of bowel function occurred significantly earlier in the LR group. The incidence and severity of 30-day postoperative complications and mortality rates were similar in the two groups. The median hospital stay was significantly shorter in the LR group. There was a trend toward a greater number of lymph nodes harvested in the OR group than in the LR group, although the difference was not statistically significant. The time to first flatus and bowel movement was significantly earlier in the LR group. Five-year overall survival and disease-free survival rates were similar in the LR and OR groups (86.4 vs. 88.6 %, p = 0.770 and 80.4 vs. 77.3 %, p = 0.516, respectively). CONCLUSIONS: LR of transverse colon cancer is feasible and safe, with similar early short-term outcomes when compared to OR. Larger prospective comparative studies with long-term follow-up are needed to assess the oncological equivalence of the two approaches.

Laparoscopy for rectal cancer is oncologically adequate: a systematic review and meta-analysis of the literature.

BACKGROUND: This review of cancer outcomes is based on key literature searches of the medical databases and meta-analysis of short-term benefits of laparoscopy in rectal cancer treatment. METHODS: We carried out a systematic review of randomized clinical trials (RCTs) and prospective non-randomized controlled trials (non-RCTs) published between January 2000 and September 2013 listed in the MEDLINE and EMBASE databases (PROSPERO Registration number: CRD42013005076). The primary endpoint was clearance of the circumferential resection margin. Meta-analysis was performed using a fixed-effect model, and sensitivity analysis by a random-effect model; subgroup analysis was performed on subsets of patients with extraperitoneal cancer of the rectum. Relative risk (RR) and mean difference (MD) were used as outcome measures. RESULTS: Twenty-seven studies (10,861 patients) met the inclusion criteria; eight were RCTs (2,659 patients). The RCTs reported involvement of the circumferential margin in 7.9 % of patients who underwent laparoscopic and in 6.9 % of those undergoing open surgery; the overall RR was 1.00 (95 % confidence interval 0.73-1.35) with no heterogeneity. Subgroup analysis of patients with extraperitoneal cancer showed equivalent involvement of the circumferential margin in the two treatment groups. Although significantly more lymph nodes were retrieved in the surgical specimen after open surgery, the MD of -0.56 was of marginal clinical significance. The sensitivity and subgroup analyses revealed no other significant differences between laparoscopic and open surgery in the rate of R0 resections, distal margin clearance, mesorectal fascia integrity, or local recurrence at 5 years. CONCLUSIONS: Based on the evidence from RCTs and non-RCTs, the short-term benefit and oncological adequacy of laparoscopic rectal resection appear to be equivalent to open surgery, with some evidence potentially pointing to comparable long-term outcomes and oncological adequacy in selected patients with primary resectable rectal cancer.

Transanal endoscopic microsurgery after endoscopic resection of malignant rectal polyps: a useful technique for indication to radical treatment.

BACKGROUND: Management of malignant rectal polyps (MRPs) after endoscopic polypectomy (EP) is still debated. It is sometimes difficult to decide whether to simply follow-up (FU) or to treat such a removed lesion. Transanal endoscopic microsurgery (TEM) could have a role both in T staging and in treating MRPs after EP. METHODS: Patients who underwent a full-thickness TEM within 3 months after an EP between January 2008 and October 2012 were retrospectively analyzed. If post-TEM histology showed locally advanced rectal cancer, patients underwent a total mesorectal excision (TME) within 4-6 weeks. Patients without malignant disease or pT1sm1 cancers at post-TEM histology were followed up every 3 months for 2 years with clinical examination, flexible rectal endoscopy, and neoplastic markers monitoring. RESULTS: A total of 39 patients were included. Post-EP histology was adenocarcinoma in 27/39 cases (69.2 %) and adenoma in 12/39. Mean operative time was 64.2 min; no 30-day mortality occurred; 30-day morbidity was 2.7 % (rectal bleeding in 1/39 cases). Post-TEM histology showed a T2 cancer in 5/39 patients, four with and one without a previous cancer diagnosis, who were further treated by TME (four RARs and one APR) and are disease free with a mean FU of 24.2 months. Post-TEM histology showed adenoma in 10/39 cases and fibrosis in 24/39. These patients are disease free with a mean FU of 13 months. CONCLUSIONS: A full-thickness TEM after EP of MRPs can establish the presence of residual malignant disease and its depth of invasion, precisely defining the indication to TME. In event of benign post-EP histology, TEM must be performed in presence of macroscopic residual disease, in order to obtain an RO resection and finally exclude cancer, while, in absence of macroscopic residual disease, only close FU is required.

Transrectal sentinel lymph node biopsy for early rectal cancer during transanal endoscopic microsurgery.

BACKGROUND: Local excision of invasive cancer by transanal endoscopic microsurgery (TEM) entails the risk of lymphnode metastases that obliges to radical surgery. A determination of metastatic lymph-nodes would avoid major surgery in the vast majority of cases. We applied the concept of sentinel lymphnode (SLN) biopsy to suspected invasive rectal cancers treated by TEM. METHODS: Indocyanine green (ICG) is injected in the submucosa underneath the lesion. The tumor is dissected full-thickness until the perirectal fat. A near infra-red (NIR) optic provides a map of mesorectal lymphatics, on which guide the perirectal fat is dissected and lymph-nodes are excised. RESULTS: The technique was tested in three patients. In all cases the pathologist confirmed presence of lymphnodes in the excised tissue, no case showed metastasis. In all cases final pathology of the rectal neoplasm did not indicate radical surgery. CONCLUSION: In suspected invasive cancers, SLN mapping could be a useful technique to identify the first lymph node receiving drainage from the tumour, whose accurate pathological examination could predict the status of the remaining nodes and indicate further radical surgery. An ongoing study on a prospective case series will assess sensitivity and negative predictive value of SLN biopsy.

Which treatment for large rectal adenoma? Preoperative assessment and therapeutic strategy.

In the present review the authors discuss the standard ways of preoperative work-up for a suspected large rectal non-invasive lesion, comparing East and West different attitudes both in staging and treatment. Looking at the literature and analyzing recent personal data, neither pit-pattern classification, nor EUS, nor biopsy histology, nor lifting sign verification, nor digital examination allow a specificity of more than three fourth of such cases. The authors disquisition about which optimal treatment excludes a role for EMR for the impossibility to obtain a single en-bloc specimen, minimum requirement for a correct lateral and vertical margin assessment. For the same reason ESD should be preferred, although a recent meta-analysis of the literature defined that one fourth of patients undergoing ESD for a preoperatively assessed non-invasive large rectal lesion fail to receive an R0 en-bloc resection. This forces about 10% of patients treated by flexible endoscopy to undergo abdominal surgery, which is about fourfold higher than TEM. While awaiting further implementation of modern technologies both to improve staging and to reduce invasiveness, a full-thickness excision of the rectal wall by TEM still represents the standard treatment even for suspected benign diseases.