Trans-anal minimally invasive surgery (TAMIS) versus trans-anal endoscopic microsurgery (TEM): a comparative case-control matched-pairs analysis.

AIM: Since its introduction, transanal endoscopic microsurgery (TEM) has become the treatment of choice for rectal benign lesions not amenable to flexible endoscopic excision and for early rectal cancer. Disposable soft devices as the Trans-anal Minimally Invasive Surgery (TAMIS) are a valid alternative to non-disposable rigid trans-anal endoscopic microsurgery (TEM) platforms. The aim of the present study is to compare TEM and TAMIS in terms of incidence of R1 resection and lesion fragmentation which were combined in a composite outcome called quality resection. Perioperative complication and operative time were also investigated. METHODS: A total of 132 patients were eligible for this study of whom 63 (47.7%) underwent TAMIS and 69 (52.3%) underwent TEM. Patients were extracted for from a prospective maintained database and groups resulted homogenous after matching using propensity score in terms of size of the lesion, height from the anal verge, position within the rectal lumen, preoperative histology, neoadjuvant treatment. A multivariate logistic and linear regression analysis was carried out using those variables that have significant independent relationship with the quality of surgical resection and operative time. RESULTS: The incidence of R0 resection and lesion fragmentation was similar between groups. No differences were found in terms of perioperative complication. TAMIS was associated with less setup time and less operative time compared with TEM. Variables influencing quality resection at the multivariate analysis were larger lesion (> 5 cm) and ≥ T2 stage. Variables influencing operative time were surgical procedure (TEM vs TAMIS), height from the anal verge and size of the lesion. CONCLUSION: The present study shows that TEM and TAMIS are equally effective in terms of quality of local excision and perioperative complication. TAMIS resulted less operative time consuming compared to TEM.

Laparoscopic colon and rectal resections with intracorporeal anastomosis and trans-vaginal specimen extraction for colorectal cancer. A case series and systematic literature review.

PURPOSE: Intracorporeal anastomosis associated to trans-vaginal specimen extraction decreases the extent of colon mobilisation and the number and size of abdominal incisions, improving the benefits of minimally invasive surgery in female patients. The aim of this study was to evaluate the safety and effectiveness of this procedure for colorectal cancer. METHODS: Between 2009 and 2013, 13 female patients underwent laparoscopic colon and rectal resection for colorectal cancer with intracorporeal anastomosis and trans-vaginal specimen extraction: 2 right colectomies, 1 transverse colon resection, 4 left colectomies and 6 anterior resections were performed. A MEDLINE search of publications on the presented procedure for colon neoplasms was carried out. RESULTS: There were no intraoperative complications and no conversions. Postoperative visual analogue scale (VAS) score in the pelvis, abdomen and shoulder was moderate. In the postoperative period, we observed two colorectal anastomotic strictures, successfully treated with pneumatic endoscopic dilation. Median length of the specimen was 18.5 cm, with a median tumour size of 5.5 cm in diameter. Median number of retrieved lymph nodes was 12. All circumferential resection margins were negative. During a mean follow-up of 31 months (range, 6-62), there was neither evidence of recurrent disease nor disorders related to the genitourinary system. The aesthetic outcome was considered satisfactory in all patients. Nine studies were identified in the systematic review. CONCLUSIONS: Our case series, according to the results of the literature, showed that intracorporeal anastomosis associated to trans-vaginal specimen extraction is feasible and safe in selected female patients.

Long-term outcome of local excision after preoperative chemoradiation for ypT0 rectal cancer.

BACKGROUND: Local excision, as an alternative to radical resection for patients with pathological complete response (ypT0) after preoperative chemoradiation, is under investigation. OBJECTIVE: The aim of the present study was to evaluate the long-term clinical outcome of a selected group of patients with ypT0 rectal cancer who underwent local excision with transanal endoscopic microsurgery as a definitive treatment. PATIENTS: Between 1993 and 2013, 43 patients with rectal adenocarcinoma underwent complete full-thickness local excision with a transanal endoscopic microsurgery procedure after a regimen of chemoradiation. In all patients, rectal wall penetration was preoperatively assessed by endorectal ultrasound and/or magnetic resonance. Chemoradiation and transanal endoscopic microsurgery were indicated in patients refusing radical procedures or patients unfit for major abdominal procedures. MAIN OUTCOME MEASURES: Patient characteristics, operative record, pathology report, and tumor recurrence were analyzed at a median follow-up of 81 months. The potential prognostic factors for recurrence, screened in univariate analysis, were analyzed by multivariate analysis by using the Cox regression model. RESULTS: Thirteen patients (30.2%), without residual tumor in the surgical specimen (ypT0), were treated with transanal endoscopic microsurgery only. In this ypT0 group, 2 patients (15.4%) had postoperative complications: 1 bleeding and 1 suture dehiscence. Postoperative mortality was nil. No local and distal recurrences were observed, and no tumor-related mortality occurred. In 30 patients (69.8%), partial tumor chemoradiation response or the absence of tumor chemoradiation response was observed. In this group, recurrence occurred in 17 patients (56.7%). LIMITATIONS: The study was limited by its retrospective nature, different protocols of chemoradiation and preoperative staging over time, and the small sample size. CONCLUSIONS: Local excision with transanal endoscopic microsurgery can be considered a definitive therapeutic option in patients with rectal cancer treated with preoperative chemoradiation, when no residual tumor is found in the specimen. In this selected group, local excision offers excellent results in terms of survival and recurrence rates. In the presence of residual tumor, transanal endoscopic microsurgery should be considered as a large excisional biopsy (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A157).

Incisional hernia: laparoscopic or open repair?

PURPOSE: To compare laparoscopic and open repair of incisional hernia in terms of complications and failure rates. METHODS: Between June 2005 and April 2012, 252 patients underwent incisional hernia repair. Of these, 126 underwent laparoscopic and 126 open repair. The median follow-up was 38.7 months. RESULTS: Baseline characteristics [age, body mass index, American Society of Anesthesiologists (ASA) score, comorbidities, hernia size, and follow-up] did not differ significantly. Mean operative time was similar (72 vs. 83 min). Laparoscopic repair was associated with less postoperative pain, less postoperative complications (3.9% vs. 13.4%, P=0.012), and shorter hospital stay (3.5 vs. 4.3, P=0.002). Recurrence occurred in 6 patients of group 1 and in 7 patients of group 2 (4.7% vs. 5.5%, P=not significant). CONCLUSIONS: In this study, the trend in favor of laparoscopic treatment for incisional hernias is remarkable. Fewer postoperative complications and shorter hospital stay with similar operative time may balance the higher costs associated with the technique.

Management and outcome of local recurrence following transanal endoscopic microsurgery for rectal cancer.

BACKGROUND: Transanal endoscopic microsurgery is a faster and safer alternative to traditional surgical treatment of adenomas and low-risk (T1) rectal tumors. However, although overall survival appears similar, transanal endoscopic microsurgery has been shown to have higher recurrence rates. OBJECTIVE: The aim of this study was to investigate the management of patients with local recurrence after transanal endoscopic microsurgery and to evaluate their long-term outcome. DESIGN: This study was a retrospective review of medical records. SETTING: Patients were treated at a large tertiary-care hospital in Rome, Italy, between 1990 and 2011. PATIENTS: Of 298 patients who underwent local excision with transanal endoscopic microsurgery, 144 patients with rectal adenocarcinoma were included in the study. INTERVENTION: Local excision was performed with transanal endoscopic microsurgery. In all cases complete full-thickness excision was attempted. MAIN OUTCOME MEASURES: Patient characteristics, operative record, pathology report, and tumor recurrence were analyzed. Survival was calculated using the Kaplan-Meyer method and groups were compared with the log-rank test. RESULTS: Tumors were classified as pT1 in 86 patients (59.7%), pT2 in 38 (26.4%), and pT3 in 20 (13.9%). Median follow-up was 85 (range, 3-234) months. Median time to recurrence was 11.5 (range, 1-62) months; 44 patients had local or distal recurrence or both. The rate of local recurrence for patients with pT1 tumors was 11.6% (10/86). A total of 27 patients (18.8%) with local recurrence were eligible for salvage surgery: 17 had radical salvage resection, 9 had transanal re-excision, and 1 refused surgery. Overall 5-year survival was 83% in all 144 patients, and 92% in patients with pT1 tumors. The overall 5-year survival rate was higher in patients who had the radical salvage procedure than in those who had transanal re-excision (69% vs 43%; p = 0.05). LIMITATIONS: The study was limited by its retrospective nature, lack of technology at the beginning of the study, and the mixed nature of the study group. CONCLUSIONS: The outcome after transanal excision for rectal cancer depends on close surveillance for early detection of recurrence. In patients able to undergo surgery, endoluminal or pelvic recurrence should be treated with an immediate radical salvage operation. Overall long-term survival after local excision with transanal endoscopic microsurgery followed by radical salvage surgery in cases of local recurrence is comparable to overall survival after initial radical surgery.

[Cavernous haemangioma of the lung: a case report and review of the literature]. / Emangioma cavernoso del polmone: caso clinico e revisione della letteratura.

Cavernous haemangioma is a rare benign vascular tumour rarely seen in the lung. A 73-year-old male complaining of haemoptysis and dyspnoea, with a solitary nodule of the left lower pulmonary lobe, underwent left lower wedge resection. Pathology showed a 3 cm cavernous haemangioma. One year later symptoms recurred and CT showed a second nodule in the left upper lobe. Upper left lobectomy was performed, confirming the diagnosis of cavernous haemangioma. There are less than 25 case reports of this type of tumour in the literature. Radiological findings usually show a single pulmonary nodule. The preoperative diagnosis is quite difficult because pulmonary biopsy is often non-diagnostic. Standard treatment is complete surgical resection. For asymptomatic patients a brief period of observation is suggested.

Assessment of surgical treatment in elderly patients with breast cancer.

AIMS AND BACKGROUND: The incidence of breast cancer increases with advancing age and in clinical practice approximately 50% of new cases occur in women over the age of 65 years. Although breast cancer in elderly patients presents more favorable biological characteristics than similar-stage cancer in younger women, disease control still remains uncertain and is becoming a major health problem. PATIENTS AND METHODS: Between 1984 and 2006, 133 patients aged over 65 with operable breast cancer underwent surgical treatment. Patients with ductal or lobular carcinoma in situ, bilateral breast cancer or a previous malignancy were excluded. The mean age was 72.8 years (range, 66-89). Breast-conserving surgery was performed in patients with early breast cancer (T1, T2 < 2.5 cm), while most patients with advanced tumors (T2 >2.5 cm, T3, T4) were treated by modified radical mastectomy. RESULTS: The pathological stage was I in 44, IIA in 54, IIB in 18, IIIA in 10 and IIIB in 7 patients. Postoperative complications occurred in 13 patients (9%); there were no postoperative deaths. Eighty-nine patients underwent adjuvant therapy (chemotherapy, hormonal therapy). After a median follow-up of 96 months (range, 5-266), disease progression was observed in 21 patients (15.8%). The overall mortality from breast cancer was 11%, whereas the cancer-unrelated mortality was 9%. CONCLUSION: There is no evidence that breast cancer has a more favorable prognosis in the elderly and surgical procedures should be carried out as has been established in younger women. At present, elderly patients are much less likely to be entered into randomized clinical trials and are often undertreated. However, in the absence of serious comorbid disease, they are able to withstand standard multimodal treatment options as well as do younger patients.

[Local excision of giant rectal polypoid neoplasms]. / Escissione locale delle neoplasie polipoidi giganti del retto.

Local excision is the best therapeutic option for giant adenomas of the rectum. Parks technique for lower rectal lesions and the T.E.M. technique for lesions localised in the middle and upper rectum offer exceptionally good exposure, allowing radical excision in the case of early low-risk T1 adenocarcinomas (well or moderately differentiated [G1/2] without lymphovascular invasion [L0]). From July 1987 to March 2006, 224 patients were treated by local excision for rectal lesions in our department. In 48 patients (21.4%) a large sessile benign lesion was diagnosed preoperatively. In 3 patients with a preoperative diagnosis of severe dysplasia (Tis) final pathology showed adenoma and for this reason they were included in our study group. A total of 51 patients with giant preoperative benign lesions were treated by local excision (Parks technique, T.E.M. or both). Twenty-five (49%) patients had a definitive diagnosis of adenocarcinoma: in situ (pTis) in 22 patients (88%), pT1 in 2 patients (8%) and pT2 in 1 patient (4%). In 26 patients (51%) the diagnosis was adenoma. The overall local recurrence rate was 9.8% (5/51); the recurrence rate was 7.6% (2/26) for adenomas and 12% (3/25) for carcinomas. The median hospital stay was 7 days (range 3-39). There was no operative mortality. Giant sessile polypoid lesions localized in the middle and upper rectum are best treated with T.E.M., while Parks technique is a good option in lower rectal tumours. These techniques, if correctly indicated and well performed, offer great advantages in terms of safety and radicality. In our experience the operative mortality was nil and the morbidity and recurrence rates were low.

[Endoscopic-laparoscopic treatment of neoplastic occlusion of the left colon]. / Il trattamento endoscopico laparoscopico dell'occluslone neoplastica del colon sinistro.

About a third of patients with colorectal carcinoma have acute colonic obstruction requiring emergency surgery. The surgical options are: intraoperative lavage and resection of the colonic segment involved with primary anastomosis; subtotal colectomy with primary anastomosis; colostomy followed by resection; and resection of the colonic segment involved with an end colostomy (Hartman's procedure) requiring a second operation to reconstruct the colon. These procedures present risks and are associated with a poor quality of life. Endoscopic colonic stent insertion effectively decompresses the obstructed colon allowing bowel preparation and elective resection. In this article we present 2 cases successfully treated with the use of stents followed by a laparoscopic resection. We also describe technical details concerning the endoscopy and laparoscopy procedure, discuss the advantages of this treatment and present a review of the literature. One patient underwent a left hemicolectomy; while the other was treated with splenic flexure resection. No complications occurred after surgery. Histological staging revealed a pT3 pNO pMx G2 and a pT4 pN1 pM1 G2 adenocarcinoma, respectively. This initial experience shows that endoscopic colonic stent insertion can effectively resolve the neoplastic obstruction, allowing safe elective surgery. The use of stents does not prevent a laparoscopic approach.

Malignant fibrous histiocytoma of the breast. Report of two cases and review of the literature.

Sarcomas of the breast are uncommon, accounting for less than 1% of all primary malignancies. Among these tumors, malignant fibrous histiocytoma (MFH) is very rare. Two cases of this neoplasm are reported, with histological findings and surgical treatment. The issue of radiation-induced lesions after surgery for carcinoma and the necessity for a correct preoperative diagnosis is examined. A review of the available literature evaluates the histopathological and biological features of MFH of the breast, for which there are no prospective trials, owing to the rarity of this kind of neoplasm. The extent of surgery or role of axillary lymph nodes dissection and multimodality therapy are discussed.

Malignant intestinal obstruction: useful technical advice in self-expanding metallic stent placement.

BACKGROUND: The use of endoluminal self-expanding metallic stents is an effective alternative to surgery in neoplastic gastrointestinal tract obstructions. It is often difficult to mark the proximal segment of the stricture under fluoroscopic guidance (due to patient movements or change of markers' position). PATIENTS AND METHODS: We placed Ultraflex precision colonic stent (Microvasive, Boston Scientific) in ten patients with neoplastic stricture of the rectosigmoid colon. Before placement of the delivery catheter, a radiopaque proximal marker was identified on the delivery catheter under fluoroscopic guidance. The external side of the delivery catheter was coloured (in correspondence with the radiopaque marker) with non toxic colour. After the introduction of the delivery catheter, we placed the proximal coloured marker just above the distal tumour margin under endoscopic guidance. RESULTS: The procedure was successful in relieving the obstruction in all patients, without mortality or complications. In all patients the coloured marker was identified and the stent correctly placed. CONCLUSION: The location of a coloured marker in the external side of the delivery catheter permits an accurate and correct placement of the stent, without unnecessary exposure to X-rays.

Palliative management of malignant antro-pyloric strictures. Gastroenterostomy vs. endoscopic stenting. A randomized prospective trial.

BACKGROUND: Gastroenterostomy was the palliative treatment of choice in patients with malignant unresectable gastric outlet obstruction. Palliative endoscopic treatment of malignant gastric outlet obstruction with endoluminal self-expanding metallic stents is nowadays a well-established procedure. PATIENTS AND METHODS: Eighteen patients referred for treatment with diagnosis of malignant strictures of the antro-pyloric tract presenting at an advanced unresectable stage. The patients were randomly assigned into two treatment groups (endoscopic vs. surgery) according to random-number tables. The length of procedure, morbidity and mortality rate, restoration of oral intake and gastric emptying at 8, 15 days and 3 months from treatment and hospital stay were assessed. RESULTS: Endoscopic group: The median length of procedure was 40 minutes. No death and one minor complication (11.1%) was reported. Mean time for oral intake was 2.1 days. Gastric emptying was satisfactory in 88.9% after 8 days and in 100% of patients after 15 days and 3 months. The median hospital stay was 3.1 days. Surgery group: The median length of the operation was 93 minutes. No mortality was reported. One patient (11.1%) developed anastomotic bleeding which required relaparotomy. Mean time for oral intake was 6.3 days. Gastric emptying was satisfactory in 66.7% of patients after 8 days, in 88.9% after 15 days and in 100% after 3 months. The median hospital stay was 10 days. CONCLUSION: There were no statistically significant differences between the 2 groups even with respect to morbidity, mortality, delayed gastric emptying and clinical outcomes at 3-month follow-up. Endoscopic stenting was significantly more effective with respect to operative time, restoration of oral intake and median hospitalization. Our results would suggest that endoscopically placed metal stents offer an effective alternative to surgical palliation in patients with unresectable malignant strictures.

Hepatocyte ultrastructural aspects after preoperative biliary drainage in pancreatic cancer patients with cholestatic jaundice.

BACKGROUND: The usefulness of preoperative biliary drainage in long-standing obstructive jaundice remains controversial. This study was designed to assess microscopic and ultrastructural changes in the morphology of hepatocytes from patients with obstructive jaundice treated with biliary drainage for 14 days. PATIENTS AND METHODS: In 8 patients with jaundice due to pancreatic neoplasms we obtained two fine-needle liver biopsies: the first during a transhepatic cholangiographic examination before placing preoperative drainage and the second at surgery, on day 14 of drainage. Biopsy samples were examined by light and electron microscopy and correlated to serum liver functional tests recorded before and after biliary drainage. RESULTS: Pre-drainage biopsy presented diffuse morphological signs of congestion and cholestasis, lipid and bilirubin cytoplasm inclusions, loss of bile canaliculi microvilli and diffuse bile canaliculi dilatation. After-drainage biopsies presented reduction of bile canaliculi dilatation, partial restoring of bile canaliculi microvilli and persistence of diffuse hepatocyte structural and ultrastructural changes. Patients' laboratory values (bilirubin, alkaline phosphatase, SGGT, SGOT and SGPT), that were significantly impaired before drainage, returned almost to normal within two weeks after drainage. CONCLUSION: Preoperative biliary drainage in patients with long-standing obstructive jaundice has received wide yet controversial support due to a well established pathophysiological background. The present findings of scarce recovery of hepatocyte changes after 14 days' drainage seemingly question its appropriateness.