Current status of trans-anal total mesorectal excision (TaTME) following the Second International Consensus Conference.

This article documents the consensus of an expert group of surgeons from the Second International Trans-anal Total Mesorectal Excision (TaTME) Conference held in Paris in July 2014. It outlines three facets of the TaTME procedure: (i) the technique and its indications, (ii) training and adoption, and (iii) data collection and the TaTME registry.

Carbon dioxide insufflation vs conventional air insufflation for colonoscopy: a systematic review and meta-analysis of published randomized controlled trials.

AIM: Conventional air insufflation (AI) may cause prolonged abdominal bloating, excessive abdominal pain and discomfort during colonoscopy. Carbon dioxide may be an acceptable alternative to avoid these complications. The object of this study was to evaluate systematically the effectiveness of carbon dioxide insufflation (CI) for colonoscopy compared with AI. METHOD: Randomized controlled trials (RCTs) comparing the effectiveness of CI with that of AI during colonoscopy were retrieved from medical electronic databases and combined analysis was performed using the RevMan statistical package. The combined outcome of dichotomous and continuous variables was expressed as an odds ratio (OR) and standardized mean difference (SMD). RESULTS: Twenty-one RCTs comprising 3607 patients were included in the study. There was statistically significant heterogeneity among included studies. CI showed a significant trend towards reduced procedural pain [SMD -1.34; 95% confidence interval (95% CI) -2.23 to -0.45; z = 2.96; P < 0.003] and also postprocedural pain at 1 h (SMD -1.11; 95% CI -1.83 to -0.38; z = 2.97; P < 0.003), 6 and 24 h (OR 0.44; 95% CI 0.23-0.85; z = 2.44; P < 0.01). CI was associated with faster caecal intubation (SMD -0.20; 95% CI -0.37 to -0.02; z = 2.23; P < 0.03) but the caecal intubation rate was similar (P = 0.59) in both colonic insufflation techniques . CONCLUSION: CI seems to have clinical advantages over AI for colonoscopy with regard to pain during and after the procedure.

Systematic review and meta-analysis of published trials comparing the effectiveness of transanal endoscopic microsurgery and radical resection in the management of early rectal cancer.

AIM: A systematic analysis was conducted of trials comparing the effectiveness of transanal endoscopic microsurgery (TEMS) with radical resection (RR) for T1 and T2 rectal cancer. METHOD: An electronic search was carried out of trials reporting the effectiveness of TEMS and RR in the treatment of T1 and T2 rectal cancers. RESULTS: Ten trials including 942 patients were retrieved. There was a trend toward a higher risk of local recurrence (odds ratio 2.78; 95% confidence interval 1.42, 5.44; z = 2.97; P < 0.003) and overall recurrence (P < 0.01) following TEMS compared with RR. The risk of distant recurrence, overall survival (odds ratio 0.90; 95% confidence interval 0.49, 1.66; z = 0.33; P = 0.74) and mortality was similar. TEMS was associated with a shorter operation time and hospital stay and a reduced risk of postoperative complications (P < 0.0001). The included studies, however, were significantly diverse in stage and grade of rectal cancer and the use of neoadjuvant chemoradiotherapy. CONCLUSION: Transanal endoscopic microsurgery appears to have clinically measurable advantages in patients with early rectal cancer. The studies included in this review do not allow firm conclusions as to whether TEMS is superior to RR in the management of early rectal cancer. Larger, better designed and executed prospective studies are needed to answer this question.

Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery.

BACKGROUND: Occult hypovolaemia is a key factor in the aetiology of postoperative morbidity and may not be detected by routine heart rate and arterial pressure measurements. Intraoperative gut hypoperfusion during major surgery is associated with increased morbidity and postoperative hospital stay. We assessed whether using intraoperative oesophageal Doppler guided fluid management to minimize hypovolaemia would reduce postoperative hospital stay and the time before return of gut function after colorectal surgery. METHODS: This single centre, blinded, prospective controlled trial randomized 128 consecutive consenting patients undergoing colorectal resection to oesophageal Doppler guided or central venous pressure (CVP)-based (conventional) intraoperative fluid management. The intervention group patients followed a dynamic oesophageal Doppler guided fluid protocol whereas control patients were managed using routine cardiovascular monitoring aiming for a CVP between 12 and 15 mm Hg. RESULTS: The median postoperative stay in the Doppler guided fluid group was 10 vs 11.5 days in the control group P<0.05. The median time to resuming full diet in the Doppler guided fluid group was 6 vs 7 for controls P<0.001. Doppler patients achieved significantly higher cardiac output, stroke volume, and oxygen delivery. Twenty-nine (45.3%) control patients suffered gastrointestinal morbidity compared with nine (14.1%) in the Doppler guided fluid group P<0.001, overall morbidity was also significantly higher in the control group P=0.05. CONCLUSIONS: Intraoperative oesophageal Doppler guided fluid management was associated with a 1.5-day median reduction in postoperative hospital stay. Patients recovered gut function significantly faster and suffered significantly less gastrointestinal and overall morbidity.

Pre-operative short-course radiotherapy is associated with faecal incontinence after anterior resection.

OBJECTIVE: To determine the contribution of total mesorectal excision (TME), short-course pre-operative radiotherapy (SCRT), the level of the anastomosis and other putative contributory factors to the incidence and degree of faecal incontinence after anterior resection of the rectum. PATIENTS AND METHODS: Survivors of anterior resection of the rectum performed between February 1996 and February 2001, with a functioning anastomosis, were asked to complete a telephone questionnaire regarding their current bowel habit. Faecal incontinence was scored using the St. Mark's Incontinence Score. RESULTS: The median age of 124 patients who completed the questionnaire was 76 years. Of these, 104 patients had neoplastic disease, 66 (53%) patients exhibited some degree of incontinence, median St. Marks' Score 6, interquartile range 3-10. There was a significant association between the anastomotic level, and the St. Mark's Score (P < 0.0001, linear regression). Male sex (P = 0.047), SCRT (P = 0.0014) and an anastomotic leak (P = 0.038) were associated with significantly higher incontinence scores. Age, splenic flexure mobilization, TME, anastomotic configuration or use of a temporary stoma had no detectable independent effect on incontinence scores. CONCLUSIONS: Poor functional outcome following anterior resection was associated with a low anastomosis, SCRT or an anastomotic leak. The finding that SCRT was a predictor of postoperative incontinence emphasizes the need for stringent patient selection for this treatment modality.

Colonoscopic surveillance after curative colorectal resection: results of an empirical surveillance programme.

INTRODUCTION: Colonoscopic surveillance after colorectal cancer resection is widely practised despite little evidence that it improves survival. The optimum protocol for colonoscopic follow-up after colorectal cancer resection has not yet been elucidated. We audited the outcome of an empirical colonoscopic follow-up programme in a cohort of patients who underwent colorectal resection with a minimum of five years follow-up to establish patterns of metachronous neoplasia and suitable surveillance intervals. METHODS: The colonoscopic records, biopsy results and follow-up details of patients diagnosed with colorectal cancer between June 1990 and June 1996 were reviewed. The number and type of metachronous neoplastic lesions diagnosed was recorded. Rates of development of new neoplasms were estimated by calculating the time from operation to their first discovery. Factors predictive of further development of polyps or cancer were sought. Results were compared to published reports of intensive follow-up programmes. RESULTS: Seven hundred and ninety-eight patients underwent colorectal resection with curative intent during the study period. 226 patients had one or more follow-up colonoscopies (mean time post resection 48.8 months). In total 352 colonoscopies, encompassing 1437 patient years of surveillance, were performed. Nine metachronous cancers in eight patients, five of which were asymptomatic were diagnosed by colonoscopy at a mean of 63 months. Three asymptomatic recurrences were diagnosed but all were inoperable. 70 (31%) patients had adenomatous polyps diagnosed after a mean time from operation of 34 months for simple adenomatous polyps and 21 months for those with advanced features. Patients with multiple polyps or advanced polyps at the initial colonoscopy were more likely to form subsequent polyps. Only 5.8% of patients with a single adenoma or a normal colon formed an advanced adenoma over the next 36 months of surveillance. CONCLUSION: The results of an empirical colonoscopic follow-up programme compared favourably to the results of the intensive programmes reported in the literature. Most patients are at very low risk of developing significant colonic pathology over the first five years after resection. Colonoscopic surveillance intervals need not be less than five years unless the patient has multiple adenomas or advanced adenomas at the first colonoscopy. Three yearly surveillance intervals are most probably adequate in these individuals.

The Bouveret syndrome: an unusual complication of gallstone disease.

We present a case of Bouveret's syndrome which is gastric outlet obstruction due to gallstone impaction in the duodenum. The paper also discusses the aetiology, presentation, methods of diagnosis and options for management of Bouveret's syndrome.