ASGE guideline on the role of endoscopy for bleeding from chronic radiation proctopathy.

Chronic radiation proctopathy is a common sequela of radiation therapy for malignancies in the pelvic region. A variety of medical and endoscopic therapies have been used for the management of bleeding from chronic radiation proctopathy. In this guideline, we reviewed the results of a systematic search of the literature from 1946 to 2017 to formulate clinical questions and recommendations on the role of endoscopy for bleeding from chronic radiation proctopathy. The following endoscopic modalities are discussed in our document: argon plasma coagulation, bipolar electrocoagulation, heater probe, radiofrequency ablation, and cryoablation. Most studies were small observational studies, and the evidence for effectiveness of endoscopic therapy for chronic radiation proctopathy was limited because of a lack of controlled trials and comparative studies. Despite this limitation, our systematic review found that argon plasma coagulation, bipolar electrocoagulation, heater probe, and radiofrequency ablation were effective in the treatment of rectal bleeding from chronic radiation proctopathy.

Importance of anal cytology and screening for anal dysplasia in individuals living with HIV with an emphasis on women.

BACKGROUND: The incidence of squamous cell carcinoma of the anal canal has been increasing in high-risk populations. To the authors' knowledge, there is no international consensus regarding screening for squamous cell carcinoma of the anal canal, but screening is commonly comprised of a Papanicolaou (Pap) test in combination with digital anorectal examination followed by high-resolution anoscopy if necessary. The current study focused on individuals living with HIV and particularly on women living with HIV. METHODS: In this 5-year retrospective study, the authors identified 5982 Pap tests, 1848 of which had follow-up biopsy within 6 months. The rate of atypical squamous cells of undetermined significance was 42%, and approximately 38.1% of cases with this interpretation were diagnosed as high-grade squamous intraepithelial lesions on follow-up biopsy. In addition, 82 women with anal cytology had long-term follow-up (>10 years) available. RESULTS: The authors investigated a relationship between cervicovaginal human papillomavirus (HPV) results, cervical pathology, CD4 T-cell count, and CD4/8 ratio with the anal cytology interpretation. A statistical correlation was noted between the CD4 count and the CD4/8 ratio and the presence of anal dysplasia. Nearly one-half of the women without cervicovaginal HPV positivity presented with anal dysplasia. CONCLUSIONS: The results of the current study demonstrated that, among women living with HIV, screening for anal dysplasia should not be eschewed, regardless of lower genital tract pathology and/or HPV status. To the authors' knowledge, the current study is the largest reported retrospective anal cytology cohort in individuals living with HIV.

Performance of Anal Cytology Compared With High-Resolution Anoscopy and Histology in Women With Lower Anogenital Tract Neoplasia.

Background: Information on the performance of anal cytology in women who are high risk for human papillomavirus-related lesions and the factors that might influence cytology are largely lacking. Methods: Retrospective study including all new referrals of women with a previous history of anogenital neoplasia from January 2012 to July 2017, with concomitant anal cytology and high-resolution anoscopy with or without biopsies. Results: Six hundred and thirty six anal cytology samples and 323 biopsies obtained from 278 women were included. Overall sensitivity and specificity of "any abnormality" on anal cytology to predict any abnormality in histology was 47% (95% confidence interval [CI], 41%-54%) and 84% (95% CI, 73%-91%), respectively. For detecting high-grade squamous intraepithelial lesions (HSIL)/cancer, sensitivity was 71% (95% CI, 61%-79%) and specificity was 73% (95% CI, 66%-79%). There was a poor concordance between cytological and histological grades (κ = 0.147). Cytology had a higher sensitivity to predict HSIL/cancer in immunosuppressed vs nonimmunosuppressed patients (92% vs 60%, P = .002). The sensitivity for HSIL detection was higher when 2 or more quadrants were affected compared with 1 (86% vs 57%, P = .006). A previous history of vulvar HSIL/cancer (odds ratio [OR], 1.71, 1.08-2.73; P = .023), immunosuppression (OR, 1.88, 1.17-3.03; P = .009), and concomitant genital HSIL/cancer (OR, 2.51, 1.47-4.29; P = .001) were risk factors for abnormal cytology. Conclusions: Women characteristics can influence the performance of anal cytology. The sensitivity for detecting anal HSIL/cancer was higher in those immunosuppressed and with more extensive disease.

Human papillomavirus as a cause of anal cancer and the role of screening.

PURPOSE OF REVIEW: Anal cancer is a serious health problem in HIV-positive men who have sex with men, and precursor lesions, anal intraepithelial neoplasia, are well defined. Given the similarities with cervical cancer, screening for and treatment of anal intraepithelial neoplasia might prevent anal cancer. Screening programmes should meet the Wilson and Jungner criteria. We used these criteria to evaluate the current body of evidence supporting a screening programme for anal dysplasia. RECENT FINDINGS: The natural history of anal intraepithelial neoplasia is gradually becoming more clear, and three prospective studies are now being performed to conclusively address this issue. High-resolution anoscopy stays the gold standard to diagnose anal intraepithelial neoplasia. The International Anal Neoplasia Society has recently published Practice Standards in the Detection of Anal Cancer Precursors. The main issue, however, is treatment. Although response rates are reasonable at early evaluation, the majority of patients has a recurrence. SUMMARY: At present, an anal cancer screening programme for HIV-positive men who have sex with men meets most of the Wilson and Jungner criteria. Given that high-resolution anoscopy is the gold standard for screening, important issues that need addressing are the need for a less invasive screening procedure and the cost-effectiveness of screening. The main issue is treatment. Development and evaluation of new treatment strategies are essential for an effective and sustainable screening programme.

Comparison of the Effect of Instrument Type on Transanal Endoscopic Surgery Learning Curves.

BACKGROUND: Transanal endoscopic surgery (TES) can be technically difficult due to the constraints of operating through a narrow proctoscope channel. In this study, we compared the performance of surgical novices using instruments with and without articulating shafts to perform a simulated TES task. METHODS: Medical students each performed 10 repetitions of the Fundamentals of Laparoscopic Surgery circle-cut task. Participants were randomized into 3 groups: 2 performed the task through a TES proctoscope using scissors with either a rigid (TES-R) or articulating (TES-A) shaft. The third group performed the task laparoscopically (LAP). RESULTS: A total of 31 medical students participated. The LAP group had a faster mean task time than both the TES-R and TES-A groups (LAP 201±120 s vs. TES-R 362±212 s and TES-A 405±212 s, both P <0.001). The TES-R group made more errors (ie, deviation from a perfect circle) than both the other groups. The TES-R group adjusted the proctoscope position during more repetitions than the TES-A group. CONCLUSIONS: Students had faster task times when operating laparoscopically than through a TES protoscope. Task times were similar between the TES groups using scissors with articulating and rigid shafts; however, use of the articulating instruments resulted in fewer errors and less need to adjust proctoscope position.

MRI-defined height of rectal tumours.

BACKGROUND: There is no standard for reporting rectal cancer distances from the distal resection margin in the literature. The objective was to demonstrate the importance of rectal cancer measurement from a standardized point. METHODS: Review of databases at two international institutions identified 50 patients with rectal adenocarcinoma within 15 cm of the anal verge (AV), who had preoperative magnetic resonance imaging (MRI) and underwent surgery with curative intent. Expert radiologists reviewed the magnetic resonance images for anatomical distances from the anorectal ring (ARR) to the AV, from the ARR to the dentate line (DL), and from the DL to the AV. Anatomical measurements were compared with preoperative measurements to assess reporting inconsistencies. RESULTS: Fifty patients with rectal adenocarcinoma were included in the study. The mean(s.d.) anatomical distance was 1.66(0.61) cm from the ARR to the DL, 3.78(0.61) cm from the ARR to the AV (maximum 5.5 cm) and 2.11(0.10) cm from the DL to the AV. The mean radiological distance from the distal tumour was 2.90(1.60) (median 3.2, range 0-7.5) cm to the ARR, 4.36(3.20) (median 4.2, range -0.5 to 12.8) cm to the DL and 6.13(3.39) (median 6.0, range 0-14.1) cm to the AV. There was a significant difference in the distal tumour margin between measurements made by the expert radiologists and reported preoperative measurements (P < 0.001). Significant differences were also found between the expert radiologists' MRI and rigid proctoscopic measurements (P = 0.025). CONCLUSION: There was up to 5.5 cm variation, depending on which landmark was chosen for reporting the distal margin of rectal cancer. This has potential implications for surgical planning, interpreting radiological images and comparative studies.

Alleged rape: an appeal case.

This paper charts the progress of an alleged rape case from first complaint to its conclusion in the Court of Criminal Appeal in England.

[Options for quality improvement in the treatment of rectum carcinoma]. / Möglichkeiten der Qualitätsverbesserung bei der Therapie des Rektumkarzinoms.

By means of a prospective multi centre study, 13 419 cases of surgically treated patients with rectum carcinomas were registered between 1.1.2000 and 31.12.2003 and assessed in regard to possible problems concerning indications and operative procedures. Beside a high rate of non-local resective procedures in T1-low risk carcinomas, unnecessary extirpations in cases of tumour localisation over 8 cm from the anal verge were found. Tumours of the lower two-thirds of the rectum were treated by incomplete TME in 20 % of the patients. In addition, there seems to be too low a rate of neo-adjuvant therapy procedures. Protective stomata were frequently foregone after low anterior resection. Endoscopic interventional methods were still used reluctantly in inoperable situations.

Blind sampling is superior to anoscope guided sampling for screening for anal intraepithelial neoplasia.

OBJECTIVES: Anal cytology smears are either collected "blind" (swab inserted 4 cm into anal canal and rotated) or guided through an anoscope (transformation zone visualised and then sampled). We compared these smear techniques with respect to sample quality and patient acceptability. METHODS: Using a paired, random sequence clinical trial, 151 homosexual men (n = 95 HIV positive) underwent both smear techniques at a single visit; smear order was randomised and specimens were read blind. Both techniques utilised a Dacron swab, with water lubrication. Cytological specimens were prepared using a liquid based collection method (ThinPrep). The outcome measures were cytological specimen adequacy, cytological classification, presence of rectal columnar, squamous and metaplastic cells, contamination, patient comfort and acceptability, and volume of fluid that remained after the ThinPrep procedure. RESULTS: Regardless of smear order, guided smears were less likely to detect higher grade abnormalities than blind smears (15 v 27 cases, p = 0.001). Controlling for smear order, guided smears were more likely to be assessed as "unsatisfactory" for cytological assessment (OR 6.93, 95% CI 1.92 to 24.94), and contain fewer squamous (OR 0.20, 95% CI 0.04 to 0.94) and metaplastic cells (OR 0.12, 95% CI 0.03 to 0.54) than blind smears; there were no other statistically significant differences between techniques. Regardless of smear technique, first performed smears were more likely to detect a higher grade abnormality than second performed smears (23 v eight cases, p < 0.001). CONCLUSIONS: Blind cytology smears are superior to anoscope guided smears for screening for anal neoplasia in homosexual men.

The value of anal cytology and human papillomavirus typing in the detection of anal intraepithelial neoplasia: a review of cases from an anoscopy clinic.

BACKGROUND: Previous studies have reached differing conclusions about the utility of anal cytology as a screening tool for anal intraepithelial neoplasia (AIN). There is a need also to establish whether HPV typing offers a useful adjunct to screening. METHODS: We analysed data from 99 consecutive homosexual/bisexual male patients (89 HIV-1 positive) who underwent high resolution anoscopy. Follow up visits for these patients were also included, giving a total of 160 anoscopic procedures. Comparison was made between results of anal cytology using the sampling method of Palefsky, and histological findings of biopsies taken from abnormal areas seen on high resolution anoscopic examination of the anal canal. Swabs taken concurrently with the cytology were analysed for the presence of human papillomavirus (HPV) DNA and compared with the cytological and histological findings. RESULTS: The sensitivity of the cytology was 83%, and the specificity 38% when compared with histology. At screening of 34 asymptomatic men, 83% had anal cytological dysplasia and 78% had AIN. There were no significant differences in the prevalence of hrHPV genotypes between different cytological or histological grades of abnormalities. CONCLUSION: Anal cytology by the Palefsky method is simple to undertake, has a sensitivity and specificity comparable with cervical cytology, and can therefore be used as the basis of a pilot screening project in centres with large cohorts of HIV positive homosexual men who have a high risk of developing anal carcinoma. HPV genotyping is not a useful adjunct to cytological screening.

Could laparoscopic colon and rectal surgery become the standard of care? A review and experience with 750 procedures.

INTRODUCTION: The benefits of the laparoscopic approach to colon and rectal surgery do not seem as great as for other laparoscopic procedures. To study this further we decided to review the current literature and the 10-year experience of a surgical group from university teaching hospitals in Montréal, Québec and Toronto in performing laparoscopic colon and rectal surgery. METHODS: The prospectively designed case series comprised all patients having laparoscopic colon and rectal surgery. The procedures were carried out by a group of 4 surgeons between April 1991 and November 2001. We noted intraoperative complications, any conversions to open surgery, operating time, postoperative complications and postoperative length of hospital stay. RESULTS: The group attempted 750 laparoscopic colon and rectal procedures of which 669 were completed laparoscopically. Malignant disease was the indication for surgery in 49.6% of cases. Right hemicolectomy and sigmoid colectomy accounted for 54.5% of procedures performed. Intraoperative complications occurred in 8.3%, with 29.0% of these resulting in conversion to open surgery. The overall rate of conversion to open surgery was 10.8%, most commonly for oncologic concerns. Median operating time was 175 minutes for all procedures. Postoperative complications occurred in 27.5% of procedures completed laparoscopically but were mostly minor wound complications. Pulmonary complications occurred in only 1.0%. The anastomotic leak rate was 2.5%. The early reoperation rate was 2.4%. Postoperative mortality was 2.2%. No port site metastases have yet been detected. The median postoperative length of stay was 5 days. CONCLUSIONS: The clinical outcomes of laparoscopic colon and rectal surgery in this 10-year experience are consistent with numerous cohort studies and randomized clinical trials. Laparoscopic colon and rectal surgery in the hands of well-trained surgeons can be performed safely with short hospital stay, low analgesic requirements and acceptable complication rates compared with historical controls and other reports in the literature. Evidence from published randomized clinical trials is emerging that under these conditions laparoscopic resection represents the better treatment option for most benign conditions, but concerns regarding its appropriateness for malignant disease are still to be resolved.

Laparoscopic treatment of rectal prolapse: experience gained in a prospective multicenter study.

BACKGROUND: We report the findings of a prospective multicenter observational study carried out by the Study Group for Laparoscopic Colorectal Surgery on patients undergoing laparoscopic or laparoscopic-assisted surgery for rectal prolapse. The study investigated the safety of various laparoscopic techniques in terms of perioperative and postoperative general and technique-specific complications and compared the results with those reported for open surgery in this area. METHODS: Of the 150 patients undergoing laparoscopic or laparoscopic-assisted colorectal surgery for rectal prolapse 124 received rectopexy combined with resection and 26 rectopexy alone. In 85 patients a mesh was employed during rectopexy. The conversion rate was 5.3%. RESULTS: Perioperative complications (21 surgical and 35 general perioperative) were recorded in 37 patients (24.7%). The reoperation rate was 5.3% (bleeding 2, anastomotic leak 2, ileus 4). No procedure-specific perioperative complications were observed. In particular, reduced surgical trauma led to fewer severe postoperative complications such as cardiopulmonary problems (3.3%). CONCLUSIONS: The techniques of conventional prolapse surgery can readily be translated to the laparoscopic modality, since oncological criteria do not have to be considered. The usually elderly patients in this group benefit to a particular degree from the known advantages associated with reduced surgical trauma. Perioperative morbidity is determined largely by the surgeon's experience. We therefore believe that rectal prolapse is a suitable indication for the minimally invasive modality in the hands of trained surgeons.

[Laparoscopic colorectal surgery: 499 interventions]. / La chirurgie laparoscopique colo-rectale, à propos de 449 interventions.

Laparoscopic colorectal surgery hasn't been generally accepted yet. We present here our experience of 449 operations performed with this method. More than a quarter of the indications were for malignancy. Conversion rate was 9.3% for the benign diseases and 14.1% for the malignant ones. Operating time was longer compare to open surgery. Postoperative complications were 9.9% for benign and 23.6% for malignant diseases. Of those complications 7.1% concerned anastomotic leakages. Four patients presented with port-site metastases and this in the beginning of our experience. Mortality rate was zero for the benign group while it was 1.6% for the malignant one. According to our experience we believe that laparoscopic colorectal surgery offers a satisfactory minimal invasive alternative. Technological advances such as the harmonic scalpel or new visual techniques give more possibilities for better application of the method. Randomised studies, running actually, should allow us to say in the following years, if this method could be a widespread standard.

[Rectoscopy: rigid or flexible? A comparative study]. / Rektoskopie: starr oder flexibel? Eine vergleichende Untersuchung.

The customary rigid rectoscope was compared prospectively, with a new, flexible one (prototypes of Olympus Opt. and Fuji) in each of 114 patients selected at random. Maximal depth of introduction was reached on average after 1 min with the rigid instruments, after 1 min 40 sec with the flexible one. Mean depth of introduction was 16 cm for the rigid and 33 cm for the flexible one. In 21 patients (18.4%) additional information was obtained with the flexible rectoscope. 80% of patients reported that the flexible instrument caused them no or only slight discomfort. Skill in using the flexible instrument can be quickly acquired.