Transanal endoscopic total mesorectal excision: technical aspects of approaching the mesorectal plane from below--a preliminary report.

BACKGROUND: Laparoscopic total mesorectal excision (TME) for low rectal cancer can be technically challenging. This report describes our initial experience with a hybrid laparoscopic and transanal endoscopic technique for TME in low rectal cancer. METHODS: Between December 2012 and October 2013, we identified patients with rectal cancer < 5 cm from the anorectal junction (ARJ) who underwent laparoscopic-assisted TME with a transanal minimally invasive surgery (TAMIS) technique. A standardized stepwise approach was used in all patients. Resection specimens were examined for completeness and measurement of margins. Preoperative magnetic resonance imaging (MRI) characteristics and short-term postoperative outcomes were examined. All values are mean ± standard deviation. RESULTS: Ten patients (8 males; median age: 60.5 (range 36-70) years) were included. On initial MRI, all tumors were T2 or T3, mean tumor height from the ARJ was 28.9 ± 12.2 mm, mean circumferential resection margin was 5.3 ± 3.1 mm , and the mean angle between the anal canal and the levator ani was 83.9° ± 9.7°. All patients had had preoperative chemoradiotherapy, TME via TAMIS, and distal anastomosis. There were no intraoperative complications, anastomotic leaks, or 30-day mortality. The pathologic quality of all mesorectal specimens was excellent. The distal resection margin was 19.4 ± 10.4 mm, the mean circumferential resection margin was 13.8 ± 5.1 mm, and the median lymph node harvest was 10.5 (range 5-15) nodes. CONCLUSIONS: A combined laparoscopic and transanal approach can achieve a safe and oncologically complete TME dissection for low rectal tumors. This approach may improve clinical outcomes in these technically difficult cases, but larger prospective studies are needed.

Genotype-defined cancer risk in juvenile polyposis syndrome.

BACKGROUND: Germline mutations in SMAD4 and BMPR1A disrupt the transforming growth factor ß signal transduction pathway, and are associated with juvenile polyposis syndrome. The effect of genotype on the pattern of disease in this syndrome is unknown. This study evaluated the differential impact of SMAD4 and BMPR1A gene mutations on cancer risk and oncological phenotype in patients with juvenile polyposis syndrome. METHODS: Patients with juvenile polyposis syndrome and germline SMAD4 or BMPR1A mutations were identified from a prospectively maintained institutional registry. Medical records were reviewed and the clinical patterns of disease were analysed. RESULTS: Thirty-five patients had germline mutations in either BMPR1A (8 patients) or SMAD4 (27). Median follow-up was 11 years. Colonic phenotype was similar between patients with SMAD4 and BMPR1A mutations, whereas SMAD4 mutations were associated with larger polyp numbers (number of patients with 50 or more gastric polyps: 14 versus 0 respectively). The numbers of patients with rectal polyps was comparable between BMPR1A and SMAD4 mutation carriers (5 versus 17). No patient was diagnosed with cancer in the BMPR1A group, whereas four men with a SMAD4 mutation developed gastrointestinal (3) or extraintestinal (1) cancer. The gastrointestinal cancer risk in patients with juvenile polyposis syndrome and a SMAD4 mutation was 11 per cent (3 of 27). CONCLUSION: The SMAD4 genotype is associated with a more aggressive upper gastrointestinal malignancy risk in juvenile polyposis syndrome.

Autonomic nerve preservation in rectal cancer surgery --the forgotten part of the TME message a practical "workshop" description for surgeons.

Conceptually TME has its basis in embryology. The original hypothesis was that cancer spread will tend, initially at least, to remain within the embryologic lymphovascular hindgut "envelope" the mesorectum and mesocolon. The corollary to the perfect specimen and cure is the perfect preservation of the layers surrounding the mesorectum which, are formed by the autonomic nerves and plexuses. The first obstacle is that few realistic photographs, sketches or diagrams have been published and visualisation and lighting low down in the pelvis is always problematic. Even when they are understood and visualised the difficulties inherent in preserving these nerves are due to the fact that they are actually adherent to the mesorectum at certain points where the dissection becomes particularly challenging. The most important and most adherent areas are the so-called "lateral ligaments"--low down laterally and anterolaterally where the inferior hypogastric plexuses (virtually the pelvic sex-brain) tether the whole mesorectal package. When the specimen has been carefully released it lifts up in a somewhat spectacular fashion--hence the old idea that there are ligaments at these points. A lesser degree of adherence may be found at various other points and particular care is required anteriorly where the nerves are converging towards the bulb of the penis with a trapezoidal septum between them--Denonvillier's "fascia"--which is in turn adherent to the anterior mesorectum and lower down in the prostate.

Better surgery and better selection for adjuvants--still the key to improving outcomes in rectal cancer.

UNLABELLED: In reviewing the current issues in rectal cancer management the word specialist recurs again and again. The modern hospital requires consultants with special interest in each of the key stages of decision making: Clinical assessment--usually the surgeon MRI. Fine slice individually orientated phased array coil studies with a specially trained radiologist. CT--now routine for metastases Neo-adjuvant therapy. Special interest in the disease in both clinical and medical oncology is essential. SURGERY: The challenges of the distal pelvis make it increasingly unacceptable for surgeons without a "special interest" to operate on mid and low cancer. Histopathology: The lessons of Professor Quirke have brought the specialised histopathologist out of his laboratory into the cruel role of "surgical auditor"--providing circumferential margin examination plus naked eye, TME quality assessment. This gives us two invaluable measurable short-term goals improving the quality for surgical practice. When a hospital can provide special interest doctors in all these fields and when they co-operate in a constructive manner the modern colorectal MDT can lead the way for the whole field of cancer management. It remains a probability that the use of high definition improved quality video based teaching of surgical technique is the single most effective weapon that we have in our battle against this most challenging of malignanvies.