[Can robotic rectal cancer surgery improve quality of total mesorectal excision?] / Muze robotická asistence pri chirurgické lécbe karcinomu rekta zlepsit kvalitu totální mezorektální excize?

INTRODUCTION: The introduction of total mesorectal excision (TME) in the 1980s was pivotal in the surgical treatment for rectal carcinoma (RC). Routinely applied TME led to a significant reduction in the incidence of local recurrences. The purpose of our paper is to present the results of our non-randomized study comparing prospectively acquired data from radical resection / rectal extirpation using classic open access, laparoscopy and da Vinci robotic system. METHOD: The study group included 116 patients with RC who underwent radical surgical treatment between 1/2014-12/2016, after which the collected resection specimens were assessed in pathology laboratories of the referring hospital using the Quirkes protocol. Analysis of data collected prospectively over a period of 3 years was done. The surgical procedures were open, laparoscopic and robotic. Robotic surgery could only be performed in patients whose health insurers guaranteed to cover the robotic resection expenses. Those patients whose health insurers did not cover the costs of the robotic assisted procedure were treated using the laparoscopic technique. RESULTS: Over a period of 3 years (2014-2016), the teams at the Department of Surgery of the 2nd Faculty of Medicine, Charles University and Central Military Hospital, Prague treated 116 patients (75 men and 41 women) for RC; resected specimens of the patients were processed according to the Quirkes protocol. Mean age was 63 years (33-80). pCRO positivity was confirmed in 5 patients (4.3%) and complete or nearly complete TME was achieved in 94 patients (81%). More than a half of the procedures were performed using the minimally invasive surgery. No patient died. CONCLUSION: Despite the high rate of technically difficult cases (male sex, tumours in the distal third of the rectum), the robotic assisted treatment showed best results in our study group in terms of quality of the mesorectal excision. Our results thus provide evidence of an unequivocal benefit of robotic assistance compared to manual laparoscopy and open procedures in terms of TME as a quality indicator of surgery in patients with CR. Given the limited time span, there are no long-term results to be assessed in our patients.Key words: rectal carcinoma - TME - evaluation of surgical treatment - robotic rectal surgery.

[Parametric monitoring of the quality of total mesorectal excision and surgical treatment of rectal carcinoma results of a multicenter study]. / Parametrické sledování kvality totální mezorektální excize a chirurgické lécby karcinomu rekta výsledky multicentrické studie.

INTRODUCTION: Tumour size and the quality of its complete surgical removal are the main prognostic factors in rectal cancer treatment. The number of postoperative local recurrences depends on whether the mesorectum has been completely removed - total mesorectal excision (TME) - and whether tumour-free resection margins have been achieved. The surgery itself and its quality depend on the accuracy of preoperative diagnosis and detection of risk areas in the rectum and mesorectum, on the surgeons skills, and finally on pathological assessment evaluating whether complete tumour excision has been accomplished including circumferential margins of the tumour, and whether mesorectal excision is complete. The aim of our study was to implement and standardize a new method of evaluation of the quality of the surgical procedure - TME - in rectal cancer treatment using an assessment of its circumferential margins (CRO) and completeness of the excision. METHODS: The study consisted of two parts. The first, multi-centre retrospective phase with 288 patients analysed individual partial parameters of the diagnosis, operations and histological examinations of the rectal cancer. Critical points were identified and a unified follow-up protocol was prepared. In the second, prospective part of this study 600 patients were monitored parametrically focusing on the quality of the TME and its effect on the oncological treatment results. RESULTS: The proportion of patients with restaging following neoadjuvant therapy increased from 60.0% to 81.7% based on preoperative diagnosis. The number of specimens missing an assessment of the mesorectal excision quality decreased from 52.9% in the retrospective part of to the study to 22.8% in the prospective part. The proportion of actually complete TMEs rose from 22.6% to 26.0%, and that of nearly complete TMEs from 10.1% to 24.0%. CONCLUSION: The introduction of parametric monitoring into routine clinical practice improved the quality of pre-treatment and preoperative diagnosis, examination of the tissue specimen, and consequently improved quality of the surgical procedure was achieved. KEY WORDS: rectal cancer TME - parametric monitoring - quality control.

[Da Vinci assisted surgery for rectal cancer - preliminary results of nonrandomized trial]. / Da Vinci asistovaná lécba karcinomu rekta - prubezné výsledky nerandomizované studie.

INTRODUCTION: The incidence of colorectal cancer (CRC) in the Czech Republic is reported to be one of the highest on the global scale. Radical tumor removal has been observed to be the most effective part in the context of current multimodal therapy. The authors present their preliminary results of robotic assisted treatment of rectal carcinoma (RC). METHOD: The observed group includes 61 patients who underwent robotic assisted treatment for rectal cancer. The data were collected prospectively in the last 31 patients. Analyses were conducted on epidemiological data, perioperative outcomes, complications and oncological results. RESULTS: Robotic assisted treatment of RC was performed in 61 patients: 34 men and 27 women, mean age of 62 years (33-80). Neoadjuvant oncological treatment was indicated in 46% of the patients. Average blood loss was 187 ml, transfusions were administered in three cases. Conversion to open procedure was performed 6 times, and 16 patients had postoperative complications. Anastomotic leak was observed in 10% of the patients, and 4 patients undewent surgical treatment. No patient died. Local recurrence of the cancer was diagnosed in 3 (5%) patients. The quality of mesorectal excision (ME) and the circumferential resection margin [(y)pCRM] have been determined in 27 patients since 2013. Positive (y)pCRM was recorded in two cases and incomplete ME was observed in 25.8% of the patients. CONCLUSION: Surgical treatment for RC is pivotal in multimodal therapy. Our preliminary results are similar to the conclusions in other published studies. The da Vinci robotic system is a safe manipulator in the treatment of RC and provides indisputable benefits to the surgeon when operating in the narrow pelvic space. However, the benefits of robotic treatment in abdominal surgery are yet to be evaluated in patients (with respect to long-term results, sufficient number of patients or a high EBM level of evidence). The high purchase price of the robotic device, individual instruments with equipment and non-systemic compensation constitute a significant hindrance that prevents wider use of the robotic system in the treatment of RC and other abdominal malignancies in the Czech Republic.

Comparing over-the-scope clip versus endoloop and clips (KING closure) for access site closure: a randomized experimental study.

BACKGROUND: A safe technique is essential for successful access site closure in Natural Orifice Translumenal Endoscopic Surgery (NOTES) and for closures of iatrogenic perforations. AIM: To compare an over-the-scope clip (OTSC) versus an endoloop + endoclips closure technique (KING closure). METHODS: 40 minipigs underwent NOTES peritoneoscopy with liver biopsy. Gastrotomies and rectotomies were closed with OTSC (n = 20; 10× stomach, 10× rectum) or KING closure (n = 20; 10× stomach, 10× rectum). The animals were euthanized 28 days after the procedure. The main outcome variables were technical feasibility, effectiveness, and healing. RESULTS: Stomach: All but one closure (KING) was successfully completed. The times of closure were similar between the techniques. At necropsy, all access sites were healed. In two animals (1× KING, 1× OTSC), an abscess, probably related to the closure technique, was found. Histologically, transmural healing with muscular bridging was observable in nine pigs for KING versus two pigs for OTSC closure (p = 0.003). Inflammation was present in three pigs for KING versus seven pigs for OTSC closure (p = 0.08). Rectum: All closures were successfully completed. The times of closure were similar between the techniques. At necropsy, all closure sites had healed. Transmural healing with muscular bridging was present in nine pigs for KING versus two pigs for OTSC closure (p = 0.003). Inflammation was present in two pigs for KING versus seven pigs for OTSC closure (p = 0.03). In one animal (OTSC), an enterocolic fistula developed in the proximity of the closure site. CONCLUSIONS: OTSC and KING closure are comparable closure techniques in terms of technical feasibility and effectiveness. KING closure provides a superior histological outcome compared with OTSC closure.

[Cooperation between the volunteer bone marrow donor section at the Institute of Hematology and Blood Transfusion, Prague, and the Caitlin Raymond Registry of Bone Marrow Donor Banks. 1 year experience]. / Spolupráce stanice dobrovolných dárcu kostní drene v Ustavu hematologie a krevní transfúze, Praha, a Caitlin Raymond Registry of Bone Marrow Donor Banks. Rocní zkusenosti.

The authors report on their one-year experience of co-operation with the Caitlin Raymond Registry of Bone Marrow Donor Banks in the selection of suitable bone marrow donors. Out of the 280 requirements received a total of seven donors were singled out - identical in HLA-AB antigens though unsuitable in the DR system.