Rectal stenosis after circular mechanical anastomosis; the influence of stapler size.

BACKGROUND: The incidence of benign anastomotic stenosis (BAS) after radical surgery for rectal cancer ranges from 2 to 30%. There are few data regarding the factors related to its occurrence. One of these factors is the diameter of the circular mechanical staplers (CMS) used. METHODS: Observational study with prospective data recording of consecutive patients with non-disseminated rectal cancer operated on at two hospitals with special dedication to rectal cancer. Patients underwent low anterior resection (LAR) of the rectum with colorectal anastomosis created using CMS of diameters of either 28-29 or 31-33 mm. The primary endpoint was BAS. Secondary variables were demographic and patient-dependent data, and preoperative, intraoperative, immediate postoperative and mid-term data. The incidence of BAS was compared in the groups in which the different stapler diameters were used. RESULTS: Between 2012 and 2022, 239 patients were included. BAS was recorded in 39 (16.3%). In the analysis of factors related to its occurrence, the only significant variable was stapler diameter (p = 0.002, 95% CI 7.27-23.53), since rates of BAS were lower in the 31-33 mm group. Similarly, in the logistic regression analysis, stapler size was not associated with postoperative complications or anastomotic dehiscence (OR 3.5, 95% CI 1.2-10.5). Comparing stapler groups, BAS was detected in 35 of 165 patients (21%) in the 28-29 mm group but in only four out of 74 (5.6%) in the 31-33 mm group (p = 0.002, 95% CI 7.27-23.53). Ileostomy closure took longer and was less frequent in the 28-29 mm group. CONCLUSIONS: The rate of BAS after LAR was not negligible, since it was recorded in 39 of 239 patients (16.3%). The use of a 31-33 mm CMS was associated with a lower incidence of BAS. Therefore, the use of larger staplers is tentatively recommended; however, clinical trials are now required to confirm these results.

Transanal versus laparoscopic total mesorectal excision for mid and low rectal cancer (Ta-LaTME study): multicentre, randomized, open-label trial.

BACKGROUND: Transanal total mesorectal excision (TaTME) is a minimally invasive surgical technique that tries to avoid conversion to open surgery. However, specific intraoperative complications and local recurrences have cast some doubt on the suitability of the technique. The primary endpoint of the present study was a composite outcome of conversion surgery. Secondary objectives were to assess postoperative recovery, and pathological and oncological outcomes. METHODS: This was a prospective, multicentre, randomized, controlled open-label study of patients diagnosed with mid and low rectal adenocarcinoma who underwent laparoscopic TaTME or laparoscopic total mesorectal excision (LaTME). The TaTME technique comprised intracorporeal resection and anastomosis. Main outcomes were conversion to open surgery. Secondary outcomes were postoperative morbidity, mortality, pathological, oncological results, and survival. Modified intention-to-treat (mITT) and per-protocol analyses were performed. RESULTS: The study was conducted between April 2015 and May 2021. Patients were randomized to the LaTME (57 patients) or TaTME (59) group. Fifty patients from the LaTME group and 55 from the TaTME group were eligible for mITT analysis. The procedure was converted to open surgery in 11 patients (11 per cent): 10 (20 per cent) in the LaTME group and 1 (2 per cent) in the laparoscopic TaTME group (difference 18.8, 95 per cent c.i. 30 to 7; P = 0.003). No significant differences were found in terms of postoperative recovery and morbidity at 30 days; nor were there significant differences in anastomotic leakage, although it was less common in laparoscopic TaTME. With a median follow-up of 39 months, there were three instances of local recurrence (6.1 per cent) in the LaTME group and one (1.8 per cent) in the laparoscopic TaTME group (95 per cent c.i. 60 to 69; P = 0.3). Registration number: NCT02550769 (http://www.clinicaltrials.gov). CONCLUSION: The conversion rate was significantly lower in laparoscopic TaTME than in LaTME. At centres with experienced surgeons, laparoscopic TaTME can avoid conversion to open surgery.

Prospective evaluation of bowel dysfunction after rectal cancer surgery.

PURPOSE: Bowel dysfunction after rectal cancer surgery may significantly affect the quality of life. Our study aimed to estimate the incidence and characterize the low anterior resection syndrome (LARS). METHODS: Prospective evaluation of patients treated with anterior resection for rectal cancer at two hospitals followed for 12 months after ileostomy reversal. The assessment was performed at baseline, after neoadjuvant treatment, and 1 month, 6 months, and 12 months after bowel transit reconstruction using several scores (Bristol scale, LARS score, Memorial Sloan Kettering bowel function instrument, Fecal Incontinence Quality of Life, EORTC-QLQ30, and a visual analogue scale). RESULTS: Of 205 patients diagnosed with rectal cancer, 78 were followed for 12 months after the exclusion criteria. "Major LARS" at 1 month, 6 months, and 12 months was 55.6%, 47.3%, and 34.6%, respectively. At 12 months, patients experienced significantly less diarrhea, higher LARS score, more percentage of "major LARS," and worse MSK-BFI score compared to baseline. Regarding the quality of life at 12 months, 77.7% of patients with "major LARS" reported impact according to the anchor question of the LARS score; all FIQL subscales were significantly lower; the overall EORTC-QLQ30 score and the functional subscales significantly correlated with the LARS and the MSK-BFI scores. CONCLUSIONS: Bowel dysfunction with an impact on the quality of life is common after rectal cancer surgery. The knowledge of the potential consequences of the treatments is essential to be able to provide patients with the best possible information.

Endoscopic treatment (endoscopic balloon dilation/self-expandable metal stent) vs surgical resection for the treatment of de novo stenosis in Crohn's disease (ENDOCIR study): an open-label, multicentre, randomized trial.

BACKGROUND: Stenosis is one of the most common complications in patients with Crohn's disease (CD). Endoscopic balloon dilation (EBD) is the treatment of choice for a short stenosis adjacent to the anastomosis from previous surgery. Self-expandable metal stents (SEMS) may be a suitable treatment option for longer stenoses. To date, however, there is no scientific evidence as to whether endoscopic (EBD/SEMS) or surgical treatment is the best approach for de novo or primary stenoses that are less than 10 cm in length. METHODS/DESIGN: Exploratory study as "proof-of-concept", multicentre, open-label, randomized trial of the treatment of de novo stenosis in the CD; endoscopic treatment (EBD/SEMS) vs surgical resection (SR). The type of endoscopic treatment will initially be with EDB; if a therapeutic failure occurs, then a SEMS will be placed. We estimate 2 years of recruitment and 1 year of follow-up for the assessment of quality of life, costs, complications, and clinical recurrence. After the end of the study, patients will be followed up for 3 years to re-evaluate the variables over the long term. Forty patients with de novo stenosis in CD will be recruited from 15 hospitals in Spain and will be randomly assigned to the endoscopic or surgical treatment groups. The primary aim will be the evaluation of the patient quality of life at 1 year follow-up (% of patients with an increase of 30 points in the 32-item Inflammatory Bowel Disease Questionnaire (IBDQ-32). The secondary aim will be evaluation of the clinical recurrence rate, complications, and costs of both treatments at 1-year follow-up. DISCUSSION: The ENDOCIR trial has been designed to determine whether an endoscopic or surgical approach is therapeutically superior in the treatment of de novo stenosis in CD. TRIAL REGISTRATION: ClinicalTrials.gov NCT04330846. Registered on 1 April 1 2020. https://clinicaltrials.gov/ct2/home.

Ingested foreign bodies: do we need a specific approach when treating inmates?

The management of foreign bodies in the gastrointestinal tract is not standardized. Foreign body ingestions in prisoners are always intentional and inmates can be manipulative, which makes medical decision even more difficult. Our objective is to propose a decisional algorithm for management of foreign body ingestion in prisoners. We reviewed the records of 198 admissions for foreign body ingestion for a 10-year period. Type and number of ingested foreign bodies, radiographic findings, outcome as well as the management method including conservative, endoscopic removal, or surgical treatment were analyzed. Most cases were managed conservatively (87.6%). Endoscopy of the upper gastrointestinal tract was performed in 37 cases with a success rate of 46 per cent. In 9.3 per cent of cases, the final treatment was endoscopic. Only five patients required surgical treatment, being emergent just in one case. We advocate conservative treatment for asymptomatic patients with foreign body ingestion. Endoscopic removal is proposed for pointed objects or objects bigger than 2.5 cm located in the stomach. Objects longer than 6 to 8 cm located in the stomach should be removed by endoscopy or laparoscopy. Patients with objects in the small bowel or colon should be treated conservatively unless there are complications or they fail to progress.