Systematic review of functional outcomes and quality of life after transanal endoscopic microsurgery and transanal minimally invasive surgery: a word of caution.

PURPOSE: The introduction of transanal endoscopic or minimally invasive surgery has allowed organ preservation for rectal tumors with good oncological results. Data on functional and quality-of-life (QoL) outcomes are scarce and controversial. This systematic review sought to synthesize fecal continence, QoL, and manometric outcomes after transanal endoscopic microsurgery (TEM) or transanal minimally invasive surgery (TAMIS). METHODS: A systematic review of the literature including Medline, Embase, and the Cochrane Library databases was conducted searching for articles reporting on functional outcomes after TEM or TAMIS between January 1995 and June 2018. The evaluated outcome parameters were pre- and postoperative fecal continence (primary endpoint), QoL, and manometric results. Data were extracted using the same scales and measurement units as from the original study. RESULTS: A total of 29 studies comprising 1297 patients were included. Fecal continence outcomes were evaluated in 23 (79%) studies with a wide variety of assessment tools and divergent results. Ten studies (34%) analyzed QoL changes, and manometric variables were assessed in 15 studies (51%). Most studies reported some deterioration in manometric scores without major QoL impairment. Due to the heterogeneity of the data, it was not possible to perform any pooled analysis or meta-analysis. CONCLUSIONS: These techniques do not seem to affect continence by themselves except in minor cases. The possibility of worsened function after TEM and TAMIS should not be underestimated. There is a need to homogenize or standardize functional and manometric outcomes assessment after TEM or TAMIS.

Selective approach for upper rectal cancer treatment: total mesorectal excision and preoperative chemoradiation are seldom necessary.

BACKGROUND: The implementation of preoperative chemoradiation combined with total mesorectal excision has reduced local recurrence rates in rectal cancer. However, the use of both types of treatment in upper rectal cancer is controversial. OBJECTIVE: The purpose of this work was to assess oncological results after radical resection of upper rectal cancers compared with sigmoid, middle, and lower rectal cancers and to determine risk factors for local recurrence in upper rectal cancer. DESIGN: This was a retrospective analysis of prospectively collected data. SETTINGS: This study was conducted in a tertiary care referral hospital in Valencia, Spain. PATIENTS: Analysis included 1145 patients who underwent colorectal resection with primary curative intent for primary sigmoid (n = 450), rectosigmoid (n = 70), upper rectal (n = 178), middle rectal (n = 186), or lower rectal (n = 261) cancer. MAIN OUTCOME MEASURES: Oncological results, including local recurrence, disease-free survival, and cancer-specific survival, were compared between the different tumor locations. Univariate and multivariate analyses were performed to identify risk factors for local recurrence in upper rectal cancer. RESULTS: A total of 147 patients (82.6%) with upper rectal tumors underwent partial mesorectal excision, and only 10 patients (5.6%) of that group received preoperative chemoradiation. The 5-year actuarial local recurrence, disease-free survival, and cancer-specific survival rates for upper rectal tumors were 4.9%, 82.0%, and 91.6%. Local recurrence rates showed no differences when compared among all of the locations (p = 0.20), whereas disease-free survival and cancer-specific survival were shorter for lower rectal tumors (p = 0.006; p = 0.003). The only independent risk factor for local recurrence in upper rectal cancer was an involved circumferential resection margin at pathologic analysis (HR, 14.23 (95% CI, 2.75-73.71); p = 0.002). LIMITATIONS: This was a single-institution, retrospective study. CONCLUSIONS: Most upper rectal tumors can be treated with partial mesorectal excision without the systematic use of preoperative chemoradiation. Involvement of the mesorectal fascia was the only independent risk factor for local recurrence in these tumors.

[Laparoscopic approach of achalasia. Long-term clinical and functional results and quality of life]. / Abordaje laparoscópico de la acalasia. Resultados clínicos, de calidad de vida y funcionales a largo plazo.

INTRODUCTION: Laparoscopic Heller myotomy has become the gold standard procedure for patients with achalasia. This study evaluates the clinical status, quality of life, and functional outcomes after laparoscopic Heller myotomy. MATERIAL AND METHODS: We analyzed patients who underwent laparoscopic Heller myotomy with an associated anti-reflux procedure from October 1998 to December 2010. Before surgery, we administered a clinical questionnaire and as of 2002, we also evaluated quality of life using a specific questionnaire (GIQLI). In 2011, we performed a follow up for all available patients. We administered the same clinical questionnaire and quality of life test as before surgery and performed manometry and 24-hour pH monitoring. According to the length of follow up, patients were divided into 3 groups. Group 1 with a follow-up between 6 and 47 months; group 2 follow-up between 48 and 119 months, and group 3 with a follow-up of more than 120 months). Moreover, 27 patients had already been evaluated with this same protocol in 2003. Pre- and postoperative data were compared for the 3 groups and for patients who completed follow up in 2003 and 2011. RESULTS: Ninety-five patients underwent laparoscopic Heller myotomy. Seventy-six (80%) were available for follow-up. Mean follow-up was 56 months (range 6-143). Global improvement in dysphagia was 89%. Total DeMeester score decreased in the 3 groups. GIQLI scores improved after surgery, reaching normal values. Manometric determinations showed normal LES pressures after myotomy in the 3 groups. Ten percent of overall 24-hour pH monitoring was abnormal. The group of patients followed up in 2003 and in 2011 showed no impairment in the variables studied in the long term. CONCLUSIONS: Long-term follow up of the laparoscopic approach to achalasia showed good results concerning clinical status and quality of life, with normal sphincteric pressures and a low incidence of gastroesophageal reflux.

[Surgical treatment of achalasia: Better than dilations?]. / Tratamiento quirúrgico de la acalasia: ¿mejor que las dilataciones?

Achalasia is an infrequent esophageal disease that severely impairs the quality of life of affected individuals. The etiology of this entity is not well defined and its main clinical features are dysphagia and regurgitation. The treatment of achalasia continues to be palliative and is aimed at providing functional and symptomatic relief through opening of the lower esophageal sphincter. The present article describes and evaluates the medical and surgical treatments most commonly used in clinical practice after the introduction of minimally invasive surgery, which has represented an important addition to the therapeutic alternatives. Currently, the most appropriate initial option is laparoscopic surgery, while pneumatic dilatation and botulinum toxin injection should be reserved for selected patients.

Laparoscopic approach to retrorectal tumors: review of the literature and report of 4 cases.

BACKGROUND: Retrorectal or presacral tumors are extremely rare and their histologic origin varies greatly. Surgical excision is indicated to prevent complications or to rule out malignancy. A laparoscopic approach has been infrequently reported to date. The aim of this article is to report our experience in 4 cases, and to review the current world experience on laparoscopic approach to retrorectal tumors. METHODS: Between 1998 and 2009, we operated 4 cases in which a presacral tumor was diagnosed. A pure laparoscopic procedure was performed in 3 cases and a combined laparoscopic/transacral approach in a fourth. In addition, a systematic literature review and relevant reports on laparoscopic approach of these tumors were analyzed. RESULTS: All patients underwent laparoscopic dissection of the tumor with extraction through a Phannestiel incision except in 1 case that was performed transsacrally. Simultaneously, the literature review showed 11 articles with a total number of 18 patients approached by laparoscopy. CONCLUSIONS: The laparoscopic approach of retrorectal tumors is feasible. The advantages are an enhanced access and visualization of the pelvic structures and a more controlled preservation of nerve and vascular integrity. It seems to be a safe procedure and can be combined with a posterior approach if needed.