Dimitrios Christoforidis

Transanal endoscopic microsurgery versus conventional transanal excision for patients with early rectal cancer.

Objective:To compare transanal endoscopic microsurgery (TEMS) with conventional transanal excision (TAE) in terms of the quality of resection, local recurrence, and survival rates in patients with stage I rectal cancer. Background:Although TEMS is often considered a superior surgical technique to TAE, it is poorly suited for excising tumors in the lower third of the rectum. Such tumors may confer a worse prognosis. Methods:We retrospectively reviewed information on all patients with stage pT1 and pT2 rectal adenocarcinoma who underwent local excision from 1997 through mid-2006. We excluded patients with node-positive, metastatic, recurrent, previously irradiated, or snare-excised tumors. Results:Our study included 42 TEMS and 129 TAE patients. We found no significant differences in patient characteristics, adjuvant therapy, tumor stage, or adverse histopathologic features. In the TAE group, 52 (40%) of tumors were <5 cm from the anal verge (AV); in the TEMS group, only 1 (2%) (P = 0.0001). Surgical margins were less often positive in the TEMS group (2%) than in the TAE group (16%) (P = 0.017). For patients with tumors ≥5 cm from the AV, the estimated 5-year disease-free survival (DFS) rate was similar between the TEMS group (84.1%) and the TAE group (76.1%) (P = 0.651). But within the TAE group, the estimated 5-year DFS rate was better for patients with tumors ≥5 cm from the AV (76.1%) vs. <5 cm from the AV (60.5%) (P = 0.029). In our multivariate analysis, the tumor distance from the anal verge, the resection margin status, the T stage, and the use of adjuvant therapy—but not the surgical technique (i.e., TEMS or TAE) itself—were independent predictors of local recurrence and DFS. Conclusions:The quality of resection is better with TEMS than with TAE. However, the apparently better oncologic outcomes with TEMS can be partly explained by case selection of lower-risk tumors of the upper rectum.

Transanal endoscopic microsurgery resection of rectal tumors: Outcomes and recommendations

PURPOSE: Transanal endoscopic microsurgery provides a minimally invasive alternative to radical surgery for excision of benign and malignant rectal tumors. The purpose of this study was to review our experience with transanal endoscopic microsurgery to clarify its role in the treatment of different types of rectal pathology. METHODS: A prospective database documented all patients undergoing transanal endoscopic microsurgery from October 1996 through June 2008. We analyzed patient and operative factors, complications, and tumor recurrence. For recurrence analysis, we excluded patients with fewer than 6 months of follow-up, previous excisions, known metastases at initial presentation, and those who underwent immediate radical resection following transanal endoscopic microsurgery. RESULTS: Two hundred sixty-nine patients underwent transanal endoscopic microsurgery for benign (n = 158) and malignant (n = 111) tumors. Procedure-related complications (21%) included urinary retention (10.8%), fecal incontinence (4.1%), fever (3.8%), suture line dehiscence (1.5%), and bleeding (1.5%). Local recurrence rates for 121 benign and 83 malignant tumors were 5% for adenomas, 9.8% for T1 adenocarcinoma, 23.5% for T2 adenocarcinoma, 100% for T3 adenocarcinoma, and 0% for carcinoid tumors. All 6 (100%) recurrent adenomas were retreated with endoscopic techniques, and 8 of 17 (47%) recurrent adenocarcinomas underwent salvage procedures with curative intent. CONCLUSIONS: Transanal endoscopic microsurgery is a safe and effective method for excision of benign and malignant rectal tumors. Transanal endoscopic microsurgery can be offered for (1) curative resection of benign tumors, carcinoid tumors, and select T1 adenocarcinomas, (2) histopathologic staging in indeterminate cases, and (3) palliative resection in patients medically unfit or unwilling to undergo radical resection.

Treatment of Complex Anal Fistulas with the Collagen Fistula Plug

PurposeAnal fistulas that involve a significant amount of sphincter may be difficult to treat without compromising continence function. In this study, we evaluated our experience with the Surgisis® anal fistula plug, which was recently reported to be successful in >80 percent of patients with complex fistulas.MethodsWe retrospectively collected patient and fistula characteristics, procedure details, and follow-up information for all patients treated with the anal fistula plug at our institution from January 2006 through April 2007. The outcome was considered successful if the external opening was closed and if the patient had no drainage at the last follow-up. Using multivariate statistics, we analyzed the relationship between anal fistula plug success and several key variables.ResultsFrom January 2006 through April 2007, 47 patients with 49 complex anal fistulas underwent 64 anal fistula plug procedures. The median follow-up time for patients who were considered healed was 6.5 (range, 3–11) months. The success rate was 31 percent per procedure and 43 percent per patient. An increased amount of external sphincter involvement was associated with a higher failure rate (P < 0.05).ConclusionsIn our early experience with the anal fistula plug, 43 percent of patients with complex anal fistulas were successfully treated. Patients with less external sphincter involvement were more likely to heal.

Treatment of transsphincteric anal fistulas by endorectal advancement flap or collagen fistula plug: a comparative study.

PURPOSE: In this study we compared the outcomes of patients with complex cryptoglandular fistulas treated by endorectal advancement flap or anal fistula plug. METHODS: We performed a retrospective analysis of patients with transsphincteric anal fistulas treated by endorectal advancement flap or anal fistula plug from January 1996 through April 2007. Patients with noncryptoglandular fistulas or insufficient follow-up were excluded. Results were obtained with a combination of chart reviews, mailed questionnaire, and phone interviews. Success was defined as a closed external opening in absence of symptoms at a minimal follow-up time of six months. RESULTS: Forty-three patients had an endorectal advancement flap and 37 patients had an anal fistula plug procedure. The two cohorts were comparable for age, gender, smoking status, fistula type, and previous failed treatments. The success rate was 63 percent in the endorectal advancement flap group and 32 percent in the anal fistula plug group (P = 0.008), after a mean follow-up of 56 (range, 6-136) months for endorectal advancement flap and 14 (range, 6-22) months for anal fistula plug. CONCLUSIONS: The current study indicates that the endorectal advancement flap provides a higher success rate than the anal fistula plug. Randomized trials are needed to further elucidate the efficacy and potential functional benefit of the anal fistula plug in the treatment of complex anal fistulas.

Who Benefits From the Anal Fistula Plug

I f healing was the only concern with anal fistulas, fistulotomy would probably be the only way to go. Obviously, continence disturbance, surgical morbidity, and cost must all be taken in account when evaluating a new fistula therapy. The Surgisis anal fistula plug (AFP) has received a lot of attention over the past 5 years as a new modality to treat complex anal fistulas. Initial publications from Atlanta, Georgia, reported success rates of over 80% for both cryptoglandular and Crohn’s related complex anal fistulas. Continence disturbance with the AFP is conceptually hard to imagine and has not been reported so far. Morbidity related to the AFP seems to be low, with a rate of abscess formation of 4% to 29%. Interestingly, even cost may not be an issue according to an analysis from Canada which, using microcosting methodology on 12 patients, found that the AFP procedure was cheaper than the endorectal advancement flap procedure, even when adjusted for length of hospital stay. The cost advantage, not necessarily transposable in other health care systems, was mainly explained by the shorter operative time and a lower anesthesiologist fee calculated for the AFP procedure. It is not surprising that numerous surgeons have adopted this simple technique to try and relieve some of the frustration of their struggle with patients who have fistulas. However, most subsequent case series failed to reproduce the initial excellent healing rates. Skepticism rose but believers claimed that bad patient selection and inexperience with the placement method leading to early extrusions were responsible for the high failure rates. To this date, excluding studies on rectovaginal fistulas only, 22 publications have reported outcomes after treatment of anal fistulas with the AFP. The success rates are strikingly variable ranging from 14% to 87%. This variability has not decreased over time (Fig. 1) and could be explained in part by the following reasons. First, a learning curve effect with the technique and postoperative care may account for variable failures rates, in particular, those related to early extrusion of the AFP. A decrease of this effect can be expected assuming that the learning curve for the AFP is rather steep because it consists mainly of learning how to secure the AFP at the internal fistula opening. In addition, standardized patient care parameters are now available following a consensus conference in 2007. Second, the methodology in most studies suffers from their retrospective nature and frequently from insufficient follow-up. Fortunately, several randomized controlled trials have been registered across the world, most often comparing the AFP with the endorectal advancement flap, but also with the cutting seton method, the “ligation of intersphincteric fistula track” procedure, or “any surgeon’s preference.” So far, only one study has been published, which was prematurely interrupted because of an unacceptably high failure rate of 80% (12/15) in the AFP arm. Results from the other ongoing studies are eagerly awaited. Finally, the study populations across the different publications are often a case mix with different proportions of simple or complex, primary or recurrent, transsphincteric or rectovaginal fistulas, or cryptoglandular origin or related to Crohn’s disease. This renders comparisons of outcomes difficult and it also raises the key question concerning patient selection: who really benefits from the AFP? McGee et al in this issue of Diseases of the Colon & Rectum report their experience with the AFP in 41 patients treated over 39 months. The study group is rather homogeneous: all patients had transsphincteric fistulas of cryptoglandular origin, all but one had a single track, all were Dis Colon Rectum 2010; 53: 1105–1106 DOI: 10.1007/DCR.0b013e3181e27efb ©The ASCRS 2010 % Success 100

Transrectal specimen extraction after laparoscopic left colectomy: a case-matched study

Aim  Avoiding ‘mini‐laparotomy’ to extract a colectomy specimen may decrease wound complications and further improve recovery after laparoscopic surgery. The aim of this study was to develop a new technique for transrectal specimen extraction (TRSE) and to compare it with conventional laparoscopy (CL) for left sided colectomy.

Endocavitary contact radiation therapy for ultrasonographically staged T1 N0 and T2 N0 rectal cancer

The purpose of this study was to determine the long‐term outcomes of patients undergoing endocavitary contact radiation therapy (ECR) for stage I rectal cancer.

Pursestring closure of the stoma site leads to fewer wound infections: results from a multicenter randomized controlled trial.

BACKGROUND:Surgical site infection after stoma reversal is common. The optimal skin closure technique after stoma reversal has been widely debated in the literature. OBJECTIVE:We hypothesized that pursestring near-complete closure of the stoma site would lead to fewer surgical site infections compared with conventional primary closure. DESIGN:This study was a parallel prospective multicenter randomized controlled trial. SETTINGS:This study was conducted at 2 university medical centers. PATIENTS:Patients (N = 122) presenting for elective colostomy or ileostomy reversal were selected. INTERVENTIONS:Pursestring versus conventional primary closure of stoma sites were compared. MAIN OUTCOME MEASURES:Stoma site surgical site infection within 30 days of surgery, overall surgical site infection, delayed healing (open wound for >30 days), time to wound epithelialization, and patient satisfaction were the primary outcomes measured. RESULTS:The pursestring group had a significantly lower stoma site infection rate (2% vs 15%, p = 0.01). There was no difference in delayed healing or patient satisfaction between groups. Time to epithelialization was measured in only 51 patients but was significantly longer in the pursestring group (34.6 ± 20 days vs 24.1 ± 17 days, p = 0.02). LIMITATIONS:This study was limited by the variability in procedures and surgeons, the limited follow-up after 30 days, and the inability to perform blinding. CONCLUSION:Pursestring closure after stoma reversal has a lower risk of stoma site surgical site infection than conventional primary closure, although wounds may take longer to heal with the use of this approach. Registration number: NCT01713452 (www.clinicaltrials.gov).

Faecal incontinence in men

Aim  A few studies have specifically addressed faecal incontinence (FI) in men. We sought to describe patterns of male FI, assess treatment outcome and compare some aspects of FI between men and women, including quality of life.

The Unresolved Case of Sacral Chordoma: From Misdiagnosis to Challenging Surgery and Medical Therapy Resistance

Purpose A sacral chordoma is a rare, slow-growing, primary bone tumor, arising from embryonic notochordal remnants. Radical surgery is the only hope for cure. The aim of our present study is to analyse our experience with the challenging treatment of this rare tumor, to review current treatment modalities and to assess the outcome based on R status. Methods Eight patients were treated in our institution between 2001 and 2011. All patients were discussed by a multidisciplinary tumor board, and an en bloc surgical resection by posterior perineal access only or by combined anterior/posterior accesses was planned based on tumor extension. Results Seven patients underwent radical surgery, and one was treated by using local cryotherapy alone due to low performance status. Three misdiagnosed patients had primary surgery at another hospital with R1 margins. Reresection margins in our institution were R1 in two and R0 in one, and all three recurred. Four patients were primarily operated on at our institution and had en bloc surgery with R0 resection margins. One had local recurrence after 18 months. The overall morbidity rate was 86% (6/7 patients) and was mostly related to the perineal wound. Overall, 3 out of 7 resected patients were disease-free at a median follow-up of 2.9 years (range, 1.6-8.0 years). Conclusion Our experience confirms the importance of early correct diagnosis and of an R0 resection for a sacral chordoma invading pelvic structures. It is a rare disease that requires a challenging multidisciplinary treatment, which should ideally be performed in a tertiary referral center.