Geert W. M. Tetteroo

Treatment of recurrence after transanal endoscopic microsurgery (TEM) for T1 rectal cancer.

PURPOSE: The aim of this study was to evaluate the management and outcome of local recurrences after transanal endoscopic microsurgery for T1 rectal cancer. METHODS: Consecutive patients who underwent transanal endoscopic microsurgery for pT1 rectal cancer at a Dutch referral center (IJsselland Hospital) were registered in a prospective database. Follow-up was according to Dutch guidelines on rectal cancer, with additional rigid rectoscopy and endorectal ultrasound examinations every 3 months for the first 2 years, and every 6 months thereafter. Annual MRI of the lesser pelvis was added during the last 2 years of the study. Patients with local recurrence during follow-up were selected for individual analysis of outcome. RESULTS: Of a total of 88 patients who underwent transanal endoscopic microsurgery for pT1 rectal cancer, 18 patients (20.5%) had a local recurrence. Median time to local recurrence was 10 (range, 4–50) months. Median age at diagnosis of recurrence was 74 (range, 56–84) years. Of the 18 patients, 2 did not undergo further surgery because of concomitant metastatic disease, and 16 underwent salvage surgery, without need for multivisceral resections. No postoperative mortality was observed. In 15 patients (94%), a microscopically negative excision margin was obtained; in 1 patient, the excision margin was microscopically positive. Median follow-up after salvage surgery was 20 (range, 2–112) months. One patient had a local renewal of recurrence, and 7 patients (39%) had distant metastases. At 3 years, overall survival was 31%; cancer-related survival was 58%. CONCLUSIONS: Recurrent disease after transanal endoscopic microsurgery for T1 rectal cancer is a major problem. Although salvage surgery for achieving local control is feasible in most patients, survival is limited, mainly because of distant metastases. Tailoring selection of T1 rectal cancers and exploring possible adjuvant treatment strategies following salvage procedures should be the next steps toward improving survival.

Transanal endoscopic microsurgery is superior to transanal excision of rectal adenomas

Aim  Comparison of transanal excision (TE) and transanal endoscopic microsurgery (TEM) of rectal adenomas (RA) has rarely been performed.

Transanal endoscopic microsurgery for rectal cancer

If curation is intended for rectal cancer, total mesorectal excision with autonomic nerve preservation (TME) is the gold standard. Transanal resection is tempting because of low mortality and morbidity rates. However, inferior tumour control, provoked by the limitations of the technique, resulted in its cautious application and use mainly for palliation. Transanal endoscopic microsurgery (TEM) is a minimal invasive technique for the local resection of rectal tumours. It is a one-port system, introduced transanally. An optical system with a 3D-view, 6-fold magnification and resolution as the human eye, together with the creation of a stabile pneumorectum, and specially designed instruments allow full-thickness excision under excellent view and a proper histological examination. The technique can also be applied for larger and more proximal tumours. Mortality, morbidity as well as incomplete excision rates are minimal. Local recurrence and survival rates seem comparable to TME in early rectal cancer. TEM is the method of choice when local resection of rectal cancer is indicated. Results justify a re-evaluation of the indications for the local excision of rectal cancer with a curative intent.

Transanal endoscopic microsurgery is feasible for adenomas throughout the entire rectum: A prospective study

INTRODUCTION: Transanal endoscopic microsurgery for rectal adenomas is safe and has low recurrence rates. However, the feasibility of the procedure for all rectal adenomas is unclear. This issue was investigated prospectively. METHODS: From 1996 to 2007, 353 consecutive rectal adenomas were evaluated according to a standard protocol. Transanal endoscopic microsurgery was intended in all rectal adenomas. RESULTS: The median diameter was 3 cm and median distance was 8 cm. The peritoneum was opened peroperatively without any adverse effects in 8.7 percent. The conversion rate was 9.6 percent, with an alternative local procedure performed in 4.2 percent and a transabdominal procedure performed in 5.4 percent. Conversion rate correlated with the distance of the tumor (P = 0.007) and the operating surgeons level of experience (P = 0.004). The median operation time was 45 minutes. Operation time correlated with specimen area, experience, and operating surgeon (all P < 0.001). All rectal adenomas were excised in one piece. Complete margins were observed in 85 percent. Rectal adenomas with incomplete margins were larger (P < 0.001) and were located more proximally (P < 0.001). Morbidity was 7.8 percent and mortality 0.6 percent. The median hospital stay was four days. The median follow-up was 27 months. The recurrence rate at three years was 9.1 percent. The median time from operation to recurrence was 12 (range, 4-54) months. Resection margin status was a predictor of recurrence, with 6.1 percent recurrence in cases of complete margins and 25.2 percent in cases of incomplete margins (P < 0.001). CONCLUSIONS: For nearly all rectal adenomas, transanal endoscopic microsurgery is safe, feasible, and has excellent results.

High tie versus low tie in rectal surgery: comparison of anastomotic perfusion

PurposeBoth “high tie” (HT) and “low tie” (LT) are well-known strategies in rectal surgery. The aim of this study was to compare colonic perfusion after HT to colonic perfusion after LT.MethodsPatients undergoing rectal resection for malignancy were included. Colonic perfusion was measured with laser Doppler flowmetry, immediately after laparotomy on the antimesenterial side of the colon segment that was to become the afferent loop (measurement A). This measurement was repeated after rectal resection (measurement B). The blood flow ratios (B/A) were compared between the HT group and the LT group.ResultsBlood flow was measured in 33 patients, 16 undergoing HT and 17 undergoing LT. Colonic blood flow slightly decreased in the HT group whereas the flow increased in the LT group. The blood flow ratio was significantly higher in the LT group (1.48 vs. 0.91; p = 0.04), independent of the blood pressure.ConclusionThis study shows the blood flow ratio to be higher in the LT group. This suggests that anastomoses may benefit from better perfusion when LT is performed.

Ultracision Harmonic Scalpel and multifunctional tem400 instrument complement in transanal endoscopic microsurgery: a prospective study

BackgroundFor transanal endoscopic microsurgery, the ultracision Harmonic Scalpel (UC) and the multifunctional TEM400 instrument (T400) seem advantageous. This study investigated their clinical use.MethodsProspective analysis of tumor, patient, and operation characteristics was performed for 196 tumor resections per instrument intended for application.ResultsThe T400 instrument was applied in 162 operations, and the UC in 34 operations. Tumor and patient characteristics were similar except for tumor area (respectively, 7.5 and 17 cm2; p = 0.003). Operative time was proportionate to the tumor area (p < 0.001) and inversely proportionate to its distance from the dentate line to the lower margin of the tumor of the UC (p = 0.002). Application reduced operative time by 26% (p = 0.02, corrected for area). Whereas, T400 was always singly sufficient for excision, the UC required T400 application in 50% of operations, especially for larger tumors (p = 0.026), with the result that more rectal wall circumference was captured (p = 0.043). Both groups had similar safety parameters.ConclusionsThe UC substantially reduced operative time compared with the T400, but frequently required the T400 for procedure completion. The T400 is always singly sufficient.

Local Formalin Instillation: An Effective Treatment for Uncontrolled Radiation-Induced Hemorrhagic Proctitis

Aim: The aim of this study was to evaluate the efficacy of local instillation of 4% formalin in the management of uncontrolled radiation-induced and ischemic hemorrhagic proctitis. Patients and Methods: Eight patients were reviewed. Operation characteristics, morbidity and long-term results were analyzed. Results: All patients were followed for a median of 18 months. In 5 patients the bleeding stopped after a single treatment and in 3 after a second one. During follow-up no recurrent rectal bleeding occurred, no further medical treatment was needed and in all patients the complaints had disappeared. Conclusion: Local instillation of 4% formalin is an effective treatment for uncontrolled radiation-induced and ischemic hemorrhagic proctitis.

Preoperative Radiotherapy Has No Value for Patients with T2–3, N0 Adenocarcinomas of the Rectum

Background: Treatment of rectal cancer with preoperative radiotherapy followed by total mesorectal excision is nowadays the standard treatment. It reduces local recurrences and improves overall survival. However, in patients with T2–3, N0 rectal cancer, the role of preoperative radiotherapy remains controversial. The aim of this study was to review the benefit of radiotherapy in T2 and T3, N0 rectal cancer patients. Methods: Between 1996 and 2003, 103 patients with T2–3, N0 rectal cancer were identified in our prospective database. This study evaluated time to local recurrence, distant metastases and overall survival. Results: Median follow-up was 4.3 years. The 5-year local control rate was 94%. The 5-year overall survival was 65%. The 5-year disease-free survival rate was 82%. Preoperative radiotherapy did not show any statistical differences. Abdominal perineal resection and T3 tumors negatively influenced overall survival (p = 0.02). Advanced age was of significant importance in overall survival. Conclusions: Preoperative radiotherapy does not seem to be of significant importance in patients with T2–3, N0 rectal cancer regarding local recurrence and survival. Since preoperative radiotherapy is associated with short- and long-term morbidity, patients with T2–3, N0 tumors should be identified and treated with surgery alone.

Malignant fibrous histiocytoma of the sigmoid: a case report and review of the literature

BackgroundMalignant fibrous histiocytoma (MFH) in the large bowel, which is composed of spindle-shaped cells arranged in a pleiomorphic and storiform pattern, is an extremely rare tumor.MethodsWe in this study report on a case of a 73-year-old man with a sarcoma arising from a diverticular sigmoid without any signs of involvement of regional lymph nodes or metastasis to liver or the abdomen.ResultsA sigmoid resection was performed with an uneventful postoperative course. Microscopically, the tumor consisted of bundles of spindle-shaped and pleiomorphic multinucleated cells without differentiation characteristics for other tumors than MFH.SummarySince the late 1970s, only 22 case reports of colorectal MFH have been documented, and little is known about its histogenesis and optimal treatment. A review of the cases and the world literature on immunohistochemistry and treatment is given.

Completeness of pathology reports in stage II colorectal cancer

Abstract Introduction: The completeness of the pathological examination of resected colon cancer specimens is important for further clinical management. We reviewed the pathological reports of 356 patients regarding the five factors (pT-stage, tumor differentiation grade, lymphovascular invasion, tumor perforation and lymph node metastasis status) that are used to identify high-risk stage II colon cancers, as well as their impact on overall survival (OS). Methods: All patients with stage II colon cancer who were included in the first five years of the MATCH study (1 July 2007 to 1 July 2012) were selected (n = 356). The hazard ratios of relevant risk factors were calculated using Cox Proportional Hazards analyses. Results: In as many as 69.1% of the pathology reports, the desired information on one or more risk factors was considered incomplete. In multivariable analysis, age (HR: 1.07, 95%CI 1.04–1.10, p < .001), moderately- (HR: 0.35, 95%CI 0.18–0.70, p = .003) and well (HR 0.11, 95%CI 0.01–0.89, p = .038) differentiated tumors were significantly associated with OS. Conclusions: Pathology reports should better describe the five high-risk factors, in order to enable proper patient selection for further treatment. Chemotherapy may be offered to stage II patients only in select instances, yet a definitive indication is still unavailable.