Jurriaan B. Tuynman

Transanal total mesorectal excision for rectal carcinoma: short-term outcomes and experience after 80 cases

AbstractBackgroundnLow anterior resection for distal and mid-rectal cancer is associated with high positive resection margins. Transanal total mesorectal excision (TaTME) is a new treatment in which the rectum is dissected transanally according to TME principles. The short-term results and oncological follow-up of the first 80 patients were described.MethodsnBetween June 2012 and September 2014, all patients in the Gelderse Vallei Hospital and the VU University Medical Center with histologically proven distal or mid-rectal carcinomas without evidence of distant metastases underwent TaTME. Patients with T4 tumors were excluded. Transanal mobilization was performed with the aid of a single port and endoscopic instruments according to TME criteria.nResultsnEighty patients were operated in a period of 2xa0years. Laparotomy was recommended and performed in four patients. Postoperative morbidity was 39xa0%. Ten (12xa0%) complications were graded as severe (Clavien–Dindo grade 3, 4 and 5) and needed re-intervention. Median operative time was 204xa0min (range 91–447). Median hospital stay was 8xa0days (range 3–41). Specimens were graded as complete in 88xa0% of the patients, nearly complete in 9xa0% and incomplete in 3xa0%. A positive circumferential resection margin (<2xa0mm) was observed in two patients. During the two and half years study period, a local recurrence was observed in two patients.ConclusionTaTME is a safe alternative to standard laparoscopic TME in selected low-risk patients with rectal carcinoma when treated by an experienced colorectal team. In the future, randomized trials are necessary to prove its oncological safety.

A multi-centred randomised trial of radical surgery versus adjuvant chemoradiotherapy after local excision for early rectal cancer

BackgroundRectal cancer surgery is accompanied with high morbidity and poor long term functional outcome. Screening programs have shown a shift towards more early staged cancers. Patients with early rectal cancer can potentially benefit significantly from rectal preserving therapy. For the earliest stage cancers, local excision is sufficient when the risk of lymph node disease and subsequent recurrence is below 5xa0%. However, the majority of early cancers are associated with an intermediate risk of lymph node involvement (5–20xa0%) suggesting that local excision alone is not sufficient, while completion radical surgery, which is currently standard of care, could be a substantial overtreatment for this group of patients.Methods/Study designIn this multicentre randomised trial, patients with an intermediate risk T1-2 rectal cancer, that has been locally excised using an endoluminal technique, will be randomized between adjuvant chemo-radiotherapylimited to the mesorectum and standard completion total mesorectal excision (TME). To strictly monitor the risk of locoregional recurrence in the experimental arm and enable early salvage surgery, there will be additional follow up with frequent MRI and endoscopy. The primary outcome of the study is three-year local recurrence rate. Secondary outcomes are morbidity, disease free and overall survival, stoma rate, functional outcomes, health related quality of life and costs. The design is a non inferiority study with a total sample size of 302 patients.DiscussionThe results of the TESAR trial will potentially demonstrate that adjuvant chemoradiotherapy is an oncological safe treatment option in patients who are confronted with the difficult clinical dilemma of a radically removed intermediate risk early rectal cancer by polypectomy or transanal surgery that is conventionally treated with subsequent radical surgery. Preserving the rectum using adjuvant radiotherapy is expected to significantly improve morbidity, function and quality of life if compared to completion TME surgery.Trial registrationNCT02371304, registration date: February 2015

Transanal minimally invasive rectal resection for deep endometriosis; a promising technique

Surgical management of patients with deep endometriosis (DE) of the rectum is difficult. Inflammation and subsequent adhesions due to DE impede access to the lower pelvis and may lead to complications during laparoscopic low anterior resection (LAR). Transanal minimally invasive surgery (TAMIS) is an alternative to an abdominal approach with potential advantages. The aim of this study was to provide a description of the TAMIS technique and to present the perioperative results of TAMIS and of conventional LAR in patients with DE.

Laparoscopic Imaging Techniques in Endometriosis Therapy: A Systematic Review.

Endometriosis is a common disease associated with pelvic pain and subfertility. Laparoscopic surgical treatment has proven effective in endometriosis, but is hampered by a high rate of recurrence. The aim of this systematic review was to evaluate the intraoperative identification of endometriosis by enhanced laparoscopic imaging techniques, focusing on sensitivity and specificity. A systematic review was conducted according to PRISMA guidelines in PubMed, Embase, Cochrane Library, and Web of Science. Published prospective studies reporting on enhanced laparoscopic imaging techniques during endometriosis surgery were included. General study characteristics and reported outcomes, including sensitivity and specificity, were extracted. Nine studies were eligible for inclusion. Three techniques were described: 5-ALA fluorescence (5-ALA), autofluorescence (AFI), and narrow-band imaging (NBI). The reported sensitivity of 5-ALA and AFI for identifying endometriosis ranged from 91% to 100%, compared with 48% to 69% for conventional white light laparoscopy (WL). A randomized controlled trial comparing NBIxa0+xa0WL with WL alone reported better sensitivity of NBI (100% vs 79%; pxa0<xa0.001). All 9 studies reported an enhanced detection rate of endometriotic lesions with enhanced imaging techniques. Enhanced imaging techniques are a promising additive for laparoscopic detection and treatment of endometriosis. The 5-ALA, AFI, and NBI intraoperative imaging techniques had a better detection rate for peritoneal endometriosis compared with conventional WL laparoscopy. None of the studies reported clinical data regarding outcomes. Future studies should address long-term results, such as quality of life, recurrence, and need for reoperation.

Metachronous Peritoneal Metastases After Adjuvant Chemotherapy are Associated with Poor Outcome After Cytoreduction and HIPEC

IntroductionCytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC) improve the survival of colorectal cancer (CRC) patients with peritoneal metastases. Patient selection is key since this treatment is associated with high morbidity. Patients with peritoneal recurrence within 1xa0year after previous adjuvant chemotherapy are thought to benefit less from HIPEC treatment; however, no published data are available to assist in clinical decision making. This study assessed whether peritoneal recurrence within 1xa0year after adjuvant chemotherapy was associated with survival after HIPEC treatment.MethodsPeritoneal recurrence within 1xa0year after adjuvant chemotherapy, as well as other potentially prognostic clinical and pathological variables, were tested in univariate and multivariate analysis for correlation with primary outcomes, i.e. overall survival (OS) and disease-free survival (DFS). Two prospectively collected databases from the VU University Medical Center Amsterdam and Catherina Hospital Eindhoven containing 345 CRC patients treated with the intent of HIPEC were utilized.ResultsHigh Peritoneal Cancer Index (PCI) scores were associated with worse DFS [hazard ratio (HR) 1.04, 95% confidence interval (CI) 1.00–1.08, pu2009=u20090.040] and OS (HR 1.11, 95% CI 1.07–1.15, pu2009<u20090.001) in multivariate analysis. Furthermore, patients with peritoneal recurrence within 1xa0year following adjuvant chemotherapy had worse DFS (HR 2.13, 95% CI 1.26–3.61, pu2009=u20090.005) and OS (HR 2.76, 95% CI 1.45–5.27, pu2009=u20090.002) than patients who did not receive adjuvant chemotherapy or patients with peritoneal recurrence after 1xa0year.ConclusionPeritoneal recurrence within 1xa0year after previous adjuvant chemotherapy, as well as high PCI scores, are associated with poor survival after cytoreduction and HIPEC. These factors should be considered in order to avoid high-morbidity treatment in patients who might not benefit from such treatment.

Volume of surgery for benign colorectal polyps in the last 11 years

BACKGROUND AND AIMSnTraditionally large, complex colorectal polyps were managed by surgical resection (SR), and in recent years endoscopic resection (ER) has progressed significantly. However, to what extent ER has replaced SR remains largely unknown. We performed a multicenter retrospective cohort study to assess the volume and volume changes of SR for benign colorectal polyps over the past decade.nnnMETHODSnPatients who underwent SR for a benign colorectal polyp in the Netherlands between 2005 and 2015 were selected from the prospective nationwide Dutch Pathology Registry (PALGA database). Clinical characteristics were obtained from the charts of patients who underwent SR in the province of Noord-Holland.nnnRESULTSnA total of 5937 patients were treated with SR for a colorectal polyp and the absolute (454-739 per year) and relative volumes (0.20%-0.37% per colonoscopy per year) of SR remained stable. In the province of Noord-Holland, 928 patients (15.6%) underwent SR. In these patients, submucosal lifting and ER were attempted in 19.9% (nxa0= 175) and 15.0% (nxa0= 134). After 2010, patients were more likely to undergo lifting (27.7% vs 11.4%, Pxa0< .001) and ER attempts (18.8% vs 10.9%, Pxa0= .001) before definitive SR. Twenty-two patients (2.4%) had been referred to another endoscopy clinic.nnnCONCLUSIONSnSR for large, complex colorectal polyps is still frequently performed and has remained stable. A small percentage of patients underwent ER attempts before SR, and referral for an additional ER attempt only occurred in a minority of cases. To increase ER attempts, implementation of a regional multidisciplinary referral network should be considered.

Avances en cirugía del cáncer de recto: recorrido histórico y nuevas perspectivas después del estudio COLOR II

Rectal cancer treatment has significantly changed during the past two centuries. Development of new surgical techniques and introduction of (neo) adjuvant therapies have contributed to the improved prognosis of rectal cancer and reduced morbidity rates. The first technically successful excision of rectal cancer was performed by LisFranc in 1826. It was a primitive procedurewithout anesthesia or hemostasis and the patient did not survive. In those days operative mortality rates of 20% and local recurrence rates of 80% were reported. In 1908 Miles published the concept of cylindrical lymphatic spread of cancer cells. He recommended more extensive mesenteric lymphadenectomy combinedwith resection of the anus and rectum in order to prevent recurrence. With the introduction of this radical ‘abdominoperineal resection’ (APR), Miles established the basis for modern rectal cancer surgery. Because the APR resulted in creation of a permanent colostomy, considered a great disadvantage for the patients, halfway through the twentieth century the focus shifted toward sphincter-sparing procedures and the ‘anterior resection’ (AR) became the standard treatment for mid and high rectal cancer. Subsequently, in the 1970s the restoration of bowel continuity after AR was introduced. In order to decrease anastomotic leakage rates and pelvic sepsis, adjustments were made such as creation of a colonic J-pouch anastomosis or diverting ileostomy. However, both the APR and AR included blunt dissection of the rectum along the presacral fascia with a cone-wise development of the most distal part of the rectum. This blunt technique resulted in high rates of involved circumferential resection margins (CRMs), which predisposes to local recurrence, and local recurrence rates up to 40%were reported. In 1982 Heald et al. introduced the technique of total mesorectal excision (TME), in which sharp excision of the complete mesorectum en bloc with the tumor to the level of the levator muscles was performed following the anatomical planes. Thismore extensive excision resulted in significant decrease of involved CRMs and decreased local recurrence rates to 3.7% at 5-years postoperatively. In the 1980s it was hypothesized that less surgical trauma would not only improve postoperative recovery, moreover it would result in less tumor recurrence and therefore improved survival. Following laparoscopic resection of the gallbladder and appendix, laparoscopic colorectal surgery was first described by Jacobs et al. For colon cancer, evidence was obtained that laparoscopic surgery was safe, causing less postoperative pain, shorter hospital stay, and resulting in comparable survival rates compared with open colectomy. However, rectal cancer surgery is considered technically more challenging than colon surgery, mainly because of the limited workspace in the lower pelvis and fibrosis of the tissue as a result of neoadjuvant radiotherapy. Recent studies showed improved short-term outcomes as well as comparable oncological outcomes after laparoscopic TME for rectal cancer compared with open TME. However, these studies included small numbers of patients. The largest randomized trial comparing laparoscopic and traditional open resection for rectal cancer is the COLOR II trial. It was undertaken in 30 hospitals in 8 countries and 1044 patients were included. Short-term outcomes showed less blood loss, less pain and shorter hospital stay after laparoscopic resection with comparable quality of the resected specimen as in open surgery. Recently, the COLOR II study group published their long-term outcomes and reported that laparoscopic surgery c i r e s p . 2 0 1 6 ; 9 4 ( 1 ) : 1 – 3

Transanal total mesorectal excision for rectal cancer: evaluation of the learning curve

AbstractBackgroundTransanal total mesorectal excision (TaTME) provides an excellent view of the resection margins for rectal cancer from below, but is challenging due to few anatomical landmarks. During implementation of this technique, patient safety and optimal outcomes need to be ensured. The aim of this study was to evaluate the learning curve of TaTME in patients with rectal cancer in order to optimize future training programs.MethodsAll consecutive patients after TaTME for rectal cancer between February 2012 and January 2017 were included in a single-center database. Influence of surgical experience on major postoperative complications, leakage rate and operating time was evaluated using cumulative sum charts and the splitting model. Correction for potential case-mix differences was performed.nResultsOver a period of 60xa0months, a total of 138 patients were included in this study. Adjusted for case-mix, improvement in postoperative outcomes was clearly seen after the first 40 patients, showing a decrease in major postoperative complications from 47.5 to 17.5% and leakage rate from 27.5 to 5%. Mean operating time (42xa0min) and conversion rate (from 10% to zero) was lower after transition to a two-team approach, but neither endpoint decreased with experience. Readmission and reoperation rates were not influenced by surgical experience.ConclusionsThe learning curve of TaTME affected major (surgical) postoperative complications for the first 40 patients. A two-team approach decreased operative time and conversion rate. When implementing this new technique, a thorough teaching and supervisory program is recommended to shorten the learning curve and improve the clinical outcomes of the first patients.

Short-term outcomes of transanal completion total mesorectal excision (cTaTME) for rectal cancer: a case-matched analysis

BackgroundLocal excision of early rectal tumors as a rectal preserving treatment is gaining popularity, especially since bowel cancer screening programs result in a shift towards the diagnosis of early stage rectal cancers. However, unfavorable histological features predicting high risk for recurrence within the “big biopsy” may mandate completion total mesorectal excision (cTME). Completion surgery is associated with higher morbidity, poorer specimen quality, and less favorable oncological outcomes compared to primary TME. Transanal approach potentially improves outcome of completion surgery for rectal cancer. The aim of this study was to compare radical completion surgery after local excision for rectal cancer by the transanal approach (cTaTME) with conventional abdominal approach (cTME).MethodsAll consecutive patients who underwent cTaTME for rectal cancer between 2012 and 2017 were case-matched with cTME patients, according to gender, tumor height, preoperative radiotherapy, and tumor stage. Surgical, pathological, and short-term postoperative outcomes were evaluated.ResultsIn total, 25 patients underwent completion TaTME and were matched with 25 patients after cTME. Median time from local excision to completion surgery was 9 weeks in both groups. In the cTaTME and cTME groups, perforation of the rectum occurred in 4 and 28% of patients, respectively (pu2009=u20090.049), leading to poor specimen quality in these patients. Number of harvested lymph nodes was higher after cTaTME (median 15; range 7–47) than after cTME (median 10; range 0–17). No significant difference was found in end colostomy rate between the two groups. Major 30-day morbidity (Clavien–Dindo≥u2009III) was 20 and 32%, respectively (pu2009=u20090.321). Hospital stay was significantly longer after cTME.ConclusionTaTME after full-thickness excision is a promising technique with a significantly lower risk of perforation of the rectum and better specimen quality compared to conventional completion TME.

C-reactive protein in predicting major postoperative complications are there differences in open and minimally invasive colorectal surgery? Substudy from a randomized clinical trial

BackgroundIn search of improvement of patient assessment in the postoperative phase, C-reactive protein (CRP) is increasingly being studied as an early marker for postoperative complications following major abdominal surgery. Several studies reported an attenuated immune response in minimally invasive surgery, which might affect interpretation of postoperative CRP levels. The aim of the present study was to compare the value of CRP as a predictor for major postoperative complications in patients undergoing open versus laparoscopic colorectal surgery.MethodsA subgroup analysis from a randomized clinical trial (LAFA-trial) was performed, including all patients with non-metastasized colorectal cancer. In the LAFA trial, patients were randomized to open or laparoscopic segmental colectomy. In a subgroup of 79 patients of the LAFA trial, postoperative assessment of CRP levels was conducted routinely preoperatively and 1, 2, 24 and 72xa0h after surgery.ResultsThirty-seven patients were randomized to the open group and 42 patients to the laparoscopic group. Major complications occurred in 19% of laparoscopic procedures and 13.5% of open procedures (pu2009=u20090.776). CRP levels rise following surgical procedures. In uncomplicated cases, the rise in CRP levels was significantly lower at 24 and 72xa0h following laparoscopic resection in comparison to open resection. No differences in CRP levels were observed when comparing open and laparoscopic resection in patients with major complications.ConclusionIn patients with an uncomplicated postoperative course, CRP levels were lower following minimally invasive resection, possibly due to decreased operative trauma. No differences in CRP were observed stratified for surgical technique in patients with major complications. These results suggest that CRP may be applied as a marker for major postoperative complications in both open and minimally invasive colorectal surgery. Future research should aim to assess the role of standardized postoperative CRP measurements.