Laura Mora-López

Randomized, Controlled, Prospective Trial of the Use of a Mesh to Prevent Parastomal Hernia

Background:The prevalence of terminal parastomal hernia (PH) after colostomy placement may be as high as 50%. The effect of the PH may range from discomfort to life-threatening complications. Surgical procedures for repairing PH are difficult to perform and present a high-failure rate. Objective:To reduce the incidence of PH by implanting a lightweight mesh in the sublay position. Material and Methods:Randomized, controlled, prospective study. Patients were scheduled for permanent end colostomy surgery to treat cancer of the lower third of the rectum, performed by the same colorectal surgery team. An Ultrapro lightweight mesh was inserted in the sublay position in the study group. Using simple randomization, the sample size required was estimated to be 27 per group. Patients were followed-up clinically and radiologically with abdominal computed tomography by an independent clinician and a radiologist who were all blind to the aims of the study, 1 month and every 6 months after surgery. Results:The groups were homogeneous in terms of their clinical and demographic characteristics. Surgical time and postoperative morbidity were similar in the 2 groups. Mortality was 0. No mesh intolerance was reported. In the clinical follow-up (median: 29 months, range: 13–49), 11/27 (40.7%) hernias were recorded in the control group compared with 4/27 (14.8%) in the study group (P = 0.03). Abdominal computed tomography identified 14/27 (44.4%) hernias in the control group compared with 6/27 (22.2%) in the study group (P = 0.08). Conclusions:Parastomal placement of a mesh reduces the appearance of PH. The technique is safe, well-tolerated, and does not increase morbidity rates.

The prevalence of parastomal hernia after formation of an end colostomy. A new clinico-radiological classification.

Introduction  Parastomal hernia (PH) is a common complication of end colostomy, found in over 50% of patients. Abdominal computerized tomography (CT) may help diagnosis. The prevalence of PH may be higher than previously reported. We present a new CT classification for use in clinical practice.

Transanal endoscopic surgery in rectal cancer

Total mesorectal excision (TME) is the standard treatment for rectal cancer, but complications are frequent and rates of morbidity, mortality and genitourinary alterations are high. Transanal endoscopic microsurgery (TEM) allows preservation of the anal sphincters and, via its vision system through a rectoscope, allows access to rectal tumors located as far as 20 cm from the anal verge. The capacity of local surgery to cure rectal cancer depends on the risk of lymph node invasion. This means that correct preoperative staging of the rectal tumor is necessary. Currently, local surgery is indicated for rectal adenomas and adenocarcinomas invading the submucosa, but not beyond (T1). Here we describe the standard technique for TEM, the different types of equipment used, and the technical limitations of this approach. TEM to remove rectal adenoma should be performed in the same way as if the lesion were an adenocarcinoma, due to the high percentage of infiltrating adenocarcinomas in these lesions. In spite of the generally good results with T1, some authors have published surprisingly high recurrence rates; this is due to the existence of two types of lesions, tumors with good and poor prognosis, divided according to histological and surgical factors. The standard treatment for rectal adenocarcinoma T2N0M0 is TME without adjuvant therapy. In this type of adenocarcinoma, local surgery obtains the best results when complete pathological response has been achieved with previous chemoradiotherapy. The results with chemoradiotherapy and TEM are encouraging, but the scientific evidence remains limited at present.

Transanal endoscopic surgery with total wall excision is required with rectal adenomas due to the high frequency of adenocarcinoma.

BACKGROUND: Colorectal adenomatous polyps are considered premalignant lesions, although a high percentage are already malignant at the time of their removal. Full-thickness excision in patients with adenoma detected in preoperative biopsy enables much more accurate pathology examination and has shown that local surgery is appropriate for T1 adenocarcinoma. OBJECTIVE: To determine whether full-thickness excision during transanal endoscopic surgery is the treatment of choice for rectal adenoma, and to identify possible predictors of invasive adenocarcinoma associated with this type of lesion. DESIGN: Prospective, observational study. SETTING: The study was conducted at a university teaching hospital. PATIENTS: All patients scheduled for transanal endoscopic surgery after detection of adenoma in a preoperative biopsy between June 2004 and February 2013 entered the study. MAIN OUTCOME MEASURES: The principal variable was the presence of invasive adenocarcinoma in the pathology study. Other study variables were the epidemiological variables sex and age; the clinical variables tumor size, number of quadrants affected, distance from the anal verge, and tumor location; and the morphological variables tumor aspect, degree of dysplasia, preoperative biopsy (tubulo-villous), endorectal ultrasound, and pelvic MRI stage. Variables found to be related to the risk of malignancy in rectal adenomas were evaluated using univariate and multivariate analysis. RESULTS: Of 471 patients who underwent surgery, 277 had a preoperative diagnosis of adenoma. Final pathology studies showed 52 (18.8%) invasive adenocarcinomas, among which 27 were pT1 (52%), 16 pT2 (30.7%), and 9 pT3 (17.3%). Factors predictive of invasive adenocarcinoma were sessile morphology (OR 3.2, 95%CI 1.4–7.1), high-grade dysplasia (OR 2.3, 95%CI 1.2–4.8), and endorectal ultrasound stage uT2-T3 (OR 3.8, 95%CI 1.6–9). LIMITATIONS: The limitations are derived from the observational design. CONCLUSIONS: In this sample, half of the adenocarcinomas from adenomas were T1 adenocarcinomas. Because a high proportion of rectal adenomas are, in fact, invasive adenocarcinomas, full-thickness excision is appropriate.

Repair of rectal trauma perforation using transanal endoscopic operation.

A 32-year-old male presented at the Emergency Service for intense proctalgia following impalement with a 15-cm metal bar after an accidental fall. On arrival the patient was haemodynamically stable, with normal temperature and a Glasgow Scale score of 15. Abdominal examination was uneventful; in the perianal region he presented rectal haemorrhage and an incision wound 3 cm to the right of the anal verge. No alterations were observed on chest and abdominal X-rays. Abdominal-pelvic CT scan (Fig. 1a) revealed penetrating trauma in the right ischiorectal fossa with gas adjacent to the mesorectal fat and intraluminal bleeding in the rectum. The intra-abdominal organs were unaffected. In view of these findings and the short time since the trauma (< 12 h) we decided to carry out examination under anaesthetic followed by rectoscopy, and then repaired the lesion using transanal endoscopic operation-TEO [3] (Karl Storz GmbH, Tüttlingen, Germany). Two penetrating wounds were seen in the rectum: one 4 cm posterolaterally to the right of the anal verge and the other 9 cm anterolaterally to the right, both approximately 1 cm in length (RIS = II) [1] (Fig. 1b). A simple suture of the entire thickness of the rectal wall was performed at the height of the lesion, followed by debridement of the perineal wound. Postoperative evolution was favourable. The patient was discharged on day 3 after surgery.

The Place of Transanal Endoscopic Surgery in the Treatment of Rectourethral Fistula

OBJECTIVE To assess the role of transanal endoscopic operation (TEO) or transanal endoscopic microsurgery (TEM) in rectourethral fistulas (RUF). RUF may appear after radical prostatectomy. Their treatment represents a challenge; many therapies have been proposed, from conservative to aggressive surgical approaches. Transanal endoscopic surgery (TEO or TEM) is a minimally invasive technique to access the site of the RUF to perform repair. MATERIALS AND METHODS This is an observational study with prospective data collection, conducted between September 2006 and December 2015. All patients were diagnosed with RUF following management of prostate cancer. Conservative treatment was administered in the form of urinary and fecal diversion with cystotomy and terminal colostomy, to achieve total urinary and fecal exclusion. If the fistula persisted, it was treated by TEO or TEM, with or without biological mesh interposition. If this failed, gracilis muscle was applied as salvage therapy. RESULTS Ten patients were diagnosed with RUF. In 1 patient (1 of 10), the fistula healed with bladder catheterization alone. In another patient (1 of 9), it resolved after total urinary and fecal exclusion. Eight patients underwent repair by TEO or TEM, 4 with biological mesh interposition; all 4 presented recurrence. In the other 4 patients treated via TEO or TEM, 2 had early recurrence, whereas the others had healed at follow-up visits after 4-6 months (2 of 8)-a success rate of 25%. The 6 patients who recurred were treated with gracilis muscle interposition via a transperineal approach. CONCLUSION The low rate of positive results obtained by TEO or TEM argues against its use as technique of choice in RUF, and against the use of biological meshes.

Endorectal ultrasound in the identification of rectal tumors for transanal endoscopic surgery: factors influencing its accuracy

Endorectal ultrasound (ERUS) is considered the technique of choice for selecting patients for transanal endoscopic surgery (TEM). The aim of this study was to evaluate the accuracy of ERUS in patients with rectal tumors who later underwent TEM, and to analyze the factors that influence this accuracy. Observational study including prospective data collection of patients with rectal tumors undergoing TEM with curative intent between June 2004 and May 2016. Preoperative staging by EUS (uT) was correlated with the pathology results after TEM (pT). The accuracy of the EUS was evaluated and a series of variables (tumor morphology, height, lesion size, quadrant, definitive pathology, the surgeon assessing the ERUS, and waiting time from the date of the ERUS until surgery) were analyzed as possible predictors of diagnostic accuracy. Six hundred and fifty-one patients underwent TEM, of whom 495 met the inclusion criteria. The overall accuracy of EUS was 78%, sensitivity 83.78%, specificity 20%, PPV 91.3%, and NPV 11%. Forty patients (8.08%) were understaged and 50 (10.9%) were overstaged. In the multivariate analysis, the surgeon’s experience emerged as the most important predictor of accuracy (p < 0.001; OR 2.75, 95% CI 1.681–4.512). The EUS was less accurate with larger lesions (p = 0.004; OR 0.219, 95% CI 0.137–0.349) and when the definitive diagnosis was adenocarcinoma (p < 0.001; OR 0.84, 95% CI 0.746–0.946). ERUS accuracy rates are variable and there is a possibility of understaging and overstaging that must be taken into consideration. This accuracy is dependent on the operator’s experience as well on lesion size; in addition, it is lower for lesions shown to be cancers in the final pathology report.

Transanal endoscopic surgery is effective and safe after endoscopic polypectomy of potentially malignant rectal polyps with questionable margins

To determine the percentage of residual lesion observed in the pathology study of transanal endoscopic surgery (TEM) specimens after endoscopic polypectomy of malignant rectal polyps with questionable margins, and the need for further surgery. Secondary aims: to determine the morbidity and mortality associated with this procedure and to identify the percentage of recurrence after excision by TEM.

How to deal with rectal lesions more than 15 cm from the anal verge through transanal endoscopic microsurgery

BACKGROUND The aim of this study is to assess postoperative morbidity and mortality in tumors with a proximal margin 15 cm or more from the anal verge operated with transanal endoscopic microsurgery (TEM). METHODS This observational study of consecutive rectal tumor patients undergoing TEM was carried out from July 2004 to June 2017. We compared the results of rectal tumors at distances of ≥15 cm (group A) and <15 cm (group B) from the anal verge. RESULTS During the study period 667 patients were included: 118 in group A and 549 in group B. In the comparative analysis there were no significant differences in morbidity (p = 0.23), mortality (p = 0.32) or free margin involvement (p = 0.545). Differences were observed in terms of lesion size (p < 0.001), surgical time (p < 0.001) and peritoneal cavity perforation, which were all increased in group A. CONCLUSION TEM for lesions in the rectosigmoid junction is feasible and is not associated with higher morbidity or mortality.