Nikolaos Gouvas

Stapled Transanal Rectal Resection (Starr) to Reverse the Anatomic Disorders of Pelvic Floor Dyssynergia

Anterior rectocele and rectoanal intussusception are anatomic disorders related to excessive straining during defecation that usually manifest with symptoms of obstructive defecation. Stapled transanal rectal resection (STARR), a newly described surgical method for correcting these disorders, is considered a good alternative to the traditional transrectal approaches. The aim of the present study was to assess the early postoperative functional results of STARR. A total of 16 patients (13 female) were subjected to the STARR procedure during a period of 12 months. The presence of anatomic disorders of the anorectum was verified by dynamic defecography. Preoperative assessment also included colonic transit time, anal sphincter ultrasonography, and anorectal stationary manometry. Postoperative assessment included the same battery of tests. Altogether, 12 patients had rectoanal intussusception of > 2 cm and rectocele. In eight of them the anterior component of the rectocele was 2 to 4 cm, and in four it was > 4 cm. Four patients had a 1- to 2-cm internal intussusception and a rectocele of < 2 cm. All of them reported evacuation difficulties, but none had significant incontinence. Preoperative endoscopy did not reveal the presence of a solitary ulcer in any of the patients. All females had had normal vaginal deliveries, and four of them were multiparous. No complications were encountered postoperatively, and the need for analgesics was minimal. At defecography, rectoanal anatomy was seen to be restored in all patients. Obstructive defecation symptoms remained rather unaffected in seven, disappeared in three, and improved significantly in the remaining six patients. The seven failures showed anismus at manometry and had biofeedback treatment with satisfactory results in five of them. Failure of the operation and biofeedback sessions to treat symptoms in those two cases was attributed to coexisting enterocele, which had been missed preoperatively. Immediately after surgery, most of the patients complained of urgency and frequent small motions that resolved spontaneously within 3 to 5 weeks in all but two cases. STARR is a safe, well tolerated surgical procedure that effectively restores anatomy and function of the anorectum in patients with anterior mucosal prolapse and rectoanal intussusception. Additional biofeedback treatment is usually necessary for further functional improvement. Failure may be the result of other coexisting anatomic and functional abnormalities of the pelvic floor.

Lymph Node Clearance after Total Mesorectal Excision for Rectal Cancer: Laparoscopic versus Open Approach

Background: Laparoscopic resection of the rectum is still under scrutiny for its adequacy of oncological clearance. Aim: To assess lymph node yield after laparoscopic total mesorectal excision (TME) for rectal cancer as compared to the open approach. Methods: 74 patients with middle and low rectal cancer were prospectively randomized in two groups. Group A included 39 patients who had an open TME (35 with low anterior resection of the rectum (LARR) and 4 with abdominoperineal resection of the rectum (APR)). In group B, there were 34 patients who had a laparoscopic TME (27 with LARR and 7 with APR). 10 of the LARR patients in group A and 14 of the LARR patients in group B had a defunctioning ileostomy. All operations were performed by one surgeon or under his supervision. Results: Gender and age distribution were similar for both groups (group A: 23 males; mean age 69 (41–85); group B: 20 males; mean age 72 (31–84)). The mean distance of the tumor from the dentate line was 7.6 cm (1–12 cm) for group A and 6.1 cm (1–12 cm) for group B. Anastomosis was formed at a mean distance of 5.5 cm (1.5–8.5 cm) from the dentate line in group A and 3.5 cm (1–4.5 cm) in group B. At histology, in group A there were 5 T4 tumors, 9 T3, 10 T3+ (<1 mm distance from the circumferential resection margin), 13 T2 and 2 T1. In group B, there were 3 T4 tumors, 14 T3, 8 T3+, 7 T2 and 2 T1. Differences between groups were not significant.The mean number of lymph nodes retrieved in group A specimens was 19.2 (5–45) and in group B 19.2 (8–41) (p = 0.2). In group A, 3.9 (1–9) regional, 13.9 (3–34) intermediate and 1.5 (1–3) apical lymph nodes were retrieved. The respective values in group B were 3.7 (3–7), 14.4 (4–33) and 1.3 (1–3). Differences between groups were not significant. Also, the incidence of lymph node involvement by the tumor was not significantly different between groups (group A: 23; group B: 19). Conclusions: Laparoscopic resection of the rectum can achieve similar lymph node clearance to the open approach. Also, distribution of the lymph nodes along the resected specimens is similar between the two approaches.

Quality of surgery for rectal carcinoma: comparison between open and laparoscopic approaches

BACKGROUND Macroscopic evaluation of a tumor specimen is an independent prognostic factor of oncologic outcome after total mesorectal excision (TME) for rectal cancer. This study aimed to assess macroscopic quality of specimens acquired after laparoscopic versus open TME in patients with low rectal cancer. PATIENTS AND METHODS Seventy-two patients with low rectal cancer underwent TME either by open (n = 39) or laparoscopic (n = 33) approach. In all specimens, the cut edge of the peritoneal reflection at the anterior mid-rectum, the Denonvilliers fascia, the visceral fascia covering the mesorectum both posteriorly and laterally, and the bowel wall below the mesorectum were macroscopically assessed. RESULTS Colorectal anastomoses were located significantly lower in the laparoscopic than in the open group (P < .001). The Denonvilliers fascia was violated in 7 patients after open surgery (P = .01). A significantly more complete TME with intact visceral pelvic fascia was performed after laparoscopy compared with open surgery (P = .025). CONCLUSIONS Laparoscopy offers a macroscopically more complete specimen after TME for rectal cancer than the open approach because it offers a better view in the pelvis.

Laparoscopic or open surgery for the cancer of the middle and lower rectum short-term outcomes of a comparative non-randomised study

IntroductionThe study compares the short-term results of the laparoscopic and open approach for the surgical treatment of rectal cancer. Consecutive cases with rectal cancer operated upon with laparoscopy from 2004 to 2007 were compared to open rectal cancer cases. Total mesorectal excision (TME) was attempted in all cases.Patients and methodsForty-two cases were included in the OPEN and 45 in the LAP group and were matched for age, gender, disease stage and operation type.Surgical procedureDuration of surgery was longer and blood transfusion requirements were less in the LAP group. Higher blood loss was observed in patients with neoadjuvant treatment in both groups. Patients with neoadjuvant treatment in the OPEN group had higher operation time, but that was not the case in the LAP group. There were three conversions (7%).ResultsOverall morbidity was higher in the OPEN group. LAP group patients were found to recover faster. R0 resection was achieved in 88% in the OPEN and 94% in the LAP group.DiscussionLess morbidity and faster recovery is offered after laparoscopic TME. Quality of surgery assessed by histopathology is similar between the approaches. Neoadjuvant chemoradiation seems to have significant impact on blood loss but results in longer operation times of the OPEN group.

Implementation of fast-track protocols in open and laparoscopic sphincter-preserving rectal cancer surgery: a multicenter, comparative, prospective, non-randomized study.

Background: Data on the role of laparoscopy within an enhanced recovery protocol for rectal cancer patients is rather limited. The aim of the study was to investigate the role of laparoscopy within a ‘fast-track’ protocol in patients who underwent sphincter-preserving surgery for rectal cancer. Patients/Methods: 156 consecutive patients with low rectal cancer from three centers were assigned in four groups: the open fast track (OPEN-FT), the laparoscopic fast track (LAP-FT), the open (OPEN), and the laparoscopic (LAP). The fast-track protocol was applied in one center and traditional care in the other two. All patients underwent sphincter-preserving surgery and were followed-up for 30 days. Results: Overall morbidity was less in the fast-track groups (p = 0.007). On the other hand, no statistical significance could be identified in mortality, readmission or reoperations rates among the groups (p = 0.562, p = 0.896, p = 0.238). Fast-track patients required significantly less intramuscular opioids for postoperative analgesia (p < 0.001). Primary (p < 0.001) and total hospital stays (p < 0.001) were significantly shorter in the fast-track groups. Conclusion: The implementation of a fast-track protocol is feasible and safe in low rectal cancer patients. Laparoscopy seems to be a basic element of such protocol as it further enhances recovery and reduces morbidity.

Impact of splenic flexure mobilization on short-term outcomes after laparoscopic left colectomy for colorectal cancer.

Background: Depending on the extent of left colon resection, splenic flexure mobilization is sometimes necessary to achieve a tension-free anastomosis. The aim of the study was the assessment of necessity and impact on morbidity of splenic flexure mobilization for laparoscopic colectomy with anastomosis for cancer located distally to the splenic flexure. Patients and Methods: Patients subjected to laparoscopic colectomy for carcinoma located at any site from the descending colon to the distal rectum from 2004 to 2010 were reviewed. Comparisons were made between cases with and without splenic flexure mobilization. Results: A total of 229 patients were operated for left colon or rectal cancer. There was no difference with regard to the intraoperative bleeding and bowel perforation and no differences concerning the conversion rates. In contrast, stoma formation rates were higher in the mobilized group. Moreover, total operative time was higher for the mobilized group except for the middle rectum cancer cases. Postoperative outcomes as far as mortality and morbidity rates and primary hospital stay are concerned, did not display any difference. Conclusions: Splenic flexure mobilization can provide a tension-free anastomosis and sufficiently vascularized anastomosis in laparoscopic colorectal surgery for distal colon pathology, with no impact on immediate postoperative outcomes, despite longer operative time.

Clinical practice guidelines for the surgical treatment of rectal cancer: a consensus statement of the Hellenic Society of Medical Oncologists (HeSMO).

In rectal cancer management, accurate staging by magnetic resonance imaging, neo-adjuvant treatment with the use of radiotherapy, and total mesorectal excision have resulted in remarkable improvement in the oncological outcomes. However, there is substantial discrepancy in the therapeutic approach and failure to adhere to international guidelines among different Greek-Cypriot hospitals. The present guidelines aim to aid the multidisciplinary management of rectal cancer, considering both the local special characteristics of our healthcare system and the international relevant agreements (ESMO, EURECCA). Following background discussion and online communication sessions for feedback among the members of an executive team, a consensus rectal cancer management was obtained. Statements were subjected to the Delphi methodology voting system on two rounds to achieve further consensus by invited multidisciplinary international experts on colorectal cancer. Statements were considered of high, moderate or low consensus if they were voted by ≥80%, 60-80%, or <60%, respectively; those obtaining a low consensus level after both voting rounds were rejected. One hundred and two statements were developed and voted by 100 experts. The mean rate of abstention per statement was 12.5% (range: 2-45%). In the end of the process, all statements achieved a high consensus. Guidelines and algorithms of diagnosis and treatment were proposed. The importance of centralization, care by a multidisciplinary team, adherence to guidelines, and personalization is emphasized.

Clinical practice guidelines for the management of metastatic colorectal cancer: a consensus statement of the Hellenic Society of Medical Oncologists (HeSMO)

There is discrepancy and failure to adhere to current international guidelines for the management of metastatic colorectal cancer (CRC) in hospitals in Greece and Cyprus. The aim of the present document is to provide a consensus on the multidisciplinary management of metastastic CRC, considering both special characteristics of our Healthcare System and international guidelines. Following discussion and online communication among the members of an executive team chosen by the Hellenic Society of Medical Oncology (HeSMO), a consensus for metastastic CRC disease was developed. Statements were subjected to the Delphi methodology on two voting rounds by invited multidisciplinary international experts on CRC. Statements reaching level of agreement by ≥80% were considered as having achieved large consensus, whereas statements reaching 60-80% moderate consensus. One hundred and nine statements were developed. Ninety experts voted for those statements. The median rate of abstain per statement was 18.5% (range: 0-54%). In the end of the process, all statements achieved a large consensus. The importance of centralization, care by a multidisciplinary team, adherence to guidelines, and personalization is emphasized. R0 resection is the only intervention that may offer substantial improvement in the oncological outcomes.

Preparation with Mechanical Bowel Cleansing or/and Oral Antibiotics orNothing for Elective Colorectal Surgery: Two-Two-Arm MulticentreRandomised Controlled Studies (MECCLANT âÂÂC and âÂÂR Trials)

Background: Based on sound evidence, traditional mechanical bowel preparation for elective colorectal surgery has mostly been abandoned during the last two decades. However, more recent evidence from USA large databases show that mechanical bowel preparation combined with oral antibiotics, reduces significantly surgical site infections (SSI) after elective colorectal surgery. Hypothesis-Aim: We hypothesise that administration of oral antibiotics only, and not mechanical bowel preparation, is the main factor that prevents SSI. Furthermore, we consider that rectal surgery for cancer differs from colon surgery in that the former is usually associated with defunctioning stoma, which requires an empty colon. Patients-Methods: Patients to be subjected to elective colectomy for colonic neoplasms or diverticular disease will be randomised to two arms; Arm A: no bowel preparation; Arm B: mechanical bowel preparation combined with oral antibiotics (MECCLAND –C Trial). Patients scheduled for elective low anterior resection of the rectum for rectal cancer will be randomised to two arms; Arm A: mechanical bowel preparation only; Arm B: mechanical bowel preparation combined with oral antibiotics (MECCLAND –R Trial). All patients will receive intravenous antibiotics one hour prior to first surgical incision. Enemas at the day prior to surgery are optional. Participating centres are advised to implement enhanced recovery programmes in all patients. Primary End-Points: The primary end point is surgical site infection (SSI), including (i) superficial wound infection, (ii) deep wound infection, and (iii) intrabdominal infection (contaminated fluid or pus collection). Statistical Points: Considering a SSI rate of 0.12 for Arm A vs. a SSI rate of 0.06 for Arm B, a randomization rate of 1:1 and negligible drop-off rate, the sample size of either Arm of either Trial should be 356 patients.

Is complete mesocolic excision oncologically superior to conventional surgery for colon cancer? A retrospective comparative study

Background: During the last decade, many efforts have been made in order to improve the oncologic outcomes following colonic resection. Complete mesocolic excision (CME) has proved to provide high rates of disease-free and overall survival rates in patients undergoing resection for colonic malignancies. The aim of our study was to further investigate the role of CME in colonic surgery through comparison with a series of conventional resections. Methods: All data regarding resections for colonic cancer since 2006 were obtained prospectively from two surgical departments. Retrieved data from 290 patients were analyzed and compared between those who underwent CME and those who had conventional surgery. Results: The CME group presented a higher rate of postoperative morbidity and readmissions. Histopathological features were in favor of CME surgery compared with the conventional group, in terms of both resected bowel length (33 vs. 20 cm) and lymph node harvest (27 vs. 18). Although CME was associated with better disease-free and overall survival times, only tumor differentiation, adjuvant chemotherapy and age had a statistically significant affect on those outcome values (P<0.05). Conclusion: CME improves histopathologic features, but without presenting oncologic superiority. Larger prospective studies following adequate surgical training are needed to prove the technique’s advantages in oncologic outcomes.