Philippa F. Middleton

Transanal Endoscopic Microsurgery: A Systematic Review

PURPOSEThe aim of this study was to systematically review the evidence relating to the safety and efficacy of transanal endoscopic microsurgery, a relatively new technique used to locally excise rectal tumors, compared with existing techniques such as anterior resections and abdominoperineal resections or local excisions.METHODSWe conducted a systematic review of comparative studies and case series of transanal endoscopic microsurgery from 1980 to August 2002.RESULTSThree comparative studies (including one randomized, controlled trial) and 55 case series were included. The first area of study was the safety and efficacy of adenomas. In the randomized, controlled trial, no difference could be detected in the rate of early complications between transanal endoscopic microsurgery (10.3 percent) and direct local excision (17 percent) (relative risk, 0.61; 95 percent confidence interval, 0.29–1.29). Transanal endoscopic microsurgery resulted in less local recurrence (6/98; 6 percent) than direct local excision (20/90; 22 percent) (relative risk, 0.28; 95 percent confidence interval, 0.12–0.66). The 6 percent rate of local recurrence for transanal endoscopic microsurgery in this trial is consistent with the rates found in case series of transanal endoscopic microsurgery (median, 5 percent). The second area of study was the safety and efficacy of carcinomas. In the randomized, controlled trial, no difference could be detected in the rate of complications between transanal endoscopic microsurgery and direct local excision (relative risk for overall early complication rates, 0.56; 95 percent confidence interval, 0.22–1.42). No differences in survival or local recurrence rate between transanal endoscopic microsurgery and anterior resection could be detected in either the randomized, controlled trial (hazard ratio,1.02 for survival) or the nonrandomized, comparative study. There were 2 of 25 (8 percent) transanal endoscopic microsurgery recurrences in the randomized, controlled trial, but no figures were given for recurrence after anterior resection. In the case series, the median local recurrence rate for transanal endoscopic microsurgery was 8.4 percent, ranging from 0 percent to 50 percent. The third comparison was cost of the procedures. Transanal endoscopic microsurgery had both a lower recurrence rate and a lower cost than local excision or anterior resection for adenomas. Although the effectiveness of transanal endoscopic microsurgery could not be established for carcinomas, costs were lower than those for either anterior resection or abdominoperineal resection.CONCLUSIONSThe evidence regarding transanal endoscopic microsurgery is very limited, being largely based on a single relatively small randomized, controlled trial. However, transanal endoscopic microsurgery does appear to result in fewer recurrences than those with direct local excision in adenomas and thus may be a useful procedure for several small niches of patient types—e.g., for large benign lesions of the middle to upper third of the rectum, for T1 low-risk rectal cancers, and for palliative, not curative, use in more advanced tumors.

Living donor liver transplantation—Adult donor outcomes: A systematic review

The objective of this study was to evaluate the safety and efficacy of adult‐to‐adult living donor liver transplantation, specifically donor outcomes. A systematic review, with searches of the literature up to January 2004, was undertaken. Two hundred and fourteen studies provided information on donor outcomes. The majority of these were case series studies, although there were also studies comparing living donor liver transplantation with deceased donor liver transplantation. Both underreporting and duplicate reporting is likely to have occurred, and so caution is required in interpretation of these results. Overall reported donor mortality was 12 to 13 in about 6,000 procedures (0.2%) (117 studies). Mortality for right lobe donors to adult recipients is estimated to be 2 to 8 out of 3,800 (0.23 to 0.5%). The donor morbidity rate ranged from 0% to 100% with a median of 16% (131 studies). Biliary complications and infections were the most commonly reported donor morbidities. Nearly all donors had returned to normal function by 3 to 6 months (18 studies). In conclusion, there are small, but real, risks for living liver donors. Due to the short history of adult‐to‐adult living donor liver transplantation, the long‐term risks for donors are unknown. Liver Transpl 12:24–30, 2006.

Urinary stress incontinence.

New minimal access surgical sling procedures such as the tension-free vaginal tape procedure are now being used to treat urinary stress incontinence in women. These procedures use minimal tension—urethral support is perhaps achieved from a tissue reaction to the tape, which produces a collagen scar along the length of the tape and increases support of the bladder when the rectus muscle contracts. The tension-free vaginal tape procedure is often carried out under regional or local anaesthesia. Many women would undoubtedly welcome the choice of a less invasive procedure than open retropubic colposuspension—as long as the minimal procedure cures urinary incontinence and does not result in major complications.nnWhat does the currently available evidence say? Two recent systematic reviews concluded that, although the minimal access surgical sling procedures (and particularly tension-free vaginal tape) may be promising, the quality of the evidence available so far is not conclusive. 1 2 So far almost all the evidence has come from case series. So the six month results for the first multicentre randomised trial of tension-free vaginal tape have been eagerly awaited,3 since only preliminary results could be included in these systematic reviews.nnWard et al concluded that in their trial …