Simone Arolfo

Results of Neoadjuvant Short-Course Radiation Therapy Followed by Transanal Endoscopic Microsurgery for T1-T2 N0 Extraperitoneal Rectal Cancer

PURPOSE This study was undertaken to assess the short-term outcomes of neoadjuvant short-course radiation therapy (SCRT) followed by transanal endoscopic microsurgery (TEM) for T1-T2 N0 extraperitoneal rectal cancer. Recent studies suggest that neoadjuvant radiation therapy followed by TEM is safe and has results similar to those with abdominal rectal resection for the treatment of extraperitoneal early rectal cancer. METHODS AND MATERIALS We planned a prospective pilot study including 25 consecutive patients with extraperitoneal T1-T2 N0 M0 rectal adenocarcinoma undergoing SCRT followed by TEM 4 to 10 weeks later (SCRT-TEM). Safety, efficacy, and acceptability of this treatment modality were compared with historical groups of patients with similar rectal cancer stage and treated with long-course radiation therapy (LCRT) followed by TEM (LCRT-TEM), TEM alone, or laparoscopic rectal resection with total mesorectal excision (TME) at our institution. RESULTS The study was interrupted after 14 patients underwent SCRT of 25 Gy in 5 fractions followed by TEM. Median time between SCRT and TEM was 7 weeks (range: 4-10 weeks). Although no preoperative complications occurred, rectal suture dehiscence was observed in 7 patients (50%) at 4 weeks follow-up, associated with an enterocutaneous fistula in the sacral area in 2 cases. One patient required a colostomy. Quality of life at 1-month follow-up, according to European Organization for Research and Treatment of Cancer QLQ-C30 survey score, was significantly worse in SCRT-TEM patients than in LCRT-TEM patients (P=.0277) or TEM patients (P=.0004), whereas no differences were observed with TME patients (P=.604). At a median follow-up of 10 months (range: 6-26 months), we observed 1 (7%) local recurrence at 6 months that was treated with abdominoperineal resection. CONCLUSIONS SCRT followed by TEM for T1-T2 N0 rectal cancer is burdened by a high rate of painful dehiscence of the suture line and enterocutaneous fistula, compared to TEM alone and TEM following LCRT, which forced us to stop the study.

Transrectal sentinel lymph node biopsy for early rectal cancer during transanal endoscopic microsurgery.

Abstract Background: Local excision of invasive cancer by transanal endoscopic microsurgery (TEM) entails the risk of lymphnode metastases that obliges to radical surgery. A determination of metastatic lymph-nodes would avoid major surgery in the vast majority of cases. We applied the concept of sentinel lymphnode (SLN) biopsy to suspected invasive rectal cancers treated by TEM. Methods: Indocyanine green (ICG) is injected in the submucosa underneath the lesion. The tumor is dissected full-thickness until the perirectal fat. A near infra-red (NIR) optic provides a map of mesorectal lymphatics, on which guide the perirectal fat is dissected and lymph-nodes are excised. Results: The technique was tested in three patients. In all cases the pathologist confirmed presence of lymphnodes in the excised tissue, no case showed metastasis. In all cases final pathology of the rectal neoplasm did not indicate radical surgery. Conclusion: In suspected invasive cancers, SLN mapping could be a useful technique to identify the first lymph node receiving drainage from the tumour, whose accurate pathological examination could predict the status of the remaining nodes and indicate further radical surgery. An ongoing study on a prospective case series will assess sensitivity and negative predictive value of SLN biopsy.

Which treatment for large rectal adenoma? Preoperative assessment and therapeutic strategy.

Abstract In the present review the authors discuss the standard ways of preoperative work-up for a suspected large rectal non-invasive lesion, comparing East and West different attitudes both in staging and treatment. Looking at the literature and analyzing recent personal data, neither pit-pattern classification, nor EUS, nor biopsy histology, nor lifting sign verification, nor digital examination allow a specificity of more than three fourth of such cases. The authors disquisition about which optimal treatment excludes a role for EMR for the impossibility to obtain a single en-bloc specimen, minimum requirement for a correct lateral and vertical margin assessment. For the same reason ESD should be preferred, although a recent meta-analysis of the literature defined that one fourth of patients undergoing ESD for a preoperatively assessed non-invasive large rectal lesion fail to receive an R0 en-bloc resection. This forces about 10% of patients treated by flexible endoscopy to undergo abdominal surgery, which is about fourfold higher than TEM. While awaiting further implementation of modern technologies both to improve staging and to reduce invasiveness, a full-thickness excision of the rectal wall by TEM still represents the standard treatment even for suspected benign diseases.

Transanal Endoscopic Operation under spinal anaesthesia

Transanal Endoscopic Operation (TEO®) for rectal benign lesions and early rectal cancer may provide better oncological outcomes than flexible endoscopy. The major advantage of flexible endoscopy is that it does not require general anaesthesia. This prospective observational study assessed the feasibility and safety of TEO® performed under spinal anaesthesia.

The Thunderbeat and Other Energy Devices in Laparoscopic Colorectal Resections: Analysis of Outcomes and Costs

BACKGROUND The THUNDERBEAT™ (TB) is a recently developed energy-based device. To date, there are no clinical studies comparing TB and other energy sources, such as standard electrosurgery (ES), ultrasonic coagulating shears (US) and electrothermal bipolar vessel sealers (EBVS) in patients undergoing laparoscopic colorectal resection (LCR). The aim of this study was to compare outcomes and costs in patients undergoing LCR with TB, US, EBVS, or ES for both benign and malignant colorectal diseases. METHODS This study is a retrospective analysis of a prospective database of patients undergoing LCR. Unselected consecutive patients who had the laparoscopic dissection conducted by using TB were compared with consecutive patients undergoing LCR with US, EBVS, or ES. RESULTS Mean operative time did not significantly differ between the groups (P = .947). Estimated blood loss was significantly higher in the ES group (P < .001). Device-related complications occurred in 2.5% of ES patients, in 2.5% of US patients, and in 5% of EBVS patients, while no complications occurred in TB patients (P = .768). No significant differences were observed in postoperative complication rates between the groups. Mean postoperative hospital stay was similar in the groups. Cost analysis showed no significant differences between US (1519.1 ± 303 €), EBVS (1474.4 ± 372.8 €), and TB (1474.3 ± 176.3 €) (P = .737). CONCLUSION This is the first clinical study comparing TB and other energy-based devices in LCR. They all appear to be equally safe and effective. Costs of surgery are very similar. Further large randomized controlled trials are needed to confirm these data.

Current status of laparoscopic colorectal surgery in the emergency setting

Laparoscopic surgery has become well established in the management of both benign as malignant colorectal disease. However there has not been the same enthusiasm for the use of laparoscopy in emergency colorectal surgery. We have critically review the indications and the results of the laparoscopic approach for the treatment of acute colorectal disease. A systemic review based on comprehensive Literature research was made on Pubmed with the primary objective to identify all clinical relevant randomized controlled trials (RCT). However, other reports, population based outcomes studies, case series and case reports were also included. Cross-link control was than performed with Google Scholar and Cochrane library databases. We have reviewed the last years’ evident literature about this last topic and the results reported , although mainly early, controversial and focused on the short term, enabled us to generally conclude that in a proper setting, laparoscopic colorectal emergency surgery is feasible, effective, safe and beneficial for patients to be a part of a common surgical practice, as long as adequate training is obtained and proper preparation observed when more advanced procedures are attempted in critically patients.

Transanal endoscopic microsurgery for giant circumferential rectal adenomas.

Transanal endoscopic microsurgery (TEM) was originally invented by Buess et al. (Chirurg, 1984, 55, 677–80) for the treatment of infraperitoneal rectal adenomas. Its indications have progressively expanded to include larger and more advanced lesions. The aim of the study was to report the results of TEM used for the treatment of circumferential rectal lesions.

A Novel Device for Measuring Forces in Endoluminal Procedures

In this paper a simple but effective measuring system for endoluminal procedures is presented. The device allows measuring forces during the endoluminal manipulation of tissues with a standard surgical instrument for laparoscopic procedures. The force measurement is performed by recording both the forces applied directly by the surgeon at the instrument handle and the reaction forces on the access port. The measuring system was used to measure the forces necessary for appropriate surgical manipulation of tissues during transanal endoscopic microsurgery (TEM). Ex-vivo and in-vivo measurements were performed, reported and discussed. The obtained data can be used for developing and appropriately dimensioning novel dedicated instrumentation for TEM procedures.

A structured light laser probe for gastrointestinal polyp size measurement: a preliminary comparative study

Background and study aims  Polyp size measurement is an important diagnostic step during gastrointestinal endoscopy, and is mainly performed by visual inspection. However, lack of depth perception and objective reference points are acknowledged factors contributing to measurement errors in polyp size. In this paper, we describe the proof-of-concept of a polyp measurement device based on structured light technology for future endoscopes. Patients and methods  Measurement accuracy, time, user confidence, and satisfaction were evaluated for polyp size assessment by (a) visual inspection, (b) open biopsy forceps of known size, (c) ruled snare, and (d) structured light probe, for a total of 392 independent polyp measurements in ex vivo porcine stomachs. Results  Visual assessment resulted in a median estimation error of 2.2 mm, IQR = 2.6 mm. The proposed probe can reduce the error to 1.5 mm, IQR = 1.67 mm ( P  = 0.002, 95 %CI) and its performance was found to be statistically similar to using forceps for reference ( P  = 0.81, 95 %CI) or ruled snare ( P  = 0.99, 95 %CI), while not occluding the tool channel. Timing performance with the probe was measured to be on average 54.75 seconds per polyp. This was significantly slower than visual assessment (20.7 seconds per polyp, P  = 0.005, 95 %CI) but not significantly different from using a snare (68.5 seconds per polyp, P  = 0.73, 95 %CI). However, the probe’s timing performance was partly due to lens cleaning problems in our preliminary design. Reported average satisfaction on a 0 – 10 range was highest for the proposed probe (7.92), visual assessment (7.01), and reference forceps (7.82), while significantly lower for snare users with a score of 4.42 ( P  = 0.035, 95 %CI). Conclusions  The common practice of visual assessment of polyp size was found to be significantly less accurate than tool-based assessment, but easy to carry out. The proposed technology offers an accuracy on par with using a reference tool or ruled snare with the same satisfaction levels of visual assessment and without occluding the tool channel. Further study will improve the design to reduce the operating time by integrating the probe within the scope tip.

TEM and TAMIS for Large Rectal Neoplasm

Minimally invasive treatment of large rectal neoplasms by transanal endoscopic microsurgery (TEM) and, more recently, by transanal minimally invasive surgery (TAMIS) has become a common procedure. Since the introduction of TEM in 1983, indications have been widely extended, even if preoperative staging actually presents many limitations. TEM is nowadays a validated and standardised technique, allowing transanal resection of wide lesions with very low recurrences and complication rate. If compared to endoscopic procedures like endoscopic submucosal dissection (ESD), TEM seems to be able to warrant better oncologic results, with similar complication rate. TAMIS has been introduced in 2010 and still requires a strong validation. It is not yet clear if it really presents advantages in comparison to TEM, both from a technical and an economical point of view. The current indications to TEM/TAMIS are represented by benign lesions and early rectal cancers deepening no more than 1 mm in the submucosal layer. The goal of the research is the extension of TEM/TAMIS procedures to more advanced rectal cancers, in order to avoid the complications related to total mesorectal excision (TME). Preoperative neoadjuvant chemoradiotherapy and mesorectal lymph node mapping with sentinel node biopsy are two promising strategies with interesting preliminary results. Rectal-sparing surgery should be the goal in treating early rectal cancer but only if capable to warrant a radical and curative resection. A consistent improvement in rectal cancer staging will therefore allow a real tailored therapy, contributing to a significant reduction of invasiveness of the treatment.