Transanal minimally invasive surgery for rectal lesions

Background and Objectives: Transanal minimally invasive surgery (TAMIS) has emerged as an alternative to transanal endoscopic microsurgery (TEM). The authors report their experience with TAMIS for the treatment of mid and high rectal tumors. Methods: From November 2011 through May 2016, 31 patients (21 females, 68%), with a median age of 65 years who underwent single-port TAMIS were prospectively enrolled. Mean distance from the anal verge of the rectal tumors was 9.5 cm. Seventeen patients presented with T1 cancer, 10 with large adenoma, 2 with gastrointestinal stromal tumor (GIST) and 2 with carcinoid tumor. Data concerning demographics, operative procedure and pathologic results were analyzed. Results: TAMIS was successfully completed in all cases. In 4 (13%) TAMIS was converted to standard Park’s transanal technique. Median postoperative stay was 3 days. The overall complication rate was 9.6%, including 1 urinary tract infection, 1 subcutaneous emphysema, and 1 hemorrhoidal thrombosis. TAMIS allowed an R0 resection in 96.8% of cases (30/31 cases) and a single case of local recurrence after a large adenoma resection was encountered. Conclusion: TAMIS is a safe technique, with a short learning curve for laparoscopic surgeons already proficient in single-port procedures, and provides effective oncological outcomes compared to other techniques

minimally invasive surgery for rectal prolapse laparoscopic procedures

Surgical treatment of external rectal prolapse, internal intussusception (or internal rectal prolapse), and rectocele is still a challenging clinical problem in the field of colorectal surgery [1, 2]. These conditions may be associated with various pelvic floor disorders, including motility and morphological/functional disorders, ranging from constipation to fecal incontinence, thus significantly affecting the patients' quality of life [3, 4]. A large variety of surgical procedures exists. The literature offers abundant publications, the main problem for an informed decision on the perfect surgical technique being an often large variability of patients' selection, diagnostic assessment and variation within the same surgical technique and materials. As a consequence, the colorectal surgeon still lacks a standardized diagnostic assessment as well as a clear ideal surgical technique [5]. Perineal procedures, such as Delorme's or perineal rectosigmoidectomy or stapled transanal rectal prolapse resection, are indicated for elderly and frail patients, who are not fit for an intervention under general anesthesia, but they have poor efficacy in terms of functional outcomes and recurrence, which may be up to 26 % [6], and also an increasing risk for postoperative incontinence [7]. Abdominal procedures, on the other side, either open or laparoscopic, employing rectal mobilization and fixation, colonic resection or a combination of both, show lower recurrence rates and better functional results, but may cause postoperative worsening of constipation, mostly due to the full rectal mobilization and the consequent possible autonomic nerve injury, which is responsible for dysmotility and impaired evacuation [8]. Laparoscopic ventral mesh recto(colpo)pexy has been introduced in order to obtain good results in terms of functional outcome of the abdominal procedures while avoiding postoperative constipation and incontinence, offering the advantages of anterolateral mobilization, mesh repair and of the laparoscopic approach compared to the open [9]

Correction to: Interstitial cells of Cajal increased in patients with rectal prolapse

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Involvement of interleukin-21 in the regulation of colitis-associated colon cancer

IL-21 expression is increased in the gut of patients with colitis-associated colon cancer, and genetic ablation or antibody neutralization of IL-21 reduces tumor size and inflammation in mice treated with dextran sulfate sodium and azoxymethane

Surgery for fistula-in-ano in a specialist colorectal unit: a critical appraisal

ABSTRACT

Natural humoral immune response to ribosomal P0 protein in colorectal cancer patients

Tumor associated antigens are useful in colorectal cancer (CRC) management. The ribosomal P proteins (P0, P1, P2) play an important role in protein synthesis and tumor formation. The immunogenicity of the ribosomal P0 protein in head and neck, in breast and prostate cancer patients and the overexpression of the carboxyl-terminal P0 epitope (C-22 P0) in some tumors were reported

Full Thickness Local Excision of Large Rectal Tumour Using A Megawindows 36 Millimetres Circular Stapler

Adenomatous rectal lesions not endoscopically removable (large, sessile or carpet-like polyps) need to be treated with surgical excision. Similarly, unexpected malignant polyps at endoscopy are referred to surgery to perform full thickness ‘total biopsy’. Local excision is the treatment of choice and several techniques have been proposed. The excision of an intact tumour is mandatory to obtain lower recurrence rate and morbidity. When a complete local excision is achieved with adequate superficial and deep margins, surgery is curative even in polyps containing carcinoma in situ (Tis) or initially invasive cancer with infiltration limited to the submucosal layer (T1). The three approaches for local surgical excision are: a) Kraske dorsal access or the Mason trans-sphincteric approaches or a combination of the two techniques. b) Parks transanal approach (and its variations according to Francillon and Faivre) is the most common one for tumour located up to 12 cm from the anal verge.c)The Transanal Endoscopic Microsurgery (TEM) that allows a full thickness resection under an excellent view of the entire rectum (up to 18 cm from the anal verge). Recently, the Transanal minimally invasive surgery (TAMIS) has been proposed with an immediate widespread worldwide. It is a technique developed as a low-cost alternative to TEM for local excision of carefully selected rectal neoplasms.Endoscopic linear stapler-cutter for trans-anal removal of rectal lesions has also been reported in literature. Indeed, staplers can offer the possibility of complete and safe excision with accurate haemostasis. Indications include rectal large lesions, polyps with dysplasia and in situ carcinoma.Differently, the use of a circular stapler similarly to a stapled transanal rectal resection for obstructed defaecation allows a full thickness resection despite, to date, this application has not been reported by others. Local excision of a rectal lesion using a circular stapler allows a standardized and straight forward procedure, overcoming the limiting factors for a successful surgery previously described. The conclusions of our previous experience using this approach indicated that it can be reserved to the full thickness removal of intact flat lesions (sessile or carpet like polyps), T1 is the cancer with a diameter up to 2 cm and located within 12 centimetres from the anal verge.Some limits were the lack of vision during the rectal wall traction within the stapler, especially for higher lesions, as well as the little volume of resectable tissue due to the circular stapler head encase. Recently, the availability of a large volume stapler with an encase of a 36 mm might overcome these limits. The larger encase that may host up to 35 centimetres cubes of tissue, might allow full thickness removal of larger tumour. Furthermore, since the stapler has a fenestrated head encase with mega-windows for each quadrant, it allows a resection under direct vision.radial 4 stitches (0 silk) are used to expose the anal verge and to fix to the perianal skin the anal dilator. Absorbable 2-0 sutures are positioned at least 1 cm all around the rectal lesion on macroscopically free margins. Stitches should include mucosa, submucosa, and rectal muscle wall. A total of 6 to 8 sutures are positioned in a parachute manner A 36 mm circular stapler is then opened and the head inserted above the lesion and the upper suture. All the sutures are inserted into the stapler through the stapler windows and pulled down. This way, the rectal wall including the lesion should create an intussusception within the stapler head. The stapler is then closed, hold for 30 seconds and fired. Occasionally a minimal mucosal bridge with a staple connecting the two edges may occur and is easily cut using heavy scissors. In our experience this technique overcomes some of the limits of incomplete surgical field exposure and difficult manipulation