Stereotactic MR-guided adaptive radiotherapy (SMART) for primary rectal cancer: evaluation of early toxicity and pathological response

Background: The purpose of this study is to measure the effects of stereotactic MR-guided adaptive radiotherapy (SMART) for rectal cancer patients in terms of early toxicity and pathological response. Materials and methods: For this prospective pilot study, patients diagnosed with locally advanced rectal cancer (LARC) with positive lymph node clinical staging underwent SMART on rectal lesion and mesorectum using hybrid MR-Linac (MRIdian ViewRay). Dose prescription at 80% isodose for the rectal lesion and mesorectum was 40 Gy (8 Gy/fr) and 25 Gy (5 Gy/fr), respectively, delivered on 5 days (3 fr/week). Response assessment by MRI was performed 3 weeks after SMART, then patients fit for surgery underwent total mesorectal excision. Primary endpoint was evaluation of adverse effect of radiotherapy. Secondary endpoint was pathological complete response rate. Early toxicity was graded according to the Common Terminology Criteria for Adverse Events (CTCAE v5.0). Results: From October 2020 to January 2022, twenty patients underwent rectal SMART. No grade 3–5 toxicity was recorded. Twelve patients were eligible for total mesorectal excision (TME). Mean interval between the completion of SMART and surgery was 4 weeks. Pathological downstaging occurred in all patients; rate of pathological complete response (pCR) was 17%. pCR occurred with a prolonged time to surgery (> 7 weeks). Conclusion: To our knowledge, this is the first study to use stereotactic radiotherapy for primary rectal cancer. SMART for rectal cancer is well tolerated and effective in terms of tumor regression, especially if followed by delayed surgery.

Standard stapled transanal rectal resection vs stapled transanal rectal resection with only one high volume stapler in the prevention of complications in old patient: our experience

BACKGROUND: The causes of obstructed defecation syndrome (ODS) can actually be either functional or mechanical (primary or secondary deficit of the sensitivity, slow bowel transit, pelvic floor dyssynergia, internal and external rectal prolapse, recto-anal intussusceptions, anterior or posterior rectocele and pelvic prolapse of the bladder, uterus, bowel or sigma). The aim of our study was evaluate the safety, efficacy and feasibility of Transanal Rectal Resection (STARR) procedure performed by a single or double stapler through clinical and functional outcomes for transanal stapled surgery. METHODS: From January 2016 to October 2017, ninety patients with ODS secondary to rectal prolapse, anal-rectal intussusception and anterior rectocele, that underwent to a STARR procedures were enrolled. Thirty of these underwent a STARR procedure with double circular stapler PPH-01 (Group A); 30 with single circular stapler CPH34HV with a purse string suture (Group B); and 30 with single circular stapler CPH34HV with a "parachute technique" (Group C). All patients were selected with clinical examination, Wexner score for fecal incontinence and ODS score for constipation. Patients also underwent a Defeco RMN for an anatomical and dynamic evaluation of the pelvic floor. RESULTS: No recurrence rates were observed in the three groups. The mean operative time was 46,3 minutes in group A; 34,5 minutes in group B; and 37,6 minutes in Group C. The volume of the resected specimen was 17 ml in group A; 15 ml in group B; and 16 ml in Group C. Complications were bleeding (3.3% in group A); fecal urgency (6.6% in group A, 10% in group B and 3.3% in group C); rectal hematoma (3.3% in group A). All symptoms significantly improved after the operation without differences between groups. CONCLUSIONS: The STARR technique performed with a single stapler CPH34HV is safe, faster and less expensive than the STARR performed by a double PPH01. Besidas, with the parachute technique, it is possible to resect asymmetric prolapses

Use of the circular compression stapler and circular mechanical stapler in the end-to-side transanal colorectal anastomosis after left colon and rectal resections A single center experience

The aim of our study was to compare the efficacy of the circular compression stapler and the circular mechanical stapler in transanal colorectal anastomosis after left colectomy or anterior rectal resection. We performed a retrospective analysis of 10 patients with disease of the, sigmoid colon or rectum (carcinoma or diverticular disease) who underwent left colectomy or anterior rectal resection with end-to-side transanal colorectal anastomosis. A follow-up was planned for all patients at 1, 3 and 6 months after surgery and the anastomosis was evaluated by colonoscopy at 1 year. In all patients an end-to-side transanal colorectal anastomosis was performed using a circular compression stapler (CCS group) or circular mechanical staplers with titanium staples (CMS group). The mean distance of the anastomosis from the anal margin was 6.4 ± 1.5 cm in the CCS group and 18.2 ± 11.2 cm in the CMS group. All patients in the CCS group expelled the ring after a mean time of 8.2 postoperative days. At 12 months colonoscopy revealed that all CCS patients had a satisfactory anastomosis with mean size of the colic lumen at the level of anastomotic line of 26.3 mm. In our experience the circular compression stapler a valuable alternative to the circular mechanical stapler for the creation of transanal colorectal anastomosis, in line with the relevant literature

External hemorrhoidal thrombosis in the elderly patients. Conservative and surgical management

BACKGROUND: External hemorrhoidal thrombosis is a common disease with an acute anal pain as the major symptom. It is astonishing the lack of studies which investigates the most effective treatment and there are not guidelines. Furthermore nobody has evaluated this peculiar condition in elderly people. METHODS: We have considered 87 patients aged >75 years who were visited and treated for this condition in our clinic, dividing them in three groups according the curative option chosen together with them after anamnesis and an interview: a conservative medical treatment (Group A), an immediate incision and evacuation of the thrombus (Group B) and the excision of hemorrhoid with the thrombus, with hemorrhoidectomy technique (Group C). The mean follow-up was 12,3 months. We analyzed immediate pain relief and time of remission of symptoms, bleeding, recurrences and major complications. RESULTS: The Group A presented a remission of symptoms in 11,8 days, Group B in 1,58 ad Group C in 7,8 days. The recurrence rate was very similar for the first two options (19,4% and 16,1 %) and lower in the excision group (no recurrence during follow-up). Bleeding is the common adverse event observed with a high frequency in the immediate incision and evacuation of thrombus, less common in hemorrhoidectomy, that did not present major complication. Surgical option is often refused by elderly patient evaluating comorbidities in the fear of adverse events. CONCLUSIONS: The surgical treatment for EHT in elderly is safe and effective, but not the most common choice for fear of complications. Medical treatment or immediate incision of thrombus can be preferred and well accepted by elderly even if followed by a higher rate of recurrences

INTESTINAL ADENOCARCINOMA AS UNEXPECTED CONTENT OF SPIGELIAN HERNIA: WHEN CT-SCAN IT'S NOT ENOUGH.

Spigelian hernias are only 1-2% of all types and are considered a very uncommon condition: it develops through a weaker area between the semilunar line and the lateral edge of rectal muscle. There is an association with female sex, obesity, prior surgery, chronic obstructive pulmonary disease, abdominal trauma or coexistence of other wall defects. The content is intraperitoneal fat or omentum, sometimes small bowel or colon. Symptoms, like abdominal pain, lateral lump and altered bowel habits are linked to the most common complication: incarceration. The CT scan can be useful in confirming the abdominal wall defect and in discriminating the content and can help in the choice of the best surgical Intestinal adenocarcinoma as unexpected content of Spigelian hernia: when CT-scan it’s not enough procedure, especially if there is an ischemia. In literature are described some case of atypical content, such

OTSC® Proctology vs. fistulectomy and primary sphincter reconstruction as a treatment for low trans-sphincteric anal fistula in a randomized controlled pilot trial

To compare OTSC® Proctology and fistulectomy with primary sphincter reconstruction results as treatment strategies for anorectal low trans-sphincteric fistula

Total fistulectomy, sphincteroplasty and closure of the residual cavity for trans-sphincteric perianal fistula in the elderly patient

Perianal fistula is a complex and frequent disease. At present, no treatment nor technique has shown an absolute superiority in terms of efficacy and recurrence rate. The technique has to be chosen considering the balance between faecal continence preservation and disease eradication. Rarely concomitant perianal abscess and fistula are treated at the same time, and often time to complete recovery is long