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Surgical Endoscopy Dec 2022T1 rectal cancer (RC) patients are increasingly being treated by local resection alone but uniform surveillance strategies thereafter are lacking. To determine whether... (Meta-Analysis)
Meta-Analysis
BACKGROUND
T1 rectal cancer (RC) patients are increasingly being treated by local resection alone but uniform surveillance strategies thereafter are lacking. To determine whether different local resection techniques influence the risk of recurrence and cancer-related mortality, a meta-analysis was performed.
METHODS
A systematic search was conducted for T1RC patients treated with local surgical resection. The primary outcome was the risk of RC recurrence and RC-related mortality. Pooled estimates were calculated using mixed-effect logistic regression. We also systematically searched and evaluated endoscopically treated T1RC patients in a similar manner.
RESULTS
In 2585 unique T1RC patients (86 studies) undergoing local surgical resection, the overall pooled cumulative incidence of recurrence was 9.1% (302 events, 95% CI 7.3-11.4%; I = 68.3%). In meta-regression, the recurrence risk was associated with histological risk status (p < 0.005; low-risk 6.6%, 95% CI 4.4-9.7% vs. high-risk 28.2%, 95% CI 19-39.7%) and local surgical resection technique (p < 0.005; TEM/TAMIS 7.7%, 95% CI 5.3-11.0% vs. other local surgical excisions 10.8%, 95% CI 6.7-16.8%). In 641 unique T1RC patients treated with flexible endoscopic excision (16 studies), the risk of recurrence (7.7%, 95% CI 5.2-11.2%), cancer-related mortality (2.3%, 95% CI 1.1-4.9), and cancer-related mortality among patients with recurrence (30.0%, 95% CI 14.7-49.4%) were comparable to outcomes after TEM/TAMIS (risk of recurrence 7.7%, 95% CI 5.3-11.0%, cancer-related mortality 2.8%, 95% CI 1.2-6.2% and among patients with recurrence 35.6%, 95% CI 21.9-51.2%).
CONCLUSIONS
Patients with T1 rectal cancer may have a significantly lower recurrence risk after TEM/TAMIS compared to other local surgical resection techniques. After TEM/TAMIS and endoscopic resection the recurrence risk, cancer-related mortality and cancer-related mortality among patients with recurrence were comparable. Recurrence was mainly dependent on histological risk status.
Topics: Humans; Digestive System Surgical Procedures; Neoplasm Recurrence, Local; Rectal Neoplasms; Transanal Endoscopic Surgery; Treatment Outcome
PubMed: 35773606
DOI: 10.1007/s00464-022-09396-3 -
BMJ Case Reports Jun 2022Basal cell carcinoma (BCC) is a common skin malignancy and usually occurs in sun-exposed areas like the head and neck. Occurrence in the perianal area is rare,...
Basal cell carcinoma (BCC) is a common skin malignancy and usually occurs in sun-exposed areas like the head and neck. Occurrence in the perianal area is rare, accounting for only 0.08% of all BCC, and 0.2% of anorectal malignancies.We present a case of a hypertensive woman in her 60s who had a 1-year history of a gradually enlarging mass on the left perianal region. Initial biopsy revealed a carcinoma with basaloid features and was confirmed on immunohistochemistry to be nodular BCC. Proctoscopy showed no intraluminal involvement. Contrast-enhanced chest and abdominal CT scans revealed no nodal or distant metastasis. MRI showed a 7.5 mm fat plane between the mass and the external sphincter muscles, projecting adequate surgical margins.A wide excision with at least 4 mm margins was performed. Reconstruction of the resulting defect was performed with a local random cutaneous flap.
Topics: Anus Neoplasms; Carcinoma, Basal Cell; Female; Humans; Margins of Excision; Skin Neoplasms; Surgical Flaps
PubMed: 35725283
DOI: 10.1136/bcr-2022-250493 -
Surgical Endoscopy Sep 2022The standard treatment of rectal carcinoma is surgical resection according to the total mesorectal excision principle, either by open, laparoscopic, robot-assisted or... (Review)
Review
BACKGROUND
The standard treatment of rectal carcinoma is surgical resection according to the total mesorectal excision principle, either by open, laparoscopic, robot-assisted or transanal technique. No clear consensus exists regarding the length of the learning curve for the minimal invasive techniques. This systematic review aims to provide an overview of the current literature regarding the learning curve of minimal invasive TME.
METHODS
A systematic literature search was performed. PubMed, Embase and Cochrane Library were searched for studies with the primary or secondary aim to assess the learning curve of either laparoscopic, robot-assisted or transanal TME for rectal cancer. The primary outcome was length of the learning curve per minimal invasive technique. Descriptive statistics were used to present results and the MINORS tool was used to assess risk of bias.
RESULTS
45 studies, with 7562 patients, were included in this systematic review. Length of the learning curve based on intraoperative complications, postoperative complications, pathological outcomes, or a composite endpoint using a risk-adjusted CUSUM analysis was 50 procedures for the laparoscopic technique, 32-75 procedures for the robot-assisted technique and 36-54 procedures for the transanal technique. Due to the low quality of studies and a high level of heterogeneity a meta-analysis could not be performed. Heterogeneity was caused by patient-related factors, surgeon-related factors and differences in statistical methods.
CONCLUSION
Current high-quality literature regarding length of the learning curve of minimal invasive TME techniques is scarce. Available literature suggests equal lengths of the learning curves of laparoscopic, robot-assisted and transanal TME. Well-designed studies, using adequate statistical methods are required to properly assess the learning curve, while taking into account patient-related and surgeon-related factors.
Topics: Humans; Laparoscopy; Learning Curve; Postoperative Complications; Rectal Neoplasms; Rectum; Robotics; Transanal Endoscopic Surgery; Treatment Outcome
PubMed: 35697853
DOI: 10.1007/s00464-022-09087-z -
Ugeskrift For Laeger Apr 2022A tailgut cyst is a rare tumour originating from the embryonic remnant of the retrorectal space. The cyst is often asymptomatic, but it can cause abdominal or rectal...
A tailgut cyst is a rare tumour originating from the embryonic remnant of the retrorectal space. The cyst is often asymptomatic, but it can cause abdominal or rectal pain and urogenital symptoms. When diagnosed, resection is the choice of treatment, and traditionally open surgery has been preferred. In this case report, we present a 30-year-old female patient with a painful tailgut cyst. She was found to be candidate for transanal endoscopic microsurgery, which was successfully performed.
Topics: Adult; Cysts; Female; Humans; Microsurgery; Rectal Neoplasms; Rectum; Transanal Endoscopic Microsurgery
PubMed: 35485794
DOI: No ID Found -
BMC Surgery Apr 2022Determine whether robotic surgery is more effective than transanal and conventional laparoscopic surgery in preserving bowel and urinary function after total mesorectal... (Observational Study)
Observational Study
Robotic surgery contributes to the preservation of bowel and urinary function after total mesorectal excision: comparisons with transanal and conventional laparoscopic surgery.
BACKGROUND
Determine whether robotic surgery is more effective than transanal and conventional laparoscopic surgery in preserving bowel and urinary function after total mesorectal excision (TME).
METHODS
Of 79 lower rectal cancer patients who underwent function-preserving TME between 2016 and 2020, 64 patients consented to a prospective questionnaire-based functional observation study (52 responded). At 6 months post-resection or ileostomy closure, Wexner, low anterior resection syndrome (LARS), modified fecal incontinence quality of life, and international prostate symptom scores were used to evaluate bowel and urinary function, comparing robotic surgery (RTME) with transanal (taTME) or conventional laparoscopic surgery (LTME).
RESULTS
RTME was performed in 35 patients (54.7%), taTME in 15 (23.4%), and LTME in 14 (21.9%). While preoperative bowel/urinary functions were similar in all three procedures, and the distance from the anal verge to tumor was almost the same, more hand-sewn anastomoses were performed and the anastomotic height from the anal verge was shorter in taTME than RTME. At 2 years post-resection, 8 patients (12.5%) had a permanent stoma; RTME showed a significantly lower rate of permanent stoma than taTME (2.9% vs. 40%, p < 0.01). Despite no significant difference, all bowel function assessments were better in RTME than in taTME or LTME. Major LARS was observed in all taTME and LTME cases, but only 78.8% of RTME. No clear difference arose between RTME and taTME in urinary function; urinary dysfunction was more severe in LTME than RTME (36.4% vs. 6.1%, p = 0.02).
CONCLUSIONS
In function-preserving TME for lower rectal cancer, robotic surgery was suggested to be more effective than transanal and conventional laparoscopic surgery in terms of bowel and urinary functions.
Topics: Humans; Laparoscopy; Male; Postoperative Complications; Prospective Studies; Quality of Life; Rectal Diseases; Rectal Neoplasms; Rectum; Robotic Surgical Procedures; Syndrome; Transanal Endoscopic Surgery; Treatment Outcome
PubMed: 35449005
DOI: 10.1186/s12893-022-01596-x -
Journal of Cancer Research and... 2022Malignant melanoma of the anorectal region is a very rare aggressive malignant neoplasm and it constitutes 1% of all malignant lesions of this area. About 70% of these...
Malignant melanoma of the anorectal region is a very rare aggressive malignant neoplasm and it constitutes 1% of all malignant lesions of this area. About 70% of these lesions are pigmented, whereas 30% are amelanotic. Demonstration of immune markers of melanoma by immunohistochemistry (IHC) is required for confirming the diagnosis of amelanotic malignant melanoma. Here, we report a case of anorectal malignant amelanotic melanoma in a 65-year-old male with no medical comorbidities, who presented with chief complaints of bleeding per rectum associated with prolapsing mass per rectum of 7 months duration. On external examination and proctoscopy, three prolapsed pedunculated fungating masses were seen externally protruding out of the rectum approximately 4 cm from the anal verge. Contrast-enhanced computed tomography of the whole abdomen and pelvis was suggestive of moderately enhancing lobulated anorectal mass with large polypoidal intraluminal component arising from anorectal walls and extension into mid-lower rectum with liver and locoregional lymph nodes metastasis. The patient was taken up for palliative local excision. Per-operatively, three large irregular highly vascular pedunculated rectal growth was seen. The growth was excised and sent for histopathological examination. Microscopic examination of mass show spindle-to-ovoid tumor cells with hyperchromatic central to eccentric nuclei arranged in intersecting fascicles with a focal alveolar pattern. The large number of atypical mitotic figures (40-50/10 High Power Field (HPF)) was seen along with areas of necrosis and the presence of few bizarre binucleated and multinucleated giant cells. A differential diagnosis of malignant amelanotic melanoma was given along with undifferentiated carcinoma, gastrointestinal stromal tumor , and Non-Hodgkin's lymphoma. On IHC, the tumor cells were reactive for HMB45, S-100, and SOX-10. Thus a diagnosis of malignant amelanotic melanoma was confirmed. The patient had symptomatic improvement.
Topics: Aged; Gastrointestinal Stromal Tumors; Humans; Immunohistochemistry; Male; Melanoma, Amelanotic; Rectal Neoplasms; Skin Neoplasms
PubMed: 35381792
DOI: 10.4103/jcrt.JCRT_461_20 -
BMC Surgery Mar 2022Robotic transanal minimally invasive surgery (R-TAMIS) is an appealing alternative to transanal minimally invasive surgery (TAMIS) and transanal endoscopic microsurgery...
BACKGROUND
Robotic transanal minimally invasive surgery (R-TAMIS) is an appealing alternative to transanal minimally invasive surgery (TAMIS) and transanal endoscopic microsurgery (TEM) for benign and early malignant rectal lesions that are not amenable to traditional open transanal excision. However, no studies to our knowledge have directly compared the three techniques. This study sought to compare peri-operative and pathologic outcomes of the three approaches.
METHODS
The records of 29 consecutive patients who underwent TEM, TAMIS, or R-TAMIS at a single academic center between 2016 and 2020 were reviewed. Intra-operative details, pathological diagnosis and margins, and post-operative outcomes were recorded. The three groups were compared using chi-square and Kruskal-Wallis tests.
RESULTS
Overall, 16/29 patients were women and the median age was 57 (interquartile range (IQR): 28-81). Thirteen patients underwent TEM, six had TAMIS, and 10 had R-TAMIS. BMI was lower in the R-TAMIS patients (24.7; IQR 23.8-28.7), than in TEM (29.3; IQR 19.9-30.2), and TAMIS (30.4; IQR 26.6-32.9) patients. High grade dysplasia and/or invasive cancer was more common in TAMIS (80%) and R-TAMIS (66.7%) patients than in TEM patients (41.7%). The three groups did not differ significantly in tumor type or distance from the anal verge. No R-TAMIS patients had a positive surgical margin compared to 23.1% in the TEM group and 16.7% in the TAMIS group. Length of stay (median 1 day for TEM and R-TAMIS patients, 0 days for TAMIS patients) and 30-day readmission rates (7.7% of TEM, 0% of TAMIS, 10% of R-TAMIS patients) also did not differ among the groups. Median operative time was 110 min for TEM, 105 min for TAMIS, and 76 min for R-TAMIS patients.
CONCLUSIONS
R-TAMIS may have several advantages over other advanced techniques for transanal excisions. R-TAMIS tended to be faster and to more often result in negative surgical margins compared to the two other techniques.
Topics: Anal Canal; Female; Humans; Middle Aged; Operative Time; Rectal Neoplasms; Rectum; Transanal Endoscopic Surgery
PubMed: 35346146
DOI: 10.1186/s12893-022-01543-w -
Asian Journal of Endoscopic Surgery Jul 2022Transanal total mesorectal excision is a relatively new approach for treating lower rectal cancer. Carbon dioxide embolism is a critical complication of this procedure....
Transanal total mesorectal excision is a relatively new approach for treating lower rectal cancer. Carbon dioxide embolism is a critical complication of this procedure. We report the case of a 69-year-old man with lower rectal cancer who underwent transanal total mesorectal excision followed by laparoscopic low anterior resection. He had a sudden intraoperative carbon dioxide embolism during the transanal mesorectal excision. During the ventral dissection of the rectum, end-tidal carbon dioxide and blood oxygen saturation suddenly decreased. We stopped the insufflation of carbon dioxide and suspended the procedure. There was no circulatory collapse, and the vital signs gradually recovered; therefore, we resumed the surgery approximately 30 minutes later and completed it without additional complications. Upon reviewing the video, we found a small injured vein that would aspirate carbon dioxide. These findings suggested that careful hemostasis is essential to prevent carbon dioxide embolus during transanal total mesorectal excision.
Topics: Aged; Carbon Dioxide; Embolism; Humans; Laparoscopy; Male; Postoperative Complications; Proctectomy; Rectal Neoplasms; Rectum; Transanal Endoscopic Surgery
PubMed: 35285147
DOI: 10.1111/ases.13049 -
BJGP Open Sep 2022Quality service delivery in primary care requires motivated and competent health professionals. In the Kenyan private sector, GPs with no postgraduate training in family...
BACKGROUND
Quality service delivery in primary care requires motivated and competent health professionals. In the Kenyan private sector, GPs with no postgraduate training in family medicine offer primary care. There is a paucity of evidence on the ability of primary care providers to deliver comprehensive care and no such evidence is available for GPs practising in the private sector in Kenya.
AIM
To evaluate GPs' training and experience in the skills required for comprehensive primary care.
DESIGN AND SETTING
A cross-sectional descriptive survey in 13 primary care clinics in the private sector of Nairobi, Kenya.
METHOD
A questionnaire, originally designed for a national survey of primary care doctors in South Africa, was adapted. The study collected self-reported data on performance of clinical skills by 25 GPs. Data were analysed using the Statistical Package for Social Sciences (SPSS, version 25).
RESULTS
GPs were mostly aged <40 years, with ≤10 years of experience, and there was an equal sex distribution. GPs reported moderate performance with adult health, communication and consultation, and clinical administration; and weak performance with emergencies, child health, surgery, ear, nose, and throat (ENT) and eyes, women's health, and orthopaedics. The GPs lacked training in specific skills such as proctoscopies, contraceptive devices, skin procedures, intra-articular injections, red reflex tests, and use of genograms.
CONCLUSION
GPs lacked training and performed poorly in some of the essential skills required in primary care. Continuing professional development, training in family medicine, broadening the model of care, and deployment of family physicians to the clinics could improve care comprehensiveness.
PubMed: 35256356
DOI: 10.3399/BJGPO.2021.0233 -
Surgical Endoscopy Oct 2022
Topics: Humans; Microsurgery; Neoplasm Recurrence, Local; Polyps; Proctoscopy; Rectal Neoplasms; Transanal Endoscopic Microsurgery; Treatment Outcome
PubMed: 35246739
DOI: 10.1007/s00464-022-09162-5