BACKGROUND Trans-anal endoscopic microsurgery(TEM)enables a good visualization of the surgical field and is considered the method of choice for excision of adenomas and early T1 rectal cancer.The rectum and retro-rect...BACKGROUND Trans-anal endoscopic microsurgery(TEM)enables a good visualization of the surgical field and is considered the method of choice for excision of adenomas and early T1 rectal cancer.The rectum and retro-rectal space might be the origin of uncommon neoplasms,benign and aggressive,certain require radical trans-abdominal surgery,while others can be treated by a less aggressive approach.In this study we report outcomes in patients undergoing TEM for rare and non-adenomatous rectal and retro-rectal lesions over a period of 11 years.METHODS Between January 2008 to December 2019 a retrospective analysis was completed for all patients who underwent TEM for non-adenomatous rectal lesion or retro-rectal mass in our institution.Patients were discharged once diet was well tolerated and no complications were identified.They were evaluated at 3 wk post operatively,then at 3-mo intervals for the first 2 years and every 6 mo depending on the nature of the final pathology.Clinical examination and rectoscopy were performed during each of the follow-up visits.RESULTS Out of 198 patients who underwent TEM during the study period,18 had non-adenomatous rectal or retro-rectal lesions.Mean age was 47 years.The mean size of the lesions was 2.9 mm,with a mean distance from the anal margin of 7.9 cm.Mean surgical time was 97.8 min.There were no intra-operative neither late post-operative complications.Mean length of stay was 2.5 d.Mean patient follow-up duration was 42 mo.CONCLUSION TEM allows for reduced morbidity given its minimally invasive nature.Surgeons should be familiar with the technique but careful patient selection should be considered.It can be used safely for uncommon rectal and selected retro-rectal lesions without compromising outcomes.We believe that it should be reasonably considered as one of the surgical methods when treating rare lesions.展开更多
BACKGROUND Endoscopic submucosal dissection(ESD)can be used for the en-bloc removal of superficial rectal lesions;however,the lack of a traction system makes the procedure long and difficult in the presence of extensi...BACKGROUND Endoscopic submucosal dissection(ESD)can be used for the en-bloc removal of superficial rectal lesions;however,the lack of a traction system makes the procedure long and difficult in the presence of extensive lesions.CASE SUMMARY A large polyp occupying 2/3 of the rectal circumference and extending 5 cm in length was removed by ESD with the help of laparoscopic forceps introduced via trans-anal rectoscopic assisted minimally invasive surgery,a disposable platform designed to aid in transanal minimally invasive surgery.Traction of the polyp by forceps during the operation was dynamic,and applied at various points and in various directions.The polyp was removed en-bloc without complications in 1 h and 55 min.A sigmoidoscopy performed 50 d later showed normal healing without polyp recurrence.CONCLUSION The technique presented here could overcome the issues caused by lack of traction during ESD for rectal lesions.展开更多
BACKGROUND Compared to traditional open surgery,laparoscopic surgery has become a standard approach for colorectal cancer due to its great superiorities including less postoperative pain,a shorter hospital stay,and be...BACKGROUND Compared to traditional open surgery,laparoscopic surgery has become a standard approach for colorectal cancer due to its great superiorities including less postoperative pain,a shorter hospital stay,and better quality of life.In 2007,Whiteford et al reported the first natural orifice trans-anal endoscopic surgery(NOTES)sigmoidectomy using transanal endoscopic microsurgery.To date,all cases of NOTES colorectal resection have included a hybrid laparoscopic approach with the use of established rigid platforms.AIM To introduce a novel technique of peroral external traction-assisted transanal NOTES rectosigmoidectomy followed by intracorporeal colorectal end-to-end anastomosis by using only currently available and flexible endoscopic instrumentation in a live porcine model.METHODS Three female pigs weighing 25-30 kg underwent NOTES rectosigmoid resection.After preoperative work-up and bowel preparation,general anesthesia combined with endotracheal intubation was achieved.One dual-channel therapeutic endoscope was used.Carbon dioxide insufflation was performed during the operation.The procedure of trans-anal NOTES rectosigmoidectomy included the following eight steps:(1)The rectosigmoid colon was tattooed with India ink by submucosal injection;(2)Creation of gastrostomy by directed submucosal tunneling;(3)Peroral external traction using endoloop ligation;(4)Creation of rectostomy on the anterior rectal wall by directed 3 cm submucosal tunneling;(5)Peroral external traction-assisted dissection of the left side of the colon;(6)Transanal rectosigmoid specimen transection,where an anvil was inserted into the proximal segment after purse-string suturing;(7)Intracorporeal colorectal end-toend anastomosis using a circular stapler by a single stapling technique;and(8)Closure of gastrostomy using endoscopic clips.All animals were euthanized immediately after the procedure,abdominal exploration was performed,and the air-under-water leak test was carried out.RESULTS The procedure was completed in all three animals,with the operation time ranging from 193 min to 259 min.Neither major intraoperative complications nor hemodynamic instability occurred during the operation.The length of the resected specimen ranged from 7 cm to 13 cm.With the assistance of a transumbilical rigid grasper,intracorporeal colorectal,tension-free,end-to-end anastomosis was achieved in the three animals.CONCLUSION Peroral traction-assisted transanal NOTES rectosigmoidectomy followed by intracorporeal colorectal end-to-end anastomosis is technically feasible and reproducible in an animal model and is worthy of further improvements.展开更多
Thirty per cent of all colorectal tumours develop in the rectum.The location of the rectum within the bony pelvis and its proximity to vital structures presents significant therapeutic challenges when considering neoa...Thirty per cent of all colorectal tumours develop in the rectum.The location of the rectum within the bony pelvis and its proximity to vital structures presents significant therapeutic challenges when considering neoadjuvant options and surgical interventions.Most patients with early rectal cancer can be adequately managed by surgery alone.However,a significant proportion of patients with rectal cancer present with locally advanced disease and will potentially benefit from down staging prior to surgery.Neoadjuvant therapy involves a variety of options including radiotherapy,chemotherapy used alone or in combination.Neoadjuvant radiotherapy in rectal cancer has been shown to be effective in reducing tumour burden in advance of curative surgery.The gold standard surgical rectal cancer management aims to achieve surgical removal of the tumour and all draining lymph nodes,within an intact mesorectal package,in order to minimise local recurrence.It is critically important that all rectal cancer cases are discussed at a multidisciplinary meeting represented by all relevant specialties.Pre-operative staging including CT thorax,abdomen,pelvis to assess for distal disease and magnetic resonance imaging to assess local involvement is essential.Staging radiology and MDT discussion are integral in identifying patients who require neoadjuvant radiotherapy.While Neoadjuvant radiotherapy is potentially beneficial it may also result in morbidity and thus should be reserved for those patients who are at a high risk of local failure,which includes patients with nodal involvement,extramural venous invasion and threatened circumferential margin.The aim of this review is to discuss the role of neoadjuvant radiotherapy in the management of rectal cancer.展开更多
BACKGROUND Emergency surgical resection is a standard treatment for right-sided malignant colonic obstruction; however, the procedure is associated with high rates of mortality and morbidity. Although a bridge to surg...BACKGROUND Emergency surgical resection is a standard treatment for right-sided malignant colonic obstruction; however, the procedure is associated with high rates of mortality and morbidity. Although a bridge to surgery can be created to obviate the need for emergency surgery, its effects on long-term outcomes and the most practical management strategies for right-sided malignant colonic obstruction remain unclear.AIM To determine the appropriate management approach for right-sided malignant colonic obstruction.METHODS Forty patients with right-sided malignant colonic obstruction who underwent curative resection from January 2007 to April 2017 were included in the study.We compared the perioperative and long-term outcomes of patients who received bridges to surgery established using decompression tubes and those created using self-expandable metallic stents(SEMS). The primary outcome was the overall survival duration(OS) and the secondary endpoints were the diseasefree survival(DFS) duration and the preoperative and postoperative morbidity rates. Analysis was performed on an intention-to-treat basis.RESULTS There were 21 patients in the decompression tube group and 19 in the SEMS group. There were no significant differences in the perioperative morbidity rates of the two groups. The OS rate was significantly higher in the decompression tube group than in the SEMS group(5-year OS rate; decompression tube 79.5%,SEMS 32%, P = 0.043). Multivariate analysis revealed that the bridge to surgery using a decompression tube was significantly associated with the OS(hazard ratio, 17.41; P = 0.004). The 3-year DFS rate was significantly higher in thedecompression tube group than in the SEMS group(68.9% vs 45.9%; log-rank test,P = 0.032). A propensity score–adjusted analysis also demonstrated that the prognosis was significantly better in the decompression tube group than in the SEMS group.CONCLUSION The bridge to surgery using trans-nasal and trans-anal decompression tubes for right-sided malignant colonic obstruction is safe and may improve long-term outcomes.展开更多
文摘BACKGROUND Trans-anal endoscopic microsurgery(TEM)enables a good visualization of the surgical field and is considered the method of choice for excision of adenomas and early T1 rectal cancer.The rectum and retro-rectal space might be the origin of uncommon neoplasms,benign and aggressive,certain require radical trans-abdominal surgery,while others can be treated by a less aggressive approach.In this study we report outcomes in patients undergoing TEM for rare and non-adenomatous rectal and retro-rectal lesions over a period of 11 years.METHODS Between January 2008 to December 2019 a retrospective analysis was completed for all patients who underwent TEM for non-adenomatous rectal lesion or retro-rectal mass in our institution.Patients were discharged once diet was well tolerated and no complications were identified.They were evaluated at 3 wk post operatively,then at 3-mo intervals for the first 2 years and every 6 mo depending on the nature of the final pathology.Clinical examination and rectoscopy were performed during each of the follow-up visits.RESULTS Out of 198 patients who underwent TEM during the study period,18 had non-adenomatous rectal or retro-rectal lesions.Mean age was 47 years.The mean size of the lesions was 2.9 mm,with a mean distance from the anal margin of 7.9 cm.Mean surgical time was 97.8 min.There were no intra-operative neither late post-operative complications.Mean length of stay was 2.5 d.Mean patient follow-up duration was 42 mo.CONCLUSION TEM allows for reduced morbidity given its minimally invasive nature.Surgeons should be familiar with the technique but careful patient selection should be considered.It can be used safely for uncommon rectal and selected retro-rectal lesions without compromising outcomes.We believe that it should be reasonably considered as one of the surgical methods when treating rare lesions.
文摘BACKGROUND Endoscopic submucosal dissection(ESD)can be used for the en-bloc removal of superficial rectal lesions;however,the lack of a traction system makes the procedure long and difficult in the presence of extensive lesions.CASE SUMMARY A large polyp occupying 2/3 of the rectal circumference and extending 5 cm in length was removed by ESD with the help of laparoscopic forceps introduced via trans-anal rectoscopic assisted minimally invasive surgery,a disposable platform designed to aid in transanal minimally invasive surgery.Traction of the polyp by forceps during the operation was dynamic,and applied at various points and in various directions.The polyp was removed en-bloc without complications in 1 h and 55 min.A sigmoidoscopy performed 50 d later showed normal healing without polyp recurrence.CONCLUSION The technique presented here could overcome the issues caused by lack of traction during ESD for rectal lesions.
基金Supported by Young and Middleaged Mainstay Talent Training Program of Fujian Provincial Health System,China,No.2014-ZQN-ZD-6.
文摘BACKGROUND Compared to traditional open surgery,laparoscopic surgery has become a standard approach for colorectal cancer due to its great superiorities including less postoperative pain,a shorter hospital stay,and better quality of life.In 2007,Whiteford et al reported the first natural orifice trans-anal endoscopic surgery(NOTES)sigmoidectomy using transanal endoscopic microsurgery.To date,all cases of NOTES colorectal resection have included a hybrid laparoscopic approach with the use of established rigid platforms.AIM To introduce a novel technique of peroral external traction-assisted transanal NOTES rectosigmoidectomy followed by intracorporeal colorectal end-to-end anastomosis by using only currently available and flexible endoscopic instrumentation in a live porcine model.METHODS Three female pigs weighing 25-30 kg underwent NOTES rectosigmoid resection.After preoperative work-up and bowel preparation,general anesthesia combined with endotracheal intubation was achieved.One dual-channel therapeutic endoscope was used.Carbon dioxide insufflation was performed during the operation.The procedure of trans-anal NOTES rectosigmoidectomy included the following eight steps:(1)The rectosigmoid colon was tattooed with India ink by submucosal injection;(2)Creation of gastrostomy by directed submucosal tunneling;(3)Peroral external traction using endoloop ligation;(4)Creation of rectostomy on the anterior rectal wall by directed 3 cm submucosal tunneling;(5)Peroral external traction-assisted dissection of the left side of the colon;(6)Transanal rectosigmoid specimen transection,where an anvil was inserted into the proximal segment after purse-string suturing;(7)Intracorporeal colorectal end-toend anastomosis using a circular stapler by a single stapling technique;and(8)Closure of gastrostomy using endoscopic clips.All animals were euthanized immediately after the procedure,abdominal exploration was performed,and the air-under-water leak test was carried out.RESULTS The procedure was completed in all three animals,with the operation time ranging from 193 min to 259 min.Neither major intraoperative complications nor hemodynamic instability occurred during the operation.The length of the resected specimen ranged from 7 cm to 13 cm.With the assistance of a transumbilical rigid grasper,intracorporeal colorectal,tension-free,end-to-end anastomosis was achieved in the three animals.CONCLUSION Peroral traction-assisted transanal NOTES rectosigmoidectomy followed by intracorporeal colorectal end-to-end anastomosis is technically feasible and reproducible in an animal model and is worthy of further improvements.
基金Supported by NBCRI,Symptomatic Breast Unit,University Hospital Galway
文摘Thirty per cent of all colorectal tumours develop in the rectum.The location of the rectum within the bony pelvis and its proximity to vital structures presents significant therapeutic challenges when considering neoadjuvant options and surgical interventions.Most patients with early rectal cancer can be adequately managed by surgery alone.However,a significant proportion of patients with rectal cancer present with locally advanced disease and will potentially benefit from down staging prior to surgery.Neoadjuvant therapy involves a variety of options including radiotherapy,chemotherapy used alone or in combination.Neoadjuvant radiotherapy in rectal cancer has been shown to be effective in reducing tumour burden in advance of curative surgery.The gold standard surgical rectal cancer management aims to achieve surgical removal of the tumour and all draining lymph nodes,within an intact mesorectal package,in order to minimise local recurrence.It is critically important that all rectal cancer cases are discussed at a multidisciplinary meeting represented by all relevant specialties.Pre-operative staging including CT thorax,abdomen,pelvis to assess for distal disease and magnetic resonance imaging to assess local involvement is essential.Staging radiology and MDT discussion are integral in identifying patients who require neoadjuvant radiotherapy.While Neoadjuvant radiotherapy is potentially beneficial it may also result in morbidity and thus should be reserved for those patients who are at a high risk of local failure,which includes patients with nodal involvement,extramural venous invasion and threatened circumferential margin.The aim of this review is to discuss the role of neoadjuvant radiotherapy in the management of rectal cancer.
文摘BACKGROUND Emergency surgical resection is a standard treatment for right-sided malignant colonic obstruction; however, the procedure is associated with high rates of mortality and morbidity. Although a bridge to surgery can be created to obviate the need for emergency surgery, its effects on long-term outcomes and the most practical management strategies for right-sided malignant colonic obstruction remain unclear.AIM To determine the appropriate management approach for right-sided malignant colonic obstruction.METHODS Forty patients with right-sided malignant colonic obstruction who underwent curative resection from January 2007 to April 2017 were included in the study.We compared the perioperative and long-term outcomes of patients who received bridges to surgery established using decompression tubes and those created using self-expandable metallic stents(SEMS). The primary outcome was the overall survival duration(OS) and the secondary endpoints were the diseasefree survival(DFS) duration and the preoperative and postoperative morbidity rates. Analysis was performed on an intention-to-treat basis.RESULTS There were 21 patients in the decompression tube group and 19 in the SEMS group. There were no significant differences in the perioperative morbidity rates of the two groups. The OS rate was significantly higher in the decompression tube group than in the SEMS group(5-year OS rate; decompression tube 79.5%,SEMS 32%, P = 0.043). Multivariate analysis revealed that the bridge to surgery using a decompression tube was significantly associated with the OS(hazard ratio, 17.41; P = 0.004). The 3-year DFS rate was significantly higher in thedecompression tube group than in the SEMS group(68.9% vs 45.9%; log-rank test,P = 0.032). A propensity score–adjusted analysis also demonstrated that the prognosis was significantly better in the decompression tube group than in the SEMS group.CONCLUSION The bridge to surgery using trans-nasal and trans-anal decompression tubes for right-sided malignant colonic obstruction is safe and may improve long-term outcomes.
