A systematic analysis of controlled clinical trials using the NiTi CAR™ compression ring in colorectal anastomoses

Anastomotic leak following colorectal surgery can be a devastating adverse event. The ideal stapling device should be capable of rapid creation of an anastomosis with serosal apposition without the persistence of a foreign body or a foreign body reaction which potentially contribute to early anastomotic dehiscence or late anastomotic stricture. A systematic review was performed examining available data on controlled randomized and non-randomized trials assessing the NiTi compression anastomosis ring-(NiTi CAR™) (NiTi Solutions, Netanyah Israel) in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) standards. A protocol for this meta-analysis has been registered on PROSPERO (CRD42016050934). The initial search yielded 45 potentially relevant articles. After screening titles and abstracts for relevance and assessment for eligibility, 39 of these articles were eventually excluded leaving 6 studies for analysis in the review. Regarding the primary outcome measure, the overall anastomotic leak rate was 2.2% (5/230) in the compression anastomosis group compared with 3% (10/335) in the conventional anastomosis group; this difference was not statistically significant (RR 0.75, 95% CI 0.25-2.24; participants = 565; studies = 6; I ² = 0%). There were no statistically significant differences between compression and conventional anastomoses in any of the secondary outcomes. This review was unable to demonstrate any statistically significant differences in favor of the compression anastomosis technique over conventional manual or stapled mechanical anastomoses.

Colonic stenting as a bridge to surgery versus emergency surgery for malignant colonic obstruction: results of a multicentre randomised controlled trial (ESCO trial)

BACKGROUND

The aim of colonic stenting with self-expandable metallic stents in neoplastic colon obstruction is to avoid emergency surgery and thus potentially reduce morbidity, mortality, and need for a stoma. Concern has been raised, however, about the effect of colonic stenting on short-term complications and long-term survival. We compared morbidity rates after colonic stenting as a bridge to surgery (SBTS) versus emergency surgery (ES) in the management of left-sided malignant large-bowel obstruction.

METHODS

This multicentre randomised controlled trial was designed with the endorsement of the European Association for Endoscopic Surgery. The study population was consecutive patients with acute, symptomatic malignant left-sided large-bowel obstruction localised between the splenic flexure and 15 cm from the anal margin. The primary outcome was overall morbidity within 60 days after surgery.

RESULTS

Between March 2008 and November 2015, 144 patients were randomly assigned to undergo either SBTS or ES; 29/144 (13.9%) were excluded post-randomisation mainly because of wrong diagnosis at computed tomography examination. The remaining 115 patients (SBTS n = 56, ES n = 59) were deemed eligible for analysis. The complications rate within 60 days was 51.8% in the SBTS group and 57.6% in the ES group (p = 0.529). Although long-term follow-up is still ongoing, no statistically significant difference in 3-year overall survival (p = 0.998) and progression-free survival rates between the groups has been observed (p = 0.893). Eleven patients in the SBTS group and 23 in the ES group received a stoma (p = 0.031), with a reversal rate of 30% so far.

CONCLUSIONS

Our findings indicate that the two treatment strategies are equivalent. No difference in oncologic outcome was found at a median follow-up of 36 months. The significantly lower stoma rate noted in the SBTS group argues in favour of the SBTS procedure when performed in expert hands.

Conversion of laparoscopic colorectal resection for cancer: What is the impact on short-term outcomes and survival?

Laparoscopic resection for colon and rectal cancer is associated with quicker return of bowel function, reduced postoperative morbidity rates and shorter length of hospital stay compared to open surgery, with no differences in long-term survival. Conversion to open surgery is reported in up to 30% of patients enrolled in randomized control trials comparing open and laparoscopic colorectal resection for cancer. In this review, reasons for conversion are anatomical-related factors, disease-related-factors and surgeon-related factors. Body mass index, local tumour extension and co-morbidities are independent predictors of conversion. The current evidence has shown that patients with converted resection for colon cancer have similar outcomes compared to patients undergoing a laparoscopic completed or open resection. The few studies that have assessed the outcomes after conversion of laparoscopic rectal resection reported significantly higher rates of complications and longer length of hospital stay in converted patients compared to laparoscopically treated patients. No definitive conclusions can be drawn when converted and open rectal resections are compared. Early and pre-emptive conversion appears to have more favourable outcomes than reactive conversion; however, further large studies are needed to better define the optimal timing of conversion. With regard to long-term oncologic outcome, overall and disease-free survival in the case of conversion in laparoscopic colorectal cancer surgery seems to be worse than those achieved in patients in whom resection was successfully completed by laparoscopy. Although a worse long-term oncologic outcome has been suggested, it remains difficult to draw a proper conclusion due to the heterogeneity of the long-term outcomes as well as the inclusion of both colon and rectal cancer patients in most of the studies. Therefore, we discuss the currently available evidence of the impact of conversion in laparoscopic resection for colon and rectal cancer on both short-term outcomes and long-term survival.

Transanal endoscopic microsurgery for giant circumferential rectal adenomas

AIM

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.

METHOD

We retrospectively reviewed the medical records of 17 consecutive patients [median age 69 (32-89) years; nine men] who underwent TEM for a circumferential rectal lesion in our department between September 2010 and January 2015.

RESULTS

The median distance from the anal verge was 4 (3-11) cm, the median longitudinal extent was 7 (3-10) cm and the median surface area was 75 (40-255) cm(2) . An end-to-end anastomosis without proximal bowel mobilization was completed endoscopically in all cases. The median operating time was 120 (40-240) min. Persistent, endoscopically uncontrollable endoluminal bleeding in one patient was successfully treated with a second TEM procedure. One patient underwent preoperative radiotherapy for adenocarcinoma detected at the preoperative assessment. Surgical histology showed a pT3 cancer in one patient who refused further surgery, a pT2 cancer in two who subsequently underwent abdominoperineal resection, a pT1 cancer in four and a ypT0 in one patient. All are at present free of disease. No patients developed faecal incontinence or urinary or sexual dysfunction. Four patients required endoscopic balloon dilatation for stenosis.

CONCLUSION

Transanal endoscopic microsurgery is a feasible and safe technique for large circumferential lesions with a satisfactory outcome. Preoperative staging may be inaccurate.

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.

Frontiers of robotic endoscopic capsules: a review

Digestive diseases are a major burden for society and healthcare systems, and with an aging population, the importance of their effective management will become critical. Healthcare systems worldwide already struggle to insure quality and affordability of healthcare delivery and this will be a significant challenge in the midterm future. Wireless capsule endoscopy (WCE), introduced in 2000 by Given Imaging Ltd., is an example of disruptive technology and represents an attractive alternative to traditional diagnostic techniques. WCE overcomes conventional endoscopy enabling inspection of the digestive system without discomfort or the need for sedation. Thus, it has the advantage of encouraging patients to undergo gastrointestinal (GI) tract examinations and of facilitating mass screening programmes. With the integration of further capabilities based on microrobotics, e.g. active locomotion and embedded therapeutic modules, WCE could become the key-technology for GI diagnosis and treatment. This review presents a research update on WCE and describes the state-of-the-art of current endoscopic devices with a focus on research-oriented robotic capsule endoscopes enabled by microsystem technologies. The article also presents a visionary perspective on WCE potential for screening, diagnostic and therapeutic endoscopic procedures.

Over-the-scope clips in the treatment of gastrointestinal tract iatrogenic perforation: A multicenter retrospective study and a classification of gastrointestinal tract perforations

AIM: To determine the outcome of the management of iatrogenic gastrointestinal tract perforations treated by over-the-scope clip (OTSC) placement.

METHODS: We retrospectively enrolled 20 patients (13 female and 7 male; mean age: 70.6 ± 9.8 years) in eight high-volume tertiary referral centers with upper or lower iatrogenic gastrointestinal tract perforation treated by OTSC placement. Gastrointestinal tract perforation could be with oval-shape or with round-shape. Oval-shape perforations were closed by OTSC only by suction and the round-shape by the “twin-grasper” plus suction.

RESULTS: Main perforation diameter was 10.1 ± 4.3 mm (range 3-18 mm). The technical success rate was 100% (20/20 patients) and the clinical success rate was 90% (18/20 patients). Two patients (10%) who did not have complete sealing of the defect underwent surgery. Based upon our observations we propose two types of perforation: Round-shape “type-1 perforation” and oval-shape “type-2 perforation”. Eight (40%) out of the 20 patients had a type-1 perforation and 12 patients a type-2 (60%).

CONCLUSION: OTSC placement should be attempted after perforation occurring during diagnostic or therapeutic endoscopy. A failed closure attempt does not impair subsequent surgical treatment.

Transanal Endoscopic Operation under spinal anaesthesia

Background

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.

Methods

The study population comprised eligible consecutive patients who underwent TEO® under spinal anaesthesia with curative or palliative intent for rectal neoplasms larger than 20 mm in diameter or for recurrent lesions of any size. The primary endpoints were feasibility and safety; secondary endpoints were postoperative pain, as measured on a visual analogue scale, heart rate, systolic and diastolic BP, opioid requested, postoperative nausea or vomiting, and urinary retention.

Results

The study included 50 patients (median age 70 years; 29 men and 21 women). No intraoperative complications occurred. The median duration of operation was 60 (range 20–165) min. No opioids were requested during the perioperative or postoperative period. The median postoperative pain score was 0 at 4, 8, 24 and 48 h after surgery. There were no significant fluctuations in heart rate, systolic and diastolic BP up to 48 h after the procedure (P = 0·379, P = 0·386 and P = 0·617 respectively). Postoperative nausea and vomiting occurred in one patient, and urinary retention in four.

Conclusion

TEO® under spinal anaesthesia was safe and feasible with no conversions to general anaesthesia.

Comfort and learnability assessment of a new soft robotic manipulator for minimally invasive surgery

Laparoscopic surgeons perform precise and time consuming procedures while holding awkward poses in their upper body and arms. There is an ongoing effort to produce robotic tools for laparoscopic surgery that will simplify these tasks and reduce risk of errors to help both the surgeon and the patient. STIFF-FLOP is an ongoing EU FP7 project focusing on this by creating a stiffness controllable soft robotic manipulator. This paper reports on a study to test the soft manipulator's learnability and the effort associated with its use. The tests involved a limited prototype of the manipulator with a custom built test rig and EMG acquisition system. Task times and video recordings along with EMG waveforms from the forearm muscles of participants (n=25) were measured for objective assessment. A questionnaire was also provided to the participants for subjective assessment. The data shows that in average EMG levels were 25.9% less in RMS when using the STIFF-FLOP arm than when conventional laparoscopic tools were used. In terms of learnability, from the first to the second attempt on the STIFF-FLOP manipulator, elapsed time was reduced by an average of 32.1%. Further details and analysis of the EMG signals as well as time and questionnaire results is presented in the paper.

Efficacy and safety of laparo-endoscopic resections of colorectal neoplasia: A systematic review

OBJECTIVE

The purpose of this review is to assess the efficacy and safety of laparo-endoscopic local resections for colorectal lesions not suitable for endoscopic resection.

SUMMARY BACKGROUND DATA

The combined laparo-endoscopic approach has been proposed for large colorectal lesions unsuitable for endoscopic resection, in order to reduce morbidity of common laparoscopic resection. However, data on the efficacy and safety of laparo-endoscopic local resections are still controversial.

METHODS

An Embase search of papers published during the period 1985-2014 was performed. Published studies that evaluated laparo-endoscopic resections for colorectal lesions were assessed using PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) recommendations by two authors. Forest plots on primary (per-lesion rate of further surgery, including surgery for complications and surgery for oncologic radical treatment) and secondary outcomes were produced based on fixed and random effects models. Heterogeneity was assessed using the I (2) statistic. Risk for within-study bias was ascertained with QUADAS (Quality Assessment of Diagnostic Accuracy Studies) system.

RESULTS

A total of 11 studies provided data on 707 lesions treated with a combined laparo-endoscopic approach. A variety of techniques were reported. The overall per-lesion rate of further surgery was 9.5%, while per-lesion rate of further surgery for oncologic treatment was 7.9%, per-lesion rate of further surgery for complications treatment was 3.5%, incidence of adenocarcinoma was 10.5%, incidence of overall complications was 7.9%, incidence of conversion to open surgery 4.3% and incidence of recurrence was 5.4%.

CONCLUSIONS

Despite laparo-endoscopic approach ensures limited invasiveness, it is affected by a consistent rate of complications and oncologic inadequacy that often requires further surgical treatment.

Laparoscopic right colectomy reduces short-term mortality and morbidity. Results of a systematic review and meta-analysis

PURPOSE

While definitive long-term results are not yet available, the global safety and oncologic adequacy of laparoscopic surgery for right colectomy remain controversial. The aim of the study was to evaluate differences in safety of laparoscopic right colectomy, compared with open surgery, with particular attention to cancer patients.

METHODS

A systematic review from 1991 to 2014 was performed searching the MEDLINE and EMBASE databases (PROSPERO Registration number: CRD42014015256). We included randomised and controlled clinical studies comparing laparoscopic and open resection for rectal cancer. Primary endpoints were 30 days mortality and overall morbidity. Then, a meta-analysis was conducted by a fixed-effect model, performing a sensitivity analysis by a random-effect model. Relative risk (RR) was used as an indicator of treatment effect; a RR less than 1.0 was in favour of laparoscopy. Publication bias was assessed by funnel plot, heterogeneity by the I (2) test and subgroup analysis on oncologic patients.

RESULTS

Twenty-seven studies, representing 3049 patients, met the inclusion criteria; only 2 were randomised for a total of 211 patients. Mortality was observed in 1.2 % of patients in the laparoscopic group and in 3.4 % of patients in the open group. The overall RR was 0.45 (95 % CI 0.21-0.93, p = 0.031). The raw incidence of overall complications was significantly lower in the laparoscopic group (16.8 %) compared to the open group (24.2 %). The overall RR was 0.81 (95 % CI 0.70-0.95, p = 0.007).

CONCLUSIONS

Based on the evidence of few randomised and mostly controlled series, mortality and morbidity were significantly lower after laparoscopy compared to open surgery.

New Trends in Acute Management of Colonic Diverticular Bleeding: A Systematic Review

Colonic diverticular disease is the most common cause of lower gastrointestinal bleeding. In the past, this condition was usually managed with urgent colectomy. Recently, the development of endoscopy and interventional radiology has led to a change in the management of colonic diverticular bleeding.The aim of this systematic review is to define the best treatment for colonic diverticular bleeding.A systematic bibliographic research was performed on the online databases for studies (randomized controlled trials [RCTs], observational trials, case series, and case reports) published between 2005 and 2014, concerning patients admitted with a diagnosis of diverticular bleeding according to the PRISMA methodology.The outcomes of interest were: diagnosis of diverticulosis as source of bleeding; incidence of self-limiting diverticular bleeding; management of non self-limiting bleeding (endoscopy, angiography, surgery); and recurrent diverticular bleeding.Fourteen studies were retrieved for analysis. No RCTs were found. Eleven non-randomized clinical controlled trials (NRCCTs) were included in this systematic review. In all studies, the definitive diagnosis of diverticular bleeding was always made by urgent colonoscopy. The colonic diverticular bleeding stopped spontaneously in over 80% of the patients, but a re-bleeding was not rare. Recently, interventional endoscopy and angiography became the first-line approach, thus relegating emergency colectomy to patients presenting with hemodynamic instability or as a second-line treatment after failure or complications of hemostasis with less invasive treatments.Colonoscopy is effective to diagnose diverticular bleeding. Nowadays, interventional endoscopy and angiographic treatment have gained a leading role and colectomy should only be entertained in case of failure of the former.

Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It addresses the diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH). Main Recommendations MR1. ESGE recommends immediate assessment of hemodynamic status in patients who present with acute upper gastrointestinal hemorrhage (UGIH), with prompt intravascular volume replacement initially using crystalloid fluids if hemodynamic instability exists (strong recommendation, moderate quality evidence). MR2. ESGE recommends a restrictive red blood cell transfusion strategy that aims for a target hemoglobin between 7 g/dL and 9 g/dL. A higher target hemoglobin should be considered in patients with significant co-morbidity (e. g., ischemic cardiovascular disease) (strong recommendation, moderate quality evidence). MR3. ESGE recommends the use of the Glasgow-Blatchford Score (GBS) for pre-endoscopy risk stratification. Outpatients determined to be at very low risk, based upon a GBS score of 0 - 1, do not require early endoscopy nor hospital admission. Discharged patients should be informed of the risk of recurrent bleeding and be advised to maintain contact with the discharging hospital (strong recommendation, moderate quality evidence). MR4. ESGE recommends initiating high dose intravenous proton pump inhibitors (PPI), intravenous bolus followed by continuous infusion (80 mg then 8 mg/hour), in patients presenting with acute UGIH awaiting upper endoscopy. However, PPI infusion should not delay the performance of early endoscopy (strong recommendation, high quality evidence). MR5. ESGE does not recommend the routine use of nasogastric or orogastric aspiration/lavage in patients presenting with acute UGIH (strong recommendation, moderate quality evidence). MR6. ESGE recommends intravenous erythromycin (single dose, 250 mg given 30 - 120 minutes prior to upper gastrointestinal [GI] endoscopy) in patients with clinically severe or ongoing active UGIH. In selected patients, pre-endoscopic infusion of erythromycin significantly improves endoscopic visualization, reduces the need for second-look endoscopy, decreases the number of units of blood transfused, and reduces duration of hospital stay (strong recommendation, high quality evidence). MR7. Following hemodynamic resuscitation, ESGE recommends early (≤ 24 hours) upper GI endoscopy. Very early (< 12 hours) upper GI endoscopy may be considered in patients with high risk clinical features, namely: hemodynamic instability (tachycardia, hypotension) that persists despite ongoing attempts at volume resuscitation; in-hospital bloody emesis/nasogastric aspirate; or contraindication to the interruption of anticoagulation (strong recommendation, moderate quality evidence). MR8. ESGE recommends that peptic ulcers with spurting or oozing bleeding (Forrest classification Ia and Ib, respectively) or with a nonbleeding visible vessel (Forrest classification IIa) receive endoscopic hemostasis because these lesions are at high risk for persistent bleeding or rebleeding (strong recommendation, high quality evidence). MR9. ESGE recommends that peptic ulcers with an adherent clot (Forrest classification IIb) be considered for endoscopic clot removal. Once the clot is removed, any identified underlying active bleeding (Forrest classification Ia or Ib) or nonbleeding visible vessel (Forrest classification IIa) should receive endoscopic hemostasis (weak recommendation, moderate quality evidence). MR10. In patients with peptic ulcers having a flat pigmented spot (Forrest classification IIc) or clean base (Forrest classification III), ESGE does not recommend endoscopic hemostasis as these stigmata present a low risk of recurrent bleeding. In selected clinical settings, these patients may be discharged to home on standard PPI therapy, e. g., oral PPI once-daily (strong recommendation, moderate quality evidence). MR11. ESGE recommends that epinephrine injection therapy not be used as endoscopic monotherapy. If used, it should be combined with a second endoscopic hemostasis modality (strong recommendation, high quality evidence). MR12. ESGE recommends PPI therapy for patients who receive endoscopic hemostasis and for patients with adherent clot not receiving endoscopic hemostasis. PPI therapy should be high dose and administered as an intravenous bolus followed by continuous infusion (80 mg then 8 mg/hour) for 72 hours post endoscopy (strong recommendation, high quality evidence). MR13. ESGE does not recommend routine second-look endoscopy as part of the management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH). However, in patients with clinical evidence of rebleeding following successful initial endoscopic hemostasis, ESGE recommends repeat upper endoscopy with hemostasis if indicated. In the case of failure of this second attempt at hemostasis, transcatheter angiographic embolization (TAE) or surgery should be considered (strong recommendation, high quality evidence). MR14. In patients with NVUGIH secondary to peptic ulcer, ESGE recommends investigating for the presence of Helicobacter pylori in the acute setting with initiation of appropriate antibiotic therapy when H. pylori is detected. Re-testing for H. pylori should be performed in those patients with a negative test in the acute setting. Documentation of successful H. pylori eradication is recommended (strong recommendation, high quality evidence). MR15. In patients receiving low dose aspirin for secondary cardiovascular prophylaxis who develop peptic ulcer bleeding, ESGE recommends aspirin be resumed immediately following index endoscopy if the risk of rebleeding is low (e. g., FIIc, FIII). In patients with high risk peptic ulcer (FIa, FIb, FIIa, FIIb), early reintroduction of aspirin by day 3 after index endoscopy is recommended, provided that adequate hemostasis has been established (strong recommendation, moderate quality evidence).

Practice parameters for early rectal cancer management: Italian Society of Colorectal Surgery (Società Italiana di Chirurgia Colo-Rettale; SICCR) guidelines

The introduction of new technologies for diagnosis and screening programs led to an increasing rate of early detection of colorectal cancer. This, associated with the evolution of endoscopic techniques of local excision, led to the assessment of new strategies to reduce morbidity related to treatment, especially for early rectal cancer (ERC). Nevertheless, the definition of ERC and its staging and treatment algorithm are still under debate. The Italian Society of Colorectal Surgery developed practice guidelines to provide recommendations on the diagnosis, staging and treatment of ERC. A systematic review on the topic was performed by a multidisciplinary group of experts selected based on their clinical and scientific expertise in endoscopy, endoscopic ultrasound, magnetic resonance and surgery, with the aid of an external international audit.

Practice parameters for early colon cancer management: Italian Society of Colorectal Surgery (Società Italiana di Chirurgia Colo-Rettale; SICCR) guidelines

Early colon cancer (ECC) has been defined as a carcinoma with invasion limited to the submucosa regardless of lymph node status and according to the Royal College of Pathologists as TNM stage T1 NX M0. As the potential risk of lymph node metastasis ranges from 6 to 17% and the preoperative assessment of lymph node metastasis is not reliable, the management of ECC is still controversial, varying from endoscopic to radical resection. A meeting on recent advances on the management of colorectal polyps endorsed by the Italian Society of Colorectal Surgery (SICCR) took place in April 2014, in Genoa (Italy). Based on this material the SICCR decided to issue guidelines updating the evidence and to write a position statement paper in order to define the diagnostic and therapeutic strategy for ECC treatment in context of the Italian healthcare system.

Total or near-total thyroidectomy versus subtotal thyroidectomy for multinodular non-toxic goitre in adults

BACKGROUND

Total thyroidectomy (TT) and subtotal thyroidectomy (ST) are worldwide treatment options for multinodular non-toxic goitre in adults. Near TT, defined as a postoperative thyroid remnant less than 1 mL, is supposed to be a similarly effective but safer option than TT. ST has been shown to be marginally safer than TT, but it may leave an undetected thyroid cancer in place.

OBJECTIVES

The objective was to assess the effects of total or near-total thyroidectomy compared to subtotal thyroidectomy for multinodular non-toxic goitre.

SEARCH METHODS

We searched the Cochrane Library, MEDLINE, PubMed, EMBASE, as well as the ICTRP Search Portal and ClinicalTrials.gov. The date of the last search was 18 June 2015 for all databases. No language restrictions were applied.

SELECTION CRITERIA

Two review authors independently scanned the abstract, title or both sections of every record retrieved to identify randomised controlled trials (RCTs) on thyroidectomy for multinodular non-toxic goitre for further assessment.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data, assessed studies for risk of bias and evaluated overall study quality utilising the GRADE instrument. We calculated the odds ratio (OR) and corresponding 95% confidence interval (CI) for dichotomous outcomes. A random-effects model was used for pooling data.

MAIN RESULTS

We examined 1430 records, scrutinized 14 full-text publications and included four RCTs. Altogether 1305 participants entered the four trials, 543 participants were randomised to TT and 762 participants to ST. A total of 98% and 97% of participants finished the trials in the TT and ST groups, respectively. Two trials had a duration of follow-up between 12 and 39 months and two trials a follow-up of 5 and 10 years, respectively. Risk of bias across studies was mainly unknown for selection, performance and detection bias. Attrition bias was generally low and reporting bias high for some outcomes. In the short-term postoperative period no deaths were reported for both TT and ST groups. However, longer-term data on all-cause mortality were not reported (1284 participants; 4 trials; moderate quality evidence). Goiter recurrence was lower in the TT group compared to ST. Goiters recurred in 0.2% (1/425) of the TT group compared to 8.4% (53/632) of the ST group (OR 0.05 (95% CI 0.01 to 0.21); P < 0.0001; 1057 participants; 3 trials; moderate quality evidence). Re-intervention due to goitre recurrence was lower in the TT group compared to ST. Re-intervention was necessary in 0.5% (1/191) of TT patients compared to 0.8% (3/379)of ST patients (OR 0.66 (95% CI 0.07 to 6.38); P = 0.72; 570 participants; 1 trial; low quality evidence). The incidence of permanent recurrent laryngeal nerve palsy was lower for ST compared with TT. Permanent recurrent laryngeal nerve palsy occurred in 0.8% (6/741) of ST patients compared to 0.7% (4/543) of TT patients (OR 1.28, (95% CI 0.38 to 4.36); P = 0.69; 1275 participants; 4 trials; low quality evidence). The incidence of permanent hypoparathyroidism was lower for ST compared with TT. Permanent hypoparathyroidism occurred in 0.1% (1/741) of ST patients compared to 0.6% (3/543) of TT patients (OR 3.09 (95% CI 0.45 to 21.36); P = 0.25; 1275 participants: 4 trials; low quality evidence). The incidence of thyroid cancer was lower for ST compared with TT. Thyroid cancer occurred in 6.1% (41/669) of ST patients compared to 7.3% (34/465)of TT patients (OR 1.32 (95% CI 0.81 to 2.15); P = 0.27; 1134 participants; 3 trials; low quality evidence). No data on health-related quality of life or socioeconomic effects were reported in the included studies.

AUTHORS' CONCLUSIONS

The body of evidence on TT compared with ST is limited. Goiter recurrence is reduced following TT. The effects on other key outcomes such as re-interventions due to goitre recurrence, adverse events and thyroid cancer incidence are uncertain. New long-term RCTs with additional data such as surgeons level of experience, treatment volume of surgical centres and details on techniques used are needed.

Systematic review and meta-analysis of endoscopic submucosal dissection vs endoscopic mucosal resection for colorectal lesions

BACKGROUND AND AIMS

This systematic review and meta-analysis compares the safety and effectiveness of endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) in the treatment of flat and sessile colorectal lesions >20 mm preoperatively assessed as noninvasive.

METHODS

We reviewed the literature published between January 2000 and March 2014. Pooled estimates of the proportion of patients with en bloc, R0 resection, complications, recurrence, and need for further treatment were compared in a meta-analysis using fixed and random effects.

RESULTS

A total of 11 studies and 4678 patients were included. The en bloc resection rate was 89.9% for ESD vs 34.9% for EMR patients (RR 1.93 p < 0.001). The R0 resection rate was 79.6% for ESD vs 36.2% for EMR patients (RR 2.01 p < 0.001). The rate of perforation was 4.9% for the ESD group and 0.9% for EMR (RR 3.19, p < 0.001), while the rate of bleeding was 1.9% for ESD and 2.9% for EMR (RR 0.68, p = 0.070). Therefore, the overall need for further surgery, including surgery for oncologic reasons and surgery for complications, was 7.8% for ESD and 3.0% for EMR (RR 2.40, p < 0.001).

CONCLUSIONS

ESD achieves a higher rate of en bloc and R0 resection compared to EMR, at the cost of a higher risk of complications. This, added to an increased need for surgery for oncologic reasons for a plausible tendency to extend indication for endoscopic excision, increases the risk of further surgery after ESD.

YKL-40/c-Met expression in rectal cancer biopsies predicts tumor regression following neoadjuvant chemoradiotherapy: a multi-institutional study

BACKGROUND

Neoadjuvant chemo-radiotherapy (CRT) followed by surgical resection is the standard treatment for locally advanced rectal cancer, although complete tumor pathological regression is achieved in only up to 30% of cases. A clinicopathological and molecular predictive stratification of patients with advanced rectal cancer is still lacking. Here, c-Met and YKL-40 have been studied as putative predictors of CRT response in rectal cancer, due to their reported involvement in chemoradioresistance in various solid tumors.

MATERIAL AND METHODS

A multicentric study was designed to assess the role of c-Met and YKL-40 expression in predicting chemoradioresistance and to correlate clinical and pathological features with CRT response. Immunohistochemistry and fluorescent in situ hybridization for c-Met were performed on 81 rectal cancer biopsies from patients with locally advanced rectal adenocarcinoma. All patients underwent standard (50.4 gy in 28 fractions + concurrent capecitabine 825 mg/m2) neoadjuvant CRT or the XELOXART protocol. CRT response was documented on surgical resection specimens and recorded as tumor regression grade (TRG) according to the Mandard criteria.

RESULTS

A significant correlation between c-Met and YKL-40 expression was observed (R = 0.43). The expressions of c-Met and YKL-40 were both significantly associated with a lack of complete response (86% and 87% of c-Met and YKL-40 positive cases, p< 0.01 and p = 0.006, respectively). Thirty of the 32 biopsies co-expressing both markers had partial or absent tumor response (TRG 2-5), strengthening their positive predictive value (94%). The exclusive predictive role of YKL-40 and c-Met was confirmed using a multivariate analysis (p = 0.004 and p = 0.007 for YKL-40 and c-Met, respectively). TRG was the sole morphological parameter associated with poor outcome.

CONCLUSION

c-Met and YKL-40 expression is a reliable predictor of partial/absent response to neoadjuvant CRT in rectal cancer. Targeted therapy protocols could take advantage of prior evaluations of c-MET and YKL-40 expression levels to increase therapeutic efficacy.

Long-term efficacy of endoscopic vacuum therapy for the treatment of colorectal anastomotic leaks

BACKGROUND

Anastomotic leaks are a severe complication after colorectal surgery. We aimed to evaluate the long-term efficacy of endoscopic vacuum therapy for their treatment.

METHODS

Retrospective review of a series of post-surgical colorectal leaks treated with endoscopic vacuum therapy, with minimum follow-up of 1 year. Generalized peritonitis or haemodynamic instability was considered contraindication to endoscopic treatment.

RESULTS

Endoscopic vacuum therapy was applied in 14 patients with colorectal leak, in 2 cases complicated by recto-vaginal fistula. Overall success rate was 79%, favoured by early beginning of treatment (90%) and presence of a stoma (100%) and no preoperative radiotherapy (86%). Median duration of treatment was 12.5 sessions (range 4-40). Median time for complete healing was 40.5 days (range 8-114), for a median cost of treatment of 3125 Euros. No complication related to endoscopic vacuum therapy was observed. Further surgery was required in 3 cases.

CONCLUSION

Endoscopic vacuum therapy is a safe treatment for post-surgical leaks, with high success rates.

Laparoscopic peritoneal lavage: a definitive treatment for diverticular peritonitis or a "bridge" to elective laparoscopic sigmoidectomy?: a systematic review

To this day, the treatment of generalized peritonitis secondary to diverticular perforation is still controversial. Recently, in patients with acute sigmoid diverticulitis, laparoscopic lavage and drainage has gained a wide interest as an alternative to resection. Based on this backdrop, we decided to perform a systematic review of the literature to evaluate the safety, feasibility, and efficacy of peritoneal lavage in perforated diverticular disease.A bibliographic search was performed in PubMed for case series and comparative studies published between January 1992 and February 2014 describing laparoscopic peritoneal lavage in patients with perforated diverticulitis.A total of 19 articles consisting of 10 cohort studies, 8 case series, and 1 controlled clinical trial met the inclusion criteria and were reviewed. In total these studies analyzed data from 871 patients. The mean follow-up time ranged from 1.5 to 96 months when reported. In 11 studies, the success rate of laparoscopic peritoneal lavage, defined as patients alive without surgical treatment for a recurrent episode of diverticulitis, was 24.3%. In patients with Hinchey stage III diverticulitis, the incidence of laparotomy conversion was 1%, whereas in patients with stage IV it was 45%. The 30-day postoperative mortality rate was 2.9%. The 30-day postoperative reintervention rate was 4.9%, whereas 2% of patients required a percutaneous drainage. Readmission rate after the first hospitalization for recurrent diverticulitis was 6%. Most patients who were readmitted (69%) required redo surgery. A 2-stage laparoscopic intervention was performed in 18.3% of patients.Laparoscopic peritoneal lavage should be considered an effective and safe option for the treatment of patients with sigmoid diverticulitis with Hinchey stage III peritonitis; it can also be consider as a "bridge" surgical step combined with a delayed and elective laparoscopic sigmoidectomy in order to avoid a Hartmann procedure. This minimally invasive staged approach should be considered for patients without systemic toxicity and in centers experienced in minimally invasive surgery techniques. Further evidence is needed, and the ongoing RCTs will better define the role of the laparoscopic peritoneal lavage/drainage in the treatment of patients with complicated diverticulitis.

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.

Role of damage control surgery in the treatment of Hinchey III and IV sigmoid diverticulitis: a tailored strategy

Many of the treatment strategies for sigmoid diverticulitis are actually focusing on nonoperative and minimally invasive approaches. The aim of this systematic review was to evaluate the actual role of damage control surgery (DCS) in the treatment of generalized peritonitis caused by perforated sigmoid diverticulitis.A literature search was performed in PubMed and Google Scholar for articles published from 1960 to July 2013. Comparative and noncomparative studies that included patients who underwent DCS for complicated diverticulitis were considered.Acute Physiology and Chronic Health Evaluation score, duration of open abdomen, intensive care unit length of stay, reoperation, bowel resection performed at first operation, fecal diversion, method, and timing of closure of abdominal wall were the main outcomes of interest.According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses algorithm for the literature search and review, 10 studies were included in this systematic review. DCS was exclusively performed in diverticulitis patients with septic shock or requiring vasopressors intraoperatively. Two surgical different approaches were highlighted: limited resection of the diseased colonic segment with or without stoma or reconstruction in situ, and laparoscopic washing and drainage without colonic resection.Despite the heterogeneity of patient groups, clinical settings, and interventions included in this review, DCS appears to be a promising strategy for the treatment of Hinchey III and IV diverticulitis, complicated by septic shock. A tailored approach to each patient seems to be appropriate.

International multicenter experience with an over-the-scope clipping device for endoscopic management of GI defects (with video)

BACKGROUND

The over-the-scope clip (OTSC) provides more durable and full-thickness closure as compared with standard clips. Only case reports and small case series have reported on outcomes of OTSC closure of GI defects.

OBJECTIVE

To describe a large, multicenter experience with OTSCs for the management of GI defects. Secondary goals were to determine success rate by type of defect and type of therapy and to determine predictors of treatment outcomes.

DESIGN

Multicenter, retrospective study.

SETTING

Multiple, international, academic centers.

PATIENTS

Consecutive patients who underwent attempted OTSC placement for GI defects, either as a primary or as a rescue therapy.

INTERVENTIONS

OTSC placement to attempt closure of GI defects.

MAIN OUTCOME MEASUREMENTS

Long-term success of the procedure.

RESULTS

A total of 188 patients (108 fistulae, 48 perforations, 32 leaks) were included. Long-term success was achieved in 60.2% of patients during a median follow-up of 146 days. Rate of successful closure of perforations (90%) and leaks (73.3%) was significantly higher than that of fistulae (42.9%) (P < .05). Long-term success was significantly higher when OTSCs were applied as primary therapy (primary 69.1% vs rescue 46.9%; P = .004). On multivariate analysis, patients who had OTSC placement for perforations and leaks had significantly higher long-term success compared with those who had fistulae (OR 51.4 and 8.36, respectively).

LIMITATIONS

Retrospective design and multiple operators with variable expertise with the OTSC device.

CONCLUSION

OTSC is safe and effective therapy for closure of GI defects. Clinical success is best achieved in patients undergoing closure of perforations or leaks when OTSC is used for primary or rescue therapy. Type of defect is the best predictor of successful long-term closure.

Laparoscopic versus open resection for colon cancer: 10-year outcomes of a prospective clinical trial

BACKGROUND

Laparoscopic resection (LR) and open resection (OR) for colon cancer have similar oncologic outcomes at 5-year follow-up. However, results from studies with longer follow-up are limited. This study aimed to compare 10-year oncologic outcomes of LR and OR for non-metastatic colon cancer.

METHODS

A prospective non-randomized trial comparing patients undergoing LR or OR for non-metastatic colon cancer at a single institution was conducted. Statistical analyses were performed on an ''intention-to-treat'' basis and by actual treatment. Kaplan-Meier curves were compared to analyze overall survival (OS) and disease-free survival (DFS). A multivariate analysis was performed to identify predictors of poor survival.

RESULTS

The study included 304 colon cancer patients: 154 patients underwent LR and 150 underwent OR. Fifteen (9.7 %) had LR converted to OR. During a median follow-up period of 138 (range, 120-220) months, no significant differences were observed between LR and OR patients in 10-year OS and DFS rates: 87.2 % versus 78.7 % (P = 0.182) and 80.9 % versus 76.8 % (P = 0.444), respectively. Conversion to open surgery was associated with a non-significant reduction in OS and DFS. Stage-by-stage comparison showed no significant differences between the two groups. Both OS and DFS were similar between right colon and left-sided colon cancer patients. On multivariate analysis, pT4 cancer and a lymph node ratio of 0.20 or more were the only independent predictors of both OS and DFS.

CONCLUSIONS

The 10-year follow-up results confirm the oncological effectiveness of the laparoscopic approach to non-metastatic colon cancer.

Laparoscopy for rectal cancer is oncologically adequate: a systematic review and meta-analysis of the literature

BACKGROUND

This review of cancer outcomes is based on key literature searches of the medical databases and meta-analysis of short-term benefits of laparoscopy in rectal cancer treatment.

METHODS

We carried out a systematic review of randomized clinical trials (RCTs) and prospective non-randomized controlled trials (non-RCTs) published between January 2000 and September 2013 listed in the MEDLINE and EMBASE databases (PROSPERO Registration number: CRD42013005076). The primary endpoint was clearance of the circumferential resection margin. Meta-analysis was performed using a fixed-effect model, and sensitivity analysis by a random-effect model; subgroup analysis was performed on subsets of patients with extraperitoneal cancer of the rectum. Relative risk (RR) and mean difference (MD) were used as outcome measures.

RESULTS

Twenty-seven studies (10,861 patients) met the inclusion criteria; eight were RCTs (2,659 patients). The RCTs reported involvement of the circumferential margin in 7.9 % of patients who underwent laparoscopic and in 6.9 % of those undergoing open surgery; the overall RR was 1.00 (95 % confidence interval 0.73-1.35) with no heterogeneity. Subgroup analysis of patients with extraperitoneal cancer showed equivalent involvement of the circumferential margin in the two treatment groups. Although significantly more lymph nodes were retrieved in the surgical specimen after open surgery, the MD of -0.56 was of marginal clinical significance. The sensitivity and subgroup analyses revealed no other significant differences between laparoscopic and open surgery in the rate of R0 resections, distal margin clearance, mesorectal fascia integrity, or local recurrence at 5 years.

CONCLUSIONS

Based on the evidence from RCTs and non-RCTs, the short-term benefit and oncological adequacy of laparoscopic rectal resection appear to be equivalent to open surgery, with some evidence potentially pointing to comparable long-term outcomes and oncological adequacy in selected patients with primary resectable rectal cancer.

Laparoscopy for extraperitoneal rectal cancer reduces short-term morbidity: Results of a systematic review and meta-analysis

BACKGROUND

The role of laparoscopy in the treatment of extraperitoneal rectal cancer is still controversial. The aim of the study was to evaluate differences in safety of laparoscopic rectal resection for extraperitoneal cancer, compared with open surgery.

MATERIALS AND METHODS

A systematic review from 2000 to July 2012 was performed searching the MEDLINE and EMBASE databases (PROSPERO registration number CRD42012002406). We included randomized and prospective controlled clinical studies comparing laparoscopic and open resection for rectal cancer. Primary endpoints were 30-day mortality and morbidity. Then a meta-analysis was conducted by a fixed-effect model, performing a sensitivity analysis by a random-effect model. Relative risk (RR) was used as an indicator of treatment effect.

RESULTS

Eleven studies, representing 1684 patients, met the inclusion criteria: four were randomized for a total of 814 patients. Mortality was observed in 1.2% of patients in the laparoscopic group and in 2.3% of patients in the open group, with an RR of 0.56 (95% CI 0.19-1.64, p = 0.287). The overall incidence of short-term complications was lower in the laparoscopic group (31.5%) compared to the open group (38.2%), with an RR of 0.83 (95% CI 0.73-0.94, p = 0.004). Surgical complications, wound complications, blood loss and the need for blood transfusion, time for bowel movement recovery, food intake recovery, and hospital stay were significantly lower or less frequent in the laparoscopic group. The incidence of intra-operative injuries, anastomotic leakages, and surgical re-interventions was similar in the two groups. Only operative time was in favour of the open group.

CONCLUSIONS

Based on the evidence of both randomized and prospective controlled series, mortality was lower after laparoscopy although not significantly so, while the short-term morbidity RR, including subgroup analysis, was significantly lower after laparoscopy for extraperitoneal rectal cancer compared to open surgery.

Systematic review and meta-analysis of endoscopic submucosal dissection versus transanal endoscopic microsurgery for large noninvasive rectal lesions

BACKGROUND

For almost 30 years, transanal endoscopic microsurgery (TEM) has been the mainstay treatment for large rectal lesions. With the advent of endoscopic submucosal dissection (ESD), flexible endoscopy has aimed at en bloc R0 resection of superficial lesions of the digestive tract. This systematic review and meta-analysis compared the safety and effectiveness of ESD and full-thickness rectal wall excision by TEM in the treatment of large nonpedunculated rectal lesions preoperatively assessed as noninvasive.

METHODS

A systematic review of the literature published between 1984 and 2010 was conducted (Registration no. CRD42012001882). Data were integrated with those from the original databases requested from the study authors when needed. Pooled estimates of the proportions of patients with en bloc R0 resection, complications, recurrence, and need for further treatment in the ESD and TEM series were compared using random-effects single-arm meta-analysis.

RESULTS

This review included 11 ESD and 10 TEM series (2,077 patients). The en bloc resection rate was 87.8 % (95 % confidence interval [CI] 84.3-90.6) for the ESD patients versus 98.7 % (95 % CI 97.4-99.3 %) for the TEM patients (P < 0.001). The R0 resection rate was 74.6 % (95 % CI 70.4-78.4 %) for the ESD patients versus 88.5 % (95 % CI 85.9-90.6 %) for the TEM patients (P < 0.001). The postoperative complications rate was 8.0 % (95 %, CI 5.4-11.8 %) for the ESD patients versus 8.4 % (95 % CI 5.2-13.4 %) for the TEM patients (P = 0.874). The recurrence rate was 2.6 % (95 % CI 1.3-5.2 %) for the ESD patients versus 5.2 % (95 % CI 4.0-6.9 %) for the TEM patients (P < 0.001). Nevertheless, the rate for the overall need of further abdominal treatment, defined as any type of surgery performed through an abdominal access, including both complications and pathology indications, was 8.4 % (95 % CI 4.9-13.9 %) for the ESD patients versus 1.8 % (95 % CI 0.8-3.7 %) for the TEM patients (P < 0.001).

CONCLUSIONS

The ESD procedure appears to be a safe technique, but TEM achieves a higher R0 resection rate when performed in full-thickness fashion, significantly reducing the need for further abdominal treatment.

Systematic review and meta-analysis of endoscopic submucosal dissection versus transanal endoscopic microsurgery for large noninvasive rectal lesions

BACKGROUND

For almost 30 years, transanal endoscopic microsurgery (TEM) has been the mainstay treatment for large rectal lesions. With the advent of endoscopic submucosal dissection (ESD), flexible endoscopy has aimed at en bloc R0 resection of superficial lesions of the digestive tract. This systematic review and meta-analysis compared the safety and effectiveness of ESD and full-thickness rectal wall excision by TEM in the treatment of large nonpedunculated rectal lesions preoperatively assessed as noninvasive.

METHODS

A systematic review of the literature published between 1984 and 2010 was conducted (Registration no. CRD42012001882). Data were integrated with those from the original databases requested from the study authors when needed. Pooled estimates of the proportions of patients with en bloc R0 resection, complications, recurrence, and need for further treatment in the ESD and TEM series were compared using random-effects single-arm meta-analysis.

RESULTS

This review included 11 ESD and 10 TEM series (2,077 patients). The en bloc resection rate was 87.8 % (95 % confidence interval [CI] 84.3-90.6) for the ESD patients versus 98.7 % (95 % CI 97.4-99.3 %) for the TEM patients (P < 0.001). The R0 resection rate was 74.6 % (95 % CI 70.4-78.4 %) for the ESD patients versus 88.5 % (95 % CI 85.9-90.6 %) for the TEM patients (P < 0.001). The postoperative complications rate was 8.0 % (95 %, CI 5.4-11.8 %) for the ESD patients versus 8.4 % (95 % CI 5.2-13.4 %) for the TEM patients (P = 0.874). The recurrence rate was 2.6 % (95 % CI 1.3-5.2 %) for the ESD patients versus 5.2 % (95 % CI 4.0-6.9 %) for the TEM patients (P < 0.001). Nevertheless, the rate for the overall need of further abdominal treatment, defined as any type of surgery performed through an abdominal access, including both complications and pathology indications, was 8.4 % (95 % CI 4.9-13.9 %) for the ESD patients versus 1.8 % (95 % CI 0.8-3.7 %) for the TEM patients (P < 0.001).

CONCLUSIONS

The ESD procedure appears to be a safe technique, but TEM achieves a higher R0 resection rate when performed in full-thickness fashion, significantly reducing the need for further abdominal treatment.

NOTES in Europe: summary of the working group reports of the 2012 EURO-NOTES meeting

The sixth EURO-NOTES workshop (4 - 6 October 2012, Prague, Czech Republic) focused on enabling intensive scientific dialogue and interaction between surgeons, gastroenterologists, and engineers/industry representatives and discussion of the state of the practice and development of natural orifice transluminal endoscopic surgery (NOTES) in Europe. In accordance with previous meetings, five working groups were formed. In 2012, emphasis was put on specific indications for NOTES and interventional endoscopy. Each group was assigned an important indication related to ongoing research in NOTES and interventional endoscopy: cholecystectomy and appendectomy, therapy of colorectal diseases, therapy of adenocarcinoma and neoplasia in the upper gastrointestinal tract, treating obesity, and new therapeutic approaches for achalasia. This review summarizes consensus statements of the working groups.

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

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.

Does conversion affect short-term and oncologic outcomes after laparoscopy for colorectal cancer?

BACKGROUND

Conversion of laparoscopic colorectal resection (LCR) for cancer has been associated with adverse short-term and oncologic outcomes. However, most studies have had small sample sizes and short follow-up periods. This study aimed to evaluate the impact of conversion to open surgery on early postoperative outcomes and survival among patients undergoing LCR for nonmetastatic colorectal cancer.

METHODS

A prospective database of consecutive LCRs for nonmetastatic colorectal cancer was reviewed. Patients who required conversion (CONV group) were compared with those who had completed laparoscopic resection (LAP group). Only patients with a minimum 5-year follow-up period were included in the oncologic analysis. Kaplan-Meier curves were compared to analyze survival. A multivariate analysis was performed to identify predictors of poor survival.

RESULTS

The conversion rate was 10.9%. The most common reason for conversion was a locally advanced tumor (48.4%). Conversion was associated with a significantly longer operative time and a greater blood loss. No differences were observed in terms of postoperative morbidity, mortality, or hospital stay between the CONV and LAP patients. During a median follow-up period of 120 months (range, 60-180 months), the CONV group had a significantly worse 5-year overall survival (OS) (79.4 vs 87.4%; p = 0.016) and disease-free survival (DFS) (65.4 vs 79.6%; p = 0.013). Univariate analysis showed that conversion to open surgery, postoperative complications, anastomotic leakage, pT4 cancer, stage 3 disease, and adjuvant chemotherapy were significant risk factors for OS and DFS. On multivariate analysis, pT4 cancer and a lymph node ratio (LNR) of 0.25 or greater were the only independent predictors of DFS and OS, whereas a LNR of 0.01 to 0.24 showed a trend that did not reach statistical significance.

CONCLUSION

Conversion to open surgery per se is not associated with worse early postoperative outcomes and does not adversely affect long-term survival per se.