Surgical outcomes of Turnbull-Cutait delayed coloanal anastomosis with pull-through versus immediate coloanal anastomosis with diverting stoma after total mesorectal excision for low rectal cancer: a systematic review and meta-analysis

BACKGROUND

Theoretical advantages of Turnbull-Cutait pull-through delayed coloanal anastomosis (DCAA) are a reduced risk of anastomotic leak and therefore avoidance of stoma. Gradually abandoned in favor of immediate coloanal anastomosis (ICAA) with diverting stoma, DCAA has regained popularity in recent years in reconstructive surgery for low RC, especially when combined with minimally invasive surgery (MIS). The aim of this study was to perform the first meta-analysis, exploring the safety and outcomes of DCAA compared to ICAA with protective stoma.

METHODS

A systematic search of MEDLINE, EMBASE, and CENTRAL and Google Scholar databases was performed for studies published from January 2000 until December 2020. The systematic review and meta-analysis were performed according to the Cochrane Handbook for Systematic Review on Interventions recommendations and Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines.

RESULTS

Out of 2626 studies screened, 9 were included in the systematic review and 4 studies in the meta-analysis. Outcomes included were postoperative complications, pelvic sepsis and risk of definitive stoma. Considering postoperative complications classified as Clavien-Dindo III, no significant difference existed in the rate of postoperative morbidity between DCAA and ICAA (13% versus 21%; OR 1.17; 95% CI 0.38-3.62; p = 0.78; I² = 20%). Patients in the DCAA group experienced a lower rate of postoperative pelvic sepsis compared with patients undergoing ICAA with diverting stoma (7% versus 14%; OR 0.37; 95% CI 0.16-0.85; p = 0.02; I² = 0%). The risk of definitive stoma was comparable between the two groups (2% versus 2% OR 0.77; 95% CI 0.15-3.85; p = 0.75; I² = 0%).

CONCLUSIONS

According to the limited current evidence, DCAA is associated with a significant decrease in pelvic sepsis. Further prospective trials focusing on oncologic and functional outcomes are needed.

[Eating and swallowing disorders in children]

INTRODUCTION

Eating and swallowing disorders in children are common and reflected in several symptoms, yet they are not well known.

PATIENTS

Three patients are presented to demonstrate the spectrum of the problems, the diagnosis and the multidisciplinary team approach to treatment.

DISCUSSION

To enable safe eating and thriving, swallowing and eating disorders need to be recognized and treated, according to the child's development. This can be done by a multidisciplinary team, such as the one at The Edith Wolfson Medical Center.

Cell autonomous commitment to an endodermal fate and behaviour by activation of Nodal signalling

In vertebrates the endoderm germ layer gives rise to most tissues of the digestive tract and controls head and heart morphogenesis. The induction of endoderm development relies on extracellular signals related to Nodals and propagated intracellularly by TGFβ type I receptors ALK4/Taram-A. It is unclear, however, whether Nodal/ALK4/Taram-A signalling is involved only in the specification of endodermal precursors or plays a more comprehensive role in the activation of the endodermal program leading to the irreversible commitment of cells to the endodermal fate. Using cell transplantation experiments in zebrafish, we show that marginal cells become committed to endoderm at the onset of gastrulation and that commitment to endoderm can be reached by intracellular activation of the Nodal pathway induced by expression of an activated form of the taram-A receptor, Tar*. In a manner similar to endoderm progenitors, Tar*-activated blastomeres translocate from their initial site of implantation in the blastoderm to reach the surface of their migration substratum, the yolk syncitial layer, where they join endogenous endodermal derivatives during gastrulation and differentiate according to their anteroposterior position. We demonstrate that Nodal/Tar*-induced commitment does not rely on a secondary signal released by Tar*-expressing cells or a signal released by endogenous endoderm since Tar*-expressing wild-type cells can restore endoderm derivatives when transplanted into the endoderm-deficient mutant casanova. Likewise, the YSL does not appear essential for the maintenance of endodermal identity during gastrulation once the Nodal pathway has been activated. Thus, our results demonstrate that the activation of Nodal signalling is sufficient to commit cells both to an endodermal fate and behaviour. Wild-type endoderm implantation into casanova embryos rescues, in a non-autonomous fashion, the defective fusion of the two heart primordia in the midline, highlighting the importance of endoderm for normal heart morphogenesis.