Transanal endoscopic microsurgery for giant polyps of the rectum

BACKGROUND

The potential for malignancy in rectal polyps increases with the size of the polyp, and unexpected malignancy is reported in up to 39 % of large rectal adenomas. Transanal endoscopic microsurgery (TEM) offers the possibility of an en bloc full-thickness excision for lesions in the rectum. We present our results with TEM in the removal of giant polyps equal or greater than 4 cm in diameter.

METHODS

In the period between 1998 and 2012, TEM was performed in 39 patients with rectal polyps measuring at least 4 cm in diameter. Transrectal ultrasound and/or magnetic resonance imaging of the rectum was used when cancer was suspected.

RESULTS

The polyp was removed with en bloc full-thickness excision in 77 % (n = 30). The preoperative diagnosis was benign rectal adenoma in 89.7 % (n = 35). The median size of the polyps was 30 cm(2) (range 16-100 cm(2)). Postoperative complications included bleeding in 4 patients (10.3 %). Histological examination showed unexpected cancer in 4 patients (10.3 %). TEM was curative in 2 of these patients, and the other 2 underwent further surgery. Recurrences occurred in 10 patients (25.6 %) and consisted of 5 adenomas and 5 adenocarcinomas. In 5 patients, these recurrences were treated with endoscopic removal or re-TEM. The remaining 5 underwent total mesorectal excision and/or chemotherapy.

CONCLUSIONS

Full-thickness TEM provides a safe and efficient treatment for excision of giant polyps. In case of unexpected cancer, TEM can be curative. Local recurrence can be often treated with a second TEM procedure.

The outcome of rectal cancer after early salvage TME following TEM compared with primary TME: a case-matched study

BACKGROUND

Transanal endoscopic microsurgery (TEM) allows locally complete resection of early rectal cancer as an alternative to conventional radical surgery. In case of unfavourable histology after TEM, or positive resection margins, salvage surgery can be performed. However, it is unclear if the results are equivalent to primary treatment with total mesorectal excision (TME). The aim of this retrospective study was to determine whether there is a difference in outcome between patients who underwent early salvage resection with TME after TEM, and those who underwent primary TME for rectal cancer.

METHODS

From 1997 to 2011, early salvage surgery with TME after TEM was performed in 25 patients in our institution. These patients were compared with 25 patients who underwent primary TME, matched according to gender, age (±2 years), cancer stage and operative procedure. Data were obtained from the patients' charts and reviewed retrospectively. No patients received preoperative chemotherapy. Perioperative data and oncological outcome were analysed. The Mann-Whitney U-test and Fisher's exact test were used to compare the results between the two groups.

RESULTS

There was no significant difference between the two groups in median operating time (P = 0.39), median blood loss (P = 0.19) or intraoperative complications (P = 1.00). The 30-day mortality was 8 % (n = 2) among patients who underwent salvage TME after TEM, and no patients died in the primary TME group (P = 0.49). There was no significant difference between two groups of patients in the median number of harvested lymph nodes (P = 0.34), median circumferential resection margin (CRM) (P = 0.99) or the completeness of the mesorectal fascia plane. No local recurrences occurred among the patients with salvage TME, and there were 2 patients (8 %) with local recurrences among the patients with primary TME (P = 0.49). Distant metastasis occurred in one patient (4 %) after salvage TME and in 3 patients (12 %) with primary TME (P = 0.61). The median follow-up time was 25 months (3-126) for patients who underwent salvage TME and 19 months (3-73) for patients after primary TME.

CONCLUSIONS

No difference was found in outcome between patients with rectal cancer undergoing salvage TME after TEM, those undergoing primary TME. In selected patients, TEM can therefore be chosen as a primary treatment, since failure of treatment and subsequent conventional resection appears not to compromise the outcome.

Transanal endoscopic microsurgery in 143 consecutive patients with rectal adenocarcinoma: results from a Danish multicenter study

OBJECTIVE

The long-term results are presented on total survival, cancer-specific survival and recurrence in 143 consecutive patients treated with transanal endoscopic microsurgery (TEM) for adenocarcinoma of the rectum.

METHOD

Four Danish centres established in 1995 a database for registration of all TEM procedures. Data were supplemented from pathology reports and death certificates were checked in the Danish patient registry. Data were analysed with multivariance regression and survival analysis.

RESULTS

The T stage was as follows: T1 50%, T2 33%, T3 14%, and stage unknown 3%. TEM was performed with curative intent in 43%, for compromise in 52% and for palliation in 5%. Five-year total survival was 66% and 5-year cancer-specific survival 87%. Cancer-specific survival for T1 was 94%. The significant predictors for total survival were age and tumour size. For cancer-specific survival T stage, radical resection, tumour size and recurrence were significant predictors. Eighteen per cent had recurrence and 15% had immediate reoperation.

CONCLUSION

The TEM provides good long-term results for pT1 cancers. In old patients and patients with co-morbidity TEM may provide acceptable long-term results for T2 cancers. Tumours larger than 3 cm should not be treated with TEM for cure.

Rectal adenocarcinoma and transanal endoscopic microsurgery. Diagnostic challenges, indications and short term results in 142 consecutive patients

PURPOSE

The objective of this study was to present short-term results of transanal endoscopic microsurgery (TEM) of rectal adenocarcinomas registered in a national database.

METHODS

A Danish TEM group was established in 1995. The group organized a database for prospective and consecutive registration of all TEM procedures. The perioperative course of all rectal cancers treated with TEM and registered in this database is analysed.

RESULTS

One hundred forty-two patients had TEM for rectal cancer. In 43%of the patients, the cancer diagnosis was not recognized before TEM. Eighty-five percent of all tumors were classified as benign based on macroscopic appearance; on digital rectal examination, 35% were benign, rectal ultrasound classified 15% as benign, and the preoperative biopsy was benign in 36%. Forty-three cancers (29%) were classified as low risk cancers. High ages were an indication for TEM in 22% and concurrent disease in 21%. Minor complications were encountered in 39 cases, major complications in 4 cases, and 1 patient died within 30 days.

CONCLUSION

All larger rectal tumors should be evaluated for malignancy before treatment, even if TEM is the only surgical option, due to high age and comorbidiy. Rectal ultrasound appears to produce the fewest false negative results, but it should be combined with biopsies and clinical evaluation. Multiple biopsies may be beneficial in the case of larger adenomas. When resecting large sessile tumors, there is a considerable risk of incomplete radicality. The short term mortality and morbidity of TEM is low even in old patients with comorbidiy.

[Coloanal pouch in surgery of rectal neoplasms]

BACKGROUND

The aim of this study was to evaluate the rate of complications and the functional result after construction of a coloanal J pouch during low anterior resection of the rectum for cancer.

DESIGN

A retrospective study of medical records and interviews with patients at follow-up.

RESULTS

32 patients were followed-up for a median of 28 months (range 12-82 months). Two patients (6%) developed anastomotic leakage, one of whom died. Two patients developed rectovaginal fistula, one of whom was given a permanent colostomy. One patient died from complications after closure of the diverting ileostomy. In two patients, local cancer recurred and four died from distant metastases. At follow-up, the frequency of bowel movements was median 2/24 h (range 0.3-4). Three of 29 (10%) experienced intermittent incontinence, whereas none complained of evacuation problems.

DISCUSSION

The complication rate was as expected after low anterior rectal resection, but there were unexpected severe complications after closure of the diverting stoma. The functional results were satisfactory and the construction of a colonic J pouch is recommended during low rectal resection, if the defecation pattern and the quality of life is to improve, especially within the first postoperative year.

Pain after groin hernia repair

BACKGROUND

The purpose of the study was to provide a detailed description of postoperative pain after elective day-case open inguinal hernia repair under local anaesthesia.

METHODS

This was a prospective consecutive case series study. After 500 hernia operations in 466 unselected patients aged 18-90 years, pain was scored (none, light, moderate or severe) at rest, while coughing and during mobilization, daily for the first postoperative week and after 4 weeks. Pain scores were added together over the first postoperative week.

RESULTS

On days 1, 6 and 28, 66, 33 and 11 per cent respectively had moderate or severe pain while coughing or mobilizing. Total pain scores were higher while coughing or mobilizing than at rest (P < 0.001). Younger patients had higher total pain scores than older patients while coughing or mobilizing (P0< 0.01), but not at rest. No significant differences were found between types of surgery or hernia.

CONCLUSION

Pain remained a problem despite the pre-emptive use of opioids, non-steroidal anti-inflammatory drugs and local anaesthesia, irrespective of surgical technique.

[Organization and results of ambulatory surgery for inguinal hernia]

The results of a reorganization of surgery for inguinal hernias within a department of surgical gastroenterology were assessed concerning staff simplifications, feasibility, patient satisfaction, safety, complications and resources. Five hundred consecutive, elective, open operations for unilateral reducible inguinal hernias were performed in 466 patients under local anaesthesia in an ambulatory setup. One hundred and fourteen of the operations were for a recurrent hernia. The median age was 60 years (44-74 years as 25% and 75% quartiles). Two of the operations were converted to general anaesthesia. The patients were discharged 85 min (median) post-operatively, but 12 patients were not discharged on the same day. Bleeding or wound infections in need of treatment were seen postoperatively in 1.6% and 1.6%, respectively. All patients were given a postoperative questionnaires with a response rate of 95%, 89% of the respondents were satisfied with the whole procedure, 11% were dissatisfied. A reorganization of surgery for inguinal hernias to a standardized ambulatory setup induced staff simplifications and saved resources with a preserved high patient satisfaction, safety and a low complication rate.

[Recurrence of inguinal hernia: ambulatory surgery under local anesthesia]

In order to assess the feasibility of repair of a recurrent inguinal hernia in unmonitored local anaesthesia in an ambulatory set-up pain scores and data on patient satisfaction were obtained from 76 unselected patients after 79 consecutive operations. Median age was 63 years, and 25%- and 75% quartiles were 49 and 72 years respectively. All operations were conducted in local anesthesia. Three patients stayed in hospital overnight after the operation. Pain: After one, six and 28 days 27, 14 og 7% respectively had severe pain during function (cough and/or rising). Satisfaction: 82% were satisfied with ambulatory surgery in local anaesthesia, 82% were satisfied with the analgesic therapy (tenoxicam and methadone), but one third needed supplementary analgesics during the first week (acetaminophen was recommended). It is concluded, that ambulatory repair of a recurrent inguinal hernia in unmonitored local anaesthesia is a safe and cost effective alternative to operation in general or spinal anaesthesia.

[Surgery for ulcerative colitis. Treatment with proctocolectomy, stapled ileum-J-pouch, stapled pouch-anal anastomosis and temporary ileostomy]

Thirty-two patients with ulcerative colitis, median age 29 (range 14-49), were submitted to restorative proctocolectomy. Twenty-five patients had a three-stage procedure and seven had a two-stage procedure. A stapled J-pouch was formed, and a pouch-anal anastomosis was created by the double stapling technique. A temporary end ileostomy was closed through peristomal incision after three months. There were no pouch failures and no cases of pouch-anal anastomosis leakage. In one patient secondary mucosectomy and neo-anastomosis became necessary due to severe inflammation of remnant rectal mucosa. Five patients were operated for small bowel obstruction, and two had to have a dilatation of a slight stricture of the pouch-anal anastomosis. In two patients the final diagnosis was verified or probable Crohns disease, of whom one developed recurrence of a previous rectovaginal fistula. Twenty-seven patients have had the ileostomy closed for more than one month, 25 of these (93%) were fully continent three months after ileostomy closure and later on. After one year the patients had median five (range 3-9) bowel movements per day. It is concluded that restorative proctocolectomy with a stapled J-pouch-anal anastomosis and a temporary end ileostomy for ulcerative colitis carries few complications and provides a good functional result.

Treatment of internal rectal intussusception in patients with chronic constipation

BACKGROUND

The significance of internal rectal intussusception (rectal invagination) in chronic constipation dominated by symptoms of obstructed defecation is not fully clarified.

METHODS

Seventeen consecutive patients with chronic constipation and a history of obstructed defecation with internal rectal intussusception demonstrated by defecography were treated by perineal rectopexy.

RESULTS

Of 15 patients followed up for more than 2 years defecography showed total disappearance of the intussusception in 12. Five of these claimed substantial improvement (42%; 17-72%). Three of four patients with concomitant anal incontinence became fully or partly continent after the rectopexy.

CONCLUSION

In some patients with chronic constipation, dominated by symptoms of obstructed defecation, rectal invagination may be an aggravating factor. The study indicates that rectal invagination does not seem to be the cause but rather a consequence of the obstructed defecation. In selected patients, including those with concomitant faecal incontinence, surgical treatment of the intussusception by a minor procedure may be indicated.

Convalescence and hospital stay after colonic surgery with balanced analgesia, early oral feeding, and enforced mobilisation

OBJECTIVE

To evaluate the combined effects of pain relief by continuous epidural analgesia, early oral feeding and enforced mobilisation on convalescence and hospital stay after colonic resection.

DESIGN

Uncontrolled pilot investigation.

SETTING

University hospital, Denmark.

SUBJECTS

17 unselected patients (median age 69 years) undergoing colonic resection.

INTERVENTIONS

Patients received combined epidural and general anaesthesia during operations and after operation were given continuous epidural bupivacaine 0.25%, 4 ml hour and morphine 0.2 mg hour, for 96 hours and oral paracetamol 4 g/daily. No patient had a nasogastric tube, and oral feeding with normal food and protein enriched solutions (1000 Kcal (4180 KJ/day) was instituted 24 hours postoperatively together with intensive mobilisation.

RESULTS

Median visual analogue pain scores were zero at rest and minimal during coughing and mobilisation, which allowed early mobilisation for up to 11 hours on the third postoperative day. Gastrointestinal function with defaecation had returned to normal in 12 patients within the first two postoperative days. Median hospital stay was five days with minimal increase in fatigue and without postoperative weight loss.

CONCLUSION

These results suggest that a combined approach of optimal pain relief with balanced analgesia, enforced early mobilisation, and oral feeding, may reduce the length of convalescence and hospital stay after colonic operations.

[Pain and convalescence after ambulatory inguinal herniotomy during local anesthesia]

Postoperative pain and convalescence following ambulatory inguinal herniotomy in local infiltration anesthesia was evaluated in this descriptive study. Sixty consecutive patients (median age 63 yr) were included. Per- and postoperative pain treatment were pre- and postoperative oral tenoxicam and methadone plus infiltration of the surgical field with up to 60 ml of 0.25% bupivacaine. Intraoperative pain intensity was slight and was treated with supplemental bupivacaine. Patients were totally relieved of pain at rest and during mobilisation in the first hours after surgery, but more than half of the patients had moderate pain from the first to the third postoperative day and still had light pain seven days after surgery. Normal daily activity was re-established five days postoperatively (median). Fifty-two patients were satisfied with the anesthesia and eight patients not satisfied due to fear of intraoperative pain. This study shows that inguinal herniotomy can be performed routinely as an outpatient procedure under local infiltration anesthesia. However, late postoperative pain was significant and should be improved with multi-modal analgesia.

[Cimetidine treatment of stomach cancer]

The effect of cimetidine treatment in cancer of the stomach was investigated in a double-blind, multicentre study comprising eight departments in Greater Copenhagen. Immediately after operation (or the decision not to operate) 181 patients were subdivided at random to treatment with a placebo or cimetidine in a dosage of 400 mg twice daily for two years or until death. Compliance control was carried out every third month. The mean survival in the cimetidine group (450 days, 1-1,826) was significantly longer (p = 0.02) than in the placebo group (316 days, 1-1,653).

No effect of topical ampicillin prophylaxis in elective operations of the colon or rectum

Whether or not topical application of ampicillin is necessary in patients undergoing elective colorectal operations was investigated. After mechanical preparation, 193 patients received 2 grams of cefotaxime administered intravenously from the start of the operation; patients received two more doses within the next 12 hours. In addition, patients were randomized to receive or not receive prophylaxis against infection of 2 grams of ampicillin in the site of the incision at closure. Twenty-three patients did not complete the study. Wound infection occurred in five of 81 patients who had topical application of ampicillin compared with six of 89 patients who did not receive prophylaxis; the difference was not significant. There were no significant differences in rates of wound dehiscence, intra-abdominal abscess or anastomotic leakage. Escherichia coli and Bacteroides fragilis were the predominant microorganisms isolated. Thus, topical application of ampicillin did not lower the wound infection rate when there was a preoperative antibiotic administered intravenously.

Effect of cimetidine on survival after gastric cancer

The effect of cimetidine on survival was investigated in 181 patients with gastric cancer. Immediately after operation or the decision not to operate, the patients were randomised in double-blind fashion to placebo or cimetidine 400 mg twice daily for two years or until death, with review every three months. Median survival in the cimetidine group was 450 days (range 1-1826) and in the placebo group 316 days (1-1653). The relative survival rates (cimetidine/placebo) were 45%/28% at 1 year, 22%/13% at 2 years, 13%/7% at 3 years, 9%/3% at 4 years, and 2%/0% at 5 years. Survival in the cimetidine group was significantly longer than in the placebo group.

Concentrations of glycine- and taurine-conjugated bile acids in portal and systemic venous serum in man

Concentrations of glycine and taurine conjugates of cholic, chenodeoxycholic, and deoxycholic acid in portal and systemic venous serum and in bile were measured in eight subjects undergoing elective cholecystectomy. Mean concentrations in systemic serum ranged from 0.07 to 0.17 mumol/l, in portal serum from 0.49 to 2.09 mumol/l, and in bile from 2.72 to 17.2 mmol/l. The percentage content of trihydroxy-bile acid conjugates in bile (49%) and in portal serum (51%) was higher than in systemic serum (35%) (P less than 0.001). The estimated hepatic fractional uptake of glycocholic acid (mean, 83%) and of taurocholic acid (83%) was higher than the uptakes of the dihydroxy-bile acid conjugates (60-68%). The percentage contents of glycine-conjugated bile acids in systemic serum (mean, 66%), portal serum (62%), and bile (65%) were not significantly different.

Cimetidine assay in human plasma by liquid chromatography

An assay for the determination of cimetidine in human plasma is described. Cimetidine was extracted from alkalized plasma with ethyl acetate, washed once over hydrochloric acid, re-extracted into ethyl acetate, and the organic phase was evaporated to dryness. The residue was dissolved in ethanol and injected into a liquid chromatograph. In vitro sulphoxidation was found to occur in whole blood, for which reason the assay was performed in plasma. The accuracy of the method was found to be within 3% and the lower limit for sensitivity was demonstrated to be 0.1 mg/l using 750 microliters plasma. Five volunteers received 1 g cimetidine perorally per day given in four doses with various intervals. Blood samples were drawn hourly, five dose intervals over two days. The average minimum concentration of plasma cimetidine was found to correlate significantly with the mean value of the area under the time/concentration curve over a period of three dose intervals (r = 0.96).

Clinical and pharmacological effectiveness of cimetidine in duodenal ulcer patients

The plasma concentration of cimetidine was measured in 40 patients with duodenal ulcer after an oral dose of 200 mg cimetidine. The peak plasma concentration was on average 1.33 mg x 1(-1) (S.D. = 0.53) and the area under the plasma concentration curve (AUC) between 60 and 120 min after cimetidine was 1.13 mg x h x 1(-1) (S.D. = 0.48). The percentage inhibition (I%) of maximal acid output (MAO) to pentagastrin during this 60-min period was 49% (S.D. = 19) with a very low, but statistically significant, correlation with the AUC, r = 0.35 (p less than 0.05), thus demonstrating a very great individual variation in sensitivity to cimetidine. In 37 of the patients the time from start of treatment with cimetidine, 1.0 g/day, to disappearance of ulcer symptoms could be assessed, and it was found that neither the individual sensitivity to cimetidine, I%/AUC, nor the gastric secretory capacity, MAO, correlated significantly with the clinical effectiveness of the cimetidine treatment, although 8 patients with a low sensitivity to cimetidine and a high MAO improved more slowly (28 days) than the other 29 patients (13 days) (p less than 0.1).

Meal-stimulated gastric acid and gastrin secretion before and after jejuno-ileal shunt operation in obese patients. A preliminary report

Meal-stimulated gastric acid secretion was measured by intragastric titration before and after jejuno-ileal bypass operation in five obese patients. Acid secretion was significantly reduced after the operation, particulary during the late phase of the acid response, suggesting that stimulation of acid secretion may be elicited from the upper small intestine by a composite meal. Serum gastrin concentrations remained unchanged after the operation.