Transanal total mesorectal excision for rectal cancer has been suspended in Norway

Background

Transanal total mesorectal excision (TaTME) for rectal cancer has emerged as an alternative to the traditional abdominal approach. However, concerns have been raised about local recurrence. The aim of this study was to evaluate local recurrence after TaTME. Secondary aims included postoperative mortality, anastomotic leak and stoma rates.

Methods

Data on all patients who underwent TaTME were recorded and compared with those from national cohorts in the Norwegian Colorectal Cancer Registry (NCCR) and the Norwegian Registry for Gastrointestinal Surgery (NoRGast). Kaplan–Meier estimates were used to compare local recurrence.

Results

In Norway, 157 patients underwent TaTME for rectal cancer between October 2014 and October 2018. Three of seven hospitals abandoned TaTME after a total of five procedures. The local recurrence rate was 12 of 157 (7·6 per cent); eight local recurrences were multifocal or extensive. The estimated local recurrence rate at 2·4 years was 11·6 (95 per cent c.i. 6·6 to 19·9) per cent after TaTME compared with 2·4 (1·4 to 4·3) per cent in the NCCR (P < 0·001). The adjusted hazard ratio was 6·71 (95 per cent c.i. 2·94 to 15·32). Anastomotic leaks resulting in reoperation occurred in 8·4 per cent of patients in the TaTME cohort compared with 4·5 per cent in NoRGast (P = 0·047). Fifty-six patients (35·7 per cent) had a stoma at latest follow-up; 39 (24·8 per cent) were permanent.

Conclusion

Anastomotic leak rates after TaTME were higher than national rates; local recurrence rates and growth patterns were unfavourable.

MRI defecography of the ileal pouch-anal anastomosis-contributes little to the understanding of functional outcome

PURPOSE

Variability in functional outcome after ileal pouch-anal anastomosis (IPAA) is to a large extent unexplained. The aim of this study was to use MRI to evaluate the morphology, emptying pattern and other pathology that may explain differences in functional outcome between well-functioning and poorly functioning pouch patients. A secondary aim was to establish a reference of normal MRI findings in pelvic pouch patients.

METHODS

From a previous study, the best and worst functioning patients undergoing IPAA surgery between 2000 and 2013 had been identified and examined with manovolumetric tests (N = 47). The patients were invited to do a pelvic MRI investigating pouch morphology and emptying patterns, followed by a pouch endoscopy.

RESULTS

Forty-three patients underwent MRI examination. We found no significant morphological or dynamic differences between the well-functioning and poorly functioning pouch patients. There was no correlation between urge volume and the volume of the bony pelvis, and no correlation between emptying difficulties or leakage and dynamic MRI findings. Morphological MRI signs of inflammation were present in the majority of patients and were not correlated to histological signs of inflammation. Of the radiological signs of inflammation, only pouch wall thickness correlated to endoscopic pouchitis disease activity index scores.

CONCLUSION

It seems MRI does not increase the understanding of factors contributing to functional outcome after ileal pouch-anal anastomosis. Unless there is a clinical suspicion of perianal/peripouch disease or pelvic sepsis, MRI does not add value as a diagnostic tool for pelvic pouch patients. Endoscopy remains the golden standard for diagnosing pouch inflammation.

Determinants of optimal bowel function in ileal pouch-anal anastomosis - physiological differences contributing to pouch function

BACKGROUND

Variability in functional outcome after ileal-pouch anal anastomosis (IPAA) is to a large extent unexplained. The aim of this study was to perform multiple physiological and biochemical tests including an endoscopic examination with histology on IPAA patients with well and poorly functioning pouches to determine factors, or combinations thereof, contributing to functional outcome.

METHODS

All patients with ulcerative colitis undergoing restorative proctocolectomy between 2000 and 2013 (N = 108) were interviewed using a pouch functioning score. The best and worst functioning quartiles were invited to undergo examination with a barostat measuring pouch volume at preset variable distension pressures, and a pouch endoscopy.

RESULTS

Forty five of 58 eligible patients agreed to participate. The most significant physiological parameter differing between the well and poorly functioning pouches was pouch volume at first sensation, urge and discomfort (p value <.001). Urge volumes were 213 (CI 171-256) ml for poorly and 352 (CI 305-401) ml for well functioning pouches. Pouchitis episodes were negatively correlated to function. The poorly functioning patients had a higher prevalence of histological signs of inflammation and hand-sewn anastomosis, and a longer remaining rectal cuff, however, nonsignificant. The pouch pressure at sensation thresholds did not differ between the groups.

CONCLUSIONS

Pouch volume is the most dominant predictor of pouch function in this study. The present comprehensive study of a multitude of different factors that possibly could be contributing to functional outcome, failed to shed much further light on the functional variability among pouch patients. The pouch physiology remains to a large extent unexplained.

Correlation between pouch function and sexual function in patients with IPAA

OBJECTIVE

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the treatment of choice for ulcerative colitis refractory to medical treatment and familial adenomatous polyposis. The objective of this study was to study the impact of postoperative pouch function on sexual function. Sexual function after IPAA surgery has also been compared to sexual function in the average Norwegian population.

MATERIAL AND METHODS

All patients having undergone IPAA from 2000 to June 2013 were identified from the hospital medical record files and sent validated questionnaires regarding their sexual function. Pouch function was scored according to Oresland score through a phone interview. Patients operated on or before June 2012 were asked to answer the same questionnaires twice with an interval of one year to see how stable sexual function is over time.

RESULTS

Sixty-eight out of 100 consecutive patients answered the questionnaire regarding both sexual function and pouch function (44 men, 24 women). There was no significant relationship between pouch and sexual function in men (p-value 0.158, corr. coefficient - 0.216). In women there was a significant relationship (p-value - 0.01, corr. coefficient 0.517). There was no significant shift in sexual function during the study period.

CONCLUSION

We found no significant correlation between sexual function and pouch function in men. In women, we found a significant correlation between poor pouch function and impaired sexual function. As similar studies have found, sexual function remains good after IPAA surgery. This is an important information for patients and physicians, both to inform patients correctly prior to surgery, and in the postoperative follow-up.