Cost Analysis of Laparoscopic Low Anterior Resection vs. Transanal Endoscopic Microsurgery for Rectal Neoplasms

Despite the increasing application of transanal endoscopic microsurgery (TEM) for rectal lesions, the cost of the equipment may play a role in a hospital’s hesitancy to invest in the platform. This study compares the cost of TEM to laparoscopic low anterior resection (LAR). Patients who underwent laparoscopic LAR (n = 24) for rectal neoplasm between 2006 and 2014 were case-matched based on sex, age, comorbidities, lesion size and location to patients who underwent TEM at a busy secondary care urban hospital. Procedure-related costs and costs associated with readmissions for complications and related subsequent surgeries in the first 3 years were calculated. There were 42 hospital admissions for 24 LAR patients, totalling 326 hospital days. For 24 TEM patients, there were 25 hospital admissions, totalling 56 hospital days. Subsequent operations for LAR patients included 2 washout and diverting ileostomies (8%), 2 adhesionolysis (8%), 4 ventral hernia repairs (16%) and 11 ileostomy reversals (46%). In the TEM group, there was one operation for recurrence (4%). The mean cost of LAR, including all related hospital costs in the subsequent 3 years, was CAD 14,851 (95% CI: CAD 10,124–19,579). The mean cost of TEM was CAD 2449 (95% CI: CAD 2133–2767; p < 0.0001), with a savings of CAD 12,402 per patient. TEM for rectal neoplasm is associated with significantly lower hospital costs, which far outweigh the costs of acquiring and maintaining the technology.

Ileo-perineal fistula: Rare late complication after rectal amputation – clinical case

Abdominal-perineal rectal amputation retains a well-defined place in the surgical treatment of rectal cancer, despite technical advances. The authors present the case of a 67-year-old patient who developed an entero-perineal fistula involving the last ileal loop, two years after an abdominal-perineal rectal amputation for a radiotreated rectal neoplasm. For surgical treatment of the fistula, right ileo-hemicolectomy with ileo-transverse anastomosis were performed. The fistulous tract is treated by soft field typhoon meshing in the same manner of treating the perineal wound after rectal amputation. The evolution is favorable, with the closure of the perineal wound, 6 weeks after surgery. The peculiarity of the case consists in the way of surgical solution. This case presentation is important due to the rarity of the ileo-perineal fistula after amputation of the rectum, as well as due to the particular way of surgical resolution.

Mixed adenoneuroendocrine carcinoma (MANEC) as a rare case of the rectum

Introduction: Mixed adenoneuroendocrine carcinoma (MANEC) is a rare tumor consist of two components, adenocarcinoma and neuroendocrine differentiation. Every each have to represents at least 30% of the tumor. Diagnosis is based on cytology, architecture and immunostaining. Specific neuroendocrine markers for MANEC are chromogranin A and synaptophysin. Purpose: In this paper, we aimed to present a case of MANEC arising from rectum. Case presentation: 67-years-old man was admitted to the hospital due to abdominal pain, obstruction and blood in the stool. From the colonoscopy simple, the histopathological examination exposed microfoci of adenocarcinoma. Small pelvis MRI disclosed clinically known circular, solid infiltrate in the middle and upper part of the rectum. Local advancement in MRI was T4b N2 EMVI + CRM +. Patient underwent the neoadjuvant radiochemo-therapy. The control MRI revealed tumor reduction. Local advancement in MRI was yT3d yN0 EMVI + CRM + RG3. The histopathological examination of the surgical material revealed MANEC tissue consisting of Adenocarcinoma G2 (60%) and Large cell neuroendocrinal carcinoma (40%) pT3 pN0 pMx. Immunohistochemical staining revealed a positive expression of chromogranin A, synaptophysin and Ki67 - 80% in the neuro-endocrine component. Lymphonodulitis reactiva 19/19. Seminal vesicles without neoplastic infiltration. The patient was discharged in good general condition, with a recommendation of a follow-up visit at a surgical clinic. Conclusions: MANEC is rare as a rectal neoplasm. Has no specific clinical symptoms. The most important in the diagnostic process is histopatho-logical analysis. Updating the knowledge about MANEC by new reports may optimize the diagnostic process, classification and treatment of this cancer.

Should the rectal defect be sutured following TEMS/TAMIS carried out for neoplastic rectal lesions? A meta-analysis

Introduction Management of the rectal defect following transanal endoscopic microsurgery (TEMS) or minimally invasive surgery (TAMIS) carried out for excision of neoplasm in the lower rectum is controversial. We aimed to extract evidence by carrying out a meta-analysis to compare the peri- and postoperative outcomes following rectal neoplasm excision carried out by TEMS and/or TAMIS, whereby the defect is either sutured or left open. Methods A literature search of Ovid MEDLINE and EMBASE was performed. Full-text comparative studies published until November 2019, in English and of adult patients, whereby TEMS or TAMIS was undertaken for rectal neoplasms were included. The main outcome measures were postoperative bleeding, infection, operative time and hospital stay. Findings Three studies (one randomised controlled trial and two comparative case series) yielded 555 cases (283 in the sutured group and 272 in the open group). The incidence of postoperative bleeding was higher and statistically significant (p = 0.006) where the rectal defect was left open following excision of the neoplasm (19/272, 6.99% vs 6/283, 2.12%). There was no statistical difference between the sutured and open groups regarding infection (p = 0.27; (10/283, 3.53% vs 5/272, 1.84%, respectively), operative time (p = 0.15) or length of stay (p = 0.67). Conclusion Suturing the rectal defect following excision of rectal neoplasm by TEMS/TAMIS reduces the incidence of postoperative bleeding in comparison to leaving the defect open. However, suturing makes the procedure slightly longer but there was no statistical difference between both groups when postoperative infection and length of hospital stay were compared.