AIM:Individual components of surgical quality in locally advanced rectal cancer (LARC) - circumferential and distal resection margins and mesorectal completeness - are known prognostic factors. However, their combined prognostic value as a composite score remains underexplored. This study aimed to evaluate the impact of a composite quality total mesorectal excision (TME) score on oncological outcomes, and how this effect may vary with intervals from neoadjuvant therapy (NAT) to surgery. METHOD:This retrospective, multicentre cohort study included patients with LARC treated between 2005 and 2020 across six referral centres in the CRONOS study. Patients were categorised by the composite quality TME (successful/unsuccessful) and by the NAT-to-TME interval: short (≤8 weeks), intermediate (>8 to ≤12), or long (>12). Primary outcomes were locoregional recurrence (LR), systemic recurrence (SR), and overall survival (OS) in the unsuccessful group. The interaction between the composite score and NAT-to-TME interval was assessed as a secondary outcome. RESULTS:Of 1485 patients, 191 (12.9%) had an unsuccessful composite quality TME. This was significantly associated with increased risk of LR (HR 4.63, 95% CI: 3.04-7.05), SR (HR 2.10, 95% CI: 1.56-2.81), and reduced OS (HR 2.31, 95% CI: 1.79-2.98). Short and intermediate intervals increased the risk of LR in the unsuccessful group (pinteraction = 0.06). CONCLUSION:Patients with an unsuccessful composite quality TME are at high risk of recurrence and death. The link between shorter NAT-to-surgery intervals and poorer outcomes in this subgroup suggests that extending the interval beyond 12 weeks may help optimise results in selected patients.

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A 38-year-old male with a history of Lynch syndrome was diagnosed with a rectal mucinous adenocarcinoma 6 years earlier. In the follow-up a pelvic nodule radiologically suggestive of a lymph node recurrence was found, and was surgically removed. Histopathological studies were suggestive of PEComa. Immunohistochemical studies showed diffuse positivity for HMB45 and TFE3, with scattered cells expressing MELAN A and actin. TFE3 gene rearrangement was confirmed with fluorescence in situ hybridization. Intact nuclear expression was observed for MLH1, MSH2, MSH6 and PMS2, and genetic studies confirmed microsatellite stability, arguing against a relation with Lynch syndrome. After 29 months, the patient remains alive with no evidence of recurrence of either the adenocarcinoma or the PEComa. Although some sarcomas have been described in Lynch syndrome families, cumulative evidence suggests that Lynch syndrome patients might also develop non-Lynch syndrome tumors. To the best of our knowledge, this is the first report of a PEComa in a patient with Lynch syndrome. TFE3-rearranged PEComas are a recently described variant defined by the translocation of TFE3, the features of which are poorly defined. This tumor adds to the list of sporadic non-Lynch syndrome-related tumors, and to the data of TFE3 rearrangement-associated PEComas.

Purpose To define the impact of the COVID-19 outbreak on hospital surgical activity and assess the incidence of perioperative COVID-19 within two protocolized screening pathways for elective and non-elective surgery. Methods We conducted a prospective cohort study of adults undergoing surgery during the COVID-19 outbreak. The elective pathway included telephone surveys and a quantitative polymerase-chain-reaction test (RT-PCR) only for patients who were asymptomatic and at low risk of infection. Only patients with negative screening underwent surgery. In the non-elective pathway, preoperative screening was performed during the hospital admission. Results Among 835 patients considered for the elective pathway, 725 had negative RT-PCR results and underwent surgery. This reflects an 83% reduction in surgical activity from 2019. Moreover, 596 patients underwent non-elective surgery, representing a 28% reduction. Preoperatively, 39 patients (6.5%) tested positive for SARS-CoV-2 and underwent surgery through the non-elective pathway, vs. none in the elective pathway ( p < 0.001). Postoperatively, 1.4% of elective surgery patients and 2.2% of non-elective surgery patients tested positive ( p > 0.05). Mortality was higher in non-elective surgery (0.6% vs. 2.9%, p < 0.001) and in patients with COVID-19 (0% vs. 14%, p < 0.001). Conclusions The low incidence of COVID-19 in elective surgeries during the outbreak demonstrates the importance and effectiveness of preoperative screening, combining surveys and RT-PCR.

Aims To evaluate the effectiveness and safety of endoscopic vacuum therapy (EVT) for the treatment of upper gastrointestinal (GI) defects. To assess risk factors associated with EVT failure and in-hospital mortality in these patients.

ImportanceThe treatment for extraperitoneal locally advanced rectal cancer (LARC) is neoadjuvant therapy (NAT) followed by total mesorectal excision (TME). Robust evidence on the optimal time interval between NAT completion and surgery is lacking.ObjectiveTo assess the association of time interval between NAT completion and TME with short- and long-term outcomes. It was hypothesized that longer intervals increase the pathologic complete response (pCR) rate without increasing perioperative morbidity.Design, Setting, and ParticipantsThis cohort study included patients with LARC from 6 referral centers who completed NAT and underwent TME between January 2005 and December 2020. The cohort was divided into 3 groups depending on the time interval between NAT completion and surgery: short (≤8 weeks), intermediate (>8 and ≤12 weeks), and long (>12 weeks). The median follow-up duration was 33 months. Data analyses were conducted from May 1, 2021, to May 31, 2022. The inverse probability of treatment weighting method was used to homogenize the analysis groups.ExposureLong-course chemoradiotherapy or short-course radiotherapy with delayed surgery.Main outcome and MeasuresThe primary outcome was pCR. Other histopathologic results, perioperative events, and survival outcomes constituted the secondary outcomes.ResultsAmong the 1506 patients, 908 were male (60.3%), and the median (IQR) age was 68.8 (59.4-76.5) years. The short-, intermediate-, and long-interval groups included 511 patients (33.9%), 797 patients (52.9%), and 198 patients (13.1%), respectively. The overall pCR was 17.2% (259 of 1506 patients; 95% CI, 15.4%-19.2%). When compared with the intermediate-interval group, no association was observed between time intervals and pCR in short-interval (odds ratio [OR], 0.74; 95% CI, 0.55-1.01) and long-interval (OR, 1.07; 95% CI, 0.73-1.61) groups. The long-interval group was significantly associated with lower risk of bad response (tumor regression grade [TRG] 2-3; OR, 0.47; 95% CI, 0.24-0.91), systemic recurrence (hazard ratio, 0.59; 95% CI, 0.36-0.96), higher conversion risk (OR, 3.14; 95% CI, 1.62-6.07), minor postoperative complications (OR, 1.43; 95% CI, 1.04-1.97), and incomplete mesorectum (OR, 1.89; 95% CI, 1.02-3.50) when compared with the intermediate-interval group.Conclusions and RelevanceTime intervals longer than 12 weeks were associated with improved TRG and systemic recurrence but may increase surgical complexity and minor morbidity.

BACKGROUND: Few studies have addressed the functional impact after transanal total mesorectal excision. OBJECTIVE: This study aimed to evaluate function and health-related quality of life among patients with rectal cancer treated with transanal total mesorectal excision. DESIGN: Consecutive patients treated between 2016 and 2018 were selected. Their function and quality of life were studied preoperatively and at 3 and 12 months after surgery. SETTING: This is a prospective case series. PATIENTS: Patients were eligible if they had primary anastomosis, their diverting stoma had been reversed, and they did not have anastomotic leakage. Forty-five patients were finally included. A total of 31 (68.8%) and 32 patients (71.1%) completed the 3- and 12-month surveys. INTERVENTIONS: Standard transanal total mesorectal excision was performed. MAIN OUTCOME MEASURES: The primary end point was functional and quality-of-life outcomes using validated questionnaires. Secondary end points included values obtained with endoanal ultrasounds, anorectal manometries, and rectal sensation testing. RESULTS: Wexner and Low Anterior Resection Syndrome scores significantly increased 3 months after surgery but returned to baseline values at 12 months. The rate of “major low anterior resection syndrome” at the end of follow-up was 25.0% (+11.7% compared with baseline, p = 0.314). Sexual and urinary functions remained stable throughout the study, although a meaningful clinical improvement was detected in male sexual interest. Among quality-of-life domains, all deteriorations returned to baseline values 12 months after surgery, except worsening of flatulence symptoms, and improvement in insomnia and constipation. At 12 months, an expected decrease in the mean width of the internal sphincter, the anal resting pressure, and the tenesmus threshold volume was found. LIMITATIONS: This study was limited by its small sample size, the absence of a comparative group, and significant missing data in female sexual difficulty and in ultrasounds and manometries at 3 months. CONCLUSIONS: Patients undergoing transanal total mesorectal excision report acceptable quality-of-life and functional outcomes 12 months after surgery. See Video Abstract at http://links.lww.com/DCR/B541. RESULTADOS FUNCIONALES Y CALIDAD DE VIDA DE LOS PACIENTES DESPUÉS DE LA ESCISIÓN MESORRECTAL TOTAL TRANSANAL PARA CÁNCER DE RECTO: UN ESTUDIO PROSPECTIVO OBSERVACIONAL ANTECEDENTES: Pocos estudios han abordado el impacto funcional después de la escisión mesorrectal total transanal. OBJETIVO: Evaluar la función y la calidad de vida relacionada con la salud en pacientes con cáncer de recto tratados con escisión mesorrectal total transanal. DISEÑO: Se seleccionaron pacientes consecutivos tratados entre 2016 y 2018. Se estudió su función y calidad de vida, en la etapa preoperatoria, a los tres y doce meses postoperatorios. METODO: Serie de casos prospectivos. PACIENTES: Los pacientes eran incluidos en presencia de anastomosis primaria, cierre del estoma de derivación y en ausencia de fuga anastomótica. Finalmente se incluyeron cuarenta y cinco pacientes. Un total de 31 (68,8%) y 32 pacientes (71,1%) completaron las encuestas de tres y doce meses, respectivamente. INTERVENCIONES: Escisión mesorrectal total transanal estándar. PRINCIPALES MEDIDAS DE RESULTADO: Los criterio de evaluación principal fueron los resultados funcionales y de calidad de vida mediante cuestionarios previamente validados. Los criterios de evaluación secundarios incluyeron los valores obtenidos con ecografía endoanal, manometría anorrectal y prueba de sensibilidad rectal. RESULTADOS: La escala de Wexner y el síndrome de resección anterior baja aumentaron significativamente tres meses después de la cirugía, pero volvieron a los valores iniciales a los doce meses. La tasa de “síndrome de resección anterior inferior grave” al final del seguimiento fue del 25,0% (+ 11,7% en comparación con el valor inicial, p = 0,314). La función sexual y urinaria se mantuvo estable durante todo el estudio, aunque se detectó una mejora clínica significativa en la libido masculina. Entre los criterios que evalúan la calidad de vida, todas las alteraciones en la misma volvieron a los valores iniciales, doce meses después de la cirugía, excepto el aumento de flatulencia, la mejoría del insomnio y el estreñimiento. A los doce meses, se encontró una disminución esperada en el grosor medio del esfínter interno, la presión anal en reposo y el volumen umbral para la presencia de tenesmo. LIMITACIONES: Tamaño de muestra limitado, ausencia de un grupo comparativo, falta significativa de datos para identificar la dificultad para la actividad sexual femenina y el efectuar ecografía y manometría a los tres meses. CONCLUSIONES: Los pacientes sometidos a escisión mesorrectal total transanal refieren una calidad de vida y resultados funcionales aceptables a los doce meses después de la cirugía. Consulte Video Resumen en http://links.lww.com/DCR/B541.

Background and Objective: The need to optimize visualization systems in minimally invasive surgery has given rise to a growing number of applications of indocyanine green (ICG) fluorescence. This narrative review aims to summarize the existing literature about the use of this fluorophore in colon and rectal surgery. Methods: A literature search was performed using PubMed database to identify relevant articles on ICG fluorescence guided surgery and colorectal surgery. Key Content and Findings: ICG fluorescent angiography has proved to be a useful tool to assess intestinal resection line perfusion, but study heterogeneity, low statistical power and confounding evidence have prevented demonstrating a decrease in anastomotic leak in colorectal surgery. Although the application of ICG near-infrared fluorescence is a safe and reliable technique for evaluating the lymphatic flow and detecting sentinel lymph nodes in colorectal surgery, especially in early cancer stage setting, current evidence does not allow to determine its use in routine clinical practice and it is far from being sufficient to establish ultra-selective colectomies programs. Endoscopic submucosal ICG injection allows intraoperative tumor site location when performed up to a week prior to surgery, but cost-effectiveness research need to define its advantage compared to traditional permanent dyes. Intraureteral ICG instillation may reduce ureteral iatrogenic lesions, but its invasive administration prevents its use in daily routine patients. Conclusions: ICG fluorescence-based technology represents a niche of opportunities for improved visualization in the field of minimally invasive surgery. However, with the exception of angiography for the intraoperative evaluation of intestinal perfusion, the currently available evidence limits the indication for routine use of the rest of the applications. Future development of quantitative fluorescence measurement methods and established protocols may achieve better performance of this tool.

Background: Fluorescence imaging with indocyanine green is increasingly being used in colorectal surgery to assess anastomotic perfusion, and to detect sentinel lymph nodes. Methods: In this 2-round, online, Delphi survey, 35 international experts were asked to vote on 69 statements pertaining to patient preparation and contraindications to fluorescence imaging during colorectal surgery, indications, technical aspects, potential advantages/disadvantages, and effectiveness versus limitations, and training and research. Methodological steps were adopted during survey design to minimize risk of bias. Results: More than 70% consensus was reached on 60 of 69 statements, including moderate-strong consensus regarding fluorescence imaging's value assessing anastomotic perfusion and leak risk, but not on its value mapping sentinel nodes. Similarly, although consensus was reached regarding most technical aspects of its use assessing anastomoses, little consensus was achieved for lymph-node assessments. Evaluating anastomoses, experts agreed that the optimum total indocyanine green dose and timing are 5 to 10 mg and 30 to 60 seconds pre-evaluation, indocyanine green should be dosed milligram/kilogram, lines should be flushed with saline, and indocyanine green can be readministered if bright perfusion is not achieved, although how long surgeons should wait remains unknown. The only consensus achieved for lymph-node assessments was that 2 to 4 injection points are needed. Ninety-six percent and 100% consensus were reached that fluorescence imaging will increase in practice and research over the next decade, respectively. Conclusion: Although further research remains necessary, fluorescence imaging appears to have value assessing anastomotic perfusion, but its value for lymph-node mapping remains questionable. (c) 2022 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

The aim of the study was to investigate the reliability and the validity of the Swedish version of the Bath Ankylosing Spondylitis Functional Index (BASFI). A total of 113 patients were assessed with the BASFI, the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), the Bath Ankylosing Spondylitis Metrology Index (BASMI), and the Bath Ankylosing Spondylitis Patient Global Score (BAS-G). The median BASFI scores on two occasions within 24 hours were 3.6 versus 3.7 (p>0.05). The patients found the BASFI items relevant. The median self-reported and physiotherapist-observed BASFI scores were 3.4 and 2.8 respectively (p>0.05). The correlation coefficient between the BASFI and the BASMI was r(s)=0.55, between the BASFI and the BASDAI r(s)=0.68, and between the BASFI and the BAS-G r(s)=0.67. Significant improvements between the pre- and post-training results for both the BASFI (3.1 vs 2.0, p<0.001) and the BASMI (3.0 vs 1.0, p<0.001) were found after three weeks' inpatient rehabilitation. The results indicated that the Swedish BASFI is reliable and valid.

BACKGROUND: In selected patients with peritoneal metastases of colorectal origin, complete cytoreduction has been the main single prognostic factor influencing long-term outcomes. In these patients, indocyanine green fluorescence imaging seems to be useful in detecting small subclinical peritoneal implants. However, quantitative fluorescence analysis has not yet been established as standard. OBJECTIVE: This study aimed to evaluate the sensitivity and specificity of quantitative indocyanine green fluorescence assessment in the detection of peritoneal metastases of nonmucinous colorectal origin. DESIGN: This is a single-center, single-arm, low-intervention prospective trial. SETTINGS: A fluorescence assessment device was used for intraoperative fluorescence quantitative assessment. PATIENTS: Consecutive patients diagnosed with peritoneal metastases of colorectal origin who met the inclusion criteria were selected for curative surgery. INTERVENTIONS: Intravenous indocyanine green was administered 12 hours before surgery. Cytoreduction was performed through nodule identification under white light and then under indocyanine green. Finally, ex vivo fluorescence was assessed. MAIN OUTCOME MEASURES: The primary outcomes measured were the sensitivity and specificity of quantitative fluorescence. RESULTS: The first 11 enrolled patients were included in this preliminary analysis. In total, 52 nodules were resected, with 37 (71.1%) being diagnosed as malignant in the histopathological analysis. Of those, 5 (13.5%) were undetectable under white light and were identified only with fluorescence. A total of 15 nonmalignant nodules were detected under white light, 8 (53.3%) of which were fluorescence negative. Fluorescence greater than 181 units might be the threshold of malignancy, with a sensitivity and specificity of 89.0% and 85.0%, whereas uptake less than 100 units appears to correlate with a benign pathology. LIMITATIONS: The limited sample size, the physiological uptake, and excretion of indocyanine green might interfere with the assessment of unnoticed implants in the bowel serosa and liver. CONCLUSIONS: Quantitative indocyanine green seems to be useful for the assessment of nonmucinous colorectal peritoneal metastases. Fluorescence uptake greater than 181 units appears to correlate with malignancy, whereas uptake less than 100 units appears to correlate with a benign pathology. See Video Abstract at http://links.lww.com/DCR/B743. EVALUACIÓN CUANTITATIVA DE IMÁGENES DE FLUORESCENCIA CON VERDE DE INDOCIANINA PARA METÁSTASIS PERITONEALES NO MUCINOSAS: RESULTADOS PRELIMINARES DEL ESTUDIO ICCP ANTECEDENTES: En pacientes seleccionados con metástasis peritoneales de origen colorrectal, la citorreducción com-pleta ha sido el único factor pronóstico principal que influye en el resultado a largo plazo. En estos pacientes, las imágenes de fluorescencia con verde de indocianina parecen ser útiles para detectar pequeños implantes peritoneales subclínicos. Sin embargo, el análisis cuantitativo de fluorescencia aún no se ha establecido como estándar. OBJETIVO: Evaluar la sensibilidad y especificidad de la evaluación cuantitativa de fluorescencia verde de indo-cianina, en la detección de metástasis peritoneales de origen colorrectal no mucinoso. DISEÑO: Ensayo prospectivo de intervención baja de un solo brazo y un solo centro. ENTORNO CLINICO: El dispositivo se utilizó para la evaluación cuantitativa de fluorescencia intraoperatoria. PACIENTES: Pacientes consecutivos diagnosticados con metástasis peritoneales de origen colorrectal, selecciona-dos para cirugía curativa y que cumplieron con los criterios de inclusión. INTERVENCIONES: Se administró verde de indocianina por vía intravenosa 12 h antes de la cirugía. La citorreducción se realizó mediante identificación de nódulos con luz blanca y luego con verde de indocianina. Final-mente, se evaluó la fluorescencia ex vivo. PRINCIPALES MEDIDAS DE VALORACION: Sensibilidad y especificidad cuantitativa de la fluorescencia. RESULTADOS: Los primeros 11 pacientes fueron incluidos en este análisis preliminar. En total se resecaron 52 nódu-los, siendo 37 (71,1%) diagnosticados como malignos en el análisis histopatológico. De ellos, 5 (13,5%) eran indetectables bajo luz blanca y solamente se identificaron con fluorescencia. Se detec-taron un total de 15 nódulos no malignos bajo luz blanca, de los cuales 8 (53,3%) fueron fluorescen-tes negativos. La fluorescencia superior a 181 unidades podría ser el umbral de malignidad, con una sensibilidad y especificidad del 89,0% y el 85,0% respectivamente; mientras que la captación por debajo de 100 unidades parece correlacionarse con una patología benigna. LIMITACIONES: El tamaño limitado de la muestra; la captación fisiológica y la excreción de verde de indocianina pueden interferir con la evaluación de implantes inadvertidos en la serosa intestinal y el hígado. CONCLUSIONES: La cuantificación del verde de indocianina, parece ser útil en la evaluación de metástasis peritonea-les colorrectales no mucinosas. La captación de fluorescencia por encima de 181 unidades parece correlacionarse con la malignidad, mientras que la captación por debajo de 100 unidades parece co-rrelacionarse con una patología benigna. Consulte Video Resumen en http://links.lww.com/DCR/B743. ( Traducción - Dr. Fidel Ruiz Healy ).

BACKGROUND: The clinical value of transanal total mesorectal excision is debated. OBJECTIVE: This study aimed to compare short- and medium-term effects of transanal versus anterior total mesorectal excision for rectal cancer. DESIGN: This was a multicenter retrospective cohort study. SETTING: The study included all Catalonian public hospitals. PATIENTS: All patients receiving transanal or anterior total mesorectal excision (open or laparoscopic) for nonmetastatic primary rectal cancer in 2015 to 2016 were included. MAIN OUTCOME MEASURES: Data on vital status were collected to March 2019. Between-group differences were minimized by applying propensity score matching to baseline patient characteristics. Competing risk models were used to assess systemic and local recurrence along with death at 2 years, and multivariable Cox regression was used to assess 2-year disease-free survival. Results are expressed with their 95% CIs. RESULTS: The final subsample was 537 patients receiving total mesorectal excision (transanal approach: n = 145; anterior approach: n = 392). Median follow-up was 39.2 months (interquartile range, 33.0–45.8). Accounting for death as a competing event, there was no association between transanal total mesorectal excision and local recurrence (matched subhazard ratio 1.28, 95% CI 0.55–2.96). There were no statistical differences in the comparative rate of local recurrence (transanal: 1.77 per 100 person-years, 95% CI 0.76–3.34; anterior: 1.37 per 100 person-years, 95% CI 0.8–2.15) or mortality (transanal: 3.98 per 100 person-years, 95% CI 2.36–6.16; anterior: 2.99 per 100 person-years, 95% CI 2.1–4.07). Groups presented similar 2-year cumulative incidence of local recurrence (4.83% versus 3.57%) and disease-free survival (HR, 1.33; 95% CI 0.92–1.92). LIMITATIONS: We used data only from the public system, the study is retrospective, and data on individual surgeons are not reported. CONCLUSION: These population-based results support the use of either the transanal, open, or laparoscopic approach for rectal cancer in Catalonia. See Video Abstract at http://links.lww.com/DCR/B744. ESCISIÓN MESORRECTAL TOTAL TRANSANAL VERSUS ESCISIÓN MESORRECTAL TOTAL ANTERIOR PARA EL CÁNCER DE RECTO: UN ESTUDIO POBLACIONAL CON EMPAREJAMIENTO DE PUNTAJE DE PROPENSIÓN EN CATALUÑA, ESPAÑA ANTECEDENTES: Se debate el valor clínico de la escisión mesorrectal total transanal. OBJETIVO: Comparar los efectos a corto y mediano plazo de la escisión mesorrectal total transanal versus anterior para el cáncer de recto. DISEÑO: Este fue un estudio de cohorte retrospectivo multicéntrico. AJUSTE: El estudio incluyó a todos los hospitales públicos de Cataluña. PACIENTES: Todos los pacientes no metastásicos que recibieron escisión mesorrectal total anterior o transanal (abierta o laparoscópica) por cáncer de recto primario en 2015-16. PRINCIPALES MEDIDAS DE VALORACION: Los datos sobre el estado vital se recopilaron hasta marzo de 2019. Las diferencias entre los grupos se minimizaron aplicando el emparejamiento de puntajes de propensión a las características iniciales del paciente. Se utilizaron modelos de riesgo competitivo para evaluar la recurrencia sistémica y local junto con la muerte a los dos años, y la regresión de Cox multivariable para evaluar la supervivencia libre de enfermedad a dos años. Los resultados se expresan con sus intervalos de confianza del 95%. RESULTADOS: La submuestra final fue de 537 pacientes que recibieron escisión mesorrectal total (abordaje transanal: n = 145; abordaje anterior: n = 392). La mediana de seguimiento fue de 39,2 meses (rango intercuartílico 33,0-45,8). Teniendo en cuenta la muerte como un evento competitivo, no hubo asociación entre la escisión mesorrectal total transanal y la recurrencia local (cociente de subriesgo apareado 1,28, 0,55-2,96). No hubo diferencias estadísticas en la tasa comparativa de recurrencia local (transanal: 1,77 por 100 personas-año, 0,76-3,34; anterior: 1,37 por 100 personas-año, 0,8-2,15) o mortalidad (transanal: 3,98 por 100 personas-año, 2,36–6,16; anterior: 2,99 por 100 personas-año, 2,1-4,07). Los grupos presentaron una incidencia acumulada de dos años similar de recidiva local (4,83% frente a 3,57%, respectivamente) y supervivencia libre de enfermedad (índice de riesgo 1,33, 0,92–1,92). LIMITACIONES: Utilizamos datos solo del sistema público, el estudio es retrospectivo y no se informan datos sobre cirujanos individuales. CONCLUSIONES: Estos resultados poblacionales apoyan el uso del abordaje transanal, abierto o laparoscópico para el cáncer de recto en Cataluña. Consulte. Video Resumen en http://links.lww.com/DCR/B744 . (Traducción— Dr. Francisco M. Abarca-Rendon)

For mid and low rectal cancer, transanal total mesorectal excision (TaTME) has been established as an alternative approach to laparoscopic surgery. However, there are concerns about an unexpected pattern of local recurrence. This study aimed to analyze the pattern of local recurrence for patients treated with TaTME in a tertiary referral center. A retrospective single-center analysis was performed. Since 2011, all patients with rectal cancer undergoing TaTME with curative intent were prospectively included in a standardized database. Patients with tumors within 12 cm, clinical stage II or III were included. The primary endpoint of the study was the overall local recurrence rate, together with a critical analysis of the patterns of local failures. Two hundred and five patients were included in this analysis. At the time of surgery, patients had a mean age of 67.1 years (SD 12.3), and 66.8% were male. Neoadjuvant therapy was administered in 73.7%. Mesorectal specimen quality was complete or near-complete in 98.5%, while circumferential resection margin was ≤ 1 mm (including T4 tumors) in 11.8%. After a median follow-up of 34.3 months (95% CI 30.1–38.5), 3.4% (n = 7) presented with local recurrent disease. Six out of the seven patients were also diagnosed with hematogenous metastases. Of the seven patients, three presented with at least one of the following risk factors: T4 tumor, N2 disease, incomplete mesorectal specimen, or positive CRM. Local failure was noted posteriorly (n = 3), laterally (n = 2), anteriorly (n = 1), and in the axial compartment (n = 1). Median time to relapse was 31.5 months (10.3—40.9). The median follow-up after local recurrence was 7.9 (95% CI 6.7–9.1) months, with an overall survival of 85.7%. TaTME provided satisfactory local recurrence outcomes, and the most common patterns of failure were in the central pelvis.

Transanal total mesorectal excision is a complex technique that should be performed in expert centers.

Surgery remains the gold standard for the treatment of locally advanced rectal cancer. The most effective approach to reduce locoregional recurrence is total mesorectal excision (TME). However, obtaining an optimal TME is demanding, especially in low rectal tumors and anatomically unfavorable pelvis. Transanal TME (taTME) was developed to facilitate low pelvis dissection and potentially provide optimal outcomes for oncologic resection. Current studies have reported satisfactory short-term outcomes. However, taTME is a technically challenging procedure and must be learned in an appropriate training process to allow for a safe implementation. Previous experience in laparoscopic and transanal surgery is strongly recommended. In this work, we provide a detailed discussion of the technique, based on the realization of more than 400 taTME interventions.