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Aim: To assess the surgical outcome of transanal endoscopic surgery (TES) for rectal neoplasms in technically challenging indications., Method: All patients who underwent TES for a rectal neoplasm from 2007 to 2014 were included. Technically challenging indications included a tumour with (i) diameter ≥ 5 cm, (ii) involving ≥ 50% of the rectal circumference and (iii) located ≥ 10 cm from the anal verge. Patients were divided into three groups according to how many of these features they had, as follows: Group 1, none; Group 2, one; Group 3, two or more., Results: Of the 168 patients (80 benign and 88 malignant tumours) included in the study, 73 (44%) were in Group 1, 46 (27%) in Group 2 and 49 (29%) in Group 3. There was no difference between Group 1 and Group 2 with regard to peritoneal perforation (P = 0.210), severe postoperative morbidity (P = 0.804), length of hospital stay (P = 0.444), incomplete resection (P = 0.441), piecemeal resection (P = 0.740), locoregional recurrence (P = 0.307) and long-term symptomatic rectal stenosis (P = 0.076). Conversely Group 3 showed significantly impaired results compared with Group 1 with regard to peritoneal perforation (P = 0.003), piecemeal resection (P = 0.005), incomplete resection (P = 0.025), locoregional recurrence (P = 0.035) and long-term symptomatic rectal stenosis (P < 0.001), but no difference in severe postoperative morbidity (P = 0.328)., Conclusion: Transanal endoscopic surgery for rectal neoplasms appears to be safe and effective, even in patients presenting with a technically challenging tumours. Although the short- and long-term outcomes after TES are worse in patients with highly challenging tumours, nevertheless the technique should still be considered in patients at high risk of requiring a proctectomy., (Colorectal Disease © 2015 The Association of Coloproctology of Great Britain and Ireland.)

Aim: There are no studies on the respective influence of microscopic involvement at the circumferential (R1c) and the distal margin (R1d) of the surgical specimen on oncological results after laparoscopic mesorectal excision., Method: We studied 333 consecutive patients undergoing laparoscopic mesorectal excision for cancer. An R1 resection was defined a by a circumferential and/or distal margin of 1 mm or less., Results: Forty (12%) patients had an R1 resection including R1c [n = 28 (70%)], R1d [n = 7 (18%)] or both [n = 5 (12%)]. After a mean of 28 (0-97) months, comparisons of R1 with R0 resection were as follows: mortality 10% and 4% (NS), overall recurrence 48% and 19% (P < 0.001), 2-year disease-free survival rate 51% and 76% (P < 0.001) and overall survival (OS) rate 91% and 96% (NS). For R1c patients mortality was 14% (4% for R0; P = 0.026), overall recurrence 46% (19% for R0; P = 0.028) and 2-year OS 88% (96% for R0; P = 0.025). No significant differences were found between R1d and R0. The metastatic recurrence rate was greater in R1c then R0 (29% vs 12%; P = 0.036) but not for R1d (14% vs 12%; NS). Locoregional recurrence rates of R1c (7%) and R1d (0%) were similar to R0 (4%)., Conclusion: This study shows that the poorer prognosis observed after R1 resection for rectal cancer is due to circumferential rather than distal involvement. This is mainly related to a higher rate of metastatic recurrence., (Colorectal Disease © 2014 The Association of Coloproctology of Great Britain and Ireland.)

Aim: This prospective case-matched study was conducted to compare the outcome of laparoscopic colorectal surgery in patients with and without prior abdominal open surgery (PAOS)., Method: From June 1997 to December 2010, 167 patients with PAOS (including midline, Pfannenstiel, subcostal, right upper quadrant or transverse incision) were manually matched to all identical patients without PAOS from our prospective laparoscopic colorectal surgery database. Matching criteria included age, gender, American Society of Anesthesiology (ASA) score, body mass index, diagnosis and surgical procedure performed. Primary end-points were postoperative 30-day mortality and morbidity. Secondary end-points included operating time, conversion rate and length of stay., Results: A total of 367 patients (167 with PAOS and 200 without PAOS) were included in this study. PAOS was associated with a significantly increased mean operating time (229±66 min vs 216±71 min, P=0.044). The conversion rate was significantly higher in patients with PAOS, compared with patients without PAOS (22%vs 13%, P=0.017). There was one (0.3%) postoperative death. The overall postoperative morbidity rate was similar in both groups (22%vs 19%, P=0.658), including Grade 3 or Grade 4 morbidity, according to Dindo's classification (5%vs 5%, P=0.694). Mean hospital stay showed no difference between both groups (10±7 days vs 9±5 days, P=0.849)., Conclusion: This large case-control study suggests that PAOS does not affect postoperative outcomes. For this reason, a systematic laparoscopic approach in patients with PAOS, even with midline incision, should be considered in colorectal surgery., (© 2012 The Authors. Colorectal Disease © 2012 The Association of Coloproctology of Great Britain and Ireland.)

Aim: A poor functional outcome is often reported after total mesorectal excision (TME) for rectal cancer, especially when sphincter-saving resection with intersphincteric dissection is performed for low tumours. Anal sphincter rehabilitation is widely proposed for faecal incontinence. Very few studies have reported results to improve anal dysfunction following rectal surgery. This prospective study aimed to assess the benefits of sphincter training after TME in terms of functional outcome and quality of life., Methods: Anal sphincter training was performed in patients undergoing laparoscopic sphincter-saving TME for rectal cancer. Rehabilitation was performed after ileostomy closure. This group was compared with 24 matched patients. Assessment included one functional and two quality of life questionnaires (SF-36 Health Status and Faecal Incontinence Quality of Life score)., Results: From 2007 to 2009, 22 patients underwent laparoscopic TME. The median follow-up after stoma closure was 21.2 (range 8-46) months. The mean stool frequency per day was significantly lower after sphincter training (2.6 in the training group vs 4.0 in the control group, P=0.025). Following rehabilitation, patients complained significantly less about dyschezia (22 vs 63%, P=0.008). Both groups had similar continence (Wexner score 8.3 after training vs 9.9 in controls, NS). Quality of life was significantly improved by sphincter training as measured by the vitality (P=0.004) and mental functioning (P=0.02) subscales on the SF-36 Health Status questionnaire and by the depression and self-perception (P = 0.005) categories of the Faecal Incontinence Quality of Life score., Conclusion: This study suggests that anal sphincter training following TME could decrease stool frequency and improve both general and specific quality of life., (© 2012 The Authors. Colorectal Disease © 2012 The Association of Coloproctology of Great Britain and Ireland.)

Aim: Minimally invasive surgery is advancing with single port access (SPA). We describe a technique for a SPA transabdominal combined with transanal approach to perform laparoscopic proctectomy with total mesorectal excision (TME) and intersphincteric resection of low rectal adenocarcinoma., Method: Transanal intersphincteric resection was followed by laparoscopic abdominal proctectomy with TME. An SPA device was placed at the site of the future stoma through a 2.5-cm incision. A hand-sewn side-to-end coloanal anastomosis was performed and a terminal loop ileostomy was created at the site of the SPA device., Results: The procedure was performed on two healthy nonobese women who had not had previous abdominal surgery. The operating times were 195 and 210 min, and blood loss < 250 ml. The postoperative course was uneventful, with discharge on postoperative days 5 and 6. Pathological examination revealed adequate surgical margins and lymph node retrieval with an intact mesorectum. Four weeks after stoma closure, the scar in the right lower quadrant was 35 mm in one patient and 45 mm in the other, and the scar from the 5-mm port was barely visible., Conclusion: This preliminary experience shows that proctectomy with TME and intersphincteric resection can be safely performed using only two ports., (© 2011 The Authors. Colorectal Disease © 2011 The Association of Coloproctology of Great Britain and Ireland.)

Aim: SILS is an area of growing interest in colorectal surgery. We report our preliminary experience of 13 consecutively selected patients undergoing colonic surgery using SILS., Method: From July 2009 to January 2010, 13 patients (five men) of median age 56 (23-82) years and a body mass index (BMI) of 23.5 (18-30) kg/m(2) underwent colonic surgery. Procedures included subtotal colectomy (1), ileocolic resection (2), right colectomy (4) and sigmoidectomy for benign disease (6). Three instruments (including camera) were introduced through a single 2.5-cm port (SILS™ Port Multiple Instrument Access Port; Covidien Inc., Norwalk, Connecticut, USA) inserted at the umbilicus., Results: The median operating time was 150 (100-240) min, and the median size of the umbilical port incision was 32 (25-50) mm. There was no postoperative mortality and morbidity, and the median hospital stay was 6 (4-10) days. The cosmetic result was judged to be excellent in 12 of 13 patients who felt it to be better than expected., Conclusion: This preliminary experience shows that SILS is technically feasible and safe for colonic resection., (© 2011 The Authors. Colorectal Disease © 2011 The Association of Coloproctology of Great Britain and Ireland.)

Aim: Anastomotic leakage (AL) after sphincter-saving resection (SSR) for rectal cancer can result in a definitive stoma (DS). The aim of the study was to assess risk factors for DS after AL-complicating SSR., Method: Between 1997 and 2007, 200 patients underwent SSR for rectal cancer. AL occurred in 20.5% (41/200) [symptomatic 13.5% (n = 27), asymptomatic 7% (n = 14)]. Possible risk factors for DS after AL were analysed., Results: Management of AL consisted in no treatment (n = 14), medical treatment (n = 6), local drainage (n = 10) and abdominal reoperation (n = 11). After a median follow-up of 38 months, the overall rate of DS was 3% (n = 6): 0% for asymptomatic vs 22% after symptomatic AL (P = 0.061). After reoperation, the risk of DS was 13% when the anastomosis was preserved vs 100% after Hartmann's procedure (P = 0.007). Risk factors of DS after AL included obesity, age over 65, American Society of Anesthesiologists (ASA) score > 2 and abdominal reoperation for AL., Conclusion: The risk of DS after SSR for cancer is low (3%) but rises to 22% after symptomatic AL. This risk depends on the surgical treatment for AL and is up to 100% if a Hartmann's procedure is performed., (© 2011 The Authors. Colorectal Disease © 2011 The Association of Coloproctology of Great Britain and Ireland.)

Aim: The purpose of this study was to assess the safety and effectiveness of a new cost-effective circular stapler for colorectal anastomosis, the Chex(®) CS., Method: From 2007 to 2009, a case-control study was conducted of 54 patients who underwent left colectomy with stapled anastomosis using the Chex stapler. The patients were matched to 64 patients in whom the anastomoses were performed using the CDH(®) stapler or the EEA(®) stapler. The following criteria were matched: sex, age, body mass index, American Society of Anesthesiology grade, diagnosis, formation of a temporary stoma and surgical approach. Primary end-points were postoperative mortality and morbidity. The surgeon was asked to fill out a questionnaire to assess the ergonomics of the device using an analogue visual scale. A cost analysis was performed to compare the cost of the different devices., Results: There were no postoperative deaths. Morbidity, including anastomotic leakage (9%vs 8%, P = 1.000), was similar in the two groups. The surgeon's overall appreciation was scored at 8.1/10 (3-9.5), including the best score for stapler removal (9.5). No major device failure was observed during the study. Mean surgical costs were significantly lower in the Chex group: € 903 ± 73 (885-1192) vs the control group € 971 ± 61 (956-1263) (P < 0.0001)., Conclusion: This study suggests that colorectal anastomosis using the Chex circular stapler is safe and does not increase overall morbidity. In particular, this device did not have a higher rate of anastomotic leakage in our patients than more expensive models currently used in our hospital., (© 2011 The Authors. Colorectal Disease © 2011 The Association of Coloproctology of Great Britain and Ireland.)

Aim: T4 colorectal cancer remains a contraindication for laparoscopy. It is argued that the risk of incomplete resection could be higher than in open surgery. Furthermore, difficulty in dissection could lead to a very high rate of conversion. There is little information on this. The study aimed at assessing feasibility and operative and oncologic results of laparoscopic resection for T4 colorectal cancer., Method: Between 2006 and 2009, 39 patients with colorectal cancer with suspected involvement of another organ (T4) on computed tomography scanning and/or magnetic resonance imaging were included. The cancers were in the right colon (n = 18), left colon (n =9) and rectum (n = 12). The distribution of possible organ involvement was abdominal or pelvic side-wall (n = 21), urinary bladder (n = 4), small bowel or colon (n = 6), vagina and ovary (n = 3), prostate or seminal vesicles (n = 3) and duodenum (n = 2)., Results: The overall conversion rate was 18%. Postoperative mortality and morbidity were 2.5 and 33%, respectively. Clinical anastomotic leakage rate was 15% (n = 6). Abdominal reoperation was required in three (7%) patients. Pathological invasion to other organs (pT4) was confirmed in 30 (77%) patients. The R1 resection rate was 13% (4 of 30). After a median follow up of 19 months (range 1.5-45 months), the overall survival and disease-free survival rates were 97 and 89%, respectively., Conclusion: This study suggests that laparoscopic surgery is feasible for colorectal T4 cancer resection. Laparoscopy cannot therefore be considered an absolute contraindication for T4 colorectal cancer., (© 2010 The Authors. Colorectal Disease © 2010 The Association of Coloproctology of Great Britain and Ireland.)