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Background: Recent non-randomized studies suggest that extended endoscopic mucosal resection (EMR) is equally effective in removing large rectal adenomas as transanal endoscopic microsurgery (TEM). If equally effective, EMR might be a more cost-effective approach as this strategy does not require expensive equipment, general anesthesia and hospital admission. Furthermore, EMR appears to be associated with fewer complications.The aim of this study is to compare the cost-effectiveness and cost-utility of TEM and EMR for the resection of large rectal adenomas.Methods/design: Multicenter randomized trial among 15 hospitals in the Netherlands. Patients with a rectal adenoma > or = 3 cm, located between 1-15 cm ab ano, will be randomized to a TEM- or EMR-treatment strategy. For TEM, patients will be treated under general anesthesia, adenomas will be dissected en-bloc by a full-thickness excision, and patients will be admitted to the hospital. For EMR, no or conscious sedation is used, lesions will be resected through the submucosal plane in a piecemeal fashion, and patients will be discharged from the hospital. Residual adenoma that is visible during the first surveillance endoscopy at 3 months will be removed endoscopically in both treatment strategies and is considered as part of the primary treatment. Primary outcome measure is the proportion of patients with recurrence after 3 months. Secondary outcome measures are: 2) number of days not spent in hospital from initial treatment until 2 years afterwards; 3) major and minor morbidity; 4) disease specific and general quality of life; 5) anorectal function; 6) health care utilization and costs. A cost-effectiveness and cost-utility analysis of EMR against TEM for large rectal adenomas will be performed from a societal perspective with respectively the costs per recurrence free patient and the cost per quality adjusted life year as outcome measures. Based on comparable recurrence rates for TEM and EMR of 3.3% and considering an upper-limit of 10% for EMR to be non-inferior (beta-error 0.2 and one-sided alpha-error 0.05), 89 patients are needed per group.Discussion: The TREND study is the first randomized trial evaluating whether TEM or EMR is more cost-effective for the treatment of large rectal adenomas.Trial Registration Number: (trialregister.nl) NTR1422. [ABSTRACT FROM AUTHOR]

Aim: Transanal endoscopic microsurgery (TEM) is used for the resection of large rectal adenomas and well or moderately differentiated T1 carcinomas. Due to difficulty in preoperative staging, final pathology may reveal a carcinoma not suitable for TEM. Although completion total mesorectal excision is considered standard of care in T2 or more invasive carcinomas, this completion surgery is not always performed. The purpose of this article is to evaluate the outcome of patients after TEM-only, when completion surgery would be indicated., Methods: In this retrospective multicenter, observational cohort study, outcome after TEM-only (n = 41) and completion surgery (n = 40) following TEM for a pT2-3 rectal adenocarcinoma was compared., Results: Median follow-up was 29 months for the TEM-only group and 31 months for the completion surgery group. Local recurrence rate was 35 and 11% for the TEM-only and completion surgery groups respectively. Distant metastasis occurred in 16% of the patients in both groups. The 3-year overall survival was 63% in the TEM-only group and 91% in the completion surgery group respectively. Three-year disease-specific survival was 91 versus 93% respectively., Conclusions: Although local recurrence after TEM-only for pT2-3 rectal cancer is worse compared to the recurrence that occurs after completion surgery, disease-specific survival is comparable between both groups. The lower unadjusted overall survival in the TEM-only group indicates that TEM-only may be a valid alternative in older and frail patients, especially when high morbidity of completion surgery is taken into consideration. Nevertheless, completion surgery should always be advised when curation is intended., (© 2018 The Author(s) Published by S. Karger AG, Basel.)

Transanal endoscopic microsurgery (TEM) is a minimally invasive treatment modality for a variety of rectal lesions. Due to its minimally invasive nature, TEM has emerged as a safe method. Among most threatening complications are hemorrhage and peritoneal perforation. We report on two patients who demonstrated intra-abdominal free air on an erect chest X-ray after TEM procedure without other findings of a pneumoperitoneum. We hypothesize that due to the combination of elevated pressures in the retroperitoneal cavity and decreased integrity of the retroperitoneal barrier, insufflated CO(2) gas can diffuse into the intraperitoneal cavity. Conservative treatment should be considered in patients with free intra-abdominal air postoperatively. However, there should be no suspicion of peritoneal entry during the procedure and the patient should be in generally good condition without severe abdominal symptoms.

Background: The CARTS study is a multicenter feasibility study, investigating the role of rectum saving surgery for distal rectal cancer., Methods/design: Patients with a clinical T1-3 N0 M0 rectal adenocarcinoma below 10 cm from the anal verge will receive neoadjuvant chemoradiation therapy (25 fractions of 2 Gy with concurrent capecitabine). Transanal Endoscopic Microsurgery (TEM) will be performed 8 - 10 weeks after the end of the preoperative treatment depending on the clinical response.Primary objective is to determine the number of patients with a (near) complete pathological response after chemoradiation therapy and TEM. Secondary objectives are the local recurrence rate and quality of life after this combined therapeutic modality. A three-step analysis will be performed after 20, 33 and 55 patients to ensure the feasibility of this treatment protocol., Discussion: The CARTS-study is one of the first prospective multicentre trials to investigate the role of a rectum saving treatment modality using chemoradiation therapy and local excision. The CARTS study is registered at clinicaltrials.gov (NCT01273051).

Objective: Analysis of palliative cryosurgery in rectal cancer patients., Design: Descriptive., Setting: Department of surgery, University Hospital Vrije Universiteit, Amsterdam, the Netherlands., Methods: Ninety-three patients (age: 45-92 years) underwent palliative cryosurgery for primary rectal cancer. They were excluded from surgical resection because of old age, accompanying disease(s), inoperability and the presence of hematogenous metastases. The palliative effect of cryosurgery on local symptoms was classified as good, moderate or none. The duration of palliation was calculated in relation to survival as a palliative index: the number of months of (moderate or good) palliation divided by the number of months of survival from the start of the treatment, multiplied by 100%., Results: In 58 patients (62%) there was complete relief of local symptoms with a palliative index of 87%. In 13 patients (14%) palliation was moderate and in 22 patients (24%) no palliation was achieved. The 50% survival duration in the 58 patients was 37 months. Especially symptoms of blood and/or mucous discharge could be easily alleviated. Good alleviation of local symptoms was associated with the extent of the primary tumour process. Palliative effect could be assessed after a few treatments. Patients with circular rectal tumours seldom had long term palliative effects of cryosurgery., Conclusion: Cryosurgery for rectal cancer is a simple and safe treatment. It should be considered for alleviation of local symptoms in patients with rectal cancer who are unsuitable for radical surgery.

Locally recurrent rectal cancer is, in most cases, unresectable and incurable. Palliative treatment is warranted in many cases because of the presence of severe distressing symptoms. In recurrent disease, intraluminal cryotherapy is an option for palliation. Twenty patients with local recurrence after anterior resection were treated palliatively with cryosurgery for their local symptoms. Six patients had previously had a colostomy before they were referred for palliative treatment. Thirteen patients had more than one symptom. Distant metastases were present in ten cases. The beneficial effect of cryosurgery was evident after two to three sessions. In nine patients cryotherapy achieved complete relief of local symptoms. In these patients the symptom free interval varied from 1 to 24 months (median 11 months); five patients died of disease without local symptoms. Three of these nine patients underwent a bowel diversion at a later stage because of complete stenosis. The number of treatment sessions in this group of patients varied from three to 14. The palliative index varied from 37 to 100% (mean 78%). In nine patients cryotherapy of the local recurrence gave no relief at all. Our results show that in almost half of the patients cryosurgery can palliate local complaints resulting from recurrent tumor growth after anterior resection.

The use of intraluminal ultrasound (IUS) as a staging technique was evaluated in 58 patients with a rectal tumour. Thirty-four patients had a rectal carcinoma, four had a local recurrence after a previous anterior resection and 20 other patients had a villous adenoma. IUS assessment of rectal wall invasion, infiltration into adjacent organs, and the presence of perirectal lymph node involvement was compared with the definitive histological findings. In 90% of all patients the pre-operative local tumour staging was predicted correctly. In 38 patients with a rectal carcinoma the overall accuracy for the T grade was 84%. The sensitivity for the detection of perirectal fat infiltration was 91%, with a specificity of 70% and a negative predictive value of 78%. The accuracy in predicting direct infiltration into adjacent organs was 100% (n = 5). In the four patients with a local recurrence, the diagnosis was suspected by means of IUS and confirmed by biopsies. Extraluminal tumour growth was predicted correctly in all cases, with extension into the coccygeal bone in one patient. IUS identified lymph nodes in 29 of 38 cases, with a sensitivity of 57% and a specificity of 76%. All 20 villous adenomas were correctly staged as non-infiltrative tumours. After transmural excision, three adenomas proved to contain a completely removed T1 carcinoma. IUS is the most accurate tool in predicting the depth of local tumour invasion and needs a place in the preoperative screening programme in patients with a rectal tumour, as well as in the postoperative follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

In 11 patients with rectal cancer, a mixture of F(ab')2 fragments of anti-carcinoembryonic antigen and anti-CA 19.9 labelled with a diagnostic dose of iodine-131 (3-10 MBq) was administered submucosally around the tumour. In this study, the local kinetics in and the dose to the rectal wall, the whole body kinetics and the effective dose equivalent are presented. The early disappearance of the activity from the injection spot was characterized by a T1/2 of 21 h. Initially, about 50% of the plasma activity was due to free 131I. After 4 h, the plasma activity was almost completely protein bound (86%). Maximum plasma activity was observed after the 2nd day. From 72 h p.i., the plasma activity decreased with a T1/2 of 53 h. In the first 24 h, 14% of the injected dose was excreted in the urine and within 4 days about half of the administered activity. The absorbed radiation dose to the rectal wall was estimated to be 0.2 Gy/MBq, presuming a 20 cm3 distribution volume. The dose to the bone marrow was 0.2 mGy/MBq or 0.4 mGy/MBq, assuming a homogeneous tracer distribution or equal blood and bone marrow activity concentrations, respectively. The effective dose equivalent is 1.9 mSv/MBq, mainly determined by the dose to the rectal wall and to a lesser extent by the dose to the remaining body. Postulating comparable kinetics, 123I- or 111In- or 99mTc-labelled fragments would result in 4-25-fold lower effective dose equivalents.(ABSTRACT TRUNCATED AT 250 WORDS)

Retrosternal dislocation of the clavicle is an uncommon injury which may affect the mediastinal structures in a life-threatening way. Therefore, computed tomography is mandatory. Manipulation in the acute situation is the treatment of choice. In case of failure or old dislocation, open reduction with stabilization of the joint is required. The literature on this subject has been reviewed and an additional two cases are reported.

Clinical anal examination, manometry (resting and squeeze pressures), and single-fiber electromyography were compared with endosonography of the anal sphincters in 14 patients with fecal incontinence. Technical aspects of the procedure and normal imaging of the puborectal muscle and both sphincters were defined. Defects in both sphincters were seen in nine patients. The defect is visualized as a clear discontinuity in the muscular ring. Compared with the conventional studies, anal endosonography gave significant information in six patients (four male patients after perianal surgery and two women), showing sphincter defects in five patients and integrity of the sphincters in another one. This information obtained by endosonography was important in understanding the type and extension of the lesion and deciding upon the surgical repair. Anal endosonography is an imaging technique of the sphincters that can assess their integrity in fecal incontinence.

Immunoscintigraphy after submucosal administration of a mixture of 131I-anti-CEA and 131I-anti-CA-19-9 around the tumor in patients with rectal carcinoma may improve pre-operative staging and may contribute to the selection of patients eligible for local treatment. However, visual discrimination of local lymph node metastasis appears unreliable, partly because of scatter from the injection site and substantial diffusion of the radiotracer into the interstitium. Analysis of the diffusion profile, however, may improve the sensitivity and accuracy of this immunoscintigraphic approach.

A patient is reported with intermittent ileal obstruction due to tumorous heterotopic gastric mucosa not associated with an anatomic anomaly.