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Background Transanal total mesorectal excision (TaTME) is a minimally invasive surgical technique that tries to avoid conversion to open surgery. However, specific intraoperative complications and local recurrences have cast some doubt on the suitability of the technique. The primary endpoint of the present study was a composite outcome of conversion surgery. Secondary objectives were to assess postoperative recovery, and pathological and oncological outcomes. Methods This was a prospective, multicentre, randomized, controlled open-label study of patients diagnosed with mid and low rectal adenocarcinoma who underwent laparoscopic TaTME or laparoscopic total mesorectal excision (LaTME). The TaTME technique comprised intracorporeal resection and anastomosis. Main outcomes were conversion to open surgery. Secondary outcomes were postoperative morbidity, mortality, pathological, oncological results, and survival. Modified intention-to-treat (mITT) and per-protocol analyses were performed. Results The study was conducted between April 2015 and May 2021. Patients were randomized to the LaTME (57 patients) or TaTME (59) group. Fifty patients from the LaTME group and 55 from the TaTME group were eligible for mITT analysis. The procedure was converted to open surgery in 11 patients (11 per cent): 10 (20 per cent) in the LaTME group and 1 (2 per cent) in the laparoscopic TaTME group (difference 18.8, 95 per cent c.i. 30 to 7; P = 0.003). No significant differences were found in terms of postoperative recovery and morbidity at 30 days; nor were there significant differences in anastomotic leakage, although it was less common in laparoscopic TaTME. With a median follow-up of 39 months, there were three instances of local recurrence (6.1 per cent) in the LaTME group and one (1.8 per cent) in the laparoscopic TaTME group (95 per cent c.i. 60 to 69; P = 0.3). Registration number: NCT02550769 (http://www.clinicaltrials.gov). Conclusion The conversion rate was significantly lower in laparoscopic TaTME than in LaTME. At centres with experienced surgeons, laparoscopic TaTME can avoid conversion to open surgery.

INTRODUCTION The doctorate is the third cycle of official university studies, which, through the defense of the doctoral thesis leads to the acquisition of the title of doctor or PhD from the Anglo-Saxon countries. Royal Decree law 99/2011 regulates doctoral programs, with a wide margin on quality requirements. The objective of this study is to find out if there is this variation in the requirements of the doctorate programs of the different departments of surgery of the Spanish public universities and to establish a quality scale. METHODS Cross-sectional observational study from 2/22/2021 to 3/3/2021, through a survey sent electronically to the professors of the departments of surgery. RESULTS Thirty-five departments of surgery were consulted, obtaining a response in 29 of them (82.9%). The observed variation regarding requirements has been basically in the quality of the research project, in fact in 25 (86.2%) there are no regulations on this. When it is presented in the form of a compendium of articles, these are required to be original in 15 (51.7%). Regarding the position as author, the doctoral student must be the preferred author, at least in 2 articles in 14 (48.4%) of the programs. In 14 departments (48.4%) there are no regulations on the position of the articles and quartiles of journals. When scoring the different programs according to their requirements, the variability is high, ranging between 2 and 19 points. Funding for the development of the doctorate is meager. CONCLUSIONS There is a wide variability in the requirement of doctoral programs. Homogeneous levels of demand must be defined to promote and protect higher-level doctorates.

The doctorate is the third cycle of official university studies, which, through the defense of the doctoral thesis leads to the acquisition of the title of doctor or PhD from the Anglo-Saxon countries. Royal Decree law 99/2011 regulates doctoral programs, with a wide margin on quality requirements. The objective of this study is to find out if there is this variation in the requirements of the doctorate programs of the different departments of surgery of the Spanish public universities and to establish a quality scale.Cross-sectional observational study from 2/22/2021 to 3/3/2021, through a survey sent electronically to the professors of the departments of surgery.Thirty-five departments of surgery were consulted, obtaining a response in 29 of them (82.9%). The observed variation regarding requirements has been basically in the quality of the research project, in fact in 25 (86.2%) there are no regulations on this. When it is presented in the form of a compendium of articles, these are required to be original in 15 (51.7%). Regarding the position as author, the doctoral student must be the preferred author, at least in 2 articles in 14 (48.4%) of the programs. In 14 departments (48.4%) there are no regulations on the position of the articles and quartiles of journals. When scoring the different programs according to their requirements, the variability is high, ranging between 2 and 19 points. Funding for the development of the doctorate is meager.There is a wide variability in the requirement of doctoral programs. Homogeneous levels of demand must be defined to promote and protect higher-level doctorates.

Resumen Introduccion La cirugia endoscopica y laparoscopica combinada (CELS) ha surgido como un metodo para el tratamiento de lesiones colonicas benignas complejas que, de otro modo, requeririan una reseccion quirurgica. El objetivo de este estudio es describir las distintas tecnicas CELS y evaluar su seguridad, en un procedimiento escasamente difundido en nuestro entorno. Metodo Estudio observacional, retrospectivo, donde se evaluaron los resultados a corto plazo de pacientes diagnosticados de polipos no resecables endoscopicamente sometidos a CELS entre octubre del 2018 a junio del 2020. Se valoraron los resultados postoperatorios, la estancia hospitalaria y los hallazgos patologicos. Resultados Diecisiete pacientes consecutivos fueron sometidos a CELS durante el periodo de estudio. El tamano medio de la lesion fue de 3,5 cm (rango 2,5 a 6,5 cm), la localizacion mas recurrente fue el ciego (10 de 17). La tecnica CELS mas frecuente aplicada fue la reseccion en cuna laparoscopica asistida por endoscopia (11 de 17). En cuatro pacientes, esta reseccion se combino con otra tecnica CELS. Dos casos se sometieron a una reseccion del segmento laparoscopico asistido por endoscopia. El exito de CELS en nuestra serie fue en 14 de 17 (82,4%). La mediana del tiempo quirurgico y estancia hospitalaria fue de 85 min (rango 50 a 225 min) y de dos dias (rango uno a 15 dias), respectivamente. Solo un paciente presento infeccion del organo-cavitaria que no requirio cirugia adicional. Conclusiones CELS es una tecnica segura multidisciplinar, que requiere la colaboracion entre gastroenterologos y cirujanos. Se puede considerar como una alternativa a la reseccion de colon para polipos benignos complejos.

Resumen Introduccion La Ley de Ordenacion de las Profesiones Sanitarias (LOPS) indica que los profesionales sanitarios realizaran a lo largo de su vida profesional una formacion continuada y acreditaran regularmente su competencia profesional. El objetivo del estudio ha sido realizar una encuesta nacional para conocer la opinion de los cirujanos espanoles y asi poder preparar un proyecto de recertificacion por la Asociacion Espanola de Cirujanos (AEC). Metodos Estudio observacional transversal efectuado en junio-julio de 2020 mediante una encuesta remitida a los miembros de la AEC. Resultados La encuesta tuvo un total de 1.230 visitas y una tasa global de finalizacion de 784 respuestas (67,3%). El 69,6% desconocian las previsiones de la LOPS, el 83,4% no conocian iniciativas similares en otras especialidades y el 95,5% coincidian en demandar una informacion adecuada. El 71,4% la creian necesaria, pero solo el 57% opinaban que deberia ser obligatoria. El 82,9% estarian de acuerdo que deberia ser regulada mediante un procedimiento oficial objetivo y previsible. Conclusiones El concepto de reacreditacion no es bien conocido en nuestra especialidad, y en vista de los resultados obtenidos parece necesaria una informacion adecuada y fiable. Por ello seria pertinente proponer por la AEC un proyecto especifico de evaluacion de actividades y competencias.

Transanal endoscopic microsurgery (TEM) allows the local excision of rectal tumors and achieves lower morbidity and mortality rates than total mesorectal excision. TEM can treat lesions up to 18 to 20 cm from the anal verge, obtaining good oncological results in T1 stage cancers and preserving sphincter function. TEM is technically demanding. Large lesions (>5 cm), those with high risk of perforation into the peritoneal cavity, those in the upper rectum or the rectosigmoid junction, and those in the anal canal are specially challenging. Primary suture after peritoneal perforation during TEM is safe and it does not necessarily require the creation of a protective stoma. We recommend closing the wall defect in all cases to avoid the risk of inadvertent perforation. It is important to identify these complex lesions promptly to transfer them to reference centers. This article summarizes complex procedures in TEM.

Resumen En la practica clinica asistencial la existencia de determinadas «unidades quirurgicas especializadas», que se distinguen por su estructura, dotacion de recursos humanos, organizacion, docencia e investigacion ya son una realidad en la mayoria de los hospitales en Espana. Igualmente, estan ya en marcha programas de formacion especializada tipo fellowship, financiados de forma no estatal, en algunas de las areas reconocidas de unidades quirurgicas especializadas dentro de la cirugia general y aparato digestivo, algunas de ellas avaladas por la AEC. No obstante, hasta el momento no existia un modelo para dotarlo de reconocimiento y acreditacion. La AEC ha disenado una normativa para la acreditacion de unidades quirurgicas especializadas en cirugia general y aparato digestivo, que servira de base tambien para definir la formacion en estas areas. El proceso de acreditacion, y con ello de mejora de la calidad, engloba aspectos de calidad estructural, calidad de proceso y calidad de resultados.

Resumen El objetivo de este articulo es ilustrar como poner en marcha y desarrollar un estudio multicentrico prospectivo, controlado y aleatorizado. Por ello, lo primero que se necesita es crear una idea que genere una hipotesis y un objetivo principal. La busqueda bibliografica nos permite ver su relevancia clinica y las evidencias publicadas. Ademas, hay que plantearse si el estudio es viable economicamente y si puede ser completado en un periodo menor a 4 anos. Una vez ideado el estudio multicentrico, para ejecutarlo se debe redactar un protocolo (segun la guia Standard Protocol items: Recommendations for Interventional Trials [SPIRIT 2013]). En el se recogeran el tipo de diseno, el tamano muestral y los centros que participaran. La aleatorizacion es clave en el diseno. Si puede ser aleatorizado, se recomienda utilizar la guia Consolidated Standards of Reporting Trials (CONSORT), si no, la Transparent Reporting of Evaluations with Non-Randomized Designs (TREND). Cuando el protocolo es aprobado por el Comite Etico de Investigacion Clinica del hospital, hay que darle visibilidad. Es por eso que se recomienda su registro en ClincalTrials.gov y su publicacion en revistas indexadas. Para el inicio del estudio, se requiere buscar fuentes de financiacion. Estas permiten tener una base de datos on line, que permiten aleatorizar al momento y mantener el registro al dia desde cualquier centro. Por ultimo, hay que destacar que es imprescindible la motivacion. La multicentricidad solo se entiende si todos los centros participan. Asi que informar de resultados y dar animos cada 1-3 meses (en forma de newsletter) es una manera de conseguir un buen funcionamiento del estudio.

Our main goal is to describe how to start and develop a multicenter, prospective, randomized, controlled trial. The first step is to have an idea that will become the hypothesis and a main objective. A bibliographic search should be done to check for clinical interest and originality. Moreover, the study must be feasible and should be finished within 4 years. In order to start the multicenter study, a protocol should be written (in accordance with the SPIRIT guidelines Standard Protocol items: Recommendations for Interventional Trials), including the design type, sample size and participating hospitals. Randomization is key to the design and, therefore, the CONSORT (Consolidated Standards of Reporting Trials) guidelines must be followed. However, if the study cannot be randomized, the TREND (Transparent Reporting of Evaluations with Non-Randomized Designs) guidelines are recommended. When the protocol is approved by the Ethics Committee for Clinical Investigation of the hospital, we ought to create visibility. It is suggested to register the trial on ClincalTrials.gov and submit its publication to indexed magazines. Financial resources are necessary to execute the study and maintain an online database. This allows the registry to be updated and accessible to all the participants in the study. What is more, randomization can be done immediately. And last, but not least, is motivation. Multicentricity equals to participation of all the chosen medical centers. Updating and motivating them by sending a newsletter every 1-3 months keeps participants engaged in the study.

Objective Mild AD can be treated safely and effectively on an outpatient basis without antibiotics. Summary of background data In recent years, it has shown no benefit of antibiotics in the treatment of uncomplicated AD in hospitalized patients. Also, outpatient treatment of uncomplicated AD has been shown to be safe and effective. Methods A Prospective, multicentre, open-label, noninferiority, randomized controlled trial, in 15 hospitals of patients consulting the emergency department with symptoms compatible with AD.The Participants were patients with mild AD diagnosed by Computed Tomography meeting the inclusion criteria were randomly assigned to control arm (ATB-Group): classical treatment (875/125 mg/8 h amoxicillin/clavulanic acid apart from anti-inflammatory and symptomatic treatment) or experimental arm (Non-ATB-Group): experimental treatment (antiinflammatory and symptomatic treatment). Clinical controls were performed at 2, 7, 30, and 90 days.The primary endpoint was hospital admission. Secondary endpoints included number of emergency department revisits, pain control and emergency surgery in the different arms. Results Four hundred and eighty patients meeting the inclusion criteria were randomly assigned to Non-ATB-Group (n = 242) or ATB-Group (n = 238). Hospitalization rates were: ATB-Group 14/238 (5.8%) and Non-ATB-Group 8/242 (3.3%) [mean difference 2.58%, 95% confidence interval (CI) 6.32 to -1.17], confirming noninferiority margin. Revisits: ATB-Group 16/238 (6.7%) and Non-ATB-Group 17/242 (7%) (mean difference -0.3, 95% CI 4.22 to -4.83). Poor pain control at 2 days follow up: ATB-Group 13/230 (5.7%), Non-ATB-Group 5/221 (2.3%) (mean difference 3.39, 95% CI 6.96 to -0.18). Conclusions Nonantibiotic outpatient treatment of mild AD is safe and effective and is not inferior to current standard treatment. Trial registration ClinicalTrials.gov (NCT02785549); EU Clinical Trials Register (2016-001596-75).

Surgical treatment of early rectal cancer T1 is either local excision or total mesorectal excision. The choice of surgery is based on the risk of metastatic lymph node involvement. The most important factor to consider is the degree of submucosal invasion. We present a different way to measure tumoral invasion derived from the measurement of the healthy residual submucosa with its prognosis and therapeutic implications METHODS: Observational study of tumor submucosal invasion in patients undergoing transanal endoscopic microsurgery was conducted. Parameters evaluated are submucosal invasion, measuring the healthy residual submucosa at the point of maximum invasion; macroscopic morphology of the tumor; presence of muscularis mucosa, muscularis propria, and measurement of submucosa in the tumor area and the healthy area. The classification proposed is compared with the ones previously published.Eighty consecutive patients diagnosed with T1 rectal cancer underwent transanal endoscopic microsurgery. Seventeen tumors (21.3%) were polypoid. En bloc resection was achieved in 77 (96.3%). The muscularis mucosa was present in 28 (35%), and the muscularis propria in 77 (96.3%) (p0.001). The healthy residual submucosa in the tumor area measured 2,343 ± 1,869 μm. Agreement was moderate with the Kikuchi classification (kappa 0.58) and very good with the Kudo classification (kappa 0.87).We describe a method for measuring submucosal invasion in T1 rectal cancer which does not depend on the morphology of the lesion or on the presence of the muscularis mucosa. It can be applied to all T1 classifications of the digestive tract in which the muscularis propria is present.

Aim The COVID‐19 pandemic has forced surgeons to adapt their standard procedures. The modifications introduced are designed to favour minimally invasive surgery. The positive results obtained with intracorporeal resection and anastomosis in the right colon and rectum prompt us to adapt these procedures to the left colon. We describe a ‘don't touch the bowel’ technique and outline the benefits to patients of the use of less surgically aggressive techniques and also to surgeons in terms of the lower emission of aerosols that might transmit the COVID‐19 infection. Methods This was an observational study of intracorporeal resection and anastomosis in left colectomy. We describe the technical details of intracorporeal resection, end‐to‐end stapled anastomosis and extraction of the specimen through mini‐laparotomy in the ideal location. Results We present preliminary results of 17 patients with left‐sided colonic pathologies, 15 neoplasia and two diverticular disease, who underwent four left hemicolectomies, six sigmoidectomies and seven high anterior resections. Median operating time was 186 min (range 120–280). No patient required conversion to extracorporeal laparoscopy or open surgery. Median hospital stay was 4.7 days (range 3–12 days). There was one case of anastomotic leak managed with conservative treatment. Conclusion Intracorporeal resection and end‐to‐end anastomosis with the possibility of extraction of the specimen by a mini‐laparotomy in the ideal location may present benefits and also adapts well to the conditions imposed by the COVID‐19 pandemic. Future comparative studies are needed to demonstrate these benefits with respect to extracorporeal anastomosis.

Background: Tissue ischemia is a key risk factor for anastomotic leakage (AL). Indocyanine green (ICG) is widely used in colorectal surgery to define the segments with the best vascularization. In an experimental model, we present a new system for quantifying ICG saturation, SERGREEN software.Methods: This was a controlled experimental study with eight pigs. In the initial control stage, ICG saturation was analyzed at the level of two anastomoses in the right and left colon. Control images of the two segments were taken after ICG administration. The images were processed with the SERGREEN program. Then, in the experimental ischemia stage, the inferior mesenteric artery was sectioned at the level of the anastomosis of the left colon. Fifteen minutes after the section, sequential images of the two anastomoses were taken every 30’ for the following 2 h.Results: At the control stage, the mean scores were 134.2 (95% CI: 116.3-152.2) for the right colon and 147 (95% CI: 134.7-159.3) for the left colon (p = 0.174). The right colon remained stable throughout the experiment. In the left colon, saturation fell by 47.9 points with respect to the preischemia value (p Conclusions: The SERGREEN program quantifies ICG saturation in normal and ischemic situations and detects differences between them. A reduction in ICG saturation of 32.6% or more was correlated with complete tissue ischemia.

Resumen Introduccion Se ha disenado un protocolo de prehabilitacion trimodal con el objetivo de valorar si contribuye a disminuir la morbilidad postoperatoria, valorar el efecto de la prehabilitacion en la estancia hospitalaria global y analizar la evolucion de la capacidad funcional antes y despues de cirugia. Metodos Estudio observacional unicentrico con pacientes con cancer colorrectal intervenidos quirurgicamente con intencion curativa despues de un protocolo de prehabilitacion trimodal. Se recoge morbilidad postoperatoria segun el Comprehensive Complication Index y estancia hospitalaria, y se compara con una matriz historica. Tambien se recoge capacidad funcional antes y despues de la aplicacion del protocolo de prehabilitacion. Resultados En comparacion con la poblacion historica se consigue disminuir el Comprehensive Complication Index global de forma estadisticamente significativa de 13,2 a 11,5. Desglosando por tipo de morbilidad, todas disminuyen en porcentaje sin conseguir significacion (infeccion espacio quirurgico del 11,7 al 8,4%; infeccion nosocomial del 15,8 al 10%, y morbilidad medica del 8,6 al 4,2%). La estancia hospitalaria global pasa de 6 a 4 dias y el porcentaje de pacientes que se preparan en casa disminuye de forma estadisticamente significativa en ambos casos. Conclusiones La prehabilitacion trimodal puede contribuir a disminuir la morbilidad postoperatoria y la estancia hospitalaria global de los pacientes intervenidos de neoplasia colorrectal.

Introduction A trimodal prehabilitation protocol was designed with the aim to evaluate whether it contributes to reducing postoperative morbidity, to evaluate the effect of prehabilitation on overall hospital stay, and to analyze the evolution of functional capacity before and after surgery. Methods A single-center observational study of patients with colorectal cancer who underwent surgery with curative intent after a trimodal prehabilitation protocol. We collected data for postoperative morbidity according to the Comprehensive Complication Index and hospital stay, which were compared with a historical matrix. Functional capacity data were also collected before and after the application of the prehabilitation protocol. Results Compared to the historical population, the overall Comprehensive Complication Index was reduced from 13.2 to 11.5, which was statistically significant. Analyzed by morbidity type, all decreased in percentage, although without achieving significance (surgical site infection from 11.7% to 8.4%, nosocomial infection 15.8 to 10% and medical morbidity 8.6% to 4.2%). The overall hospital stay went from 6 to 4 days, and the decrease in the percentage of patients who prepared at home was statistically significant in both cases. Conclusions Trimodal prehabilitation can contribute to lowering the postoperative morbidity and overall hospital stay of patients undergoing colorectal cancer surgery.

Introduction Physicians, especially surgeons, are significatively affected by burnout. Duty-hour violation, as well as discrimination, abuse and sexual harassment may contribute to burnout. A study about this topic has been published in residents from United States, demonstrating a high incidence of burnout. Our objective is to know which is the situation in Spain and to compare it with United States. Methods Cross-sectional observational study carried out in January-February 2020, based on the responses to a validated survey administered to General Surgery residents in Spain. Results There are 931 General Surgery Residents. 739 have entered in the survey and 452 (61.2%) eventually responded to it. In any occasion during the training period, 55.1% reported discrimination based on their gender, 8.8% reported racial discrimination, 73.9% reported verbal/psychological abuse, 7.1% reported physical abuse and 16.4% reported sexual harassment. Attending surgeons are the most frequent source of sexual harassment and physical and verbal abuse, whereas patients are the most frequent cause of gender discrimination. Burnout symptoms were reported by 47.6% of residents and 4.6% reported suicidal thoughts. 98% of residents reported duty-hour violations and 47% of them do not have the day off after to be on call. Both of these issues are burnout predictive factors. Conclusions Mistreatment (discrimination, abuse and harassment) occurs among General Surgery residents during their training period in our country. Every kind of mistreatment is more frequent in Spain than in the United States, with the exception of racial discrimination. It is associated with exceeding weekly duty-hour. It is necessary to know these problems and to avoid them in order to improve work environment of General Surgery training period.

Background The aim of this study is to assess the feasibility of transanal endoscopic surgery (TES) in obese patients. Methods Observational descriptive study evaluating the feasibility of TES in obese rectal tumors between June 2004 and January 2019. Patients were assigned to two groups: body mass index (BMI) Results From 775 patients, 681 were enrolled in the study, 145 (21.3%) of them obese. No statistically significant differences between groups were found with respect to overall morbidity (27, 18.6%).The obese patients presented trends towards shorter mean surgical time (65 min, IQR 48 min), less perforation in the peritoneal cavity (eight, 5.5%), and 133 (91.7%) presented a lower rate of lesion fragmentation. Conclusion There were no significant differences in postoperative outcomes in obese patients (BMI ≥30 kg/m2). TES in those obese patients does not represent a factor of surgical difficulty.

Resumen Introduccion La fragilidad se asocia con una mayor morbimortalidad postoperatoria. El manejo multidisciplinar individualizado de estos pacientes puede mejorar la calidad asistencial. Los objetivos de este trabajo son conocer el porcentaje de pacientes fragiles con cancer colorrectal en nuestra poblacion y describir la morbimortalidad asociada a la cirugia y la evolucion del tratamiento paliativo. Metodos Estudio observacional prospectivo de pacientes con cancer colorrectal quirurgico (1 de febrero del 2018-30 de abril del 2019). Cribado de paciente fragil y clasificacion segun grados de fragilidad. Decision terapeutica (cirugia o tratamiento paliativo) segun grado de fragilidad y voluntades explicitas del paciente. Analisis de comorbilidad postoperatoria (segun Clavien-Dindo y Comprehensive Complication Index), mortalidad y seguimiento oncologico. Resultados Fueron visitados 193 pacientes con cancer colorrectal quirurgico, con una edad media de 74 anos (44-92). Cribado: 46 pacientes fragiles (24%), con una edad media de 80 anos (57-92). Se optimizo e intervino a 22 pacientes (48%), con una edad media de 78 anos (57-89). Efectos adversos relevantes del 27,7% (4 efectos adversos grado iv a, uno iv b y otro v, segun Clavien-Dindo). Comprehensive Complication Index de 17,5. Tratamiento paliativo en 24 pacientes (52%), con una edad media de 82 anos (59-92). Seguimiento medio de 7,8 meses, 2 muertes por progresion de la enfermedad (8,3%), 5 reconsultas por complicaciones del cancer colorrectal (20,1%). Conclusiones El manejo multidisciplinar e individualizado del paciente fragil con cancer colorrectal es clave para mejorar la calidad asistencial en el tratamiento de este grupo de pacientes.

The aim was to describe the robot-assisted intracorporeal anastomosis technique in left colon surgery (rLCS) and report the initial results.The rLCS was performed in 25 consecutive patients, starting with a Pfannenstiel incision and introducing a prepared anvil. The robot was docked and the affected segment resected. Colotomy was performed and the anvil was introduced in the proximal segment. End-to-end anastomosis was performed and reinforced. An air-leak test was performed.The results varied in terms of patient's age, American Society of Anesthesiologists grade, weight and the technique performed. Most patients had cancer. There was no suture failure or mortality, and the mean hospital stay was 3 days.The rLCS is a safe, reproducible technique with good initial results. Prospective studies should be performed to demonstrate its advantages.

Transanal endoscopic microsurgery (TEM) has become the treatment of choice for benign rectal lesions and early rectal cancer (T1). The size classification of rectal polyps is controversial. Some articles define giant rectal lesions as those larger than 5 cm, which present a significantly increased risk of complications. The aim of this study was to evaluate the feasibility of TEM in these lesions.An observational descriptive study with prospective data collection evaluating the feasibility of TEM in large rectal adenomas was performed between June 2004 and September 2018. Patients were assigned to one of the three groups according to size: 5 cm, very large (5-7.9 cm) and ultra-large (≥ 8 cm). Descriptive and comparative analyses between groups were performed.TEM was indicated in 761 patients. Five hundred and seven patients (66.6%) with adenoma in the preoperative biopsy were included in the study. Three hundred and nine out of 507 (60.9%) tumors 5 cm, 162/507 (32%) very large tumors (5-7.9 cm) and 36/507 (7.1%) ultra-large tumors (≥ 8 cm) were reviewed. Morbidity increased with tumor size: 17.5% in tumors 5 cm, 26.5% in those 5-7.9 cm, and 36.1% in those 8 cm. Peritoneal perforation, fragmentation, free margins and stenosis were also more common in very large and ultra-large tumors (p 0.001). There were no statistical differences between the groups in the definitive pathology (p = 0.38).TEM in these large tumors is associated with higher rates of morbidity, peritoneal perforation, free margins and stenosis. Although these tumors do not require total mesorectal excision and are eligible for TEM, the surgery must be carried out by experienced surgeons.

Loop ileostomy reduces the rates of morbidity due to colorectal anastomotic dehiscence. For its part, ileostomy closure is associated with low mortality (0–4%) but substantial morbidity (11–37%). Incisional surgical site infection (SSI) is one of the most frequent complications (2–40%). A single-center, prospective, randomized controlled clinical trial of two study groups: control (conventional primary skin closure) and experimental (primary skin closure with a contralateral Penrose® drain). Seventy patients undergoing loop ileostomy closure between April 2013 and June 2017 were included (35 per branch). Four were later removed from the study. Six of the remaining 66 patients (per protocol analysis) were diagnosed with incisional SSI (9.1%); there were no statistically significant differences between the two groups (control group: 9.7%; experimental group: 8.6%) or between the risk factors associated with incisional SSI. Rates of overall and relevant morbidity (Clavien ≥ III) were considerable (28.1% and 9.1%, respectively), and there were no statistically significant differences between the two groups. No patients died. Contralateral drainage does not significantly affect the results of primary ileostomy closure. The rate of incisional SSI was similar in the drainage and non-drainage groups, and the overall rate of 9.1% was in the low range of those reported in the literature. The absence of mortality (0%) and the non-negligible rates of overall and relevant morbidity (28.1% and 9.1%, respectively) in our series suggest that loop ileostomy is a safe procedure. However, the bowel reconstruction involves risks that must be borne in mind. The study was registered and approved by the clinical research ethics committee of the study center (reference number 2012076). Clinical trial was registered in ClinicalTrial.gov (identification number NCT02574702 and reference: ILEOS-ISS_2013).

PURPOSE The intrarectal suture is considered a high technically complex procedure. The study's objectives were to assess the feasibility of making an intrarectal knot, through an in vitro study and assessing whether the video tutorial facilitates learning. MATERIALS AND METHODS A detailed description of the technique. A comparative observational cross-sectional study in surgeons with no previous experience in intrarectal knots. RESULTS Twenty-one of these 32 participants passed the intrarectal knot test without video tutorial (T1) (65.6%), and 26 (81.2%) after the video tutorial (T2) (P=0.26). The mean time taken to tie the knot fell from 74 seconds (SD=46) in T1 to 41 seconds (SD=41) in T2 (P

BACKGROUND Despite the publication of the guidelines for enhanced recovery after surgery (ERAS), attitudes to urinary catheter (UC) management vary widely in colorectal surgery. The aim of the present study was to define current practices in UC management in colorectal surgery. METHODS Cross-sectional observational study carried out in March-April 2019, based on the responses to a survey administered to public hospitals in Catalonia. Respondents were asked about their observance of ERAS programs, the percentage of laparoscopic procedures performed, and the time of UC withdrawal in surgery of the colon and rectum. RESULTS Forty-three of 45 hospitals contacted eventually responded (95.6%). As two hospitals reported that they did not perform colorectal surgery, the study is based on the results from 41 centers. Thirty-five (85.4%) reported following ERAS programs; 30 (73.2%) have coloproctology units, and 39 (95.1%) perform more than 70% of colorectal surgeries by laparoscopy. In colon surgery, 27 (65.9%) remove the UC at 24 h, and 12 (29.3%) on day 2 or day 3. In rectal surgery, 17 (58.6%) remove the UC on day 2-3. CONCLUSIONS Management of UC in colon and rectal surgery varies widely. There is clearly room for improvement in UC management, but needs to be thoroughly assessed in randomized multicenter studies.

3501 Background: The standard surgical treatment of rectal adenocarcinoma above T1 is total mesorectal excision (TME), but it is associated with high morbidity and quality of life disorders. Transanal endoscopic microsurgery (TEM) achieves minimal postoperative morbidity rates. The treatment of T2, T3 superficial, N0, M0 rectal cancers is TME due to local excision achieving high recurrence rates. Initial reports of preoperative chemoradiotherapy (CRT) in association with TEM shows reduction in local recurrence. The TAU-TEM study aims to demonstrate the non-inferiority of the oncological outcomes and the improvement in morbidity and quality of life achieved with CRT-TEM compared with TME. Methods: Prospective, multicenter, randomized controlled non-inferiority trial including patients with rectal adenocarcinoma less than 10 cm from the anal verge and up to 4 cm in size, staged as T2T3sN0M0. Patients were randomized to: CRT-TEM (Arm A) or TME (Arm B). Postoperative morbidity and mortality were recorded and patients in both arms completed quality of life questionnaires when starting treatment and 6 months after surgery. Patients attended follow-up controls for local and systemic relapse. Trial registration: ClinicalTrials.gov Identifier: NCT01308190. Results: From July/2010 to October/2021, 173 patients from 17 Spanish hospitals were included (Arm A: 86, Arm B: 87). Ten were excluded after randomization (Arm A: 4, [3 re-staged > T2T3sN0M0, 1 refused follow-up study]; Arm B: 6 [4 refused the arm, 2 re-staged > T2T3sN0M0]). Therefore, the patients with modified intention to treat analysis were: TME, 81 and CRT-TEM, 82. There was no mortality after CRT. In this group, 2 patients abandoned neoadjuvant therapy; thus 80/82 (97.6%) completed CRT. The CRT-morbidity was low (25/82, 30%) and of low grade (95% G1-2). In the CRT-TEM group, MRI showed disease progression in 3 patients who were treated with TME. Finally, 77 patients underwent TEM surgery. One patient died in each arm (1.2%). Postoperative morbidity was 41/81 (50.6%) (Arm B) and 17/82 (20.7%) (Arm A) (p < 0.001, 95 CI% 43.9 to 15.9). Median Comprehensive Complication Index was 8.7 (IQR 20.9) Arm B and 0 (IQR 0) Arm A (p < 0.001). Median hospital stay was 7 days (IQR 7) Arm B and 2 days (IQR 2) Arm A (p < 0.001). Complete response in Arm A was 45.3% (34/75 patients) with 5.3% ypT3 (4/75 patients) and in Arm B: pT1 (12.3%; 10/81patients), deep-pT3 (4.95; 4/81patients), pN1 (21%; 17/81). Conclusions: CRT-TEM treatment obtains high pathological complete response rates (45.3%), with a high CRT compliance rate (97.6%) and low morbidity. Postoperative complications and hospitalization are significantly lower in the CRT-TEM group. We await the results of the follow-up. Clinical trial information: NCT01308190.

Our main goal is to describe how to start and develop a multicenter, prospective, randomized, controlled trial. The first step is to have an idea that will become the hypothesis and a main objective. A bibliographic search should be done to check for clinical interest and originality. Moreover, the study must be feasible and should be finished within 4 years. In order to start the multicenter study, a protocol should be written (in accordance with the SPIRIT guidelines Standard Protocol items: Recommendations for Interventional Trials), including the design type, sample size and participating hospitals. Randomization is key to the design and, therefore, the CONSORT (Consolidated Standards of Reporting Trials) guidelines must be followed. However, if the study cannot be randomized, the TREND (Transparent Reporting of Evaluations with Non-Randomized Designs) guidelines are recommended. When the protocol is approved by the Ethics Committee for Clinical Investigation of the hospital, we ought to create visibility. It is suggested to register the trial on ClincalTrials.gov and submit its publication to indexed magazines. Financial resources are necessary to execute the study and maintain an online database. This allows the registry to be updated and accessible to all the participants in the study. What is more, randomization can be done immediately. And last, but not least, is motivation. Multicentricity equals to participation of all the chosen medical centers. Updating and motivating them by sending a newsletter every 1-3 months keeps participants engaged in the study.

Introduction Transanal endoscopic microsurgery (TEM) is a safe procedure and the rates of intra- and post-operative complications are low. The information in the literature on the management of these complications is limited, and so their importance may be either under- or overestimated (which may in turn lead to under- or overtreatment). The present article reviews the most relevant series of TEM procedures and their complications and describes various approaches to their management. Evidence acquisition A systematic review of the literature, including TEM series of more than 150 cases each. We analyzed the population characteristics, surgical variables and intraoperative and postoperative complications. Evidence gathering A total of 1043 records were found. After review, 1031 were excluded. The review therefore includes 12 independent cohorts of TEM procedures with a total of 4395 patients. The rate of perforation into the peritoneal cavity was 5.1%, and conversion to abdominal approach was required in 0.8% of cases. The most frequent complications were acute urinary retention (AUR, 4.9%) and rectal bleeding (2.2%). Less common complications included abscesses (0.99%) and rectovaginal fistula (0.62%). Mortality rates were low, with a mean value of 0.29%. Conclusions Awareness and knowledge of TEM complications and their management can play an important role in their treatment and patient safety. Here, we present a review of the most important TEM series and their complication rates and describe various approaches to their management.

Background Unfavorable adenocarcinoma after transanal endoscopic microsurgery requires "completion surgery" with total mesorectal excision. The literature on this procedure is very limited. Objective This study aims to assess the percentage of transanal endoscopic microsurgery that will require completion surgery. Design This is an observational study with prospective data collection and retrospective analysis from patients who were operated on consecutively. Settings The study was conducted at a single academic institution. Patients Patients undergoing transanal endoscopic microsurgery from June 2004 to December 2018 who later required total mesorectal excision were included. Main outcome measures All the patients followed the same protocol: preoperative study, indication of transanal endoscopic microsurgery with curative intent, performance of transanal endoscopic microsurgery, and completion surgery indication 3 to 4 weeks after transanal endoscopic microsurgery. Results Seven hundred seventy-four patients underwent transanal endoscopic microsurgery, 622 with curative intent (group I: adenoma, 517; group II: adenocarcinoma, 105). Completion surgery was indicated in 64 of 622 (10.3%) patients: group I, 40 of 517 (7.7%) and group II, 24 of 105 (22.9%). After applying exclusion criteria, completion surgery was performed in 55 patients (8.8%). Abdominoperineal resection was performed in 23 (45.1%); the initial lesion was within 6 cm of the anal verge in 19 of these 23 (82.6%). The clinical morbidity rate (Clavien Dindo> II) was 3 of 51 (5.9%). Total mesorectal excision was graded as complete in 42 of 49 (85.7%). The circumferential resection margin was tumor-free in 47 of 50 (94%). Median follow-up was 58 months. Local recurrence was recorded in 2 of 51 (3.9%) and systemic recurrence was recorded in 7 of 51 (13.7%); 5-year disease-free survival was 86%. Limitations The limitations are defined by the study's observational design and the retrospective analysis. Conclusion The indication of completion surgery after transanal endoscopic microsurgery is low, but is higher in the indication of adenocarcinoma. Compared with initial total mesorectal excision, completion surgery requires a higher rate of abdominoperineal resection, but has similar postoperative morbidity, total mesorectal excision quality, and oncological results. See Video Abstract at http://links.lww.com/DCR/B423. Ciruga complementaria en cncer de recto desfavorable despus de una tem se obtiene satisfactoriamente preservacin del esfnter, calidad de muestra de etm y resultados oncolgicos a largo plazo ANTECEDENTES:El adenocarcinoma con evolucion desfavorable luego de una de microcirugia endoscopica transanal (TEM) requiere "cirugia de finalizacion" con la excision total del mesorecto. La literatura sobre este procedimiento es muy limitada.OBJETIVO:Evaluar el porcentaje de microcirugia endoscopica transanal que requerio cirugia completa.DISENO:Estudio observacional con recoleccion prospectiva de datos y analisis retrospectivo de pacientes operados consecutivamente.AJUSTES:El estudio se realizo en una sola institucion academica.PACIENTES:Aquellos pacientes sometidos a microcirugia endoscopica transanal desde junio de 2004 hasta diciembre de 2018 que luego requirieron excison toztal del mesorecto.PRINCIPALES MEDIDAS DE RESULTADO:Todos los pacientes siguieron el mismo protocolo: estudio preoperatorio, indicacion de microcirugia endoscopica transanal con intencion curativa, realizacion de microcirugia endoscopica transanal e indicacion de cirugia complementaria 3-4 semanas despues de la microcirugia endoscopica transanal.RESULTADOS:Setecientos setenta y cuatro pacientes fueron sometidos a microcirugia endoscopica transanal, 622 con intencion curativa (grupo I, adenoma: 517, grupo II, adenocarcinoma: 105). la cirugia complementaria fue indicada en 64/622 (10.3%), grupo I: 40/517 (7.7%) y grupo II 24/105 (22.9%). Despues de aplicar los criterios de exclusion, la cirugia complementaria se realizo en 55 pacientes (8,8%). La reseccion abdominoperineal fue realizada en 23 (45,1%); en 19 de estos casos 23 (82,6%) la lesion inicial se encontraba dentro los 6 cm del margen anal. La tasa de morbilidad clinica (Clavien-Dindo > II) fue de 3/51 (5,9%). La excision total del mesorecto se califico como completa en 42/49 (85,7%). El margen de reseccion circunferencial se encontraba libre de tumor en 47/50 (94%). La mediana de seguimiento fue de 58 meses. La recurrencia local se registro en 2/51 (3.9%) y la recurrencia sistemica en 7/51 (13.7%); La supervivencia libre de enfermedad a 5 anos fue del 86%.LIMITACIONES:Todas definidas por el diseno observacional y el analisis retrospectivo del mismo.CONCLUSION:La indicacion de completar la cirugia despues de una TEM es baja, pero es mas alta cuando la indicacion es por adenocarcinoma. En comparacion con la excision total del mesorecto inicial, la cirugia complementaria requiere una tasa mas alta de reseccion abdominoperineal, pero tiene una morbilidad postoperatoria, una calidad de excision total del mesorecto y resultados oncologicos similares. ConsulteVideo Resumen en http://links.lww.com/DCR/B423. (Traduccion-Dr. Xavier Delgadillo).

The Law for the Regulation of Health Professions (LOPS) indicates that health professionals will carry out continuous training throughout their professional life, and will regularly prove their professional competence. The objective of the study was to carry out a national survey to find out the opinion of Spanish surgeons and thus be able to prepare a recertification project by the Spanish Association of Surgeons (AEC).Cross-sectional observational study carried out in June-July 2020, through a survey sent to the members of the AEC.The survey had a total of 1230 visits and an overall completion rate of 784 responses (67.3%). 69.6% were unaware of the LOPS forecasts and 83.4% were unaware of similar initiatives in other specialties and 95.5% agreed to demand adequate information. 71.4% believed it necessary but only 57% believed that it should be mandatory. 82.9% would agree that it should be regulated through an objective and predictable official procedure.The concept of re-accreditation is not well known in our specialty and in view of the results obtained, adequate and reliable information seems necessary. Therefore, it would be pertinent to propose by the AEC a specific project to assess activities and skills.

Combined endoscopic and laparoscopic surgery (CELS) has emerged as a promising method for managing complex benign lesions that would otherwise require major colonic resection. The aim of this study was to describe the different techniques and to evaluate the safety of CELS, assess its outcomes in a technique that is scarcely widespread in our environment.Observational retrospective study, short-term outcomes of patients undergoing CELS for benign colon polyps from October 2018 to June 2020 were evaluated. Postoperative outcomes, length of hospital stay and pathological findings were evaluated.Seventeen consecutive patients underwent CELS during the study period. The median size of the lesion was 3.5 cm (range 2.5 - 6.5 cm), the most frequent location was the cecum (10 from 17). Most patients treated with CELS underwent an endoscopic-assisted laparoscopic wedge resection (11 from 17). In four patients this resection was combined with another CELS technique, and two patients underwent an endoscopic-assisted laparoscopic segment resection. The success rate of CELS in our series was in 14 from 17 (82,4%). The median operative time was 85 min (range 50-225 min). The median hospital stay was 2 days (range 1-15 days). One patient experienced an organ/space surgical site infection which did not require further intervention. Four lesions were shown to be malignant by postoperative pathology study.CELS is a safe and multidisciplinar technique that requires collaboration between gastroenterologists and surgeons. It can be considered as an alternative to colonic resection for complex benign colonic polyps.

Purpose Laparoscopic ventral rectopexy is the most favored surgical treatment for rectal prolapse. Perineal approaches are recommended for frail patients and those with major comorbidities, and in young men to avoid genitourinary disorders. There are very few descriptions in the literature of transanal endoscopic surgery to treat complete rectal prolapse. The aim of this article is to describe our experience with this technique. Patients and methods Patients undergoing transanal endoscopic surgery for rectal prolapse repair between 2010 and 2019 were recruited for the study. Preoperative, surgical, and postoperative variables were recorded. Surgical technique, 30-day morbidity and follow-up are described. Results Five patients have been included. The postoperative period was uneventful and all patients were discharged in 48 hours without complications. All showed improved symptoms at 1-year control, and none presented recurrence in a mean follow-up period of 6 years. Conclusions The transanal endoscopic procedure allows improved endoscopic vision, and the reconstruction is performed transpelvically by fixing the anastomosis suture to the pelvic wall to prevent recurrence. Therefore, we think it is a valid alternative to other perineal procedures in patients in whom abdominal surgery is contraindicated.

The aim of this study is to assess postoperative morbidity and mortality in tumors with a proximal margin 15 cm or more from the anal verge operated with transanal endoscopic microsurgery (TEM).This observational study of consecutive rectal tumor patients undergoing TEM was carried out from July 2004 to June 2017. We compared the results of rectal tumors at distances of ≥15 cm (group A) and15 cm (group B) from the anal verge.During the study period 667 patients were included: 118 in group A and 549 in group B. In the comparative analysis there were no significant differences in morbidity (p = 0.23), mortality (p = 0.32) or free margin involvement (p = 0.545). Differences were observed in terms of lesion size (p 0.001), surgical time (p 0.001) and peritoneal cavity perforation, which were all increased in group A.TEM for lesions in the rectosigmoid junction is feasible and is not associated with higher morbidity or mortality.

Background The role of self-expandable metallic stents (SEMS) as a bridge to surgery in left-sided malignant colonic obstruction is still debated. Here we assess the morbidity, mortality and long-term oncological outcomes as a bridge to surgery for patients with left-sided malignant colonic obstruction. Method Prospective observational study with retrospective analysis of patients with left-sided malignant colonic obstruction undergoing stenting. April 2006–April 2018. We assessed all patients with intent-to treat and per protocol analyses and long-term follow-up variables. Results Colonic stent was performed in 117 patients. Technical and clinical success of SEMS placement: 94.4% (111/117), only 4.3% perforation. Elective surgery resection following the strategy of SEMS was performed in 83.8% (98/117). A laparoscopic approach was: 25.6% (30/117); 76.9% in the last two years. Primary anastomosis rate: 92.8% (91/98), without protective stoma in any patients. Anastomotic leakage rate: 8.2% (8/97). Median follow-up: 44.5 months (range 0–109). The intent-to-treat analysis showed overall and disease-free survival rates of 63.3% (74/117) and 58.1% (68/117), and local and distant recurrence rates: 9.4% (11/117) and 58.1% (68/117). In the per protocol analysis, overall and disease-free survival rates: 63.2% (62/98) and 60.2% (58/98), and local and distant recurrence rates: 10.2% (10/98) and 36.7% (36/98). Disease progression was predominantly observed during the first 5 years' follow-up as disease recurrence; after five years' follow-up, 60% of the patients were disease-free. Conclusions According to the results of the study SEMS as a bridge to surgery achieves perioperative results comparable to non-occlusive colonic cancer surgery and does not adversely affect long-term oncological outcomes. Further investigations are needed.

Currently, endoscopic resection of early colorectal cancer defined as carcinoma with limited invasion of the mucosa (Tis) and submucosa (T1) is possible. However, lymph node spreading increases to 16.2% of cases when tumor invades the submucosa. We analyzed the previously identified factors for lymph node dissemination and recurrence, in our population. We analyzed retrospectively all patients with T1 tumors, treated at our center with endoscopic resection and some with additional surgery between January 2006 and January 2018. Statistical analysis was performed using IBM SPSS Statistics 25.0. One hundred fifty-nine patients were treated with endoscopic resection, 56.6% with additional surgery. The mean age was 68.74 years and 69. 9% were male. All patients who underwent additional surgery presented negative margins and 8.8% presented positive lymph nodes. In a mean follow-up of 23.36 months, 13 patients had relapsed. The risk of relapse did not differ between patients treated with additional surgery from those who only underwent endoscopic resection (p = 0.506). On the other hand, lymph node dissemination (p = 0.007) and a positive endoscopic margin (p = 0.01) were independent risk factors for relapse. There was a positive association between lymph node dissemination and lymphatic (p = 0.07), vascular (p = 0.007), and perineural (p = 0.001) invasion and also with degree of histological differentiation (p = 0.001). In our study, lymphatic, vascular, and perineural invasion and also the degree of histological differentiation were associated with lymph node dissemination. However, the only independent risk factors for long-term recurrence were a positive margin and lymph node dissemination.

Perforation in the peritoneal cavity during transanal endoscopic microsurgery represents a major challenge. It is usually treated by primary suture, though some authors propose laparoscopic repair with or without ostomy. It is unclear whether perforation increases the risk of tumor dissemination. The purpose of the study is to assess the safety of primary suture of peritoneal perforation and the long-term risk of dissemination, also, to determine risk factors for perforation and to propose a predictive model for lesions with risk of perforation. This is an observational study with prospective data collection at Parc Tauli University Hospital, Sabadell, of patients undergoing transanal surgery with perforation into the peritoneal cavity from June 2004 to September 2017. The main variable is postoperative morbidity and mortality. The long-term follow-up of local recurrence and peritoneal tumor dissemination is described, and a quantitative predictive model for peritoneal cavity perforation is proposed. Forty-five patients out of 686 (6.6%) presented perforation into the peritoneal cavity. Ten patients (22.2%) in the perforation group had morbidity, a rate similar to the non-perforated group. There was no peritoneal dissemination in patients with adenoma or with carcinoma treated with curative intent. In the quantitative predictive model, risk factors for perforation were proximal edge of tumor > 14 cm from anal verge (6 points), size ≥ 6 cm (2), age ≥ 85 years (4), anterior quadrant (3) , and sex (2). Total scores of ≥ 6 points predicted perforation. Primary suture after peritoneal cavity perforation during transanal surgery is safe and does not increase the risk of recurrence or peritoneal dissemination. Our predictive model provides guidance regarding the risk of perforation and the need to suture the defect after transanal surgery resection.

Compared with the open approach, laparoscopic total mesorectal excision (TME) achieves faster patient recovery, reduces morbidity rates, and shortens hospital stay. However, in laparoscopic low anterior resection (L-LAR), conversion to open surgery is required in almost 20% of cases. Transanal TME (Ta-TME) combined with laparoscopy, also called hybrid natural orifice transluminal endoscopic surgery (NOTES), is a less invasive procedure that can overcome some of the limitations of laparoscopic rectal surgery. In this study, we aim to determine whether Ta-TME has a lower rate of conversion to open surgery than L-LAR, and thus achieves faster patient recovery without altering the pathological, functional, or oncological results. The main objective is to compare the results for conversion to open surgery between Ta-TME and L-LAR. Multicenter, prospective randomized controlled study of patients diagnosed with rectal adenocarcinoma who will be randomly allocated to Ta-TME or L-LAR groups after the application of inclusion and exclusion criteria. The main endpoint is conversion to open surgery and the secondary endpoints are general morbidity and mortality and hospital stay. Demographic, surgical, and pathological variables will also be studied, along with quality of life and survival. A sample size of 53 patients per group is calculated. With an estimated loss of 10%, the final sample required will be 116 patients. Ta-TME achieves a lower conversion rate to open surgery than L-LAR, thus improving patient recovery and reducing overall morbidity. ClinicalTrials.gov Identifier: NCT02550769. Registration no. Ethical and Clinical Research Committee, Parc Tauli University Hospital: ID 2014/064.

PURPOSE Completion proctectomy is the traditional approach in the rectal stump remaining after subtotal colectomy for benign disease. It is associated with high morbidity and urinary and sexual dysfunction. To reduce this risk, a minimally invasive approach is presented, intersphincteric intramesorectal proctosigmoidectomy by transanal endoscopic operation and laparoscopy. PATIENTS AND METHODS Patients who had undergone total or subtotal colectomy for benign disease, those with a rectosigmoid stump who had rejected intestinal reconstruction and with refractory symptoms or risk of degeneration were selected. The technique proposed and the morbidity outcomes are described. RESULTS Three patients underwent this minimally invasive approach, operative time was 130 to 150 minutes. The median postoperative hospital stay was 6.6 days. Genitourinary and sexual tests performed in the male patient showed no dysfunction. CONCLUSIONS This minimally invasive technique, with intersphincteric resection and dissection close to the rectal wall, theoretically reduces morbidity and the damage to the autonomic pelvic nerves.

Objective To assess the role of transanal endoscopic operation (TEO) or transanal endoscopic microsurgery (TEM) in rectourethral fistulas (RUF). RUF may appear after radical prostatectomy. Their treatment represents a challenge; many therapies have been proposed, from conservative to aggressive surgical approaches. Transanal endoscopic surgery (TEO or TEM) is a minimally invasive technique to access the site of the RUF to perform repair. Materials and Methods This is an observational study with prospective data collection, conducted between September 2006 and December 2015. All patients were diagnosed with RUF following management of prostate cancer. Conservative treatment was administered in the form of urinary and fecal diversion with cystotomy and terminal colostomy, to achieve total urinary and fecal exclusion. If the fistula persisted, it was treated by TEO or TEM, with or without biological mesh interposition. If this failed, gracilis muscle was applied as salvage therapy. Results Ten patients were diagnosed with RUF. In 1 patient (1 of 10), the fistula healed with bladder catheterization alone. In another patient (1 of 9), it resolved after total urinary and fecal exclusion. Eight patients underwent repair by TEO or TEM, 4 with biological mesh interposition; all 4 presented recurrence. In the other 4 patients treated via TEO or TEM, 2 had early recurrence, whereas the others had healed at follow-up visits after 4-6 months (2 of 8)—a success rate of 25%. The 6 patients who recurred were treated with gracilis muscle interposition via a transperineal approach. Conclusion The low rate of positive results obtained by TEO or TEM argues against its use as technique of choice in RUF, and against the use of biological meshes.