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Introduction Transanal total mesorectal excision (taTME) is a novel approach to surgery for rectal cancer. The technique has gained significant popularity in the surgical community due to the promising ability to overcome technical difficulties related to the access of the distal pelvis. Recently, Norwegian surgeons issued a local moratorium related to potential issues with the safety of the procedure. Early adopters of taTME in Canada have recognized the need to create guidelines for its adoption and supervision. The objective of the statement is to provide expert opinion based on the best available evidence and authors' experience. Methods The procedure has been performed in Canada since 2014 at different institutions. In 2016, the first Canadian taTME congress was held in the city of Toronto, organized by two of the authors. In early 2019, a multicentric collaborative was established [The Canadian taTME expert Collaboration] which aimed at ensuring safe performance and adoption of taTME in Canada. Recently surgeons from 8 major Canadian rectal cancer centers met in the city of Toronto on December 7 of 2019, to discuss and develop a position statement. There in person, meeting was followed by 4 rounds of Delphi methodology. Results The generated document focused on the need to ensure a unified approach among rectal cancer surgeons across the country considering its technical complexity and potential morbidity. The position statement addressed four domains: surgical setting, surgeons' requirements, patient selection, and quality assurance. Conclusions Authors agree transanal total mesorectal excision is technically demanding and has a significant risk for morbidity. As of now, there is uncertainty for some of the outcomes. We consider it is possible to safely adopt this operation and obtain adequate results, however for this purpose it is necessary to meet specific requirements in different domains.

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HighlightsRare presentation of ruptured hepatic teratoma in an adult.<1% of teratomas are found to originate from liver and predominantly found in pediatric populations.Complete surgical resection is mainstay treatment.Definitive diagnosis is found on histopathological results.

Aim:The main objective of this study was to compare the oncological outcomes of patients undergoing abdominoperineal resection (APR) versus low anterior resection (LAR) through a transanal total mesorectal excision (taTME) approach.Method: A total of 360 adult patients with a diagnosis of rectal cancer were enrolled at participating centres from the Canadian taTME Expert Collaboration. Forty-three patients received taTME-APR and received 317 taTME-LAR. Demographic, operative, pathological and follow-up data were collected and merged into a single database. Results are presented as hazard ratio (HR) and 95% confidence interval. All analyses were performed in the R environment (v.3.6). Results:The proportion of patients with a positive circumferential radial margin status was higher in the taTME-APR group than the taTME-LAR group (21% vs. 9%, p = 0.001).Complete TME was achieved in 91% of those undergoing APR compared with 96% of those undergoing LAR (p = 0.25). APR was associated with a greater rate of local recurrence relative to LAR, although it was not significant [crude HR = 3.53 (95% CI 0.92-13.53)]. Circumferential margin positivity was significantly associated with a higher rate of systemic recurrence [crude HR = 3.59 (95% CI 1.38-9.3)]. Conclusion:Our results demonstrate inferior outcomes in those undergoing taTME-APR compared with taTME-LAR. The use of this technique for this particular indication needs to be carefully considered.

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HighlightsGastrointestinal cytomegalovirus infections can occur in immunocompetent patients.Diagnosis relies on histopathologic examination of endoscopic biopsy specimen.Early recognition and antiviral treatment are important to patient outcome.Cytomegalovirus duodenitis has significant potential to be life-threatening.