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Background: Transanal total mesorectal excision (TaTME) has been proposed as an approach in patients with mid and low rectal cancer. The TaTME procedure has been introduced in the Netherlands in a structured training pathway, including proctoring. This study evaluated the local recurrence rate during the implementation phase of TaTME. Methods: Oncological outcomes of the first ten TaTME procedures in each of 12 participating centres were collected as part of an external audit of procedure implementation. Data collected from a cohort of patients treated over a prolonged period in four centres were also collected to analyse learning curve effects. The primary outcome was the presence of locoregional recurrence. Results: The implementation cohort of 120 patients had a median follow up of 21⋅9 months. Short-term outcomes included a positive circumferential resection margin rate of 5⋅0 per cent and anastomotic leakage rate of 17 per cent. The overall local recurrence rate in the implementation cohort was 10⋅0 per cent (12 of 120), with a mean(s.d.) interval to recurrence of 15⋅2(7⋅0) months. Multifocal local recurrence was present in eight of 12 patients. In the prolonged cohort (266 patients), the overall recurrence rate was 5⋅6 per cent (4⋅0 per cent after excluding the first 10 procedures at each centre). Conclusion: TaTME was associated with a multifocal local recurrence rate that may be related to suboptimal execution rather than the technique itself. Prolonged proctoring, optimization of the technique to avoid spillage, and quality control is recommended.

Early (<1 year) primary patency rates of the medial approach were significantly better than the posterior approach, possibly because of the limited posterior exposure. However, in the absence of a significant difference in long-term primary and secondary patency rates between the posterior and medial approach, and considering the substantial risk of aneurysm growth after medial approach (up to 22%), the posterior approach might be the surgical method of preference for PAA repair in the long run.

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Fistulotomy seems to be associated with a healing rate of 0.81 (95% CI 0.71-0.85) after 5 years. However, major incontinence is still reported by 26.8% of patients and only 26.3% of patients had a perfect continence status.

Background PET-CT scanning is increasingly applied in the primary work-up of esophageal

Blunt and penetrating abdominal traumas are an important source of morbidity and mortality in the western world, especially in the young populations. Although most attention during the (primary) diagnostic process is directed toward the detection of internal injuries of the abdomen, blunt or penetrating trauma to the abdomen may result in defects of the abdominal wall. The diagnosis of traumatic abdominal wall hernia (TAWH) is rarely made. Morbidity due to TAWH, however, may be significant. In this article we report the delayed diagnosis of a TAWH in two patients after abdominal wall trauma and present a review of the literature concerning the diagnostic workup and treatment.

BACKGROUND It is uncertain whether protective ventilation reduces ventilation-induced pulmonary inflammation and injury during one-lung ventilation. OBJECTIVE To compare intra-operative protective ventilation with conventional during oesophagectomy with respect to pulmonary levels of biomarkers for inflammation and lung injury. DESIGN Randomised clinical trial. SETTING Tertiary centre for oesophageal diseases. PATIENTS Twenty-nine patients scheduled for one-lung ventilation during oesophagectomy. INTERVENTIONS Low tidal volume (V T ) of 6 ml kg−1 predicted body weight (pbw) during two-lung ventilation and 3 ml kgpbw−1 during one-lung ventilation with 5 cmH2O positive end expired pressure versus intermediate V T of 10 ml kgpbw−1 during two-lung ventilation and 5 ml kgpbw−1 body weight during one-lung ventilation with no positive end-expiratory pressure. OUTCOME MEASURES The primary outcome was the change in bronchoalveolar lavage (BAL) levels of preselected biomarkers for inflammation (TNF-α, IL-6 and IL-8) and lung injury (soluble Receptor for Advanced Glycation End-products, surfactant protein-D, Clara Cell protein 16 and Krebs von den Lungen 6), from start to end of ventilation. RESULTS Median [IQR] V T in the protective ventilation group (n = 13) was 6.0 [5.7 to 7.8] and 3.1 [3.0 to 3.6] ml kgpbw−1 during two and one-lung ventilation; V T in the conventional ventilation group (n = 16) was 9.8 [7.0 to 10.1] and 5.2 [5.0 to 5.5] ml kgpbw−1 during two and one-lung ventilation. BAL levels of biomarkers for inflammation increased from start to end of ventilation in both groups; levels of soluble Receptor for Advanced Glycation End-products, Clara Cell protein 16 and Krebs von den Lungen 6 did not change, while levels of surfactant protein-D decreased. Changes in BAL biomarkers levels were not significantly different between the two ventilation strategies. CONCLUSION Intra-operative protective ventilation compared with conventional ventilation does not affect changes in pulmonary levels of biomarkers for inflammation and lung injury in patients undergoing one-lung ventilation for oesophagectomy. TRIAL REGISTRATION The ‘Low versus Conventional tidal volumes during one-lung ventilation for minimally invasive oesophagectomy trial’ (LoCo) was registered at the Netherlands Trial Register (study identifier NTR 4391).