We present the case of a patient with a giant paraesophageal hernia associated with paroxysmal postprandial atrial fibrillation that was suppressed after surgery. The imaging investigations showed the intrathoracic displacement of a large part of the stomach, which pushed the left atrial wall causing atrial fibrillation. The laparoscopic surgical repair acted as sole treatment for this condition.

Introduction Transanal total mesorectal excision (TaTME) has rapidly emerged as a novel approach for rectal cancer surgery. Safety profiles are still emerging and more comparative data is urgently needed. This study aimed to compare indications and short‐term outcomes of TaTME, open, laparoscopic, and robotic TME internationally. Methods A pre‐planned analysis of the European Society of Coloproctology (ESCP) 2017 audit was performed. Patients undergoing elective total mesorectal excision (TME) for malignancy between 1 January 2017 and 15 March 2017 by any operative approach were included. The primary outcome measure was anastomotic leak. Results Of 2579 included patients, 76.2% (1966/2579) underwent TME with restorative anastomosis of which 19.9% (312/1966) had a minimally invasive approach (laparoscopic or robotic) which included a transanal component (TaTME). Overall, 9.0% (175/1951, 15 missing outcome data) of patients suffered an anastomotic leak. On univariate analysis both laparoscopic TaTME (OR 1.61, 1.02–2.48, P = 0.04) and robotic TaTME (OR 3.05, 1.10–7.34, P = 0.02) were associated with a higher risk of anastomotic leak than non‐transanal laparoscopic TME. However this association was lost in the mixed‐effects model controlling for patient and disease factors (OR 1.23, 0.77–1.97, P = 0.39 and OR 2.11, 0.79–5.62, P = 0.14 respectively), whilst low rectal anastomosis (OR 2.72, 1.55–4.77, P < 0.001) and male gender (OR 2.29, 1.52–3.44, P < 0.001) remained strongly associated. The overall positive circumferential margin resection rate was 4.0%, which varied between operative approaches: laparoscopic 3.2%, transanal 3.8%, open 4.7%, robotic 1%. Conclusion This contemporaneous international snapshot shows that uptake of the TaTME approach is widespread and is associated with surgically and pathologically acceptable results.

Introduction The mainstay of management for locally advanced rectal cancer is chemoradiotherapy followed by surgical resection. Following chemoradiotherapy, a complete response may be detected clinically and radiologically (cCR) prior to surgery or pathologically after surgery (pCR). We aim to report the overall complete pathological response (pCR) rate and the reliability of detecting a cCR by conventional pre‐operative imaging. Methods A pre‐planned analysis of the European Society of Coloproctology (ESCP) 2017 audit was performed. Patients treated by elective rectal resection were included. A pCR was defined as a ypT0 N0 EMVI negative primary tumour; a partial response represented any regression from baseline staging following chemoradiotherapy. The primary endpoint was the pCR rate. The secondary endpoint was agreement between post‐treatment MRI restaging (yMRI) and final pathological staging. Results Of 2572 patients undergoing rectal cancer surgery in 277 participating centres across 44 countries, 673 (26.2%) underwent chemoradiotherapy and surgery. The pCR rate was 10.3% (67/649), with a partial response in 35.9% (233/649) patients. Comparison of AJCC stage determined by post‐treatment yMRI with final pathology showed understaging in 13% (55/429) and overstaging in 34% (148/429). Agreement between yMRI and final pathology for T‐stage, N‐stage, or AJCC status were each graded as ‘fair’ only (n = 429, Kappa 0.25, 0.26 and 0.35 respectively). Conclusion The reported pCR rate of 10% highlights the potential for non‐operative management in selected cases. The limited strength of agreement between basic conventional post‐chemoradiotherapy imaging assessment techniques and pathology suggest alternative markers of response should be considered, in the context of controlled clinical trials.

Background Laparoscopy has now been implemented as a standard of care for elective colonic resection around the world. During the adoption period, studies showed that conversion may be detrimental to patients, with poorer outcomes than both laparoscopic completed or planned open surgery. The primary aim of this study was to determine whether laparoscopic conversion was associated with a higher major complication rate than planned open surgery in contemporary, international practice. Methods Combined analysis of the European Society of Coloproctology 2017 and 2015 audits. Patients were included if they underwent elective resection of a colonic segment from the caecum to the rectosigmoid junction with primary anastomosis. The primary outcome measure was the 30‐day major complication rate, defined as Clavien‐Dindo grade III‐V. Results Of 3980 patients, 64% (2561/3980) underwent laparoscopic surgery and a laparoscopic conversion rate of 14% (359/2561). The major complication rate was highest after open surgery (laparoscopic 7.4%, converted 9.7%, open 11.6%, P < 0.001). After case mix adjustment in a multilevel model, only planned open (and not laparoscopic converted) surgery was associated with increased major complications in comparison to laparoscopic surgery (OR 1.64, 1.27–2.11, P < 0.001). Conclusions Appropriate laparoscopic conversion should not be considered a treatment failure in modern practice. Conversion does not appear to place patients at increased risk of complications vs planned open surgery, supporting broadening of selection criteria for attempted laparoscopy in elective colonic resection.

Cele mai multe centre oncologice din lume recomandă actualmente în cancerul de col uterin avansat loco-regional (LACC) chimioradioterapie (fără chirurgie). În România, în practica clinică, un număr însemnat de paciente cu LACC sunt încă îndrumate către serviciile de chirurgie. Un grup de experţi în oncologie şi chirurgie oncologică (grupul de studiu SURCECAN-surgery of cervical cancer) din România şi-au propus să analizeze cauzele acestei opţiuni. Au constat că nici indicaţiile terapeutice din literatura de specialitate nu sunt consensuale. Condiţiile practice de realizare a radioterapiei (inclusiv brahiterapie) prezintă în România unele particularităţi: accesibilitate limitată la centrele specializate, dispoziţie geografică neuniformă, etc. Pe de altă parte, şi statisticile din România şi cele internaţionale arată prezenţa de ţesut tumoral restant după iradiere. În aceste condiţii, se poate spune că, în cazuri selectate, chirurgia păstrează încă un rol în tratamentul LACC. Este de dorit ca criteriile de indicaţie operatorie şi de abord

The purpose of this article is to identify the risk factors for local recurrence and anastomotic leakage after sphincter-sparing surgery for low and mid rectal cancer. Material and We prospectively analyzed a group of 38 patients with low and middle rectal cancer who underwent sphincter-sparing surgery. Low anterior resection was performed in 32 cases (84.2%) and 6 cases (15.8%) benefited of ultralow anterior resection. Clinical stadialization cTNM included 3 patients (7.9%) T1 stage, 11 patients (28.9%) T2 stage and 24 patients (63.2%) T3 stage. Preoperative radiotherapy was performed in 33 cases (86.4%), and chemotherapy was associated in 20 cases (52.6%). The stages I and II cancers were prevalent (63.2%), followed by stage III cancers (23.7%) and stage IV cancers (13.2%). The rate of complications of 52.6% (20 cases) was associated with T3 stage cancers. Anastomotic leakage has occurred in 4 cases (10.5%) and tumor recurrence has developed in 3 cases (7.9%). The rate of local recurrence and anastomotic leakage is associated with the number of positive lymph nodes (more than 4 nodes, 5.3%, p = 0.023). We found no association between chemoradiotherapy and the risk of local recurrence (p 0.05). Other postoperative complications included intestinal obstruction by adhesions or bowel volvulus (5 cases, 13.2%), postradiation colitis (3 cases, 7.7%), coloanal anastomotic stenosis (1 case, 2.6%), rectovaginal fistula (1 case, 2.6%), ileostomy bleeding (1 case, 2.6%), wound infection (2 cases, 5.3%). Risk factors associated with local recurrence and anastomotic leakage are aggressive stage tumor, lymphnodes involvement, neoadjuvant therapy and postoperative anemia. The postoperative outcome was favorable after sphincter preservation surgery and the absence of definitive colostomy had an important impact on the quality of life of the patients with distal rectal cancer.

Aim:The Enhanced Recovery After Surgery (ERAS®) Society guidelines aim to standardize perioperative care in colorectal surgery via 25 principles. We aimed to assess the variation in uptake of these principles across an international network of colorectal units.Method: An online survey was circulated amongst European Society of Coloproctology members in 2019-2020. For each ERAS principle, respondents were asked to score how frequently the principle was implemented in their hospital, from 1 ('rarely') to 4 ('always'). Respondents were also asked to recall whether practice had changed since 2017.Subgroup analyses based on hospital characteristics were conducted.Results: Of hospitals approached, 58% responded to the survey (195/335), with 296 individual responses (multiple responses were received from some hospitals). The majority were European (163/195, 83.6%). Overall, respondents indicated they 'most often' or 'always' adhered to most individual ERAS principles (18/25, 72%). Variability in the uptake of principles was reported, with universal uptake of some principles (e.g., prophylactic antibiotics; early mobilization) and inconsistency from 'rarely' to 'always' in others (e.g., no nasogastric intubation; no preoperative fasting and carbohydrate drinks). In alignment with 2018 ERAS guideline updates, adherence to principles for prehabilitation, managing anaemia and postoperative nutrition appears to have increased since 2017.Conclusions: Uptake of ERAS principles varied across hospitals, and not all 25 principles were equally adhered to. Whilst some principles exhibited a high level of acceptance, others had a wide variability in uptake indicative of controversy or barriers to uptake. Further research into specific principles is required to improve ERAS implementation.

Introduction