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Surgical Endoscopy Jun 2024This study aims to report our surgical techniques for robot-assisted laparoscopic anterior resection, specifically focusing on mesorectal division using rolling division...
BACKGROUND
This study aims to report our surgical techniques for robot-assisted laparoscopic anterior resection, specifically focusing on mesorectal division using rolling division of the mesorectum, and to elucidate short-term outcomes at a single institution. Tumor-specific mesorectal excision (TSME) is commonly performed for resection of a tumor located in the upper rectum. However, especially in a narrow pelvis, it is difficult to perform appropriate mesorectal division at an adequate distance from the tumor in robot-assisted laparoscopic anterior resection.
METHODS
Retrospective case series of patients with rectal cancer who underwent robot-assisted TSME using rolling division of mesorectum. Patient characteristics, perioperative clinical results, surgical and pathological details were recorded.
RESULTS
A total of 198 patients underwent robot-assisted TSME for rectal cancer using rolling division of mesorectum between May 2019 and December 2023.The tumor was located in the upper rectum in 45 patients, middle rectum in 115 patients and lower rectum in 38 patients. The types of resections were 40 high anterior resection and 158 low anterior resections. The median operation time was 175 (range 109-310) min, and median mesorectal division time was 24 (range 15-45) min. Median blood loss was 3 (range 0-20) ml; no patients required blood transfusion. The overall complication rate of Clavien-Dindo classification grades I-IV was 7.1%. Anastomotic leakage was observed in two patients (1.0%) with grade III. There was no surgical mortality in this series.
CONCLUSION
This robotic technique for anterior resection is a feasible and reliable procedure for achieving sufficient and safe TSME in this cohort.
Topics: Humans; Rectal Neoplasms; Robotic Surgical Procedures; Male; Female; Middle Aged; Retrospective Studies; Aged; Adult; Aged, 80 and over; Proctectomy; Treatment Outcome; Operative Time; Laparoscopy; Rectum; Postoperative Complications
PubMed: 38769186
DOI: 10.1007/s00464-024-10878-9 -
World Journal of Gastroenterology May 2024Colorectal surgeons are well aware that performing surgery for rectal cancer becomes more challenging in obese patients with narrow and deep pelvic cavities. Therefore,...
BACKGROUND
Colorectal surgeons are well aware that performing surgery for rectal cancer becomes more challenging in obese patients with narrow and deep pelvic cavities. Therefore, it is essential for colorectal surgeons to have a comprehensive understanding of pelvic structure prior to surgery and anticipate potential surgical difficulties.
AIM
To evaluate predictive parameters for technical challenges encountered during laparoscopic radical sphincter-preserving surgery for rectal cancer.
METHODS
We retrospectively gathered data from 162 consecutive patients who underwent laparoscopic radical sphincter-preserving surgery for rectal cancer. Three-dimensional reconstruction of pelvic bone and soft tissue parameters was conducted using computed tomography (CT) scans. Operative difficulty was categorized as either high or low, and multivariate logistic regression analysis was employed to identify predictors of operative difficulty, ultimately creating a nomogram.
RESULTS
Out of 162 patients, 21 (13.0%) were classified in the high surgical difficulty group, while 141 (87.0%) were in the low surgical difficulty group. Multivariate logistic regression analysis showed that the surgical approach using laparoscopic intersphincteric dissection, intraoperative preventive ostomy, and the sacrococcygeal distance were independent risk factors for highly difficult laparoscopic radical sphincter-sparing surgery for rectal cancer ( < 0.05). Conversely, the anterior-posterior diameter of pelvic inlet/sacrococcygeal distance was identified as a protective factor ( < 0.05). A nomogram was subsequently constructed, demonstrating good predictive accuracy (C-index = 0.834).
CONCLUSION
The surgical approach, intraoperative preventive ostomy, the sacrococcygeal distance, and the anterior-posterior diameter of pelvic inlet/sacrococcygeal distance could help to predict the difficulty of laparoscopic radical sphincter-preserving surgery.
Topics: Humans; Laparoscopy; Rectal Neoplasms; Female; Male; Nomograms; Middle Aged; Retrospective Studies; Aged; Anal Canal; Tomography, X-Ray Computed; Risk Factors; Organ Sparing Treatments; Adult; Pelvis; Imaging, Three-Dimensional; Treatment Outcome; Aged, 80 and over; Proctectomy; Logistic Models
PubMed: 38764764
DOI: 10.3748/wjg.v30.i18.2418 -
Techniques in Coloproctology May 2024
Topics: Humans; Rectal Neoplasms; Robotic Surgical Procedures; Surgical Stapling; Male; Proctectomy; Middle Aged; Female
PubMed: 38762703
DOI: 10.1007/s10151-024-02935-1 -
ANZ Journal of Surgery May 2024The impact of a permanent stoma, such as post-abdominoperineal resection (APR), on quality of life (QoL) is well-documented. While stoma-related QoL tools exist, their...
PURPOSE
The impact of a permanent stoma, such as post-abdominoperineal resection (APR), on quality of life (QoL) is well-documented. While stoma-related QoL tools exist, their relationship with stoma satisfaction is unclear. This study aimed to identify which aspects of QoL were most associated with stoma satisfaction.
METHODOLOGY
A cross-sectional study of consecutive patients who had an APR for rectal cancer at an Australian tertiary hospital (2012-2021), identified from a prospectively maintained database, was conducted. The Stoma-QoL questionnaire was used. Overall patient satisfaction with stoma function, and whether healthcare advice was sought for stoma dysfunction, were explored. Linear regression assessed the association between individual issues examined in the Stoma-QoL questionnaire and overall patient satisfaction with stoma function.
RESULTS
Overall, 64 patients (62.5% male, mean 68.1 years) participated. Stoma-QoL score was associated with stoma satisfaction (P < 0.05). QoL items impacting satisfaction were: needing to know nearest toilet location (P = 0.04), pouch smell concerns (P = 0.008), needing daytime rest (P = 0.02), clothing limitations (P = 0.02), sexual attractiveness concerns (P < 0.05), embarrassment (P < 0.05), difficulty hiding the pouch (P = 0.02), concerns about being burdensome (P = 0.04) and difficulty with interpersonal interaction (P = 0.03). Only 11 (17.2%) patients sought healthcare advice for stoma dysfunction.
CONCLUSION
While stoma-specific QoL is associated with stoma satisfaction, individual QoL aspects impact differently on satisfaction in permanent colostomy patients. These findings may help identify focus areas for peri-operative counselling for clinicians and stomal therapists, highlight the importance of tailored multidisciplinary care in ostomates and suggests that a stoma type-specific Stoma-QoL questionnaire is required.
PubMed: 38761003
DOI: 10.1111/ans.19034 -
Colorectal Disease : the Official... Jun 2024Some patients with inflammatory bowel disease (IBD) require subtotal colectomy (STC) with ileostomy. The recent literature reports a significant number of patients who...
AIM
Some patients with inflammatory bowel disease (IBD) require subtotal colectomy (STC) with ileostomy. The recent literature reports a significant number of patients who do not undergo subsequent surgery and are resigned to living with a definitive stoma. The aim of this work was to analyse the rate of definitive stoma and the cumulative incidence of secondary reconstructive surgery after STC for IBD in a large national cohort study.
METHOD
A national retrospective study (2013-2021) was conducted on prospectively collected data from the French Medical Information System Database (PMSI). All patients undergoing STC in France were included. The association between definitive stoma and potential risk factors was studied using univariate and multivariate analyses.
RESULTS
A total of 1860 patients were included (age 45 ± 9 years; median follow-up 30 months). Of these, 77% (n = 1442) presented with ulcerative colitis. Mortality and morbidity at 90 days after STC were 5% (n = 100) and 47% (n = 868), respectively. Reconstructive surgery was identified in 1255 patients (67%) at a mean interval of 7 months from STC. Seveny-four per cent (n = 932) underwent a completion proctectomy with ileal pouch anal anastomosis and 26% (n = 323) an ileorectal anastomosis. Six hundred and five (33%) patients with a definitive stoma had an abdominoperineal resection (n = 114; 19%) or did not have any further surgical procedure (n = 491; 81%). Independent risk factors for definitive stoma identified in multivariate analysis were older age, Crohn's disease, colorectal neoplasia, postoperative complication after STC, laparotomy and a low-volume hospital.
CONCLUSION
We found that 33% of patients undergoing STC with ileostomy for IBD had definitive stoma. Modifiable risk factors for definitive stoma were laparotomy and a low-volume hospital.
Topics: Humans; Middle Aged; Female; Male; France; Colectomy; Ileostomy; Retrospective Studies; Adult; Risk Factors; Inflammatory Bowel Diseases; Surgical Stomas; Reoperation; Postoperative Complications; Colitis, Ulcerative; Crohn Disease
PubMed: 38757256
DOI: 10.1111/codi.17020 -
Scandinavian Journal of Surgery : SJS :... May 2024Rectal cancer patients commonly benefit from neoadjuvant therapy before resection surgery. For these patients, an elective ostomy diversion is frequently considered,...
BACKGROUND
Rectal cancer patients commonly benefit from neoadjuvant therapy before resection surgery. For these patients, an elective ostomy diversion is frequently considered, despite the absence of conclusive evidence when a diversion is advantageous. This is a retrospective observational single-center study on a 4-year consecutive rectal cancer cohort undergoing neoadjuvant therapy, aiming at improving the understanding of risks and benefits associated with ostomy diversion.
MATERIAL AND METHOD
Baseline characteristics, tumor-specific data, clinical events, and outcomes were collected using the Swedish Colorectal Cancer Registry and medical records.
RESULTS
Thirty-two (30.2%) of the 106 included patients presented with endoscopic impassable tumors at diagnosis, of which 18 (56.2%) had diverting ostomy. Three out of 14 with impassable tumor and no diversion developed a bowel obstruction. None of the patients with an endoscopically passable tumor at diagnosis (n = 74) experienced a bowel obstruction. The elective diversions (n = 40) were not associated with serious complications (Clavien-Dindo grade ⩾ 3b). Patients with a diverting ostomy (n = 30) had similar time intervals from diagnosis to neoadjuvant treatment and to definite tumor resection as those without diversion but experienced more complex primary tumor resections in terms of blood loss and operation time.
CONCLUSION
An elective diverting ostomy is a relatively safe procedure in rectal cancer patients requiring neoadjuvant therapy. More than one out of five non-diverted patients with endoscopically impassable rectal tumors developed bowel obstruction and would potentially have benefited from an elective diversion.
PubMed: 38751171
DOI: 10.1177/14574969241252481 -
Colorectal Disease : the Official... Jun 2024Although proximal faecal diversion is standard of care to protect patients with high-risk colorectal anastomoses against septic complications of anastomotic leakage, it... (Randomized Controlled Trial)
Randomized Controlled Trial
SafeHeal Colovac Colorectal Anastomosis Protection Device evaluation (SAFE-2) pivotal study: an international randomized controlled study to evaluate the safety and effectiveness of the Colovac Colorectal Anastomosis Protection Device.
AIM
Although proximal faecal diversion is standard of care to protect patients with high-risk colorectal anastomoses against septic complications of anastomotic leakage, it is associated with significant morbidity. The Colovac device (CD) is an intraluminal bypass device intended to avoid stoma creation in patients undergoing low anterior resection. A preliminary study (SAFE-1) completed in three European centres demonstrated 100% protection of colorectal anastomoses in 15 patients, as evidenced by the absence of faeces below the CD. This phase III trial (SAFE-2) aims to evaluate the safety and effectiveness of the CD in a larger cohort of patients undergoing curative rectal cancer resection.
METHODS
SAFE-2 is a pivotal, multicentre, prospective, open-label, randomized, controlled trial. Patients will be randomized in a 1:1 ratio to either the CD arm or the diverting loop ileostomy arm, with a recruitment target of 342 patients. The co-primary endpoints are the occurrence of major postoperative complications within 12 months of index surgery and the effectiveness of the CD in reducing stoma creation rates. Data regarding quality of life and patient's acceptance and tolerance of the device will be collected.
DISCUSSION
SAFE-2 is a multicentre randomized, control trial assessing the efficacy and the safety of the CD in protecting low colorectal anastomoses created during oncological resection relative to standard diverting loop ileostomy.
TRIAL REGISTRATION
NCT05010850.
Topics: Humans; Anastomosis, Surgical; Anastomotic Leak; Prospective Studies; Rectal Neoplasms; Rectum; Colon; Female; Male; Treatment Outcome; Ileostomy; Middle Aged; Quality of Life; Adult; Aged; Proctectomy; Postoperative Complications
PubMed: 38750621
DOI: 10.1111/codi.17012 -
Seminars in Colon & Rectal Surgery Dec 2023Anorectal mucosal melanoma accounts for less than 1 % of all anorectal malignant tumors and a tendency for delayed diagnosis leads to advanced disease at presentation....
Anorectal mucosal melanoma accounts for less than 1 % of all anorectal malignant tumors and a tendency for delayed diagnosis leads to advanced disease at presentation. Due to the rarity of the disease, there are limited prospective trials exploring the optimal treatment strategies. Generally, tumors are surgically excised, with a preference for conservative management with wide local excision. In the past decade, there have been advances with immunotherapy and other targeted therapies. Multiple clinical trials continue exploring neoadjuvant/adjuvant combination treatments in the setting of advanced or unresectable disease.
PubMed: 38746826
DOI: 10.1016/j.scrs.2023.100990 -
Chirurgia (Bucharest, Romania : 1990) Apr 2024In this editorial, the authors bring to the attention of surgeons a personal point of view with the intention of offering a series of anatomical arguments to explain the...
In this editorial, the authors bring to the attention of surgeons a personal point of view with the intention of offering a series of anatomical arguments to explain the high rate of functional complications following ultralow rectal resections, resections dominated by faecal incontinence of various intensities. Having as a starting point the anatomy of the pelvic floor and the posterior perineum, the authors are concerned with the functional outcomes of the sphincter-saving anterior rectal resection, regarding the low and ultralow resection. Technically, a conservative surgery for low rectal cancer has been currently performed. If 25 years ago the abdominoperineal resection was the gold standard for rectal cancer located under 7cm from the anal verge, nowadays the preservation of the anal canal as a partner for colon anastomosis has been accomplished. Progressively, from a desire to preserve the normal passage of stool into the anal canal, as anatomically and physiologically as possible, the distal limit of resection was lowered to 2-4 cm from the anal verge and ultra-low anastomoses were created, within the anal sphincter complex. The stated goal: keep the oncological safety standard and, at the same time, avoid definitive colostomy. Starting from the normal anatomy of the pelvic floor and the anorectal segment, the authors take a look at the alterations of the visceral, muscular, and nerve structures as a consequence of the low anterior resection and, particularly, the ultralow anterior resection. A significant degree of functional outcomes regarding defecation, with the onset of marked disabilities of anal continence, the major consequence being anal incontinence (30-70%), have been noticed. The authors go under review for the main anatomical and physiological changes that accompany anterior rectal resection. Thus, the following questions arise: what is the lower limit of resection to avoid total fecal incontinence? Is total incontinence a greater handicap than colostomy or is it not? The answers cannot be supported by solid arguments at this time, but the need to initiate future studies dedicated to this problem emerges.
Topics: Humans; Fecal Incontinence; Rectal Neoplasms; Proctectomy; Anal Canal; Treatment Outcome; Syndrome; Pelvic Floor; Anastomosis, Surgical; Perineum; Rectum; Risk Factors; Low Anterior Resection Syndrome
PubMed: 38743827
DOI: 10.21614/chirurgia.2024.v.119.i.2.p.125 -
Asian Journal of Endoscopic Surgery Jul 2024In May 2023, the Hugo RAS system obtained pharmaceutical approval for use in gastroenterological surgery in Japan. It is expected to be particularly effective in rectal...
In May 2023, the Hugo RAS system obtained pharmaceutical approval for use in gastroenterological surgery in Japan. It is expected to be particularly effective in rectal cancer surgery, which require the manipulation of the deep pelvic cavity and communication with surgeons operating from the intraperitoneal and anal approaches. A 68-year-old woman presented to our hospital with bloody stools and was diagnosed with cStage I (cT2N0M0) rectal cancer and underwent abdominoperineal resection employing the Hugo RAS system. Two arm carts were placed on the left and right lateral sides with an interleg space, and trocars were placed in a straight line between the right superior iliac spine and umbilicus. Herein, we report the first abdominoperineal resection for rectal cancer using the Hugo RAS system.
Topics: Humans; Rectal Neoplasms; Female; Aged; Proctectomy; Adenocarcinoma
PubMed: 38741376
DOI: 10.1111/ases.13321