Rectal Sparing Approach after preoperative Radio- and/or Chemo-therapy (ReSARCh): a prospective, multicenter, observational study.

BACKGROUND: Rectal-sparing approaches for patients with rectal cancer who achieved a complete or major response following neoadjuvant therapy constitute a paradigm of a potential shift in the management of patients with rectal cancer; however, their role remains controversial. The aim of this study was to investigate the feasibility of rectal-sparing approaches to preserve the rectum without impairing the outcomes. METHODS: This prospective, multicenter, observational study investigated the outcomes of patients with clinical stage II-III mid-low rectal adenocarcinoma treated with any neoadjuvant therapy, and either transanal local excision or watch-and-wait approach, based on tumor response (major or complete) and patient/surgeon choice. The primary endpoint of the study was rectum preservation at a minimum follow-up of 2 years. Secondary endpoints were overall, disease-free, local and distant recurrence-free, and stoma-free survival at 3 years. RESULTS: Of the 178 patients enrolled in 16 centers, 112 (62.9%) were managed with local excision and 66 (37.1%) with watch-and-wait. At a median (interquartile range) follow-up of 36.1 (30.6-45.6) months, the rectum was preserved in 144 (80.9%) patients. The 3-year rectum-sparing, overall survival, disease-free survival, local recurrence-free survival, and distant recurrence-free survival was 80.6% (95% CI 73.9-85.8), 97.6% (95% CI 93.6-99.1), 90.0% (95% CI 84.3-93.7), 94.7% (95% CI 90.1-97.2), and 94.6% (95% CI 89.9-97.2), respectively. The 3-year stoma-free survival was 95.0% (95% CI 89.5-97.6). The 3-year regrowth-free survival in the watch-and-wait group was 71.8% (95% CI 59.9-81.2). CONCLUSIONS: In rectal cancer patients with major or complete clinical response after neoadjuvant therapy, the rectum can be preserved in about 80% of cases, without compromising the outcomes.

Rectal Sparing Approach After Neoadjuvant Therapy in Patients with Rectal Cancer: The Preliminary Results of the ReSARCh Trial.

BACKGROUND: Rectum-preservation for locally advanced rectal cancer has been proposed as an alternative to total mesorectal excision (TME) in patients with major (mCR) or complete clinical response (cCR) after neoadjuvant therapy. The purpose of this study was to report on the short-term outcomes of ReSARCh (Rectal Sparing Approach after preoperative Radio- and/or Chemotherapy) trial, which is a prospective, multicenter, observational trial that investigated the role of transanal local excision (LE) and watch-and-wait (WW) as integrated approaches after neoadjuvant therapy for rectal cancer. METHODS: Patients with mid-low rectal cancer who achieved mCR or cCR after neoadjuvant therapy and were fit for major surgery were enrolled. Clinical response was evaluated at 8 and 12 weeks after completion of chemoradiotherapy. Treatment approach, incidence, and reasons for subsequent TME were recorded. RESULTS: From 2016 to 2019, 160 patients were enrolled; mCR or cCR at 12 weeks was achieved in 64 and 96 of patients, respectively. Overall, 98 patients were managed with LE and 62 with WW. In the LE group, Clavien-Dindo 3+ complications occurred in three patients. The rate of cCR increased from 8- to 12-week restaging. Thirty-three (94.3%) of 35 patients with cCR had ypT0-1 tumor. At a median 24 months follow-up, a tumor regrowth was found in 15 (24.2%) patients undergoing WW. CONCLUSIONS: LE for patients achieving cCR or mCR is safe. A 12-week interval from chemoradiotherapy completion to LE is correlated with an increased cCR rate. The risk of ypT > is reduced when LE is performed after cCR.

Right colectomy with intracorporeal anastomosis for cancer: a prospective comparison between robotics and laparoscopy.

Robotics in right colectomy are still under debate. Available studies compare different techniques of ileocolic anastomosis but results are non-conclusive. Our study aimed to compare intraoperative outcomes, and short-term postoperative results between robotic and standard laparoscopic right colectomies for cancer with intracorporeal anastomosis (ICA) fashioned with the same technique. All consecutive patients scheduled for laparoscopic or robotic right hemicolectomies with ICA for cancer in two hospitals, one of which is a tertiary care centre, were prospectively enrolled in our prospective observational study, from April 2018 to December 2019. ICA was fashioned with the same stapled hand-sewn technique. Continuous and categorical variables were analysed using t test and chi-squared test as required. Statistical significance was set at p < 0.05. Forty patients underwent laparoscopic surgery, and 48 underwent robotic right colectomy and were included in the intention-to-treat analysis. Operative time was not statistically different between the two groups (robotic group 265.9 min vs laparoscopic group 254.2 min, p = 0.29). The robotic group had a significantly shorter time for stump oversewing (ileum reinforcement: robotic group 9.3 min vs laparoscopic group 14.2 min, p < 0.001; colon reinforcement: robotic 7.7. min, laparoscopy 13.9 min, p < 0.001) and for ICA (robotic 31.6 min vs laparoscopy 43.0, p < 0.001). One patient underwent extracorporeal anastomosis in the robotic group. The short-term outcomes were comparable between standard laparoscopic and robotic right colectomies with ICA. The limitation of the study is its small sample size and the fact that it was done in two institutions under the supervision of one person. Our data demonstrate that intracorporeal ileocolic anastomosis is safe, and faster and easier with robotic systems. Robotics can facilitate more challenging ICA in minimally invasive surgery.

More Favorable Short and Long-Term Outcomes for Screen-Detected Colorectal Cancer Patients.

BACKGROUND: Screening significantly reduces mortality from colorectal cancer (CRC). Screen detected (SD) tumors associate with better prognosis, even at later stage, compared to non-screen detected (NSD) tumors. We aimed to evaluate the association between diagnostic modality (SD vs. NSD) and short- and long-term outcomes of patients undergoing surgery for CRC. MATERIALS AND METHODS: This retrospective cohort study involved patients aged 50-69 years, residing in Veneto, Italy, who underwent curative-intent surgery for CRC between 2006 and 2018. The clinical multi-institutional dataset was linked with the screening dataset in order to define diagnostic modality (SD vs. NSD). Short- and long-term outcomes were compared between the two groups. RESULTS: Of 1,360 patients included, 464 were SD (34.1%) and 896 NSD (65.9%). Patients with a SD CRC were more likely to have less comorbidities (p = 0.013), lower ASA score (p = 0.001), tumors located in the proximal colon (p = 0.0018) and earlier stage at diagnosis (p < 0.0001). NSD patients were found to have more aggressive disease at diagnosis, higher complication rate and higher readmission rate due to surgical complications (all p < 0.05). NSD patients had a significantly lower Disease Free Survival and Overall Survival (all p < 0.0001), even after adjusting by demographic, clinic-pathological, tumor, and treatment characteristics. CONCLUSIONS: SD tumors were associated with better long-term outcomes, even after multiple adjustments. Our results confirm the advantages for the target population to participate in the screening programs and comply with their therapeutic pathways.

Colonic J-Pouch or Straight Colorectal Reconstruction After Low Anterior Resection For Rectal Cancer: Impact on Quality of Life and Bowel Function: A Multicenter Prospective Randomized Study.

BACKGROUND: Patient-reported outcomes associated with different bowel reconstruction techniques following anterior resection for rectal cancer are still a matter of debate. OBJECTIVE: This study aimed to assess quality of life and bowel function in patients who underwent colonic J-pouch or straight colorectal anastomosis reconstruction after low anterior resection. DESIGN: Bowel function and quality of life were assessed within a multicenter randomized trial. Questionnaires were administered before the surgery (baseline) and at 6, 12, and 24 months after surgery. SETTINGS: Patients were enrolled by 19 centers. The enrollment started in October 2009 and was stopped in February 2016. The study was registered at www.clinicaltrials.gov (Identifier: NCT01110798). PATIENTS: Patients who underwent low anterior resection for primary mid-low rectal cancer and who were randomly assigned in a 1:1 ratio to receive either stapled colonic J-pouch or straight colorectal anastomosis were selected. MAIN OUTCOME MEASURES: The primary outcomes measured were quality of life and bowel function. RESULTS: Of the 379 patients who were evaluable, 312 (82.3%) completed the baseline, 259 (68.3%) the 6-month, 242 (63.9%) the 12-month, and 199 (52.5%) the 24-month assessment. Bowel functioning and quality of life did not significantly differ between arms for almost all domains. The total bowel function score, the urgency, and the stool fractionation scores significantly worsened after surgery and remained impaired over time in both arms (p < 0.0032), whereas constipation improved after surgery but recovered to baseline levels from 1 year onward (p < 0.0036). All patients showed a significant and continuous improvement in emotional functioning (p < 0.0013) and future perspective (p < 0.0001) from baseline to the end of the study. LIMITATIONS: Limitations of the study include missing data, which increased over time; the possibility that some treatments have slightly changed since the study was conducted; and investigators not blind to treatment allocation. CONCLUSION: The findings of this study do not support the routine use of colonic J-pouch reconstruction in patients with rectal cancer who undergo a low anterior resection. See Video Abstract at http://links.lww.com/DCR/B328. BOLSA J COLÓNICA O RECONSTRUCCIÓN COLORRECTAL RECTA DESPUÉS DE RESECCIÓN ANTERIOR BAJA PARA CÁNCER RECTAL: IMPACTO EN LA CALIDAD DE VIDA Y LA FUNCIÓN INTESTINAL: UN ESTUDIO ALEATORIZADO PROSPECTIVO MULTICÉNTRICO: Los resultados informados por el paciente asociados con diferentes técnicas de reconstrucción intestinal después de la resección anterior para el cáncer de recto aún son tema de debate.Evaluar la calidad de vida y la función intestinal en pacientes que se sometieron a una bolsa en J colónica o reconstrucción de anastomosis colorrectal recta después de una resección anterior baja.La función intestinal y la calidad de vida se evaluaron en un ensayo aleatorizado multicéntrico. Los cuestionarios se administraron antes de la cirugía (basal) y a los 6, 12 y 24 meses después de la cirugía.Los pacientes fueron incluidos en 19 centros. La inscripción comenzó en Octubre de 2009 y se detuvo en Febrero de 2016. El estudio se registró en www.clinicaltrials.gov (Identificador: NCT01110798).Pacientes que se sometieron a resección anterior baja por cáncer rectal primario medio-bajo y que fueron aleatorizados en una proporción de 1: 1 para recibir bolsa J colónica con grapas o anastomosis colorrectal recta.calidad de vida y función intestinal.De los 379 pacientes que fueron evaluables, 312 (82.3%) completaron la evaluación inicial, 259 (68.3%) a los 6 meses, 242 (63.9%) a los 12 meses y 199 (52.5%) a los 24 meses. . El funcionamiento intestinal y la calidad de vida no difirieron significativamente entre los dos grupos en casi todos los dominios. La puntuación total de la función intestinal, la urgencia y las puntuaciones de fraccionamiento de las heces empeoraron significativamente después de la cirugía y continuaron con el tiempo extra en ambos grupos (p <0.0032), mientras que el estreñimiento mejoró después de la cirugía pero se recuperó a los niveles basales a partir de 1 año en adelante (p <0.0036). Todos los pacientes mostraron una mejora significativa y continua en el funcionamiento emocional (p <0.0013) y la perspectiva futura (<0.0001) desde el inicio hasta el final del estudio.Datos faltantes, que aumentaron con el tiempo; la posibilidad de que algunos tratamientos hayan cambiado ligeramente desde que se realizó el estudio; investigadores no cegados a la asignación del tratamiento.Los hallazgos de este estudio no respaldan el uso rutinario de la reconstrucción de la bolsa J colónica en pacientes con cáncer rectal que se someten a una resección anterior baja. Consulte Video Resumen en http://links.lww.com/DCR/B328. (Traducción-Dr. Yesenia Rojas-Khalil).

Expression levels of circulating miRNAs as biomarkers during multimodal treatment of rectal cancer - TiMiSNAR-mirna: a substudy of the TiMiSNAR Trial (NCT03962088).

BACKGROUND: Neoadjuvant chemoradiotherapy followed by surgery is the mainstay treatment for locally advanced rectal cancer, leading to significant decrease in tumor size (downsizing) and a shift towards earlier disease stage (downstaging). Extensive histopathological work-up of the tumor specimen after surgery including tumor regression grading and lymph node status helped to visualize individual tumor sensitivity to chemoradiotherapy, retrospectively. As the response to neoadjuvant chemoradiotherapy is heterogeneous, however, valid biomarkers are needed to monitor tumor response. A relevant number of studies aimed to identify molecular markers retrieved from tumor tissue while the relevance of blood-based biomarkers is less stringent assessed. MicroRNAs are currently under investigation to serve as blood-based biomarkers. To date, no screening approach to identify relevant miRNAs as biomarkers in blood of patients with rectal cancer was undertaken. The aim of the study is to investigate the role of circulating miRNAs as biomarkers in those patients included in the TiMiSNAR Trial (NCT03465982). This is a biomolecular substudy of TiMiSNAR Trial (NCT03962088). METHODS: All included patients in the TiMiSNAR Trial are supposed to undergo blood collection at the time of diagnosis, after neoadjuvant treatment, after 1 month from surgery, and after adjuvant chemotherapy whenever indicated. DISCUSSION: TiMiSNAR-MIRNA will evaluate the association of variation between preneoadjuvant and postneoadjuvant expression levels of miRNA with pathological complete response. Moreover, the study will evaluate the role of liquid biopsies in the monitoring of treatment, correlate changes in expression levels of miRNA following complete surgical resection with disease-free survival, and evaluate the relation between changes in miRNA during surveillance and tumor relapse. TRIAL REGISTRATION: Clinicaltrials.gov NCT03962088 . Registered on 23 May 2019.

Correction to: Standard (8 weeks) vs long (12 weeks) timing to minimally-invasive surgery after NeoAdjuvant Chemoradiotherapy for rectal cancer: a multicenter randomized controlled parallel group trial (TiMiSNAR).

Following publication of the original article [1], the authors reported that the family name of the author, Ludovica Baldari, was misspelled.

Standard (8 weeks) vs long (12 weeks) timing to minimally-invasive surgery after NeoAdjuvant Chemoradiotherapy for rectal cancer: a multicenter randomized controlled parallel group trial (TiMiSNAR).

BACKGROUND: The optimal timing of surgery in relation to chemoradiation is still controversial. Retrospective analysis has demonstrated in the recent decades that the regression of adenocarcinoma can be slow and not complete until after several months. More recently, increasing pathologic Complete Response rates have been demonstrated to be correlated with longer time interval. The purpose of the trial is to demonstrate if delayed timing of surgery after neoadjuvant chemoradiotherapy actually affects pathologic Complete Response and reflects on disease-free survival and overall survival rather than standard timing. METHODS: The trial is a multicenter, prospective, randomized controlled, unblinded, parallel-group trial comparing standard and delayed surgery after neoadjuvant chemoradiotherapy for the curative treatment of rectal cancer. Three-hundred and forty patients will be randomized on an equal basis to either robotic-assisted/standard laparoscopic rectal cancer surgery after 8 weeks or robotic-assisted/standard laparoscopic rectal cancer surgery after 12 weeks. DISCUSSION: To date, it is well-know that pathologic Complete Response is associated with excellent prognosis and an overall survival of 90%. In the Lyon trial the rate of pCR or near pathologic Complete Response increased from 10.3 to 26% and in retrospective studies the increase rate was about 23-30%. These results may be explained on the relationship between radiation therapy and tumor regression: DNA damage occurs during irradiation, but cellular lysis occurs within the next weeks. Study results, whether confirmed that performing surgery after 12 weeks from neoadjuvant treatment is advantageous from a technical and oncological point of view, may change the current pathway of the treatment in those patient suffering from rectal cancer. TRIAL REGISTRATION: ClinicalTrials.gov NCT3465982.

From Laparoscopic Right Colectomy with Extracorporeal Anastomosis to Robot-Assisted Intracorporeal Anastomosis to Totally Robotic Right Colectomy for Cancer: The Evolution of Robotic Multiquadrant Abdominal Surgery.

BACKGROUND: Intracorporeal anastomosis (IA) in right colectomies shows many advantages over extracorporeal anastomosis (EA). Many difficulties encountered in laparoscopic IA can be overcome with hybrid robot-assisted IA or recently with totally robotic procedures. In the literature, few works have been published comparing laparoscopic, hybrid, and totally robotic right colectomies. The aim of this study is to retrospectively analyze the improvements brought on by the evolution of robotic surgery at our specialized center. MATERIALS AND METHODS: Two hundred six (hybrid and totally) robotic right colectomies (RRCs) with IA were compared with 160 laparoscopic right colectomies (LRCs) with EA. A separate analysis carried out by the robotic group compared 30 totally robotic right colectomies (TRRCs) with 176 hybrid robot-assisted right colectomies (HRRCs). Demographics, pathological features, operative details, and postoperative outcomes were retrospectively analyzed from a prospectively maintained database. RESULTS: The groups were comparable with respect to demographics and tumor staging. When compared with LRC, RRC showed shorter time to first flatus (P < .001), stools (P < .001), solid diet (P < .001), and discharge (P < .001). The number of lymph nodes harvested was 23.13 ± 11.2 in RRC versus 20.5 ± 11.2 in LRC (P = .031). Operative time was longer in RRC (253.0 ± 47 minutes versus 209.9 ± 64 minutes; P < .001), but conversion to open (2.4% versus 18.1%; P < .001), anastomotic leaks (0.5% versus 5%; P = .012), and bleeding (0.3% versus 4.4%; P = .024) were significantly less frequent. Subsequent analysis shows no significant increase in operative time in TRRC versus HRRC (261.0 ± 41 minutes versus 251.6 ± 47.6 minutes; P = .310). Even if not statistically significant, TRRC showed faster bowel function recovery and tolerance to solid diet. CONCLUSIONS: We confirmed the clinical advantages of RRC with IA over LRC with EA in postoperative recovery outcomes and complication rate. Furthermore, our preliminary analysis in a cohort of 30 TRRC shows promising results.

The Role of Laparoscopy in the Treatment of Anastomotic Leaks After Minimally Invasive Colorectal Resections for Cancer.

AIM OF THE STUDY: The aim of this study was to describe the role of laparoscopy in the treatment of leaks occurring after minimally invasive colorectal resections. MATERIALS AND METHODS: Thirty-four of 566 consecutive patients who underwent minimally invasive colorectal resection for cancer between January 2004 and December 2012 and who showed signs of anastomotic leakage (6%) requiring reoperation were studied using a prospectively maintained database. Patient characteristics, clinical signs, the surgical approach, the role of laparoscopy, operative and postoperative results, and the rate of permanent stoma were analyzed. RESULTS: The median time to diagnosis of an anastomotic leak after surgery was 5.5 days. The median time to reoperation from the diagnosis of leakage was 2 days. Leaks were treated laparoscopically in 21 of 34 (61.8%) patients. Anastomoses were dismantled in 14 patients (41.2%) and the procedure was performed laparoscopically in 28.6% of the cases. The postoperative morbidity was 55.9%, the perioperative mortality 5.7%, and the rate of permanent stoma was 8.8%. CONCLUSIONS: Laparoscopic reoperation can be performed in most cases of anastomotic leaks occurring after minimally invasive colorectal resection for cancer. Anastomosis can be dismantled laparoscopically in 28.6% of the cases. A permanent stoma was necessary only in patients with terminal stomas.

Robotic-assisted intracorporeal anastomosis versus extracorporeal anastomosis in laparoscopic right hemicolectomy for cancer: a case control study.

INTRODUCTION: Extracorporeal ileocolic anastomosis in laparoscopic right hemicolectomy for cancer has a significant risk of complications. The aim of this study is to evaluate the operative and postoperative results of hybrid right hemicolectomy with intracorporeal robotic-assisted anastomosis for adenocarcinoma of the ascending colon compared with the standard extracorporeal anastomosis in a case control study. PATIENTS AND METHODS: Forty-eight right hemicolectomies for cancer (2009-2012) with laparoscopic medial to lateral dissection, vascular ligation, bowel transection, and robotic-assisted intracorporeal anastomosis with specimen extraction through a Pfannestiel incision (robotic group [RG]) were compared with 48 laparoscopic hemicolectomies (2009-2011) with extracorporeal anastomosis (laparoscopic group [LG]). RESULTS: The two groups were comparable with respect to age, gender, stage of cancer, and body mass index. Surgery time was significantly longer in RG patients (RG, 266±41 minutes; LG, 223±51 minutes; P<.05). Operative results were similar in the two groups. Recovery of bowel function (day of first bowel movement: RG, 3.0±1.0 days; LG, 4.0±1.2 days; P<.05) and hospital stay (RG, 7.5±2.0 days; LG, 9.0±3.2 days; P<.05) were quicker and shorter, respectively, in RG. There were four anastomotic complications and four incisional hernias in LG and none in RG (P<.05). CONCLUSIONS: There are fewer anastomotic and wound complications in RG patients. Intracorporeal robotic-assisted ileocolic anastomosis allows a faster recovery compared with extracorporeal anastomosis.

Full robotic gastrectomy with extended (D2) lymphadenectomy for gastric cancer: surgical technique and preliminary results.

BACKGROUND: Widespread diffusion of minimally-invasive surgery for gastric cancer treatment is limited by the complexity of performing an extended D2-lymphadenectomy. This surgical step can be facilitated by using robot-assisted surgery. The aim of this study is to describe our technique and short-term results of a consecutive series of full robotic gastrectomies with D2-lymphadenectomy for gastric cancer, using the da Vinci Surgical System. MATERIALS AND METHODS: Between May 2004 and December 2009, we performed 24 consecutive full robot-assisted total and subtotal gastrectomies with extended D2-lymphadenectomy for histologically-proven gastric adenocarcinoma. Data referring to 11 robot-assisted total gastrectomies and 13 subtotal gastrectomies were collected in a database and analyzed. RESULTS: Median operative time was 267.50 min (255-305). Median intraoperative blood loss was 30 mL. Median number of harvested lymph nodes was 28 (23-34). Resection margins were negative in all cases. No conversions occurred. Surgery-related morbidity was 8%. Thirty-day mortality was 0%. Liquid diet started on postoperative d 5 (2-5). Median length of stay was 6 d (5-8). CONCLUSIONS: Robot-assisted gastrectomy with D2-lymphadenectomy is a safe technique and allows achieving an adequate lymph node harvest and optimal R0-resection rates with low postoperative morbidity and the learning curve appears to be shorter than in laparoscopic surgery. Longer follow-up and randomized clinical trials are needed to define the role of robot-assistance in gastric cancer surgery.

Robotic right colon resection: evaluation of first 50 consecutive cases for malignant disease.

BACKGROUND: Colorectal cancer is the fourth leading cause of death in the world. Minimally invasive surgery has been demonstrated to have the same oncological results as open surgery, with better clinical outcomes. Robotic assistance is an evolution of minimally invasive technique. This study aims to evaluate surgical and oncological short-term outcomes of robotic-assisted right colon resection in malignant disease. METHODS: Fifty consecutive patients affected by right-sided colon cancer were operated from May 2001 to May 2009 using the da Vinci(®) surgical system. Data regarding surgical and early oncological outcomes were systematically collected in a specific database for statistical analysis. RESULTS: Twenty-four male and 26 female patients underwent robotic right colectomy. Median age was 73.34 ± 11 years. Median operative time was 223.50 (180-270) min. No conversion occurred. Specimen length was 26.7 ± 8 cm (range 21-50 cm), number of harvested lymph nodes was 18.76 ± 7.2 (range 12-44), and mean number of positive lymph nodes was 1.65 ± 3 (range 0-17). Surgery-related morbidity was 1/50 (2%): one twisting of the mesentery in one case with extracorporeal anastomosis. All patients were included in a follow-up regimen. Disease-free survival was 90% (45/50), and overall survival was 92% (46/50). Cancer-related mortality was 8% (4/50). CONCLUSIONS: Robotic assistance allows performance of oncologically adequate dissection of the right colon with radical lymphadenectomy and to fashion a handsewn intracorporeal anastomosis as in open surgery, confirming the safety and oncological adequacy of this technique, with acceptable results and short-term outcomes.

[Robotic surgery: considerations after 250 procedures]. / La chirurgia robotica. Considerazioni dopo 250 interventi.

The aim of this study was to investigate the results of the first 250 procedures performed on 216 patients with the da Vinci Robotic Surgical System (34/216 patients were submitted to double procedure). The purpose of the da Vinci surgical system is to exactly translate the surgeon's hand movements to the robotic arms that manipulate the laparoscopic instruments, thus facilitating minimally invasive surgery. The da Vinci system has been available in our department since 2001. The first 50 procedures were simple cases (cholecystectomies and transperitoneal hernia repairs) and were performed during the learning curve of the surgical team. The last 200 procedures were more complex cases. Time of preparation of the robot gradually decreased with growing experience. The total conversion rate (to standard laparoscopy and to open surgery) was 4.8% (12/250); conversion to laparotomy was 2.8% (7/250). Morbidity was 8.8% (19/216), and reoperation was needed in 6 patients. Mortality was 1.8% (4/216). We conclude that robotic surgery has now moved beyond the learning phase with the device and may be routinely used in selected, more complex cases, such as colorectal surgery and surgery of the gastro-oesophageal junction. The device can also be used in pancreatic and gastric surgery.

A simple technique for identification and preservation of the hypogastric nerves during rectal surgery.

HYPOTHESIS: Rectal resection is associated with a risk of sexual dysfunction even when performed for benign disease, with the most frequent type resulting in retrograde ejaculation due to injury to the hypogastric nerves. DESIGN: A simple technique to identify and protect these nerves during rectal mobilization. SETTING: Exposure of the hypogastric plexus during rectal resection. CONCLUSION: Careful identification of the hypogastric nerves during rectal mobilization using the described technique may reduce injury to these nerves and related sexual dysfunction.

Clinical characteristics of familial adenomatous polyposis and management of duodenal adenomas.

The aim of this study was to evaluate the clinical characteristics of patients with familial adenomatous polyposis (FAP) undergoing surgical treatment over a 10-year period and specifically to evaluate the incidence and clinical outcome of patients treated for duodenal adenomas. Patients with FAP who underwent surgical treatment for colonic polyposis at the University of Louisville from January 1992 to July 2002 were investigated. Surgical treatment included colectomy and ileal J-pouch-anal anastomosis (IPAA) or completion proctectomy with or without IPAA in those who had previously undergone subtotal colectomy elsewhere. All patients underwent screening gastroduodenoscopy at 3-year intervals beginning at the time of diagnosis or referral. Postoperative morbidity, mortality, and functional outcome were evaluated, as well as the occurrence of extracolonic manifestations and results of treatment for duodenal adenomas when required. Fifty-four patients were included in the study (mean age 28 +/- 2 years). Twenty-seven of them (50%) underwent colectomy and IPAA as the initial operation. Twenty-seven patients had previously undergone subtotal colectomy. Eight of these 27 patients had cancer in the rectum, of which three were T4 and one was T2N1 cancer. Twenty-two patients underwent a completion proctectomy and three required abdominoperineal resection. Twenty of the 54 patients developed duodenal adenomas. The mean age of diagnosis of duodenal disease was not significantly different from that of patients who were still free of duodenal polyps (40 +/- 11 vs. 34 +/- 12 years). Seven of these 20 patients underwent local excision of duodenal polyps (either endocopically or transduodenally); four of these patients developed recurrent disease. Six patients underwent pancreaticoduodenectomy for duodenal adenomas with severe dyplasia. These patients experienced an increased number of bowel movements, from five per day (range 4 to 8) to 10 per day (range 6 to 15). One patient required pouch excision and end ileostomy to control diarrhea. Our data demonstrate the following: (1) patients with FAP who have undergone prior subtotal colectomy and ileorectal anastomosis have a high risk of developing advanced cancer in the rectal stump; (2) duodenal adenomas are common in patients with FAP and may occur at an early age; (3) screening duodenoscopy should be initiated at the time of diagnosis of FAP; (4) local excision of duodenal adenomas is associated with a high risk of local recurrence; and (5) even though pancreaticoduodenectomy is the treatment of choice for advanced duodenal adenomas, this procedure may adversely affect pouch function in some patients.