Early Experience with EndoRobotic Submucosal Dissection (ERSD): Pathologic and Short-term Outcomes in the First 28 Patients.

OBJECTIVE: To evaluate the safety and feasibility of single-port endorobotic submucosal dissection (ERSD) using the Da Vinci SP platform for the management of rectal neoplasms. SUMMARY BACKGROUND DATA: Endoscopic submucosal dissection (ESD) offers a potential organ-sparing treatment for advanced colorectal neoplasms but demands high technical skill and a steep learning curve. Advances in semiflexible robotic platforms, such as the Da Vinci SP, promise to simplify this procedure, potentially offering improved outcomes for patients with benign rectal neoplasms. METHODS: A retrospective analysis of 28 patients who underwent ERSD using the Da Vinci SP platform between 2020 and 2023 was performed. Patient demographics, lesion characteristics, procedure details, outcomes, and complications were reviewed. The primary endpoint was successful en-bloc resection. RESULTS: The cohort had a median age of 60.5 years and a median BMI of 28.2 kg/m², predominantly male(67.8%) with ASA categories 2 or 3(82%). Lesions had a median size of 38 mm and were located a median of 9 cm from the anal verge. The median procedure time was 87.5 minutes. En-bloc resection was achieved in all cases(100%), with no intraoperative complications or mortality. One patient experienced urinary retention, and one had late bleeding requiring blood transfusion. Pathology outcomes included 46.4% tubulovillous adenomas, 21.4% adenocarcinomas, and high-grade dysplasia in 53.6% of patients. CONCLUSION: Single-port ERSD using the Da Vinci SP platform is safe and feasible for the management of colorectal neoplasia, ensuring a high rate of en-bloc resection. It potentially offers advantages over conventional ESD, including shorter dissection times, although further studies are necessary for a definitive comparison.

A multicenter, retrospective study of a through-the-needle injection-capable electrosurgical knife for endoscopic submucosal dissection.

BACKGROUND AND AIMS: Endoscopic submucosal dissection (ESD) is a technically challenging resection technique for en bloc removal of dysplastic and early cancerous GI lesions. We conducted a single-arm retrospective study evaluating the safety and efficacy of a new through-the-needle injection-capable electrosurgical knife used in upper and lower ESD procedures performed at 6 U.S. academic centers. METHODS: Data were retrospectively collected on consecutive cases in which the new ESD knife was used. The primary efficacy endpoint was successful ESD (en bloc resection with negative margins). Secondary efficacy endpoints included en bloc resection rate, curative resection rate, median ESD time, and median dissection speed. The safety endpoint was device- or procedure-related serious adverse events. RESULTS: ESD procedures of 581 lesions in 579 patients were reviewed, including 187 (32.2%) upper GI and 394 (67.8%) lower GI lesions. Prior treatment was reported in 283 (48.9%) patients. Successful ESD was achieved in 477 (82.1% of 581) lesions-lower for patients with versus without submucosal fibrosis (73.6% vs 87.0%, respectively; P < .001) but similar for those with versus without previous treatment (81.7% vs 82.3%, respectively; P = .848). A total of 443 (76.2% of 581) lesions met criteria for curative resection. Median ESD time was 1.0 (range, 0.1-4.5) hour. Median dissection speed was 17.1 (interquartile range, 5.3-29.8) cm2/h. Related serious adverse events were reported in 15 (2.6%) patients, including delayed hemorrhage (1.9%), perforation (0.5%), or postpolypectomy syndrome (0.2%). CONCLUSION: A newly developed through-the-needle injection-capable ESD knife showed a good success rate and excellent safety at U.S. CENTERS: (Clinical trial registration number: NCT04580940.).

Managing prostate cancer after proctocolectomy and ileal pouch-anal anastomosis: feasibility and outcomes of single-port transvesical robot-assisted radical prostatectomy.

INTRODUCTION: Patients with proctocolectomy and ileal pouch-anal anastomosis (PC-IPAA) face unique challenges in managing prostate cancer due to their hostile abdomens and heightened small bowel mucosa radiosensitivity. In such cases, external beam radiation therapy (EBRT) is contraindicated, and while brachytherapy provides a safer option, its oncologic effectiveness is limited. The Single-Port Transvesical Robot-Assisted Radical Prostatectomy (SP TV-RARP) offers promise by avoiding the peritoneal cavity. Our study aims to evaluate its feasibility and outcomes in patients with PC-IPAA. METHODS: A retrospective evaluation was done on patients with PC-IPAA who had undergone SP TV-RARP from June 2020 to June 2023 at a high-volume center. Outcomes and clinicopathologic variables were analyzed. RESULTS: Eighteen patients underwent SP TV-RARP without experiencing any complications. The median hospital stay was 5.7 h, with 89% of cases discharged without opioids. Foley catheters were removed in an average of 5.5 days. Immediate urinary continence was seen in 39% of the patients, rising to 76 and 86% at 6- and 12-month follow-ups. Half of the cohort had non-organ confined disease on final pathology. Two patients with ISUP GG3 and GG4 exhibited detectable PSA post-surgery and required systemic therapy; both had SVI, multifocal ECE, and large cribriform pattern. Positive surgical margins were found in 44% of cases, mostly Gleason pattern 3, unifocal, and limited. After 11.1 months of follow-up, no pouch failure or additional BCR cases were found. CONCLUSION: Patients with PC-IPAA often exhibit aggressive prostate cancer features and may derive the greatest benefit from surgical interventions, particularly given that radiation therapy is contraindicated. SP TV-RARP is a safe option for this group, reducing the risk of bowel complications and promoting faster recovery.

Using Remotely Operated Suction Irrigation System in da Vinci SP Submucosal Dissection.

BACKGROUND: Submucosal dissection using the da Vinci SP® system (Intuitive Surgical, Sunnyvale, CA, USA) is an emerging approach for treating premalignant lesions in the colon and rectum. The endoluminal space is tight and small, and during the procedure, this tight space is accessed by the 40 mm GelPOINT® Path transanal platform (Applied Medical, Rancho Santa Margarita, CA, USA). Most of the trocar space is occupied by the 25 mm port of the da Vinci SP® system. There is limited space for an additional trocar, and the full mobility of this trocar is restricted; hence there is a need for an effective suction irrigator during these procedures. Although the da Vinci SP® system has four instrument capabilities, it does not have a suction irrigation instrument. To address this issue, we tested a Remotely Operated Suction Irrigation System (ROSI™) (VTI, Nashua, NH, USA) in three patients undergoing da Vinci SP® submucosal dissection. IMPACT OF INNOVATION: The impact of innovation is the evaluation of a flexible suction irrigator during endorobotic submucosal dissection (ERSD), addressing space constraints and enhancing surgical precision. TECHNOLOGY MATERIALS AND METHODS: This was a single-center retrospective observational study involving three patients who underwent ERSD, between February 2023 and May 2023. ROSI™ was used selectively for rectal lesions. PRELIMINARY RESULTS: The first patient was a 67-year-old male with a 30 mm tubulovillous adenoma found in the rectum at 4 cm. The second patient was a 49-year-old female, referred after a screening colonoscopy, with a 40 mm rectal mass 12 cm from the anal verge. A biopsy revealed a tubular adenoma without dysplasia. The last patient was a 66-year-old male with a 25 mm tubulovillous adenoma with a focal high-grade dysplasia at 10 cm. There was no evidence of invasive carcinoma or lymph node metastasis on MRI in any of the patients. The patients were placed in a modified lithotomy position, and the GelPOINT® Path was inserted. A silk suture was attached at the proximal end of ROSI™ to facilitate tubing manipulation. ROSI™ was freely passed into the endoluminal space through the gel using a surgical clamp. Any bleeding during the operation was aspirated and irrigated using ROSI™ with the assistance of bipolar forceps. All surgeries were completed without complications and the patients were discharged on the same day. CONCLUSION AND FUTURE DIRECTIONS: ROSI™ is a flexible foot pedal-controlled suction irrigator that can facilitate da Vinci SP® submucosal dissection. The flexibility and controllability of ROSI in the surgeon's hand may qualify it as an essential tool for performing ERSD and possibly other TAMIS procedures.

Use of Snare Tip Endoscopic Submucosal Dissection in the Endoluminal Management of Complex Colon Lesions.

BACKGROUND: Endoscopic submucosal dissection for advanced colon lesions is typically performed with specialized and costly endoscopic knives, potentially limiting accessibility and increasing procedural cost. Alternatively, the tip of an endoscopic snare, which is inexpensive and universally available, has demonstrated safe and efficient use in gastric lesions but lacks sufficient data for use in colon lesions. OBJECTIVE: This study aimed to assess patient outcomes following endoscopic submucosal dissection of advanced colon lesions using the endoscopic snare tip. DESIGN: A retrospective review of a prospectively maintained database at a single tertiary care center was conducted. SETTINGS: This study was conducted at a single tertiary care center. PATIENTS: Adult patients with colon lesions that were not amenable to snare polypectomy were evaluated for endoscopic submucosal dissection. Snare tip resection was performed in select patients with lesions that lifted adequately after submucosal injection. Patients who underwent hybrid resections with endoscopic mucosal dissection were excluded. MAIN OUTCOME MEASURES: En bloc resection rates, operative time, perioperative complications, and short-term outcomes such as length of stay and lesion recurrence on follow-up colonoscopy were evaluated. RESULTS: A total of 121 patients underwent snare tip endoscopic submucosal dissection, with a mean lesion size of 28.8 ± 9.84 mm. Most procedures were performed in the endoscopy suite (81.8%). The en bloc resection rate was 81.8% with an average procedure time of 37.1 ± 29.8 min. There were two perforations (1.70%), one of which was managed operatively. Recurrence occurred in 6 patients (7.89%) at the time of follow-up colonoscopy. LIMITATIONS: This study was retrospective, conducted by two skilled endoscopists with experience in endoscopic resection, and had short-term follow up. CONCLUSIONS: Snare tip endoscopic submucosal dissection for advanced colon lesions demonstrates satisfactory short-term outcomes, suggesting its potential as a safe and accessible alternative to specialized knives, thereby possibly enhancing adoption of endoscopic resection and improving patient accessibility. See Video Abstract.

A Propensity Score-Matched Analysis of Single-Port Vs Multiport Laparoscopic Total Abdominal Colectomy With End Ileostomy for Medically Refractory Ulcerative Colitis.

BACKGROUND: Medically refractory ulcerative colitis necessitates surgical intervention, with total abdominal colectomy with end ileostomy being a definitive treatment. The comparison between single-port and multiport laparoscopic surgery outcomes remains underexplored. OBJECTIVE: To compare the surgical outcomes of single-port versus multiport laparoscopic surgery in patients undergoing total abdominal colectomy with end ileostomy for medically refractory ulcerative colitis. DESIGN: A retrospective analysis comparing single-port to multiport surgery in patients with ulcerative colitis from 2010 to 2020. Patients were propensity score-matched 3:1 (multiport to single-port) on baseline characteristics. SETTINGS: Single-center academic hospital. PATIENTS: A total of 756 patients with medically refractory ulcerative colitis who underwent multiport vs single-port total abdominal colectomy with end ileostomy from 2010 to 2020 were included. MAIN OUTCOME MEASURES: Binary outcomes were compared using a multivariable logistic regression model, and a subset analysis was conducted for postoperative stump leak based on stump implantation during surgery. These metrics were compared between the single-port and multiport groups to assess the differences in surgical outcomes. RESULTS: The multiport and single-port groups included 642 and 114 patients, respectively. The matched cohort included 342 multiports and 114 single ports. We observed a statistically significant difference in mean operation time, with the single-port procedure taking 43 minutes less than the multiport laparoscopy. There were no significant differences between the 2 groups in postoperative stump leaks, postoperative ileus, stoma site complications, postoperative readmission within 30 days, postoperative reoperation within 30 days, and subsequent IPAA surgery. In the subset analysis, stump implantation was associated with a higher risk of stump leak in the multiport group. The single-port group had a shorter hospital stay. LIMITATIONS: Retrospective nature and being conducted at a single center. CONCLUSION: Single-incision laparoscopic total abdominal colectomy in the treatment of mucosal ulcerative colitis is a safe, effective, and efficient approach. In our cohort, single-incision laparoscopy has had shorter operation times and better overall length of stay compared with the multiport approach. Taking into account a less invasive approach, decreased abdominal trauma, and faster recovery, single-port surgery is a viable alternative to multiport surgery. See Video Abstract . UN ANLISIS EMPAREJADO POR PUNTUACIN DE PROPENSIN DE LA COLECTOMA ABDOMINAL TOTAL LAPAROSCPICA CON PUERTO NICO VERSUS PUERTO MLTIPLE CON ILEOSTOMA TERMINAL PARA LA COLITIS ULCEROSA MDICAMENTE REFRACTARIA: ANTECEDENTES:La colitis ulcerosa (CU) médicamente refractaria requiere una intervención quirúrgica, siendo la colectomía abdominal total con ileostomía terminal un tratamiento definitivo. La comparación entre los resultados de la cirugía laparoscópica con puerto único y con puerto múltiple aún no se ha explorado lo suficiente.OBJETIVO:Comparar los resultados quirúrgicos de la cirugía laparoscópica con puerto único versus con puerto múltiple en pacientes sometidos a colectomía abdominal total con ileostomía terminal para CU médicamente refractaria.DISEÑO:Un análisis retrospectivo que comparó la cirugía de puerto único con la de puerto múltiple en pacientes con CU de 2010 a 2020. Los pacientes fueron emparejados por puntuación de propensión 3:1 (puerto múltiple a puerto único) según las características iniciales.AJUSTES:Hospital académico unicentrico.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados binarios se compararon utilizando un modelo de regresión logística multivariable y se realizó un análisis de subconjunto para la fuga postoperatoria del muñón basado en la implantación del muñón durante la cirugía. Estas métricas se compararon entre los grupos de puerto único y de puerto múltiple para evaluar las diferencias en los resultados quirúrgicos.RESULTADOS:Los grupos de puerto único y multipuerto incluyeron 642 y 114 pacientes, respectivamente. La cohorte emparejada incluyó 342 puertos múltiples y 114 puertos únicos. Observamos una diferencia estadísticamente significativa en el tiempo medio de operación, ya que el procedimiento de puerto único duró 43 minutos menos que la laparoscopia de puerto múltiple. No hubo diferencias significativas entre los dos grupos en las fugas del muñón posoperatorio, el íleo posoperatorio, las complicaciones del sitio del estoma, el reingreso posoperatorio dentro de los 30 días, la reoperación posoperatoria dentro de los 30 días y la cirugía IPAA posterior. En el análisis de subconjunto, la implantación del muñón se asoció con un mayor riesgo de fuga del muñón en el grupo multipuerto. El grupo de puerto único tuvo una estancia hospitalaria más corta.LIMITACIONES:Carácter retrospectivo, realizándose en un único centro.CONCLUSIÓN:La colectomía abdominal total laparoscópica de incisión única en el tratamiento de la colitis ulcerosa mucosa es un enfoque seguro, eficaz y eficiente. En nuestra cohorte, en comparación con el abordaje multipuerto, la laparoscopia de incisión única ha mostrado tiempos de operación más cortos y una mejor duración total de la estancia hospitalaria. Teniendo en cuenta un enfoque menos invasivo, un menor traumatismo abdominal y una recuperación más rápida, la cirugía con puerto único es una alternativa viable a la cirugía con puertos múltiples. (Traducción-Dr. Mauricio Santamaria ).

Predictors of En Bloc, R0 Resection, and Postprocedural Complications After Advanced Endoscopic Resections for Colorectal Neoplasms: Results of 1213 Procedures.

BACKGROUND: Advanced endoscopic resection techniques are used to treat colorectal neoplasms that are not amenable to conventional colonoscopic resection. Literature regarding the predictors of the outcomes of advanced endoscopic resections, especially from a colorectal surgical unit, is limited. OBJECTIVE: To determine the predictors of short-term and long-term outcomes after advanced endoscopic resections. DESIGN: Retrospective case series. SETTINGS: Tertiary care center. PATIENTS: Patients who underwent advanced endoscopic resections for colorectal neoplasms from November 2011 to August 2022. INTERVENTIONS: Endoscopic mucosal resection, endoscopic submucosal dissection, hybrid endoscopic submucosal dissection, and combined endoscopic laparoscopic surgery. MAIN OUTCOME MEASURES: Predictors of en bloc and R0 resection, bleeding, and perforation were determined using univariable and multivariable logistic regression models. Cox regression models were used to determine the predictors of tumor recurrence. RESULTS: A total of 1213 colorectal lesions from 1047 patients were resected (median age 66 [interquartile range, 58-72] years, 484 women [46.2%], median BMI 28.6 [interquartile range, 24.8-32.6]). Most neoplasms were in the proximal colon (898; 74%). The median lesion size was 30 (interquartile range, 20-40; range, 0-120) mm. Nine hundred eleven lesions (75.1%) underwent previous interventions. The most common Paris and Kudo classifications were 0 to IIa flat elevation (444; 36.6%) and IIIs (301; 24.8%), respectively. En bloc and R0 resection rates were 56.6% and 54.3%, respectively. Smaller lesions, rectal location, and procedure type (endoscopic submucosal dissection) were associated with significantly higher en bloc and R0 resection rates. Bleeding and perforation rates were 5% and 6.6%, respectively. Increased age was a predictor for bleeding (OR 1.06; 95% CI, 1.03-1.09; p < 0.0001). Lesion size was a predictor for perforation (OR 1.02; 95% CI, 1.00-1.03; p = 0.03). The tumor recurrence rate was 6.6%. En bloc (HR 1.41; 95% CI, 1.05-1.93; p = 0.02) and R0 resection (HR 1.49; 95% CI, 1.11-2.06; p = 0.008) were associated with decreased recurrence risk. LIMITATIONS: Single-center, retrospective study. CONCLUSIONS: Outcomes of advanced endoscopic resections can be predicted by patient-related and lesion-related characteristics. See Video Abstract . PREDICTORES DE LA RESECCION R, EN BLOQUE Y LAS COMPLICACIONES POR RESECCIONES ENDOSCPICAS AVANZADAS EN CASOS DE NEOPLASIA COLORRECTAL RESULTADOS DE PROCEDIMIENTOS: ANTECEDENTES:Las técnicas avanzadas de resección endoscópica se utilizan para el tratamiento de neoplasias colorrectales que no son susceptibles de resección colonoscópica convencional. La literatura sobre los predictores de los resultados de las resecciones endoscópicas avanzadas, especialmente en una unidad de cirugía colorrectal, es limitada.OBJETIVO:Determinar los predictores de resultados a corto y largo plazo después de resecciones endoscópicas avanzadas.DISEÑO:Serie de casos retrospectivos.LUGAR:Centro de tercer nivel de atención.PACIENTES:Pacientes sometidos a resecciones endoscópicas avanzadas por neoplasias colorrectales desde noviembre de 2011 hasta agosto de 2022.INTERVENCIÓNES:Resección endoscópica de la mucosa, disección endoscópica submucosa (ESD), ESD híbrida, cirugía laparoscópica endoscópica combinada.PRINCIPALES MEDIDAS DE RESULTADO:Los predictores de resección en bloque y R0, sangrado y perforación se determinaron mediante modelos de regresión logística univariables y multivariables. Se utilizaron modelos de regresión de Cox para determinar los predictores de recurrencia del tumor.RESULTADOS:Se resecaron 1.213 lesiones colorrectales en 1.047 pacientes [edad media 66 (58-72) años, 484 (46,2%) mujeres, índice de masa corporal medio 28,6 (24,8-32,6) kg/m 2 ]. La mayoría de las neoplasias se encontraban en el colon proximal (898, 74%). El tamaño medio de la lesión fue de 30mm (RIC: 20-40, rango: 0-120). 911 (75,1%) lesiones tenían intervenciones previas. Las clasificaciones de París y Kudo más comunes fueron 0-IIa elevación plana (444, 36,6%) y III (301, 24,8%), respectivamente. Las tasas de resección en bloque y R0 fueron del 56,6% y 54,3%, respectivamente. Las lesiones más pequeñas, la ubicación rectal y el tipo de procedimiento (ESD) se asociaron con tasas de resección en bloque y R0 significativamente más altas. Las tasas de sangrado y perforación fueron del 5% y 6,6%, respectivamente. La edad avanzada [1,06 (1,03-1,09), p < 0,0001] fue un predictor de sangrado. El tamaño de la lesión [1,02 (1,00-1,03), p = 0,03] fue un predictor de perforación. La tasa de recurrencia del tumor fue del 6,6%. En bloque [HR 1,41 (IC 95% 1,05-1,93), p = 0,02] y la resección R0 [HR 1,49 (IC 95% 1,11-2,06), p = 0,008] se asociaron con un menor riesgo de recurrencia.LIMITACIONES:Estudio unicéntrico, retrospectivo.CONCLUSIONES:Los resultados de las resecciones endoscópicas avanzadas pueden predecirse según las características del paciente y de la lesión. (Traducción-Dr. Xavier Delgadillo ).

What Predicts Complete Response to Total Neoadjuvant Therapy in Locally Advanced Rectal Cancer?

BACKGROUND: Total neoadjuvant therapy in treatment of stage II-III rectal cancer involves administration of either induction or consolidation chemotherapy with chemoradiation before surgery. Total neoadjuvant therapy is associated with increased complete response rate, which is defined as the proportion of patients who either had pathological complete response after surgery or sustained clinical complete response at least for a year under surveillance. OBJECTIVE: To identify the predictors of complete response to total neoadjuvant therapy and compare different diagnostic tools in predicting complete response. DESIGN: Retrospective cohort study. SETTINGS: A single tertiary-care center. PATIENTS: Stage II-III rectal cancer patients who were diagnosed between January 2015 and December 2021. INTERVENTION: Total neoadjuvant therapy. MAIN OUTCOME MEASURES: Complete response rate, predictors of complete response, sensitivity and specificity of sigmoidoscopy and MRI in predicting complete response. RESULTS: One hundred nineteen patients (mean age 56 [±11.3] years, 47 [39.5%] female, 100 [84%] stage III rectal cancer were included. Median tumor size was 5.1 (4-6.5) cm, 63 (52.9%) were low rectal tumors. Twenty-one (17.6%) patients had extramural vascular invasion, 62 (52.1%) had elevated carcinoembryonic antigen at baseline. One hundred eight (90.8%) patients received consolidation chemotherapy. After total neoadjuvant therapy, 88 (73.9%) out of 119 patients underwent surgery, of whom 20 (22.7%) had pathological complete response. Thirty-one (26.1%) patients underwent watch-and-wait, of whom 24 (77.4%) had sustained clinical complete response. Overall complete response rate was 37%. Low rectal tumors (OR 2.6 [95% CI, 1.1-5.9], p = 0.02) and absence of EMVI [OR 5.4 (95% CI, 1.2-25.1), p = 0.01] were predictors of complete response. In predicting complete response, sigmoidoscopy was more sensitive (76.0% vs. 62.5%) and specific (72.5% vs. 69.2%) than MRI. The specificity further increased when 2 techniques were combined (82.5%). LIMITATIONS: Retrospective study. CONCLUSIONS: Complete response rate after total neoadjuvant therapy was 37%. Low rectal tumors and absence of extramural vascular invasion were predictors of complete response. Sigmoidoscopy was better in predicting incomplete response, whereas combination (MRI and sigmoidoscopy) was better in predicting complete response.

Fact or fiction? Does the position of the end-to-end (EEA) stapler spike matter for colorectal anastomoses using a double-stapled technique?

AIM: Surgeons often have strong opinions about how to perform colorectal anastomoses with little data to support variations in technique. The aim of this study was to determine if location of the end-to-end (EEA) stapler spike relative to the rectal transection line is associated with anastomotic integrity. METHOD: This study was a retrospective analysis of a quality collaborative database at a quaternary centre and regional hospitals. Patients with any left-sided colon resection with double-stapled anastomosis were included (December 2019 to August 2022). Our primary endpoint was a composite outcome including positive air insufflation test, incomplete anastomotic donut, or thin/eccentric donut. Our secondary endpoint was clinical leak. RESULTS: Overall, 633 patients were included and stratified by location of the stapler spike relative to the rectal transection line. Of note, 86 patients had an end-colon to anterior rectum ("reverse Baker") anastomosis with no crossing staple lines. The rates of the composite endpoint based on position of the stapler spike were 12.4% (anterior), 8.1% (through), 12.8% (posterior), 5.1% (corner), and 2.3% for the "reverse Baker" (p = 0.03). The overall rate of clinical leak was 3.8% and there were no differences between methods. In a multivariate analysis, the "reverse Baker" anastomosis was associated with decreased odds of poor anastomotic integrity when compared to anastomoses with crossing staple lines (OR 0.20, 95% CI: 0.05-0.87, p = 0.03). CONCLUSIONS: For anastomoses with crossing staple lines, the position of the stapler spike relative to the rectal staple line is not associated with differences in anastomotic integrity. In contrast, anastomoses with no crossing staple lines resulted in significantly lower rates of poor anastomotic integrity, but no difference in clinical leaks.

Outcome of incidental versus preoperatively diagnosed colorectal cancer during total proctocolectomy with ileal pouch-anal anastomosis for inflammatory bowel disease.

AIM: Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the treatment of choice for colorectal cancer (CRC) in inflammatory bowel disease. CRC may also be discovered incidentally at IPAA for other indications. We sought to determine whether incidentally found CRC at IPAA was associated with worse outcomes. METHODS: Our institutional pouch registry (1983-2021) was retrospectively reviewed. Patients with CRC at pathology after IPAA were divided into two groups: a preoperative diagnosis (PreD) group and an incidental diagnosis (InD) group. Their long-term outcomes (overall survival, disease-free survival and pouch survival) were compared. RESULTS: We included 164 patients: 53 (32%) InD and 111 (68%) PreD. There were no differences in cancer staging, differentiation and location. After a median follow-up of 11 (IQR 3-25) years for InD and 9 (IQR 3-20) years for the PreD group, deaths were 14 (26%) in the InD group and 18 (16%) in the PreD group. Pouch failures were five (9%) in the InD group and nine (8%) in the PreD group, of which two (5%) and four (4%) were cancer related. Ten-year overall survival was 94% for InD and 89% for PreD (P = 0.41), disease-free survival was 95% for InD and 90% for PreD (P = 0.685) and pouch survival was 89% for InD and 97% for PreD (P = 0.80). Pouch survival at 10 years was lower in rectal versus colon cancer (87% vs. 97%, P = 0.01). No difference was found in outcomes in handsewn versus stapled anastomoses. CONCLUSION: Inflammatory bowel disease patients with incidentally found CRC during IPAA appear to have similarly excellent oncological and pouch outcomes to patients with a preoperative cancer diagnosis.

The role of advanced endoscopy in appendiceal polyp management and outcomes.

BACKGROUND: Appendiceal orifice lesions are often managed operatively with limited or oncologic resections. The aim is to report the management of appendiceal orifice mucosal neoplasms using advanced endoscopic interventions. METHODS: Patients with appendiceal orifice mucosal neoplasms who underwent advanced endoscopic resections between 2011 and 2021 with either endoscopic mucosal resection (EMR), endoscopic mucosal dissection (ESD), hybrid ESD, or combined endoscopic laparoscopic surgery (CELS) were included from a prospectively collected dataset. Patient and lesion details and procedure outcomes are reported. RESULTS: Out of 1005 lesions resected with advanced endoscopic techniques, 41 patients (4%) underwent appendiceal orifice mucosal neoplasm resection, including 39% by hybrid ESD, 34% by ESD, 15% by EMR, and 12% by CELS. The median age was 65, and 54% were male. The median lesion size was 20 mm. The dissection was completed piecemeal in 49% of patients. Post-procedure, one patient had a complication within 30 days and was admitted with post-polypectomy abdominal pain treated with observation for 2 days with no intervention. Pathology revealed 49% sessile-serrated lesions, 24% tubular adenomas, and 15% tubulovillous adenomas. Patients were followed up for a median of 8 (0-48) months. One patient with a sessile-serrated lesion experienced a recurrence after EMR which was re-resected with EMR. CONCLUSION: Advanced endoscopic interventions for appendiceal orifice mucosal neoplasms can be performed with a low rate of complications and early recurrence. While conventionally lesions at the appendiceal orifice are often treated with surgical resection, advanced endoscopic interventions are an alternative approach with promising results which allow for cecal preservation.

Acute colonic pseudo-obstruction: a retrospective review of the surgical outcomes.

PURPOSE: Limited data exist regarding the surgical outcomes of acute colonic pseudo-obstruction (ACPO), commonly referred to as Ogilvie syndrome, in modern clinical practice. The prevailing belief is that surgery should be avoided due to previously reported high mortality rates. We aimed to describe the surgical results of ACPO treated within our institution. METHODS: Our prospectively maintained colorectal surgery registry was queried for patients diagnosed with ACPO, who underwent surgery between 2009 and 2022. Postoperative complications were graded according to Clavien-Dindo (CD) classification. The primary outcome was postoperative mortality. RESULTS: A total of 32 patients who underwent surgery for ACPO were identified. Overall, nonoperative therapy was initially administered to 21 patients (65.6%). The surgeries performed included total abdominal colectomy (15, 43.1%), ascending colectomy with end ileostomy (8, 25%), transverse colostomy (5, 15.6%), ileostomy and transverse colostomy (3, 9.4%), and Hartmann's operation (1, 3.1%). Severe postoperative complications (CD grade 3 or 4) occurred in five patients (15.6%). No recurrence of ACPO was observed and no patient required reoperation. The average postoperative length of stay was 14.5 days, 30-day mortality was 6.3% (n = 2), and 90-day mortality was 15.6% (n = 5) due to complications of underlying comorbidities. CONCLUSIONS: Surgical treatment was effective for patients with ACPO refractory to medical therapy or presenting with acute complications. Although postoperative complications were frequent, both the 30- and 90-day mortality rates were lower than previously documented in the literature. Further investigations are warranted to determine the optimal surgical strategy, which may involve total or segmental colectomy, or diversion alone without resection.

Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection.

Up to 15% of colorectal polyps are amenable for conventional polypectomy. Advanced endoscopic resection techniques are introduced for the treatment of those polyps. They provide higher en bloc resection rates compared with conventional techniques, while helping patients to avoid the complications of surgery. Note that 20 mm is considered as the largest size of a polyp that can be resected by polypectomy or endoscopic mucosal resection (EMR) in an en bloc fashion. Endoscopic submucosal dissection (ESD) is recommended for polyps larger than 20 mm. Intramucosal carcinomas and carcinomas with limited submucosal invasion can also be resected with ESD. EMR is snare resection of a polyp following submucosal injection and elevation. ESD involves several steps such as marking, submucosal injection, incision, and dissection. Bleeding and perforation are the most common complications following advanced endoscopic procedures, which can be treated with coagulation and endoscopic clipping. En bloc resection rates range from 44.5 to 63% for EMR and from 87.9 to 96% for ESD. Recurrence rates following EMR and ESD are 7.4 to 17% and 0.9 to 2%, respectively. ESD is considered enough for the treatment of invasive carcinomas in the presence of submucosal invasion less than 1000 µm, absence of lymphovascular invasion, well-moderate histological differentiation, low-grade tumor budding, and negative resection margins.

Role of Lateral Pelvic Node Dissection in Rectal Cancer Surgery.

The role of lateral pelvic lymph node dissection in the treatment of patients with locally advanced rectal cancer is a matter of controversy. Surgical practices in Korea and Japan have accepted this approach and are widely utilized; however, it is not routinely incorporated in the practice of countries in the Western hemisphere. This review will examine the role of lateral pelvic lymph node dissection.

Single-Port Endorobotic Rectal Mucosa Harvest For Urethral Reconstruction.

BACKGROUND: Colorectal mucosal grafts for substitution urethroplasty are alternatives for patients when buccal mucosa is not adequate for long urethral strictures. IMPACT OF INNOVATION: This study presents the first cases of single-port endorobotic rectal mucosa harvesting for urethral reconstruction. TECHNOLOGY MATERIALS AND METHODS: The patients are 43- and 57-year-old men with medical histories of lichen sclerosis. The urethrograms demonstrated panurethral strictures requiring long mucosal grafts. The single-port robot was docked under general anesthesia in the modified lithotomy position. The procedure began with a submucosal injection of a lifting agent. After achieving an adequate lift of the mucosa, the dissection was started 2 cm proximal to the sphincter complex with a hook and continued cephalad. The semiflexible robotic platform eased and facilitated the dissection providing the required traction and counter traction. The injecting needle and aspiration device were directed with the help of a silk knot at the tip of the tools to create a handle for robot arms. The procedure was continued with a spatula tip thinner than the hook, which delivers less energy to the dissection field and creates a precise cut. The harvested graft was provided to the urology team after pinning it for measurement. The urologists prepared and completed the reconstruction of the urethra with the autograft. PRELIMINARY RESULTS: The patient had no complications related to his rectal mucosa harvest. CONCLUSIONS: We report the first 2 cases of single-port robotic rectal mucosal harvesting for long panurethral strictures with single-port endorobotic submucosal dissection technique. FUTURE DIRECTIONS: The technique seems promising to facilitate the precise submucosal dissection with meticulous control of traction and delivered energy.

Impact of Total Neoadjuvant Therapy on Postoperative Outcomes After Proctectomy for Rectal Cancer.

BACKGROUND: Total neoadjuvant therapy is an alternative to neoadjuvant chemoradiation alone for rectal cancer and has the benefits of more completion of planned therapy, increased downstaging, earlier treatment of micrometastases, and assessment of chemosensitivity; however, it may increase surgical complications, especially with increased radiation-to-surgery interval. OBJECTIVE: The study aimed to determine the impact of total neoadjuvant therapy on postoperative complications compared with neoadjuvant chemoradiation alone. DESIGN: Retrospective cohort study. SETTINGS: Single tertiary referral center. PATIENTS: The patient included was a stage II/III rectal cancer patient who underwent total neoadjuvant therapy or long-course neoadjuvant chemoradiation followed by surgical resection from 2018-2020. MAIN OUTCOME MEASURES: The main outcome measures included severe postoperative complications (Clavien-Dindo grade ≥3). RESULTS: Of 181 patients, 86 (47.5%) underwent total neoadjuvant therapy and 95 (52.5%) underwent neoadjuvant chemoradiation. There was no difference in severe postoperative complications or any complications. There was also no difference in the rate of complete total mesorectal excision or negative circumferential margin. Total neoadjuvant therapy had a mean operative time of 355.5 minutes and estimated blood loss of 263.6 mL compared with 326.7 minutes and 297.5 mL in the neoadjuvant chemoradiation group. Total neoadjuvant therapy patients had a lower mean lymph node yield than neoadjuvant chemoradiation patients. On multivariable analysis, total neoadjuvant therapy was associated with increased operative time (OR, 1.19; p < 0.001) and estimated blood loss (OR, 1.22; p < 0.001) and decreased lymph node yield (OR, 0.67; p < 0.001). There was no difference in severe complications or any complications. LIMITATIONS: Selection bias uncontrolled by modeling. CONCLUSIONS: We found no difference in risk of postoperative complications between patients who received total neoadjuvant therapy vs neoadjuvant chemoradiation. Total neoadjuvant therapy patients had longer operations and greater estimated blood loss. This may be a reflection of increased operative difficulty because of increased radiation-to-surgery interval and/or the effects of chemotherapy; however, the absolute differences were small and, therefore, should be interpreted cautiously. See Video Abstract at http://links.lww.com/DCR/C44 . IMPACTO DE LA TERAPIA NEOADYUVANTE TOTAL EN LOS RESULTADOS POSOPERATORIOS DESPUS DE UNA PROCTECTOMA POR CNCER DE RECTO: ANTECEDENTES:La terapia neoadyuvante total es una alternativa a la quimiorradiación neoadyuvante sola para el cáncer de recto y tiene los beneficios de una mayor finalización de la terapia planificada, mayor reducción del estadiage, tratamiento más temprano de las micrometástasis y evaluación de la quimiosensibilidad; sin embargo, puede aumentar las complicaciones quirúrgicas, especialmente con un mayor intervalo entre la radiación y la cirugía.OBJETIVO:Determinar el impacto de la terapia neoadyuvante total sobre las complicaciones posoperatorias en comparación con la quimiorradiación neoadyuvante sola.DISEÑO:Estudio de cohorte retrospectivo.ENTORNO CLINICO:Centro único de referencia terciario.PACIENTES:Paciente con cáncer de recto en estadio II/III que se sometieron a terapia neoadyuvante total o quimiorradiación neoadyuvante de larga duración seguida de resección quirúrgica entre 2018 y 2020.PRINCIPALES MEDIDAS DE RESULTADO:Complicaciones postoperatorias graves (grado de Clavien-Dindo ≥3).RESULTADOS:De 181 pacientes, 86 (47,5%) se sometieron a terapia neoadyuvante total y 95 (52,5%) se sometieron a quimiorradioterapia neoadyuvante. No hubo diferencia en las complicaciones postoperatorias graves o cualquier otra complicación. Tampoco hubo diferencia en la tasa de escisión mesorrectal total completa o margen circunferencial negativo. La terapia neoadyuvante total tuvo un tiempo operatorio promedio de 355,5 minutos y una pérdida de sangre estimada de 263,6 ml en comparación con 326,7 minutos y 297,5 ml en el grupo de quimiorradiación neoadyuvante. Los pacientes con terapia neoadyuvante total tuvieron una media de ganglios linfáticos más bajo en comparación con los pacientes con quimiorradioterapia neoadyuvante. En el análisis multivariable, la terapia neoadyuvante total se asoció con un mayor tiempo operatorio (OR = 1,19, p < 0,001) y pérdida de sangre estimada (OR = 1,22, p < 0,001) y menor cantidad los ganglios linfáticos (OR = 0,67, p < 0,001). No hubo diferencia en las complicaciones graves o cualquier complicación.LIMITACIONES:Sesgo de selección no controlado por modelado.CONCLUSIONES:No encontramos diferencias en el riesgo de complicaciones postoperatorias entre los pacientes que recibieron terapia neoadyuvante total versus quimiorradiación neoadyuvante. Los pacientes con terapia neoadyuvante total tuvieron operaciones más prolongadas y una mayor pérdida de sangre estimada. Esto puede ser un reflejo de una mayor dificultad quirúrgica como resultado de un mayor intervalo entre la radiación y la cirugía y/o los efectos de la quimioterapia; sin embargo, las diferencias absolutas fueron pequeñas y, por lo tanto, deben interpretarse con cautela. Consulte Video Resumen en http://links.lww.com/DCR/C44 . (Traducción- Dr. Francisco M. Abarca-Rendon ).

The Learning Curve for Advanced Endoscopy for Colorectal Lesions: A Surgeon's Experience at a High-Volume Center.

BACKGROUND: Advanced endoscopy can be used for the complete removal of large colorectal polyps. To date, few surgeons perform advanced endoscopy, and it is unknown how many procedures are needed to reach proficiency. OBJECTIVE: This study aimed to determine the learning curve for colorectal advanced endoscopy. DESIGN: Retrospective. SETTING: Tertiary referral center. PATIENTS: We queried a prospectively maintained institutional database of advanced endoscopy performed by a high-volume colorectal surgeon between 2011 and 2018. MAIN OUTCOME MEASURES: Advanced endoscopy characteristics were compared for 6 chronological intervals. Primary end points were the rates of complications and polyp recurrence. Secondary end point was the change in polyp removal rate (mm/h) over time. RESULTS: A total of 207 patients underwent advanced endoscopy for a single colorectal polyp. The median polyp size was 30 (4-70) mm, 61.5% were located in the right colon, and 8.8% were malignant. The mean procedure time was 77 (range, 16-320) minutes. Immediate colon resection occurred in 25 patients because of suspicion of cancer or concern for perforation and was excluded from the learning curve analysis. The remaining 182 advanced endoscopy procedures were divided into intervals of 30 procedures. The median removal rate was highest in the last interval and in the endoscopy suite. A removal rate of 30 mm/h was achieved after performing 100 cases. The complication rate (bleeding or return to operating room) was 12.1% and was similar across intervals. The readmission rate was 11.5%, and 6.6% of 6-month follow-up colonoscopies showed polyp recurrence at the resection site. LIMITATIONS: Retrospective design and single surgeon. CONCLUSION: The learning curve for achieving proficiency with advanced endoscopy in the colon and rectum required a minimum of 100 cases with a low complication rate, low polyp recurrence rate, high en bloc resection rate, and a polyp removal rate of 30 mm/h. See Video Abstract at http://links.lww.com/DCR/C162 .LA CURVA DE APRENDIZAJE DE LA ENDOSCOPIA AVANZADA PARA LESIONES COLORRECTALES: LA EXPERIENCIA DE UN CIRUJANO EN UN CENTRO DE ALTO VOLUMENANTECEDENTES:La endoscopia avanzada se puede utilizar para la extirpación completa de pólipos colorrectales grandes. Hasta la fecha, pocos cirujanos realizan endoscopia avanzada y se desconoce cuántos procedimientos se necesitan para alcanzar la competencia.OBJETIVO:Determinar la curva de aprendizaje de la endoscopia colorrectal avanzada.DISEÑO:Retrospectivo.AJUSTE:Centro de referencia terciario.PACIENTES:Consultamos una base de datos institucional mantenida prospectivamente de endoscopia avanzada realizada por un cirujano colorrectal de alto volumen entre 2011 y 2018.PRINCIPALES MEDIDAS DE RESULTADO:Se compararon las características de la endoscopia avanzada en seis intervalos cronológicos. Los puntos finales primarios fueron las tasas de complicaciones y recurrencia de pólipos. El criterio de valoración secundario fue el cambio en la tasa de eliminación de pólipos (mm/h) a lo largo del tiempo.RESULTADOS:Un total de 207 pacientes se sometieron a una endoscopia avanzada por un solo pólipo colorrectal. La mediana del tamaño de los pólipos fue de 30 (4-70) mm, el 61,5% se ubicaron en el colon derecho y el 8,8% fueron malignos. El tiempo medio del procedimiento fue de 77 (rango: 16-320) minutos. La resección inmediata del colon ocurrió en 25 pacientes debido a la sospecha de cáncer o preocupación por la perforación y fueron excluidos del análisis de la curva de aprendizaje. Los restantes 182 procedimientos de endoscopia avanzada se dividieron en intervalos de 30 procedimientos. La mediana de la tasa de extirpación fue más alta en el último intervalo y en la sala de endoscopia. Se logró una tasa de extirpación de 30 mm/hr después de realizar 100 casos. La tasa de complicaciones (sangrado o retorno al quirófano) fue del 12,1% y fue similar en todos los intervalos. La tasa de reingreso fue del 11,5% y el 6,6% de las colonoscopias de seguimiento a los 6 meses mostraron recurrencia de pólipos en el sitio de la resección.LIMITACIONES:Diseño retrospectivo, cirujano único.CONCLUSIÓN:La curva de aprendizaje para lograr el dominio de la endoscopia avanzada en el colon y el recto requiere un mínimo de 100 casos con una baja tasa de complicaciones, baja tasa de recurrencia de pólipos, alta tasa de resección en bloque y una tasa de eliminación de pólipos de 30 mm/h. Consulte el Video Resumen en http://links.lww.com/DCR/C162 . (Traducción-Dr. Yesenia.Rojas-Khalil ).

Leaks From the Tip of the J-pouch: Diagnosis, Management, and Long-term Pouch Survival.

BACKGROUND: The standard of care for surgical treatment of ulcerative colitis is restorative proctocolectomy with ileal J-pouch. Leaks from the tip of the J-pouch are a known complication, but there is a paucity of literature regarding this type of leak. OBJECTIVE: We aimed to describe the diagnosis, management, and long-term clinical outcomes of leaks from the tip of the J-pouch at our institution. DESIGN: This was a retrospective study of a prospectively maintained pouch registry. SETTING: This study was conducted at a quaternary IBD referral center. PATIENTS: Patients included those with ileal J-pouches diagnosed with leaks from the tip of the J-pouch. MAIN OUTCOME MEASURES: The main measures of outcomes were pouch salvage rate, type of salvage procedures, and long-term Kaplan-Meier pouch survival. RESULTS: We identified 74 patients with leaks from the tip of the J-pouch. Pain (68.9%) and pelvic abscess (40.9%) were the most common presentations, whereas 10.8% of patients presented with an acute abdomen. The leak was diagnosed by imaging and/or endoscopy in 74.3% of patients but only discovered during surgical exploration in 25.6% of patients. Some 63.5% of patients were diagnosed only after loop ileostomy closure, whereas 32.4% of patients were diagnosed before ileostomy closure. The most common methods used for diagnosis were pouchoscopy (31.1%) and gastrograffin enema (28.4%). A definitive nonoperative approach was attempted in 48.6% of patients but was successful in only 10.8% of patients overall. Surgical repair was attempted in 89.2% of patients, whereas 4.5% of patients had pouch excision. Salvage operations (n = 63) included sutured or stapled repair of the tip of the J (65%), pouch excision with neo-pouch (25.4%), and pouch disconnection, repair, and reanastomosis (9.5%). Ultimately' 10 patients (13.5%) required pouch excision, yielding an overall 5-year pouch survival rate of 86.3%. LIMITATIONS: This was a retrospective review; referral bias may limit the generalizability. CONCLUSIONS: Leaks from the tip of the J-pouch have variable clinical presentations and require a high index of suspicion. Pouch salvage surgery is required in the majority of patients and is associated with a high pouch salvage rate. See Video Abstract at http://links.lww.com/DCR/C50 . FUGAS DEL EXTREMO DE LA BOLSA EN J DIAGNSTICO, MANEJO Y SUPERVIVENCIA A LARGO PLAZO DE LA BOLSA: ANTECEDENTES:El estándar de atención para el tratamiento quirúrgico de la colitis ulcerosa es la proctocolectomía restauradora con bolsa ileal en J. Las fugas del extremo de la bolsa en J son una complicación conocida, pero hay escasez de literatura sobre este tipo de fuga.OBJETIVO:Describir el diagnóstico, manejo y resultados clínicos a largo plazo de las fugas del extremo de la bolsa en J en nuestra institución.DISEÑO:Estudio retrospectivo de registro de bolsa mantenido prospectivamente.ENTORNO CLINICO:Centro de referencia de enfermedad inflamatoria intestinal cuaternaria.PACIENTES:Pacientes con bolsas ileales en J diagnosticadas con fugas del extremo de la J.PRINCIPALES MEDIDAS DE VALORACIÓN:Tasa de rescate de la bolsa, tipo de procedimientos de rescate y supervivencia a largo plazo de la bolsa Kaplan-Meier.RESULTADOS:Identificamos 74 pacientes con fugas del extremo de la bolsa en J. El dolor (68,9%) y el absceso pélvico (40,9%) fueron las presentaciones más comunes, mientras que el 10,8% de los pacientes presentaron abdomen agudo. La fuga se diagnosticó por imagen y/o endoscopia en el 74,3%, pero solo se descubrió durante la exploración quirúrgica en el 25,6%. El 63,5% fueron diagnosticados solo después del cierre de la ileostomía en asa, mientras que el 32,4% lo fueron antes del cierre de la ileostomía. Los métodos más comunes utilizados para el diagnóstico fueron la endoscopia (31,1%) y el enema de gastrografín (28,4%). Se intentó un abordaje no quirúrgico definitivo en el 48,6%, pero tuvo éxito en solo el 10,8% de los pacientes en general. Se intentó la reparación quirúrgica en el 89,2% de los pacientes, mientras que en el 4,5% se realizó la escisión del reservorio. Las operaciones de rescate (n = 63) incluyeron la reparación con sutura o grapas del extremo de la J (65%), la escisión del reservorio con neo-reservorio (25,4%) y la desconexión, reparación y reanastomosis del reservorio (9,5%). Finalmente, 10 (13,5%) pacientes requirieron la escisión de la bolsa, lo que se asocio con una alta tasa de supervivencia general de la bolsa a los 5 años del 86,3%.LIMITACIONES:Revisión retrospectiva; el sesgo de referencia puede limitar la generalización.CONCLUSIONES:Las fugas del extremo de la bolsa en J tienen presentaciones clínicas variables y requieren un alto índice de sospecha. La cirugía de rescate de la bolsa se requiere en la mayoría y se asocia con una alta tasa de rescate de la bolsa. Consulte Video Resumen en http://links.lww.com/DCR/C50 . (Traducción- Dr. Ingrid Melo ).

Effect of Incisional Negative Pressure Wound Therapy on Surgical Site Infections in High-Risk Reoperative Colorectal Surgery: A Randomized Controlled Trial.

BACKGROUND: Colorectal resections have relatively high rates of surgical site infections causing significant morbidity. Incisional negative pressure wound therapy was introduced to improve wound healing of closed surgical incisions and to prevent surgical site infections. OBJECTIVE: This randomized controlled trial aimed to investigate the effect of incisional NPWT on superficial surgical site infections in high-risk, open, reoperative colorectal surgery. DESIGN: This was a single-center randomized controlled trial conducted between July 2015-October 2020. Patients were randomly assigned to incisional negative pressure wound therapy or standard gauze dressing with a 1:1 ratio. A total of 298 patients were included. SETTINGS: This study was conducted at the colorectal surgery department of a tertiary-level hospital. PATIENTS: This study included patients older than 18 years who underwent elective reoperative open colorectal resections. Patients were excluded who had open surgery within the past 3 months, who had active surgical site infection, and who underwent laparoscopic procedures. MAIN OUTCOME MEASURES: The primary outcome was superficial surgical site infection within 30 days. Secondary outcomes were deep and organ-space surgical site infections within 7 days and 30 days, postoperative complications, and length of hospital stay. RESULTS: A total of 149 patients were included in each arm. The mean age was 51 years, and 49.5% were women. Demographics, preoperative comorbidities, and preoperative albumin levels were comparable between the groups. Overall, most surgeries were performed for IBD, and 77% of the patients had an ostomy fashioned during the surgery. No significant difference was found between the groups in 30-day superficial surgical site infection rate (14.1% in control versus 9.4% in incisional negative pressure wound therapy; p = 0.28). Deep and organ-space surgical site infections rates at 7 and 30 days were also comparable between the groups. Postoperative length of stay and complication rates (Clavien-Dindo grade) were also comparable between the groups. LIMITATIONS: The patient population included in the trial consisted of a selected group of high-risk patients. CONCLUSIONS: Incisional negative pressure wound therapy was not associated with reduced superficial surgical site infection or overall complication rates in patients undergoing high-risk reoperative colorectal resections. See Video Abstract at http://links.lww.com/DCR/B956 . EFECTO DE LA TERAPIA DE HERIDA INSICIONAL CON PRESIN NEGATIVA EN INFECCIONES DEL SITIO QUIRRGICO EN CIRUGA COLORRECTAL REOPERATORIA DE ALTO RIESGO UN ENSAYO CONTROLADO ALEATORIZADO: ANTECEDENTES:Las resecciones colorrectales tienen tasas relativamente altas de infecciones del sitio quirúrgico que causan una morbilidad significativa. La terapia de heridas incisionales con presión negativa se introdujo para mejorar la cicatrización de las heridas de incisiones quirúrgicas cerradas y para prevenir infecciones del sitio quirúrgico.OBJETIVO:El objetivo de este ensayo controlado y aleatorizado fue investigar el efecto de la terapia de herida incisional con presión negativa en infecciones superficiales del sitio quirúrgico en cirugía colorrectal re operatoria, abierta y de alto riesgo.DISEÑO:Ensayo controlado y aleatorizado de un solo centro entre julio de 2015 y octubre de 2020. Los pacientes fueron aleatorizados para recibir tratamiento para heridas incisionales con presión negativa o vendaje de gasa estándar en una proporción de 1:1. Se incluyeron un total de 298 pacientes.AJUSTE:Este estudio se realizó en el departamento de cirugía colorrectal de un hospital de tercer nivel.PACIENTES:Se incluyeron pacientes mayores de 18 años que se fueron sometidos a resecciones colorrectales abiertas, re operatorias y electivas. Se excluyeron aquellos pacientes que tuvieron cirugía abierta en los últimos 3 meses, con infección activa del sitio quirúrgico y que fueron sometidos a procedimientos laparoscópicos.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue infección superficial del sitio quirúrgico dentro de los 30 días. Los resultados secundarios fueron infecciones del sitio quirúrgico profundas y del espacio orgánico dentro de los 7 y 30 días, las complicaciones posoperatorias y la duración de la estancia hospitalaria.RESULTADOS:Se incluyeron un total de 149 pacientes en cada brazo. La edad media fue de 51 años y el 49,5% fueron mujeres. La demografía, las comorbilidades preoperatorias y los niveles de albúmina preoperatoria fueron comparables entre los grupos. En general, la mayoría de las cirugías fueron realizadas por enfermedad inflamatoria intestinal y al 77 % de los pacientes se les confecciono una ostomía durante la cirugía. No hubo diferencias significativas entre los grupos en la tasa de infección del sitio quirúrgico superficial a los 30 días (14,1 % en el control frente a 9,4 % en el tratamiento de herida incisional con presión negativa, p = 0,28). Las tasas de infecciones del sitio quirúrgico profundas y del espacio orgánico a los 7 y 30 días también fueron comparables entre los grupos. La duración de la estancia postoperatoria y las tasas de complicaciones (Clavien-Dindo Graduacion) también fueron comparables entre los grupos.LIMITACIONES:La población de pacientes incluida en el ensayo consistió en un grupo seleccionado de pacientes de alto riesgo.CONCLUSIONES:Video Resumen en http://links.lww.com/DCR/B956 . (Traducción-Dr. Osvaldo Gauto ).

Laparoscopic versus open resection of primary colorectal cancers and synchronous liver metastasis: a systematic review and meta-analysis.

PURPOSE: Combined resection of primary colorectal cancer and associated liver metastases is increasingly common. This study compares peri-operative and oncological outcomes according to surgical approach. METHODS: The study was registered with PROSPERO. A systematic search was performed for all comparative studies describing outcomes in patients that underwent laparoscopic versus open simultaneous resection of colorectal primary tumours and liver metastases. Data was extracted and analysed using a random effects model via Rev Man 5.3 RESULTS: Twenty studies were included with a total of 2168 patients. A laparoscopic approach was performed in 620 patients and an open approach in 872. There was no difference in the groups for BMI (mean difference: 0.04, 95% CI: 0.63-0.70, p = 0.91), number of difficult liver segments (mean difference: 0.64, 95% CI:0.33-1.23, p = 0.18) or major liver resections (mean difference: 0.96, 95% CI: 0.69-1.35, p = 0.83). There were fewer liver lesions per operation in the laparoscopic group (mean difference 0.46, 95% CI: 0.13-0.79, p = 0.007). Laparoscopic surgery was associated with shorter length of stay (p < 0.00001) and less overall postoperative complications (p = 0.0002). There were similar R0 resection rates (p = 0.15) but less disease recurrence in the laparoscopic group (mean difference: 0.57, 95% CI:0.44-0.75, p < 0.0001). CONCLUSION: Synchronous laparoscopic resection of primary colorectal cancers and liver metastases is a feasible approach in selected patients and does not demonstrate inferior peri-operative or oncological outcomes.