Totally Laparoscopic Ileocolic Resection with Intracorporeal Anastomosis for Crohn's Disease: A Comparative Study.

BACKGROUND: Although minimally invasive surgery for Crohn's disease has been validated in previous studies, most of those reports have referred to laparoscopic-assisted procedures with an extra-corporeal anastomosis. OBJECTIVES: To evaluate the short- and long-term outcomes of total laparoscopic ileocolic resection with an intracorporeal anastomosis for Crohn's disease patients. METHODS: We conducted a single-center retrospective review of all patients who underwent primary ileocolic resection for Crohn's disease between 2010 and 2021. Group A included 34 patients who underwent total laparoscopic ileocolic resection with intracorporeal anastomosis. Group B comprised 144 patients who underwent an open or laparoscopic-assisted procedure. RESULTS: No differences were noted in operative time (mean 167 minutes vs. 152 minutes, P = 0.122), length of stay (median 6.4 days vs. 7.5 days, P = 0.135), readmission rates (11.8% vs. 13.2%, P = 1), and microscopic involvement of surgical margins (7.7% vs. 18.5%, P = 0.249). Group A had significantly fewer postoperative surgical site infections (2.9% vs. 22.2% respectively, P = 0.013), with no differences in other complications prevalence. After a median follow-up of 46 months, there were similar rates of endoscopic recurrence (47.1% vs. 51.4%, P = 0.72), clinical recurrence (35.3% vs. 47.9%, P = 0.253), and surgical recurrence (2.9% vs. 4.9%, P = 0.722). CONCLUSIONS: Total laparoscopic ileocolic resection with intracorporeal anastomosis for Crohn's disease is safe and resulted in favorable outcomes in terms of postoperative wound healing. The long-term disease recurrence rates were like those of laparoscopic-assisted and open ileocolic resection.

Resection of Recurrent Pelvic Soft Tissue Sarcoma: Is the Risk Worth the Reward?

INTRODUCTION: Soft tissue sarcomas (STS) of the pelvis present a surgical and oncological challenge. We investigated the outcomes of patients undergoing resection of pelvic sarcomas. METHODS: A retrospective analysis of all patients who underwent surgical resection for STS between 2014 and 2021 at a tertiary academic referral center (n = 172). Included all patients with primary or recurrent STS which originated or extended to the pelvic cavity (n = 29). RESULTS: The cohort was divided into primary pelvic sarcomas (n = 18) and recurrent pelvic sarcomas (rPS, n = 11). Complete R0/R1 resection was achieved in 26 patients (89.6%). The postoperative complication rate was 48.3%. The rate of major complications was 27.5%. The median time of follow-up from surgery was 12.3 months (range, 0.6-60.3 months). Disease-free survival was superior in the primary pelvic sarcomas group compared to the rPS group (P = 0.002). However, there was no significant difference in overall survival, (P = 0.52). Univariant and multivariant analyses identified rPS group (Hazard Ratio 8.68, P = 0.006) and resection margins (Hazard Ratio 6.29, P = 0.004) to be independently associated with disease-free survival. CONCLUSIONS: We have demonstrated that achieving R0/R1 resection is feasible. Oncological outcomes are favorable for primary tumors, whereas recurrent tumors exhibit early recurrences. Consideration of resection of recurrent pelvic STS should involve a careful multidisciplinary evaluation.

Bedside Drainage of Perianal Abscesses: Is It Safe and Effective?

BACKGROUND: Perianal abscesses require immediate incision and drainage (I&D). However, prompt bedside drainage is controversial as it may compromise exposure and thorough anal examination. OBJECTIVES: To examine outcomes of bedside I&D of perianal abscesses in the emergency department (ED) vs. the operating room (OR). METHODS: We conducted a retrospective review of all patients presented to the ED with a perianal abscesses between January 2018 and March 2020. Patients with Crohn's disease, horseshoe or recurrent abscesses were excluded. RESULTS: The study comprised 248 patients; 151 (60.89%) underwent I&D in the OR and 97 (39.11%) in the ED. Patients elected to bedside I&D had smaller abscess sizes (P = 0.01), presented with no fever, and had lower rates of inflammatory markers. The interval time from diagnosis to intervention was significantly shorter among the bedside I&D group 2.13 ± 2.34 hours vs. 10.41 ± 8.48 hours (P < 0.001). Of patients who underwent I&D in the OR, 7.3% had synchronous fistulas, whereas none at bedside had (P = 0.007). At median follow-up of 24 months, recurrence rate of abscess and fistula formation in patients treated in the ED were 11.3% and 6.2%, respectively, vs. 19.9% and 15.23% (P = 0.023, 0.006). Fever (OR 5.71, P = 0.005) and abscess size (OR 1.7, P = 0.026) at initial presentation were risk factors for late fistula formation. CONCLUSIONS: Bedside I&D significantly shortens waiting time and does not increase the rates of long-term complications in patients with small primary perianal abscesses.

Natural History and Management of Small-Bowel Obstruction in Patients After Cytoreductive Surgery and Intraperitoneal Chemotherapy.

BACKGROUND: Small-bowel obstruction (SBO) after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is a common complication associated with re-admission that may alter patients' outcomes. Our aim was to characterize and investigate the impact of bowel obstruction on patients' prognosis. METHODS: This was a retrospective analysis of patients with SBO after CRS/HIPEC (n = 392). We analyzed patients' demographics, operative and perioperative details, SBO re-admission data, and long-term oncological outcomes. RESULTS: Out of 366 patients, 73 (19.9%) were re-admitted with SBO. The cause was adhesive in 42 (57.5%) and malignant (MBO) in 31 (42.5%). The median time to obstruction was 7.7 months (range, 0.5-60.9). Surgical intervention was required in 21/73 (28.7%) patients. Obstruction eventually resolved (spontaneous or by surgical intervention) in 56/73 (76.7%) patients. Univariant analysis identified intraperitoneal chemotherapy agents: mitomycin C (MMC) (HR 3.2, p = 0.003), cisplatin (HR 0.3, p = 0.03), and doxorubicin (HR 0.25, p = 0.018) to be associated with obstruction-free survival (OFS). Postoperative complications such as surgical site infection (SSI), (HR 2.2, p = 0.001) and collection (HR 2.07, p = 0.015) were associated with worse OFS. Multivariate analysis maintained MMC (HR 2.9, p = 0.006), SSI (HR 1.19, p = 0.001), and intra-abdominal collection (HR 2.19, p = 0.009) as independently associated with OFS. While disease-free survival was similar between the groups, overall survival (OS) was better in the non-obstruction group compared with the obstruction group (p = 0.03). CONCLUSIONS: SBO after CRS/HIPEC is common and complex in management. Although conservative management was successful in most patients, surgery was required more frequently in patients with MBO. Patients with SBO demonstrate decreased survival.

Perioperative and Oncological Outcomes of Combined Hepatectomy with Complete Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy for Metastatic Colorectal Cancer.

BACKGROUND: Synchronous peritoneal and liver metastasis in colorectal cancer is a relative contraindication for curative surgery. We aimed to evaluate the safety and oncological outcomes of combined treatment of peritoneal and liver metastasis. METHODS: We conducted a retrospective analysis of metastatic colorectal cancer patients from two prospective databases: peritoneal surface malignancy (n = 536) and hepatobiliary (n = 286). We compared 60 patients treated with cytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC) and hepatectomy; 80 patients treated with cytoreduction and HIPEC only; and 63 patients treated with hepatectomy alone. RESULTS: No differences in demographics were observed between the groups. Median hospital and intensive care unit (ICU) stay was shorter in group C (7 and 1 days, respectively) versus groups A and B (13 and 1 days, and 12 and 1 days, respectively; p < 0.001). Postoperative complications were not significantly different. Median follow-up was 18.6, 23.1, and 30.6 months for groups A, B, and C, respectively. Estimated 5-year overall survival (OS) was 48.8% (group A), 55.4% (group B), and 60.2% (group C) [p = 0.043 for group A vs. group C], and estimated 5-year disease-free survival (DFS) was 14.2% (group A), 23.0% (group B), and 18.6% (group C). Five-year OS was superior in group C compared with group A (p = 0.043), and DFS was superior in group C compared with groups A and B (p = 0.043 and 0.03, respectively). The peritoneum was the site of first recurrence in groups A and B (23.3% and 32.5%, respectively), and the liver was the site of first recurrence in group C (44.4%). CONCLUSIONS: We report favorable perioperative and oncological outcomes in combined cytoreduction/HIPEC and hepatectomy for patients with peritoneal and liver metastasis. Surgical intervention after multidisciplinary discussion should be considered in patients with both peritoneal and hepatic lesions when complete cytoreduction is feasible.

Ratio of Pathological Response to Preoperative Chemotherapy in Patients Undergoing Complete Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy for Metastatic Colorectal Cancer Correlates with Survival.

BACKGROUND: Pathological response of colorectal peritoneal metastasis (CRPM) may affect prognosis. We investigated the relationship between oncological outcomes and pathological response to chemotherapy of CRPM following cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). METHODS: We conducted a retrospective analysis of a prospectively maintained Peritoneal Surface Malignancies database between 2015 and 2020. Analysis included patients with CRPM who underwent a CRS/HIPEC procedure (n = 178). The cohort was divided into three groups according to the response ratio (ratio of tumor-positive specimens to the total number of specimens resected): Group A, complete response; Group B, high response ratio, and Group C, low response ratio. RESULTS: The group demographics were similar, but the overall complication rate was higher in Group C (65.2%) compared with Groups A (55%) and B (42.8%) [p = 0.03]. Survival correlated to response ratio; the estimated median disease-free survival of Group C was 9.1 months (5.97-12.23), 14.9 months (4.72-25.08) for Group B, and was not reached in Group A (p = 0.001). The estimated median overall survival in Group C was 35 months (26.69-43.31), and was not reached in Groups A and B (p = 0.001). CONCLUSIONS: The pathological response ratio to systemic therapy correlates with survival in patients undergoing CRS/HIPEC. This study supports the utilization of preoperative therapy for better patient selection, with a potential impact on survival.

Transanal total mesorectal excision for rectal cancer: Surgical outcomes and short-term oncological outcomes in a single-institution consecutive series.

INTRODUCTION: Rectal cancer surgery is continuously evolving. Transanal total mesorectal excision (TaTME) is a relatively new surgical approach with possible advantages in comparison to current standard surgical techniques. Several studies in recent years have validated this approach regarding safety and effectiveness. We describe our initial experience with TaTME evaluating surgical parameters, post-operative outcomes and short-term oncological outcomes. METHODS: This is a retrospective study reviewing all patients who underwent TaTME in a single institution from May 2015 to April 2018. RESULTS: The cohort included 25 patients with an average age of 60.4 (range: 40-86), of which 13 (52%) patients were male. The average body mass index was 26.1. The overall 30-day morbidity rate was 40%, with 20% (five cases) being severe complications, defined by Clavien-Dindo Grade of 3b or above. There were three major interoperative complications. Four cases (16%) required reoperation during the first 30 post-operative days. The median length of stay was 8 days. The surgery duration was on average 296 min (range: 205-510). Negative resection margins were achieved in all patients. At a median follow-up period of 14 months, there were no local recurrences, and 4 cases (16%) had a distant recurrence. CONCLUSION: This study describes our initial experience with TaTME, which requires a substantial learning curve to minimise complications and morbidity. Oncological outcomes as expressed by the resection margins, number of lymph nodes harvested and local recurrence rates were all comparable to previously published data.

Hazardous Postoperative Outcomes of Unexpected COVID-19 Infected Patients: A Call for Global Consideration of Sampling all Asymptomatic Patients Before Surgical Treatment.

BACKGROUND: In December 2019, a novel coronavirus was identified as the cause of many pneumonia cases in China and eventually declared as a pandemic as the virus spread globally. Few reports were published on the outcome of surgical procedures in diagnosed COVID-19 patients and even fewer on the surgical outcomes of asymptomatic undiagnosed COVID-19 surgical patients. We aimed to review all published data regarding surgical outcomes of preoperatively asymptomatic untested coronavirus disease 2019 (COVID-19) patients. METHODS: This report is a review on the perioperative period in COVID-19 patients who were preoperatively asymptomatic and not tested for COVID-19. Searches were conducted in PubMed April 4th, 2020. All publications, of any design, were considered for inclusion. RESULTS: Four reports were identified through our literature search, comprising 64 COVID-19 carriers, of them 51 were diagnosed only in the postoperative period. Synthesis of these reports, concerning the postoperative outcomes of patients diagnosed with COVID-19 during the perioperative period, suggested a 14/51 (27.5%) postoperative mortality rate and severe mostly pulmonic complications, as well as medical staff exposure and transmission. CONCLUSIONS: COVID-19 may have potential hazardous implications on the perioperative course. Our review presents results of unacceptable mortality rate and a high rate of severe complications. These observations warrant further well-designed studies, yet we believe it is time for a global consideration of sampling all asymptomatic patients before surgical treatment.

The Impact of the COVID-19 Pandemic on General Surgery Acute Admissions and Urgent Operations: A Comparative Prospective Study.

BACKGROUND: As part of the effort to control the coronavirus disease-19 (COVID-19) outbreak, strict emergency measures, including prolonged national curfews, have been imposed. Even in countries where healthcare systems still functioned, patients avoided visiting emergency departments (EDs) because of fears of exposure to COVID-19. OBJECTIVES: To describe the effects of the COVID-19 outbreak on admissions of surgical patients from the ED and characteristics of urgent operations performed. METHODS: A prospective registry study comparing all patients admitted for acute surgical and trauma care between 15 March and 14 April 2020 (COVID-19) with patients admitted in the parallel time a year previously (control) was conducted. RESULTS: The combined cohort included 606 patients. There were 25% fewer admissions during the COVID-19 period (P < 0.0001). The COVID-19 cohort had a longer time interval from onset of symptoms (P < 0.001) and presented in a worse clinical condition as expressed by accelerated heart rate (P = 0.023), leukocyte count disturbances (P = 0.005), higher creatinine, and CRP levels (P < 0.001) compared with the control cohort. More COVID-19 patients required urgent surgery (P = 0.03) and length of ED stay was longer (P = 0.003). CONCLUSIONS: During the COVID-19 epidemic, fewer patients presented to the ED requiring acute surgical care. Those who did, often did so in a delayed fashion and in worse clinical condition. More patients required urgent surgical interventions compared to the control period. Governments and healthcare systems should emphasize to the public not to delay seeking medical attention, even in times of crises.

Laparoscopic right hemicolectomy with intracorporeal anastomosis: short- and long-term benefits in comparison with extracorporeal anastomosis.

BACKGROUND: Laparoscopic right colectomy with intracorporeal anastomosis is a procedure of increasing popularity. This study aims to compare short- and long-term outcomes of intracorporeal and extracorporeal anastomoses. METHODS: This is a comparative study of two anastomosis techniques for laparoscopic right hemicolectomy. A total of 191 consecutive patients, operated for neoplasm of the right colon, were identified. The intracorporeal group included 91 patients and the extracorporeal group 100 patients. RESULTS: Patient demographics and disease-related characteristics were similar. Mean operative time was longer in the intracorporeal group (155 vs. 142 min; P = 0.006). Intracorporeal anastomosis was associated with less overall postoperative complications (18.7 vs. 35 %, P = 0.011) and decreased rate of surgical site infections (4.4 vs. 14 %, P = 0.023). The need for postoperative intervention (Clavien-Dindo 3) was higher in the extracorporeal group (7 vs. 0 %; P = 0.015). There was no statistically significant difference in the incidence of postoperative leak, ileus and bleeding. Mean length of stay was significantly shorter in the intracorporeal group (5.9 ± 2.1 vs. 6.9 ± 3.0; P = 0.04). Moreover, more patients with intracorporeal anastomosis had a length of stay shorter than 4 days (28.6 vs. 14.1 %, P = 0.015). Extraction incision was periumbilical in 99 % of the patients in the extracorporeal group. In the intracorporeal group extraction, incision was transverse suprapubic (Pfannenstiel) in 85.7 %, transvaginal in 9.9 % and periumbilical in 3.3 % of the patients. The incidence rate of incisional hernia was lower in the intracorporeal group (2.2 vs. 17.0 %, P = 0.001). CONCLUSIONS: Laparoscopic right hemicolectomy with intracorporeal anastomosis is associated with improved short- and long-term outcomes. The rates of postoperative complications requiring intervention and incisional hernias are decreased.

Laparoscopic versus open ventral hernia repair in obese patients: a long-term follow-up.

BACKGROUND: Ventral hernia repair in obese patients has a high perioperative morbidity and recurrence. The laparoscopic approach may reduce those rates. This study compares those outcomes following laparoscopic ventral hernia repair (LVHR) with the standard open approach (OVHR) in obese patients. METHODS: A retrospective review of patients with a BMI > 30 kg/m(2) that had undergone ventral hernia repair (VHR) between 2004 and 2012 was included. Demographics, perioperative complications and recurrence rates were compared between the two approaches. Hernia size was divided into three categories (small, medium and large). Physical examination and CT imaging mainly evaluated recurrences. RESULTS: A total of 186 patients that underwent VHR were included, 35 patients had LVHR. Groups did not differ in terms of age, gender, ASA score, BMI and in rates of primary or incisional ventral hernia repair. The laparoscopic repairs were performed on significantly larger hernias (48.6 vs. 28.9% categorized as large, p = 0.02). The operative time was significantly longer in the laparoscopic repair (102 vs. 67 min, p < 0.01). Overall, perioperative complications following LVHR and OVHR were 17.1 versus 20.5% (p = 0.53). Wound-related complications were lower in the LVHR group (5.7 vs. 15.8%, p = 0.09). After a mean follow-up of 58 months, recurrence rates in the laparoscopic and open approaches were 20.0 versus 27.1% (p = 0.28), respectively. Advanced age was found to be a significantly protector from recurrence (OR -0.03; 95% CI 0.96-0.01, p = 0.01). OVHR carries an odds ratio of 2.7 (95% CI 0.88-8.2, p = 0.07) for recurrence compared with OVHR. CONCLUSIONS: The risk of recurrence after VHR in obese patients is high. Laparoscopic approach offers a better perioperative and recurrence outcome. We believe that change in those outcomes is possible through weight loss procedures, but may need further studies to be conducted in the form of prospective randomized trials.

Redo Ileocolic Resection for Crohn's Disease, Does It Palliate the Patients as Good as the Primary Resection?

Objective: We questioned how redo ileocolic resection (R-ICR) in Crohn's disease (CD) alleviates patients in the long-term compared with primary resection. Methods: A single-center retrospective analysis of patients who underwent an elective ICR without diversion between the years 2010-2022. The cohort was divided into two groups, namely, R-ICR and primary ileocolic resection (P-ICR). Results: The study included 181 patients, of which 30 patients are in the R-ICR group (mean age 42.3 years) and 151 patients in the P-ICR group (mean age 32.6 years). The R-ICR patients underwent an open approach (76.7% versus 25.2% among the P-ICR, p < .001), had significantly longer operations (mean 200.9 minutes versus 157.2 minutes, respectively, P = .002), and had higher estimated blood loss (mean 350 mL versus 267.4 mL, P = .043). The groups were similar in overall postoperative morbidity, severe postoperative complications (10% versus 13.2%, P = .762), and median length of hospital stay (12.1 days versus 7.4 days, P = .214). After a median follow-up of 64.2 months, there were no significant differences between the groups in terms of endoscopic recurrence (43.3% versus 60.9% in the P-ICR group, P = .104) or in clinical recurrence (43.3% versus 55.6%, respectively, P = .216), but the R-ICR had a significant higher rate of surgical recurrences (23.3% versus 5.3%, respectively, P = .004). Conclusion: R-ICR for CD is a significantly more challenging operation than the primary resection, and patients undergoing a R-ICR are more susceptible to a future surgical intervention than those having P-ICR.

Long-term outcomes following ileocolic resection for Crohn's disease: does earlier elective resection affect disease recurrence rates?

BACKGROUND: Surgical resection in Crohn's disease is sometimes the only alternative treating disease complications or refractory disease. The implications of early resection on disease course are still debatable. We aimed to assess the influence of preoperative disease duration on long-term postoperative disease course. METHODS: A retrospective analysis of all Crohn's disease patients who underwent an elective primary ileocolic resection between 2010 and 2021 in a single tertiary medical center. The cohort was divided based on disease duration, Group A (47 patients) had a disease duration shorter than 3 years (median of 1 year) and Group B (139 patients) had a disease duration longer than 3 years (median of 11 years). RESULTS: Surgeries were less complex among Group A as noted by higher rates of laparoscopic assisted procedures (68.1% vs. 45.3%, P = 0.006), shorter surgery duration (134 vs. 167 min, P < 0.0001) less estimated blood loss (72.5 vs. 333 mL, P = 0.016) and faster return of bowel function (3 vs. 4 days, P = 0.011). However, propensity score matching nullified all the differences. Younger age (OR = 0.86, P = 0.004), pre-op steroids (OR = 3.69, P = 0.037) and longer disease duration (OR = 1.18, P = 0.012) were found to be independently significantly associated with severe complications. After a median follow-up time of 71.38 months no significant differences were found between the groups in terms of endoscopic (P = 0.59), or surgical recurrences rates (P = 0.82). CONCLUSIONS: The main effect of preoperative short disease duration was noted within the surgical complexity; however, matching suggests confounders as cause of the difference. No significant long-term implication was noted on disease recurrence.

Predisposing factors for high output stoma in patients with a diverting loop ileostomy after colorectal surgeries.

PURPOSE: One of the most common ileostomy-related complications is high output stoma (HOS) which causes significant fluids and electrolytes disturbances. We aimed to analyze the incidence, severity, and risk factors for readmission for HOS. METHODS: We reviewed all patients who underwent loop ileostomy closure in a single institution between 2010 and 2020. Patients that were readmitted for dehydration due to HOS during the time interval between the creation and the closure of the stoma were identified and divided into a study (HOS) group. The remaining patients constructed the control group. RESULTS: A total of 307 patients were included in this study, out of which, 41 patients were readmitted 73 times (23.7% readmission rate) for the HOS group, and the remaining 266 patients constructed the control group. Multivariate analysis identified; advanced American Society of Anesthesiologists (ASA) physical status (PS) classification, elevated baseline creatinine, and open surgery as risk factors for HOS. Renal function worsened among the entire cohort between the construction of the stoma to its closure (mean creatinine of 0.82 vs. 0.96, P<0.0001). CONCLUSION: Loop ileostomy formation is associated with a substantial readmission rate for dehydration as a result of HOS, and increasing the risk for renal impairment during the duration of the diversion. We identified advanced ASA PS classification, open surgery, and elevated baseline creatinine as predictors for HOS.

Increased risk for incisional hernia following cytoreductive surgery with hyperthermic intraperitoneal chemotherapy.

INTRODUCTION: The incidence of incisional hernias (IH) after midline laparotomy varies from 11% to 20%. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is potentially prone to hernias because a Xiphoid to pubis laparotomy incision performed on patients who have undergone previous abdominal surgeries with the addition of chemotherapy and its related adverse effects. METHODS: We performed a retrospective analysis on a prospectively maintained single institution database from March 2015 to July 2020. The inclusion criteria were patients who underwent CRS-HIPEC and had at least 6 months postoperative follow-up with post-operative cross-sectional imaging study. RESULTS: Two hundred and one patients were included in the study. All patients underwent CRS-HIPEC with resection of previous scar and umbilectomy. Fifty-four patients were diagnosed with IH (26.9%). The major risk factors for IH in multivariate analysis were higher American society of Anesthesiologists score (ASA) (OR 3.9, P = 0.012), increasing age (OR 1.06, P = 0.004) and increasing BMI (OR 1.1, P = 0.006). Most of the hernia sites were median (n = 43, 79.6%). Eleven (20.4%) patients had lateral hernias due to stoma incisions or drain sites. Most of the median hernias were at the level of the resected umbilicus 58.9% (n = 23). Five (9.3%) of the patients with IH necessitated an urgent surgical repair. CONCLUSION: We have demonstrated that more than a quarter of the patients after CRS-HIPEC suffer from IH and up to 10% of them may require surgical intervention. More research is needed to find the appropriate intraoperative interventions to minimize this sequela.

Pelvic Peritonectomy Poorly Affects Outcomes in Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Colorectal Metastases.

BACKGROUND: Constraints of pelvic anatomy render complete cytoreduction (CRS) challenging. The aim of this study is to investigate the impact of pelvic peritonectomy during CRS/HIPEC on colorectal peritoneal metastasis (CRPM) patients' outcomes. METHODS: This is a retrospective analysis of a prospectively maintained CRS/hyperthermic intraperitoneal chemotherapy (HIPEC) database. The analysis included 217 patients with CRPM who had a CRS/HIPEC between 2014 and 2021. We compared perioperative and oncological outcomes of patients with pelvic peritonectomy (PP) (n = 63) to no pelvic peritonectomy (non-PP) (n = 154). RESULTS: No differences in demographics were identified. The peritoneal cancer index (PCI) was higher in the PP group with a median PCI of 12 vs. 6 in the non-PP group (p < 0.001). Operative time was 4.9 vs. 4.3 h in the PP and non-PP groups, respectively (p = 0.63). Median hospitalization was longer in the PP group at 12 vs. 10 days (p = 0.007), and the rate of complications were higher in the PP group at 57.1% vs. 39.6% (p = 0.018). Pelvic peritonectomy was associated with worse disease-free (DFS) and overall survival (OS) with 3-year DFS and OS of 7.3 and 46.3% in the PP group vs. 28.2 and 87.8% in the non-PP group (p = 0.028, p .> 0.001). The univariate OS analysis identified higher PCI (p = 0.05), longer surgery duration (p = 0.02), and pelvic peritonectomy (p < 0.001) with worse OS. Pelvic peritonectomy remained an independent prognostic variable, irrespective of PCI, on the multivariate analysis (p < 0.001). CONCLUSIONS: Pelvic peritonectomy at the time of CRS/HIPEC is associated with higher morbidity and worse oncological outcomes. These findings should be taken into consideration in the management of patients with pelvic involvement.

The Influence of Laparoscopic Sleeve Gastrectomy on Pregnancy, Delivery, and Infant: Does Timing of Pregnancy Following Laparoscopic Sleeve Gastrectomy Affect Outcomes?

PURPOSE: Maternal obesity is associated with newborn morbidity and mortality; however, the literature discussing bariatric surgical effects on women's fertility and pregnancy has reached diverse conclusions. We examined the effect of laparoscopic sleeve gastrectomy (LSG) on pregnancy, birth, and newborn outcomes regarding the time of conception. MATERIALS AND METHODS: We conducted a retrospective review of women who had LSG and conceived between 2007 and 2017. Data included maternal parameters, pregnancy progression, delivery, and newborn status. Pregnancies were divided into subgroups according to surgery to conception interval (≤ 12, 12-24, ≥ 24 months). RESULTS: We reviewed 68 patients: 48 (70%) conceived once, 13 (19%) conceived twice, 7 women (10%) conceived three times. There were 95 pregnancies and 80 live births. The group sizes were 18 (18.9%), 29 (30.5%), and 48 (50.5%) pregnancies for ≤ 12, 12-24, and 24 months after surgery, respectively. No difference was found between the subgroups regarding basic characteristics at time of surgery (age (p = 0.100), weight (p = 0.180), BMI (p = 0.616); and at beginning of pregnancy weight (p = 0.309), BMI (p = 0.707), %EBMIL (p = 0.321)). No significant differences were found concerning pregnancy progression, complications, and the newborns' weight (p = 0.41), GCT (p > 0.99), preeclampsia (p = 0.492), eclampsia (p > 0.99), Pre-term (p = 0.428), live birth (p = 0.432), LGA (p > 0.99), SGA (p = 0.732). A statistically significant trend of increased rates of caesarean section in subject with longer surgery-to-conception intervals was detected (P = 0.022). CONCLUSIONS: Our results did not show that the interval between LSG and conception affects the pregnancy and newborn outcomes. Therefore, we believe that early conception following LSG does not increase the risk of maternal or neonatal morbidity or mortality.

The pattern of peritoneal colorectal metastasis predicts survival after cytoreductive surgery and hyperthermic intra-peritoneal chemotherapy.

BACKGROUND: Peritoneal cancer index (PCI) has been used reliably to prognosticate patients with peritoneal metastasis, however, it fails to describe the patterns of peritoneal spread and to correlate these patterns to survival outcomes. We aim to define the scattered peritoneal spread (SPS) as a pattern associated with worse survival in colorectal peritoneal metastasis. METHODS: A retrospective analysis of metastatic colorectal cancer patients from a prospectively maintained database of peritoneal surface malignances (n = 280) between 2015 and 2020. SPS was defined by the presence of at least two distant and non-contiguous PCI regions. We compared patients with SPS (n = 73) and clustered peritoneal spread (CPS) (n = 88) for demographics, perioperative and survival outcomes. RESULTS: No difference in demographics or post-operative course was noted between the groups. The median follow-up was 15.4 months (0.4-70.8 months). Worse disease-free survival (DFS) in the SPS group with an estimated median of 8.2 months compared to 22.5 months in the CPS spread group, (p = 0.001). The estimated median overall survival (OS) for SPS group was 35.7 months whereas in the CPS group the median was not reached (p = 0.025). The same effect of SPS was preserved even after stratification of PCI. CONCLUSIONS: We defined and described the association of the peritoneal spread pattern to survival outcomes. SPS patients exhibit worse DFS and OS independent of the PCI level. Integration of malignant spread pattern into prognostication models along with PCI may aid in predicting oncological outcomes.

The impact of gastrointestinal anastomotic leaks on survival of patients undergoing cytoreductive surgery and heated intraperitoneal chemotherapy.

BACKGROUND: Gastrointestinal (GI) leaks after cytoreductive surgery and hyperthermic Intraperitoneal Chemotherapy (CRS/HIPEC) is a known life-threatening complication that may alter patients' outcomes. Our aim is to investigate risk factors associated with GI leaks and evaluate the impact of GI leaks on patient's oncological outcomes. METHODS: A retrospective analysis of perioperative and oncological outcomes of patients with and without GI leaks after CRS/HIPEC. RESULTS: Out of 191 patients included in this study, GI leaks were identified in 17.8% (34/191) of patients. Small bowel anastomoses were the most common site (44%). Most of the GI leaks were managed conservatively and re-operation was needed in 44.1% of cases. Univariate analysis identified higher PCI (p = 0.03), higher number of packed cells transfused (p = 0.036), pelvic peritonectomy (p = 0.013), high number of anastomoses (p = 0.003) and colonic resection (p = 0.042) as factors associated with GI leaks. Multivariate analysis identified stapled anastomoses (OR 2.59, p = 0.001) and pelvic peritonectomy (OR 2.33, p = 0.044) as independent factors associated with GI leaks. Disease-free survival tended to be worse in the leak group but did not reach statistical significance (p = 0.235). The 3- and 5-year OS was 73.2% and 52.9% in the leak group compared to 75.8% and 73.2% in the non-leak group (p = 0.236). CONCLUSIONS: GI leak showed no impact on overall and disease free survival after CRS/HIPEC.Avoidance of stapled reconstruction in high risk patients with high tumor burden and large number of anastomoses may yield improved outcomes.