Extended-duration antibiotics are not associated with a reduction in surgical site infection in patients with ovarian cancer undergoing cytoreductive surgery with large bowel resection.

OBJECTIVE(S): To evaluate whether extended dosing of antibiotics (ABX) after cytoreductive surgery (CRS) with large bowel resection for advanced ovarian cancer is associated with reduced incidence of surgical site infection (SSI) compared to standard intra-operative dosing and evaluate predictors of SSI. METHODS: A retrospective single-institution cohort study was performed in patients with stage III/IV ovarian cancer who underwent CRS from 2009 to 2017. Patients were divided into two cohorts: 1) standard intra-operative dosing ABX and 2) extended post-operative ABX. All ABX dosing was at the surgeon's discretion. The impact of antibiotic duration on SSI and other postoperative outcomes was assessed using univariate and multivariable Cox regression models. RESULTS: In total, 277 patients underwent cytoreductive surgery (CRS) with large bowel resection between 2009 and 2017. Forty-nine percent (n = 137) received standard intra-operative ABX and 50.5% (n = 140) received extended post-operative ABX. Rectosigmoid resection was the most common large bowel resection in the standard ABX (89.9%, n = 124) and extended ABX groups (90.0%, n = 126), respectively. No significant differences existed between age, BMI, hereditary predisposition, or medical comorbidities (p > 0.05). No difference was appreciated in the development of superficial incisional SSI between the standard ABX and extended ABX cohorts (10.9% vs. 12.9%, p = 0.62). Of patients who underwent a transverse colectomy, a larger percentage of patients developed a superficial SSI versus no SSI (21% vs. 6%, p = 0.004). CONCLUSION(S): In this retrospective study of patients with advanced ovarian cancer undergoing CRS with LBR, extended post-operative ABX was not associated with reduced SSI, and prolonged administration of antibiotics should be avoided unless clinically indicated.

Do resected colorectal cancer patients need early chest imaging? Impact of clinicopathologic characteristics on time to development of pulmonary metastases.

BACKGROUND AND OBJECTIVES: For patients with colorectal cancer (CRC), the lung is the most common extra-abdominal site of distant metastasis. However, practices for chest imaging after colorectal resection vary widely. We aimed to identify characteristics that may indicate a need for early follow-up imaging. METHODS: We retrospectively reviewed charts of patients who underwent CRC resection, collecting clinicopathologic details and oncologic outcomes. Patients were grouped by timing of pulmonary metastases (PM) development. Analyses were performed to investigate odds ratio (OR) of PM diagnosis within 3 months of CRC resection. RESULTS: Of 1600 patients with resected CRC, 233 (14.6%) developed PM, at a median of 15.4 months following CRC resection. Univariable analyses revealed age, receipt of systemic therapy, lymph node ratio (LNR), lymphovascular and perineural invasion, and KRAS mutation as risk factors for PM. Furthermore, multivariable regression showed neoadjuvant therapy (OR: 2.99, p < 0.001), adjuvant therapy (OR: 6.28, p < 0.001), LNR (OR: 28.91, p < 0.001), and KRAS alteration (OR: 5.19, p < 0.001) to predict PM within 3 months post-resection. CONCLUSIONS: We identified clinicopathologic characteristics that predict development of PM within 3 months after primary CRC resection. Early surveillance in such patients should be emphasized to ensure timely identification and treatment of PM.

Procalcitonin and C-reactive protein as early markers of anastomotic leakage in intestinal resections for advanced ovarian cancer (EDMOCS).

INTRODUCTION: Serum levels of procalcitonin and C-reactive protein (CRP) have been used to predict anastomotic leakage after colorectal surgery, but information is scarce in advanced ovarian cancer (AOC) surgery with bowel resection. This study aimed to assess the predictive value of procalcitonin and CRP in detecting anastomotic leakage after AOC surgery with bowel resection. The study also aimed to determine the optimal postoperative reference values and the best day for evaluating these markers. MATERIAL AND METHODS: This prospective, observational and multicentric trial included 92 patients with AOC undergoing debulking surgery with bowel resection between 2017 and 2020 in 10 reference hospitals in Spain. Procalcitonin and CRP levels were measured at baseline and on postoperative days 1-6. Receiver operating characteristic analysis was performed to evaluate the predictive value of procalcitonin and CRP at each postoperative day. Sensitivity, specificity, positive and negative predictive values were calculated. RESULTS: Anastomotic leakage was detected in six patients (6.5%). Procalcitonin and CRP values were consistently higher in patients with anastomotic leakage at all postoperative days. The maximum area under the curve (AUC) for procalcitonin was observed at postoperative day 1 (AUC = 0.823) with a cutoff value of 3.8 ng/mL (83.3% sensitivity, 81.3% specificity). For CRP, the maximum AUC was found at postoperative day 3 (AUC = 0.833) with a cutoff level of 30.5 mg/dL (100% sensitivity, 80.4% specificity). CONCLUSIONS: Procalcitonin and C-reactive protein are potential biomarkers for early detection of anastomotic leakage after ovarian cancer surgery with bowel resection. Further prospective studies with a larger sample size are needed to confirm these findings.

Prospective observational study comparing the perioperative outcomes of laparoscopic colectomy with or without epidural anesthesia: the Kanagawa Yokohama Colorectal Cancer Study Group (KYCC) 1806.

PURPOSE: There have been no adequate comparisons of the efficacy, safety, and efficiency of analgesia after laparoscopic colorectal resection (LAC), with and without epidural anesthesia (EDA). METHODS: This was a multicenter prospective observational study of patients undergoing LAC. The primary end point was the mean visual analog scale (VAS) score on postoperative days (PODs) 1-7. The secondary end points were the highest VAS, complication rate, days to first ambulation and fatigue, length of hospital stay, and time to commencement of surgery. RESULTS: We compared an EDA group (Group E, n = 48) and a no-EDA group (Group O, n = 48) after matching. The mean VAS was not significantly different between the groups (28.7 vs. 30.1, p = 0.288). On assessing the secondary end points, the highest VAS was not significantly different between the groups. In fact, the VAS was lower in Group E only on POD 2. There was no difference in the incidence of complications, the time to first postoperative evacuation was shorter in Group E, and postoperative hospitalization was similar. The time to surgery was shorter in Group O. CONCLUSION: These results suggest that LAC without EDA is a feasible option, but with the early and regular use of adjunctive measures to provide more stable analgesia.

Low anterior resection syndrome (LARS) and quality of life after colectomy.

PURPOSE: Clinical experience shows complaints similar to LARS not only after rectal surgery, but even after other types of colorectal surgery. Our aim was to investigate the occurrence of LARS after several types of colorectal surgery and its impact on quality of life. METHODS: We included adult patients who underwent colorectal surgery at our centre from January 2016 until March 2019, regardless of indication. A questionnaire was sent evaluating LARS and quality of life. RESULTS: The questionnaire was answered by 119 patients. We noticed highest LARS-score after rectum surgery (26.1), but also surprisingly higher LARS-score after right-sided colectomy (21.0) compared to left-sided colectomy (16.4). We report lowest quality of life after rectal surgery, but higher quality of life in left colectomy compared to right colectomy. CONCLUSION: LARS-score did not significantly correlate with type of procedure; however, higher LARS-scores were noted after right-sided colectomy compared to left-sided colectomy with similar impact on quality of life. We suggest CORS (colorectal resection syndrome) as a more suiting conceptual name instead of LARS to describe functional bowel complaints after colorectal surgery.

Novel antibiotic irrigation device versus standard O-ring wound retractor in the prevention of surgical site infection following colorectal resection.

PURPOSE: We sought to compare the effectiveness of a novel antibiotic irrigation device to the standard O-ring wound retractor in preventing surgical site infections (SSIs) following colorectal resections. METHODS: This single-arm clinical trial included patients undergoing colorectal resections utilizing the novel device. A retrospective cohort of patients undergoing the same procedures with the O-ring retractor was selected as the control group. The primary outcome assessed was SSI. Secondary outcomes assessed were overall complications, hospital length of stay (LOS), and 30-day readmission. A univariable and multivariable logistic regression model was built to evaluate the association between SSI as the outcome variable and the use of the novel device as the main independent variable. The model was adjusted for any confounding variables. RESULTS: Eighty-six novel device cases and 170 O-ring retractor cases were enrolled. There were no significant differences between the two groups in terms of demographics and preoperative comorbidities. Cases with the novel device had fewer Pfannenstiel incisions (1.2% vs. 14.6%, p < 0.001). There were no other significant differences in intraoperative variables. SSI rates were significantly lower in the novel device group (1.2% vs. 9.1%, p = 0.014). There were no other significant differences in postoperative complications. Multivariable logistic regression with backward elimination showed that the use of the novel device was significantly more effective against SSI by 92.5% compared to the use of the O-ring retractor. CONCLUSION: The novel device may contribute to lower SSI rates compared to the O-ring retractor following colorectal resection.

Nationwide volume-outcome relationship concerning in-hospital mortality and failure-to-rescue in surgery of sigmoid diverticulitis.

PURPOSE: A correlation between the hospital volume and outcome is described for multiple entities of oncological surgery. To date, this has not been analyzed for the surgical treatment of sigmoid diverticulitis. The aim of this study was to explore the impact of the annual caseload per hospital of colon resection on the postoperative incidence of complications, failure to rescue, and mortality in patients with diverticulitis. METHODS: Patients receiving colorectal resection independent from the diagnosis from 2012 to 2017 were selected from a German nationwide administrative dataset. The hospitals were grouped into five equal caseload quintiles (Q1-Q5 in ascending caseload order). The outcome analysis was focused on patients receiving surgery for sigmoid diverticulitis. RESULTS: In total, 662,706 left-sided colon resections were recorded between 2012 and 2017. Of these, 156,462 resections were performed due to sigmoid diverticulitis and were included in the analysis. The overall in-house mortality rate was 3.5%, ranging from 3.8% in Q1 (mean of 9.5 procedures per year) to 3.1% in Q5 (mean 62.8 procedures per year; p < 0.001). Q5 hospitals revealed a risk-adjusted odds ratio of 0.85 (95% CI 0.78-0.94; p < 0.001) for in-hospital mortality compared to Q1 during multivariable logistic regression analysis. High-volume centers showed overall lower complication rates, whereas the failure-to-rescue did not differ significantly. CONCLUSION: Surgical treatment of sigmoid diverticulitis in high-volume colorectal centers shows lower postoperative mortality rates and fewer postoperative complications.

Is ICG essential in all colorectal surgery? A 3-year experience in a single center: a cohort study.

INTRODUCTION AND OBJECTIVES: Indocyanine green (ICG) was introduced as a promising diagnostic tool to provide real-time assessment of intestinal vascularization. Nevertheless, it remains unclear whether ICG could reduce the rate of postoperative AL. The objective of this study is to assess its usefulness and to determine in which patients is most useful and would benefit the most from the use of ICG for intraoperative assessment of colon perfusion. METHODS: A retrospective cohort study was conducted in a single center, including all patients who underwent colorectal surgery with intestinal anastomosis between January 2017 and December 2020. The results of patients in whom ICG was used prior to bowel transection were compared with the results of the patients in whom this technique was not used. Propensity score matching (PSM) was employed to compare groups with and without ICG. RESULTS: A total of 785 patients who underwent colorectal surgery were included. The operations performed were right colectomies (35.0%), left colectomies (48.3%), and rectal resections (16.7%). ICG was used in 280 patients. The mean time since the infusion of ICG until detection of fluorescence in the colon wall was 26.9 ± 1.2 s. The section line was modified in 4 cases (1.4%) after ICG due to a lack of perfusion in the chosen section line. Globally, a non-statistically significant increase in anastomotic leak rate was observed in the group without ICG (9.3% vs. 7.5%; p = 0.38). The result of the PSM was a coefficient of 0.026 (CI - 0.014 to 0.065, p = 0.207). CONCLUSIONS: ICG is a safe and useful tool to assess the perfusion of the colon prior to performing the anastomosis in colorectal surgery. However, in our experience, it did not significantly lower the anastomotic leakage rate.

Necessity of routine perioperative epidural catheter placement in laparoscopic colorectal resections: a retrospective data analysis.

PURPOSE: Whether epidural anesthesia leads to further improvement in the postoperative course of colorectal procedures is under discussion. The aim of this study was to evaluate the effects of minimally invasive colorectal oncological interventions without epidural anesthesia (EDA). METHODS: This retrospective data analysis included the clinical data of all patients who underwent minimally invasive oncological colorectal resection at our clinic between January 2013 and April 2019. Of 385 patients who met the inclusion criteria, 183 (group I; 47.5% of 385) received EDA, and 202 (group II; 52.5% of 385) received transversus abdominis plane block instead. The relevant target parameters were evaluated and compared between the groups. The postoperative complications were graded according to the Clavien-Dindo classification. RESULTS: The patients in group I (n=183; women, 77; men, 106; age 66.8 years) were younger (p=0.0035), received a urinary catheter more often (99.5% versus [vs.] 28.2% p<0.001), required longer, more frequent arterenol treatment (1.1 vs. 0.6 days; p<0.001), and had a longer intermediate care unit stay than those in group II (2.8 vs. 1.1 days; p<0.001). Postoperative pain levels were not significantly different between the groups (p=0.078). The patients in group I were able to ambulate later than those in group II (4 vs. 2 days; p<0.001). The difference in the postoperative day of the first defecation was not significant between the groups (p=0.236). The incidence of postoperative complications such as bleeding (p=0.396), anastomotic leaks (p=0.113), and wound infections (p=0.641) did not differ between the groups. The patients in group I had significantly longer hospital stays than those in group II (12.2 vs. 9.4 days; p<0.001). CONCLUSION: EDA can be safely omitted from elective minimally invasive colorectal resections, and its omission is not accompanied by any relevant disadvantages to the patient.

Real-time semi-quantitative assessment of anastomotic blood perfusion in mini­invasive rectal resections by Sidestream Dark Field (SDF) imaging technology: a prospective in vivo pilot study.

PURPOSE: Anastomotic leakage (AL) is one of the severe complications after rectal surgery, and anastomotic ischemia is one of the main factors. This prospective in vivo pilot study aimed to evaluate the effectiveness of Sidestream Dark Field (SDF) imaging in quantitative assessment of anastomotic microcirculation and to analyze its correlation with AL. METHODS: Thirty-three patients with rectal cancer who underwent laparoscopic low anterior resection from 2019 to 2020 were enrolled. Microcirculation was measured by SDF imaging at the descending colon, the mesocolon transection line (MTL), and 1 cm and 2 cm distal to the MTL. Anastomotic microcirculation was measured at the stapler anvil edge before anastomosis. Quantitative perfusion-related parameters were as follows: microcirculation flow index (MFI), perfused vessel density (PVD), proportion of perfused vessels (PPV), and total vessel density (TVD). RESULTS: All patients obtained stable microcirculation images. Functional microcirculation parameters (MFI, PPV, PVD) decreased successively from the descending colon, the colon at MTL, and 1 cm and 2 cm distal to the MTL (all P < 0.01). Extremely poor microcirculation was found at the intestinal segment 2 cm distal to the MTL. Micro-perfusion was significantly lower at the colonic limb of the anastomosis compared with the descending colon (all P < 0.001). Anastomotic leakage occurred in 3 patients (9.1%) whose anastomotic microcirculation was significantly lower than those without AL (all P < 0.01). Blood perfusion at the colonic limb of the anastomosis was significantly higher in patients with left colic artery preservation than in controls. CONCLUSION: SDF imaging is a promising technique for evaluating anastomotic microcirculation and has potential clinical significance for risk stratification of AL.

Association between Enhanced Recovery After Surgery (ERAS) protocol, risk factors and 3-year survival after colorectal surgery for cancer in the elderly.

INTRODUCTION: As life expectancy is currently growing, more elderly and fragile patients need colorectal resection for cancer. We sought to assess the link between enhanced rehabilitation after surgery (ERAS), risk factors and overall survival at 3 years, in patients aged 65 and over. METHODS: Between 2005 and 2017, all patients undergoing colorectal resection for cancer were included. Overall survival at 3 years was compared for patients treated in following ERAS guidelines compared to conventional treatment (pre-ERAS). RESULTS: 661 patients were included (ERAS, n = 325; pre-ERAS, n = 336). The 3-year overall survival rate was significantly better regardless of age for ERAS vs pre-ERAS patients (73.1% vs 64.4%; p = 0.016). With overall survival rates of 83.2% vs 73.8%, 65.4% vs 62.8% and 59.6% vs 40% for the age bands 65-74, 75-84 and ≥ 85 years. The analysis of survival at 3 years by a multivariate Cox model identified ERAS as a protective factor with a reduction in the risk of death of 30% (HR = 0.70 [0.50-0.94], p = 0017) independently of other identified risk factors: age bands, ASA score > 2, smoking, atrial fibrillation and abdominal surgery. This result is confirmed by an analysis of the propensity score (HR = 0.67 [0.47-0.97], p = 0.032). CONCLUSIONS: Our study shows that ERAS is associated with better 3-year survival in patients undergoing colorectal resection for cancer, independent of risk factors. The practice of ERAS is effective and should be offered to patients aged 65 and over.

Evaluating the longitudinal effect of colorectal surgery on health-related quality of life in patients with colorectal cancer.

BACKGROUND AND OBJECTIVES: Surgery for colorectal cancer (CRC) negatively affects health-related quality of life (HRQoL). Addressing shortcomings in literature, the purpose of this study was to evaluate the impact of surgery for CRC on the course of HRQoL from baseline up to 2 years after diagnosis. METHODS: In this prospective, population-based study patients with newly diagnosed CRC were included between 2016 and 2019. HRQoL was assessed by the EORTC QLQ-C30 questionnaire over time both between and within subgroups of patients that underwent right-sided colonic, left-sided colonic, and rectal resection using linear mixed model analyses. RESULTS: The study included 415 patients of whom 148 patients underwent right-sided colonic (36%), 147 left-sided colonic (35%), and 120 rectal resection (29%). Overall, HRQoL scores restored to baseline level 1 year after diagnosis. Impact of surgery seems to be more prominent in patients who underwent rectal resection, as they experienced more pain and had worse role and social functioning scores 4 weeks after surgery. Finally, among patients who underwent left-sided and rectal resection, physical functioning did not return to baseline level during follow-up. CONCLUSION: This study shows several differences (between-group and within-group) in HRQoL according to surgery type and offers perspective which patients may need additional support in the care pathway.

Effect of implementation of enhanced recovery after surgery (ERAS) protocol and risk factors on 3-year survival after colorectal surgery for cancer-a retrospective cohort of 1001 patients.

PURPOSE: Several recent studies have shown that the enhanced recovery after surgery (ERAS) protocol reduces morbidity and mortality and shortens the length of stay compared to conventional recovery strategy (pre-ERAS). The aim of this study was to evaluate the effect of the implementation of this protocol on 3-year overall survival and postoperative outcome in patients undergoing colorectal resection for cancer. METHODS: This was a retrospective, single-center, comparative, and non-randomized study. Between January, 2005, and December, 2017, 1001 patients were included (ERAS, n = 497; pre-ERAS, n = 504). RESULTS: The 3-year overall survival rate was significantly better for ERAS than for pre-ERAS patients (76.1 vs 69.2%; p = 0.017). The length of hospital stay (median 10 days vs 15; p = ≤ 0.001) and the 90-day readmission rate (15 vs 20%; p = 0.037) were significantly lower in the ERAS group. Three-year recurrence-free survival (p = 0.398) and 90-day complications (p = 0.560) were similar in the two groups. Analysis of 3-year survival by a multivariate Cox model identified ERAS as a protective factor with a 30% reduction in the risk of death: (HR = 0.70 [0.55-0.90]). CONCLUSION: The implementation of the ERAS protocol was associated with an improvement in 3-year survival, a reduction of the length of hospital stay and the rate of readmission. ERAS is associated with better 3-year survival, independent of other commonly considered parameters. An ASA score > 2, smoking, a history of cancer, and atrial fibrillation are deleterious risk factors linked to earlier mortality.

Outcomes associated with the use of a new powered circular stapler for left-sided colorectal reconstructions: a propensity score matching-adjusted indirect comparison with manual circular staplers.

BACKGROUND: This was a retrospective, matching-adjusted indirect comparison of clinical outcomes between patients from a single-arm trial of the ECHELON CIRCULAR™ Powered Stapler (ECP) and those from a historical cohort of patients who underwent left-sided colorectal resection using conventional manual circular staplers, extracted from the Premier Healthcare Database. METHODS: Patients in the ECP trial cohort were propensity score matched to those in the historical cohort through nearest neighbor matching. Outcomes included 30-day readmission rates; length of stay (LOS) for the index admission; rates of anastomotic leak, pelvic abscess, ileus/small bowel obstruction, infection, bleeding, and stoma creation. RESULTS: The study included 168 patients in the ECP trial cohort and 4544 patients in the historical cohort; 165 ECP trial patients were matched to 1348 historical cohort patients. After matching, conversions were more prevalent in the historical cohort than the ECP trial cohort (4.2% ECP vs. 10.2% historical, p = 0.001). Relative to the historical cohort, the ECP trial cohort had statistically significant lower rates of 30-day inpatient readmission (6.1% vs. 10.8%, p = 0.019), anastomotic leak (1.8% vs. 6.9%, p < 0.001), ileus/small bowel obstruction (4.8% vs. 14.7%, p < 0.001), infection (1.8% vs. 5.7%, p = 0.001), and bleeding (1.8% vs. 9.2%, p < 0.001) during the index admission or within 30 days thereafter. No statistically significant differences in rates of pelvic abscess, stoma creation, or LOS were found between the two cohorts. Three sensitivity analyses to address the difference in conversion rates yielded largely consistent results, with loss of statistical significance for inpatient admission in some cases. This study is limited by its potential for differences in unmeasurable factors between the ECP trial and historical cohorts. CONCLUSIONS: In this study, the ECP trial cohort had lower incidence proportions of several surgical complications as compared with the historical cohort. Further controlled prospective clinical studies are needed to confirm the validity of this finding.

Peritoneal contamination and associated post-operative infectious complications after natural orifice specimen extraction for laparoscopic colorectal surgery.

BACKGROUND: Peritoneal contamination is a major concern during natural orifice specimen extraction after laparoscopic colorectal resection (LCR-NOSE), but few data are available. We explored the prevalence, risk factors, and association between clinical outcomes and infectious complications in patients with positive peritoneal drain fluid culture (PDFC) after LCR-NOSE. METHOD: We retrospectively analyzed patient records in our prospectively maintained registry database who underwent LCR-NOSE between 2011and 2020. Peritoneal drain fluid was collected within 12 h post-operative and cultures for microorganisms were obtained. The relationships between PDFC, clinical variables, and infectious complications were examined by univariate and multivariable analysis. RESULTS: Of 241 consecutive patients who underwent LCR-NOSE and drainage fluid culture, 59 (24.5%) had PDFC. Anterior resection (Odds ratio OR 2.40) was identified as an independent predictor for PDFC. Twenty-eight patients (11.6%) developed infectious complications. Multivariable analysis identified low anterior resection (OR 2.74), prolonged operative time (OR 3.20), and PDFC (OR 5.14) as independent risk factors. Pseudomonas aeruginosa was the most frequently found microorganism (OR 5.19) responsible for infectious complications. CONCLUSIONS: Microorganisms are commonly present in the peritoneum after LCR-NOSE and play a critical role in the development of infectious complications and related morbidity. Specific caution is warranted in patients contaminated with specific types of microorganisms.

Long-term Outcomes Following Surgical Management of Rectal Endometriosis: Seven-year Follow-up of Patients Enrolled in a Randomized Trial.

STUDY OBJECTIVE: To compare functional outcomes, recurrence rate, and pregnancy likelihood in patients undergoing conservative or radical surgery for deep rectal endometriosis followed up for 7 years. DESIGN: Prospective study in a cohort of patients enrolled in a 2-arm randomized trial from March 2011 to August 2013. SETTING: A tertiary referral center. PATIENTS: Fifty-five patients with deep endometriosis infiltrating the rectum. INTERVENTIONS: Patients underwent either segmental resection or nodule excision via shaving or disk excision, depending on randomization that was performed preoperatively using sequentially numbered, opaque sealed envelopes. MEASUREMENTS AND MAIN RESULTS: The primary end point was the number of patients experiencing one of the following symptoms: constipation, frequent bowel movements, anal incontinence, or bladder dysfunction 24 months after surgery. The secondary end points were values of gastrointestinal and overall quality of life scores. The 7-year recurrence rates (new deep endometriosis nodules infiltrating the rectum) in the excision vs segmental resection arms were 7.4 % vs 0% (p = .24). One of the symptoms included in the definition of the primary outcomes was recorded in 55.6% vs 60.7% of patients (p = .79). However, 51.9% vs 53.6% of patients considered their bowel movements as normal (p = .99). An intention-to-treat comparison of overall quality of life scores did not find a difference between the 2 groups 7 years after surgery. At the end of the 7-year study period, 31 of 37 patients who tried to conceive were successful (83.8%), including 27 pregnancies (57.4%) resulting from natural conception and 20 pregnancies (42.6%) resulting from assisted reproductive technology procedures. The pregnancy rate was 82.4% vs 85% in the 2 arms (p = .99). A 75.7% live birth rate was recorded. At the end of the follow-up, there were 15 women with 1 child (40.5%) and 13 women with 2 children (35.1%). During the 7-year follow-up, the reoperation rates were 37% and 35.7%, respectively, in each arm (p = .84). Among the 27 reoperation procedures during the follow-up period, 11 (40.7%) were for postoperative complications, 7 (25.9%) were necessary before assisted reproductive technology management, 8 (29.6%) were for recurrent abdominal or pelvic pain, and 1 (3.7%) was for midline ventral hernia after pregnancy. CONCLUSION: Our study did not reveal a considerable difference in terms of digestive functional outcomes, recurrence rate, reoperation risk, and pregnancy likelihood when conservative and radical rectal surgeries for deep endometriosis were compared 7 years after surgery. The postoperative pregnancy rate observed in our series was high.

Feasibility and safety of transvaginal specimen extraction in deep endometriosis colorectal resectional surgery and analysis of risk factors for postoperative complications.

BACKGROUND: The aim of the present study was to demonstrate that transvaginal specimen extraction is a feasible and safe approach in colorectal resection for deep endometriosis (DE) and to assess the risk factors for postoperative complications. METHODS: This retrospective cohort study included all the consecutive patients undergoing segmental bowel resection for symptomatic endometriosis at "La Paz" University Hospital (Madrid, Spain) and at "Hospital General Universitario de Valencia" (Valencia, Spain) from January 2014 to December to 2017. Patients were grouped according to specimen extraction approach into those who had transvaginal extraction (Group I) and those who had suprapubic extraction (Group II). Clinic-demographical, surgical and post-surgical data were recorded. Intra- and postoperative complications were classified according to Clavien-Dindo criteria. Postoperative data were compared between groups. Risk factors associated with surgery were investigated. RESULTS: Out of 99 female patients included (average age 36.91 ± 5.36 years), 23 patients (23.2%) had transvaginal and 76 (76.8%) had suprapubic specimen extraction. The groups were comparable regarding operative time, nodule size, level of anastomosis, hospital stay and intraoperative complications. We observed no statistically significant differences in postoperative complications and rectovaginal fistula rate between the groups. Binary logistic regression analyses determined that vaginal endometriosis is an independent risk factor for postoperative complications (OR: 2.63, 95% CI [1.10-6.48], p = 0.03). CONCLUSIONS: Transvaginal specimen extraction is a safe and feasible technique in DE colorectal surgery and should be taken into consideration whenever vaginal endometriosis exists. Nevertheless, vaginal endometriosis can be an independent risk factor for postoperative complications in DE surgery.

Perspectives on modes of labour and delivery after different modalities of surgery for bowel endometriosis.

Bowel or intestinal endometriosis is estimated to affect 5-37% of women with deep infiltrative endometriosis (DIE), especially in the rectum and recto-sigmoid junction. However, there are no current guidelines or consensus regarding safest mode of delivery in pregnant women after different surgical interventions for bowel/intestinal endometriosis. From October 2019 to February 2020, we conducted an online survey of members of the British Society for Gynaecological Endoscopy (BSGE). These included questions on what gynaecologist members would recommend as modes of delivery in women who had different surgical modalities for bowel endometriosis, and the particular factors that influence such recommendations. Analysis of data was performed using SPSS for Windows (V9) software package. One hundred and two members of BSGE completed the survey (61.76% of BSGE gynaecologist members). Only 30.39% of respondents counsel women, pre-operatively, about possible effects of surgical treatment of bowel endometriosis on their subsequent mode of delivery. Our survey highlights wide variation in practice that currently exists. Around 70% of clinicians are not counselling patients regarding delivery options pre-surgery despite almost one-third recommending planned caesarean section if the vagina is opened. Further studies are required to stratify the risk factors for such patients when attempting vaginal delivery or caesarean section.IMPACT STATEMENTWhat is already known on this subject? Treatment of colorectal endometriosis consists of rectal shaving, discoid resection or segmental colorectal resection. However, the relationship between different surgical modalities for bowel endometriosis and the subsequent safe mode of labour and delivery remains unclear.What do the results of this study add? No study has been published that specifically looked at the particular course and outcome of labour and delivery after each of these bowel surgeries; rectal shaving, disc excision, or segmental colorectal resection. Our study highlights the wide variations in practice that currently exists. Despite around 70% of clinicians not counselling women regarding delivery options pre-surgery, almost one-third would recommend a planned caesarean section if the vagina is opened.What are the implications of these findings for clinical practice and/or further research? This study suggests that risk factors should be stratified for such patients when attempting a vaginal delivery or undergoing a caesarean section. Guidance from the ESGE and/or BSGE would be useful to aid in the counselling and informed consent of such patients.

Anastomotic leak following interval debulking surgery with or without hyperthermic intraperitoneal chemotherapy in women with advanced epithelial ovarian Cancer.

OBJECTIVE(S): To evaluate the incidence and associated risk factors for anastomotic failure following interval debulking surgery (IDS) with or without hyperthermic intraperitoneal chemotherapy (HIPEC) in women with advanced ovarian cancer. METHODS: We performed a retrospective cohort study in women with stage III/IV high-grade ovarian cancer treated with neoadjuvant chemotherapy followed by IDS with colorectal resection and HIPEC from 2017 to 2020. These patients were compared to a historical control cohort who underwent IDS with colorectal resection without HIPEC from 2009 to 2016. Data was collected for demographics, surgical variables, and perioperative outcomes. The univariate analysis compared progression-free survival and overall survival. RESULTS: 61 women were identified; 21 (34.4%) underwent IDS with HIPEC from 2017 to 2020, and 40 underwent IDS alone from 2009 to 2016. None of the patients who had IDS with HIPEC had protective ileostomy, compared to 10.0% of those who received had IDS alone (n = 4)(p = 0.29). The cumulative incidence of anastomotic leak rate was 8.2% (n = 5). There was no significant difference in anastomotic leak rate for women who underwent IDS with HIPEC (9.5%, n = 2) versus without HIPEC (7.5%, n = 3) (p = 0.99). While there was no difference in PFS (12.2 vs. 13.3 months, log-rank p = 0.31), OS (9.4 vs. 40.6 months, log-rank p = 0.013) was significantly decreased following postoperative anastomotic leak. CONCLUSIONS: In this retrospective series of women with advanced ovarian cancer, HIPEC was not associated with increased risk for anastomotic leak at the time of IDS with colorectal resection and reanastomosis. While further study is needed, HIPEC alone should not preclude colorectal resection or dictate practices for colonic diversion in IDS.

Comparison of hyperspectral imaging and fluorescence angiography for the determination of the transection margin in colorectal resections-a comparative study.

PURPOSE: One relevant aspect for anastomotic leakage in colorectal surgery is blood perfusion of both ends of the anastomosis. The clinical evaluation of this issue is limited, but new methods like fluorescence angiography with indocyanine green or non-invasive and contactless hyperspectral imaging have evolved as objective parameters for perfusion evaluation. METHODS: In this prospective, non-randomized, open-label and two-arm study, fluorescence angiography and hyperspectral imaging were compared in 32 consecutive patients with each other and with the clinical assessment by the surgeon. After preparation of the bowel and determination of the surgical resection line, the tissue was evaluated with hyperspectral imaging for 5 min before and after cutting the marginal artery and assessed by 6 hyperspectral pictures followed by fluorescence angiography with indocyanine green. RESULTS: In 30 of 32 patients, the image data could be evaluated and compared. Both methods provided a comparable borderline between well-perfused and poorly perfused tissue (p = 0.704). In 15 cases, the surgical resection line was shifted to the central position due to the imaging. The border zone was sharper in fluorescence angiography and best assessed 31 s after injection. With hyperspectral imaging, the border zone was visualized wider and with more differences between proximal and distal border. CONCLUSION: Hyperspectral imaging and fluorescence angiography provide similar results in determining the perfusion border. Both methods allow a good and safe visualization of the blood perfusion at the central resection margin to create a well-perfused anastomosis. TRIAL REGISTRATION: This study was registered at Clinicaltrials.gov ( NCT04226781 ) on January 13, 2020.