Robotic Versus Laparoscopic Total Mesorectal Excision for Sphincter-Saving Surgery: Results of a Single-Center Series of 400 Consecutive Patients and Perspectives.

OBJECTIVE: The aim of this study is to compare robotic total mesorectal excision (R-TME) with laparoscopic TME (L-TME) in a series of consecutive rectal cancer patients. BACKGROUND: R-TME and L-TME have drawn contradictory reports. A recent phase III trial (ROLARR) concluded that R-TME performed by surgeons with varying experience did not confer an advantage in rectal cancer resection. PATIENTS AND METHODS: In this retrospective single-center cohort study (8/2008 to 4/2015), data were prospectively registered. A total of 200 L-TME and 200 R-TME were operated consecutively without selection. The primary outcome was the conversion rate to open laparotomy or transanal TME. The secondary endpoints were type of anastomosis, operative time, postoperative morbidity, circumferential radial (CRM) and distal margins, quality of life, bladder and sexual dysfunction, and oncological outcomes. RESULTS: Baseline characteristics were well balanced. Type of anastomosis [colo-anal anastomosis (CAA) 40% vs 49%; p < 0.001], transanal TME (5% vs 13%; p = 0.005), and conversion rate (2% vs 9.5%; odd ratio (OR): 0.19 [95% confidence interval (CI): 0.05-0.60]) were significantly different. Intersphincteric resection (39% vs 47%), diverting stoma (66.5% vs 68%), CRM involvement, median operative time (243 vs 232 min), and R0 resection rate were similar. Conversion risk was lower for R-TME in male patients and those with small tumors (< 5 cm). The 3-year overall survival rate was 84.1% [77.3-88.9%] and 88.4% [82.9-92.2%] in the R-TME and L-TME group. No significant differences were reported in quality of life, and urinary or sexual function. CONCLUSIONS: R-TME is less likely to be converted to open surgery than L-TME; operative time and curative pathologic criteria are equivalent. Future prospective trial should compare standardized procedures performed by experienced surgeons for subgroups of high-risk patients.

Oncovascular compartmental resection for retroperitoneal soft tissue sarcoma with vascular involvement.

OBJECTIVE: This study analyzed the outcomes of a series of consecutive patients diagnosed with a retroperitoneal soft tissue sarcoma (RSTS) with vascular involvement and who underwent a multidisciplinary operation. METHODS: Between 2000 and 2013, 126 patients were referred for oncovascular surgery in our institution. Among these, 31 consecutive patients underwent operations for RSTS with vascular involvement. A vascular/oncologic team determined the surgical strategy preoperatively. RESULTS: Median follow-up was 34.4 months (interquartile range, 48.1 months). Twenty patients (65%) were referred for primary RSTS and 11 (35%) for local recurrence. The most common histologic diagnosis was liposarcoma (54.8%), mainly high-grade and intermediate-grade RSTS. Prosthetic grafts were usually used for vascular reconstruction. Median hospital stay was 17 days (interquartile range, 14.5; range, 7-190 days). The grade 3 and 4 morbidity rate was 19.3%. Each resection was macroscopically complete (R0-R1). Median progression-free survival was 10 months, and median overall survival was not reached. Overall survival rates were 77.4% at 1 year and 61.3% at 3 years. CONCLUSIONS: Vascular resection and reconstruction are safe and feasible in case of RSTS. The morbidity rate was acceptable, and there were no perioperative deaths. Despite recurrence rates that remain high, oncovascular resection enhances resection margins and allows encouraging survival results for patients often considered as nonresectable.

Health economic evaluation of a clinical pharmacist's intervention on the appropriate use of devices and cost savings: A pilot study.

BACKGROUND: Good management of disposable and reusable supplies may improve surgical efficiency in the operating room (OR) and also corresponds to the best eco-responsible approach. The purpose of this study was to assess the impact of a clinical pharmacist's intervention in the OR on the non-compliant use of medical devices. We also assessed the economic impact of the pharmaceutical intervention. MATERIALS AND METHODS: We conducted a monocentric prospective study in the OR of a University hospital over one year. Three surgical specialties: urologic, digestive and gynecologic were audited after a preparatory phase to optimize usage of medical devices used for surgeries. The supply costs concerning the three specialties were compared before and after the pharmacist intervention. RESULTS: One hundred and fifty surgical procedures were audited in digestive (33.3%, n = 50), gynecologic (32%, n = 48) and urologic (34.7%, n = 52) surgeries. With the pharmacist in OR, 51 procedures (34% CI95%[26.4%; 41.6%]) with a non-compliance concerning at least one medical device were found compared to the 50% rate without the pharmacist reported previously (P < .0001). Eighteen percent of surgical procedures had at least one circulator retrieval for the reason "incomplete case cart despite device listed on the case cart list" versus 29.1% before pharmacist intervention (P = .0028). A €33 014 saving associated with the presence of the pharmacist in OR was observed. CONCLUSIONS: This prospective interventional study showed that the intervention of a pharmacist specialized in the medical device field could significantly reduce non-compliances in medical device use and reduce costs in OR.

Primary prevention of peristomial hernias via parietal prostheses: A randomized, multicentric study (GRECCAR 7 trial).

BACKGROUND: Peristomal hernia (PH) is a common complication of colostomy. It often leads to a decrease in the patient's quality of life. Surgical procedures for PH are difficult and present high failure and morbidity rates. This randomized, double blind, multicentre trial was conducted to determine the benefits and risks of mesh reinforcement vs conventional stoma formation in preventing PH. METHODS: 200 patients undergoing a permanent end colostomy are randomized into two groups. In the mesh group an end-colostomy is created inserting a lightweight (<50g/m(2)) monofilament mesh in a sublay location, and compared to a group with traditional stoma creation. The presence or absence of a PH is determined by another practitioner by clinical exam and by a CT scan or MRI after 24 months of follow-up. 19 university hospitals participate during a 3-year inclusion period. The primary endpoint is the comparison of the PH incidence. To find a difference of 20% with a power of 80% a total number of 174 patients must be included. CONCLUSION: This GRECCAR study is a multicentre, double blind, and randomized trial conducted to determine whether a preventive insertion of a prosthetic mesh decreases the incidence of a PH with an acceptable morbidity. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01380860.

Standardized single docking, four arms and fully robotic proctectomy for rectal cancer: the key points are the ports and arms placement.

Rectal cancer continues to be a surgical challenge. As more technology is developed, the surgeon must both incorporate this new technology into his practice and, at the same time, keep improving oncologic surgery and overall outcomes. We describe a standardized approach and fully robotic proctectomy, using four arms and one single docking (SI system). Patient cart and ports placement, as well as arms position to avoid collision, are key points to perform the entire procedure with one single docking. Although the place of robotic surgery might still need to be defined, standardizing the procedures is a step towards its evaluation. We propose with this report a solution to perform a single docking four arms robotic proctectomy.

[Lymph node dissection: what for? From esophagus to rectum: surgical and lymph node related prognostic factors]. / De l'œsophage au rectum: les facteurs pronostiques ganglionnaires et chirurgicaux.

Surgery has still a key role in curative treatment of digestive carcinomas, and for almost all localisations, lymph node status is a major prognostic factor. As far as oesophageal and gastric cancer are concerned, there is not yet any internationally standardized approach. Occidental guidelines recommend more limited lymph node dissections than Asiatic ones. Lymph node numbers requested during surgery of such cancers remain high, at least 23 lymph nodes for oesophageal cancer, and 25 for a D2 or D1.5 lymphadenectomy for gastric cancer. Generalisation of neo-adjuvant and adjuvant treatments has not yet modified these standards. On the other hand, rectal cancer surgery is well standardized since the global adoption of Total Mesorectal Excision (TME) for the late eighties. Development of mini-invasive techniques (laparoscopy and robot-assisted surgery) enabled an important decrease of surgery related morbidity as well as an enhanced post-operative recovery. However, rectal cancer surgery still has an important morbidity. Development of neo-adjuvant chemo-radiotherapy as well as in-depth knowledge of risk factor of lymph node invasion opened up the path for transanal full thickness resection without lymphadenectomy. The goal of such an approach is to avoid TME's morbidity without risking local recurrence rate increase. As a consequence, this technique might need to be completed with a TME case histological factors are not favorable.

[Laparoscopic versus open surgery for colorectal cancer. A comparative study]. / Estudio comparativo entre cirugía laparoscópica y cirugía abierta en cáncer colorrectal.

BACKGROUND: Laparoscopic surgery for colorectal cancer is currently accepted and widespread worldwide. However, according tol the surgical experience on this approach, surgical and short-term oncologic results may vary. Studies comparing laparoscopic vs. open surgery in our population are scarce. OBJECTIVE: To determine the superiority of the laparoscopic vs. open technique for colorectal cancer surgery. METHODS: This retrospective and comparative study collected data from patients operated on for colorectal cancer between 1999 and 2011 at the Angeles Lomas Hospital, Mexico. RESULTS: A total of 82 patients were included in this study; 47 were operated through an open approach and 35 laparoscopically. Mean operative time was significantly lower in the open approach group (p= 0.008). There were no significant difference between both techniques for intraoperative bleeding (p= 0.3980), number of lymph nodes (p= 0.27), time to initiate oral feeding (p= 0.31), hospital stay (p= 0.12), and postoperative pain (p= 0.19). Procedure-related complications rate and type were not significantly different in both groups (p= 0.44). Patients operated laparoscopically required significantly less analgesic drugs (p= 0.04) and less need for epidural postoperative analgesia (p= 0.01). CONCLUSIONS: Laparoscopic approach is as safe as the traditional open approach for colorectal cancer. Early oncological and surgical results confirm its suitability according to this indication.

Antecedentes: la cirugía laparoscópica para tratar pacientes con cáncer colorrectal ha sido ampliamente aceptada y difundida en todo el mundo. Sin embargo, dependiendo de la experiencia en este abordaje los resultados quirúrgicos y oncológicos a corto plazo pueden variar. En nuestra población existen pocos estudios que comparan los resultados de esta técnica con los de la cirugía abierta. Objetivos: determinar la superioridad de la técnica laparoscópica o abierta en cirugía de cáncer colorrectal. Material y métodos: estudio retrospectivo y comparativo de pacientes operados con técnica abierta o laparoscópica por cáncer de colon y recto entre 1999 y 2011 en nuestro centro. Resultados: se incluyeron 47 pacientes intervenidos de manera convencional y 35 por laparoscopia. El tiempo operatorio fue menor en el grupo de cirugía abierta (p= 0.008). No se encontraron diferencias en: sangrado intraoperatorio (p= 0.3980), número de ganglios resecados (p= 0.27), inicio de la vía oral (p= 0.31), tiempo de estancia hospitalaria (p= 0.12), y dolor referido por el paciente (p= 0.19). En el grupo de cirugía laparoscópica se requirieron menos dosis de analgésicos (p= 0.04) y menor necesidad de catéter epidural para analgesia postoperatoria (p= 0.01). Las tasas de morbilidad (p= 0.44) y mortalidad (p= 0.39) fueron similares en ambos grupos. Conclusiones: la cirugía laparoscópica es equiparable a la técnica abierta en cuanto a estándares oncológicos y resultados técnicos. Este trabajo demuestra que en nuestro hospital la cirugía laparoscópica en pacientes con cáncer de colon y recto es tan segura como la cirugía abierta.