Robotic "Double Loop" Roux-en-Y gastric bypass reduces the risk of postoperative internal hernias: a prospective observational study.

BACKGROUND: Internal herniation (IH) is a potentially serious complication after laparoscopic Roux-en-Y gastric bypass (RYGB). The aim of the study is to evaluate the incidence of IH after robot-assisted RYGB (RA-RYGB) performed with the "Double Loop" technique at our Institution. METHODS: Prospective cohort study of patients submitted to RA-RYGB with the "Double Loop" technique, with a minimum follow-up of 2 years. Patients with complaints of abdominal pain at clinical visits or entering the emergency department were evaluated. Primary outcome was the incidence of IH, defined as the presence of herniated bowel through a mesenteric defect, diagnosed at imaging or at surgical exploration. RESULTS: A total of 129 patients were included: 65 (50.4%) were primary procedures, while 64 (49.6%) were revisional operations after primary restrictive bariatric surgery. Mean age was 47.9 ± 10.2 years, mean weight, and body mass index were, respectively, 105.3 ± 22.6 kg and 39.7 ± 9.6 kg/m2. Postoperative morbidity rate was 7.0%. Mean follow-up was 53.2 ± 22.6 (range 24-94) months. During the follow-up period, a total of 14 (10.8%) patients entered the emergency department: 1 patient had melena, 4 renal colic, 1 acute cholecystitis, 2 gynecologic pathologies, 2 anastomotic ulcers, 1 perforated gastric ulcer, 1 diverticulitis and 2 gastroenteritis. There were no diagnoses of IH. During the follow-up period, no patient experienced recurrence of symptoms. CONCLUSIONS: In the present study, the robotic approach confirms the low complication rate and absence of IH after "Double Loop" RA-RYGB in a large case-series at a medium-term follow-up.

Impact of COVID-19 outbreak on esophageal cancer surgery in Northern Italy: lessons learned from a multicentric snapshot.

Coronavirus Disease-19 (COVID-19) outbreak has significantly burdened healthcare systems worldwide, leading to reorganization of healthcare services and reallocation of resources. The Italian Society for Study of Esophageal Diseases (SISME) conducted a national survey to evaluate changes in esophageal cancer management in a region severely struck by COVID-19 pandemic. A web-based questionnaire (26 items) was sent to 12 SISME units. Short-term outcomes of esophageal resections performed during the lockdown were compared with those achieved in the same period of 2019. Six (50%) centers had significant restrictions in their activity. However, overall number of resections did not decrease compared to 2019, while a higher rate of open esophageal resections was observed (40 vs. 21.7%; P = 0.034). Surgery was delayed in 24 (36.9%) patients in 6 (50%) centers, mostly due to shortage of anesthesiologists, and occupation of intensive care unit beds from intubated COVID-19 patients. Indications for neoadjuvant chemo (radio) therapy were extended in 14% of patients. Separate COVID-19 hospital pathways were active in 11 (91.7%) units. COVID-19 screening protocols included nasopharyngeal swab in 91.7%, chest computed tomography scan in 8.3% and selective use of lung ultrasound in 75% of units. Postoperative interstitial pneumonia occurred in 1 (1.5%) patient. Recovery from COVID-19 pandemic was characterized by screening of patients in all units, and follow-up outpatient visits in only 33% of units. This survey shows that clinical strategies differed considerably among the 12 SISME centers. Evidence-based guidelines are needed to support the surgical esophageal community and to standardize clinical practice in case of further pandemics.

The Landmark Series: Minimally Invasive (Laparoscopic and Robotic) Colorectal Cancer Surgery.

Current high-quality evidence supports the routine use of the laparoscopic approach for patients with colon cancer. Laparoscopic colectomy is associated with earlier resumption of gastrointestinal function and shorter hospital stay, with no increased morbidity or mortality. Pathology and long-term oncologic outcomes are similar to those achieved with open surgery. The absolute benefits of laparoscopic resection for rectal cancer are still under evaluation. While its safety in terms of early postoperative clinical outcomes has been confirmed, two recent randomized controlled trial (RCTs) have questioned its routine use even in expert hands, since its non-inferiority has not been demonstrated when compared with the gold standard of open surgery. Furthermore, the impact of robotic technology is still unclear, since the only RCT available so far failed to demonstrate any benefits compared with standard laparoscopic rectal resection.

Long-term oncologic outcomes following anastomotic leak after anterior resection for rectal cancer: does the leak severity matter?

BACKGROUND: The evidence regarding the impact of anastomotic leak (AL) after anterior resection (AR) for rectal cancer on oncologic outcomes is controversial, and there are no data about the prognostic relevance of the International Study Group of Rectal Cancer (ISREC) AL classification. The aim was to evaluate the oncologic outcomes in patients with AL after AR for rectal cancer. The prognostic value of the ISREC AL grading system was also investigated. METHODS: It is a retrospective analysis of a prospectively collected database including all patients undergoing curative elective AR for rectal cancer (April 1998-September 2013). AL severity was defined according to the ISREC criteria. A multivariable analysis was performed to identify predictors of poor survival. RESULTS: A total of 532 patients underwent curative AR (69% laparoscopic) for rectal cancer. The overall AL rate was 7.9%: 15 grade B and 27 grade C ALs. With a median follow-up of 80 (range 12-266) months, 5-year overall survival (OS) was 67.2% in patients with AL and 86.5% in those without AL (P = 0.001). Five-year disease-free survival (DFS) was 50.5% and 80.3%, respectively (P < 0.001). Local recurrence and distant metastases developed more frequently in AL patients (P < 0.05). Grade B AL and no administration or delay of adjuvant chemotherapy were independent predictors for poorer OS and DFS. Grade B AL independently affected also the administration of adjuvant chemotherapy. Circulating C-reactive protein levels at 2 weeks after AL treatment were higher in grade B than grade C patients (P = 0.006) and in patients with tumor relapse (P = 0.011). CONCLUSION: AL after curative AR for rectal cancer and impaired use of adjuvant chemotherapy are associated with poor survival. Postoperative systemic inflammation seems to be more sustained in grade B than that in grade C AL patients, with possible adverse impact on long-term survival.

Analysis of Early and Long-Term Oncologic Outcomes After Converted Laparoscopic Resection Compared to Primary Open Surgery for Rectal Cancer.

BACKGROUND: Laparoscopic rectal resection (LRR) for cancer is a challenging procedure, with conversion to open surgery being reported in up to 30% of cases. Since only a few studies with short follow-up have compared converted LRR and open RR (ORR), it is unclear if conversion to open surgery should be prevented by preferring an open approach in those patients with preoperatively known risk factors for conversion. The aim of this study was to compare early postoperative outcomes and long-term survival after completed LRR, converted LRR or ORR for non-metastatic rectal cancer. METHODS: A prospective database of consecutive curative LRRs and ORRs for rectal cancer was reviewed. Patients undergoing LRR who required conversion (CONV group) were compared with those who had primary open rectal surgery (OPEN group) and completed LRR (LAP group). A multivariate analysis was performed to identify predictors of poor survival. RESULTS: A total of 537 patients were included in the study: 272 in the LAP group, 49 in the CONV group and 216 in the OPEN group. There were no significant differences in perioperative morbidity, mortality and length of hospital stay between the three groups. Five-year overall survival and disease-free survival rates did not significantly differ between LAP, CONV and OPEN patients: 83.9 versus 77.8 versus 81% (P = 0.398) and 74.5 versus 62.9 versus 72.7% (P = 0.145), respectively. Similar 5-year OS and DFS rates were observed between patients who had converted LRR for locally advanced tumor or for non-tumor-related reasons: 81.2 versus 80.8% (P = 0.839) and 62.5 versus 63.7% (P = 0.970), respectively. Poor grade of tumor differentiation, lymphovascular invasion and a lymph node ratio of 0.25 or greater, but not conversion, were independently associated with poorer survival. CONCLUSION: Conversion to open surgery does not impair short-term outcomes and does not jeopardize 5-year survival in patients with rectal cancer when compared to primary open surgery.

Surgical Treatment of Gastroesophageal Reflux Disease.

BACKGROUND: Gastroesophageal reflux disease (GERD) affects an estimated 20% of the population in the USA, and its prevalence is increasing worldwide. Lifestyle modifications and proton pump inhibitors (PPI) therapy are effective in the majority of patients and remain the mainstay of treatment of GERD. However, some patients will need surgical intervention because they have partial control of symptoms, do not want to be on long-term medical treatment, or suffer complications related to PPI therapy. AIMS: The aim of this study was to review the available evidence that supports laparoscopic antireflux surgery, and to study the effect of surgical therapy on the natural history of GERD. RESULTS: The key elements for the success of antireflux surgery are proper patient selection, careful analysis of the indications for surgery, complete pre-operative work-up, and proper execution of the surgical technique. CONCLUSIONS: When the key elements are respected, antireflux surgery is very effective in controlling GERD, and it is associated to minimal morbidity and mortality.

Gastroesophageal Reflux and Idiopathic Pulmonary Fibrosis.

BACKGROUND: Idiopathic pulmonary fibrosis (IPF) is a progressive interstitial lung disease of unknown origin that affects about 40,000 new patients every year in the USA. Albeit the disease is labelled as idiopathic, it is thought that pathologic reflux, often silent, plays a role in its pathogenesis through a process of microaspiration of gastric contents. AIMS: The aim of this study was to review the available evidence linking reflux to IPF, and to study the effect of medical and surgical therapy on the natural history of this disease. RESULTS: Medical therapy with acid-reducing medications controls the production of acid and has some benefit. However, reflux and aspiraion of weakly acidic or alkaline gastric contents can still occur. Better results have been reported after laparoscopic anti-reflux surgery, as this form of therapy re-establishes the competence of the lower esophageal sphincter, therefore stopping any type of reflux. CONCLUSIONS: A phase II NIH study in currently in progress in the USA to determine the role of antireflux surgery in patients with GERD and IPF. The hope is that this simple operations might alter the natural history of IPF, avoiding progression and the need for lung transplantation.

Increased Esophageal Exposure to Weakly Acidic Reflux 5 Years After Laparoscopic Roux-en-Y Gastric Bypass.

OBJECTIVE: To evaluate the long-term effects of laparoscopic Roux-en-Y Gastric Bypass (LRYGB) on gastroesophageal function. BACKGROUND: LRYGB is considered the weight loss procedure of choice for obese patients with gastroesophageal reflux disease (GERD). However, long-term instrumental evaluations of GERD after LRYGB are not available. METHODS: Morbidly obese patients selected for LRYGB were included in a prospective study. We performed clinical evaluation with GERD-HRQoL questionnaire, upper endoscopy, esophageal manometry, and 24-hour impedance pH (24-hour MII-pH) monitoring preoperatively and at 12 and 60 months after surgery. This trial is registered with ClinicalTrials.gov (no. NCT02618044). RESULTS: From May 2006 to May 2009, 86 patients entered the study and 72 (84%) completed the 5-year protocol. At preoperative 24-hour MII-pH monitoring, 54 patients (group A) had normal values, whereas 32 (group B) had diagnosis of GERD: 23 had acidic reflux, whereas 9 had combined reflux [acidic + weakly acidic reflux (WAR)]. The groups were similar in preoperative age, body mass index, and comorbidities. At 12 and 60 months, significant improvement in questionnaire scores was observed in group B patients. No manometric changes occurred in both groups; 24-hour MII-pH monitoring showed a significant reduction in acid exposure, but an increase of WAR in both group A (from 0% to 52% to 74%) and group B (from 35% to 42% to 77%). At long-term follow-up, esophagitis was found in 14 group A (30%) and in 18 group B patients (69%) (P < 0.001). CONCLUSIONS: LRYGB allows to obtain an effective GERD symptom amelioration and a reduction in acid exposure. However, 3 out 4 patients present with distal esophagus exposure to WAR.

10-Year Oncologic Outcomes After Laparoscopic or Open Total Mesorectal Excision for Rectal Cancer.

BACKGROUND: Only few studies have compared laparoscopic total mesorectal excision (LTME) and open total mesorectal excision (OTME) for rectal cancer with follow-up longer than 5 years. The aim of this study was to compare 10-year oncologic outcomes after LTME and OTME for nonmetastatic rectal cancer. METHODS: We conducted a retrospective analysis of a prospective database of rectal cancer patients undergoing LTME or OTME. Statistical analyses were performed on an ''intention-to-treat'' basis and by actual treatment. Overall survival (OS) and disease-free survival (DFS) were compared by using the Kaplan-Meier method. A multivariable analysis was performed to identify predictors of poor survival. RESULTS: Between April 1994 and August 2005, a total of 153 LTME patients and 154 OTME patients were included. Similarly, 10-year OS and DFS after LTME and OTME were observed: 76.8 versus 70.6 % (P = 0.138) and 69.1 versus 67.6 % (P = 0.508), respectively. Conversion to OTME did not adversely affect OS and DFS. Stage-by-stage comparison showed no significant differences between LTME and OTME. No significant differences were observed in local recurrence rates after LTME and OTME (6.5 vs. 7.8 %, P = 0.837). Median time until local recurrence was 24.5 (range, 12-56) months after LTME and 22 (6-64) months after OTME (P = 0.777). Poor tumor differentiation, lymphovascular invasion, and a lymph node ratio of 0.25 or more were the independent predictors of poorer OS and DFS. CONCLUSION: This retrospective study with long follow-up did not show significant differences between the two groups in OS and DFS.