Low Ligation of Inferior Mesenteric Artery in Laparoscopic Anterior Resection for Rectal Cancer Reduces Genitourinary Dysfunction: Results From a Randomized Controlled Trial (HIGHLOW Trial).

OBJECTIVES: The aim of the present study was to compare the incidence of genitourinary (GU) dysfunction after elective laparoscopic low anterior rectal resection and total mesorectal excision (LAR + TME) with high or low ligation (LL) of the inferior mesenteric artery (IMA). Secondary aims included the incidence of anastomotic leakage and oncological outcomes. BACKGROUND: The criterion standard surgical approach for rectal cancer is LAR + TME. The level of artery ligation remains an issue related to functional outcome, anastomotic leak rate, and oncological adequacy. Retrospective studies failed to provide strong evidence in favor of one particular vascular approach and the specific impact on GU function is poorly understood. METHODS: Between June 2014 and December 2016, patients who underwent elective laparoscopic LAR + TME in 6 Italian nonacademic hospitals were randomized to high ligation (HL) or LL of IMA after meeting the inclusion criteria. GU function was evaluated using a standardized survey and uroflowmetric examination. The trial was registered under the ClinicalTrials.gov Identifier NCT02153801. RESULTS: A total of 214 patients were randomized to HL (n = 111) or LL (n = 103). GU function was impaired in both groups after surgery. LL group reported better continence and less obstructive urinary symptoms and improved quality of life at 9 months postoperative. Sexual function was better in the LL group compared to HL group at 9 months. Urinated volume, maximum urinary flow, and flow time were significantly (P < 0.05) in favor of the LL group at 1 and 9 months from surgery. The ultrasound measured post void residual volume and average urinary flow were significantly (P < 0.05) better in the LL group at 9 months postoperatively. Time of flow worsened in both groups at 9 months compared to baseline. There was no difference in anastomotic leak rate (8.1% HL vs 6.7% LL). There were no differences in terms of blood loss, surgical times, postoperative complications, and initial oncological outcomes between groups. CONCLUSIONS: LL of the IMA in LAR + TME results in better GU function preservation without affecting initial oncological outcomes. HL does not seem to increase the anastomotic leak rate.

Laparoscopic versus open resection for the treatment of gastric GIST: a retrospective 10-year single-center experience.

BACKGROUND: Laparoscopic resection (LR) is increasingly performed for gastrointestinal stromal tumors (GIST). The aim of this study is to investigate the short-term outcomes and therapeutic effects of LR compared to Open Resection (OR) for gastric GISTs. METHODS: All 12 patients undergoing surgery (LR vs. OR) for gastric GISTs during 2012-2021 in a single center, were analyzed retrospectively. All outcomes were compared between the two groups. RESULTS: No statistical significant differences were observed between the two groups (LR vs. OR) as far as operative time (143 vs. 144.5 minutes, P=0.81 NS) blood loss (70 vs. 125 mL, P=0.2 NS), early postoperative complications (2 vs. 1, Fisher 1 P=NS), length of hospital stay (8.5 vs. 14.2 days, P=0.17 NS). CONCLUSIONS: LR for GISTs is safe and effective. The only limiting factor for the widespread application of Minimally Invasive Surgery (MIS) is surgeon expertise in challenging cases.

Overcoming of a "surgical dogma" in acute cholecystitis treated in postponed emergency.

AIM: To demonstrate the overcoming of a surgical dogma related to acute cholecystitis treatment, in particular to the timing of the operation. METHODS: One hundred cases of observed acute cholecystitis, submitted to an emergency postponed laparoscopic cholecystectomy surgery and histological control of specimens to evaluate rate of surgical complications and rate of reconver-tion to open surgery RESULTS: The complications rate observed and the surgical conversion to open technique was only 1% where in 96% of the cases the histological examination of the specimen confirmed the state of acute inflammation. Therefore there was a substantial success rate of laparoscopic therapy even in emergency situations, in spite of an overcoming of the conventional timing within 72 hours of surgery for acute cases, which has few restrictions from some authors. The reasons allowing in safety that time extension were ascribed to the laparoscopic procedure, apt to overcome the anatomo-pathological barriers through an accurate vision of the operative field, and the use of specialized devices allowing the coagulative dissection of inflamed tissues. CONCLUSIONS: Postponed colecistectomy in acute cholecystitis, in extention of the canonical coded timing of 72 hours, confirmed to be a safe and successful procedure, even in emergency, with only rare exceptions.

Reliability and validity assessment of administrative databases in measuring the quality of rectal cancer management.

PURPOSE: Measurement and monitoring of the quality of care using a core set of quality measures are increasing in health service research. Although administrative databases include limited clinical data, they offer an attractive source for quality measurement. The purpose of this study, therefore, was to evaluate the completeness of different administrative data sources compared to a clinical survey in evaluating rectal cancer cases. METHODS: Between May 2012 and November 2014, a clinical survey was done on 498 Lombardy patients who had rectal cancer and underwent surgical resection. These collected data were compared with the information extracted from administrative sources including Hospital Discharge Dataset, drug database, daycare activity data, fee-exemption database, and regional screening program database. The agreement evaluation was performed using a set of 12 quality indicators. RESULTS: Patient complexity was a difficult indicator to measure for lack of clinical data. Preoperative staging was another suboptimal indicator due to the frequent missing administrative registration of tests performed. The agreement between the 2 data sources regarding chemoradiotherapy treatments was high. Screening detection, minimally invasive techniques, length of stay, and unpreventable readmissions were detected as reliable quality indicators. Postoperative morbidity could be a useful indicator but its agreement was lower, as expected. CONCLUSIONS: Healthcare administrative databases are large and real-time collected repositories of data useful in measuring quality in a healthcare system. Our investigation reveals that the reliability of indicators varies between them. Ideally, a combination of data from both sources could be used in order to improve usefulness of less reliable indicators.

[Laparoscopic management of oesophageal epiphrenic diverticulum: a case report]. / Trattamento laparoscopico di diverticolo esofageo epifrenico: presentazione di un caso.

Epiphrenic diverticuli are rare pulsion "pseudodiverticuli" of the distal oesophagus that are commonly associated with oesophageal motility disorders. Surgical treatment is usually reserved for patients with symptoms. Traditionally, patients are treated with diverticulectomy, myotomy and fundoplication via a left thoracotomy. The aim of this study was to describe the laparoscopic technique and review the international literature on this minimally invasive approach. We report the case of a 66-year-old woman with a 1-year history of retrosternal pain, regurgitation and weight loss caused by an oesophageal epiphrenic diverticulum. The patient underwent barium oesophagography and oesophagogastroduodenoscopy. The oesophageal diverticulum measured 5 cm. We treated the condition with a laparoscopic oesophageal diverticulectomy, Heller myotomy and Dor fundoplication with intraoperative endoscopy. The operative time was 210 minutes. The postoperative course was complicated by a suspected leakage from the staple line, which was not subsequently confirmed. The patient is now totally asymptomatic after 3 months. Laparoscopy offers good access to the distal oesophagus and the inferior mediastinum. Resection of the diverticulum, treatment of the motor disorder and prevention of postoperative reflux can be obtained with this approach. It should be considered as an alternative to the traditional transthoracic approach and may eventually become the standard technique.

"High or low Inferior Mesenteric Artery ligation in Laparoscopic low Anterior Resection: study protocol for a randomized controlled trial" (HIGHLOW trial).

BACKGROUND: The position of arterial ligation during laparoscopic anterior rectal resection with total mesorectal excision can affect genito-urinary function, bowel function, oncological outcomes, and the incidence of anastomotic leakage. Ligation to the inferior mesenteric artery at the origin or preservation of the left colic artery are both widely performed in rectal surgery. The aim of this study is to compare the incidence of genito-urinary dysfunction, anastomotic leak and oncological outcomes in laparoscopic anterior rectal resection with total mesorectal excision with high or low ligation of the inferior mesenteric artery in a controlled randomized trial. METHODS/DESIGN: The HIGHLOW study is a multicenter randomized controlled trial in which patients are randomly assigned to high or low inferior mesenteric artery ligation during laparoscopic anterior rectal resection with total mesorectal excision for rectal cancer. Inclusion criteria are middle or low rectal cancer (0 to 12 cm from the anal verge), an American Society of Anesthesiologists score of I, II, or III, and a body mass index lower than 30. The primary end-point measure is the incidence of post-operative genito-urinary dysfunction. The secondary end-point measure is the incidence of anastomotic leakage in the two groups. A total of 200 patients (100 per arm) will reliably have 84.45 power in estimating a 20% difference in the incidence of genito-urinary dysfunctions. With a group size of 100 patients per arm it is possible to find a significant difference (α = 0.05, ß = 0.1555). Allowing for an estimated dropout rate of 5%, the required sample size is 212 patients. DISCUSSION: The HIGHLOW trial is a randomized multicenter controlled trial that will provide evidence on the merits of the level of arterial ligation during laparoscopic anterior rectal resection with total mesorectal excision in terms of better preserved post-operative genito-urinary function. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02153801 Protocol Registration Receipt 29/5/2014.