Preoperative lateral lymph node features and impact on local recurrence after neoadjuvant chemoradiotherapy and total mesorectal excision for locally advanced rectal cancer: results from a multicentre international cohort study.

AIM: Locally advanced rectal cancer (LARC) is commonly treated with neoadjuvant chemoradiotherapy (nCRT) and total mesorectal excision (TME) to reduce local recurrence (LR) and improve survival. However, LR, particularly associated with lateral lymph node (LLN) involvement, remains a concern. The aim of this study was to investigate preoperative factors associated with LLN involvement and their impact on LR rates in LARC patients undergoing nCRT and curative surgery. METHOD: This multicentre retrospective study, including four academic high-volume institutions, involved 301 consecutive adult LARC patients treated with nCRT and curative surgery between January 2014 and December 2019 who did not undergo lateral lymph node dissection (LLND). Baseline and restaging pelvic MRIs were evaluated for suspicious LLNs based on institutional criteria. Patients were divided into two groups: cLLN+ (positive nodes) and cLLN- (no suspicious nodes). Primary outcome measures were LR and lateral local recurrence (LLR) rates at 3 years. RESULTS: Among the cohort, 15.9% had suspicious LLNs on baseline MRI, and 9.3% had abnormal LLNs on restaging MRI. At 3 years, LR and LLR rates were 4.0% and 1.0%, respectively. Ten out of 12 (83.3%) patients with LR showed no suspicious LLNs at the baseline MRI. Abnormal LLNs on MRI were not independent risk factors for LR, distant recurrence or disease-free survival. CONCLUSION: Abnormal LLNs on baseline and restaging MRI assessment did not impact LR and LLR rates in this cohort of patients with LARC submitted to nCRT and curative TME surgery.

Short-term outcomes of surgical treatment for primary ileocaecal Crohn's disease: Results of the Crohn's(urg) study, a multicentre, retrospective, comparative analysis between inflammatory and complicated phenotypes.

AIM: Recent evidence challenges the current standard of offering surgery to patients with ileocaecal Crohn's disease (CD) only when they present complications of the disease. The aim of this study was to compare short-term results of patients who underwent primary ileocaecal resection for either inflammatory (luminal disease, earlier in the disease course) or complicated phenotypes, hypothesizing that the latter would be associated with worse postoperative outcomes. METHOD: A retrospective, multicentre comparative analysis was performed including patients operated on for primary ileocaecal CD at 12 referral centres. Patients were divided into two groups according to indication of surgery for inflammatory (ICD) or complicated (CCD) phenotype. Short-term results were compared. RESULTS: A total of 2013 patients were included, with 291 (14.5%) in the ICD group. No differences were found between the groups in time from diagnosis to surgery. CCD patients had higher rates of low body mass index, anaemia (40.9% vs. 27%, p < 0.001) and low albumin (11.3% vs. 2.6%, p < 0.001). CCD patients had longer operations, lower rates of laparoscopic approach (84.3% vs. 93.1%, p = 0.001) and higher conversion rates (9.3% vs. 1.9%, p < 0.001). CCD patients had a longer hospital stay and higher postoperative complication rates (26.1% vs. 21.3%, p = 0.083). Anastomotic leakage and reoperations were also more frequent in this group. More patients in the CCD group required an extended bowel resection (14.1% vs. 8.3%, p: 0.017). In multivariate analysis, CCD was associated with prolonged surgery (OR 3.44, p = 0.001) and the requirement for multiple intraoperative procedures (OR 8.39, p = 0.030). CONCLUSION: Indication for surgery in patients who present with an inflammatory phenotype of CD was associated with better outcomes compared with patients operated on for complications of the disease. There was no difference between groups in time from diagnosis to surgery.

The number of comorbidities as an important cofactor to ASA class in predicting postoperative outcome: An international multicentre cohort study.

BACKGROUND: Multimorbidity is a growing burden in our ageing society and is associated with perioperative morbidity and mortality. Despite several modifications to the ASA physical status classification, multimorbidity as such is still not considered. Thus, the aim of this study was to quantify the burden of comorbidities in perioperative patients and to assess, independent of ASA class, its potential influence on perioperative outcome. METHODS: In a subpopulation of the prospective ClassIntra® validation study from eight international centres, type and severity of anaesthesia-relevant comorbidities were additionally extracted from electronic medical records for the current study. Patients from the validation study were of all ages, undergoing any type of in-hospital surgery and were followed up until 30 days postoperatively to assess perioperative outcomes. Primary endpoint was the number of comorbidities across ASA classes. The associated postoperative length of hospital stay (pLOS) and Comprehensive Complication Index (CCI®) were secondary endpoints. On a scale from 0 (no complication) to 100 (death) the CCI® measures the severity of postoperative morbidity as a weighted sum of all postoperative complications. RESULTS: Of 1421 enrolled patients, the mean number of comorbidities significantly increased from 1.5 in ASA I (95% CI, 1.1-1.9) to 10.5 in ASA IV (95% CI, 8.3-12.7) patients. Furthermore, independent of ASA class, postoperative complications measured by the CCI® increased per each comorbidity by 0.81 (95% CI, 0.40-1.23) and so did pLOS (geometric mean ratio, 1.03; 95% CI, 1.01-1.06). CONCLUSIONS: These data quantify the high prevalence of multimorbidity in the surgical population and show that the number of comorbidities is predictive of negative postoperative outcomes, independent of ASA class.

Virtual reality simulation training in laparoscopic surgery - does it really matter, what simulator to use? Results of a cross-sectional study.

BACKGROUND: Virtual reality simulation training plays a crucial role in modern surgical training, as it facilitates trainees to carry out surgical procedures or parts of it without the need for training "on the patient". However, there are no data comparing different commercially available high-end virtual reality simulators. METHODS: Trainees of an international gastrointestinal surgery workshop practiced in different sequences on LaparoS® (VirtaMed), LapSim® (Surgical Science) and LapMentor III® (Simbionix) eight comparable exercises, training the same basic laparoscopic skills. Simulator based metrics were compared between an entrance and exit examination. RESULTS: All trainees significantly improved their basic laparoscopic skills performance, regardless of the sequence in which they used the three simulators. Median path length was initially 830 cm and 463 cm on the exit examination (p < 0.001), median time taken improved from 305 to 167 s (p < 0.001). CONCLUSIONS: All Simulators trained efficiently the same basic surgery skills, regardless of the sequence or simulator used. Virtual reality simulation training, regardless of the simulator used, should be incorporated in all surgical training programs. To enhance comparability across different types of simulators, standardized outcome metrics should be implemented.

There is a need for a paradigm shift in laparoscopic surgical training: results of a nationwide survey among teaching hospitals in Switzerland.

BACKGROUND: Surgical training curricula have changed little over the past decades. Current advances in surgical techniques, especially in minimally invasive surgery, as well as the rapidly changing socioeconomic environment pose a major challenge for the training of young surgeons. The aim of this survey was to provide a representative overview of the surgical training landscape in Switzerland focusing on laparoscopic surgical training: How do department chairs of teaching hospitals deal with the above challenges, and what should a future training curriculum look like? METHODS: This is a prospective, questionnaire-based, cross-sectional study among the heads of departments of all certified surgical teaching hospitals in Switzerland. RESULTS: The overall response rate was 56% (48/86) and 86% (19/22) for tertiary centers. Two-thirds of the centers (32) organize themselves in training networks. Laparoscopic training courses are offered in 25 (52%) hospitals, mainly in tertiary centers. Self-training opportunities exist in 40 (83%) hospitals. In addition to commercial (27) and self-built (7) box trainers, high-fidelity trainers are available in 16 (33%) hospitals. A mandatory training curriculum exists in 7 (15%) facilities, and a training assessment is performed in 15 (31%) institutions. Thirty-two (65%) heads of departments indicated that residents have sufficient practical exposure in the operating room, but the ability to work independently with obtaining the specialist title is seen critically (71%). They state that the surgical catalog does not adequately reflect the manual skills of the resident (64%). The desire is for training to be restructured from a numbers-based to a performance-based curriculum (53%) and for tools to assess residents' manual skills (56%) to be introduced. CONCLUSIONS: Department chairs stated that the existing curriculum in Switzerland does not meet the requirements of a modern training curriculum. This study highlights the need to create an improved, competency-based curriculum that ensures the training of a new generation of surgeons, taking into account the growing evidence of the effectiveness of state-of-the-art training modalities such as simulation or proficiency-based training.

Long-Term Outcome of Surgery for Perianal Crohn's Fistula.

Background and Objectives: Patients with perianal Crohn's (CD) fistula often need repetitive surgeries and none of the established techniques was shown to be superior or preferable. Furthermore, the long-term outcome of fistula Seton drainage is not well described. The aims of this study were to analyze the long-term healing and recurrence rate of CD perianal fistulas in a large patient cohort. Materials and Methods: Database analysis of the Swiss IBD (Inflammatory Bowel Disease) cohort study. Results: 365 perianal fistula patients with 576 surgical interventions and a median follow-up of 7.5 years (0-12.6) were analyzed. 39.7% of patients required more than one procedure. The first surgical interventions were fistulectomies ± mucosal sliding flap (59.2%), Seton drainage (29.6%), fistula plugs or fibrin glue installations (2.5%) and combined procedures (8.8%). Fistulectomy patients required no more surgery in 69%, one additional surgery in 25% and more than one additional surgery in 6%, with closure rates at 7.5 years follow-up of 77.1%, 74.1% and 66.7%, respectively. In patients with Seton drainage as index surgery, 52% required no more surgery, and over 75% achieved fistula closure after 10 years. Conclusions: First-line fistulectomies, when feasible, achieved the highest healing rates, but one-third of patients required additional surgeries, and one-fourth of patients will remain with a fistula at 10 years. Initial Seton drainage and concurrent medical therapy can achieve fistula closure in 75%. However, in 50% of patients, more surgeries are needed, and fistula closure is achieved in only two-thirds of patients.

[Management of acute and chronic anal pain]. / Prise en charge des douleurs anales aiguës et chroniques.

Anal pain can be acute (most commonly related to anal fissure, perianal abcess or fistula, perianal vein thrombosis) or chronic (functional or neuropathic) including levator ani syndrome, proctalgia fugax, pudendal nevralgia and coccygodynia. History and clinical examination are keys to diagnose acute causes. Diagnosis of chronic anal pain on the other hand is more challenging and based on thorough history and analysis of symptoms. The aim of this article is to discuss the main etiologies and treatments of acute and chronic anal pain, including an update on the management and treatment of hemorrhoidal disease and postoperative pain management.

La douleur anale peut être de survenue aiguë (le plus fréquemment en lien avec une fissure anale, un abcès ou fistule anale, ou une thrombose des veines périanales) ou chronique (fonctionnelle ou neuropathique), comportant le syndrome du releveur de l'anus, la proctalgia fugax, la névralgie du pudendal et les coccygodynies. Le diagnostic d'une douleur anale aiguë est rapidement posé grâce à l'anamnèse et surtout l'examen clinique. Les causes chroniques sont en revanche plus difficiles à diagnostiquer et nécessitent un interrogatoire détaillé avec une analyse approfondie des symptômes. Le but de cet article est d'explorer le traitement des étiologies de douleur anale aiguë, de pouvoir reconnaître une grande part des douleurs anales chroniques, sans oublier une mise à jour sur la maladie hémorroïdaire avec la prévention et gestion des douleurs postopératoires.

Protective ileostomy creation after anterior resection of the rectum: Shared decision-making or still subjective?

AIM: The choice of whether to perform protective ileostomy (PI) after anterior resection (AR) is mainly guided by risk factors (RFs) responsible for the development of anastomotic leakage (AL). However, clear guidelines about PI creation are still lacking in the literature and this is often decided according to the surgeon's preferences, experiences or feelings. This qualitative study aims to investigate, by an open-ended question survey, the individual surgeon's decision-making process regarding PI creation after elective AR. METHOD: Fifty four colorectal surgeons took part in an electronic survey to answer the questions and describe what usually led their decision to perform PI. A content analysis was used to code the answers. To classify answers, five dichotomous categories (In favour/Against PI, Listed/Unlisted RFs, Typical/Atypical, Emotions/Non-emotions, Personal experience/No personal experience) have been developed. RESULTS: Overall, 76% of surgeons were in favour of PI creation and 88% considered listed RFs in the question of whether to perform PI. Atypical answers were reported in 10% of cases. Emotions and personal experience influenced surgeons' decision-making process in 22% and 49% of cases, respectively. The most frequently considered RFs were the distance of the anastomosis from the anal verge (96%), neoadjuvant chemoradiotherapy (88%), a positive intraoperative leak test (65%), blood loss (37%) and immunosuppression therapy (35%). CONCLUSION: The indications to perform PI following rectal cancer surgery lack standardization and evidence-based guidelines are required to inform practice. Until then, expert opinion can be helpful to assist the decision-making process in patients who have undergone AR for adenocarcinoma.

Feasibility of on-demand robotics in colorectal surgery: first cases.

INTRODUCTION: The key benefits of robotics are improved precision and control, thanks to fully articulated robotic instruments and enhanced, stable endoscope control. However, colorectal procedures also require large movements such as medialization of the colon where a robotic platform is not always needed. We present the world's first experience in colorectal surgery with a new open platform of on-demand robotics. METHODS AND PROCEDURES: Standard laparoscopic 3-D camera, insufflator, trocars and energy devices, available in all hospitals performing laparoscopic surgery, are used in combination with the Dexter System™ from Distalmotion SA, which includes two robotic instrument arms, one robotic endoscope arm and a sterile surgeon console. We present the first 12 colorectal cases of robotic assisted ventral mesh rectopexy (n = 2), oncologic right colectomies (n = 8), transverse colectomy (n = 1) and ileocecal resection (n = 1) using the Dexter System. RESULTS: The two ventral mesh rectopexies were fully robotic, requiring no switching from standard laparoscopy to robotic assistance. The robotic platform was used for central vascular ligation (CVL) in all 8 oncologic colectomies, whereas medialization of the colon and transection was performed with standard laparoscopy. The switch from laparoscopy to robotics and back was performed in 15-30 s. Intracorporal anastomosis was performed in 4 patients (stapling by standard laparoscopy and suturing of the defect with robotic assistance). Conversion or permanent switch to standard laparoscopy was required in two patients due to visceral obesity. No robotic platform-related intraoperative adverse event occurred. No major morbidity occurred at 60 days. CONCLUSIONS: On-demand robotics is feasible and combines the best of two worlds: Robotics where precision and enhanced dexterity are required and standard laparoscopy where it is at its best. The surgeon remains scrubbed-in at all times, allowing a switch between robotics and laparoscopy within seconds.

Robot-assisted pelvic floor reconstructive surgery: an international Delphi study of expert users.

BACKGROUND: Robotic surgery has gained popularity for the reconstruction of pelvic floor defects. Nonetheless, there is no evidence that robot-assisted reconstructive surgery is either appropriate or superior to standard laparoscopy for the performance of pelvic floor reconstructive procedures or that it is sustainable. The aim of this project was to address the proper role of robotic pelvic floor reconstructive procedures using expert opinion. METHODS: We set up an international, multidisciplinary group of 26 experts to participate in a Delphi process on robotics as applied to pelvic floor reconstructive surgery. The group comprised urogynecologists, urologists, and colorectal surgeons with long-term experience in the performance of pelvic floor reconstructive procedures and with the use of the robot, who were identified primarily based on peer-reviewed publications. Two rounds of the Delphi process were conducted. The first included 63 statements pertaining to surgeons' characteristics, general questions, indications, surgical technique, and future-oriented questions. A second round including 20 statements was used to reassess those statements where borderline agreement was obtained during the first round. The final step consisted of a face-to-face meeting with all participants to present and discuss the results of the analysis. RESULTS: The 26 experts agreed that robotics is a suitable indication for pelvic floor reconstructive surgery because of the significant technical advantages that it confers relative to standard laparoscopy. Experts considered these advantages particularly important for the execution of complex reconstructive procedures, although the benefits can be found also during less challenging cases. The experts considered the robot safe and effective for pelvic floor reconstruction and generally thought that the additional costs are offset by the increased surgical efficacy. CONCLUSION: Robotics is a suitable choice for pelvic reconstruction, but this Delphi initiative calls for more research to objectively assess the specific settings where robotic surgery would provide the most benefit.

[Anal cancer screening. A decade's experience of a consultation in a tertiary centre]. / Dépistage du cancer anal. Expérience d'une décennie de consultation spécialisée.

Anal cancer is a disease with a low but gradually increasing incidence, especially in developed countries. Most of these cancers are caused by the HPV. In Switzerland, more than 70 % of the sexually active population is infected with HPV at least once, making it the most common sexually transmitted disease. Immunosuppression and anal sex remain other major risk factors. Precancerous lesions can progress to anal cancer (up to 13 % at 5 years), hence the importance of early detection. High resolution anoscopy is the standard of care for diagnosis and primary treatment of lesions. It is therefore important to monitor at-risk groups and to proactively screen for gynaecological and anal HPV infection.

Le cancer anal a une incidence faible mais en constante augmentation, particulièrement dans les pays développés. Le HPV est responsable de la plupart de ces cancers. En Suisse, plus de 70 % de la population sexuellement active est infectée au moins une fois par le HPV, ce qui en fait la maladie sexuellement transmissible la plus fréquente. D'autres facteurs de risque incluent l'immunosuppression et les rapports sexuels anaux. Les lésions précancéreuses peuvent évoluer en cancer de l'anus (jusqu'à 13 % à 5 ans), justifiant l'importance d'un dépistage précoce. L'anuscopie de haute résolution est l'examen privilégié pour le diagnostic et le traitement primaire des lésions. Il est donc crucial de surveiller les groupes à risque et d'adopter une attitude proactive en matière de dépistage de l'infection HPV gynécologique et anale.

Modest agreement between magnetic resonance and pathological tumor regression after neoadjuvant therapy for rectal cancer in the real world.

Magnetic resonance imaging (MRI) is routinely used for preoperative tumor staging and to assess response to therapy in rectal cancer patients. The aim of our study was to evaluate the accuracy of MRI based restaging after neoadjuvant chemoradiotherapy (CRT) in predicting pathologic response. This multicenter cohort study included adult patients with histologically confirmed locally advanced rectal adenocarcinoma treated with neoadjuvant CRT followed by curative intent elective surgery between January 2014 and December 2019 at four academic high-volume institutions. Magnetic resonance tumor regression grade (mrTRG) and pathologic tumor regression grade (pTRG) were reviewed and compared for all the patients. The agreement between radiologist and pathologist was assessed with the weighted k test. Risk factors for poor agreement were investigated using logistic regression. A total of 309 patients were included. Modest agreement was found between mrTRG and pTRG when regression was classified according to standard five-tier systems (k = 0.386). When only two categories were considered for each regression system, (pTRG 0-3 vs pTRG 4; mrTRG 2-5 vs mrTRG 1) an accuracy of 78% (95% confidence interval [CI] 0.73-0.83) was found between radiologic and pathologic assessment with a k value of 0.185. The logistic regression model revealed that "T3 greater than 5 mm extent" was the only variable significantly impacting on disagreement (OR 0.33, 95% CI 0.15-0.68, P = .0034). Modest agreement exists between mrTRG and pTRG. The chances of appropriate assessment of the regression grade after neoadjuvant CRT appear to be higher in case of a T3 tumor with at least 5 mm extension in the mesorectal fat at the pretreatment MRI.

Outcomes of the Composite Anterolateral Thigh Flap for Perineal Reconstruction After Postoncological Abdominoperineal Resection.

BACKGROUND: The vertical rectus abdominis flap is considered the gold standard in perineal reconstruction after oncological abdominoperineal resection; however, it has a nonnegligible donor site morbidity. The anterolateral thigh flap offers reliable soft tissue coverage. OBJECTIVE: The aim was to analyze long-term outcomes of composite anterolateral thigh-vastus lateralis flaps in oncological abdominoperineal resections. DESIGN: We conducted a retrospective cohort analysis of a prospectively maintained database. SETTINGS: This study was conducted in the Lausanne University Hospital. Annually, approximately 10 oncological abdomioperineal resections are performed. Literature reports 7% to 20% of patients undergoing abdominoperineal resection require flap reconstruction; in our institution, approximately 2 patients with large defects after abdominoperineal resections required reconstruction. PATIENTS: Twenty-nine pedicled anterolateral thigh-vastus lateralis flaps in 27 consecutive patients (mean age 63 years +/-11.2, 23 with radiochemotherapy) after abdominoperineal resection to cover large defects (median 190 cm2, 48-600 cm2) were analyzed. INTERVENTION: Pedicled composite anterolateral thigh-vastus lateralis flaps were performed after oncological abdominoperineal resection. MAIN OUTCOME MEASURES: Descriptive statistical analysis was conducted. Short- and long-term outcomes were analyzed, univariate and multivariate analyses were performed. Median follow-up was 16 months (12-48 months). RESULTS: Flap-related postoperative complications occurred in 16 flaps; flap-survival was 100%. Multivariate logistic analysis identified initial defect size as predictive for complications. Patients with larger defects (≥ 190 cm2) had higher complication rates (p = 0.006). Long-term analysis revealed 3 chronic fistulae, 2 tumor recurrences, 1 flap dysesthesia, and one perineal acne inversa. LIMITATIONS: Limitations include retrospective analysis, selection bias, and lacking a control group. Sample size limits statistical power. CONCLUSIONS: The pedicled anterolateral thigh-vastus lateralis flap offers reliable, stable tissue with low morbidity and good long-term outcomes. Complications compared favorably with current literature describing perineal reconstructions with rectus abdominis flaps. The composite anterolateral thigh flap is a valid alternative without the setback of abdominal donor site morbidity. See Video Abstract at http://links.lww.com/DCR/B757.RESULTADOS DEL COLGAJO COMPUESTO ANTEROLATERAL DE MUSLO PARA LA RECONSTRUCCIÓN PERINEAL DESPUÉS DE LA RESECCIÓN ABDOMINOPERINEAL POST ONCOLÓGICAANTECEDENTES:El colgajo vertical de recto abdominal se considera el estándar de oro en la reconstrucción perineal después de la resección abdominoperineal oncológica, sin embargo, tiene una morbilidad no despreciable en el sitio donante. El colgajo anterolateral del muslo ofrece una cobertura confiable de los tejidos blandos.OBJETIVO:El objetivo fue analizar los resultados a largo plazo de los colgajos compuestos anterolaterales del muslo - vasto lateral - en resecciones abdominoperineales oncológicas.DISEÑO:Realizamos un análisis, retrospectivo, de tipo cohorte, de una base de datos mantenida prospectivamente.AJUSTES:Este estudio fue realizado en el hospital universitario de Lausanne. Anualmente se realizan aproximadamente 10 resecciones abdominoperineales oncológicas. La literatura reporta que entre el 7 y el 20% de los pacientes que se someten a una resección abdominoperineal requieren de reconstrucción con colgajo; en nuestra institución, aproximadamente 2 pacientes con grandes defectos tras la resección abdominoperineal requirieron reconstrucción.PACIENTES:Fueron analizados veintinueve colgajos pediculados anterolaterales de muslo - vasto lateral - en 27 pacientes consecutivos (edad media 63 años +/- 11,2, 23 con radio quimioterapia) después de la resección abdominoperineal para cubrir defectos grandes (mediana 190 cm2, 48-600 cm2).INTERVENCIÓN:Tras la resección abdominoperineal oncológica se realizaron colgajos pediculados compuestos anterolaterales de muslo - vasto lateral.PRINCIPALES MEDIDAS DE RESULTADO:Fue realizado un análisis estadístico descriptivo. Fueron analizados los resultados a corto y largo plazo - fueron realizados así mismo análisis uni y multivariados. La mediana de seguimiento fue de 16 meses (12-48 meses).RESULTADOS:Complicaciones postoperatorias relacionadas con el colgajo ocurrieron en 16 colgajos, la supervivencia del colgajo fue del 100%. El análisis logístico multivariado identificó al tamaño del defecto inicial como predictor de complicaciones. Aquellos pacientes con defectos más grandes (≥190 cm2) tuvieron mayores tasas de complicaciones (p = 0,006). El análisis a largo plazo reveló tres fístulas crónicas, dos recidivas tumorales, una disestesia de colgajo y un acné perineal inverso.LIMITACIONES:Las limitaciones incluyen análisis retrospectivo, sesgo de selección y falta de grupo de control. El tamaño de la muestra limita el poder estadístico.CONCLUSIONES:El colgajo pediculado anterolateral de muslo - vasto lateral - ofrece tejido confiable y estable con baja morbilidad y buenos resultados a largo plazo. Los resultados de las complicaciones se mostraron favorables con respecto a la literatura actual que describe reconstrucciones perineales con colgajos de recto abdominal. El colgajo compuesto anterolateral de muslo es una alternativa válida sin el revés de la morbilidad del sitio donante abdominal. Consulte Video Resumen en http://links.lww.com/DCR/B757. (Traducción-Dr. Osvaldo Gauto).

[Obstructed colon cancer: which strategy in 2022?] / Cancer colique en occlusion : quelle prise en charge en 2022 ?

The key priority for obstructed colon cancer (OCC) is urgent resolution of the large bowel obstruction with ideally no compromise of oncological outcomes and low initial and permanent ostomy rates. Proactive management is pivotal to decrease the risk of perforation and septic shock. Staged procedures have an important place to provide optimal treatment and offer similar treatment and outcomes as in the elective setting. The approach is tailored to the patient's condition, the oncological situation and expertise of the available surgical team. This overview concludes by proposing a comprehensive treatment algorithm for individualized treatment of OCC.

La principale priorité du cancer du côlon obstructif (CCO) est la levée urgente de l'obstacle colique, sans compromettre les résultats oncologiques tout en réduisant les taux de stomies initiales et permanentes. Une prise en charge proactive est essentielle pour minimiser le risque de perforation et de choc septique. Les procédures par étapes (staged procedures) ont une place primordiale afin de permettre un traitement optimal associé à des résultats proches des conditions de la chirurgie élective. L'approche doit être adaptée à l'état des patients, au stade oncologique, ainsi qu'à l'expertise chirurgicale disponible. Cette synthèse de la littérature se conclut par la proposition d'un algorithme pour le traitement individualisé du CCO.

Crohn's versus Cancer: Comparison of Functional and Surgical Outcomes after Right-Sided Resections.

BACKGROUND: The objective of this study was to compare functional and surgical outcomes of patients undergoing ileocecal resection for Crohn's disease (CD) to patients undergoing oncological right colectomy. METHODS: Retrospective single-center cohort study including consecutive patients undergoing right colectomy for adenocarcinoma (oncological resection) or CD (mesentery-sparing resection) between July 2011 and November 2017. Outcome measures were pathological details (lymph node yield), postoperative recovery (pain levels, return to flatus and stool, intake of fluids, weight change, and mobilization), and early (30-day) outcomes (surgical/medical complications, hospital stay, readmissions). RESULTS: A total of 195 patients (153 [78%] with cancer and 42 [22%] with CD) were included. Overall compliance with the institutional enhanced recovery protocol was comparable between the 2 groups (compliance ≥70%: 60% in CD patients vs. 62% in cancer, p = 0.458). The adenocarcinoma group had a larger lymph node yield than the CD group (26 ± 13 vs. 2.4 ± 5, respectively, p < 0.001). While the CD group experienced significantly more pain (3.7 ± 1.9/10 vs. 2.8 ± 2.5/10, p = 0.007, patients requiring opioids: 65 vs. 28%, p = 0.001), return of flatus (2.3 ± 1.2 days vs. 2.4 ± 2.8 days, p = 0.642) and stool (4.1 ± 6.0 vs. 3.0 ± 1.8 days, p = 0.292) was no different in both groups. No difference was observed regarding postoperative complications, length of stay, and readmission rate. CONCLUSION: This study revealed no differences in both functional and surgical outcomes in CD and cancer patients undergoing mesentery-sparing or formal oncological right colectomy, respectively.

Proposition of a simple binary grading of estimated blood loss during colon surgery.

PURPOSE: Intraoperative estimated blood loss (EBL) is often reported in nearly all surgical papers; however, there is no consensus regarding its measurement. The aim of this study was to determine whether EBL (ml) is as reliable and reproducible in predicting complications as a simple binary grading of EBL. METHODS: All consecutive patients undergoing colectomies between January 2015 and December 2018 were included. EBL was assessed prospectively by the surgeon and anaesthesiologist in ml and with a binary scale: bleeding "as usual" versus "more than usual" by the surgeon. Differences between pre- and post-operative haemoglobin levels (ΔHb g/dl) were correlated to EBL. Blood loss impact on 30-day postoperative morbidity was analysed. RESULTS: A total of 270 patients were included, with a mean age of 65 years (SD 17). Mean EBL documented by surgeons correlated to EBL by anaesthesiologists (79.5 ml, SD 99 vs. 84.5 ml, SD 118, ϱ = 0.926, p < 0.001). Surgeons and anaesthesiologists' EBL correlated also with ΔHb (ϱ = - 0.273, p = 0.01 and ϱ = - 0.344, p = 0.01, respectively). Patient with surgeon EBL ≥ 250 ml or graded as "more than usual" bleeding had significantly more severe complications (8% vs. 20%, p = 0.02 and 8% vs. 27%, p = 0.001, respectively). CONCLUSION: Anaesthesiologist and surgeon's EBL correlated with ΔHb. Simple grading of blood loss as "usual" and "more than usual" predicted severe complications and higher mortality rates. This simple binary grading of blood loss in colon surgery could be an alternative to the estimation of blood loss in ml as it is easy to apply but needs to be validated externally.

[Surgery for colon cancer in 2021]. / Chirurgie du cancer du côlon en 2021.

Over the last decade, surgical management of colon cancer became more individualized due to new preoperative, surgical and oncological strategies. Recent high-level evidence demonstrated a favorable impact of these advanced concepts, which require proper planning and challenging surgical management form a technical standpoint, on cancer-specific survival. To tailor the best strategy, cases have to be discussed in multidisciplinary tumor boards with specialists in medical oncology, radiology, gastroenterology and pathology. In this review, these innovations are summarized within their scientific context, with focus on new strategies of preoperative bowel preparation, neoadjuvant chemotherapy and technical aspects, to illustrate the complexity of current colon cancer management.

Ces dernières années, la prise en charge du cancer du côlon est devenue plus personnalisée en raison de nouveaux concepts préopératoires, chirurgicaux et de nouvelles stratégies oncologiques. De récentes études de qualité ont démontré un impact favorable en termes de survie spécifique au cancer en employant ces concepts complexes qui nécessitent une planification soigneuse et une prise en charge chirurgicale exigeante au niveau technique. Dans cet article, ces innovations sont résumées dans leur contexte scientifique, en détaillant les nouveaux concepts de préparation colique, de nouvelles stratégies de chimiothérapie néoadjuvante et des techniques chirurgicales plus précises, pour illustrer la complexité de la prise en charge.

Recovery to Usual Activity After Outpatient Anorectal Surgery.

BACKGROUND: Most elective anorectal procedures are performed in an outpatient setting, and the supposed recovery time is short. The aim of the present study was to assess return to usual physical activity (UPA), return to work and quality of life (QOL). METHODS: This prospective single-center cohort study included consecutive patients undergoing outpatient anorectal procedures. Physical and work activities were assessed using the validated International Physical Activity Questionnaire 7 days before surgery and 7, 14 and 30 days thereafter. In addition, patients were inquired daily on their postoperative QOL until postoperative day (POD)10 on a visual analogue scale (0-10). Patients were stratified by their preoperative physical activity score (POPAS; low, moderate and high). RESULTS: Out of 379 patients, 100 (63 men) were included with a median age of 40 years [interquartile range (IQR) 27]. General QOL was rated at a median of 8/10 (IQR 3.5) at POD10. On POD30, only 69% and 71% of patients had returned to UPA and work, respectively. Patients who returned to UPA at POD30 had a better median QOL at POD10 than those who did not (9 vs. 7/10, p = 0.015). Patients with low POPAS and moderate POPAS returned to UPA earlier than patients with high POPAS (83%, 86% and 44% on POD30, respectively, p = 0.005). CONCLUSIONS: Return to UPA and work after outpatient anorectal surgery took longer than expected despite a good QOL 10 days after surgery. High physical activity was associated with longer recovery time. These elements should be emphasized during preoperative counseling.

Physical Activity and Outcomes in Colorectal Surgery: A Pilot Prospective Cohort Study.

BACKGROUND: Mobilization after surgery is recommended to reduce the risk of adverse effects and to improve recovery. The aim of this study was to examine the associations between perioperative physical activity and postoperative outcomes in colorectal surgery. METHODS: The daily number of footsteps was recorded from preoperative day 5 to postoperative day 3 in a prospective cohort of patients using wrist accelerometers. Timed Up and Go Test (TUGT), 6 Min Walking Test (6MWT), and peak expiratory flow (PEF) were assessed preoperatively. ROC curves were used to assess the performance of physical activity as a diagnostic test of complications and prolonged length of stay (LOS) of more than 5 days. RESULTS: A total of 50 patients were included. Patients with complications were significantly older (67 years) than those without complications (53 years, p = 0.020). PEF was significantly lower in the group with complications (mean flow 294.3 vs. 363.6 L/min, p = 0.038) while there was no difference between groups for the other two tests (TUGT and 6MWT). The tests had no capacity to discriminate the occurrence of complications and prolonged LOS, except the 6MWT for LOS (AUC = 0.746, p = 0.004, 95% CI: 0.604-0.889). There was no difference in the mean number of preoperative footsteps, but patients with complications walked significantly less postoperatively (mean daily footsteps 1,101 vs. 1,243, p = 0.018). CONCLUSIONS: Colorectal surgery patients with complications were elderly, had decreased PEF, and walked less postoperatively. The 6MWT could be used preoperatively to discriminate patients with potentially increased LOS and foster mobilisation strategies.

Stringent fluid management might help to prevent postoperative ileus after loop ileostomy closure.

PURPOSE: The present study aimed to analyze the impact of perioperative fluid management on postoperative ileus (POI) after loop ileostomy closure. METHODS: Consecutive loop ileostomy closures over a 6-year period (May 2011-May 2017) were included. Main outcomes were POI, defined as time to first stool beyond POD 3, and postoperative complications of any grade. Critical fluid management-related thresholds including postoperative weight gain were identified through receiver operator characteristics (ROC) analysis and tested in a multivariable analysis. RESULTS: Of 238 included patients, 33 (14%) presented with POI; overall complications occurred in 91 patients (38%). 1.7 L IV fluids at postoperative day (POD) 0 was determined a critical threshold for POI (area under ROC curve (AUROC), 0.64), yielding a negative predictive value (NPV) of 93%. Further, a critical cutoff for a postoperative weight gain of 1.2 kg at POD 2 was identified (AUROC, 0.65; NPV, 95%). Multivariable analysis confirmed POD 0 fluids of > 1.7 L (OR, 4.7; 95% CI, 1.4-15.3; p = 0.01) and POD 2 weight gain of > 1.2 kg (OR, 3.1; 95% CI, 1-9.4; p = 0.046) as independent predictors for POI. CONCLUSIONS: Perioperative fluid administration of > 1.7 L and POD 2 weight gain of > 1.2 kg represent critical thresholds for POI after loop ileostomy closure.