Colorectal Surgery in Romania during the COVID-19 Pandemic.

As the COVID-19 pandemic extends, its negative consequences on the effectiveness of therapeutic programs - previously assumed by the medical community and imperatively suspended for a difficult-to-predict period of time - are becoming increasingly worrying. In this context, as the evidence-based recommendations are not possible, most of the national and international scientific societies tried to develop balanced recommendations (1-4). The Romanian Society of Coloproctology (SRCP) and the Romanian Association for Endoscopic Surgery (ARCE) have created a working group that, taking into account recent publications, the statements of international academic societies, the national legislative context and the unique experience of countries severely affected by this pandemic (China, Italy, Spain, USA, etc.) proposes for Romania, the following recommendations for medical practice in colorectal surgery during the COVID-19 pandemic. These recommendations are subjected to continuous review, depending on the global and national situation of the pandemic, the particular needs of each hospital, the recommendations of the competent authorities and the evolution of the literature that publishes the conclusions of ongoing clinical trials.

SRED-ARCE Recommendations for Minimally Invasive Interventions During the COVID-19 Pandemic in Romania.

The Romanian Society of Digestive Endoscopy (SRED) and the Romanian Association of Endoscopic Surgery (ARCE) have decided to establish a joint working group to elaborate specific recommendations for organizing the diagnostic and the minimally invasive interventional procedures, in the context of the COVID-19 pandemic. The recommendations are based on the guidelines of the international societies of endoscopy and gastroenterology (ESGE / BSG / ASGE / ACG / AGA), respectively endoscopic surgery (EAES SAGES) (4-8), on the experience of countries severely affected by the pandemic (Italy, France, Spain, USA, Germany, etc.) and they will be applied within the limits of measures imposed at local and governmental level by the competent authorities. On the other hand, these recommendations should have a dynamic evolution, depending on the upward or downward trend of the COVID-19 pandemic at regional and local level, but also according to the findings of professional and academic societies, requiring regular reviews based on the publica tion of further recommendations or international clinical trials. The objectives of the SRED and ARCE recommendations target the endoscopic and laparoscopic surgery activities, to support their non discriminatory used for diagnostic or therapeutic purposes, pursuing the demonstrated benefits of these procedures, in safe conditions for patients and medical staff.

Partial Adrenalectomy - Arguments for the Minimally Invasive Surgical Approach.

Background: Partial adrenalectomy has been widely performed in the last decades in order to diminish the number of patients who would become lifetime dependent of hormonal replacement. Method: between 2016 and 2018 seven patients were submitted to minimally invasive partial adrenalectomy in Ponderas Academic Hospital. Results: the median age at the time of surgery was 56 years (range 42-67 years) while the indications for partial adrenalectomy (PA) were represented by Conn's syndrome in four cases, bilateral pheochromocytoma in one cases and nonfunctional adrenal tumors in two cases. Preoperatively successful adrenal vein sampling was performed in one case. The indocyanine green test (ICG) as well as intraoperative ultrasound were used each in three cases. The transperitoneal approach was used for PA in all patients, laparoscopic in five and robotic assisted in two patients. No conversion to open surgery or to total suprarenalectomy was encountered. Conclusions: minimally invasive surgery seems to be a safe and effective method to perform partial adrenalectomy. Moreover, development of novel technologies such as adrenal vein sampling, indocyanine green test or intraoperative ultrasound seem to increase the feasibility of the method as well as the number of cases who could benefit from the type of approach. Use of new technology?

Early Laparoscopic Ileostomy Reversal After Rectal Cancer Surgery - Technique and Outcomes.

Background: A temporary diverting ileostomy (TDI) is performed in a significant number of patients undergoing colorectal surgery. The best timing for ileostomy reversal (IR), early or late after its formation and the proper technique used for its closure are controversial.The objective of the present study is to describe the particular aspects of the laparoscopic technique of ileostomy reversal and to analyze the outcomes of its early closure. Methods: A retrospective analysis on all the patients who underwent laparoscopic ileostomy reversal (LIR) after MIS rectal surgery between 2015 and 2018 in Ponderas Academic Hospital was performed. No patient was excluded from the study. The outcomes of the early laparoscopic closure of the diverting ileostomy (less than 30 days) were analyzed and compared with the standard closure ones. Results: Twenty-one patients, (10 males), average age and BMI of 57 years (range 33-77) and 21.6 kg/m2 (range 14.4-34) were included into the study. All the procedures were completed laparoscopically. No patient was lost from follow-up. The laparoscopic ileostomy reversal was performed at 50.4 days (range 7-150) from the open (1 patient) or laparoscopic (20 patients) rectal cancer resection. Twelve patients had preoperative RCT (48%), 17 low colorectal anastomosis and the coloanal one was performed in three patients with TDI. Eleven patients (52%) had an early ileostomy reversal after 23.6 days (7-30 days). A very early LIR (7-10 days) was necessary in 3 patients with complicated evolution after TDI. No significant intra-operative or postoperative complications between the two subgroups of early or late LIR was encountered. The hospital stay (LOS) after LIR was 3.9 days (2-5) with no difference between the two subgroups. We encountered one postoperative complication (5%), - enteral bleeding conservatively treated. Conclusions: Laparoscopic ileostomy reversal may be considered as a primary option for temporary diverting ileostomy after colorectal resection. The early ileostomy reversal is safe and improved postoperative outcomes in are demonstrated selected patients. Careful investigation and rigorous selection of the patients for EIR is mandatory.

Technical Issues and Early Outcomes of Restorative Proctocolectomy for Familial Adenomatous Polyposis and Ulcerative Colitis: The Largest Romanian Single-Team Experience.

Background/ Aim: Restorative proctocolectomy (RPC) is a complex surgical procedure used to treat patients with ulcerative colitis (UC) and familial adenomatous polyposis (FAP). The present study aims to assess the technical issues and early outcomes of RPC for FAP and UC, in a relatively large single-team series of patients. Patients and Methods: The data of all patients with RPC performed by a single surgical team between 1991 and 2018 were retrospectively assessed from a prospectively maintained electronic database. Results: The study group included 77 patients with RPC, and 70.1% have had FAP. The average number of RPC per year was 3.3 for the surgical team and 4.3 for the institution. A J pouch was performed in 93.5% of the patients. A hand-sewn reservoir was made in 76.6% of the patients. A hand-sewn ileal pouch-anal anastomosis was performed in 81.8% of the patients. A diverting ileostomy was performed in 92.2% of the patients. Mucosectomy was performed in 84.4% of the patients. The early morbidity rate was 36.4%, with severe complications rate of 13%. The main complications were pouch-related septic complications (18.2%), wound infections (9.1%), small-bowel obstruction (6.5%) and hemorrhage (6.5%). Conclusions: Although a RPC remains an uncommon surgical procedure in Romania, however, the early outcomes of the present series are comparable to those reported in high volume centers. Good outcomes after RPC can be obtained if such complex surgical procedures are performed by dedicated surgical teams, with high case-load.

Laparoscopic Mobilization of the Splenic Flexure as the First Step of Restorative Colorectal Resection.

Background: Mobilization of the colonic splenic flexure (SFM) is an essential surgical step of the restorative rectal resections. However, the surgical procedures are technically complex thereby overcoming the learning curve may not be an easy process. Looking for improved expertise and better outcomes, in 2016, we have decided to routinely perform SFM as a first step of all the laparoscopic or robotic sigmoid and rectal resections. The aim of this paper is to describe the technique of laparoscopic splenic flexure mobilization and to discuss the advantages of using it as the first surgical step in colorectal rectal resection analyzing our last 12 months experience (2018). Method: A detailed description of the laparoscopic surgical technique for SFM is performed. There are four routes for SFM: two from medial to lateral, one starting from the splenic vein the other one from the promontory, a superior to inferior approach and a lateral to medial approach. However, the combination of different maneuvers for an easier, safer approach decreases the morbidity and is saving surgical time. Results: Between January and December 2018, 47 patients had SPM as a first step of the performed colorectal procedure in our institution. There were 30 patients with rectal cancer, 10 with sigmoidal tumors, five with sigmoidal resection for diverticulitis and Hartmann reversal was indicated in two. The robotic approach has been used in 40% (16 patients). No intraoperative incidents were associated with the SFM. No colorectal fistula was encountered. No early cancer recurrence, deaths or major complication were encountered. The mean follow-up for these patients is 7 months (range, 4-12 months). Conclusions: In our perspective, the routine mobilization of the splenic flexure as a first step of the colorectal restorative resections associate many advantages and these strategies should be largely used. There is a learning curve involved in such procedure and it can easily be overcome in high volume centers.

Laparoscopic Spleen Preserving Distal Pancreatectomy with Splenic Vessels Preservation.

Spleen preserving Distal Pancreatectomy (SPDP) is commonly applied in patients with benign or low-grade malignant tumors in the body and tail of the pancreas. Our aim is to present our technique and the early results in performing laparoscopic spleen preserving distal pancreatectomy with splenic vessel preservation (LSPDP-SVP) during 2017-2018 in Ponderas Academic Hospital.

Robotic Approach in Benign and Malignant Esophageal Tumors; A Preliminary Seven Case Series.

Esophageal surgery has been recognized as very challenging for surgeons and risky for patients. Thoracoscopic approach have proved its benefit in esophageal surgery but has some drawbacks as tremor and limited degrees of freedom, contra-intuitive movements and fulcrum effect of the surgical tools. Robotic technology has been developed with the intent to overcome these limitations of the standard laparoscopy or thoracoscopy. These benefits of robotic procedure are most advantageous when operating in remote areas difficult to reach as in esophageal surgery. AIM: The aim of this paper is to present our small experience related with robotic approach in benign and malignant esophageal tumors and critically revise the evidence available about the use of the robotic technology for the treatment of these pathology. Methods: From January 2008 to September 2016 robotic surgery interventions related with benign or malignant esophageal tumors were performed in "Dan Setlacec" Center for General Surgery and Liver Transplantation of Fundeni Clinical Institute in seven patients. This consisted of dissection of the entire esophagus as part of an abdomino-thoracic-cervical procedure for esophageal cancer in 3 patients and the extirpation of an esophageal leiomyoma in 3 cases and a foregut esophageal cyst in one case. Results: All procedures except one were completed entirely using the da Vinci robotic system. The exception was the first case - a 3 cm leiomyoma of the inferior esophagus with ulceration of the superjacent esophageal mucosa. Pathology reports revealed three esophageal leiomyoma, one foregut cyst and three squamous cell carcinomas with free of tumor resection margins. The mean number of retrieved mediastinal nodes was 24 (22 - 27). The postoperative course was uneventful in four cases, in the other three a esophageal fistula occurred in the converted leiomyoma case (closed in the 14th postoperative day), a prolonged drainage in one esophageal cancer case and a temporary right recurrent nerve palsy in an other one. One patient with esophageal cancer and all patients with benign lesions are alive with no signs of recurrence and no symptomatology. CONCLUSION: Our experience is limited and we cannot conclude for the long term benefits of robotic surgery for esophageal tumors. In our experience the early outcomes were better then using classic open approach, but similar with the cases performed by thoracoscopic approach. We have noticed significant advantages of robotic surgery in relation of lymph node retrieval, leiomyoma dissection safe from esophageal mucosa and suturing. Ergonomics for the surgeon was incomparable better then with the thoracoscopic approach.

Laparoscopic HIPEC for Peritoneal Carcinomatosis from Gastric Cancer - Technique and Early Outcomes of Our First Cases.

Gastric cancer remains one of the most aggressive malignancies, being associated with very poor therapeutic outcomes, especially in the advanced disease patients. Due to this evidence, finding a better treatment, a better control and higher survival rates is the current scientific focus of the medical community. Once the benefits of cytoreductive surgery in association with intraperitoneal hyperthermy (HIPEC) have been widely demonstrated in patients presenting peritoneal carcinomatosis from colorectal or ovarian origin,attention was focused on the possible benefit of this method in patients diagnosed with peritoneal carcinomatosis with gastric origin. Moreover, using laparoscopy for the cytoreductive surgery (L-CRS) and hyperthermic intraperitoneal chemotherapy (L-HIPEC), the advantages of minimal invasive surgery (MIS) are expected to contribute to improved postoperative outcomes. In this way, the patients benefit from a faster administration of the adjuvant chemotherapeutic treatment, whenever is necessary. AIM: to present the technique of L-CRS + L-HIPEC and the early therapeutic outcomes in a case series of two patients diagnosed with peritoneal carcinomatosis from gastric cancer. METHOD: A complete investigational work-up including diagnostic laparoscopy to evaluate the Peritoneal Carcinomatosis Index (PCI) was fulfilled in all the cases. The institutional Tumor Board decided the therapeutic strategy: laparoscopic radical resection and HIPEC (L-CRS +L-HIPEC). The procedures were performed into a private setting (Ponderas Academic Hospital). Results: Two male patients,46 and 69years old, presenting carcinomatosis from gastric cancer were included into the study. Initial PCI was assessed by laparoscopy and it was 18 and 7, respectively. Both cases underwent neoadjuvant chemotherapy. D2 laparoscopic radical gastrectomy and L-HIPEC was then performed. Time of procedure was360 and 320 minutes, respectively. The intraperitoneal temperature varied between 41 and 42°C, while the intra-esophageal temperature reached a maximum value of 37,7 °C. There was no perioperative or postoperative complication, nor mortality. The hospital stay was 8 days. Conclusions: Explorative laparoscopy can help select patients for conversion chemotherapy in the setting of high peritoneal carcinomatosis index (PCI) score. Laparoscopy radical excision + L-HIPEC were successfully performed with very good therapeutic outcomes.

A research agenda for the European Association for Endoscopic Surgeons (EAES).

INTRODUCTION: The European Association of Endoscopic Surgeons (EAES) conducted this study aiming to identify the top research questions which are relevant to surgeons in Minimal Access Surgery (MAS). This is in order to promote and link research questions to the current clinical practice in MAS in Europe. METHODS: Using a systematic methodology, (modified Delphi), the EAES members and leadership teams were surveyed to obtain consensus on the top research priorities in MAS. The responses were categorized and redistributed to the membership to rate the level of importance of each research question. The data were reported as the weighted average score with a scale from 1 (lowest agreement) to 5 (highest agreement). RESULTS: In total, 324 of 2580 (12.5%) of the EAES members and the leaders responded to the survey and contributed to the final consensus. The ranked responses over the 80th percentile identified 39 research priorities with rating ranged from 4.22 to 3.67. The top five highest ranking research priorities in the EAES were centered on improving training in MAS, laparoscopic surgery for benign upper gastrointestinal conditions, integration of novel technology in OR, translational and basic science research in bariatric surgery and investigating the role of MAS in rectal cancer. CONCLUSION: An EAES research agenda was developed using a systematic methodology and can be used to focus MAS research. This study was commissioned by the European Association for Endoscopic Surgery (EAES).

Robotic oncologic complexity score - a new tool for predicting complications in computer-enhanced oncologic surgery.

BACKGROUND: While there is little doubt that robotic interventions have already opened new horizons in surgery due to its inherent complexity, there is still an unmet need for tools allowing center-to-center performance comparisons. A complexity score could be a valuable instrument for further research. METHODS: The items of the robotic oncologic complexity score (ROCS) were based on risk factors identified in previous studies. We attempt to build the score and validate it on 400 consecutive cases of robotic oncologic surgery. The primary endpoint is to assess the value of ROCS in predicting major complications. RESULTS: The mean ROCS in the group was 3.3(+/-1.4). Different correlations were calculated: the score and the complications (r=0.38), the major complications (r=0.42), Clavien grade (r=0.5), the operating time (r=0.35), and the length of stay (r=0.47). On the ROC-curve a score >4 has the best specificity and sensibility for predicting major complications (P<0.05). CONCLUSION: ROCS has potential in predicting complications and hospital length of stay, as well as a role in classifying oncologic robotic surgical interventions. Copyright © 2015 John Wiley & Sons, Ltd.

Predictors of short term treatment outcome in patients with achalasia following endoscopic or surgical therapy.

BACKGROUND/AIMS: Pneumatic balloon dilation and surgical myotomy are the most effective treatments for achalasia. While there is controversy which method is best, the aim of the current study was to identify predictors of symptom recurrence after endoscopic or surgical therapy. METHODOLOGY: Patients undergoing pneumatic balloon dilatation (30mm) or laparoscopic Heller myotomy with Dor fundoplication were included in the study. Analyzed parameters include total symptom score (sum of 0-5 point intensity for dysphagia, regurgitation and chest pain), width and height of esophageal column at 2 and 5 minutes after oral barium ingestion, lower esophageal sphincter (LES) length, resting (LESP) and residual pressure (LESRP) before and 3 months after intervention. Patients with symptoms score <3 at the 3-month follow-up visit were considered asymptomatic. RESULTS: Twenty-one patients underwent pneumatic dilation (14) or laparoscopic myotomy (7). Total symptom score improved (p<0.01) from pre- (7.2±2.7) to post-intervention (1.7±2.6). Eleven (85.8%) patients in the endoscopic group vs. 7 (100%) patients in the surgical group were symptom-free 3 months after intervention. Therapies improved LESP (24.4±8.2mmHg pre- vs. 15.4±10.3mmHg post-therapy; p=0.003) and mean LESRP (7.9±4.3mmHg pre- vs. 5.3±6.7mmHg post-therapy; p=0.03). Univariate linear regression analysis identified barium contrast column width >5cm at 2 minutes (p=0.04), LES length <2cm (p=0.003) and LESRP >10mmHg (p=0.02) as predictors for persistent symptoms. CONCLUSIONS: While >85% of achalasia patients responded well to 30mm pneumatic balloon dilation, patients with elevated LES pressure, short LES and wide esophagus should be considered as primary surgical candidates.

Unilateral extended thoracoscopic thymectomy for nontumoral myasthenia gravis--a new standard.

Myasthenia gravis (MG) is a heterogeneous disorder with a fluctuating, clinical, pathologic, and immunobiological picture. Today, it is believed that effective treatment of MG must include both immunosuppression and surgery. Thymectomy is recommended by neurologists for patients with nontumoral MG as an option to increase the probability of remission or improvement. Currently, thoracoscopic thymectomy is considered a good alternative to the standard open approach because of its higher rate of acceptance, low morbidity, and high efficacy, as measured by complete stable remission rates. We present a review of the experience of unilateral extended thoracoscopic thymectomy for nontumoral MG, a technique that could became a new standard in the complex management of MG treatment.

Neuroendocrine tumours of the ampulla of Vater: clinico-pathological features, surgical approach and assessment of prognosis.

BACKGROUND/AIMS: Neuroendocrine tumours occur very rarely in the ampulla of Vater and their clinical behaviour is unknown. The aim of this study is to assess the clinico-pathological features, surgical approach and prognosis of these patients. METHODS: Six patients with neuroendocrine tumours of the ampulla of Vater treated with curative intent surgery at a single centre were retrospectively analysed. A univariate analysis of potential prognostic factors was also performed (data provided from the present study and literature review). RESULTS: Pancreaticoduodenectomy was curative in all the patients. Overall and disease-free survival rates were significantly better for G1/G2 tumours (p = 0.006 and p = 0.004, respectively). Although frequent, lymph node metastases did not influenced both overall (p = 0.760) and disease-free survival rates (p = 0.745). No significant differences of survival were observed in patients with ENETS stage I/II disease, as compared to ENETS stage III disease (p = 0.169 and p = 0.137, respectively). No differences were observed according to UICC staging system (p = 0.073 and p = 0.177, respectively). Tumours that are less than 2 cm or limited to the ampulla appear to have a better prognosis. CONCLUSION: The WHO 2010 classification appear to accurately predict patient prognosis, while the ENETS or UICC staging systems have a limited value (especially in regard to lymph node metastases). Radical surgery (i.e. pancreaticoduodenectomy with lymphadenectomy) should be the standard approach in most patients with NET of the ampulla of Vater because this procedure removes all the potential tumour-bearing tissue.

Ten-year results of thoracoscopic unilateral extended thymectomy performed in nonthymomatous myasthenia gravis.

OBJECTIVE: The aim of this study was to analyze the 10-year results of thoracoscopic unilateral extended thymectomy (TUET) performed in nontumoral myasthenia gravis according to the Myasthenia Gravis Foundation of America recommendations. BACKGROUND DATA: Thoracoscopic unilateral extended thymectomy has the benefits of a minimally invasive approach. Previous data have shown promising midterm results but long-term results were lacking. METHODS: Two hundred forty patients with nontumoral myasthenia gravis who underwent surgery between 1999 and 2009 were eligible for the study. The mean follow-up was of 67 months (range: 12-125), 134 patients completed follow-up assessments more than 60 months after TUET. RESULTS: There were 39 males (16.3%) and 201 females (83.7%), with an age range from 8 to 60 years. The mean preoperative disease duration was 21.5 months. All patients underwent preoperative steroid therapy. Anticholinesterase drugs were required for 123 patients (51.3%), and immunosuppressive drugs were required for 87 (36.3%) patients. The pathologic findings were as follows: normal thymus in 13 patients (5.5%), involuted thymus in 65 patients (27%), and hyperplastic thymus in 162 patients (67.5%). The average weight of the thymus was 110 ± 45 g. Ectopic thymic tissue was found in 147 patients (61.3%). There was no mortality, and morbidity consisted of 12 patients (5%). Complete stable remission was achieved in 61% of the patients, and the cumulative probability of achieving complete stable remission was 0.88 at 10 years. CONCLUSIONS: With zero mortality, low morbidity, and comparable long-term results to open surgery, TUET can be regarded as the best treatment option for patients undergoing surgery for myasthenia gravis.

Central pancreatectomy for pancreatoblastoma in a 16-year-old girl.

Long-term functional results after standard pancreatic resections are a major concern, especially in children. An alternative pancreas-sparing procedure (such as central pancreatectomy) should be taken into consideration whenever it is feasible, and a prolonged survival is expected. Pancreatoblastoma is an unusual malignant tumor in childhood. However, in initially resectable tumors, the 15-year survival is more than 80%. Thus, there is a potential role of a conservative pancreatic resection in successful treatment of pancreatoblastoma. The management in a case of a 16-year-old girl with a pancreatoblastoma in the body of pancreas is presented. Complete surgical resection by central pancreatectomy followed by chemotherapy led to a prolonged disease-free survival, with good functional results. Central pancreatectomy could be an alternative surgical technique in some selected cases of pancreatoblastoma, having the lowest incidence of postoperative exocrine and endocrine insufficiency rate and offering the best nutritional status.

Thoracoscopic thymectomy mid-term results.

BACKGROUND: Results of thymectomy in patients with myasthenia gravis need to be reported in a standardized way to allow accurate comparison. METHODS: A retrospective study was conducted of 107 patients with myasthenia gravis without thymoma. Patients were followed-up for more than 12 months after thoracoscopic thymectomy and analyzed according to Myasthenia Gravis Foundation of America Recommendations for Clinical Research Standards. RESULTS: The study population was aged 8 to 60 years old and included 15 men (14%) and 92 women (86%). A right-side approach was used in 36 patients, and the remaining 71 patients had a left-side approach. Mortality was 0% and morbidity was 9.34%. The mean operative time was 90 +/- 45 minutes. The histologic diagnosis of the resected thymus was hyperplasia (78.5%), atrophy (15%), and normal status (6.5%). The mean length of hospitalization was 2.3 days (range, 2 to 6 days). The mean follow-up was 36.4 months (range, 12 to 74 months). The rate of complete stable remission was 59.5% by the end of postoperative year 6. An earlier onset age and early operation were significantly associated with complete stable remission and pharmacologic remission. A comparison of right side versus left side approach showed similarities in mean operative time, mean length of hospitalization, histopathologic results, and remission rates. CONCLUSIONS: Outcomes of the thoracoscopic approach in myasthenia gravis without thymoma were similar to those provided by open surgery, with the acknowledged benefits of minimally invasive surgery and good patient acceptance.