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1.
Ann Surg ; 2024 May 06.
Artículo en Inglés | MEDLINE | ID: mdl-38708881

RESUMEN

OBJECTIVE: To develop and analyze a risk-adjusted cumulative sum (RA-CUSUM) chart as a potential method to monitor individual surgeon performance in robotic total mesorectal excision (TME) for rectal cancer. SUMMARY BACKGROUND DATA: Currently, surgeons lack real-time tools to monitor and enhance their performance beyond residency completion. While national quality programs exist, granular, individual-level data is crucial for continuous improvement. Previous studies suggest CUSUM charts hold promise in identifying performance trends and outliers. METHODS: This retrospective study analyzed data from 640 robotic TME cases performed by 12 surgeons at two institutions. RA-CUSUM charts were generated for three outcomes: complications, operative time, and length of stay. RESULTS: The overall RA-CUSUM curves for operative time and complications showed an initial learning phase followed by a plateau or downward slope, indicating proficiency or improvement. However, individual surgeon curves revealed significant heterogeneity. Three surgeons consistently excelled in operative time, while five minimized complications most effectively. Potential quality improvement could be implemented to drive performance toward positive outliers. No differences were found in unadjusted outcomes, including conversion, number of lymph nodes harvested, and positive circumferential margins. CONCLUSIONS: The RA-CUSUM chart is a promising method for identifying individual surgeon performance in robotic TME. It could help surgeons, teams, and leaders identify improvement areas and benchmark themselves against positive outliers. Further studies are needed to explore the potential of RA-CUSUM for implementing interventions to improve surgical quality.

2.
J Gastrointest Surg ; 28(5): 667-671, 2024 May.
Artículo en Inglés | MEDLINE | ID: mdl-38704204

RESUMEN

BACKGROUND: The evolution of enhanced recovery pathways (ERPs) in colon and rectal surgery has led to the development of same-day discharge (SDD) procedures for selected patients. Early discharge after diverting loop ileostomy (DLI) closure was first described in 2003. However, its widespread adoption remains limited, with SDD accounting for only 3.2% of all DLI closures in 2005-2006, according to the American College of Surgeons National Surgical Quality Improvement Program database, and rising to just 4.1% by 2016. This study aimed to compare the outcomes of SDD DLI closure with those of DLI closure after the standard ERP. METHODS: A retrospective case-matched study compared 125 patients undergoing SDD DLI closure with 250 patients undergoing DLI closure after the standard ERP based on age (±1 year), sex, American Society of Anesthesiologists score, body mass index, surgery date (±2 months), underlying disease, and hospital site. The primary outcome was comparative 30-day complication rates. RESULTS: Patients in the traditional ERP group received more intraoperative fluids (1221.1 ± 416.6 vs 1039.0 ± 368.3 mL, P < .001) but had similar estimated blood loss. Ten patients (8%) in the SDD-ERP group failed SDD. The 30-day postoperative complication rate was significantly lower in the SDD group (14.8%) than the standard ERP group (25.7%, P = .025). This difference was primarily driven by a lower incidence of ileus in the SDD group (9.6% vs 14.8%, P = .034). There were no significant differences in readmission rate (9.6% of SDD-ERP vs 9.2% of standard ERP, P = .900) and reoperation rates (3.2% of SDD-ERP vs 2.4% of standard ERP, P = .650). CONCLUSION: SDD ileostomy closure is a safe, feasible, and effective procedure associated with fewer complications than the present study's standard ERP. This could represent a new standard of care. Further prospective trials are required to confirm the findings of this study.


Asunto(s)
Ileostomía , Alta del Paciente , Complicaciones Posoperatorias , Humanos , Ileostomía/métodos , Ileostomía/efectos adversos , Masculino , Femenino , Estudios Retrospectivos , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Alta del Paciente/estadística & datos numéricos , Anciano , Cuidados Posoperatorios/métodos , Readmisión del Paciente/estadística & datos numéricos , Recuperación Mejorada Después de la Cirugía , Resultado del Tratamiento , Estudios de Casos y Controles , Tiempo de Internación/estadística & datos numéricos
3.
Ann Surg Oncol ; 2024 Apr 28.
Artículo en Inglés | MEDLINE | ID: mdl-38679679

RESUMEN

INTRODUCTION: Presacral neuroendocrine neoplasms (PNENs) are rare tumors, with limited data on management and outcomes. METHODS: A retrospective review of institutional medical records was conducted to identify all patients with PNENs between 2008 and 2022. Data collection included demographics, symptoms, imaging, surgical approaches, pathology, complications, and long-term outcomes. RESULTS: Twelve patients were identified; two-thirds were female, averaging 44.8 years of age, and, for the most part, presenting with back pain, constipation, and abdominal discomfort. Preoperative imaging included computed tomography scans and magnetic resonance images, with somatostatin receptor imaging and biopsies being common. Half of the patients had metastatic disease on presentation. Surgical approach varied, with anterior, posterior, and combined techniques used, often involving muscle transection and coccygectomy. Short-term complications affected one-quarter of patients. Pathologically, PNENs were mainly well-differentiated grade 2 tumors with positive synaptophysin and chromogranin A. Associated anomalies were common, with tail-gut cysts prevalent. Mean tumor diameter was 6.3 cm. Four patients received long-term adjuvant therapy. Disease progression necessitated additional interventions, including surgery and various chemotherapy regimens. Skeletal, liver, thyroid, lung, and pancreatic metastases occurred during follow-up, with no mortality reported. Kaplan-Meier analysis showed a 5-year local recurrence rate of 23.8%, disease progression rate of 14.3%, and de novo metastases rate of 30%. CONCLUSION: The study underscores the complex management of PNENs and emphasizes the need for multicenter research to better understand and manage these tumors. It provides valuable insights into surgical outcomes, recurrence rates, and overall survival, guiding future treatment strategies for PNEN patients.

4.
Tech Coloproctol ; 28(1): 43, 2024 Apr 01.
Artículo en Inglés | MEDLINE | ID: mdl-38561571

RESUMEN

BACKGROUND: Up to 20% of patients with ileal pouch will develop pouch failure, ultimately requiring surgical reintervention. As a result of the complexity of reoperative pouch surgery, minimally invasive approaches were rarely utilized. In this series, we present the outcomes of the patients who underwent robotic-assisted pouch revision or excision to assess its feasibility and short-term results. METHODS: All the patients affected by inflammatory bowel diseases and familial adenomatous polyposis who underwent robotic reoperative surgery of an existing ileal pouch were included. RESULTS: Twenty-two patients were included; 54.6% were female. The average age at reoperation was 51 ± 16 years, with a mean body mass index of 26.1 ± 5.6 kg/m2. Fourteen (63.7%) had a diagnosis of ulcerative colitis at reoperation, and seven (31.8%) had Crohn's disease. The mean time to pouch reoperation was 12.8 ± 11.8 years. Seventeen (77.3%) patients underwent pouch excision, and five (22.7%) had pouch revision surgery. The mean operative time was 372 ± 131 min, and the estimated blood loss was 199 ± 196.7 ml. The conversion rate was 9.1%, the 30-day morbidity rate was 27.3% (with only one complication reaching Clavien-Dindo grade IIIB), and the mean length of stay was 5.8 ± 3.9 days. The readmission rate was 18.2%, the reoperation rate was 4.6%, and mortality was nihil. All patients in the pouch revisional group are stoma-free. CONCLUSION: Robotic reoperative pouch surgery in highly selected patients is technically feasible with acceptable outcomes.


Asunto(s)
Colitis Ulcerosa , Reservorios Cólicos , Proctocolectomía Restauradora , Procedimientos Quirúrgicos Robotizados , Humanos , Femenino , Adulto , Persona de Mediana Edad , Anciano , Masculino , Reoperación , Procedimientos Quirúrgicos Robotizados/efectos adversos , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugía , Proctocolectomía Restauradora/efectos adversos , Proctocolectomía Restauradora/métodos , Colitis Ulcerosa/cirugía , Colitis Ulcerosa/complicaciones , Reservorios Cólicos/efectos adversos , Anastomosis Quirúrgica/efectos adversos , Resultado del Tratamiento , Estudios Retrospectivos
5.
J Gastrointest Surg ; 28(4): 513-518, 2024 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-38583904

RESUMEN

BACKGROUND: The effect of previous abdominal surgery (PAS) in laparoscopic surgery is well known and significantly adds to longer hospital length of stay (LOS), postoperative ileus, and inadvertent enterotomies. However, little evidence exists in patients with PAS undergoing robotic-assisted (RA) rectal surgery. METHODS: All patients undergoing RA surgery for rectal cancer were reviewed. Patients with PAS were divided into minor and major PAS groups, defined as surgery involving >1 quadrant. The primary outcome was the risk of conversion to open surgery. RESULTS: A total of 750 patients were included, 531 in the no-PAS (NPAS) group, 31 in the major PAS group, and 188 in the minor PAS group. Patients in the major PAS group had significantly longer hospital LOS (P < .001) and lower adherence to enhanced recovery pathways (ERPs; P = .004). The conversion rates to open surgery were similar: 3.4% in the NPAS group, 5.9% in the minor PAS group, and 9.7% in the major PAS group (P = .113). Estimated blood loss (EBL; P = .961), operative times (OTs; P = .062), complication rates (P = .162), 30-day readmission (P = .691), and 30-day mortality (P = .494) were similar. Of note, 53 patients underwent lysis of adhesions (LOA). On multivariate analysis, EBL >500 mL and LOA significantly influenced conversion to open surgery. EBL >500 mL, age >65 years, conversion to open surgery, and prolonged OT were risk factors for prolonged LOS, whereas adherence to ERPs was a protector. CONCLUSION: PAS did not seem to affect the outcomes in RA rectal surgery. Given this finding, the robotic approach may ultimately provide patients with PAS with similar risk to patients without PAS.


Asunto(s)
Procedimientos Quirúrgicos del Sistema Digestivo , Laparoscopía , Neoplasias del Recto , Procedimientos Quirúrgicos Robotizados , Humanos , Anciano , Procedimientos Quirúrgicos Robotizados/efectos adversos , Laparoscopía/efectos adversos , Procedimientos Quirúrgicos del Sistema Digestivo/efectos adversos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugía , Neoplasias del Recto/cirugía , Resultado del Tratamiento , Estudios Retrospectivos , Tiempo de Internación
6.
J Gastrointest Surg ; 28(4): 501-506, 2024 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-38583902

RESUMEN

BACKGROUND: Although laparoscopic Ileal pouch-anal anastomosis (IPAA) has become the gold standard in restorative proctocolectomy, surgical techniques have experienced minimal changes. In contrast, substantial shifts in perioperative care, marked by the enhanced recovery program (ERP), modifications in steroid use, and a shift to a 3-staged approach, have taken center stage. METHODS: Data extracted from our prospective IPAA database focused on the first 100 laparoscopic IPAA cases (historic group) and the latest 100 cases (modern group), aiming to measure the effect of these evolutions on postoperative outcomes. RESULTS: The historic IPAA group had more 2-staged procedures (92% proctocolectomy), whereas the modern group had a higher number of 3-staged procedures (86% proctectomy) (P < .001). Compared with patients in the modern group, patients in the historic group were more likely to be on steroids (5% vs 67%, respectively; P < .001) or immunomodulators (0% vs 31%, respectively; P < .001) at surgery. Compared with the historic group, the modern group had a shorter operative time (335.5 ± 78.4 vs 233.8 ± 81.6, respectively; P < .001) and length of stay (LOS; 5.4 ± 3.1 vs 4.2 ± 1.6 days, respectively; P < .001). Compared with the modern group, the historic group exhibited a higher 30-day morbidity rate (20% vs 33%, respectively; P = .04) and an elevated 30-day readmission rate (9% vs 21%, respectively; P = .02). Preoperative steroids use increased complications (odds ratio [OR], 3.4; P = .01), whereas 3-staged IPAA reduced complications (OR, 0.3; P = .03). ERP was identified as a factor that predicted shorter stays. CONCLUSION: Although ERP effectively reduced the LOS in IPAA surgery, it failed to reduce complications. Conversely, adopting a 3-staged IPAA approach proved beneficial in reducing morbidity, whereas preoperative steroid use increased complications.


Asunto(s)
Colitis Ulcerosa , Reservorios Cólicos , Laparoscopía , Proctocolectomía Restauradora , Humanos , Proctocolectomía Restauradora/efectos adversos , Proctocolectomía Restauradora/métodos , Colitis Ulcerosa/cirugía , Estudios Prospectivos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/prevención & control , Complicaciones Posoperatorias/etiología , Resultado del Tratamiento , Laparoscopía/efectos adversos , Laparoscopía/métodos , Anastomosis Quirúrgica/efectos adversos , Anastomosis Quirúrgica/métodos , Esteroides/uso terapéutico , Estudios Retrospectivos
8.
Ann Surg ; 2024 Mar 28.
Artículo en Inglés | MEDLINE | ID: mdl-38545779

RESUMEN

OBJECTIVE: This study aims to assess the costs of a Same-Day Discharge Enhanced Recovery Pathway (SDD) for diverting loop ileostomy closure compared to a standard institutional enhanced recovery protocol (ERP). SUMMARY BACKGROUND DATA: Every year, 50,155 patients in the United States undergo temporary stoma reversal. While ambulatory stoma closure has shown promise, widespread adoption remains slow. This study builds on previous research, focusing on the costs of a novel SDD protocol introduced in 2020. METHODS: A retrospective case-control study was conducted at Mayo Clinic, Rochester, Minnesota, and Mayo Clinic, Jacksonville, Florida, comparing patients undergoing same-day discharge diverting loop ileostomy closure (SDD) from August 2020 to February 2023 to those in a matched cohort receiving standard inpatient ERP. Patients were matched based on age, sex, ASA score, surgery period, and hospital. Primary outcomes included direct hospitalization and additional costs in the 30 days post-discharge. RESULTS: The SDD group (n=118) demonstrated a significant reduction in median index episode hospitalization and 30-day post-operative costs compared to the inpatient group (n=236), with savings of $4,827 per patient. Complication rates were similar, and so were readmission and reoperation rates. CONCLUSIONS: Implementation of the SDD for diverting loop ileostomy closure is associated with substantial cost savings without compromising patient outcomes. The study advocates for a shift towards same-day discharge protocols, offering economic benefits and potential improvements in healthcare resource utilization.

9.
J Am Coll Surg ; 2024 Mar 25.
Artículo en Inglés | MEDLINE | ID: mdl-38525960

RESUMEN

BACKGROUND: The COVID-19 pandemic has severely affected healthcare systems globally, resulting in significant delays and challenges in various medical treatments, particularly in cancer care. This study aims to investigate the repercussions of the pandemic on surgical interventions for colorectal cancer in the United States, using data from the National Cancer Database (NCDB). METHODS: We conducted a retrospective analysis of the NCDB, encompassing adult patients who underwent surgical procedures for colon and rectal cancer in 2019 (pre-COVID) and 2020 (COVID). We examined various demographic and clinical variables, including patient characteristics, tumor staging, surgical approaches, and socioeconomic factors. RESULTS: The analysis included 105,517 patients, revealing a 17.3% reduction in surgical cases during the initial year of the pandemic. Patients who underwent surgery in 2020 displayed more advanced clinical and pathological tumor stages compared to those treated in 2019. After diagnosis, no delay was reported in the treatment. Patients operated during the pandemic, African American patients, uninsured and Medicaid beneficiaries had worse stage colon and rectal cancer, and individuals with lower incomes bore the burden of advanced colon cancer. CONCLUSIONS: The impact of the COVID-19 pandemic on colorectal cancer surgery transcends a mere decline in case numbers, resulting in a higher prevalence of patients with advanced disease. This study underscores the exacerbated disparities in cancer care, particularly affecting vulnerable populations. The COVID-19 pandemic has left a significant and enduring imprint on colorectal cancer surgery, intensifying the challenges faced by patients and healthcare systems. Comprehensive studies are imperative to comprehend the long-term consequences of delayed screenings, diagnoses, and treatments, as healthcare planning for the future must consider the unintended repercussions of pandemic-related disruptions.

10.
Surg Endosc ; 38(5): 2677-2688, 2024 May.
Artículo en Inglés | MEDLINE | ID: mdl-38519609

RESUMEN

BACKGROUND: The introduction of laparoscopy in 1989 revolutionized surgical practices, reducing post-operative complications, and enhancing outcomes. Despite its benefits, limitations in laparoscopic tools have led to continued use of open surgery. Robotic-assisted surgery emerged to address these limitations, but its adoption trends and potential impact on open and laparoscopic surgery require analysis. METHODS: A retrospective analysis used the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) databases from 2012 to 2021. The study encompassed various abdominal procedures, employing Vector Autoregressive (VAR) models to analyze the dynamic relationships between surgical techniques. The models predicted future trends in open, laparoscopic, and robotic surgery until Q2 of 2025. RESULTS: The analysis included 360,171 patients across diverse procedures. In urology, robotic surgery dominated prostatectomies (83.1% in 2021) and nephrectomies (55.1% in 2021), while the open approach remained the predominant surgical technique for cystectomies (72.5% in 2021). In general surgery, robotic colectomies were forecasted to surpass laparoscopy, becoming the primary approach by 2024 (45.7% in 2025). Proctectomies also showed a shift towards robotic surgery, predicted to surpass laparoscopy and open surgery by 2025 (32.3%). Pancreatectomies witnessed a steady growth in robotic surgery, surpassing laparoscopy in 2021, with forecasts indicating further increase. While hepatectomies remained predominantly open (70.0% in 2025), esophagectomies saw a rise in robotic surgery, predicted to become the primary approach by 2025 (52.3%). CONCLUSIONS: The study suggests a transformative shift towards robotic-assisted surgery, poised to dominate various minimally invasive procedures. The forecasts indicate that robotic surgery may surpass laparoscopy and open surgery in colectomies, proctectomies, pancreatectomies, and esophagectomies by 2025. This anticipated change emphasizes the need for proactive adjustments in surgical training programs to align with evolving surgical practices. The findings have substantial implications for future healthcare practices, necessitating a balance between traditional laparoscopy and the burgeoning role of robotic-assisted surgery.


Asunto(s)
Laparoscopía , Procedimientos Quirúrgicos Robotizados , Humanos , Laparoscopía/métodos , Laparoscopía/estadística & datos numéricos , Procedimientos Quirúrgicos Robotizados/estadística & datos numéricos , Procedimientos Quirúrgicos Robotizados/tendencias , Estudios Retrospectivos , Masculino , Estados Unidos
11.
J Clin Med ; 13(3)2024 Jan 30.
Artículo en Inglés | MEDLINE | ID: mdl-38337495

RESUMEN

The present review discusses restrictive perioperative fluid protocols within enhanced recovery after surgery (ERAS) pathways. Standardized definitions of a restrictive or liberal fluid regimen are lacking since they depend on conflicting evidence, institutional protocols, and personal preferences. Challenges related to restrictive fluid protocols are related to proper patient selection within standardized ERAS protocols. On the other hand, invasive goal-directed fluid therapy (GDFT) is reserved for more challenging disease presentations and polymorbid and frail patients. While the perfusion rate (mL/kg/h) appears less predictive for postoperative outcomes, the authors identified critical thresholds related to total intravenous fluids and weight gain. These thresholds are discussed within the available evidence. The authors aim to introduce their institutional approach to standardized practice.

12.
Ann Surg Oncol ; 31(5): 3233-3241, 2024 May.
Artículo en Inglés | MEDLINE | ID: mdl-38381207

RESUMEN

INTRODUCTION: Implementing perioperative interventions such as enhanced recovery pathways (ERPs) has improved short-term outcomes and minimized length of stay. Preliminary evidence suggests that adherence to the enhanced recovery after surgery protocol may also enhance 5-year cancer-specific survival (CSS) in colorectal cancer surgery. This retrospective study presents long-term survival outcomes and disease recurrence from a high-volume, single-center practice. METHODS: All patients over 18 years of age diagnosed with rectal adenocarcinoma and undergoing elective minimally invasive surgery (MIS) were retrospectively reviewed between February 2005 and April 2018. Relevant data were extracted from Mayo electronic records and securely stored in a database. Short-term morbidity and long-term oncological outcomes were compared between patients enrolled in ERP and those who received non-enhanced care. RESULTS: Overall, 600 rectal cancer patients underwent MIS, of whom 320 (53.3%) were treated according to the ERP and 280 (46.7%) received non-enhanced care. ERP was associated with a decrease in length of stay (3 vs. 5 days; p < 0.001) and less overall complications (34.7 vs. 54.3%; p < 0.001). The ERP group did not show an improvement in overall survival (OS) or disease-free survival (DFS) compared with non-enhanced care on multivariable (non-ERP vs. ERP OS: hazard ratio [HR] 1.268, 95% confidence interval [CI] 0.852-1.887; DFS: HR 1.050, 95% CI 0.674-1.635) analysis. CONCLUSION: ERP was found to be associated with a reduction in short-term morbidity, with no impact on long-term oncological outcomes, such as OS, CSS, and DFS.


Asunto(s)
Procedimientos Quirúrgicos del Sistema Digestivo , Laparoscopía , Neoplasias del Recto , Humanos , Adolescente , Adulto , Estudios Retrospectivos , Recurrencia Local de Neoplasia/cirugía , Neoplasias del Recto/cirugía , Supervivencia sin Enfermedad , Tiempo de Internación
14.
Colorectal Dis ; 26(3): 466-475, 2024 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-38243617

RESUMEN

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.


Asunto(s)
Terapia Neoadyuvante , Neoplasias del Recto , Adulto , Humanos , Quimioradioterapia/métodos , Escisión del Ganglio Linfático/métodos , Ganglios Linfáticos/patología , Metástasis Linfática/patología , Terapia Neoadyuvante/métodos , Recurrencia Local de Neoplasia/patología , Estadificación de Neoplasias , Neoplasias del Recto/diagnóstico por imagen , Neoplasias del Recto/terapia , Neoplasias del Recto/patología , Estudios Retrospectivos
15.
Dis Colon Rectum ; 67(1): 90-96, 2024 Jan 01.
Artículo en Inglés | MEDLINE | ID: mdl-38091415

RESUMEN

BACKGROUND: Using standard anterior approaches, consistent R0 resection of locally advanced primary and recurrent rectal and anal cancer involving the deep pelvic sidewall may be unattainable. Therefore, to improve R0 resection rates, we have used a posterior-first, then anterior 2-stage approach to resection of tumors in this location. OBJECTIVE: To assess the R0 resection rate and surgical outcomes of the first 10 patients operated on using this approach. DESIGN: We conducted a retrospective case series review of our prospectively maintained surgical pathology and tumor registries. SETTING: This study was conducted at the Mayo Clinic in Rochester, Minnesota. PATIENTS: Ten patients (6 female individuals, median age 53.5 years) with primary or recurrent anal or rectal cancer treated with a posterior-first, then anterior 2-stage approach were identified. MAIN OUTCOME MEASURES: The primary outcome measures were the R0 resection rate and surgical outcomes. RESULTS: An R0 resection was achieved in all 10 patients. Nine patients developed 1 or more 30-day Clavien-Dindo grade III complications. Nine patients developed gluteal wound complications ranging from superficial wound dehiscence to flap necrosis. During the follow-up period, 4 patients were found to have metastatic disease and 1 patient had local re-recurrence. LIMITATIONS: Small cohort with heterogeneous tumors and a short follow-up duration. CONCLUSION: A posterior-first, then anterior 2-stage approach has allowed us to achieve consistent R0 resection margins in locally advanced primary and recurrent rectal and anal cancers involving the deep pelvic sidewall. Poor wound healing of the posterior gluteal incision is a common complication. See Video Abstract. MEJORANDO LAS TASAS DE RESECCIN R CON UN ABORDAJE DE DOS ETAPAS PRIMERO POSTERIOR PARA LA RESECCIN EN BLOQUE DE CNCERES ANORRECTALES PRIMARIOS Y RECURRENTES LOCALMENTE AVANZADOS QUE AFECTAN LA PARED LATERAL PLVICA PROFUNDA: ANTECEDENTES:Utilizando abordajes anteriores estándares, la resección R0 consistente del cáncer de recto y ano primario y recurrente localmente avanzado involucrando la pared lateral pélvica profunda puede ser inalcanzable. Por lo tanto, para mejorar las tasas de resección R0, hemos empleado un abordaje de 2 etapas primero posterior y luego anterior para la resección de tumores en esta ubicación.OBJETIVO:Este estudio tuvo como objetivo evaluar la tasa de resección R0 y los resultados quirúrgicos de los primeros 10 pacientes operados con este abordaje.DISEÑO:Realizamos una revisión retrospectiva de series de casos de nuestros registros de patología quirúrgica y tumores mantenidos prospectivamente.AJUSTE:Este estudio se realizó en la Clínica Mayo en Rochester, Minnesota, EE. UU.PACIENTES:Se identificaron diez pacientes (6 mujeres, mediana de edad 53.5 años) con cáncer anal o rectal primario o recurrente tratados con un abordaje de dos etapas, primero posterior y luego anterior.PRINCIPALES MEDIDAS DE RESULTADO:Las medidas de resultado primarias fueron la tasa de resección R0 y los resultados quirúrgicos.RESULTADOS:Se logró una resección R0 en los 10 pacientes. Nueve pacientes desarrollaron una o más complicaciones de grado III de Clavien-Dindo a los 30 días. Nueve pacientes desarrollaron complicaciones de la herida del glúteo que variaron desde dehiscencia superficial de la herida hasta necrosis del colgajo. Durante el período de seguimiento, se encontró que 4 pacientes tenían enfermedad metastásica y un paciente tuvo recurrencia local.LIMITACIONES:Cohorte pequeño con tumores heterogéneos y corta duración de seguimiento.CONCLUSIÓN:Un abordaje en 2 etapas, primero posterior y luego anterior, nos ha permitido lograr márgenes de resección R0 consistentes en cánceres de recto y anal primarios y recurrentes localmente avanzados que afectan la pared lateral pélvica profunda. La mala cicatrización de la incisión glútea posterior es una complicación común. (Traducción-Dr. Aurian Garcia Gonzalez).


Asunto(s)
Neoplasias del Ano , Neoplasias Gastrointestinales , Neoplasias del Recto , Humanos , Femenino , Persona de Mediana Edad , Neoplasias del Ano/cirugía , Estudios Retrospectivos , Neoplasias del Recto/cirugía , Recurrencia Local de Neoplasia/epidemiología , Complicaciones Posoperatorias , Necrosis
16.
HPB (Oxford) ; 25(11): 1337-1344, 2023 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-37626006

RESUMEN

BACKGROUND: Open combined resections of colorectal primary tumors and synchronous liver metastases have become common in selected cases. However, evidences favoring a minimally invasive (MIS) approach are still limited. The aim of this study is to evaluate the outcomes of MIS vs. open synchronous liver and colorectal resections. METHODS: 384 cases of synchronous colorectal and liver resections performed at one institution were identified during the study period. MIS vs open approach were compared after a propensity score matching; surgical outcomes were analyzed. RESULTS: MIS cases featured longer operative time (399 vs 300 min, p < 0.001), fewer blood loss (200 vs 500 ml, p = 0.003), and shorter hospitalization (median LOS 4 vs 6 days, p = 0.001). No difference was observed between the two groups for use of Pringle maneuver (p = 0.083), intraoperative blood transfusion (p = 0.061), achievement of negative colorectal (p = 0.176) and liver margins (p = 1.000), postoperative complications (p = 1.000) and significant (Clavien-Dindo ≥ 3a) complications (p = 0.817), delay of adjuvant therapy due to complications (p = 0.555), 30- and 90-day mortality. CONCLUSION: Synchronous colorectal and liver metastases resections via a minimally-invasive approach in high-volume centers with appropriate expertise result in significantly lower blood loss and length of stay despite longer operative time in comparison to open, with no oncological inferiority.

17.
J Robot Surg ; 17(5): 2157-2166, 2023 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-37264221

RESUMEN

Laparoscopy is the first-line approach in ileocolic resection for Crohn's disease. Emerging data has shown better short-term outcomes with robotic right colectomy for cancer when compared to laparoscopic approach. However, robotic ileocolic resection for Crohn's disease has only shown faster return to bowel function. We aimed to evaluate short-term outcomes of ileocolic resection for Crohn's disease between robotic intracorporeal anastomosis (RICA) and laparoscopic extracorporeal anastomosis (LECA). Patients undergoing minimally invasive ileocolic resections for Crohn's disease were retrospectively identified using a prospectively maintained database between 2014 and 2021 in two referral centers. Among the 239 patients, 70 (29%) underwent RICA while 169 (71%) LECA. Both groups were similar according to baseline and preoperative characteristics. RICA was associated with more intraoperative adhesiolysis and longer operative time [RICA: 238 ± 79 min vs. LECA: 143 ± 52 min; p < 0.001]. 30-day postoperative complications were not different between the two groups [RICA: 17/70(24%) vs. LECA: 54/169(32%); p = 0.238]. Surgical site infections [RICA: 0/70 vs. LECA: 16/169(10%); p = 0.004], intra-abdominal septic complications [RICA: 0/70 vs. LECA: 14/169(8%); p = 0.012], and Clavien-Dindo ≥ III complications [RICA: 1/70(1%) vs. LECA: 15/169(9%); p = 0.044] were less frequent in RICA. Return to bowel function [RICA: 2.1 ± 1.1 vs. LECA: 2.6 ± 1.2 days; p = 0.002] and length of stay [RICA: 3.4 ± 2.2 vs. LECA: 4.2 ± 2.5 days; p = 0.015] were shorter after RICA, with similar readmission rates. RICA demonstrated better short-term postoperative outcomes than LECA, with reduced Clavien-Dindo ≥ III complications, surgical site infections, intra-abdominal septic complications, shorter length of stay, and faster return to bowel function, despite the longer operative time.


Asunto(s)
Enfermedad de Crohn , Laparoscopía , Procedimientos Quirúrgicos Robotizados , Humanos , Enfermedad de Crohn/cirugía , Estudios Retrospectivos , Procedimientos Quirúrgicos Robotizados/métodos , Íleon/cirugía , Colectomía/efectos adversos , Infección de la Herida Quirúrgica , Anastomosis Quirúrgica , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/cirugía , Resultado del Tratamiento
18.
Langenbecks Arch Surg ; 408(1): 251, 2023 Jun 29.
Artículo en Inglés | MEDLINE | ID: mdl-37382678

RESUMEN

PURPOSE: One-third of patients with Crohn's disease (CD) require multiple surgeries during their lifetime. So, reducing the incisional hernia rate is crucial. We aimed to define incisional hernia rates after minimally invasive ileocolic resection for CD, comparing intracorporeal anastomosis with Pfannenstiel incision (ICA-P) versus extracorporeal anastomosis with midline vertical incision (ECA-M). METHODS: This retrospective cohort compares ICA-P versus ECA-M from a prospectively maintained database of consecutive minimally invasive ileocolic resections for CD performed between 2014 and 2021 in a referral center. RESULTS: Of the 249 patients included: 59 were in the ICA-P group, 190 in the ECA-M group. Both groups were similar according to baseline and preoperative characteristics. Overall, 22 (8.8%) patients developed an imaging-proven incisional hernia: seven at the port-site and 15 at the extraction-site. All 15 extraction-site incisional hernias were midline vertical incisions [7.9%; p = 0.025], and 8 patients (53%) required surgical repair. Time-to-event analysis showed a 20% rate of extraction-site incisional hernia in the ECA-M group after 48 months (p = 0.037). The length of stay was lower in the intracorporeal anastomosis with Pfannenstiel incision group [ICA-P: 3.3 ± 2.5 vs. ECA-M: 4.1 ± 2.4 days; p = 0.02] with similar 30-day postoperative complication [11(18.6) vs. 59(31.1); p = 0.064] and readmission rates [7(11.9) vs. 18(9.5); p = 0.59]. CONCLUSION: Patients in the ICA-P group did not encounter any incisional hernias while having shorter hospital length of stay and similar 30-day postoperative complications or readmission compared to ECA-M. Therefore, more consideration should be given to performing intracorporeal anastomosis with Pfannenstiel incision during Ileocolic resection in patients with CD to reduce hernia risk.


Asunto(s)
Enfermedad de Crohn , Hernia Incisional , Humanos , Enfermedad de Crohn/cirugía , Hernia Incisional/epidemiología , Hernia Incisional/etiología , Estudios Retrospectivos , Colectomía/efectos adversos , Anastomosis Quirúrgica , Complicaciones Posoperatorias/epidemiología
19.
Updates Surg ; 75(5): 1179-1185, 2023 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-37149508

RESUMEN

Minimally invasive surgery (MIS) is the first-line approach for ileocolic resection in Crohn's disease (CD), and it is safe and feasible, even with severe penetrating CD or redo surgery. While MIS indications are continually broadening, challenging CD cases might still require an open approach. This study aimed to report rate and indications for an upfront open approach in ileocolic resection for CD. Comprehensive perioperative data for all consecutive patients undergoing ileocolic resection for CD between 2014 and 2021 in a high-volume referral center for CD and MIS, were collected retrospectively. Indications for an upfront open approach were reviewed separately by two authors according to the preoperative visit. Among 319 ileocolic resections for CD, 45 (14%) were open and 274 (86%) MIS. Two or more of the below indications were present in 40 patients (89%) in the open group, while only in 6 patients (2%) in the MIS group (p < 0.0001). Indications for upfront open approach were severe penetrating disease (58%), adhesions at previous surgery (47%), history of abdominal sepsis (33%), multifocal and extensive disease (24%), abdominal wall involvement (22%), concomitant open procedures (9%), small bowel dilatation (9%), and anesthesiologic contraindications (4%). MIS was never performed in a patient with abdominal wall involvement, concomitant open procedure, and anesthesiologic contraindication to MIS. This study can help guide patients, physicians, and surgeons. An abdominal wall involvement or the presence of two of the above indications predicts a high surgical complexity and may be considered as a no-go for the MIS approach. These criteria should prompt surgeons to strongly consider an upfront open approach to optimize the perioperative planning and care of these complex patients.


Asunto(s)
Enfermedad de Crohn , Laparoscopía , Humanos , Enfermedad de Crohn/cirugía , Enfermedad de Crohn/complicaciones , Estudios Retrospectivos , Colectomía , Anastomosis Quirúrgica , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Resultado del Tratamiento
20.
Clin Exp Gastroenterol ; 16: 29-43, 2023.
Artículo en Inglés | MEDLINE | ID: mdl-37013200

RESUMEN

Symptomatic Uncomplicated Diverticular Disease (SUDD) is a syndrome within the diverticular disease spectrum, characterized by local abdominal pain with bowel movement changes but without systemic inflammation. This narrative review reports current knowledge, delivers practical guidance, and reveals challenges for the clinical management of SUDD. A broad and common consensus on the definition of SUDD is still needed. However, it is mainly considered a chronic condition that impairs quality of life (QoL) and is characterized by persistent left lower quadrant abdominal pain with bowel movement changes (eg, diarrhea) and low-grade inflammation (eg, elevated calprotectin) but without systemic inflammation. Age, genetic predisposition, obesity, physical inactivity, low-fiber diet, and smoking are considered risk factors. The pathogenesis of SUDD is not entirely clarified. It seems to result from an interaction between fecal microbiota alterations, neuro-immune enteric interactions, and muscular system dysfunction associated with a low-grade and local inflammatory state. At diagnosis, it is essential to assess baseline clinical and Quality of Life (QoL) scores to evaluate treatment efficacy and, ideally, to enroll patients in cohort studies, clinical trials, or registries. SUDD treatments aim to improve symptoms and QoL, prevent recurrence, and avoid disease progression and complications. An overall healthy lifestyle - physical activity and a high-fiber diet, with a focus on whole grains, fruits, and vegetables - is encouraged. Probiotics could effectively reduce symptoms in patients with SUDD, but their utility is missing adequate evidence. Using Rifaximin plus fiber and Mesalazine offers potential in controlling symptoms in patients with SUDD and might prevent acute diverticulitis. Surgery could be considered in patients with medical treatment failure and persistently impaired QoL. Still, studies with well-defined diagnostic criteria for SUDD that evaluate the safety, QoL, effectiveness, and cost-effectiveness of these interventions using standard scores and comparable outcomes are needed.

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