Early colorectal cancer diagnosed after endoscopic resection: Conservative treatment is safe in most of the cases. Proposal for a risk-based management / Cáncer colorrectal inicial tras resección endoscópica: el tratamiento conservador es seguro en la mayoría de los casos. Propuesta de un manejo basado en los factores de riesgo

Introduction Endoscopic resection offers advantages over surgical resection for early colorectal cancer (ECC). However, there might be a presumed risk of recurrence. We aimed to determine the risk of recurrence after endoscopic removal of ECC. Methods A single-centre series of endoscopic resections for ECC. Patients were stratified according to four risk factors: positive resection margins, Haggitt 4, lymphatic/vascular invasion and tumour budding. Results We included 127 patients. Haggitt classification was grade 4 in 54.0%. Positive margins were found in 43 (33.9%), 16 (12.6%) had lymphatic or vascular invasion, and 5 (4.0%) had high grade budding. In 82 (64.5%) endoscopic excision was the definitive treatment, 45 (35.4%) underwent surgery. Six patients (13.3%) had residual tumour on specimen and/or node metastases. Postoperative complications occurred in ten (22.2%). At a median follow-up of 63 months, none of the 82 patients treated with endoscopic resection alone had recurrence. After stratifying patients according to risk factors, those who had residual tumour also had ≥2 risk factors. Conclusions Endoscopic follow up might be a valid option for patients with ECC. A risk-adjusted management seems prudent (AU)

Introducción La resección endoscópica ofrece claras ventajas frente a la cirugía en el tratamiento del cáncer de colon inicial (ECC). Sin embargo, existe un riesgo de recurrencia tanto a nivel del lecho de polipectomía como a nivel ganglionar. El objetivo del estudio es determinar el riesgo de recurrencia tras la resección endoscópica del ECC. Métodos Serie retrospectiva unicéntrica de resecciones endoscópicas de ECC. Se analizaron cuatro factores de riesgo en la pieza de polipectomía: el margen de resección afecto, Haggitt 4, invasión linfovascular y la presencia de budding tumoral. Resultados Se incluyeron 127 pacientes: Haggitt 4 en el 54%, margen de resección afecto en el 33,9%, infiltración linfática o vascular en el 12,6% y budding tumoral de alto grado en el 4%. En 82 pacientes (64,5%), la resección endoscópica fue el tratamiento definitivo. En 45 (35,4%) se realizó una colectomía oncológica. Seis pacientes (13,3%) presentaron tumor residual en el lecho de la polipectomía y/o a nivel de los ganglios linfáticos. La morbilidad postoperatoria fue del 22% y la mortalidad del 0%. Tras un seguimiento medio de 63 meses, ninguno de los 82 pacientes del grupo de polipectomía presentó recurrencia tumoral. Tras dividir a los pacientes según el número de factores de riesgo presentes, aquellos que presentaron tumor residual en la pieza de colectomía presentaban a su vez ≥ 2 factores de riesgo. Conclusiones El seguimiento endoscópico puede ser una opción válida en los pacientes con ECC. El manejo de estos pacientes debe ajustarse al riesgo individual, en función del número de factores de riesgo (AU)

Biological mesh reconstruction versus primary closure for preventing perineal morbidity after extralevator abdominoperineal excision: a multicentre retrospective study.

AIM: The aim of the study was to compare the incidence of perineal hernia and the perineal wound morbidity following extralevator abdominoperineal excision (ELAPE) between two groups - primary perineal closure and reconstruction with a biological mesh. METHOD: One hundred and forty-seven consecutive patients who underwent ELAPE for primary rectal cancer between January 2007 and December 2018 in two tertiary referral centres were retrospectively identified from prospective databases. Perineal closure was carried out via primary closure or with a biological mesh (porcine dermal collagen mesh). Outcome measures were perineal hernia and perineal wound morbidity (infection, dehiscence, persistent sinus and chronic pain). RESULTS: A total of 139 patients were included in the study. A prophylactic mesh was used in 80 (57.5%) and primary closure was practised in 59 (42.4%) patients. The median follow-up was 30 (interquartile range 46.88) months. Thirty patients (21.6%) developed perineal hernia. No significant differences were found between prophylactic mesh and primary closure (16.3% vs 23.3%, P = 0.07). The median period between surgery and hernia diagnosis was 8 months in the primary closure group and 24 months in the mesh group (P < 0.01). Perineal wound morbidity was significantly higher in the prophylactic mesh group (55% vs 33.9%, P < 0.01). CONCLUSION: In our study, the use of a biological mesh did not reduce the rate of perineal hernia, although it did delay its appearance. Perineal closure using a biological mesh may increase perineal morbidity, both acute and chronic.

Importance of the Moskowitz artery in the laparoscopic medial approach to splenic flexure mobilization: a cadaveric study.

BACKGROUND: The medial approach in laparoscopic splenic flexure mobilization is based on the entrance to the lesser sac just above the ventral edge of the pancreas (VEOP). The artery of Moskowitz runs through the base of the mesocolon, just above the VEOP. The aim of this study was to assess the incidence of the artery of Moskowitz, its route and its distance from the VEOP. METHODS: We performed a cadaveric study on 27 human cadavers. The vascular arcades of the splenic flexure were dissected, the number of vascular arches, and the origin and localization of its terminal anastomosis were recorded. The splenic flexure avascular space (SFAS) was defined as the avascular zone in the mesocolon delimited by the VEOP, middle colic artery, ascending branch of the left colic artery and the vascular arch of the splenic flexure nearest to the VEOP and was quantified as the distance between the VEOP and the most proximal arch RESULTS: The artery of Drummond was identified in 100% of the cadavers. In 5 of 27 (18%) Riolan's arch was present, and in 3 of 27 (11%) the Moskowitz artery was found. The mean distance from the VEOP to the artery of Moskowitz was 0.3 cm (SD 0.04). This vascular arch travelled from the origin of the middle colic artery to the distal third of the ascending branch of the left colic artery. The SFAS was greater (p = 0.001) in cadavers that only presented the artery of Drummond (mean 6.8 cm; SD 1.25) than in those with Riolan's arch (mean 4.5 cm; SD 0.5) CONCLUSIONS: In the medial approach for laparoscopic mobilization of the splenic flexure, when only one of the arches is present, the avascular area is an extensive and secure territory. If the artery of Moskowitz is present, the area is nonexistent and this would contraindicate the approach due to risk of iatrogenic bleeding. A radiological preoperatory study could be essential for accurate and safe surgery in this area.

Modified components separation technique: experience treating large, complex ventral hernias at a University Hospital.

BACKGROUND: An increasing number of patients have large or complex abdominal wall defects. Component separation technique (CST) is a very effective method for reconstructing complex midline abdominal wall defects in a manner that restores innervated muscle function without excessive tension. Our goal is to show our results by a modified CST for treating large ventral hernias. MATERIALS AND METHODS: A total of 351 patients with complex ventral hernias have been treated over a 10-year period. Pre- and postoperative CT scans were performed in all patients. All ventral hernias were W3, according to the EHS classification 1. We analyzed demographic variables, co-morbidities, hernia characteristics, operative, and postoperative variables. RESULTS: One hundred and seventy patients (48.4%) were men; the average age of the study population was 51.6 ± 23.2 years with an average BMI of 32.3 ± 1.3. The hernia was located in the midline in 321 cases (91.5%) versus the flank in 30 (8.5%). In 45 patients, preoperative botulinum toxin (BT) and progressive pneumoperitoneum (PPP) were needed due to giant hernia defects when the VIH/VAC ratio was >20%. Postoperative complications related to the surgical site were seroma (35.1%), hematoma (9.1%), infection (7.2%), and wound necrosis (8.8%). Complications related to the repair were evisceration in 3 patients (1.1%), small bowel fistula in 4 patients (1.5%), 11 cases of mesh infection (2.9%), and abdominal compartment syndrome (ACS) in 2 patients. There were 29 hernia recurrences (8.2%) with a mean follow-up of 31.6 ± 8.1 months. CONCLUSION: The modified CST is an effective strategy for managing complex ventral hernias that enables primary fascial closure with low rates of morbidity and hernia recurrence.