The Multidisciplinary Approach of Rectal Cancer: The Experience of "COMRE Group" Model.

Background: Total mesorectal excision (TME) is the gold standard to treat locally advanced rectal cancer. This monocentric retrospective study evaluates the results of laparotomic, laparoscopic and robotic surgery in "COMRE GROUP" (REctalCOMmittee). Methods: 327 selected stage I-II-III patients (pts) underwent TME between November 2005 and April 2020 for low or middle rectal cancer; 91 pts underwent open, 200 laparoscopic and 36 robotic TME. Of these, we analyzed the anthropomorphic, intraoperative, anatomopathological parameters and outcome during the follow up. Results: The length of hospital stay was significantly different between robotic TME and the other two groups (8.47 ± 3.54 days robotic vs. 11.93 ± 5.71 laparotomic, p < 0.001; 8.47 ± 3.54 robotic vs. 11.10 ± 7.99 laparoscopic, p < 0.05). The mean number of harvested nodes was higher in the laparotomic group compared to the other two groups (19 ± 9 laparotomic vs. 15 ± 8 laparoscopic, p < 0.001; 19 ± 9 laparotomic vs. 15 ± 7 robotic, p < 0.05). Median follow-up was 52 months (range: 1−169). Overall survival was significantly shorter in the open TME group compared with the laparoscopic one (Chi2 = 13.36, p < 0.001). Conclusions: In the experience of the "COMRE" group, laparoscopic TME for rectal cancer is a better choice than laparotomy in a multidisciplinary context. Robotic TME has a significant difference in terms of hospital stay compared to the other two groups.

Efficacy of High-Resolution Preoperative 3D Reconstructions for Lesion Localization in Oncological Colorectal Surgery-First Pilot Study.

When planning an operation, surgeons usually rely on traditional 2D imaging. Moreover, colon neoplastic lesions are not always easy to locate macroscopically, even during surgery. A 3D virtual model may allow surgeons to localize lesions with more precision and to better visualize the anatomy. In this study, we primary analyzed and discussed the clinical impact of using such 3D models in colorectal surgery. This is a monocentric prospective observational pilot study that includes 14 consecutive patients who presented colorectal lesions with indication for surgical therapy. A staging computed tomography (CT)/magnetic resonance imaging (MRI) scan and a colonoscopy were performed on each patient. The information gained from them was provided to obtain a 3D rendering. The 2D images were shown to the surgeon performing the operation, while the 3D reconstructions were shown to a second surgeon. Both of them had to locate the lesion and describe which procedure they would have performed; we then compared their answers with one another and with the intraoperative and histopathological findings. The lesion localizations based on the 3D models were accurate in 100% of cases, in contrast to conventional 2D CT scans, which could not detect the lesion in two patients (in these cases, lesion localization was based on colonoscopy). The 3D model reconstruction allowed an excellent concordance correlation between the estimated and the actual location of the lesion, allowing the surgeon to correctly plan the procedure with excellent results. Larger clinical studies are certainly required.

Effect of Geriatric Comanagement in Older Patients Undergoing Surgery for Gastrointestinal Cancer: A Retrospective, Before-and-After Study.

OBJECTIVE: To determine the effect of geriatric comanagement on clinical outcomes of older patients undergoing surgery for gastrointestinal cancer. DESIGN: This was a single-center, nonrandomized, before-and-after study, which compared patient outcomes before and after the implementation of geriatric comanagement in an oncological surgery division. SETTING AND PARTICIPANTS: The study included patients aged 70 or older, who were treated for a gastrointestinal cancer at the Oncological Surgery Division of the Policlinico San Martino Hospital (Genoa, Italy). Patients from the control group were treated between January 2015 and October 2018, and the patients who received geriatric comanagement during their stay in the surgical ward were treated between November 2018 and December 2019. METHODS: Patients from both groups received a preoperative comprehensive geriatric assessment in the preoperative phase and were followed according to the Enhanced Recovery After Surgery model in the perioperative period. In the geriatric comanagement group, targeted interventions during daily geriatrician-led ward rounds were performed. Inverse probability weighting was used to adjust estimates for potential baseline confounders. RESULTS: A total of 207 patients were included: 107 in the control group and 90 who received geriatric comanagement. Overall, patients from both groups had similar demographic and clinical characteristics with a median [interquartile range (IQR)] age of 80.0 (77.0, 84.0) years and a pre-frail phenotype [median (IQR) 40-item Frailty Index 0.15 (0.10, 0.26)]. In the geriatric comanagement group, a significant reduction in grade I-V complications (adjusted odds ratio 0.29; 95% CI 0.21-0.40); P < .001) and in 1-year readmissions (adjusted hazard ratio 0.53; 95% CI 0.28-0.98; P < .044) was observed. No difference between the 2 groups in terms of 1-year mortality was detected. CONCLUSIONS AND IMPLICATIONS: Our study supports the implementation of geriatric comanagement in the care of older patients undergoing surgery for gastrointestinal cancer.

Reporting ChAracteristics of cadaver training and sUrgical studies: The CACTUS guidelines.

INTRODUCTION: Recent systematic reviews highlighted increasing use of cadaveric models in the surgical training, but reports on the characteristics of the models and their impact on training are lacking, as well as standardized recommendations on how to ensure the quality of surgical studies. The aim of our survey was to provide an easy guideline that would improve the quality of the studies involving cadavers for surgical training and research. METHODS: After accurate literature review regarding surgical training on cadaveric models, a draft of the CACTUS guidelines involving 10 different items was drawn. Afterwards, the items were improved by questionnaire uploaded and spread to the experts in the field via Google form. The guideline was then reviewed following participants feedback, ergo, items that scored between 7 and 9 on nine-score Likert scale by 70% of respondents, and between 1 and 3 by fewer than 15% of respondents, were included in the proposed guideline, while items that scored between 1 and 3 by 70% of respondents, and between 7 and 9 by 15% or more of respondents were not. The process proceeded with Delphi rounds until the agreement for all items was unanimous. RESULTS: In total, 42 participants agreed to participate and 30 (71.4%) of them completed the Delphi survey. Unanimous agreement was almost always immediate concerning approval and ethical use of cadaver and providing brief outcome statement in terms of satisfaction in the use of the cadaver model through a short questionnaire. Other items were subjected to the minor adjustments. CONCLUSION: 'CACTUS' is a consensus-based guideline in the area of surgical training, simulation and anatomical studies and we believe that it will provide a useful guide to those writing manuscripts involving human cadavers.

Risk factors for anastomotic leakage after anterior resection for rectal cancer (RALAR study): A nationwide retrospective study of the Italian Society of Surgical Oncology Colorectal Cancer Network Collaborative Group.

AIM: Anastomotic leakage after restorative surgery for rectal cancer shows high morbidity and related mortality. Identification of risk factors could change operative planning, with indications for stoma construction. This retrospective multicentre study aims to assess the anastomotic leak rate, identify the independent risk factors and develop a clinical prediction model to calculate the probability of leakage. METHODS: The study used data from 24 Italian referral centres of the Colorectal Cancer Network of the Italian Society of Surgical Oncology. Patients were classified into two groups, AL (anastomotic leak) or NoAL (no anastomotic leak). The effect of patient-, disease-, treatment- and postoperative outcome-related factors on anastomotic leak after univariable and multivariable analysis was measured. RESULTS: A total of 5398 patients were included, 552 in group AL and 4846 in group NoAL. The overall incidence of leaks was 10.2%, with a mean time interval of 6.8 days. The 30-day leak-related mortality was 2.6%. Sex, body mass index, tumour location, type of approach, number of cartridges employed, weight loss, clinical T stage and combined multiorgan resection were identified as independent risk factors. The stoma did not reduce the leak rate but significantly decreased leak severity and reoperation rate. A nomogram with a risk score (RALAR score) was developed to predict anastomotic leak risk at the end of resection. CONCLUSIONS: While a defunctioning stoma did not affect the leak risk, it significantly reduced its severity. Surgeons should recognize independent risk factors for leaks at the end of rectal resection and could calculate a risk score to select high-risk patients eligible for protective stoma construction.

Colorectal Cancer Surgery During the COVID-19 Pandemic: A Single Center Experience.

BACKGROUND/AIM: A notable re-allocation of healthcare resources and specific clinical and organizational measures have been required to prevent COVID-19 infection among hospitalized patients and healthcare workers. PATIENTS AND METHODS: From March 9th to May 9th 2020 we performed colorectal cancer elective surgery on 25 patients: a pre-hospital screening was carried out in order to avoid hospitalization of patients suspected of COVID-19 infection. RESULTS: All patients (median age=76 years; range=37-88 years) were considered suitable for admission after telephone triage; the median interval between primary diagnosis and hospital admission was 23.1 days (range=1-55 days). The median hospitalization was 7.8 days (range=4-18 days). One COVID-19-associated death was reported. CONCLUSION: Our experience demonstrates that safe colorectal cancer elective surgery can be performed during the pandemic COVID-19. Further consensus and guidelines to prevent diffusion of pandemic diseases among hospitalized patients and healthcare workers still need to be implemented.

Consensus Statement of the Italian Polispecialistic Society of Young Surgeons (SPIGC): Diagnosis and Treatment of Acute Appendicitis.

BACKGROUND: Acute appendicitis (AA) is one of the most common causes of abdominal pain requiring surgical intervention. Approximately 20% of AA cases are characterized by complications such as gangrene, abscesses, perforation, or diffuse peritonitis, which increase patients' morbidity and mortality. Diagnosis of AA can be difficult, and evaluation of clinical signs, laboratory index and imaging should be part of the management of patients with suspicion of AA. METHODS: This consensus statement was written in relation to the most recent evidence for diagnosis and treatment of AA, performing a literature review on the most largely adopted scientific sources. The members of the SPIGC (Italian Polispecialistic Society of Young Surgeons) worked jointly to draft it. The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by the American College of Chest Physicians (CHEST) for the strength of the recommendations. RESULTS: Fever and migratory pain tend to be present in patients with suspicion of AA. Laboratory and radiological examinations are commonly employed in the clinical practice, but today also scoring systems based on clinical signs and laboratory data have slowly been adopted for diagnostic purpose. The clinical presentation of AA in children, pregnant and elderly patients can be unusual, leading to more difficult and delayed diagnosis. Surgery is the best option in case of complicated AA, whereas it is not mandatory in case of uncomplicated AA. Laparoscopic surgical treatment is feasible and recommended. Postoperative antibiotic treatment is recommended only in patients with complicated AA.

The impact of COVID-19 pandemic on surgical residency programmes in Italy: a nationwide analysis on behalf of the Italian Polyspecialistic Young Surgeons Society (SPIGC).

INTRODUCTION: Recently, Italy has been heavily hit by COVID-19 pandemic and today it is still one of the most affected countries in the world. The subsequent necessary lockdown decreed by the Italian Government had an outstanding impact on the daily life of the entire population, including that of Italian surgical residents' activity. Our survey aims to evaluate the impact of COVID-19 on the training programme of Italian surgical residents. MATERIALS AND METHODS: We designed a 12-item-electronic anonymous questionnaire on SurveyMonkey© web application. The survey was composed of different sections concerning demographic characteristics and impacts of COVID-19 on the concrete participation in clinical, surgical and research activities. Future perspectives of responders after the pandemic were also investigated. RESULTS: Eighty hundred responses were collected, and 756 questionnaires were considered eligible to be included in the study analysis. Almost 35 and 27% of respondents experienced, respectively, complete interruption of surgical and clinical activities. A subgroup analysis, comparing the COVID-19 impact on clinical activities with demographics data, showed a statistically significant difference related to specialties (p = 0.0062) and Italian regions (p < 0.0001). Moreover, 112 residents have been moved to non-surgical units dealing with COVID-19 or, in some case, they voluntarily decided to interrupt their residency programme to support the ongoing emergency. CONCLUSION: Our survey demonstrated that COVID-19 pandemic has severely impacted the educational programme of Italian surgical residents. Despite many regional differences, this survey highlighted the overall shortage of planning in the re-allocation of resources facing this unexpected health emergency.

The GPS for surgery: A user-centered evaluation of a navigation system for laparoscopic surgery.

BACKGROUND: Unsafe surgical care has emerged as a significant public health concern, motivated by a high percentage of major complications happening during surgery, attributed to surgeons' skills and experience, and determined to be preventable. METHODS: This article presents APSurg, an Abdominal Positioning Surgical system designed to improve awareness and safety during laparoscopic surgery. The proposed system behaves like a GPS, offering an additional dynamic virtual reality view of the surgical field. RESULTS: This work presents an evaluation study in terms of accuracy, effectiveness, and usability. Tests were conducted performing a localization task on an abdomen phantom in a simulated scenario. Results show a navigation accuracy below 5 mm. The task execution time was reduced by a 15% and the performed incision dimension was reduced by a 46%, with respect to a standard setup. A custom questionnaire showed a significant positive impact in exploiting APSurg during the surgical task execution.

A two-step surgery and a multidisciplinary approach in a centenarian patient with an acute presentation of right colon cancer.

BACKGROUND: As surgery remains the cornerstone of colorectal cancer (CRC) treatment, the number of older patients presented for colorectal resection is rapidly increasing. Nevertheless, the choice to operate an oldest-old patient still remain challenging and requires a careful assessment of risk to benefit ratio in order to guarantee appropriate surgical strategies and perioperative management. CASE PRESENTATION: A centenarian patient, acutely admitted to the emergency department, was diagnosed with an ileus caused by stenosing ascending colon cancer with abnormal distension of the right colon at high risk of perforation. Facing with this complex clinical scenario, a lateral decompressive cecostomy as alternative surgical procedure, was performed in local anesthesia in order to avoid the stressful event of an emergency surgery. Thereafter, the patient was admitted to the surgical ward and followed by a geriatrician who performed a comprehensive geriatric assessment (CGA) and daily clinical evaluations. This integrated plan of care was mainly focused on rehabilitation, nutritional interventions and therapeutic reconciliation, maximizing patient's clinical conditions and performance status. Then, the second surgical step, the radical colon surgery with curative intent and bowel continuity reestablishment was performed, demonstrating to be feasible and safety also in a very advanced age patient in term of prolonged survival and preservation of an adequate quality of life. CONCLUSIONS: This is the first case-report that illustrates a successful two step surgery for CRC in a centenarian patient thanks to a multidisciplinary based approach, overwhelming the mere concept of chronological age.

Development and Validation of a Homemade, Low-Cost Laparoscopic Simulator for Resident Surgeons (LABOT).

Several studies have demonstrated that training with a laparoscopic simulator improves laparoscopic technical skills. We describe how to build a homemade, low-cost laparoscopic training simulator (LABOT) and its validation as a training instrument. First, sixty surgeons filled out a survey characterized by 12 closed-answer questions about realism, ergonomics, and usefulness for surgical training (global scores ranged from 1-very insufficient to 5-very good). The results of the questionnaires showed a mean (±SD) rating score of 4.18 ± 0.65 for all users. Then, 15 students (group S) and 15 residents (group R) completed 3 different tasks (T1, T2, T3), which were repeated twice to evaluate the execution time and the number of users' procedural errors. For T1, the R group had a lower mean execution time and a lower rate of procedural errors than the S group; for T2, the R and S groups had a similar mean execution time, but the R group had a lower rate of errors; and for T3, the R and S groups had a similar mean execution time and rate of errors. On a second attempt, all the participants tended to improve their results in doing these surgical tasks; nevertheless, after subgroup analysis of the T1 results, the S group had a better improvement of both parameters. Our laparoscopic simulator is simple to build, low-cost, easy to use, and seems to be a suitable resource for improving laparoscopic skills. In the future, further studies should evaluate the potential of this laparoscopic box on long-term surgical training with more complex tasks and simulation attempts.

Laparoscopic "double-port" splenectomy. A new minimally-invasive option in a giant spleen.

INTRODUCTION: In case of massive splenomegaly, laparoscopic splenectomy (LS) becomes challenging, uncomfortable and risky both for the surgeon and for the patient. As a consequence of ongoing research to obtain efficient and cheaper "scarless surgery", single-port technique and hand-assisted devices were developed and improved in this field. PRESENTATION OF CASE: We present the clinical case of a patient affected by idiopathic myelofibrosis (MF) and splenomegaly who was admitted to our Department to perform a splenectomy for a suspected 5-cm splenic lesion. DISCUSSION: The splenic longitudinal diameter measured 26 cm. The patient underwent splenectomy by laparoscopy, combining a single-port access and a gel-port device. The operation was completed laparoscopically. The operating time was 220 min and the estimate blood loss was 100 ml. The patient was discharged at 11 post-operative day in overall good conditions. Upon pathological analysis the splenic lesion was a localization of diffuse large B-cell Lymphoma in the context of MF. CONCLUSION: this novel "hybrid technique" of splenectomy, combining the advantages of reduced number of abdominal incisions of the single-port technique to those of the hand assistance, is feasible in massive splenomegaly with good results. Furthermore, the use of the sovrapubic retrieval incision as the introduction site for the hand assisted device is convincing, since it's useful for both tasks. Further studies with large casuistries are necessary to confirm the effectiveness of the technique.