Right Hemicolectomy with Complete Mesocolic Excision Using the Versius Surgical System: A Step-by-Step Guide.

The application of new robotic platforms in colorectal surgery has increased greatly in the last 10 years. New systems have been released and entered the surgical panorama, broadening the technological offer. Robotic surgery applied to colorectal oncological surgery has been widely described. Hybrid robotic surgery in right sided colonic cancer has been previously reported. According to the site and local extension of a right-sided colon cancer, a different lymphadenectomy could be required. For more distant and locally advanced tumors a complete mesocolic excision (CME) is indicated. CME for right colon cancer is a complex operation compared to standard right hemicolectomy. Therefore a hybrid robotic system may be effectively applied to CME during a minimally-invasive right hemicolectomy to improve the dissection accuracy. Here we report a step-by-step hybrid laparoscopic/robotic right hemicolectomy with CME performed with the Versius Surgical System, a tele-operated surgical robotic system intended for the use of robotic assisted surgery.

Laparoscopic versus open surgery for left flexure colon cancer: A propensity score matched analysis from an international cohort.

AIM: Surgical treatment of splenic flexure cancer (SFC) still presents some debated issues, including the role of laparoscopic surgery. The literature is based on small single-centre series, while randomized controlled studies comparing open and laparoscopic treatment for colon cancer exclude SFC. This study aimed to determine the role of laparoscopic surgery in the treatment of SFC, comparing short- and long-term outcomes with open surgery. METHOD: This was an international multicentre retrospective cohort study that analysed patients from 10 tertiary referral centres. From a cohort of 641 cases, 484 patients with Stage I-III SFC submitted to elective surgery with curative intent were selected. After 1:1 propensity score matching, 130 patients in the laparoscopic group (LapGroup) were compared with 130 patients in the open surgery group (OpenGroup). RESULTS: After propensity score matching, the two groups were comparable for demographic and clinical parameters. OpenGroup presented a higher incidence of overall (P = 0.02) and surgery-related complications (P = 0.05) but a similar rate of severe complications (P = 0.75). Length of stay was notably shorter in the LapGroup (P = 0.001). Overall (P = 0.793) as well as cancer-specific survival (P = 0.63) did not differ between the two groups. CONCLUSIONS: Elective laparoscopic surgery for Stage I-III SFC is feasible and associated with improved short-term postoperative outcomes compared to open surgery. Moreover, laparoscopic surgery appears to provide excellent long-term cancer outcomes.

Survival impact of adjuvant chemotherapy in patients with stage IIA colon cancer: Analysis of the National Cancer Database.

Utility of adjuvant chemotherapy for stage II cancer remains a matter of debate. Clinical guidelines suggest adjuvant chemotherapy for stage II tumors with high-risk features, in particular T4 tumors. However, limited consensus exists regarding the importance of other high-risk features (lymphovascular or perineural invasion, microsatellite instability). Our study aimed to investigate the impact of adjuvant chemotherapy for stage IIA (T3N0) colon cancer patients. Patients who underwent colectomy for stage IIA colon adenocarcinoma (2010-2015) were identified in the National Cancer Database (NCDB) and divided in two groups based on receipt of adjuvant chemotherapy vs observation. Inverse probability of treatment weighting (IPTW)-adjusted Kaplan-Meier and Cox proportional hazards regression analyses were performed to compare overall survival between the two groups. Subgroup analysis of patients with specific high-risk features LVI, PNI and MSI was performed. Among 46 688 surgical patients with stage IIA colon adenocarcinoma 5937 (12.7%) received adjuvant chemotherapy, while 40 751 (87.3%) were observed. Five-year IPTW-adjusted survival was higher in the adjuvant chemotherapy group (79.7% [95% CI 79.1, 80.2]) compared to the observation group (70.3% [95% CI 69.7, 70.9]). Patients with high-risk pathological features showed an estimated 5-year survival benefit of 11.3% (78.2% [95% CI 77.4, 79.1] vs 66.9% [95% CI 65.9, 67.8]) when treated with adjuvant chemotherapy. This NCDB analysis revealed a survival benefit for patients with stage IIA colon adenocarcinoma and high-risk features that were treated with adjuvant chemotherapy.

Robotic Surgery for Rectal Cancer Provides Advantageous Outcomes Over Laparoscopic Approach: Results From a Large Retrospective Cohort.

OBJECTIVE: To compare short term outcomes of patients undergoing laparoscopic or robotic rectal cancer surgery. BACKGROUND: Significant benefits of robotic rectal cancer surgery over laparoscopy have yet to be demonstrated. Operative time and direct institutional cost seem in favor of the laparoscopic approach. METHODS: We performed a retrospective review of consecutive patients operated on for rectal cancer with a mini-invasive approach at Mayo Clinic from 2005 to 2018. The primary aim of this study was to investigate the difference in postoperative morbidity between the laparoscopic and robotic approach. Multivariable models for odds to complications and prolonged (≥6 days) length of stay were built. RESULTS: A total of 600 patients were included in the analysis. The number of patients undergoing robotic surgery was 317 (52.8%). The 2 groups were similar in respect to age, sex, and body mass index. Laparoscopic surgery was correlated to shorter operative time (214 vs 324 minutes; P < 0.001). Patients undergoing robotic surgery had a lower overall complications rate (37.2% vs 51.2%; P < 0.001). Robotic surgery was found to be the most protective factor [odds ratio (OR) 0.485; P = 0.006] for odds to complications. The event of a complication (OR 9.33; P < 0.001) and conversion to open surgery (OR 3.095; P = 0.002) were identified as risk factors for prolonged length of stay whereas robotic surgery (OR 0.62; P = 0.027) was the only independent protective factor. CONCLUSIONS: Robotic rectal cancer surgery is strongly associated with better short-term outcomes over laparoscopic surgery.

Surgical Approach to Transverse Colon Cancer: Analysis of Current Practice and Oncological Outcomes Using the National Cancer Database.

BACKGROUND: Surgical treatment for transverse colon cancer involves either extended colectomy or segmental resection, depending on the location of the tumor and surgeon perspective. However, the oncological safety of segmental resection has not yet been established in large cohort studies. OBJECTIVE: This study aims to compare segmental resection versus extended colectomy for transverse colon cancer in terms of oncological outcomes. DESIGN: This was a retrospective cohort study. SETTINGS: This study was conducted using a nationwide cohort. PATIENTS: A total of 66,062 patients who underwent colectomy with curative intent for transverse stage I to III adenocarcinoma were identified in the National Cancer Database (2004-2015). MAIN OUTCOME MEASURES: Patients were divided in 2 groups based on the type of surgery received (extended versus segmental resection). The primary outcome was overall survival. Secondary outcomes were 30- and 90-day mortality, length of hospital stay, and readmission rate within 30 days of surgical discharge. RESULTS: Extended colectomy was performed in 44,417 (67.2%) patients, whereas 21,645 (32.8%) patients underwent segmental resection. Extended colectomy was associated with lower survival at multivariate analysis (HR, 1.07; 95% CI, 1.04-1.10; p < 0.001). The subgroup analysis showed that extended resection was independently associated with poorer survival in mid transverse colon cancers (HR, 1.08; 95% CI, 1.04-1.12; p < 0.001) and in stage III tumors (HR, 1.11; 95% CI, 1.04-1.18; p < 0.001). The number of at least 12 harvested lymph nodes was an independent predictor of improved survival in both overall and subgroup analyses. LIMITATIONS: This study was limited by its retrospective design. CONCLUSION: Extended colectomy was not associated with a survival advantage compared with segmental resection. On the contrary, extended colectomy was associated with slightly poorer survival in mid transverse cancers and locally advanced tumors. Segmental resection was found to be safe when appropriate margins and adequate lymph node harvest were achieved. See Video Abstract at http://links.lww.com/DCR/B454. ABORDAJE QUIRRGICO DEL CNCER DE COLON TRANSVERSO ANLISIS DE LA PRCTICA ACTUAL Y LOS RESULTADOS ONCOLGICOS UTILIZANDO LA BASE DE DATOS NACIONAL DE CNCER: ANTECEDENTES:El tratamiento quirúrgico para el cáncer de colon transverso implica colectomía extendida o resección segmentaria, según la ubicación del tumor y la perspectiva del cirujano. Sin embargo, la seguridad oncológica de la resección segmentaria aún no se ha establecido en estudios de cohortes grandes.OBJETIVO:Este estudio tiene como objetivo comparar la resección segmentaria versus la colectomía extendida para el cáncer de colon transverso en términos de resultados oncológicos.DISEÑO:Este fue un estudio de cohorte retrospectivo.ESCENARIO:Este estudio se realizó utilizando una cohorte a nivel nacional.PACIENTES:Un total de 66,062 pacientes que se sometieron a colectomía con intención curativa por adenocarcinoma de colon transverso en estadio I-III fueron identificados en la Base de Datos Nacional del Cáncer (2004-2015).PRINCIPALES MEDIDAS DE RESULTADO:Los pacientes se dividieron en dos grupos según el tipo de cirugía recibida (resección extendida versus resección segmentaria). El resultado primario fue la supervivencia global. Los resultados secundarios fueron la mortalidad a los 30 y 90 días, la duración de la estancia hospitalaria y la tasa de reingreso dentro de los 30 días posteriores al alta quirúrgica.RESULTADOS:Se realizó colectomía extendida en 44,417 (67.2%) casos, mientras que 21,645 (32.8%) pacientes fueron sometidos a resección segmentaria. La colectomía extendida se asoció con una menor supervivencia en el análisis multivariado (HR 1.07 IC 95% 1.04-1.10; p <0.001). El análisis de subgrupos mostró que la resección extendida se asoció de forma independiente con una menor supervivencia en los cánceres de colon transverso medio (HR 1.08 IC 95% 1.04-1.12; p <0.001) y en tumores en estadio III (HR 1.11 IC 95% 1.04-1.18; p <0.001). Un número de al menos 12 ganglios linfáticos cosechados fue un predictor independiente de una mejor supervivencia en los análisis general y de subgrupos.LIMITACIONES:Este estudio estuvo limitado por su diseño retrospectivo.CONCLUSIÓN:La colectomía extendida no se asoció con una ventaja de supervivencia en comparación con la resección segmentaria. Por el contrario, la colectomía extendida se asoció con una supervivencia levemente menor en cánceres de colon transverso medio y tumores localmente avanzados. Se encontró que la resección segmentaria es segura cuando se logran los márgenes apropiados y la cosecha adecuada de ganglios linfáticos. Consulte Video Resumen en http://links.lww.com/DCR/B454.

MRI-Pathology Agreement in Rectal Cancer: Real-World Data from a Prospective Rectal Cancer Registry.

Introduction: Magnetic Resonance Imaging (MRI) is routinely used in preoperative rectal cancer staging. The concordance of MRI staging with final pathologic exam, albeit improved, has not yet reached perfection. The aim of this study is to analyze the agreement between MRI and pathologic exam in patients operated on for mid-low rectal cancer. Material and Method: Patients undergoing neoadjuvant chemoradiation therapy (nCRT) or upfront surgery were analyzed. Between January 2019 to December 2019, 140 patients enrolled in the AIMS Academy rectal cancer registry were analyzed. Sixty-two patients received nCRT and 78 underwent upfront surgery. Results: Overall, the agreement between MRI and pathologic exam on T stage and N stage were 64.7% and 69.2%, respectively. The agreement between MRI and pathologic exam on T stage was 62.7% for patients who did not receive nCRT and 67.4% for patients who received nCRT (p = 0.62). The agreement on N stage was 76.3% for patients who did not receive nCRT and 60.0% for patients who received nCRT (p = 0.075). Conclusions: Real-world data shows MRI is still far from being able to correlate with the pathology findings which raises questions about the accuracy of the real-life decision-making process during cancer boards.

Is BMI a Factor in Compliance to Adjuvant Chemotherapy for Locally Advanced Rectal Cancer?

Background: Compliance to adjuvant chemotherapy (AC) for patients undergoing rectal surgery ranges from 43% to 73.6%. Reasons reported for not initiating or completing AC include onset of postoperative complications, drug toxicity, disease progression and/or patient preferences. Little is known regarding the impact of obesity on the compliance to AC in this setting. Methods: This multicenter, retrospective study analyzed compliance to AC and treatment-related morbidity in 511 patients having undergone surgery with curative intent for rectal cancer in six Italian colorectal centers between January 2013 and December 2017. Results: 70 patients were obese (BMI 30 kg/m2). The proportion of open procedures (22.9% vs. 13.4%) and conversions (14.3% vs. 4.8%) was greater in obese compared to non-obese patients (p 0.001). Median hospital stay was one day longer for obese patients (9 days vs. 10 days, p=0.038) while there was no statistically significant difference in the complication rate, whether overall (58.6% in obese vs. 52.3% in non-obese) or with a Clavien-Dindo score 3 (17.1% vs 10.9%). AC was offered to 49/70 (70%) patients in the obese group and 306/441 (69.4%) in the non-obese group (p=0.43). There was no statistically significant difference in AC compliance: 18.4% and 22.9% did not start AC, while 36.7% and 34.6%, started AC but did not complete the scheduled treatment (p=0.79) in the obese and non-obese group, respectively. Overall, 55% of patients who started AC successfully completed their adjuvant treatment. Conclusions: Obesity did not impact compliance to AC for locally advanced rectal cancer: compliance was poor in obese and non-obese patients with no statistically significant difference between the two groups. Major complication rate was not statistically significantly affected by increased BMI.

Long-term Oncological Outcomes Following Anastomotic Leak in Rectal Cancer Surgery.

BACKGROUND: Anastomotic leak remains a critical complication after restorative rectal cancer surgery and is associated with significant morbidity and mortality rates, whereas reported rates range from 4% to 29%. Whether the occurrence of leak may have an impact on long-term oncological outcomes is under debate. OBJECTIVE: This study aimed to describe the oncological impact of anastomotic leak on patients undergoing sphincter-preserving surgery for rectal adenocarcinoma. DESIGN: This is a retrospective review of a prospectively maintained database. SETTINGS: The study was conducted at a high-volume colorectal center. PATIENTS: Data on patients who underwent restorative surgery for rectal adenocarcinoma from January 2000 until December 2013 were retrospectively analyzed. MAIN OUTCOME MEASURES: The primary outcome measured was the impact of anastomotic leak, defined according to the classification proposed by the International Study Group of Rectal Cancer, on long-term overall survival, disease-free survival, disease-specific survival, and local recurrence. RESULTS: A total of 787 patients undergoing sphincter-preserving surgery for rectal cancer met the inclusion criteria. Forty-two (5.3%) patients presented a symptomatic anastomotic leak. The median follow-up period was 64 months. Fifty-one (6.5%) patients experienced a cancer-related death, 2 of 42 in the anastomotic leak group. Five-year overall survival, disease-specific survival, and disease-free survival were 88%, 94.7%, and 85.3%. Local recurrence rate was 2%. There was no difference in long-term overall survival, disease-specific survival, disease-free survival, and local recurrence rate between groups. On a multivariable analysis, anastomotic leak did not impact oncological outcomes. LIMITATIONS: This study was limited by retrospective analysis. CONCLUSIONS: The occurrence of anastomotic leak after restorative resection for rectal cancer did not impact long-term oncological outcomes in our cohort of patients. See Video Abstract at http://links.lww.com/DCR/B187. RESULTADOS ONCOLÓGICOS A LARGO PLAZO DESPUÉS DE UNA FUGA ANASTOMÓTICA EN CIRUGÍA DE CÁNCER RECTAL: La fuga anastomótica sigue siendo una complicación crítica después de la cirugía restauradora del cáncer rectal y se asocia con tasas significativas de morbilidad y mortalidad, mientras que las tasas reportadas varían del 4% al 29%. Se está debatiendo si la aparición de fugas puede tener un impacto en los resultados oncológicos a largo plazo.Describir el impacto oncológico de la fuga anastomótica en pacientes sometidos a cirugía de preservación del esfínter para adenocarcinoma rectal.Revisión retrospectiva de una base de datos mantenida prospectivamente.El estudio se realizó en un centro colorrectal de alto volumen.Se analizaron retrospectivamente los datos de pacientes que se sometieron a cirugía reparadora por adenocarcinoma rectal desde Enero de 2000 hasta Diciembre de 2013.Impacto de la fuga anastomótica, definida de acuerdo con la clasificación propuesta por el Grupo de Estudio Internacional del Cáncer Rectal (International Study Group of Rectal Cancer), sobre la supervivencia general a largo plazo, la supervivencia libre de enfermedad, la supervivencia específica de la enfermedad y la recurrencia local.Un total de 787 pacientes sometidos a cirugía para preservar el esfínter por cáncer rectal cumplieron con los criterios de inclusión. Cuarenta y dos (5.3%) pacientes presentaron una fuga anastomótica sintomática. El tiempo mediano del período de seguimiento fue de 64 meses. Cincuenta y un (6.5%) pacientes sufrieron muerte relacionada con el cáncer, 2 de 42 en el grupo de fuga anastomótica. La supervivencia global a cinco años, la supervivencia específica de la enfermedad y la supervivencia libre de enfermedad fueron del 88%, 94.7% y 85.3%, respectivamente. La tasa de recurrencia local fue del 2%. No hubo diferencias en la supervivencia global a largo plazo, la supervivencia específica de la enfermedad, la supervivencia libre de enfermedad y la tasa de recurrencia local entre los grupos. En un análisis multivariable, la fuga anastomótica no afectó los resultados oncológicos.Este estudio fue limitado por análisis retrospectivo.La aparición de fuga anastomótica después de la resección restauradora para el cáncer rectal no afectó los resultados oncológicos a largo plazo en nuestra cohorte de pacientes. Consulte Video Resumen en http://links.lww.com/DCR/B187. (Traducción-Dr. Yesenia Rojas-Kahlil).

Potential Association Between Perioperative Fluid Management and Occurrence of Postoperative Ileus.

BACKGROUND: Postoperative ileus remains an issue after colorectal surgery delaying recovery and increasing the length of hospital stay and costs. OBJECTIVE: The purpose of this study was to analyze the impact of perioperative fluid management on ileus occurrence after colorectal surgery within a fully implemented enhanced recovery pathway. DESIGN: This was a retrospective cohort study of a prospectively maintained institutional database. SETTINGS: The study was conducted at a tertiary academic facility with fully implemented standardized enhanced recovery pathway over the entire study period. PATIENTS: All of the consecutive elective major colorectal resections for benign or malign indications between 2011 and 2016 were included. MAIN OUTCOME MEASURES: Postoperative ileus was defined as the need for nasogastric tube reinsertion. Perioperative fluid management and surgical outcome were compared between patients presenting with ileus and those without. Potential risk factors for ileus were identified through multinomial logistic regression. RESULTS: Postoperative ileus occurred in 377 (9%) of 4205 included patients at day 4 (interquartile range, 2-5 d). Intraoperatively, ileus patients received 3.2 ± 2.6 L of fluids, whereas the remaining patients received 2.5 ± 1.7 L (p < 0.001). Weight gain was 3.8 ± 7.1 kg in ileus patients versus 3.0 ± 6.6 kg (p = 0.272) in the remaining patients at postoperative day 1, 4.4 ± 6.5 kg versus 3.1 ± 7.0 kg (p = 0.028) at postoperative day 2, and 1.8 ± 6.0 kg versus 0.0 ± 6.0 kg at discharge (p = 0.002). The multivariable model including all significant (p < 0.05) demographic, fluid management-related, and surgical parameters retained postoperative day 0 fluids of >3 L (OR = 1.65 (95% CI, 1.13-2.41); p = 0.009), postoperative day 2 weight gain of >2.5 kg (OR = 1.49 (95% CI, 1.01-2.21); p = 0.048), and occurrence of postoperative complications (OR = 2.00 (95% CI, 1.39-2.90); p < 0.001) as independent risk factors for ileus. LIMITATIONS: This study was limited by its retrospective design. Fluid management depends on patient-, disease-, and surgery-related factors and cannot be generalized and extrapolated. CONCLUSIONS: Fluid overload and occurrence of postoperative complications were independent risk factors for postoperative ileus. This calls for action to keep perioperative fluids below suggested thresholds. See Video Abstract at http://links.lww.com/DCR/B54. ASOCIACIÓN POTENCIAL ENTRE EL MANEJO DEL LÍQUIDO PERIOPERATORIO Y EL SUCESO DE ÍLEO POSTOPERATORIO: El íleo postoperatorio sigue siendo un problema después de una cirugía colorrectal que retrasa la recuperación y aumenta la duración de la estancia hospitalaria y los costos.Analizar el impacto del manejo del líquido perioperatorio en la incidencia de íleo después de la cirugía colorrectal dentro de una vía de recuperación mejorada totalmente implementada.Estudio de cohorte retrospectivo de una base de datos institucional mantenida prospectivamente.Centro académico terciario con una ruta de recuperación mejorada estandarizada completamente implementada durante todo el período del estudio.Se incluyeron todas las resecciones colorrectales mayores electivas consecutivas para indicaciones benignas o malignas entre 2011 y 2016.El íleo postoperatorio se definió como la necesidad de reinserción de la sonda nasogástrica. El manejo del líquido perioperatorio y el resultado quirúrgico se compararon entre los pacientes con íleo y los que no. Los posibles factores de riesgo para el íleo se identificaron mediante regresión logística multinominal.El íleo postoperatorio se ocurrió en 377 (9%) de los 4205 pacientes incluidos al cuarto día (RIC 2-5). Intraoperatoriamente, los pacientes con íleo recibieron 3.2 ± 2.6 L de líquidos, mientras que los pacientes restantes recibieron 2.5 ± 1.7 L (p < 0.001). El aumento de peso fue de 3.8 ± 7.1 kg en pacientes con íleo versus 3 ± 6.6 kg (p = 0.272) en los pacientes restantes en el día postoperatorio 1, 4.4 ± 6.5 kg vs. 3.1 ± 7 kg (p = 0.028) en el día postoperatorio 2 y 1.8 ± 6 kg versus a 0 ± 6 kg al tiempo de alta hospitalaria (p = 0.002). El modelo multivariable que incluye todos los parámetros demográficos, del manejo de líquidos y quirúrgicos significativos (p <0.05) mantuvo líquidos del día 0 después de la operación de> 3L (proporción de probabilidad 1.65, intervalo de confianza del 95% 1.13-2.41, p = 0.009), ganancia de peso de > 2.5 kg en el dia postoperatorio 2 (proporción de probabilidad 1.49, 95% intervalo de confianza 1.01-2.21, p = 0.048) y aparición de complicaciones postoperatorias (proporción de probabilidad 2, 95% intervalo de confianza 1.39-2.9, p <0.001) como factores de riesgo independientes para íleo.Diseño retrospectivo. El manejo de líquidos depende de factores relacionados con el paciente, la enfermedad y la cirugía, y no puede generalizarse ni extrapolarse.La sobrecarga de líquidos y la aparición de complicaciones postoperatorias fueron factores de riesgo independientes para el íleo postoperatorio. Esto requiere medidas para mantener los líquidos perioperatorios por debajo de los umbrales sugeridos. Vea el Video del Resumen en http://links.lww.com/DCR/B54.

Readmissions Within 48 Hours of Discharge: Reasons, Risk Factors, and Potential Improvements.

BACKGROUND: Hospital readmission rate is an important quality metric and has been recognized as a key measure of hospital value-based purchasing programs. OBJECTIVE: This study aimed to assess the risk factors for hospital readmission with a focus on potentially preventable early readmissions within 48 hours of discharge. DESIGN: This is a retrospective cohort study. SETTINGS: This study was conducted at a tertiary academic facility with a standardized enhanced recovery pathway. PATIENTS: Consecutive patients undergoing elective major colorectal resections between 2011 and 2016 were included. MAIN OUTCOME MEASURES: Univariable and multivariable risk factors for overall and early (<48 hours) readmissions were identified. Specific surgical and medical reasons for readmission were compared between early and late readmissions. RESULTS: In total, 526 of 4204 patients (12.5%) were readmitted within 30 days of discharge. Independent risk factors were ASA score (≥3; OR, 1.5; 95% CI, 1.1-2), excess perioperative weight gain (OR, 1.7; 95% CI, 1.3-2.3), ileostomy (OR, 1.4; 95% CI, 1-2), and transfusion (OR, 2; 95% CI, 1.4-3), or reoperation (OR, 11.4; 95% CI, 7.4-17.5) during the index stay. No potentially preventable risk factor for early readmission (128 patients, 24.3% of all readmissions, 3% of total cohort) was identified, and index hospital stay of ≤3 days was not associated with increased readmission (OR, 0.9; 95% CI, 0.7-1.2). Although ileus and small-bowel obstruction (early: 43.8% vs late: 15.5%, p < 0.001) were leading causes for early readmissions, deep infections (3.9% vs 16.3%, p < 0.001) and acute kidney injury (0% vs 5%, p = 0.006) were mainly observed during readmissions after 48 hours. LIMITATIONS: Risk of underreporting due to loss of follow-up and the potential co-occurrence of complications were limitations of this study. CONCLUSIONS: Early hospital readmission was mainly due to ileus or bowel obstruction, whereas late readmissions were related to deep infections and acute kidney injury. A suspicious attitude toward potential ileus-related symptoms before discharge and dedicated education for ostomy patients are important. A short index hospital stay was not associated with increased readmission rates. See Video Abstract at http://links.lww.com/DCR/B237. REINGRESOS DENTRO DE LAS 48 HORAS POSTERIORES AL ALTA: RAZONES, FACTORES DE RIESGO Y POSIBLES MEJORAS: La tasa de reingreso hospitalario es una métrica de calidad importante y ha sido reconocida como una medida clave de los programas hospitalarios de compras basadas en el valor.Evaluar los factores de riesgo para el reingreso hospitalario con énfasis en reingresos tempranos potencialmente prevenibles dentro de las 48 horas posteriores al alta.Estudio de cohorte retrospectivo.Institución académica terciaria con programa de recuperación mejorada estandarizado.Pacientes consecutivos sometidos a resecciones colorrectales mayores electivas entre 2011 y 2016.Se identificaron factores de riesgo uni y multivariables para reingresos totales y tempranos (<48 horas). Se compararon razones médicas y quirúrgicas específicas para el reingreso entre reingresos tempranos y tardíos.En total, 526/4204 pacientes (12,5%) fueron readmitidos dentro de los 30 días posteriores al alta. Los factores de riesgo independientes fueron puntuación ASA (≥3, OR 1.5; IC 95% 1.1-2), aumento de peso perioperatorio excesivo (OR 1.7; IC 95% 1.3-2.3), ileostomía (OR 1.4, IC 95%: 1-2) y transfusión (OR 2, IC 95% 1.4-3) o reoperación (OR 11.4; IC 95% 7.4-17.5) durante la estadía índice. No se identificó ningún factor de riesgo potencialmente prevenible para el reingreso temprano (128 pacientes, 24.3% de todos los reingresos, 3% de la cohorte total), y la estadía hospitalaria índice de ≤ 3 días no se asoció con un aumento en el reingreso (OR 0.9; IC 95% 0.7-1.2) Mientras que el íleo / obstrucción del intestino delgado (temprano: 43.8% vs. tardío: 15.5%, p < 0.001) fueron las principales causas de reingresos tempranos, infecciones profundas (3.9% vs 16.3%, p < 0.001) y lesión renal aguda (0 vs 5%, p = 0.006) se observaron principalmente durante los reingresos después de 48 horas.Riesgo de subregistro debido a la pérdida en el seguimiento, posible co-ocurrencia de complicaciones.El reingreso hospitalario temprano se debió principalmente a íleo u obstrucción intestinal, mientras que los reingresos tardíos se relacionaron con infecciones profundas y lesión renal aguda. Es importante tener una actitud suspicaz hacia los posibles síntomas relacionados con el íleo antes del alta y una educación específica para los pacientes con ostomía. La estadía hospitalaria índice corta no se asoció con mayores tasas de reingreso. Consulte Video Resumen en http://links.lww.com/DCR/B237.

Clinical-Pathologic Characteristics and Long-term Outcomes of Left Flexure Colonic Cancer: A Retrospective Analysis of an International Multicenter Cohort.

BACKGROUND: Colorectal cancer seldom presents at the splenic flexure. Small series on left flexure tumors reported a high occurrence of negative prognostic factors called into question as causes of poor prognosis. However, because of the small number of cases, no definite conclusions can be drawn. OBJECTIVE: The aim of this study was to compare clinical-pathologic characteristics and short- and long-term outcomes of left flexure tumors with other colonic locations. DESIGN: This was a retrospective analysis of consecutive patients who underwent surgery for tumors at the splenic flexure. Each tumor was paired in a 1 to 1 fashion with a right-sided and sigmoid tumor. SETTINGS: The study was conducted in 10 international centers. PATIENTS: A total of 641 patients with left flexure tumors were included in the study. MAIN OUTCOME MEASURES: Overall survival and cancer-specific survival were measured. RESULTS: Left flexure tumors presented more frequently with stenosis (30.5%; p < 0.001), with lesions infiltrating beyond the serosa (21.9%; p = 0.001) and with a high rate of mucinous histology (8.8%; p = 0.001). Looking at long-term prognosis, no differences were observed among the 3 groups, both considering overall and cancer-specific survival. However, left flexure tumors recurred more frequently as peritoneal carcinomatosis (20.6%; p < 0.001). LIMITATIONS: This study was limited because of its retrospective nature. CONCLUSIONS: Although left flexure tumors display several negative prognostic factors, they are not characterized by a worse prognosis compared with other colon cancer locations. See Video Abstract at http://links.lww.com/DCR/B395. CARACTERÍSTICAS CLÍNICO-PATOLÓGICAS Y RESULTADOS A LARGO PLAZO DEL CÁNCER DE COLON DE ÁNGULO IZQUIERDO: UN ANÁLISIS RETROSPECTIVO DE UNA COHORTE MULTICÉNTRICA INTERNACIONAL: El cáncer colorrectal rara vez se presenta en el ángulo esplénico. Pequeñas series sobre tumores de ángulo izquierdo informaron una alta incidencia de factores pronósticos negativos cuestionados como causas de mal pronóstico. Sin embargo, debido al pequeño número de casos, no se pueden sacar conclusiones definitivas.El objetivo de este estudio fue comparar las características clínico-patológicas, los resultados a corto y largo plazo de los tumores de ángulo izquierdo con otras ubicaciones de colon.Análisis retrospectivo de pacientes consecutivos que se sometieron a cirugía por tumores en el ángulo esplénico. Cada tumor se emparejó de forma individual con un tumor del lado derecho y sigmoide.El estudio se realizó en 10 centros internacionales.Se incluyeron en el estudio un total de 641 pacientes con tumores del ángulo izquierdo.Supervivencia general y específica del cáncerLos tumores de ángulo izquierda se presentaron con mayor frecuencia con estenosis (30.5%, p <0.001), con lesiones infiltradas más allá de la serosa (21.9%, p = 0.001), y con una alta tasa de histología mucinosa (8.8%, p = 0.001). En cuanto al pronóstico a largo plazo, no se observaron diferencias entre los tres grupos, considerando la supervivencia general y específica del cáncer. Sin embargo, los tumores de ángulo izquierdo recurrieron con mayor frecuencia como carcinomatosis peritoneal (20,6%; p <0,001).Este estudio fue limitado debido a su naturaleza retrospectiva.Aunque los tumores de ángulo izquierdo muestran varios factores pronósticos negativos, no se caracterizan por un peor pronóstico en comparación con otras ubicaciones de cáncer de colon. Consulte Video Resumen en http://links.lww.com/DCR/B395.

Symptomatic Uncomplicated Diverticular Disease and Incidence of Unexpected Abscess during Sigmoidectomy: A Multicenter Prospective Observational Study.

BACKGROUND: Symptomatic uncomplicated diverticular disease can affect patients' everyday routine. Considerable efforts have been made to identify clinical features that correlate to the severity of the disease. Unexpected intraoperative abscesses are reported in large retrospective series, showing how uncomplicated symptoms and presentations can underlie a complicated disease. The aim of this study was to investigate the incidence of pericolic or intramural abscess in patients undergoing elective sigmoidectomy for symptomatic uncomplicated diverticular disease and see if chronic symptoms correlate to the presence of an abscess. METHODS: Between January 2016 and June 2018, we prospectively collected data of patients who were given indication to elective sigmoidectomy for symptomatic uncomplicated diverticular disease. Patients were divided into 3 groups: acute resolving, smoldering, and atypical according to a previously described classification of uncomplicated diverticular disease. RESULTS: One hundred fifty-eight consecutive patients were enrolled in the study. The median age was 63 years (22- 88), and the mean body mass index was 26 (±7) kg/m2. There were 114 patients in the acute resolving group, 36 in the smoldering group, and 8 in the atypical group. An unexpected abscess was reported in 75 patients (47.5%) during surgery or pathological examination. The incidence of -abscess was greater for patient in the smoldering group (p = 0.0243). CONCLUSION: Our series of patients affected by symptomatic uncomplicated diverticular disease showed an incidence of unexpected pericolic or intramural abscess of 47.5%. Patients affected by smoldering diverticular disease presented a greater abscess rate.

Totally Laparoscopic Pancreaticoduodenectomy: Technical Notes.

Introduction: Laparoscopic pancreaticoduodendectomy is still rarely adopted due to its inherent complexity. We hereby present our experience of laparoscopic pancreaticoduodenectomy focused on technical notes. Technical description: A 5 trocars technique is used. Vision is provided by a 30 degree scope with 4K technology for the demolitive phase and 3D for the reconstructive phase. The right colic flexure is mobilized and an extensive Kocher maneuver is carried out exposing the inferior vena cava and left renal vein. The gastric antrum is resected with a mechanical stapler. The common hepatic artery is identified behind the superior pancreatic margin; lymphadenectomy of stations 7, 8, 9, 12 a and b is performed, until the gastroduodenal artery is cleared from the lymphatic tissue; a bull-dog clamp is placed to interrupt the arterial flow through the gastroduodenal artery, in order to exclude aberrant vascularization of the liver from the SMA. The common hepatic duct is transected just above the cystic duct. The pancreas is sectioned with monopolar energy, dividing the main pancreatic duct 2-3 mm distal to the parenchymal transection line with cold scissors, as to leave a stump that will facilitate the duct-to-mucosa anastomosis then the first jejunal loop is sectioned. A complete dissection of the mesopancreas is performed, moving from a caudal to cephalad fashion. Prior to perform the pancreatico-jejunal anastomosis, a fistula risk score based on pancreatic parenchymal texture, tumor type, Wirsung diameter, intraoperative blood loss is assessed. The pancreatico-jejunal anastomosis is carried out using prolene and pds sutures. The end-to-side hepaticojejunostomy is performed about 10 cm distant from the pancreaticojejunostomy. The side to- side gastrojejunostomy is performed using a 60 mm linear stapler. Conclusion: Laparoscopic pancreaticoduodenectomy is a demanding procedure affected by high morbidity rates. The standardization of the technique could lead the way to reduce such rates and favor its adoption.

Low Ligation of Inferior Mesenteric Artery in Laparoscopic Anterior Resection for Rectal Cancer Reduces Genitourinary Dysfunction: Results From a Randomized Controlled Trial (HIGHLOW Trial).

OBJECTIVES: The aim of the present study was to compare the incidence of genitourinary (GU) dysfunction after elective laparoscopic low anterior rectal resection and total mesorectal excision (LAR + TME) with high or low ligation (LL) of the inferior mesenteric artery (IMA). Secondary aims included the incidence of anastomotic leakage and oncological outcomes. BACKGROUND: The criterion standard surgical approach for rectal cancer is LAR + TME. The level of artery ligation remains an issue related to functional outcome, anastomotic leak rate, and oncological adequacy. Retrospective studies failed to provide strong evidence in favor of one particular vascular approach and the specific impact on GU function is poorly understood. METHODS: Between June 2014 and December 2016, patients who underwent elective laparoscopic LAR + TME in 6 Italian nonacademic hospitals were randomized to high ligation (HL) or LL of IMA after meeting the inclusion criteria. GU function was evaluated using a standardized survey and uroflowmetric examination. The trial was registered under the ClinicalTrials.gov Identifier NCT02153801. RESULTS: A total of 214 patients were randomized to HL (n = 111) or LL (n = 103). GU function was impaired in both groups after surgery. LL group reported better continence and less obstructive urinary symptoms and improved quality of life at 9 months postoperative. Sexual function was better in the LL group compared to HL group at 9 months. Urinated volume, maximum urinary flow, and flow time were significantly (P < 0.05) in favor of the LL group at 1 and 9 months from surgery. The ultrasound measured post void residual volume and average urinary flow were significantly (P < 0.05) better in the LL group at 9 months postoperatively. Time of flow worsened in both groups at 9 months compared to baseline. There was no difference in anastomotic leak rate (8.1% HL vs 6.7% LL). There were no differences in terms of blood loss, surgical times, postoperative complications, and initial oncological outcomes between groups. CONCLUSIONS: LL of the IMA in LAR + TME results in better GU function preservation without affecting initial oncological outcomes. HL does not seem to increase the anastomotic leak rate.

Hybrid minimally invasive/open approach versus total minimally invasive approach for rectal cancer resection: short- and long-term results.

OBJECTIVES: To reduce the technical challenges of a totally minimally invasive approach (TMA) and to decrease the morbidity associated with open surgery, a hybrid minimally invasive/open approach (HMOA) has been introduced as a surgical technique for rectal cancer. The aim of this study was to compare postoperative results and long-term oncologic outcomes between hybrid minimally invasive/open approach and totally minimally invasive approach in patients who underwent rectal resection for cancer. METHODS: All patients with rectal cancer undergoing a totally minimally invasive approach or hybrid minimally invasive/open approach proctectomy between 2012 and 2016 were analyzed. Preoperative and postoperative outcomes were collected from a prospectively maintained institutional database. RESULTS: Among 283 patients, 138 (48.8%) underwent a hybrid minimally invasive/open approach and 145 (51.2%) a totally minimally invasive approach. Preoperative characteristics were similar between groups except for distance from the anal verge, which was lower in totally minimally invasive approach group (50.7% vs 29%; p = 0.0008). Length of stay (LOS) was significantly longer in the hybrid minimally invasive/open approach group (6.4 vs 4.3; p = < 0.0001). The median follow-up was 29.6 (14-40.6) months. Overall survival and disease-free survival were not significantly different between groups. CONCLUSIONS: Compared with a hybrid minimally invasive/open approach, a totally minimally invasive approach has a shorter length of stay and may improve short-term outcomes in patients undergoing proctectomy for cancer.

Feasibility and safety of robotic resection of complicated diverticular disease.

This study aimed to assess intra- and postoperative outcomes of robotic resection of left-sided complicated diverticular disease. Retrospective analysis of a prospectively maintained institutional database on consecutive patients undergoing elective robotic resection for diverticular disease (2014-2018). All procedures were performed within an enhanced recovery pathway (ERP). Demographic, surgical and ERP-related items were compared between patients with simple and complicated diverticular disease according to intra-operative presentation. Postoperative complications and length of stay were compared between the two groups. Out of 150 patients, 78 (52%) presented with complicated and the remaining 72 (48%) with uncomplicated disease. Both groups were comparable regarding demographic baseline characteristics and overall ERP compliance. Surgery for complicated disease was longer (288 ± 96 vs. 258 ± 72 min, p = 0.04) and more contaminated (≥ class 3: 57.7 vs. 23.6%, p < 0.001) with a trend to higher conversion rates (10.3 vs. 2.8%, p = 0.1). While postoperative overall complications tended to occur more often after resections for complicated disease (28.2 vs. 15.3%, p = 0.075), major, surgical and medical complications did not differ between the two groups, and median length of stay was 3 days in both settings (p = 0.19). Robotic resection of diverticular disease was feasible and safe regardless of disease presentation by the time of surgery.

Early Acute Kidney Injury Within an Established Enhanced Recovery Pathway: Uncommon and Transitory.

BACKGROUND: The present study aimed to assess the impact of perioperative fluid management on early acute kidney injury (AKI) rate and long-term sequelae in patients undergoing elective colorectal procedures within an enhanced recovery pathway (ERP). METHODS: Retrospective analysis of consecutive patients from a prospectively maintained ERP database (2011-2015) is performed. Pre- and postoperative creatinine levels (within 24 h) were compared according to risk (preoperative creatinine rise ×1.5), injury (×2), failure (×3), loss of kidney function and end-stage kidney disease (RIFLE) criteria. Risk factors for early AKI were identified through logistic regression analysis, and long-term outcome in patients with AKI was assessed. RESULTS: Out of 7103 patients, 4096 patients (58%) with pre- and postoperative creatinine levels were included. Of these, 104 patients (2.5%) presented postoperative AKI. AKI patients received higher amounts of POD 0 fluids (3.8 ± 2.4 vs. 3.2 ± 2 L, p = 0.01) and had increased postoperative weight gain at POD 2 (6 ± 4.9 vs. 3 ± 2.7 kg, p = 0.007). Independent risk factors for AKI were high ASA score (ASA ≥ 3: OR 1.7; 95% CI 1.1-2.5), prolonged operating time (>180 min: OR 1.9; 95% CI 1.3-2.9) and diabetes mellitus (OR 2.5; 95% CI 1.5-4), while minimally invasive surgery was a protective factor (OR 0.6; 95% CI 0.4-0.9). Five patients (0.1%) developed chronic kidney disease, and two of them needed dialysis after a mean follow-up of 33.7 ± 22.4 months. CONCLUSIONS: Early AKI was very uncommon in the present cohort of colorectal surgery patients treated within an ERP, and long-term sequelae were exceptionally low.

Compliance to Adjuvant Chemotherapy of Patients Who Underwent Surgery for Rectal Cancer: Report from a Multi-institutional Research Network.

INTRODUCTION: Adjuvant chemotherapy for locally advanced rectal cancer is associated with improved overall survival. However, recent evidence from randomized trials showed a compliance rate of 43 to 73%, which may affect efficacy. The aim of this multicenter retrospective analysis was to investigate the compliance rate to adjuvant treatment for patients who underwent rectal surgery for cancer. METHODS: Patients who underwent surgery with curative intent for rectal cancer in six Italian colorectal centers between January 2013 and December 2017 were retrospectively reviewed. Exclusion criteria were age less than 18 years, palliative or emergency surgery, and stage IV disease. Parameters of interest were patients' characteristics, preoperative tumor stage, neo-adjuvant chemoradiation therapy, intra-operative and postoperative outcomes. Although the participating centers referred to the same treatment guidelines for treatment, the chemotherapy regiment was not standardized across the institutions. Reasons for not starting adjuvant chemotherapy when indicated, interruption, and modification of drug regimen were collected to investigate compliance. RESULTS: A total of 572 patients were included in the analysis. Two hundred and fifty-two (44.1%) patients received neo-adjuvant chemoradiation therapy. All patients underwent high anterior rectal resection, low anterior rectal resection, or Miles' procedure. Of 399 patients with an indication to adjuvant chemotherapy, 176 (44.1%) completed the treatment as planned. Compliance for patients who started chemotherapy was 56% (95% CI 50.4-61.6%). Sixty-six patients interrupted the treatment, 76 patients significantly reduced the drug dose, and 41 patients had to switch to other therapeutic regimens. CONCLUSIONS: The present multicenter investigation reports a low compliance rate to adjuvant chemotherapy after rectal resection for cancer. Multidisciplinary teams should focus on future effort to improve compliance for these patients.

Endoscopic Treatment of Anastomotic Bleeding in Laparoscopic Colorectal Surgery.

Bleeding from the stapled line is a rare but potentially lethal complication that requires a proper and immediate management. Treatment for stapled anastomotic hemorrhage may be operative or conservative. We report three cases of anastomotic stapled line bleeding after colorectal surgery successfully treated endos-copically. Laparoscopic High Anterior Resection with a trans anal anastomosis according to Knight-Griffen with circular a stapler was performed for adenocarcinoma, rectal endometriosis and diverticular disease. All three patients had major rectal bleeding within 24 hours from surgery. 1 patients had endoscopy before the end of the surgical procedure. Endoscopic wash out with removal of the clots and infiltration of the bleeding sites along the stapled line with Adrenaline 1 : 10000 (2 ml) was performed achieving a good hemostasis. Early endoscopy is a safe and efficient treatment in colorectal anastomotic bleeding.