Background
Insufficient vascular supply is one of the main causes of anastomotic leak in colorectal surgery. Intraoperative indocyanine-green (ICG) angiography has been shown to provide information ...on tissue perfusion, identifying a well-perfused location for colonic and rectal transections, and thus possibly reducing the leak rate. Aim of this study was to evaluate the usefulness of intraoperative assessment of anastomotic perfusion using ICG angiography in patients undergoing left-sided colon or rectal resection with colorectal anastomosis.
Methods
This randomized trial involved 252 patients undergoing laparoscopic left-sided colon and rectal resection randomized 1:1 to intraoperative ICG or to subjective visual evaluation of the bowel perfusion without ICG. The primary aim was to assess whether ICG angiography could lead to a reduction in anastomotic leak rate. Secondary outcomes were possible changes in the surgical strategy and postoperative morbidity.
Results
After randomization, 12 patients were excluded. Accordingly, 240 patients were included in the analysis; 118 were in the study group, and 122 in the control group. ICG angiography showed insufficient perfusion of the colic stump, which led to extended bowel resection in 13 cases (11%). An anastomotic leak developed in 11 patients (9%) in the control group and in 6 patients (5%) in the study group (
p
= n.s.).
Conclusions
Intraoperative ICG fluorescent angiography can effectively assess vascularization of the colic stump and anastomosis in patients undergoing colorectal resection. This method led to further proximal bowel resection in 13 cases, however, there was no statistically significant reduction of anastomotic leak rate in the ICG arm.
Clinical trial
ClinicalTrials.gov NCT02662946.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
Anastomotic leak still represents the most feared surgical complication following colorectal resection and is associated with high morbidity and mortality rates. The aim of this study is ...to assess the feasibility and safety of laparoscopic reoperation for symptomatic anastomotic leak (AL) after laparoscopic right colectomy with mechanical intracorporeal anastomosis (IA).
Methods
From January 2012 to December 2019, 428 consecutive laparoscopic right colectomy with IA were performed. Overall symptomatic AL rate requiring reoperation was 5.8% (26/428). Data on patient demographics as well as operative findings, time elapsed from primary surgery and from the onset of symptoms of anastomotic leak, time and duration of re-laparoscopy, ICU stay, morbidity, mortality rate, length of hospital stay and readmission, were all retrospectively reviewed
.
Results
Laparoscopic approach was attempted in 23 (88.4%) hemodynamically stable patients. Conversion rate was 21.4%. Reasons for conversion were gross fecal peritonitis (
n
= 2), colonic ischemia (
n
= 1), severe bowel distension (
n
= 2). Eighteen (78.2%) patients underwent successfully laparoscopic (LPS) reoperation. A repair of the anastomotic defect was done in 11 (61.1%) patients, while in 7 patients the intracorporeal mechanical anastomosis was refashioned. A diverting ileostomy was done in 22.2% of cases (
n
= 4). A second reoperation for leak persistence was necessary in two cases (11.1%). Median (range) length of postoperative hospital stay from re-laparoscopy was 15.5 (9–53) days. Overall morbidity rate was 38.7%. Mortality rate was 5.5% (
n
= 1)
Conclusion
laparoscopic re-intervention for the treatment of anastomotic leak following LPS right colectomy with intracorporeal anastomosis in hemodynamically stable and highly selected patients in the experienced hands of dedicated laparoscopic surgeons, is a safe option with acceptable morbidity and mortality rate.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
Anastomotic leakage (AL) during Ivor-Lewis esophagectomy (ILE), owing to gastric conduit (GC) ischemia, is a serious complication. Measurement parameters during intraoperative ICG ...fluorescence angiography (ICG-FA) are unclear. We aimed to identify objective ICG-FA parameters associated with AL.
Study design
Patients > 18 years with an indication for ILE were enrolled. ICG-FA was performed at the abdominal and thoracic stage, and data, such as time of fluorescence appearance, speed of ICG perfusion, quality of GC perfusion (good, poor, ischemic), blood pressure, baseline patient characteristics, GC dimensions, and other intraoperative parameters were collected. On postoperative day 4 to 6, Gastrografin swallow radiography was performed. AL development was classified based on the Clavien–Dindo and SISG severity classifications. Univariate analysis with a 95% confidence level (
p
< 0.05) was performed. Factors with
p
< 0.05 were included in the multivariate analysis.
Results
100 patients were enrolled. During ICG-FA, evaluation of subjective perfusion was a very specific test (94.1%) with good negative predictive value (NPV 71.9%,
p
0.034), but not powerful enough to detect patients at risk of leak (sensibility 21.8%, PPV 63.6%). The GC perfusion speed (cm/s) after gastric vascular isolation and before tubulization showed a significant association with AL (
p
< 0.003). Median arterial blood pressure in the thoracic stage (
p
< 0.001) or use of inotropic (
p
< 0.033) was associated with AL development.
Conclusion
GC perfusion speed at ICG-FA is an objective parameter that could predict AL risk. Other results emphasize the importance of the microcirculation in the development of AL.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
Although nowadays considered as feasible and effective surgery in terms of short- and long-term results and oncological radicality, laparoscopic right colectomy is performed by a small ...number of surgeons, and in the vast majority of cases, this technique was performed with an extracorporeal anastomosis. Current literature failed to solve the controversies between intracorporeal and extracorporeal anastomosis after laparoscopic right colectomy.
Methods
A multicenter case-controlled study has been designed, including 286 patients who underwent laparoscopic right hemicolectomy with intracorporeal anastomosis (IA) compared with 226 matched patients who underwent laparoscopic right hemicolectomy with extracorporeal anastomosis (EA).
Results
There was no significant difference in terms of age, sex, BMI, and ASA score between the two groups. Surgical post history, tumor localization, and stage of disease according to AJCC/UICC TNM were similar too. Although similar oncologic radicality in term of number of lymph nodes harvested (25.7 ± 10.7 of IA group vs. 24.8 ± 8.7 of EA group;
p
= 0.3), as well as similar operative time (166 ± 43.7 min. in IA group vs. 157.5 ± 67.2 min in EA group) have been registered, time to flatus was statistically lower after intracorporeal anastomosis (40.8 ± 24.3 h in TLRC group vs. 55.2 ± 19.2 h in LARC group;
p
< 0.001) Laparoscopic colectomy with intracorporeal anastomosis was associated with a lower rate of post-operative complications (OR 0.65, 95 % CI 0.44, 0.95,
p
= 0.027). However, when stratifying according to clavien classification, the difference was consistently confirmed for less severe (class I and II) complications (OR 0.63, 95 % CI 0.42, 0.94,
p
= 0.025), but not for class III, IV, and V complications (OR 1.015, 95 % CI 0.64, 1.6,
p
= 0.95).
Conclusion
Our results are encouraging to consider the intracorporeally approach the better way to fashion the anastomosis after laparoscopic right colectomy. This study clearly provides the rationale for a randomized clinical trial, which would be useful to give definitive conclusion.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Although intracorporeal anastomosis has been demonstrated to be safe and effective after right colectomy, limited data are available about its efficacy after left colectomy for colon cancer located ...in splenic flexure. A multi-institutional audit was designed, including 92 patients who underwent laparoscopic left colectomy with intracorporeal anastomosis (IA) compared with 89 matched patients who underwent a laparoscopic left colectomy with extracorporeal anastomosis (EA). There was no significant difference in terms of age, sex, BMI, and ASA score between the two groups. Post-surgical history and stage of disease according to AJCC/UICC TNM were also similar. IA and EA groups demonstrated similar oncologic radicality in terms of the number of lymph nodes harvested (18.5 ± 9 vs. 17.5 ± 8.4;
p
= 0.48). Recovery after surgery was also better in patients who underwent IA, as confirmed by the shorter time to flatus in the IA group (2.6 ± 1.1 days vs. 3.4 ± 1.2 days;
p
< 0.001) and higher post-operative pain expressed in the mean VAS Scale in the EA group (1.7 ± 2.1 vs. 3.5 ± 1.6;
p
< 0.001). Laparoscopic left colectomy with intracorporeal anastomosis was associated with a lower rate of post-operative complications (OR 6.7, 95% CI 2.2–20;
p
= 0.001). However, when stratifying according to Clavien classification, the difference was consistently confirmed for less severe (class I and II) complications (OR 7.6, 95% CI 2.5–23,
p
= 0.001) but not for class III, IV, and V complications (OR 1.8, 95% CI 0.1–16.9;
p
= 0.59). Our results were consistent to hypothesize that a complete laparoscopic approach could be considered a safe method to perform laparoscopic left colectomy with the advantage of a guaranteed faster recovery after surgery. Further randomized clinical trials are needed to obtain a more definitive conclusion.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
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.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
AIM:To study the implementation of an enhanced recovery after surgery(ERAS)program at a large University Hospital from"pilot study"to"standard of care".METHODS:The study was ...designed as a prospective single centre cohort study.A prospective evaluation of compliance to a protocol based on full application of all ERAS principles,through the progressive steps of its implementation,was performed.Results achieved in the initial pilot study conducted by a dedicated team(n=47)were compared to those achieved in the shared protocol phase(n=143)three years later.Outcomes were length of postoperative hospital stay,readmission rate,compliance to the protocol and morbidity.Primary endpoint was the description of the results and the identification of critical issues of large scale implementation of an ERAS program in colorectal surgery emerged in the experience of a single center.Secondary endpoint was the identification of interventions that have been proven to be effective for facilitating the transition from traditional care pathways to a multimodal management protocol according to ERAS principles in colorectal surgery at a single center.RESULTS:During the initial pilot study(March 2009 to December 2010;47 patients)conducted by a dedicated multidisciplinary team,compliance to the items of ERAS protocol was 93%,with a median length of hospital stay(LOS)of 3 d.Early anastomotic fistulas were observed in 2 cases(4.2%),which required reoperation(Clavien-Dindo gradeⅢb).None of the patients had been discharged before the onset of the complication,which could therefore receive prompt treatment.There were also four(8.5%)minor complications(ClavienDindo gradeⅡ).Thirty days readmission rate was 4%.Perioperative mortality was nil.After implementation of the protocol throughout the Hospital in unselected patients(May 2012 to December 2012;147 patients)compliance was 74%,with a median LOS of 6 d.Early anastomotic fistulas were observed in 11 cases(7.7%),5(3.5%)of which required reoperation(Clavien-Dindo gradeⅢb).Two early anastomotic fistulas were treated by radiologic/endoscopic manoeuvres and 4 were treated conservatively.There were also 36(25.2%)minor complications,21(14.7%)of which were Clavien-Dindo gradeⅡand 15(10.5%)of which were Clavien-Dindo gradeⅠ.Only two patients whose course was adversely affected by the development of an anastomotic leak had been discharged before the onset of the complication itself,requiring readmission.Readmission rate within 30 d was 4%.Perioperative mortality was 1%.CONCLUSION:Our results confirm that introduction of an ERAS protocol for colorectal surgery allows quickerpostoperative recovery and shortens the length of stay compared to historical series.
BACKGROUND:Global experience with splenic flexure cancer is limited because of its low incidence. Both limited (segmental) and extended resections are performed, because agreement on which is the ...adequate procedure has not been reached.
OBJECTIVE:The purpose of this study was to investigate whether segmental resection is as safe and effective as extended resection.
DESIGN:This nationwide retrospective cohort study included all consecutive resections of splenic flecure cancer between January 2006 and December 2016 using data from the National Colorectal Cancer Network of the Italian Society of Surgical Oncology following the guidelines set out in the STROBE statement.
SETTING:Data were obtained for 31 Italian Referral Centers for Colorectal Surgery.
PATIENTS:A total of 1304 patients were submitted to resection of the splenic flexure (n = 791, 60.7%) or extended procedures (extended right and left colectomies; n = 513, 39.3%).
MAIN OUTCOME MEASURES:We evaluated Clavien-Dindo ≥3 postoperative complications and oncological (number of lymph nodes removed, length of free proximal and distal margins, rate of R0 resections) and survival outcomes.
RESULTS:The 2 arms were well balanced in regard to sex, BMI, ASA and Eastern Cooperative Oncology Group scores, and disease stage. Limited resection was performed more frequently using a minimally invasive approach (62.1% vs 50.9%, p < 0.001) and with shorter operation times than extended procedures (165 vs 189 minutes, p < 0.001), but the same Clavien-Dindo ≥3 postoperative complications (6.44% vs 6.43%, p = 0.99), 30-day mortality (0.63% vs 0.38%), oncological outcomes, and survival rates (5-year overall survival 0.84 vs 0.83, 5-year progression-free survival 0.85 vs 0.84).
LIMITATIONS:There are limitations inherent to the retrospective nature of the study and a potential lack of consistency in treatment across centers over time. Indications as to why a specific operation was chosen were based mostly on surgeons’ beliefs.
CONCLUSIONS:Segmental resection is a safe and effective treatment option for cancer of the splenic flexure. See Video Abstract at http://links.lww.com/DCR/B307.
LA RESECCIÓN DE COLON SEGMENTARIA ES UNA OPCIÓN DE TRATAMIENTO SEGURA Y EFICAZ PARA EL CÁNCER DE COLON DE LA FLEXIÓN ESPLÉNICAUN ESTUDIO RETROSPECTIVO A NIVEL NACIONAL DE LA SOCIEDAD ITALIANA DE ONCOLOGÍA QUIRÚRGICA - GRUPO COLABORATIVO RED DE CÁNCER COLORRECTALLa experiencia global con el cáncer de flexión esplénica es limitada debido a su baja incidencia. Se realizan resecciones limitadas (segmentarias) y extendidas, ya que no se ha llegado a un acuerdo sobre cuál es el procedimiento adecuado.El propósito de este estudio fue investigar si la resección segmentaria es tan segura y efectiva como la resección extendida.Este estudio de cohorte retrospectivo a nivel nacional incluyó todas las resecciones consecutivas de cáncer de flecura esplénica entre enero de 2006 y diciembre de 2016 utilizando datos de la Red Nacional de Cáncer Colorrectal de la Sociedad Italiana de Oncología Quirúrgica siguiendo las pautas establecidas en la declaración STROBE.Se obtuvieron datos para 31 centros de referencia italianos para cirugía colorrectal.Un total de 1304 pacientes fueron sometidos a resección de la flexión esplénica (n = 791, 60.7%) o procedimientos extendidos (colectomías extendidas derecha e izquierda; n = 513, 39.3%).Evaluamos Clavien-Dindo ≥3 complicaciones postoperatorias y oncológicas (número de ganglios linfáticos extirpados, longitud de márgenes proximales y distales libres, tasa de resecciones R0) y resultados de supervivencia.Los dos brazos estaban bien equilibrados en cuanto a sexo, IMC, ASA y puntajes ECOG, y etapa de la enfermedad. La resección limitada se realizó con mayor frecuencia utilizando un enfoque mínimamente invasivo (62.1% versus 50,9%, p < 0.001) y con tiempos de operación más cortos que los procedimientos extendidos (165 min versus 189 min, p <0.001), pero el mismo Clavien-Dindo ≥3 complicaciones postoperatorias (6,44% versus 6,43%, p = 0.99), mortalidad a los 30 días (0,63% versus 0,38%), resultados oncológicos y tasas de supervivencia (5-y OS 0,84 versus 0,83, 5-PFS 0,85 versus 0,84).Existen limitaciones inherentes a la naturaleza retrospectiva del estudio y una posible falta de consistencia en el tratamiento entre centros a lo largo del tiempo. Las indicaciones de por qué se eligió una operación específica se basaron principalmente en crieterios de los cirujanos.La resección segmentaria es una opción de tratamiento segura y efectiva para el cáncer de la flexión esplénica. Consulte Video Resumen en http://links.lww.com/DCR/B307. (Traducción—Dr. Adrian Ortega)
Minimally invasive surgery has provided several clinical advantages in locally advanced gastric cancer (LAGC) care, although a consensus on its application criteria remains unclear. Surgery remains a ...careful choice in elderly patients, who frequently present with frailty, comorbidities, and other disabling diseases. This study aims to assess the possible advantages of laparoscopic gastric resections in elderly patients presenting with LAGC. This retrospective study analyzed a single-center series of elderly patients (≥75 years) undergoing curative resections for LAGC between 2015 and 2020. A comparative analysis of open versus laparoscopic approaches was conducted, focusing on postoperative complications, length of hospital stay (LOS), and long-term survival. A total of 62 patients underwent gastrectomy through an open or a laparoscopic approach (31 pts each). The study population did not show statistically significant differences in demographics, operative risk, and neoadjuvant chemotherapy. The laparoscopic group reported significantly minimized overall complications (45.2 vs. 71%, p = 0.039) and pulmonary complications (0 vs. 9.7%, p = 0.038) as well as a shorter LOS (8 vs. 12 days, p = 0.007). Lymph node harvest was equal between the groups, although long-term overall survival presented significantly better after laparoscopic gastrectomy (p = 0.048), without a relevant difference in terms of disease-free and disease-specific survivals. Laparoscopic gastrectomy proves effective in elderly LAGC patients, offering substantial short- and long-term postoperative benefits.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Background
The aim of the study was to evaluate perioperative outcomes and to evaluate factors influencing rative morbidity and adoption of minimally invasive technique in 1-team (1-T) versus two ...teams (2-T) management of synchronous colorectal liver metastases.
Methods
Within four referral centers, a group of 234 patients treated in 1-T centers was identified and compared with a group of 253 patients treated in 2-T. A nonparametric bootstrap process was applied to the original cohorts of 1-T group and 2-T group as a resampling method to obtain bootstrapped cohorts (155 patients per group).
Results
33.5% of patients in 1-T boot group and 38.1% in the 2-T boot group were operated by laparoscopic approach. Multivariate analysis revealed that approach to primary tumor (laparoscopic or open) and intraoperative blood loss were independent prognostic factors for morbidity. Team approach did not show any significant correlation with incidence of postoperative complications nor with choice for laparoscopic approach.
Conclusion
The optimization of team strategy for patients with SCRLM is not solely based on the adoption of a 1-T or 2-T approach, but should instead be based on the implementation of a standard protocol for management of these patients.
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EMUNI, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
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